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:
1. How do “morning sickness” and hyperemesis gravidarum compare in terms of onset, duration and effect on the patient? What criteria would have resulted in Divya being diagnosed with Hyperemesis Gravidarum rather than morning sickness?
2. What are common electrolyte imbalances associated with hyperemesis gravidarum and what symptoms might you see in Divya as a result of these imbalances?
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3. What are common antiemetics that may be used to treat Divya's nausea as an inpatient and as an outpatient? Why do you think the medications ordered for Divya while in the hospital and upon discharge were chosen for her by her Doctor?
4. Identify a minimum of 3 nursing goals you would prioritize in the care of Divya and the therapeutic management of her hyperemesis gravidarum?
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

1.morning sickness is a condition which occurs during first trimester of pregnance.this considered as normal as most of the pregnant women experiences this problem due to hormo el changes.this will not make any harm to mother and baby.patient may be nauseated or has vomitting especially at morning time.

While,the vomitting become severe and it continues through out the first trimester or whole day is considered as hyperemesis gravidarum.in this condition patient can not eat any thing which may leads to dehydration.this can be harmful for mother and baby.
Divya being diagnosed with hyperemesis gravidarum as she had 3 episodes of vomitting after admitting and showed signs of dehydration.this occurs in hyperemesis gravidarum.

2.patient will have hypokalemia and hypo natremia due to severe vomitting.she will have weight lose,muscle pain,dehydration or shock associated with eletrolyte loss.

3.ondanestron or domaperidol can be used as anti emetic for divya as these medicine are safe during pregnancy.it is ne essary to take medication as prescribed by doctor because some medi ations are co traindicated during pregnancy which may harm both mother and baby.so i think divya should take the medication choosen by her doctor.

4.1.To administer medications as ordered

2.encourage her to take fluids to improve hydration status.

3.give psychological support as she may worried about her baby.

Therapeutic treatment includes anti emetics,antacids,intravenous fluids ,electrolytes.