Nursing Assessment for Hyperemesis Gravidarum
- Activity / rest
Systolic blood pressure decreases, pulse rate increased by more than 100 times per minute. - Ego Integrity
Interpersonal family conflicts, economic difficulties, changes in perception about the conditions, unplanned pregnancies. - Elimination
Changes in consistency; defecation, increased frequency of urination
Urinalysis: increased concentration of urine. - Food / fluid
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 smelled of acetone, reduced skin turgor, sunken eyes and dry tongue. - Breathing
Respiratory frequency increased. - Security
The temperature sometimes rises, weakness, icterus and may lapse into a coma. - Sexuality
Cessation of menstruation, when a state endangering the mother carried a therapeutic abortion. - Social Interaction
Changes in health status / stressors of pregnancy, changes in roles, the response of family members that can be varied to hospitalization and illness, the less support system. - Learning and education
- Everything is eaten and drunk vomited, especially if lasts long.
- Weight loss of more than 1 / 10 of normal body berast
- Skin turgor, dry tongue
- The presence of acetone in the urine.
Nursing Diagnosis and Intervention : Imbalanced Nutrition - Less Than Body Requirements for Hyperemesis Gravidarum
Nursing Diagnosis for Hyperemesis Gravidarum
Imbalanced Nutrition: Less Than Body Requirements related to the frequency of excessive nausea and vomiting.
Nursing Intervention for Hyperemesis Gravidarum
1. Restrict oral intake until the vomiting stops.
Rationale: Maintaining a fluid electrolyte balance and prevent further vomiting.
2. Give the anti-emetic drugs are prescribed.
Rationale: Preventing vomiting and maintain fluid and electrolyte balance.
3. Maintain fluid therapy can be saved.
Rationale: Correction of hypovolemia and electrolyte balance.
4. Record intake and output.
Rationale: Determining hydration fluids, and spending through vomiting.
5. Encourage to eat small meals but often
Rational: Can adequate intake of nutrients your body needs.
6. Advise to avoid fatty foods
Rational: fatty foods can stimulate nausea and vomiting.
7. 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.
8. Record intake, if oral intake can not be given within a certain period.
Rationale: To maintain a balance of nutrients.
9. Inspection of irritation or Iesi the mouth.
Rational: To know the integrity of the oral mucosa.
10. 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.
11. 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.
12. 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.
13. 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.
Imbalanced Nutrition: Less Than Body Requirements related to the frequency of excessive nausea and vomiting.
Nursing Intervention for Hyperemesis Gravidarum
1. Restrict oral intake until the vomiting stops.
Rationale: Maintaining a fluid electrolyte balance and prevent further vomiting.
2. Give the anti-emetic drugs are prescribed.
Rationale: Preventing vomiting and maintain fluid and electrolyte balance.
3. Maintain fluid therapy can be saved.
Rationale: Correction of hypovolemia and electrolyte balance.
4. Record intake and output.
Rationale: Determining hydration fluids, and spending through vomiting.
5. Encourage to eat small meals but often
Rational: Can adequate intake of nutrients your body needs.
6. Advise to avoid fatty foods
Rational: fatty foods can stimulate nausea and vomiting.
7. 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.
8. Record intake, if oral intake can not be given within a certain period.
Rationale: To maintain a balance of nutrients.
9. Inspection of irritation or Iesi the mouth.
Rational: To know the integrity of the oral mucosa.
10. 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.
11. 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.
12. 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.
13. 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 Diagnosis and Intervention : Imbalanced Nutrition - Less Than Body Requirements for Hyperemesis Gravidarum
