Western Mindanao State University

College of Nursing
Zamboanga City

Alternative Learning System

Related Learning Experience
Delivery Room

Instructions:
Answer the provided questions comprehensively following the subsequent format.:
A. Use the Times New Roman Font Style with 12-point font size, 1.5 spacing, 8.5 x 13 paper size
B. Utilize at least three (3) or more references
C. References should be at least from the year 2015 onwards
D. Refer to the rubrics for alternative learning system for the rating system of your output

CASE SCENARIO: HYPEREMESIS GRAVIDARUM

Ms F ,a 35 year old woman in her first pregnancy was admitted in Labor Room. On examination, she was
tachycardiac and had postural hypotension and ketonuria. Ms F was admitted and treated with intravenous fluids
of normal saline / PNSS 1L to run at 30gttds/minute and metoclopramide(Plasil), 10 mg IV every 8 hours . A
viable intrauterine pregnancy was confirmed on ultrasound scan; she improved on the above therapy and was
discharged 2 days later.

In the subsequent 2 weeks, she had three further admissions with hyperemesis gravidarum (HG). On the third
occasion, she was severely dehydrated, had lost 7 kg in weight and was ketotic. She was admitted, rehydrated and
given regular cyclizine, 50 mg intravenously three times daily. Over the following week, she improved and was
sent home with oral antiemetic of metoclopramide 50mg as need for nausea and vomiting. folic acid (5 mg) and
thiamine hydrochloride (25 mg three times daily).

Vital Signs:
1) Blood pressure (BP) : 90/60 mmhg
2) Heart rate (HR) : 102 bpm
3) Respiratory rate (RR) : 22 b/min
4) Temperature : 36.7 0 C
5) Height : 158 cm (5’4)
6) Weight : 82.7 kg (starting weight)

History:
a.) Hyperemesis gravidarum during an earlier pregnancy
b.) Being overweight
c.) Being a first-time mother

Laboratory results:

Examinations Patient’s Result Normal Value Indication

Blood Exam
RBC 4.4 x 1,000,000/mm3 4.2-5.4 x 1,000,000/mm3 Normal
Hemoglobin 12.0 g/dL 12.0-15.5 g/dL Normal
WBC 6.2 x 1000/mm3 5.7-13.6 x 1000/mm3 Normal
Platelets 250 x 10^9/L 150 -400 x 10^9/L Normal

Page 1 of 16
 Urinalysis
Appearance hazy Clear-very slight cloudy Abnormal
Color Dark yellow Pale light yellow – Yellow Abnormal
pH 5.0 4.5-8 Normal
Protein 4+ Negative Abnormal
Sp. Gravity 1.025 1.010-1.030 Normal
Glucose Negative Negative Normal
Casts None 0-5 Normal
WBC 1–2 <=2-5 Normal
RBC 0–1 <=2 Normal
Fecalysis
Color Dark brown Shades of Brown Normal
Consistency Soft formed Soft-firm Normal
Occult blood negative Negative Normal
Ova parasites None seen None Normal

Based on the Physical exam and history, the patient is diagnosed with Hyperemesis Gravidarum

Your Tasks:

1. Determine the need for the required laboratory and diagnostic examinations
• Give the indications for the abnormal result/values
2. Illustrate the organ involved and label accordingly.
3. Discuss the normal function of the organ involved.
4. Explain the pathophysiology based on the patient’s diagnosis.
5. Explain the pathophysiology based on the diagnosis.
A. Create the pathologic pathway of the pathogenesis (the development of the disease and the chain
of events leading to the illness) contributing to the patient’s illness condition.
Indications for Abnormal Results or Values

Urinalysis Normal Values High Values Low Values

Appearance/Turbidity Clear to very slight Excessive turbidity is due to Not applicable.
cloudy the presence of micro particles
in the urine which may be
determine base on the results
of microscopic urine sediment
examination. This may
indicate that there are amounts
of cellular debris, casts,
crystals, bacteria, or
significant proteinuria, vaginal
discharge, sperm, and prostatic
secretions.
Color Pale yellow to Urine color varies on urine In contrast, diluted urine has
Yellow concentration and its chemical lighter color. This may be an
composition. The darker the indication of diabetes insipidus.
color, the more concentrated

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 the urine is. It may indicate Or also that the patient is taking
that a patient is dehydrated. good amounts of fluid.

Note that urine color may vary

due to some certain
medication, foods, and
medical conditions.
Protein Negative Note that in this section, high Note that in this section, low
value will be referred as value will be refereed as
Positive. Negative.

By using a multi reagent Normal urine contains little

dipstick which only detects protein to negative to trace
presence of urinary protein, A reactions are usual in
trace to 1+ reaction in a very concentrated urine.
dilute urine is suggestive of
significant proteinuria. A
dipstick protein reaction > 2+
in concentrated or dilute urine
indicates significant
proteinuria. There are
numerous causes of
proteinuria, the most common
of which are urinary tract
inflammation, hematuria, and
glomerular disease.

Reference:

190 N Independence Mall West, Philadelphia, PA 19106-1572, 215-351-2400, 800-523-1546 @

www.acponline.org

Larsson A, Palm M, Hansson L-O, et al. Reference values for clinical chemistry tests during normal pregnancy.
Br J Obstet Gynaecol 2008;115:874. Lockitch G. Handbook of Diagnostic Biochemistry and Hematology in
Normal Pregnancy. Boca Raton, FL: CRC Press, 1993.

Page 3 of 16
 A. outputt Template

1. Study of the Illness Condition

ASSESSMENT ANATOMY PHYSIOLOGY PATHOPHYSIOLOGY ANALYSIS

First Pregnancy. Hyperemesis
At the 6th week of gravidarum often occurs during first
Cues (1) Fetus at 6th week in womb pregnancy where the pregnancies, and usually recurs in
hCG or Human subsequent pregnancies. (1)
Subjective Cues: Chorionic gonadotropin
• First Pregnancy is continuously Tachycardic. The amount of blood
progressing. It circulating the body, or blood volume,
Objective Cues: stimulates the decreases when dehydrated. To
• Tachycardic production of the compensate, the heart beats faster and
• Has postural estrogen. This is the increasing the heart rate. (2)
hypotension key reason of vomiting
• Ketonuria in early pregnancy. This Postural Hypotension. Pregnant
• Has viable triggers the part of the women with hyperemesis gravidarum
intrauterine brain that controls are significantly dehydrated that may
Pregnancy nausea and vomiting, cause postural hypotension and low
• Severely Dehydrated specifically the medulla blood pressure. (3)
(2) Medulla Oblongata and oblongata. (1)
• Lost 7kg
Stomach Viable intrauterine pregnancy.
• Ketotic
The Medulla Oblongata Progressively, when pregnancy is
possess a receptor in confirmed, HGC levels ris naturally.
Vital signs:
controlling emesis Thus triggering the brain for emesis.
• BP - 90/60 mmhg action. This receptor is (4)
• HR - 102 bpm CTZ or Chemoreceptor
• RR - 22 b/min trigger zone that resides Once a pregnant woman is severely
• Temperature - 36.7 0 in the vomiting center dehydrated, this is due to frequent
C of the brain. When this vomiting. Which may cause severe
• Height - 158 cm receptor detects the weight loss and build upe of ketone.
(5’2) high levels of Hcg, the Ketone usually builds up if there is
As the pathophysiology base from the
• Weight - 82 kg chemoreceptor trigger lower than 50grams of carbohydrates
patient’s assessment, two factors may
(starting weight) zone then sends a signal are being digested. Babies do not need
Page 4 of 16
 to the vomiting center cause the patient’s condition: Are excess ketones, because this would
History: and stimulates the Overweight, and Viable Intrauterine affect the brain cells and may lead to
Reference/s: stomach. This results to Pregnancy. lower IQ.
• Hyperemesis (1) increase of peristalsis
Gravidarum during https://raisingchildren.net.au/pre movement, the closure Since the patient is obese, with a 33 BMI, References:
an earlier pregnancy gnancy/week-by-week/first- of the epiglottis, the most likely her test was shown as
• Being overweight trimester/6-weeks contraction of the ketonuria, which might be caused by (1) Fejzo, M. (2020). Hyperemesis
• Being first-time (2) diaphragm and underlying disease such as diabetes. Gravidarum. Rare Disease
mother https://basicmedicalkey.com/gas abdominal muscles to Information. Department of
trointestinal-tract-disorders/ emit a vomit reaction. In viable intrauterine pregnancy, there is Maternal-Fetal Medicine,
The term hyperemesis a progressive increase of HCG levels that UCLA. Retrieved from:
gravidarum means may trigger the hyperemesis gravidarum. https://rarediseases.org/rare-
further vomiting while Frequent vomiting due to the condition diseases/hyperemesis-
in pregnancy. may result in dehydration that leads to gravidarum/#:~:text=In%20ma
postural hypotension and ketonuria. ny%20HG%20patients%2C%2
Hyperemesis may lead Severe weight loss can cause the patient 0symptoms,usually%20recurs
to psychological to be ketotic. %20in%20subsequent%20preg
impacts. Studies have nancies.
shown that mothers in Intravenous cyclizine was used to (2) Heart and Vascular Institute
first trimester has a increases the lower esophageal sphincter (2014). The Importance of
higher risk of cognitive, tone and thereby reduces the hazard of Hydration for Your Heart.
behavioral dysfunction, regurgitation and aspiration of gastric Heart and Vascular Health.
and emotional stress in contents if given to patients, undergoing UPMC Healthbeat [Blog Post].
pregnancy. Moreover, emergency surgery. While, oral Retrieved from:
nutritional deficiency is metoclopramide was used to treat or https://share.upmc.com/2014/0
also possible due to the relieve symptoms of nausea, and 9/importance-hydration-
rejection of macro and vomiting of the patient. heart/#:~:text=The%20amount
micronutrients. %20of%20blood%20circulatin
Electrolyte imbalances If there is no intervention made, the g,causing%20you%20to%20fe
and metabolic mother would experience severe el%20palpitations.
disturbances are also a dehydration, esophageal damage, and (3) Johnson DR, Douglas D,
lead to cause liver disease, while the baby can be on Hauswald M, Tandberg D.
dehydration, preterm birth, perinatal death, or low Dehydration and orthostatic
hypokalemia, ketosis, weight baby. vital signs in women with
and acetonuria. This hyperemesis gravidarum. Acad
might cause further References: Emerg Med. 1995
symptoms such as Aug;2(8):692-7. DOI:
Page 5 of 16
headache, fatigue, and Jennings LK, Mahdy H. Hyperemesis 10.1111/j.1553-
lethargy. (3) Gravidarum. [Updated 2021 Aug 25]. In: 2712.1995.tb03620.x. PMID:
StatPearls [Internet]. Treasure Island 7584747.
(FL): StatPearls Publishing; 2022 Jan-. (4) Complications of Hyperemesis
Reference/s: Available from: Gravidarum; A Disease of
(1) Irina Burd, MD, https://www.ncbi.nlm.nih.gov/books/NB Both Mother and Fetus,
Ph.D., Maternal-Fetal K532917/?report=classic Review Article, 2018,
Medicine, Johns Abanoub Gabra, Chief
Hopkins University, NSW Government Health Pathology Resident, Obstetrics and
Baltimore, MD. Review (hCG factsheet), Lab Tests Online Gynecology, Assuit
provided by VeriMed (Human chorionic gonadotropin), UNSW University, Egypt
Healthcare Network. Embryology (Human Chorionic
Internet source: Gonadotropin), Elsevier Patient
http://pennmedicine.ada Education (Human Chorionic
m.com/content.aspx?pr Gonadotropin test), SydPath (hCG
oductid=14&pid=14&g (human Chorionic Gonadotrophin)
id=000198#:~:text=Hig
h%20levels%20of%20h Robinson, H. L., Barrett, H. L., Foxcroft,
CG%20(human,that%2 K., Callaway, L. K., & Dekker Nitert, M.
0controls%20nausea%2 (2018). Prevalence of maternal urinary
0and%20vomiting. ketones in pregnancy in overweight and
obese women. Obstetric Medicine, 11(2),
(2) Davis CJ, Lake- 79–82.
Bakaar GV, Grahame- https://doi.org/10.1177/1753495X177431
Smith DG (eds). 63\
Nausea and Vomiting:
Mechanisms and https://www.medicines.org.uk/emc/produ
treatment. Berlin: ct/5552/smpc#gref
Springer-Verlag; 1986.
Internet source:
https://books.google.co
m.au/books?id=qYprA
AAAMAAJ&hl=en

(3) Complications of
Hyperemesis
Gravidarum; A Disease
Page 6 of 16
 of Both Mother and
Fetus, Review Article,
2018, Abanoub Gabra,
Chief Resident,
Obstetrics and
Gynecology, Assuit
University, Egypt

2. Surgical Procedure and Instruments used

Surgical Procedure Instruments Category Functions
Name Image
Intravenous Rehydration Infusion Pump Medical Pump An infusion pump is a device used in a
health care facility
to pump fluids into a patient in a
controlled manner

Needle Sharps hollow tube with one sharp tip. It is

commonly used with a syringe, a hand-
operated device with a plunger, to inject
substances into the body. used for rapid
delivery of liquids, or when the injected
substance cannot be ingested

Peripheral Venous Catheter introduced into the vein by a needle. A

Catheter peripheral venous catheter is the most
commonly used vascular access in
medicine

Page 7 of 16
IV set Intravenous purpose For intravenous medication and fluid

IV bag hydration specially formulated liquids that are

injected into a vein to prevent or treat
dehydration.

Page 8 of 16
3. Nursing Care Plan

PLANNING
NURSIN
ASSESSMENT OBJECTIVE OF IMPLEMENTATION EVALUATION
G INTERVENTION RATIONALE
CARE
DIAGNO
SIS
Imbalanced Short term goals: Independent The patient reported
Subjective Cues: Nutrition: less than The patient will report decreased severity of
• client stated that "These
Determine the cause of Assessing the patient The patient had been
body requirements decreased severity or nausea and vomiting with the causes of diagnosed with hyperemesis nausea and
days, I throw up at any
random moments, and I don't
related to nausea elimination of nausea. nausea will guide the gravidarum. demonstrated behaviors
have an appetite to eat and vomiting choice of interventions and lifestyle, such as
because of this." secondary to Long term goals: to be used. Treatment sticking to healthy fiber
Hyperemesis The patient will demonstrate may not be needed if diet to regain and
gravidarum as behaviors and lifestyle the stimulus is maintain appropriate
Objective Cues: evidenced by loss changes to regain and weight during
• had postural hypotension
eliminated.
7kg in 2 subsequent maintain appropriate weight pregnancy.
• tachycardiac
• ketonuria/ketotic weeks. during her pregnancy. Determine lifestyle factors Socioeconomic The patient is 35 years old
• three further admissions with that may affect weight. resources, amount of with viable intrauterine
hyperemesis gravidarum money available for pregnancy. Initially, she’s
• had lost 7kg purchasing food, the 87kg at 5’4 ft height with 33
• severely dehydrated proximity of grocery BMI classified as obese.
store, and available After 2 weeks diagnosed
storage space for food with HG, she had lost 7kg in
are all factors that may just 2 weeks.
impact food choices
and intake.

Encourage a rest period of 1 Helps reduce fatigue The patient had rest before
hour before and after meals. during mealtime and and after meals in small
Provide frequent small provides an frequent feedings to avoid
feedings opportunity heavy vomiting.
to increase total caloric
intake

Page 9 of 16
Weigh, as indicated Useful in determining 2/20 – 80kg
caloric needs, setting 2/27-80.3kg
weight goals, and
evaluating the
adequacy of nutritional
plan.

Assess client’s knowledge of Identifies teaching The patient understood that

nutritional needs and ways needs and/or helps a fiber diet is the best choice
client is meeting these guide choice of for her condition as it is
needs. interventions packed with good nutrients.

Review laboratory studies Baseline screening Lab results are within

and Vital signs. may be done to normal range and vital signs,
determine whether especially BP is now
more in-depth normal.
evaluation is
needed.

Collaborative
Consult dietitian or feeding and caloric Consulted dietitian for
nutritional support team to requirements are based modification of patient’s
provide easily digested, on the individual diet.
nutritionally balanced meals. situation and specific
needs to provide
maximal nutrients with
minimal client effort
and energy
expenditure.
Establish an ongoing method To assist in Established an ongoing
of evaluating intake determining both method of evaluating food
amount of food taken intake.
and what food groups
are consumed or left
uneaten, to identify
nutritional deficits

Page 10 of 16
 Discuss with to preserve those that Negotiate with client aspects
client/significant other (SO) are valuable or of diet that need to be
aspects of diet that can meaningful to changed
remain unchanged individual, and
enhance sense of
control

Assist in prescribing to improve intake and Assisted for IV therapy with

medicine, as indicated. utilization of cyclizine, and administering
nutrients metoclopramide.

References:
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2018). Nursing diagnosis manual: Planning, individualizing, and documenting client care. Philadelphia, PA: F.A. Davis.
In Herdman, T. H., In Kamitsuru, S., & North American Nursing Diagnosis Association,. (2018). NANDA International, Inc. nursing diagnoses: Definitions & classification 2018-2020.
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nursing care plans: Guidelines for individualizing client care across the life span. Philadelphia: F.A. Davis Co.

Page 11 of 16
4. Drug study

GENERIC NAME: Metoclopramide MECHANISM OF ACTION: SIDE EFFECTS/ADVERSE REACTION NURSING RESPONSIBILITY
Blocks dopamine/serotonin receptors in chemoreceptor trigger
zone of the CNS. Enhances acetylcholine response in upper Side effects: Baseline Assessment:
GI tract, causing increased motility and accelerated gastric • drowsiness • Antiemetic: Assess for dehydration
emptying without stimulating gastric, biliary, or pancreatic • restlessness (poor skin turgor, dry mucous
secretions; increases lower esophageal sphincter • fatigue membranes, longitudinal furrows
tone. Therapeutic Effect: Accelerates intestinal transit, • lethargy in tongue).
promotes gastric emptying. Relieves nausea, vomiting. • dizziness • Assess for nausea, vomiting,
• anxiety abdominal distention, bowel
BRAND NAME: Plasil INDICATION: • headache sounds
• insomnia Intervention/Evaluation
Oral
• altered menstruation • Monitor for anxiety, restlessness,
• symptomatic treatment of diabetic gastroparesis extrapyramidal symptoms (EPS)
• gastroesophageal reflux • constipation
during IV administration.
IV/IM • rash
• Monitor daily pattern of bowel
DRUG • symptomatic treatment of diabetic gastroparesis • dry mouth
activity, stool consistency.
• placement of enteral feeding tubes • galactorrhea
• Assess skin for rash.
• prevent nausea • gynecomastia
• Evaluate for therapeutic response
• stimulate gastric emptying and intestinal transit barium
from gastroparesis (nausea,
when delayed emptying interferes with the radiological Adverse Reaction:
vomiting, bloating).
examination of the stomach and/or small intestine. • extrapyramidal reactions
• • Monitor renal function, B/P, heart
To facilitate small bowel intubation in adults and • akathisia
children. rate.
• neuroleptic malignant syndrome Patient/Family Teaching
• fever • Avoid tasks that require alertness,
• unstable Blood pressure motor skills until response to drug
• muscular rigidity is established.
• Report involuntary eye, facial,
ILLUSTRATION:
CLASSIFICATION: CONTRAINDICATION: limb movement
Pharmacotherapeutic: Dopamine, Serotonin • Hypersensitivity to metoclopramide • Avoid alcohol
receptor antagonist • Concurrent use of medication likely to produce
Clinical: GI agent, Antiemetic extrapyramidal reactions.

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DOSAGE/FREQUENCY/ROUTE: • GI damages
• History of seizure disorder
Nausea/Vomiting • pheochromocytoma
IV: ADULTS, ELDERLY, CHILDREN: 1–2 mg/
kg 30 min before chemotherapy; repeat
q2h for 2 doses, then q3h for 3 doses.

GENERIC NAME: Cyclizine MECHANISM OF ACTION: SIDE EFFECTS/ADVERSE REACTION NURSING RESPONSIBILITY
The vomiting centre possesses neurons which are rich in muscarinic
cholinergic and histamine containing synapses. These types of neurons Side effects: Baseline Assessment:
are especially involved in transmission from the vestibular apparatus to • drowsiness • If pt is having an reaction, obtain a
the vomiting centre. Motion sickness principally involves overstimulation • blurred vision history of recently ingested foods,
of these pathways due to various sensory stimuli. Hence the action of • dry mouth drugs, environmental exposure,
cyclizine which acts to block the histamine receptors in the vomiting • headache emotional stress.
centre and thus reduce activity along these pathways. Furthermore, • constipation • Monitor B/P rate; depth, rhythm,
since cyclizine possesses anti-cholinergic properties as well, the type of respiration; quality, rate of
muscarinic receptors are similarly blocked. pulse.
Adverse Reaction: Intervention/Evaluation
• extrapyramidal reactions • Monitor B/P.
BRAND NAME: Cyclizine INDICATION: • hemorrhage • Monitor effect of sedation
• liver problems Patient/Family Teaching
Oral • anaphylaxis • Tolerance to antihistaminic effect
• symptomatic treatment of diabetic gastroparesis • psychomotor impairment does not occur
• gastroesophageal reflux • Tolerance to sedation may occur
IV/IM • Avoid task that requires alertness
DRUG ILLUSTRATION: • symptomatic treatment of diabetic gastroparesis • Dry mouth, drowsiness, dizziness
• placement of enteral feeding tubes may be an expected response to
• prevent nausea drug.
• stimulate gastric emptying and intestinal transit barium when • Avoid alcohol
delayed emptying interferes with the radiological examination of
the stomach and/or small intestine.
• To facilitate small bowel intubation in adults and children.

Page 13 of 16
CLASSIFICATION: CONTRAINDICATION:
Pharmacotherapeutic: Piperazine- • Hypersensitivity to cyclizine
derivative antihistamine, antimuscarinic • Taking anti-depressants
agent Clinical: Antivertigo, Antiemetic • Hypotension
DOSAGE/FREQUENCY/ROUTE: • Glaucoma
• Prostatic hypertrophy
Nausea and vomiting • Urinary retention
Adult: As hydrochloride: 50 mg up to • Hepatic disease
tid, up to 200 mg/day. For prevention of • epilepsy
motion sickness, 1st dose should be given
30 min before travelling.
Child: 6-12 yr: As hydrochloride: 25 mg
up to tid. For prevention of motion
sickness, 1st dose should be given 30 min
before travelling.

Prophylaxis of postoperative nausea and

vomiting
Adult: As cyclizine lactate: 50 mg up to
tid via slow IV inj over 20 minutes. May
give 1st dose 20 minutes before
anticipated end of surgery. Treatment
should start within the the 1st 24 hours
of surgery and should not continue
beyond 48 hours.

Page 14 of 16
 B. Rubric for ALS

4 3 2 1
Follows and
Follows Demonstrat
Exceeds Follows
CATEGORY some but es little
expectations instructi
not all comprehens
noted in ons
instructions ion
instructions
I. STUDY OF ILLNESS CONDITION (total score = 48 points)
1. Assessment
• Differentiates between subjective and
objective cues
• Analyzes laboratory examinations
2. Anatomy
• Indicates and labels the affected organ
• Cites reference/s & Paraphrases
3. Physiology
• Discusses the normal functions of the
organ involved
• Cites reference/s & Paraphrases
4. Pathophysiology
• Explains the pathophysiology based on
the diagnosis
• Develops the pathologic pathway of the
patient’s current illness
• Cites reference/s & Paraphrases
5. Analysis
• Correlates signs & symptoms to the
illness condition
• Relates laboratory / diagnostic exams to
the illness condition
• Indicates the normal values and
significance of the laboratory results
TOTAL
POINTS

46 – 48 = 1.0
44 – 45 = 1.25
42 – 43 = 1.5
39 – 41 = 1.75
37 – 38 = 2.0
34 – 36 = 2.25
32 – 33 = 2.5
30 – 31 = 2.75
29 = 3.0

Prepared by: Noted by:

DR. MARIA SOCORRO C. DOMINGO FREDIE M. OMAR, MAN, RN

Clinical Coordinator Curriculum Chair

Page 15 of 16
Approved:

DR. MARY JOSELYN C. BIONG

Dean

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