ANTENATAL MOTHER

Submitted To: Submitted By:

Mrs.Daram Kaur Nurain Syafiqah Safie
Cilinal Instructor SCKL2000203

Submitted on:
13-11-2022

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 IDENTIFICATION DATA OF THE PATIENT

▪ Name of the patient: Mrs.Nur Syafira bt. Abdul Razak

▪ Age: 30
▪ Sex: female
▪ Marital Status: Married
▪ Address: D-12-10 Ppr Lembah Subang 2.
▪ Religion: Muslim
▪ Education: Degree
▪ Occupation: Customer Services
▪ Diagnosis: hyperemesis graviderm

CHIEF COMPLAINTS WITH DURATION:

She was having pain and excessive vomitting from last 14 days, Weight loss
from weeks,Weakness from last 12 days and headache from last 1 weeks.

HISTORY OF PRESENT ILLNESS:

Present Medical History:
Onset of symptoms:- patient was apparently well 15 days back when she had
started vomitting
and headache from last 1week and she was feeling very week.
Present surgical history
not significant
PAST HEALTH HISTORY:
Past Medical History:
▪ Childhood illnesses: Not significant
▪ Other illnesses: Not significant
▪ Childhood immunization: All immunization is done
Past surgical history

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Patient was not going any surgical procedure in past.

MENSTURAL HISTORY
She attaned he menarche at the age of 14 years. She don’t felt the
desmenorrehea during the menstrual cycle. And she having 30 days of
menstrual cycle.
LMP: 22/06/2022
EDD: 29/03/2023

OBSTRACTICAL HISTORY
G2P1
HISTORY OF 1ST TRIMESTER
No history of fever
No history of rashes
No history of burining micturition
No history of x-ray exposure
There was a history of vomiting and headache

FAMILY HEALTH HISOTRY:

▪ Type of family: Nuclear family
▪ No. of family members: 5
▪ Any Illness: Thare is no history of Epilepsy, DM,HTN,Twins pregnancy,
congenital malformation.

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 Family Composition

Family Age Sex Relationship occupation Education Health

Members with the status
patient

Mr. Abdul 64 M Father - Diploma Healthy

Razak yrs.

Mrs. 58 F Mother housewife - Healthy

Rahima yrs.
Mr. 33yrs. M Husband RHB Degree Healthy
Zalisman Kajang
Mrs. Nur 30yrs F Patient Customer Degree Hyperemesis
Syafira services graviderm
Miss Adelia 2yrs F Daughter ------- --------- Healthy

PERSONAL HISOTRY
Personal Hygiene:
▪ Oral Hygiene: not maintained
▪ Bath: Bath is taken once a day
▪ Diet: non vegetarian diet
▪ Food preferences: More fluids preferences
▪ Sleep & Rest – 7 hours in night, 1 hrs. in a day
▪ Elimination: Bowel –1-2 times in a day
▪ Urine frequency: Normal
▪ Exercise / Activity: moderate
▪ Substance use: Not significant

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 PHYSICAL EXAMINATION

GENERAL EXAMINATION
▪ Weight: 48 kg
▪ Height: 154 cm
▪ Foul Body Odour: Absent
▪ Foul Breath: present
▪ Sensorium: Conscious
▪ Orientation: oriented to time, place & person
▪ Nourishment- malnourished
▪ Body built: Modearate
▪ Activity: moderate
▪ Look: Anxious
▪ Hygiene: not mantained
VITAL SIGNS
▪ Temperature: 36.5c
▪ Pulse : 74bt / min
▪ Respiration : 18 bt / min
▪ Blood Pressure : 120/70 mmHg

HEAD
▪ Shape : Normal cephalic
▪ Scalp : Clean
▪ Face : Pallor
▪ Subjective symptoms Patient feels headache
▪ Subjective symptoms : No any complaints
▪ Decreased tear production/ if any other- not significant

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 ABDOMEN
▪ On Inspection : Globular
▪ Umbilicus : Clean
▪ On Percussion Not done
▪ Bowel sound : Present
▪ Inguinal Lymph Nodes : Not enlarged
▪ Appetite : Anorexia
▪ Subjective Symptoms Nausea, vomiting present

TREATMENT CHART

Sr. Name of the Dose Route Frequency Action Side effects Nursing
Drug responsibilitie
no.
s
1 Inj 10mg i/v B.D. Antiemetic Diziness, ▪ Assess
Metaclopram Tiredness the
ide Headache vital
diarrhoea signs
Anxiety of
Allergic reaction patient
▪ Provide
hydrati
on
therapy
2. Inj. Metrogyl 500 IV TDS Antibiotics Dizziness to
patient
mg Headache ▪ Maintai
Diarrhea n I/o
chart of
Change in taste patient
Dry mouth ▪ About
over
3. inj Rantac 50 mg IV BD H2 Nausea dose of
receptor Vomiting drug
▪ Educat
antagonist Constipation e about
Dehydration the side

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 ypersensitivity effects
▪ Contin
Rash
uous
tachycardia monito
ring of
4. Ing 75 mg IM BD analgesics Abdominal pain
client
Diclofenac Bloating ▪ Provide
fiber
Heart burn
rich
Itching skin diet to
the
Shortness of breath
client
5. Inj 1gm IV BD Antibiotic Headache
Ceftriaxone Diarrhea
Change in taste
Dry mouth

DISEASE CONDITION
HYPEREMESIS GRAVIDERUM

INTRODUCTION

Hyperemesis gravidarum is a condition characterized by severe nausea,

vomiting, weight loss, and electrolyte disturbance. Mild cases are treated with
dietary changes, rest, and antacids. More severe cases often require a stay in the
hospital so that the mother can receive fluid and nutrition through an
intravenous line (IV). DO NOT take any medications to solve this problem
without first consulting your health care provider.

DEFINITION:It is severe type of vomiting of pregnancy which has got

deleterious effect on the health of the mother and day to day activity.

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INCIDENCE: There has been marked fall in the incidence during the last 30
years. It is now a rarity in hospital practices . Thr reason are better application
of the family planning , reduced the no of unplanned pregnancy .Early visit to
the antenatal visits

CAUSES
excessive vomiting is caused by a rise in hormone levels.
▪ it is more common in first trimester
▪ younger age
▪ low body mass
▪ history of motion
▪ Fmily history it is more common in unplanned pregnancy

SIGNS AND SYMPTOMS

▪ When vomiting is severe, it may result in the following:

▪ Loss of 5% or more of pre-pregnancy body weight
▪ Dehydration, causing ketosis, and constipation

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 ▪ Nutritional disorders, such as vitamin B1 (thiamine) deficiency, vitamin
B6 (pyridoxine) deficiency or vitamin B12 (cobalamin) deficiency
▪ Metabolic imbalances such as metabolic ketoacidosis or thyrotoxicosis
▪ Physical and emotional stress
▪ Difficulty with activities of daily living
▪ Symptoms can be aggravated by hunger, fatigue, prenatal vitamins
(especially those containing iron), and diet. Many women with HG are
extremely sensitive to odors in their environment; certain smells may
exacerbate symptoms.
▪ Excessive salivation, also known as sialorrhea gravidarum, is another
symptom experienced by some women.

SYMPTOMS
Book picture Patient picture
• increased frequency of vomiting Present

• diminished quantity of urine Present

• epigastric pain Present

• constipation may occur

Some times constipation occurs
• Featured of dehydration

• Dry coated tongue Dehydrated

Present
• Rise in temperature
Absent
• jaundice
Absent
• excessive salivation
Present
• Emotional stress

DIAGNOSIS

• Ultrasound – uses sound Done

waves to produce the

picture. The ultrasound

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 probe can be placed on the
abdomen or it can be Done
placed inside the vagina to
make the picture.

• UPT(urine pregnancy test)-

UPT is done to identify the
pregnancy.

TREATMENT

Anti emetic drug promethazine- 25 mg or prochlorperazine 5 mg ,twice a

day I/M.

Metoclopramide –it stimulates gastric and intestinal mortality with out

stimulating secreation. Metoclopramide is also used and relatively well
tolerated. Evidence for the use of corticosteroids is weak.
there is some evidence that corticosteroid use in pregnant women may slightly
increase the risk of cleft lip and cleft palate in the infant and may suppress fetal
activity.
However, hydrocortisone and prednisolone are inactivated

Hydrocortisone- 100 mg i/v in drip is given in case with hypotension or in

intractable vomiting

Ondansetron may be beneficial, however, there are some concerns regarding

an association with cleft palate,and there is little high-quality data. in the

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placenta and may be used in the treatment of hyperemesis gravidarum after 12
weeks.

Nutritional supplements – vitamin 100mg daily, vit B6 , Vit C are also given
in some cases.

Fluids- the amount of fluid to be infused in 24 hrs is approximately 3litters in

which half os dextrose 5% and half in ringer lactate.
After IV rehydration is completed, patients typically begin to tolerate frequent
small liquid or bland meals.

After rehydration, treatment focuses on managing symptoms to allow normal

intake of food. However, cycles of hydration and dehydration can occur,
making continuing care necessary. Home care is available in the form of
a peripherally-inserted central catheter (PICC) line for hydration and nutrition.
Home treatment is often less expensive and reduces the risk for a hospital-
acquired infection compared with long-term or repeated hospitalization.

Alternative medicine Acupuncture (both with P6 and traditional method) has

been found to be ineffective.

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The use of ginger products may be helpful, but evidence of effectiveness is
limited and inconsistent, though three recent studies support ginger over
placebo.

THEORY APPLICATION:- Orem’s theory self care deficit.

UNIVERSAL SELF – CARE REQUISITE :-

Sr.no. Components Patient componemts
01 Maintenance of sufficient intake of air , Patient were having poor appatite she
water , food. had feeling of nausea less intake of the
water .
02 Balance between activity and rest Patient having tiredness, patient not
between solitude and social interaction able to perform activity of daily living
because of weakness and not able to
maintain interation with society.
03 Prevention of hazards to human life, Not able to prevent hazards of his life
functioning and well being and also not able to perform the
function of daily living
04 Promotion of human functioning and Patient is not promoting his
development. functioning and development

DEVELOPMENTAL SELF CARE REQUISITIES:-

Sr.no. Components Patient components
01 Maintenance of developmental Not able to feed, difficult to perform
environment the
02 Prevention/ management of the conditions Feel that the problem are due to his
threatening the normal development own behavior .

HEALTH DEVIATION SELF- CARE REQUISITE:

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Sr. no Components Patient components
01 Seeking and securing appropriate medical Patient need medical assistance
assistance
02 Being aware of and attending to the effects Patient was aware about her diseases
and results of pathologic conditions. condition
03 Effectively caring out medically prescribed Patient effectively carrying medically
measures. prescribed measures.
04 Modify self concepts is accepting oneself Patient accepting her diseases
as being in a particular state of health and condition and herself
in specific forms of health care.
05 Learning to live with effects of Patient living with his pathological
pathological conditions conditions.

NURSING DIAGNOSIS (Priority Wise):

▪ Fluid volume deficit related to excessive vomiting as evidenced by
physical examination & Intake output chart
▪ Imbalance nutrition: less than body requirement related to loss of appetite
as evidenced by less body weight
▪ Anxiety related to hospitalization as evidence by her facial experience
▪ Hopelessness related to life threatening disease as evidence by while
comunucating with patient
▪ Knowledge deficit regarding disease condition as evidenced by
conversation.
▪ Risk for complications related to alteration in normal fluid level

Short term goals:

▪ To relieve the headache induced by excessive vomiting.
▪ To maintain normal nutritional status
▪ To prevent the risk for infection

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 Long term goals
▪ To maintain the normal fluid level
▪ To relieve anxiety related to hospitalization
▪ To provide knowledge related to condition

Nursing care plan (1)

Assessment Nursing Goal Nursing Implementa Scientific Evaluati
Diagnosis interventio tion Rationale on
ns
Subjective Fluid Assess the Physical To collect The
Nor

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 data volume mal physical examination the base line patient’s
body
Patient told deficit condition of has been data fluid
fluid
that I have related to level the patient. done level is
will
suffering excessive Check thr To improve come to
be
from severe vomiting main intke output RL and D5% the body normal
taine
vomiting as chart of the has been normal fluid ata some
d
and I have evidenced patint. given to the To prevent extent.
also feeling by patient from any
the physical Provide the harm.
abdominal examinati fluid to the Provide bed To reduce
pain , on & patient . rest to the the
Objective Intake patient . vomoitting
data output Advise rest Antiemetics episodes.
I observed chart to the drugs has It will
the patient patient been given diminished
by vomiting Provide to the the episodes
episodes 5- antiemetic patient. of vomiting.
6 /day, drugs to the Provide
Facial mother. proper
expression Eliminate ventilation to
the smell of the patient.
the
environment

Nursing care plan 2

Assessment Nursing Goal Nursing Implementa Scientific Evaluatio
Diagnos interventio tion Rationale n
is ns

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Subjective Anxiety Anxiet Assess the General To provide Anxiety
general condition baseline
data related y will has been
condition of has been data for
Patient to be the patient assessed by planning of reduced to
the care
asked the hospitali reduce some
inspection.
questions zation as d to Ask the Patient has It will extent.
client to been reduces her
about her evidence some now the
express her ventilate anxiety
condition by extend feelings with general patient is
about the verbalization
treatment mother’s feeling
condition.
and the I facial It will help relax.
Advise Individual to improve
am feeling expressi
counselling counselling the
anxiety on. about the has been knowledge
condition provided to about the
Objective
the patient . condition .
data
Observed
Provide Psychologic it will help
the patient psychologic al support to reduced
al support to has been the anxirty
by facial
the patint provided to level.
expression the patint
Crying
questioning

Nursing care plan 3

Assessment Nursing Goal Nursing Implementa Scientific Evaluati
Diagnosi interventio tion Rationale on
s ns

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Subjective Risk Assess the Assessed the To know My
Risk for of
data general condition of the baseline patient
compl
complica
Mother told ication condition of patient data. has
tions will be
me that I client Dry skin and increased
minim
related to
am feeling ize Reduced fluid
alteratio
very urine output volume
n in
weak,restle nd
normal
ss and dry decreased
fluid
tounge and Provide Provided the
level as
mucus more fluids more water To hydrate chances
evidence
membrane . to patient & juices to the patient of
d by
patient. infection.
patient’s
Objective
lab
data Maintain Maintained To hydrate
reports
Observed intake intake output the patient
the patient output chart chart
by lab
reports Provide I/V provided I/V To maintain
Unable to hydrations hydration hydration.
stand therapy to
Dry skin patient
and tongue

Health education
Date Topic Health education
11/10/22 Diet managemt • Diet- patient is taught regarding
balanced diet , Patient is advised

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 to, fruits, juices & salad in diet
• advise the patient to take plnty
of water.
• Avoid the food that cause
irritation.
• Avoid junk food
• advise to note her intale output
chart.
12/10/22 Physical and rest • Exercise – patient is advised to
management refused exercise for some time .
• Hygiene –patient is advised to
keep her surroundings clear &
perform hand hygiene properly.
• perform lab test after some times
repeat .
• advised to walk in a fresh
environment.

13/10/22 Anxiety • Advised to talk with others to

management ventilate her ideas it will reduce
the anxiety.
• Follow Up- follow up dates are
given to patient & they should be
clearly explained regarding it.
• explain the family manber to
engaged her in a little work so
that she can divert her mind from
the feelings of vomiting during
the pregnancy period .

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 • help the clint to gain her self
esteem

PROGRESS NOTES
Day- 1
Monitor the vital sign of the patient. ie.
• temp =36.4c
• pulse =74 b/ min.
• BP=110/80 mmhg
ADVICE
• Provide personal hygiene to the patient.
• advice the patient about the for ambulation
• provide fluid to the patient.
DAY-2
• patient fluid level is maintaing.
• Advice regarding the personal hygiene.
• help the patient in ambulation
Day -3
• patient is afebrile
• physical movement is in progress
• Now the pain is reduced.
• patient is feeling comfortable.

RECORDING AND REPORTING

• Provide medication to the patient

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 • Help the patient in early ambulation.
• Clean the suture and dressing over the sutures
• Checked vital signs of the patient
• Give health education to the patient
• Maintain intake output of the patient

CONCLUSION
Taking this case is beneficial for me during my clinical practical at Klinik

Kesihatan Kelana Jaya. Becauses I got Oppurtunity to learn many things from

patient which I can easly seen in patient. The case gives me the new experience

that how we have to take care of patients suffering from hyperemesis

gravidrum.

Raferences
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Antenatal care. (2022, August 9). UNICEF DATA. https://data.unicef.org/topic/maternal-

health/antenatal-care/

NHS website. (2022, September 16). Your antenatal care. nhs.uk.

https://www.nhs.uk/pregnancy/your-pregnancy-care/your-antenatal-care/

McNellan, C. R. (2019, February 12). BMC Pregnancy and Childbirth. BioMed Central.

https://bmcpregnancychildbirth.biomedcentral

Hyperemesis gravidarum. (n.d.). https://medlineplus.gov/ency/article/001499.htm

Hyperemesis Gravidarum: Symptoms & Treatment. (n.d.). Cleveland Clinic.

https://my.clevelandclinic.org/health/diseases/12232-hyperemesis-gravidarum-severe-

nausea--vomiting-during-pregnancy

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