Basic Concepts of Nursing
Assessment of Hyperemesis Gravidarum
a. Activity / rest
- Decreased systolic blood pressure, increased pulse rate (> 100 beats per minute).
- Family interpersonal conflict, economic hardship, change perceptions about conditions, unplanned pregnancies.
- Changes in consistency; defecation, increased frequency of urination, Urinalysis: increased concentration of urine.
- Excessive nausea and vomiting (4-8 weeks), epigastric pain, weight loss (5-10 kg), oral mucous membrane irritation and red, low hemoglobin and hematocrit, breath smelling of acetone, reduced skin turgor, sunken eyes and dry tongue .
- Increased respiratory rate.
- Temperature sometimes rose, weakness, icterus and can fall into a coma
- Cessation of menstruation, when the state of the mother harm done therapeutic abortion.
- Changes in health status / stressors of pregnancy, changes in roles, family members response can vary to hospitalization and illness, lack of support system.
- Everything is eaten and drunk vomited, especially if lasts long apalahi
- Weight loss of more than 1/10 of the normal body berast
- Skin turgor, dry tongue
- The presence of acetone in the urine.
- Ultrasound (using the appropriate time): assessment of the gestational age of the fetus and the presence of multiple gestation, fetal abnormality detecting, localizing the placenta.
- Urinalysis: culture, bacterial detection, BUN.
- Liver function tests: AST, ALT and LDH levels.
Nursing Diagnosis for Hyperemesis Gravidarum
1. Imbalanced Nutrition, Less Than Body Requirements related to the frequency of excessive nausea and vomiting.
2. Fluid Volume Deficit related to excessive fluid loss.
3. Anxiety related to ineffective coping, physiological changes of pregnancy.
4. Activity intolerance related to weakness.
Nursing Interventions for Hyperemesis Gravidarum
1. Imbalanced Nutrition, Less Than Body Requirements related to the frequency of excessive nausea and vomiting.
Interventions:
- Limit oral intake until the vomiting stops.
- Give anti-emetic drugs are programmed with a low dose.
- Maintain fluid therapy programmed.
- Record intake and output.
- Encourage eating in small portions but frequently.
- Instruct to avoid fatty foods.
- Instruct to eat a snack such as biscuit, bread and the (hot) warm before bed get up during the day and before bed.
- Catal intake, if oral intake can not be given within a certain period.
- Inspection Iesi irritation or mouth.
- Assess oral hygiene and personal hygiene as well as the use of oral cleaning fluids as often as possible.
- Monitor hemoglobin levels and Hemotokrit
- Urine Test against acetone, albumin and glucose.
- Measure uterine enlargement.
Rational:
- Maintain fluid electrolyte balance and prevent further vomiting.
- Prevent vomiting and maintaining fluid and electrolyte balance.
- Correction presence of hypovolemia and electrolyte balance.
- Determining hydration fluids and spending synthetically by vomiting.
- Be sufficient intake of nutrients your body needs.
- To stimulate nausea and vomiting.
- Snack can reduce or avoid excessive excitatory nausea vomiting.
- To maintain a balance of nutrients.
- To determine the integrity inukosa mouth.
- To maintain the integrity of the oral mucosa.
- Identifying the presence of anemia and the potential reduction in the oxygen-carrying capacity of the mother. Clients with hemoglobin levels less than 12 g / dl or hematocrit levels less than 37% considered anemic in the first trimester.
- Establish a baseline; done routinely to detect potential high-risk situations such as the inadequate intake of carbohydrates, Diabetic ketoacidosis and hypertension due to pregnancy.
- Maternal malnutrition affect fetal growth and aggravate the decline in the complement of brain cells in the fetus, resulting in fetal development setbacks and further possibilities.
2. Fluid Volume Deficit related to excessive fluid loss.
Interventions :
- Determine the frequency or severity of nausea / vomiting.
- Review the history of the possibility of other medical problems (such as peptic ulcer, gastritis).
- Assess body temperature and skin turgor, mucous membranes, blood pressure, input / output and urine specific gravity. Measure weight and compare it with the standard.
- Encourage increased intake of carbonated drinks, eat as often as possible with the least amount. Foods high in carbonates such as: dry toast before getting up from bed.
Rational:
- Provide data with respect to all conditions. Elevated levels of chorionic gonadotropin hormone (HCG), changes in carbohydrate metabolism and decreased gastric motility aggravate nausea / vomiting trimester.
- Assist in other causes aside to address specific problems in identifying interventions.
- As an indicator of the level or need help evaluating hydration.
- Assist in minimizing nausea / vomiting by reducing gastric acidity.
3. Anxiety related to ineffective coping, physiological changes of pregnancy.
Interventions:
- Control of the client environment and limit visitors.
- Assess the client's level of psychological functioning.
- Provide psychological support.
- Give positive reinforcement.
- Give maximum health.
- To prevent and reduce anxiety.
- To maintain psychological integrity.
- To reduce anxiety and foster mutual trust.
- To alleviate the psychological effect due to pregnancy.
- It is important for improving the mental health of the client.
4. Activity intolerance related to weakness.
Interventions:
- Encourage clients to restrict the activities of the isrirahat enough.
- Encourage clients to avoid heavy lifting.
- Help clients activities gradually.
- Encourage bed rest were modified as indicated.
Rational:
- Save energy and avoid spending power continuously to minimize fatigue / sensitivity of the uterus.
- Previously tolerated activity may not be modified for women at risk.
- Activity gradually minimize trauma Seita ease in meeting their needs.
- Periu activity levels may be modified as indicated.
Nursing Care Plan for Hyperemesis Gravidarum
