Question

Divya Shetty
Scenario Details:
Patient data: Female – Age 26 years (Feb. 11, 1994). Weight 58 kg (128 lbs). Height: 167.64 cm (5’5)
Allergies: Seasonal allergies
Prior Medical History: Two previous pregnancies. The first pregnancy was a spontaneous abortion at 8 weeks, and the second pregnancy was three years ago with spontaneous vaginal delivery of a healthy baby girl. During that pregnancy, she was hospitalized several times for IV and antiemetic therapy until week 20. Divya was taking prenatal vitamins, disclosed she has now stopped taking them due to intolerance.
Recent Medical History: Divya came to ED with severe vomiting and dizziness 6 hours ago. She is 12 weeks pregnant. In her first hour after being admitted she had x3 episodes of emesis and voided 225mL of dark concentrated urine . Since being admitted to the ED, she underwent treatment for dehydration and nausea, she has since voided 300 mL of clear straw coloured urine and had no further episodes of vomiting. Divya has not been tolerating fluids or a regular diet well since her pregnancy, a snack has been provided and Divya has been encouraged to eat following the administration of an antiemetic has been effective.
Social History: Single parent, father not involved in the pregnancy Divya is unaware of his health history. Patient’s mother also has a history of hyperemesis gravidarum during pregnancy. Patient’s father has hypertension and adult onset diabetes.
Primary Medical Diagnosis: hyperemesis gravidarum during pregnancy Provider’s Orders:
Advanced Care Planning
● Goals of Care Designation – R1, Designation Definition: Patient is expected to benefit from and is accepting of any appropriate investigations/ interventions that can be offered including attempted resuscitation and ICU care.
Medication and IV’s
● IV Normal Saline 500mL bolus over 30 min STAT
● IV of D5LR with 20 mEq of potassium chloride and one ampule of multivitamins at 125mL/hour
● Ondansetron 4mg IV q 8hrs PRN
● Metoclopramide 10mg IV q 6Hrs PRN
Respiratory Care
● O2 therapy – Titrate to Saturation – Oxygen to maintain SpO2 greater than 95% Patient Care
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● Vital signs every hour
● Intake and output
● Activity as tolerated
Nutrition
● Clear fluids to diet as tolerated
Diagnostics
● STAT CBC, electrolytes amylase, lipase, AST, ALT, BUN, creatinine and bilirubin
● Obtain ultrasound of uterus
● Midstream urine for drug screen, specific gravity, ketones, WBCs and culture and sensitivity
● Monitor patient and fetal heart tones
Radiology/ Lab Results
● Blood work and urine within normal ranges
● Ultra sound showed no significant findings
Discharge Orders
● Prescriptions for Doxylamine and Pyridoxine (Diclectin) faxed to local pharmacy for home delivery
● Book 2 week follow up appointment with family doctor
Admission to ED Assessment
Vital signs: BP 130/98 HR 98, RR 16, SPO2 99% on room air, Temp 37.4 General appearance: Slightly anxious
Cardiovascular: Sinus tachycardia
Respiratory: Breath sounds clear
GI: Bowel sounds normal, not able to tolerate fluids or regular diet
GU: Voiding adequate amount since arrival in ED, first hour voided 225 mL concentrated dark yellow
urine, following administration of IV fluids voided additional 300 mL of clear straw coloured urine. Extremities: No abnormalities found. Ambulates independently
Skin: Slightly sluggish skin turgor, cap refill normal, mucous membranes moist and pink.
Simulation Preparation Questions:

5. What are some other possible causes of nausea and vomiting during pregnancy?

6. Identify a minimum of 5 possible complications or consequences to Divya or the baby of
hyperemesis gravidarum?

7. Create a discharge teaching plan for Divya. Be sure to address diet, follow-up care and
medication instruction.

8. Identify elements of Divya’s history that may have put her at a higher risk for developing
hyperemesis gravidarum?

9. What are common complementary therapies that you can share with Divya to help her manage
her hyperemesis?

10. Why does the healthcare provider order a complete blood count (CBC), electrolyte panel,
Amylase, Lipase, Aspartate Aminotransferase (AST), Alanine Aminotransferase (ALT), BUN, Creatinine and Bilirubin? What are the normal ranges and what does each test indicate if high, low or normal?

References
Leifer, G. (2019). Introduction to maternity and pediatric nursing. St. Louis, MO: Elsevier.
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Answer 1

5.1.increase in the level of oestrogen and orogestron may cause the vomitting during pregnancy.stress is a factor to occur this condition.if the patient has any other medical condition like stomach ulcer,gall stone or kidney stone may sometimes lead to nausea and vomitting.

6.1.electrolyte imbalance

2.hypovolemic shock due to dehydration.

3.gestationel hypertension or pre eclampsia

4.preterm delivery

5.intra uterine growth retardation

6.low birth weight baby.

7.1.tell her to take proper rest

2.advice her to increase hydration status.

3.advice her to include more fruits and vegetables in her diet.

4.advice her to avoid gas forming food.

5.advice her to avoud junk food .

6.tell her to take anti emetics before meal if vomitting is not controlled.

7.advise her to meet the doctor if the cobdition worses.

8..she may have stress due to her first abortion and her mother also has a history of hyperemesis gravidarum.

9.1.she can eat ginger whenever she feel to vomit.this will reduce nausea.

2.meditation may help her to relieve the stress which is a factor of vomitting.

3.she can do walking to reduce acidity.

4.she can do accupuncture which is also assist to reduce vomitting.

10.Inorder to find out anemia,hypokalemia and hyponatremia this blood test are necessary as patient is not taking enough food and getting dehydrated due to excessive vomitting.