Hyperemesis gravidarum is a condition affecting pregnant women which causes intractable nausea and vomiting during pregnancy. While the exact cause remains unclear, this condition is thought to be caused by rapidly rising hormone levels like HCG and estrogen during the first trimester. Another potential cause may include an increased incidence of gastroesophageal reflux disease (GERD), causing nausea. Hyperemesis gravidarum risk does increase among women with family members who also experienced this condition.
Clinical manifestations of hyperemesis gravidarum typically occur in the first trimester of pregnancy and include the following:
- Nausea accompanied by severe vomiting
- Vomiting that occurs more than 3-4 times per day
- Weight loss of more than 5% of pre-pregnancy weight
- Dizziness
- Lightheadedness
- Dehydration
- Headaches
- Fainting
A physical examination and medical history can diagnose hyperemesis gravidarum. Laboratory tests like complete blood count, electrolyte levels, and urine ketones are monitored for the effects of severe dehydration.
Nursing Process
The priority of nursing care for patients with hyperemesis gravidarum is to identify the severity of nausea and vomiting, the degree of dehydration, and the extent of the weight loss. Nurses provide medications to prevent nausea and vomiting and administer IV fluids and electrolyte supplementation for severe cases. Patient education helps prevent complications and manage discomfort at home.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for hyperemesis gravidarum, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for hyperemesis gravidarum.
Acute Pain
Hyperemesis gravidarum is characterized by extreme and persistent nausea and vomiting that may coincide with abdominal pain.
Nursing Diagnosis: Acute Pain
Related to:
- Disease process
- Hormonal imbalance
- Nausea and vomiting
- Constipation
As evidenced by:
- Appetite change
- Nausea
- Vomiting
- Abdominal pain
- Distraction behavior
- Expressive behavior
- Facial expression of pain
- Guarding behavior
- Hopelessness
- Positioning to ease pain
- Protective behavior
Expected outcomes:
- Patient will report decreased pain along with manageable nausea and vomiting symptoms.
- Patient will perform interventions to help relieve abdominal discomfort, nausea, and vomiting.
Assessment:
1. Perform a comprehensive pain assessment.
Intermittent abdominal pain may accompany persistent nausea and vomiting in patients suffering from hyperemesis gravidarum. The pain is described as occurring in the upper middle abdominal area. Sharp, stabbing pain, pain in the RUQ, or cramps accompanied by spotting are signs of other conditions requiring immediate investigation.
2. Assess the patient’s previous pain experience and pain management interventions.
Assessing previous pain management interventions used to relieve abdominal pain can help guide and create appropriate treatment and management plans for the patient.
Interventions:
1. Encourage small, frequent meals.
Patients diagnosed with hyperemesis gravidarum can benefit from eating small, frequent meals of bland and dry foods like toast and crackers, as this can help alleviate gastrointestinal upset and reduce nausea, vomiting, and abdominal pain.
2. Encourage the patient to avoid greasy and spicy foods.
Eating spicy and greasy foods can cause further stomach upset and aggravate nausea, vomiting, and abdominal pain in patients diagnosed with hyperemesis gravidarum.
3. Administer medications as indicated.
Combining OTC pyridoxine and doxylamine may be effective for nausea during pregnancy.
4. Consider an ultrasound or imaging tests.
If abdominal pain is severe or felt in the RUQ, an ultrasound or other imaging test can rule out other causes like appendicitis or gallstones.
5. Encourage non-pharmacological pain interventions.
Non-pharmacological pain interventions like relaxation techniques, massage, guided imagery, and heat can help reduce abdominal pain.
Deficient Fluid Volume
Hyperemesis gravidarum is characterized by excessive nausea and vomiting, which can result in excess fluid loss, weight loss, and dehydration.
Nursing Diagnosis: Deficient Fluid Volume
Related to:
- Nausea and vomiting
- Inadequate fluid and food intake
- Increased gastric secretions
- Disease process
As evidenced by:
- Thirst
- Weight loss
- Dry skin
- Altered skin turgor
- Dry mucous membranes
- Increased body temperature
- Decreased blood pressure
- Increased heart rate
- Decreased urine output
- Dizziness
- Fainting
- Altered mental status
- Weakness
Expected outcomes:
- Patient will remain adequately hydrated, as evidenced by urine output within normal limits.
- Patient will deny the presence of dizziness, weakness, or faintness.
Assessment:
1. Monitor intake and output.
Patients with hyperemesis gravidarum often are unable to keep any food down. Strict monitoring of intake (oral or IV) and output (vomiting, urine) is required as dehydration can occur quickly.
2. Assess for any signs of dehydration.
Signs of dehydration like dry skin, dry mucous membranes, poor skin turgor, reduced blood pressure, tachycardia, and fever can result from excessive nausea and vomiting.
Interventions:
1. Evaluate and monitor laboratory values.
With excessive and prolonged vomiting, fluid loss and electrolyte imbalances occur. When potassium and magnesium are low, complications such as cardiac dysrhythmias and altered kidney function can occur.
2. Administer intravenous fluid replacement as ordered.
Intravenous fluid replacement can help manage fluid loss, prevent dehydration, and correct electrolyte imbalances in patients with hyperemesis gravidarum.
3. Provide ice chips.
The patient may not be able to tolerate large quantities of food or liquids. Ice chips can feel soothing and support hydration
4. Promote safety.
Dehydration can cause feelings of dizziness and fainting. Ensure the pregnant patient’s safety by always assisting with ambulation, encouraging non-slip socks, and keeping bed rails upright.
Deficient Knowledge
Patient education is integral to managing hyperemesis gravidarum to ensure effective treatment and adherence.
Nursing Diagnosis: Deficient Knowledge
Related to:
- Insufficient information
- Inadequate knowledge of resources
- Insufficient interest in learning
- Misinformation
- Unfamiliarity of condition
As evidenced by:
- Inaccurate follow-through of instructions
- Nonadherence with the treatment regimen
- Inaccurate statements about the condition
Expected outcomes:
- Patient will verbalize understanding of the condition, its complications, and the treatment regimen.
- Patient will verbalize or demonstrate appropriate interventions to control nausea and vomiting.
Assessment:
1. Assess the patient’s current knowledge about hyperemesis gravidarum.
Reviewing the patient’s knowledge about the current condition can help identify patient education needed and correct myths that the patient believes, enabling adherence to the treatment regimen.
2. Assess the patient’s health literacy and readiness to learn.
The patient’s health literacy and readiness to learn can affect patient education outcomes and help the healthcare provider determine the appropriate approach to achieve comprehension.
3. Assess the patient’s support system that can help with reinforcing education.
First-time mothers and younger patients can benefit from having a concrete support system to help them manage the signs and symptoms of hyperemesis gravidarum.
Interventions:
1. Educate the patient about the signs and symptoms of hyperemesis gravidarum.
While the exact cause of hyperemesis gravidarum is unknown, it is believed to be due to the rapid increase of HCG and estrogen production during pregnancy. Educating the patient on the signs and symptoms of the condition and controlling fluid loss is important to prevent complications.
2. Use a patient-centered approach to engaging the patient in learning.
Various teaching methods are available depending on the patient’s preference and style, ensuring positive teaching outcomes. Utilize printed materials, approved online resources, and verbal education to meet the learning styles of all patients.
3. Request verbalization of teaching.
The patient must understand the importance of maintaining hydration and preventing fluid loss that could result in electrolyte imbalances. Ask the patient to teach-back signs and symptoms of dehydration and when to seek medical assistance.
4. Refer the patient to appropriate support and community groups.
The patient may benefit from peer support groups where women share their personal experiences. Hearing the stories of other women with hyperemesis gravidarum and how they managed their symptoms can help the pregnant patient feel less alone.
Imbalanced Nutrition: Less Than Body Requirements
Pregnant women with hyperemesis gravidarum experience excessive vomiting causing weight loss, dehydration, malnutrition, and electrolyte imbalances. It becomes impossible for these patients to take in adequate food and fluids for several weeks to months, compromising their nutrition and the development of the fetus.
Nursing Diagnosis: Imbalanced Nutrition
Related to:
- Nausea and vomiting
- Disease process
- Altered taste perception
- Food aversion
As evidenced by:
- Muscle weakness
- Malnutrition
- Weight loss
- Dehydration
- Fatigue
- Food intake less than recommended daily allowance
- Hypoglycemia
- Pale mucous membranes
- Dry skin
- Poor fetal growth
Expected outcomes:
- Patient will progressively gain weight with decreased severity of nausea and vomiting.
- Patient will be able to increase food and fluid intake, recognize triggers for nausea, and demonstrate interventions that can help alleviate nausea and vomiting.
Assessment:
1. Assess the fetus.
If inpatient management is required, continuous fetal monitoring may be recommended to monitor the fetal heart rate.
2. Assess and monitor maternal weight.
Severe and prolonged nausea and vomiting can cause malnutrition, dehydration, and weight loss. A weight loss of 5% of the pre-pregnancy weight is a common finding to support hyperemesis gravidarum.
Interventions:
1. Administer parenteral nutrition as indicated.
Administration of parenteral nutrition may be required for patients with hyperemesis gravidarum who cannot tolerate foods and fluid intake.
2. Encourage small meals.
Small meals allow food intake without aggravating bouts of nausea and vomiting.
3. Consult with a dietitian.
A dietitian can help plan an appropriate and well-balanced meal for patients with hyperemesis gravidarum giving special attention to the nutritional needs of pregnant women.
4. Offer ginger or change prenatal vitamins as ordered.
Switching the mother’s prenatal vitamins to folic acid alone may help. Ginger chews or drinks can also help relieve nausea.
Nausea
Pregnant women with hyperemesis gravidarum experience severe and persistent nausea and vomiting, leading to weight loss and dehydration.
Nursing Diagnosis: Nausea
Related to:
- Pregnancy
- Unpleasant sensory stimuli
- Rise in hormone levels
- Multiple gestation pregnancy
- Genetic predisposition
As evidenced by:
- Food aversion
- Increased salivation
- Gagging sensation
- Sour taste
- Increased swallowing
- Vomiting
Expected outcomes:
- Patient will verbalize the reduction of incidence and severity of nausea and vomiting.
- Patient will demonstrate effective interventions that can help alleviate nausea and vomiting.
- Patient will be able to eat small meals and/or consume fluids.
Assessment:
1. Assess for possible causes and triggers of nausea aside from pregnancy.
Proper assessment of the triggers and causes of nausea can help plan an appropriate treatment regimen, preventing the condition from becoming severe.
2. Assess for a history of nausea.
Research shows that women who experience nausea and vomiting outside of pregnancy, such as due to motion sickness or migraine headaches, are at a higher risk of experiencing nausea and vomiting during pregnancy.
Interventions:
1. Eliminate objects or food with strong and unpleasant odors.
Pregnancy can cause odor sensitivity, which may trigger nausea and vomiting. Strong and unpleasant odors can exacerbate hyperemesis gravidarum.
2. Encourage nonpharmacologic interventions to manage nausea.
Meditation, diversion, music therapy, and deep breathing exercise can help reduce the incidence of nausea and vomiting in pregnant women.
3. Administer antiemetics as indicated.
Antiemetics may be provided to pregnant women with hyperemesis gravidarum to help alleviate nausea and vomiting.
4. Encourage acupressure.
Placing pressure on the point located in the middle of the inner wrist is thought to reduce nausea. Special acupressure bands can be bought to put pressure on this site.
References
- Hyperemesis Gravidarum. American Pregnancy Association. 2022. From: https://americanpregnancy.org/healthy-pregnancy/pregnancy-complications/hyperemesis-gravidarum/
- Hyperemesis Gravidarum. Jennings LK, Mahdy H. [Updated 2022 Sep 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532917/
- Hyperemesis Gravidarum. Medline Plus. Updated: January 1, 2021. From: https://medlineplus.gov/ency/article/001499.htm
- Hyperemesis Gravidarum. NORD. Updated: 2020. From: https://rarediseases.org/rare-diseases/hyperemesis-gravidarum/
- Hyperemesis Gravidarum (Severe Nausea & Vomiting During Pregnancy). Cleveland Clinic. Reviewed: December 2, 2020. From: https://my.clevelandclinic.org/health/diseases/12232-hyperemesis-gravidarum-severe-nausea–vomiting-during-pregnancy
