Thursday, July 19, 2012
Nursing Interventions for Hyperemesis Gravidarum
1. Assess for signs of dehydration
Rational: improve fluid balance, and maintain a homeostatic mechanism, is the basis for the mother and fetus to maintain balance.
2. Assess vital signs
Rational: temperature, pulse rate increased and decreased BP are signs of dehydration and hypovolemia.
3. Give parenteral fluids: electrolytes, glucose and vitamins according to program
Rational: This fluid will provide or meet the needs of the body's acid-base balance, electrolytes and hypoavitaminosis.
4. Provide nutrition in small but frequent portions.
Rational: feeding gradually or slowly may help.
5. Monitor the provision of fluids and food in 24 hours as well as expenditures and recorded fluid intake.
Rational: the provision of fluids and electrolytes is a way to deal with persistent vomiting, this recording will be able to assess the balance of electrolytes are given, while the number of how many calories can already be given.
6. Review of edema in the legs or elsewhere.
Rational: the edema may also occur due to lack of albumin or renal failure.
7. Assess the presence of ketones in the urine.
Rational: presence of ketones in the urine indicates maternal fat supplies for energy use due to inadequate caloric intake.
8. Do collaborations with other teams for the administration of antiemetic drugs.
Rational: usually to cope with vomiting.
9. Give the food a light, when it is allowed in small portions and frequent (liquid and solid)
Rational: the provision of solid and liquid foods in small portions and often may reduce vomiting.
10. Increase feeding of this, if the client is able to accept (tolerance).
Rational: an increase in feeding demonstrate efficacy in the treatment.
11. Monitor FHR and fetal activity.
Rational: FHR and fetal movement is an indication that the fetal / fetus in good condition.
12. Monitor symptoms of morning sickness.
Rational: hormonal changes, maternal Hypoglycemia and decreased gastric motility, emotional and cultural factors.
13. Examine the skin: the texture and turgor.
Rational: dry skin and poor turgor is a sign of dehydration.
14. Encourage clients to multiply the rest.
15. Create a comfortable environment.
Nursing Assessment for Hyperemesis Gravidarum
Nursing Diagnosis for Hyperemesis Gravidarum
Activity Intolerance (2) Acute Pain (5) Altered Family Processes (1) Anxiety (1) Constipation (5) Decreased Cardiac Output (2) Deficient Fluid Volume (2) Deficient Knowledge (1) Disturbed Sensory Perception (1) Imbalanced Nutrition: Less Than Body Requirements (3) Impaired Gas Exchange (2) Impaired Physical Mobility (2) Impaired Skin Integrity (4) Impaired Social Interaction (1) Impaired Urinary Elimination (1) Ineffective Airway Clearance (1) Ineffective Cerebral Tissue Perfusion (1) Ineffective Tissue Perfusion (2) Knowledge Deficit (3) Low Self-esteem (2) Risk for Decreased Cardiac Output (2) Risk for Fluid Volume Deficit (2) Risk for Infection (4) Risk for Injury (1) Risk for Social Isolation (1) Self-care deficit (1) Self-concept Disturbance (1) Social Isolation (1)