Watch More! Unlock the full videos with a FREE trial
Add to Study plan
Master
Included In This Lesson
Study Tools
Hyperemesis Gravidarum (Picmonic)
Hyperemesis Gravidarum Pathochart (Cheat Sheet)
Care Plan Example_Hyperemesis Gravidarum (Cheat Sheet)
Blank Nursing Care Plan_CS (Cheat Sheet)
Access More! View the full outline and transcript with a FREE trial
Example Nursing Diagnosis for Hyperemesis Gravidarum
- Fluid Volume Deficit: Hyperemesis gravidarum can lead to severe dehydration due to excessive vomiting. This diagnosis addresses fluid balance.
- Imbalanced Nutrition: Less than Body Requirements: Patients with hyperemesis gravidarum often struggle with food intake. This diagnosis focuses on nutritional deficits.
- Risk for Maternal Injury: Severe vomiting and electrolyte imbalances can pose a risk to the mother. This diagnosis emphasizes injury prevention.
Transcript
Hey everyone. We are going to be working on the nursing care plan for hyperemesis gravidarum. So let's get started. So we're going to first look at pathophysiology. So hyperemesis gravidarum is a morning sickness that causes long lasting, intense nausea, vomiting, and weight loss. While morning sickness is common, hyperemesis gravidarum develops between the fourth and six weeks of pregnancy, and it may last beyond week 20. Some nursing considerations: you want to assess vital signs, assess for dehydration, monitor lab values, administer IV fluids, medications, monitor I & O, and monitor for constipation. Some desired outcomes: reduce and manage the symptoms of nausea and vomiting, maintain appropriate nutrition and hydration, and avoid any sort of complications and injury to the patient and the fetus.
So we're going to go ahead and get started on the care plan. We're going to be looking at some of the subjective data and the objective data. So what are we going to see with these patients? Some of the biggest things are nausea and vomiting. So for some of them, this can be pretty debilitating to where it's very difficult to be able to get through some of your daily tasks. So this is one of the main things that they talk about. Another thing is weakness. You'll also see that they're going to be very dehydrated and you'll see hypotension - decreased blood pressure. Other things to consider: dizziness, fatigue, some food or smell aversions, headache, confusion, also fainting, jaundice, tachycardia (increased heart rate), and some weight loss.
So what interventions are we going to look for in these patients? Well, one of the things that we want to make sure we're always doing with every patient is we're going to be checking and assessing their vital signs - their heart rate, respirations, and blood pressure. You’ll want to get a baseline vital and note any other changes. So if you do see that they're pretty tachycardic, and they have decreased blood pressure, it could be because of the vomiting. Another intervention that we're going to look for is any sort of signs of dehydration; because, once again, if they're super nauseous and vomiting a lot, they're losing a lot of those fluids, which can make them pretty confused. You're going to look for any sort of dry membranes, any skin tenting, which are all signs of dehydration. Another intervention we're going to be looking to do is monitor their lab values.
Okay. Monitor lab values. So metabolic panel is typically what you would want to run for these patients. You want to see if they have any sort of electrolyte imbalance or any sort of renal impairment from the excessive vomiting, which could lead to metabolic alkalosis. Other interventions: we're going to make sure we're giving them IV fluids and medications. The IV fluids will be necessary and will help manage their electrolyte balance and maintain adequate hydration. Certain medications can be administered for these patients and are able to help relieve the nausea that they're feeling. We're going to monitor their I & O: we want to make sure that they're taking in enough and monitoring their urine output and the amount of emesis. You also want to note any sort of dark colored urine and any decreased urine output, which could imply that there's some sort of renal function impairment.
Another intervention we're going to do is we're going to be treating for constipation. A decrease in intestinal mobility from dehydration can cause some uncomfortable constipation. So you really want to encourage oral intake as tolerated and increase intestinal motility to relieve the constipation. And sometimes you may end up needing to give stool softeners. And another intervention that we want to do is we want to make sure that the patient is not losing any more weight. You want to encourage them to have an increased food intake or fluid intake, and you may have to insert an NG tube for feeding if excessive vomiting and food smell aversions make it difficult to maintain proper nutrition. And tube feedings may be necessary to provide adequate nutrition for patients and the fetus.
So let's go over some of the key points. So pathophysiology: basically it is extreme morning sickness that can cause long lasting intense nausea, vomiting, and weight loss and is usually caused by a rapid rise in hormone or HCG levels. Some subjective objective data you'll see in these patients: nausea and vomiting. You'll also see weight loss, headache, weakness, dehydration, and hypotension. You're going to see a high heart rate, fainting and confusion. You're going to want to make sure you're doing your assessments and giving medications. You're going to look at their vital signs, check for the signs of dehydration, monitor the lab values and give antiemetics for that nausea and vomiting. Lastly, you're going to assist with nutrition and help with constipation. Prevent any further weight loss by encouraging fluid and food intake as tolerated and give any stool softeners for constipation as needed.
Great job guys. We love you go out and be your best self today. And, as always, happy nursing.
So we're going to go ahead and get started on the care plan. We're going to be looking at some of the subjective data and the objective data. So what are we going to see with these patients? Some of the biggest things are nausea and vomiting. So for some of them, this can be pretty debilitating to where it's very difficult to be able to get through some of your daily tasks. So this is one of the main things that they talk about. Another thing is weakness. You'll also see that they're going to be very dehydrated and you'll see hypotension - decreased blood pressure. Other things to consider: dizziness, fatigue, some food or smell aversions, headache, confusion, also fainting, jaundice, tachycardia (increased heart rate), and some weight loss.
So what interventions are we going to look for in these patients? Well, one of the things that we want to make sure we're always doing with every patient is we're going to be checking and assessing their vital signs - their heart rate, respirations, and blood pressure. You’ll want to get a baseline vital and note any other changes. So if you do see that they're pretty tachycardic, and they have decreased blood pressure, it could be because of the vomiting. Another intervention that we're going to look for is any sort of signs of dehydration; because, once again, if they're super nauseous and vomiting a lot, they're losing a lot of those fluids, which can make them pretty confused. You're going to look for any sort of dry membranes, any skin tenting, which are all signs of dehydration. Another intervention we're going to be looking to do is monitor their lab values.
Okay. Monitor lab values. So metabolic panel is typically what you would want to run for these patients. You want to see if they have any sort of electrolyte imbalance or any sort of renal impairment from the excessive vomiting, which could lead to metabolic alkalosis. Other interventions: we're going to make sure we're giving them IV fluids and medications. The IV fluids will be necessary and will help manage their electrolyte balance and maintain adequate hydration. Certain medications can be administered for these patients and are able to help relieve the nausea that they're feeling. We're going to monitor their I & O: we want to make sure that they're taking in enough and monitoring their urine output and the amount of emesis. You also want to note any sort of dark colored urine and any decreased urine output, which could imply that there's some sort of renal function impairment.
Another intervention we're going to do is we're going to be treating for constipation. A decrease in intestinal mobility from dehydration can cause some uncomfortable constipation. So you really want to encourage oral intake as tolerated and increase intestinal motility to relieve the constipation. And sometimes you may end up needing to give stool softeners. And another intervention that we want to do is we want to make sure that the patient is not losing any more weight. You want to encourage them to have an increased food intake or fluid intake, and you may have to insert an NG tube for feeding if excessive vomiting and food smell aversions make it difficult to maintain proper nutrition. And tube feedings may be necessary to provide adequate nutrition for patients and the fetus.
So let's go over some of the key points. So pathophysiology: basically it is extreme morning sickness that can cause long lasting intense nausea, vomiting, and weight loss and is usually caused by a rapid rise in hormone or HCG levels. Some subjective objective data you'll see in these patients: nausea and vomiting. You'll also see weight loss, headache, weakness, dehydration, and hypotension. You're going to see a high heart rate, fainting and confusion. You're going to want to make sure you're doing your assessments and giving medications. You're going to look at their vital signs, check for the signs of dehydration, monitor the lab values and give antiemetics for that nausea and vomiting. Lastly, you're going to assist with nutrition and help with constipation. Prevent any further weight loss by encouraging fluid and food intake as tolerated and give any stool softeners for constipation as needed.
Great job guys. We love you go out and be your best self today. And, as always, happy nursing.
View the FULL Transcript
When you start a FREE trial you gain access to the full outline as well as:
- SIMCLEX (NCLEX Simulator)
- 6,500+ Practice NCLEX Questions
- 2,000+ HD Videos
- 300+ Nursing Cheatsheets
“Would suggest to all nursing students . . . Guaranteed to ease the stress!”
