Vomiting in Pregnancy
Vomiting in Pregnancy
Vomiting in Pregnancy
CASE PRESENTATION
ON
HYPEREMESIS
GRAVIDARUM
Education: Graduate
Religion: Sikh
Education: Graduate
Address: Amritsar
LMP: 07-12-2020
EDD: 14-09-2020
CHIEF COMPLAINTS: The chief complaints of the patient are Nausea, vomiting,
dehydration and weight loss since 1 week with pregnancy.
HISTORY OF PRESENT ILLNESS:
1) MEDICAL HISTORY: Patient has admitted in hospital with the chief complaints
of Nausea, vomiting, dehydration and weight loss since 1 week with pregnancy. After
investigations doctor diagnosed her as Hyper-emesis Gravidarum. Now she is under
treatment in Bebe Nanki Hospital, Pandher.
FAMILY HISTORY: Patient lives in joint family with her husband. All the family
members are good & healthy. No any medical or congenital disorder present in
family.
FAMILY MEMBERS:-
S NAME OF AGE/ RELATIONSHIP EDUCATION Occupation HEALTH
No. FAMILY SEX WITH CLIENT STATUS
MEMBERS
1. Mr. Roop 30y/M Husband Graduate Shopkeeper Healthy
Singh
2. Mrs. 27y/F Patient Graduate Housewife Unhealthy
Simranpreet
Kaur
3. Mst. Ambar 3y/M Son - - Healthy
singh
FAMILY TREE
Keys:
Male
Female patient
MENSTRUAL HISTORY:
Age of menarche: 13 years
Duration of cycle: 30 days
Number of days: 5 days
Flow: Normal
Discomfort during menstruation: Mild Dysmenorrhoea
MARITAL HISTORY:
Age of Marriage: 23 years
Nature of marriage: Arranged marriage
OBSTETRICAL HISTORY:
SOCIO-ECONOMIC STATUS:
Type of house : Cemented house
Number of Rooms : 3 rooms
Total income per month : 30,000 from all sources
Latrine facility : Available
Drainage facility : Good
PERSONAL HISTORY:
Sleeping pattern : About 9 hours
Diet Habit : Disturbed due to vomits
Bowel and bladder Habit : Good
Allergic to diet : No any significant
Personal hygiene : Good
Amount of water intake :10-12 glasses per day
PHYSICAL EXAMINATION:
GENERAL APPEARANCE:
Nourishment : Moderate
Body Build : Moderate
Health : Unhealthy
Activity : Dull
VITAL SIGNS:
Temperature : 99 F
Pulse : 86/min
Respiration : 20/min
B.P : 100/60mm (Hg)
MENTAL STATUS:
Consciousness : Conscious
Look : Depressed
POSTURE:
Body curves : Normal
Movement : Allowed
HEIGHT & WEIGHT:
Height : 5’4”
Weight : 58 kg
SKIN CONDITION:
Colour : Fair
Texture : Normal
HEAD:
Hair Colour : Black
Texture of hairs : Rough
Dandruff : Present
Scalp : Clean
EYES:
Eye brows : Symmetrical
Conjunctiva : Normal
Eye Lids : No infection present
Pupillary reaction : Reacting to light
Vision : Normal
Sclera : White
NOSE:
Nasal drainage : Absent
Nostrils : Normal
Epistaxis : Absent
MOUTH:
Lip colour : Pink
Lip Texture : Rough
Teeth : Pale yellow in colour (Normal)
Colour of teeth : Pale yellow
Dental carries : Absent
Gums : No inflammation
TONGUE:
Colour : Pink
Pharynx : Normal
EAR:
Alignment : Normal (Symmetrical)
Discharge : Absent
Hearing : Normal
NECK:
Range of motion : Normal
Lymph nodes : Not palpable
Thyroid glands : Normal, no enlargement
CHEST:
Chest measurement : Normal
Respiratory rate : 24 per minute
Breath sound : Normal, no wheezing sound
Heart sound : S1 and S2 sound present
BREAST:
Shape : Round
Axillary lymph nodes : Not palpable
Nipples : Symmetrical, not cracked and not inverted
Discharge : No any abnormal discharge present
NAILS:
Shape : Round
Texture : Smooth
Colour : Pink
ABDOMEN:
Inspection:
Skin colour : Fair
Linea nigra : Present
Umblicus: Round
Striae gravidarum: Absent
BACK:
Back ache : Absent
Lesions : Absent
EXTREMITIES:
Deformities : No any deformity present
Edema : Absent
Range of motion : Proper
GENITALIA:
Lesions : Absent
Inguinal lymph node : Present
Anal patency : Good
VITAL SIGNS:
INVESTIGATIONS:
Ultra sonography (USG): Normal gestational period. Level of AFI is normal.
Liver function test: Elevated liver enzymes and serum amylase.
Serum Electrolyte test: hypokalemia ketones in blood and urine.
Urine analysis: Concentrated urine in small quantities with high specific
gravity with the presence of acetone and with diminished or absent chloride.
LAB INVESATIGATION:
SUMMARY:
I have taken the patient Mrs. Simranpreet kaur, 27 years old, diagnosed with
Hyperemesis gravidarum. She came in hospital with the chief complaints of nausea,
vomiting, weakness and weight loss since1 week. Advise is given to take proper rest,
nutritious diet and plenty of fluids.
In this case presentation, I have presented:-
Introduction of patient
Obstetrical history
Menstrual history
Personal history
Physical examination
Investigations
Medications
Disease condition
Nursing diagnosis and
Health education
RECAPITULATION:
After this presentation, group will able to give answers to my questions:
Define Hyperemesis gravidarum?
Explain causes of Hyperemesis gravidarum?
What are the sign and symptoms of Hyperemesis gravidarum?
Explain diagnostic evaluation of Hyperemesis gravidarum?
What are the managements of Hyperemesis gravidarum?
Explain its complications and nursing management?
CONCLUSION
Through this case presentation, Group has learned about Hyperemesis gravidarum, its:
Definition
Causes
Clinical manifestations
Diagnostic evaluations
Managements
Complications and its
Nursing management
Now, they have sufficient knowledge about placenta previa that will helpful for them
in future.
HEALTH EDUCATION:
Regarding Diet:
Instruct the client to take meal thrice in a day.
Instruct the client to avoid more spicy & fatty food.
Instruct the client to take high caloric and iron rich diet.
Take plenty off fluids.
Take small and frequent meals.
Regarding Activity:
Teach the client to take the proper rest & sleep.
Instruct client to avoid heavy weight lifting.
Regarding Hygiene:
Instruct the client & family members to maintain proper personal &
environmental hygiene.
Teach the client & family members about hand washing methods.
Regarding Treatment:
Instruct the client to complete her full course of medications.
Instruct the client about every procedure done on client.
Instruct client about common side effects of medicines.
Regarding Follow-up:
Instruct the client for follow up visits.
Instruct the woman to notify her health care provider if she experiences any
change in health.
BIBLIOGRAPHY: