AMA

College of Nursing
East Rizal Campus

A CASE STUDY PRESENTED TO THE CLINICAL INSTRUCTOR OF

AMA EAST RIZAL COLLEGE OF NURSING

HYPEREMESIS GRAVIDARUM(HG)

RELATED LEARNING EXPERIENCE (RLE) AT EMING LYING-IN CLINIC AND

MEDICAL CENTER

SUBMITTED BY:
PN/BSN LEVEL II

SUBMITTED TO:
PROF. JULIET B. BATAC, RN, MAN, CLINICAL INSTRUCTOR

27 AUGUST 2019
SY 2019-2020

Acknowledgement
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 The BSNII and PNII would like to express their gratitude to all the people
behind this case study especially the group who made this case study easy through
their joint effort, collaboration, steadfast support and good camaraderie.

To our patient Ms. E.D, diagnosed with Hyperemesis Gravidarum (HG) to the
Administration and staff of Eming Lying-In Clinic and Medical Center who showed
courtesy and respect towards the practice of their profession, thank you.

To our Clinical Instructor Prof. Juliet B. Batac, RN, MAN, who guided us
through this knowledge with patience, concern and care, we are truly grateful and
felt a sense of Pride of the profession. Indeed, Nursing is a noble profession.

To our Dean Florante Z. Artienda, RN, MAN, thanks for the useful bits and
pieces of advises and unflinching support guiding us all the way.

To all the students who exerted their joint efffort gathering and compiling
whose names are as follows: Evangeline Zarate, Rhoaisa S. Matolo-Osagie, Jen Polido,
Daisy Diza, Jean Casiquin and Joannah Maribbay, thanks for being amazingly
beautiful.

Finally, we offer our Great to the God Almighty for making all things possible.
We thank Him for the beautiful people He sent and used for us to learn nursing skills
and knowledge with greater impact but in the most easiest and fun way. Truly, one
of the perks and blessings of life.

TABLE OF CONTENTS
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Title Page
Acknowledgement

I. INTRODUCTION
A. Background of the Study
B. Objectives
a. General Objectives
b. Specific Objectives
C. Scope and Limitation
D. Conceptual Framework

II. CLINICAL SUMMARY

A. General Data
B. Chief Complaint
C. Source of Information
D. Past and Medical History
E. History of Present Illness
F. Personal and Social History
G. Familial History

III. REVIEW OF SYSTEM

IV. PHYSICAL ASSESSMENT

A. Head to Toe Assessment
B. Gordon’s Functional Pattern
V. CLINICAL DISCUSSIONS
A. Anatomy and Physiology
B. Pathophysiology

VI. NURSING CARE PLAN

VII. DRUG STUDY

VIII. DISCHARGE PLAN

INTRODUCTION
A. Background of the Study

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 Hyperemesis Gravidarum (HG) is a condition where the pregnant woman suffers from
grave, persistent and severe nausea, extreme headache, decreased appetite, constant
and abnormal regorge of food intake (vomiting) which can dangerously cause
dehydration, weight loss of more than 5% of body weight and imbalances in electrolytes.

In layman, it is called morning sickness, however, Hyperemesis Gravidarum is a life

threatening and an extreme condition of nausea and/or vomitin0g which departs from
the normal and common state of a pregnant woman. The signs and symptoms of
hyperemesis are salivating a lot more than normal, weight loss, dehydration such as dark
urine, dry skin, weakness, light headedness or fainting, constipation and Inability to take
in adequate amounts of fluid or nutrition.

Normally, pregnant women experienced only nausea and/or vomiting for the first
three (3) months. In the case of Hyperemesis Gravidarum, the abovementioned
conditions are longer and can last up to the third (3rd) trimester of pregnancy. According
to “Medline Plus”, out of 100% of pregnant women, this ailment is uncommon and less
likely to appear, thus, only less than 3% of women suffer from Hyperemesis Gravidarum.
Based on research, this can happen to any pregnancy but is improbable on twin
pregnancy.

Hyperemesis Gradivarum appears on the first trimester, particularly on the 4 th and 6th
week of pregnancy, and aggravates and worsens on the 9th to 13th weeks.

Concurrently, doctors agree that Hyperemesis Gravidarum cause is unknown. It is

however considered to be linked or related to hormonal changes in pregnancy,
specifically the Human Chorionic Gonadotropin (HCG). HCG takes place when there is
brisk rise of blood level. This HCG hormone is released by placenta. Unfortunately, there
is also no treatment to this illness, only ways and means to manage the said symptoms
and conditions.

Women are at higher risk for hyperemesis if they have had the problem in previous
pregnancies or are prone to motion sickness.

It is suggested that Exams and laboratory test should be undertaken by the health
care provider such as Complete blood count, Electrolytes, Urine ketones and Weight loss
to ensure that pregnant women has no liver and gastrointestinal problems.

B. Objectives

a. General Objectives

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 At the end of this study, the group presenters hope to provide nursing
measures and client care plans for the patients undergoing this condition.
Moreover, it is our purpose to educate patients of hyperemesis gravidarum,
more so, ourselves as the front line health providers in the field.

b. Specific Objectives

This study aims to identify and understand the clients pertaining to

this condition and equip the patient as well as the nurses with the
knowledge, skills and right attitude on handling and management when
confronted by this illness.

c. Scope and Limitation

This case was based on a real patient, aged 24 years old, handled by
the Eming Lying-In Clinic and Medical Center at Antipolo City, where the
presenters were on duty as assigned by the school. The case will be limited
only to one patient, her personal health condition and manifestations of
hyperemesis gravidarum, nursing intervention, nursing interventions, medical
management and some other beneficial facts pertaining to illness.

d. Theoretical Framework

Faye Glenn Abdullah (March 13, 1919-February 24, 2017)

Abdellah developed the 21 Nursing Problems. Metaparadigm:

i. Nursing

- A helping profession

- Nursing care is doing something to or for the person or

providing information to the person with the goal of
meeting needs, increasing or restoring their self-help
ability, or alleviating impairment.

ii. Person

- People with physical, emotional, and sociological needs

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 Overt : Physical needs

Covert : Emotional and social needs

- The only justification for the existence of nursing.

iii. Health

- State when the individual has no unmet needs and no

anticipated or actual impairments.

iv. Environment

- “To create and/or maintain in Therapeutic environment”.

- Patient interacts with and responds to their environment

and the nurse is part of the environment.

FAYE GLENN ABDELLAH (1960)

According to Abdella’s theory “ nursing is based on an art and science that moulds the
attitudes, intellectual competencies, and technical skills of the individual nurse into the
desire and the ability to help people, sick or well, cope with their health needs.”

Abdellah’s 21 Nursing Problems are the following:

1. To maintain good hygiene and physical comfort.

2. To promote optimal activity: exercise, rest, sleep.

3. To promote safety through prevention of accident, injury, or other

trauma and through prevention of the spread of infection.

4. To maintain good body mechanics and prevent and correct

deformity.

5. To facilitate the maintenance of a supply of oxygen to all body

cells.

6. To facilitate the maintenance of nutrition for all body cells.

7. To facilitate the maintenance of elimination.

8. To facilitate the maintenance of fluid and electrolyte balance.

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 9. To recognize the physiologic responses of the body to disease
conditions—pathologic, physiologic, and compensatory.

10. To facilitate the maintenance of regulatory mechanisms and

functions.

11. To facilitate the maintenance of sensory function.

12. To identify and accept positive and negative expressions, feelings,

and reactions.

13. To identify and accept interrelatedness of emotions and organic

illness.

14. To facilitate the maintenance of effective verbal and nonverbal

communication.

15. To promote the development of productive interpersonal

relationships.

16. To facilitate progress toward achievement and personal spiritual

goals.

17. To create or maintain a therapeutic environment.

18. To facilitate awareness of self as an individual with varying

physical, emotional, and developmental needs.

19. To accept the optimum possible goals in the light of limitations,

physical and emotional.

20. To use community resources as an aid in resolving problems that

arise from illness.

21. To understand the role of social problems as influencing factors in

the cause of illness.

As a nurse we should assist the patient to provide for the satisfaction of her own needs.
The entire care plan is directed at having the patient help herself during the entire process of
her pregnancy. Likewise client’s family members should also be involved in the entire care
plan throughout the hospitalization and after discharge.

CLINICAL SUMMARY
Patient’s Profile

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 Name : Ms. E.B

Age/Gender : 24 years old

Address : Inarawan, Antipolo City

Religion : Baptist

Birth Place : Antipolo

Eduational Attainment : Accounting graduate

Occupation : Certified Public Accountant

Civil Status : Single with Live-in partner

Date of Admission : July 31 2019

Time of Admission : 7:00 PM

Attending Physician : Dr. Arlyn V. Eming

Admitting Diagnosis : G1, P0, (0000); Hyperemesis Gravidarum

(HG); Pregnancy uterine 10 weeks and 1 day AOG by LMP
not in labor; EDC March 1, 2020.

Chief Complaint: Severe Headache, dizziness, weight loss, nausea, dehydration, loss
of appetite and vomiting.

Source of Information: The data was gathered from the patient’s record and personal
interview during Nurse-Patient interaction.

General Data: This is a case of a single unwed woman, aged 24 years old, first time
pregnant and employed as a Certified Public Accountant (CPA), Filipino, Baptist, residing at
Inarawan Antipolo City, admitted on 31 July 2019, 7:00 PM at Eming Lying-In Clinic and
Medical Center.

Herein Patient, Ms. EB, has experienced severe nausea, vomiting, dehydration, headache,
dizziness and loss of weight and appetite.

History of Past Illness

Prior to her confinement at Eming Lying-In Clinic and Medical Cente, Ms. EB, is in normal
state of condition showing no sign or symptoms of any ailment.

History of Present Illness

Ms. EB was admitted at Eming’s Lying-In Clinic and Medical Center on July 31, 2019
@7:00pm. On the 1st Week of July, she experienced onset of morning sickness. On the 2 nd to
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3rd week of the same month, her nausea worsened and suffered 1x to 3x vomiting a day, so
she decided to go to Eming Lyin-In for Consultation and Check-up. She was prescribed with
Plasil as an anti-emetic once a day but theres no effect on her so on the last week of july she
went back to Eming Lying-In Clinic and Medical Center because she feel’s like she almost lost
her consciousness so Dra. Arlyn Eming decided to admit her.

LMP : 22 May 2019

OB-Gyne History : G1, P0, (0000)

AOG : 10weeks and 1day

Family History

According to Ms. E.B, her maternal side has Hypertension while on her paternal side they
have Diabetes.

Personal-Social History

Ms. E.B works as a Public Accountant.

REVIEW OF SYSTEM
HEAD

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  HEADACHE

EYES

 GLASSES OR CONTACTS

 CHANGE IN VISION

 SUNKEN EYEBALLS

EARS

 DIZZINESS

MOUTH/ THROAT

 DRY LIPS

 PALE COLOR

GASTROINTESTINAL

 CHANGE OF APPETITE

 NAUSEA

 VOMITING

MUSCULOSKELETAL

 BODY MALLAE

 BODY WEAKNESS

NEUROLOGICAL

 HEADACHE

 ALMOST LOSS OF CONSCIOUSNESS

 WEAKNESS

SIGNATURE:______________

DATE:______________

PHYSICAL ASSESSMENT
A. Cephalocaudal (IPPA Sequence) Inspection, Palpation, Percussion, Auscultation

Body Part Normal Findings Actual Findings Analysis

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Head

Skull Smooth, skull Head is symmetrical, Normal

contour, symmetrical fontanels intact,
smooth, skull contour

Scalp is moist; Moist scalp and hair

Hair Hair is not oily and Normal
absence of scar in the
scalp
Symmetrical facial
features equal in size
Face Symmetrical, palpebral fissures Normal
palpebral fissures
equal, oval, round, or
slightly square.
Eyes Eyeballs were sunken
and Dark
a) Eyeball Round and Not Normal
symmetrical
Lies within the upper
portion of the iris
Lies within the upper
b) Lid Margins portion of the iris Normal
Pink and moist
c) Conjunctiva Pink and moist Normal
Black in color, round
d) Pupils Normal
Deep, black, round
and equal of
diameter (2-6mm)
Equal movement and
alignment, hair
Hair evenly
evenly distributed,
e) Eyebrow, eyelashes distributed, Normal
slightly outward
symmetrical, equal
movements curved
slightly outward.
Both eyes move
smoothly and
Both eyes should
f) Eye movement symmetrically Normal
move smoothly and
symmetrically.

Vision Testing
150 grade vision of
a) Visual field Able to move With Astigmatism
both eyes, wearing
peripherally, clear
eyeglasses (near sighted)
vision of 20/20

Ears Color same as facial

Color same as facial,
skin, ears are
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 a) Pinna symmetrical, free symmetrical with Normal
from lesions and each other, no
tenderess over the lesions
area

Grayish-tan in color Normal

b) External Grayish-tan in color
canal
Able to hear sound
c) Hearing Can hear clear sounds clearly at the Normal
acuity at the distance of distance of 3feet.
3feet

Located
Nose
Located symmetrically, mid Normal
symmetrically, mid line of the face and is
line of the face and is without swelling,
without swelling, bleeding, lesions, and
bleeding, lesions, and masses
masses

Mouth /Lips

a) Gums Pinks gums and moist

Pink gums (bluish or Normal
brown patches in
dark-skinned clients)
moist, firm texture to
gums
Complete teeth Normal
b) Teeth
32 adult teeth,
smooth white, shiny
tooth enamel Central position, pink
c) Tongue in color, has a
Midline of the mouth, smooth lateral Normal
pink, moist, rough, margin; no lesions
symmetrical, moves raised papillae, thin
freely whitish coating,
moves freely

d) Palate
Lighter pink in color,
a) Hard Pink and smooth rough in texture, Normal
posterior hard palate

Lighter pink in color.

b) Soft
Lighter pink, smooth Smooth texture Normal
soft palate
Dry lips. Pale in color

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Lips Pinkish color, moist
Color same as facial
Cheeks Same color as the skin, symmetrical Not Normal
skin and symmetrical
Normal
No neck
Neck Symmetrical with the engorgement, no
head in the central palpable mass, no
Normal
position, able to lymph nodes
move in full ROM palpable, short neck
turns head easily side
to side, raises head
when prone.

Lungs No abnormal sounds

No chest pain, heard when
absence of cough, no ascultated Normal
crackles, wheezes,
rhonchi and stridor
heard during
auscultation
No swelling on both
Muscles/Joints
Muscle/joints are in upper and lower
good motion. extremities. Low
Not Normal
Absence of stiffness. muscle tone. Body
Nonappearance of mallae, feeling weak.
joint redness or Low muscle tone.
swelling
Chest wall intact, no
Chest Chest wall intact, no tenderness and no
tenderness and no masses.
masses Normal
Recent change in
Breast Rounded shape, breast size and
slightly unequal size, swelling due to
generally symmetric pregnancy, marked Normal
asymmetry.

Abdomen
Increased
Linea nigra due to pigmentation of the Normal
pregnancy nipple and areola

Upper extremities No deformities, no

No deformities, no swelling or
swelling or tenderness, joints Not Normal
tenderness, joints move smoothly.

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 move smoothly. Weak movements
Normal movements due to body mallae
and body weakness.

Linea nigra is present

Lower of extremities No deformities, no Not Normal
swelling or No deformities, no
tenderness, joints swelling or
move smoothly. tenderness, joints
Normal movements. move smoothly.
Weak movements
due to body mallae
and body weakness.

Rest and Activity:

Having a hard time sleeping due to headache, dizziness and pregnancy .

Works as a public accountant. No proper exercise. No restricted diet.

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ANATOMY AND PHYSIOLOGY

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 PATHOPHISIOLOGY
The exact cause of Hyperemesis Gravidarum remains unclear. However, there are several
theories for what may contribute to the development of this disease process.

High levels of hormone hCG

Precipitating Factors: Predisposing factors:
or Estrogen
° Dec. secretion of free HCL in ° First time pregnancy
the stomach (G1P0)

° Slow emptying of the stomach ° Sex: Female

° Environmental nor lifestyle

Factor
Excessive
° Vitamin deficiency (B6) vomiting

° Psychological Factors

Loss of Appetite

Weight loss Starvation

Abnormally Dehydration
thin/weak

output
Water electrolyte Dry Skin
Lessen urine
imbalance

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 NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: After INDEPENDENT:

“Matindi ang Imbalanced 30minutes of Let the patient To avoid After 30
pagsusuka ko nutritionless nursing eat smaller but pressure at minutes of
tuwing than body intervention more frequent the stomach. nursing
pagkatapos requirements the patient meals. intervention
kong kumain.” related to will identify the patient
As verbalized inability to relief from Suggest adding Because was able to
by the ingest, digest, vomiting and ginger ginger may be feel relief.
patient. or absorb discomfort. tea/supplements beneficial for
nutrients lessening The feeling of
OBJECTIVE: (prolonged vomiting vomiting was
Pale, sunken vomiting) and attacks. reported
eyeballs, dry weight loss. lessened.
lips, low weak Advice patient to To prevent
voice have smaller but dehydration.
often fluid
V/S TAKEN: intake.
T: 36.2°C
P: 81 bpm Bland Diet To replenish
R: 20 cpm the nutrients
BP: 100/70 loss due to
mmHg vomiting.

DEPENDENT:
Administer
multivitamins in
the IV fluid as
prescribed by
the physician.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Independent:
“pakiramdam Alteration in Within Advice the To facilitate Within
ko ako ay body 30minutes the patient to take the 30minutes the
nanghihina.” movement. patient will a bed rest. maintenance patient was
As verbalized feel alive and of a supply of able to relax
by the patient. strong and be oxygen to all and move
able to move body cells. comfortably
OBJECTIVE: comfortably. without
Weak-low Avoid loud To provide a feeling weak.
voice when sounds. healthy
speaking, environment
free from
stress.

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