Hyperemesis gravidarum is uncontrollable vomiting during pregnancy that results in dehydration, weight loss, and ketosis. Diagnosis is clinical and by measurement of urine ketones and renal function. Treatment is with temporary suspension of oral intake and IV fluids, antiemetics if needed, and vitamin and electrolyte repletion.
Nursing Diagnosis for Hyperemesis Gravidarum
Imbalanced Nutrition: Less Than Body Requirements related to the frequency of excessive nausea and vomiting.
Nursing Intervention and Rationale for Hyperemesis Gravidarum
- Restrict oral intake until the vomiting stops.
Rationale: Maintaining a fluid electrolyte balance and prevent further vomiting.
- Give the anti-emetic drugs are prescribed.
Rationale: Preventing vomiting and maintain fluid and electrolyte balance.
- Maintain fluid therapy can be saved.
Rationale: Correction of hypovolemia and electrolyte balance.
- Record intake and output.
Rationale: Determining hydration fluids, and spending through vomiting.
- Encourage to eat small meals but often
Rational: Can adequate intake of nutrients your body needs.
- Advise to avoid fatty foods
Rational: fatty foods can stimulate nausea and vomiting.
- Encourage to eat a snack such as crackers, bread and tea (hot) warm before waking up at noon and before bed.
Rational: snack can reduce or prevent nausea, vomiting, excessive excitatory.
- Record intake, if oral intake can not be given within a certain period.
Rationale: To maintain a balance of nutrients.
- Inspection of irritation or Iesi the mouth.
Rational: To know the integrity of the oral mucosa.
- Review oral hygiene and personal hygiene and the use of oral cleaning fluid as often as possible.
Rationale: To maintain the integrity of the oral mucosa.
- Monitor hemoglobin levels and Hemotokrit
Rationale: To identify the potential presence of anemia and decreased oxygen-carrying capacity. Clients with Hb levels less than 12 mg / dl or hematocrit levels are low, consider-trimester anemia I.
- Urine Test against acetone, albumin and glucose ..
Rationale: Establish baseline data; done routinely to detect potential high-risk situations such as inadequate intake of carbohydrates.
- Measure uterine enlargement
Rationale: Malnutrition mother affects fetal growth and aggravate the decrease in the complement of brain cells in the fetus, resulting in deterioration of fetal development and the possibilities further.
Nursing Assessment Nursing Care Plan for Hyperemesis Gravidarum
Nanda Nursing Diagnosis for Hyperemesis Gravidarum