Hyperemesis gravidarum is a condition characterized by severe nausea, vomiting, weight loss, and electrolyte disturbance. Malnutrition and other serious complications such as fluid or electrolyte imbalances may result. The majority of pregnant women experience some type of morning sickness (70 – 80%). Nausea and vomiting of pregnancy (NVP), more widely known as morning sickness, is a common condition of pregnancy. Many researchers believe that NVP should be regarded as a continuum of symptoms that may impact an affected woman's physical, mental and social well-being to varying degrees.
Signs and symptoms:
- Severe nausea and vomiting
- Food aversions
- Decrease in urination
- Dehydration
- Weight loss of 5% or more of pre-pregnancy weight
- Headaches
- Confusion
- Fainting
- Extreme fatigue
- Low blood pressure
- Rapid heart rate
- Jaundice
- Loss of skin elasticity
- Secondary anxiety/depression
Nursing Diagnosis for Hyperemesis Gravidarum : Fluid And Electrolyte Imbalances related to active fluid loss
Goal:
- Mucous membranes moist
- CRT is less than 3 seconds
- Normal vital signs
Nursing Interventions:
1. Monitor and record vital signs every 2 hours as needed or as often as possible until stable. Then monitor and record vital signs every 4 hours.
Rational: Tachycardia, dyspnea, or hypotension may indicate a lack of fluid volume or electrolyte imbalance.
2. Measure intake and output every 1 to 4 hours. Record and report significant changes including urine, feces, vomit, wound drainage, nasogastric drainage, chest tube drainage, and output another.
Rationale: Urine output low and high urine specific gravity indicates hypovolemia.
3. Measure the weight of the patient at the same time every day.
Rationale: To provide data that is more accurate and consistent. Weight loss is a good indicator of fluid status.
4. Assess skin turgor and mucous membranes of the mouth every 8 hours.
Rationale: To check dehydration.
5. Give careful oral care every 4 hours.
Rationale: To avoid dehydration of the mucous membrane.
6. Check the specific gravity of urine every 8 hours.
Rationale: Increased urine specific gravity may indicate dehydration.