Care of the Patient with Hyperemesis Gravidarum by alicejenny


									                                     POLICY/ PROCEDURE/PROTOCOL
Title:     Care of the Patient with Hyperemesis Gravidarum                     Policy # MAT.4
Audience: All Maternity, Ambulatory, Acute Care, Critical Care Units

Key Word:       Hyperemesis, Nausea, Vomiting                                  Date            Page:
                                                                               11/15/10         1 of 3
Distribution:     All holders of the policy and procedure manual

Prepared by: Women Service’s Policy and Procedure Committee                    Effective
                                                                               Date: 7/25/11

Approved by:                                     Date:
Women Service’s Standards Committee              8/10, 4/25/11
Women Service’s Quality Council                  8/10, 4/26/11
Infection Control                                6/10, 6/2011
Kaleida Nurse Policy Council                     9/14/10, 6/14/11
Kaleida Nurse Executive Council                  10/1/10, 7/1/11

Regulation/ Standards- N/A
Accreditation Standards:
Review Date         4/11
Revision Date         5/11

I.       Introduction
         Hyperemesis is a complication of pregnancy characterized by persistent, uncontrollable nausea
         and vomiting before 20 weeks of pregnancy. 50-70 percent of all pregnant women experience
         nausea and vomiting in early pregnancy. Only a small percentage develop hyperemesis, which
         can lead to 5 percent weight loss, dehydration, acid imbalance, electrolyte imbalance and may
         jeopardize fetal and maternal well being.

II.      Communication and Responsibility
         Department of Nursing, Department of OB/GYN, Department of Maternal Fetal Medicine

III.     Scope of Practice
         Physicians, Residents, Certified Nurse Midwives (CNM), Nurse Practitioners (NP), RNs and

IV.      Policy
         The purpose is to outline the role of the nurse in the care of patients with hyperemesis
         gravidarum in the outpatient and hospital setting, an obstetrical patient may present with severe
         A.     Risk factors include but are not limited to
                1.      Pregnancy at young age
                2.      Obesity
                3.      Nausea and vomiting in previous pregnancy
                4.      History of intolerance to oral contraceptives
                5.      Multi-fetal pregnancy
                6.      Gestational trophoblastic disease
Title:   Care of Patient with Hyperemesis Gravidarum              Date         Page        Policy #
                                                                  Issued:      2 of 3      MAT.4

V.       Procedure - NA

VI.      Protocol
         A.     Supportive Data
                The exact cause of hyperemesis gravidarum is unknown. Several theories exist
                concerning etiology.

         B.     Content
                1.    Assessment/Data Collection
                      a.    Nausea and vomiting
                      b.    Weight loss over 5 percent
                      c.    Dehydration
                      d.    Decreased blood pressure
                      e.    Decreased skin turgor
                      f.    Increased pulse
                      g.    Increased temperature
                      h.    Decreased urinary output
                      i.    Dizziness, weakness

                2.     Admission Criteria may include the following:
                       a.    Vomiting – persistent and unresponsive to both antiemetics and
                             outpatient hydration greater than 24 hours
                       b.    NPO greater than 2 days or active vomiting
                       c.    Need for Intravenous flow equal to 125 ml/hr
                       d.    Na greater than 150 mEq/L
                       e.    BUN: CREAT Ratio greater20
                       f.    Heart rate greater than 100 bpm
                       g.    Postural systolic drop greater than 30mmHg
                       h.    Urine specific gravity greater than1.030
                       i.    Mental status change

                3.     Care and Management should include;
                       a.    Weigh patient daily
                       b.    As ordered:
                             1)       Monitor intake and output
                             2)       Monitor vital signs
                             3)       Assess fetal heart rate (FHR)
                             4)       Monitor lab values (CBC, CMP, UA)
                             5)       Establish IV line
                             6)       Administer IV fluids
                             7)       Administer IV antiemetics (i.e. Phenothiazines, metoclopramide,
                             8)       Administer parenteral and enteral nutrition
                       c.    Assess level of consciousness, reflexes, cognition.
                       d.    Provide supplies for oral care.
                       e.     Nutrition Consult
                       f.     Follow up care at home when applicable4. Safety
                       a.    As ordered:
                             1)       Bed rest
                             2)       Restricted activity
Title:   Care of Patient with Hyperemesis Gravidarum                                     Date              Page            Policy #
                                                                                         Issued:           3 of 3          MAT.4

                    4.        Infection Control
                              Standard Precaution

                    5.        Complications and Reportable Incidents
                              a.    Report any change in maternal status to primary care providers
                              b.    Report inability to detect FHR to primary care provider

                    6.        Emergency Management
                              Notify primary care provider if any signs and symptoms of metabolic acidosis or
                              cardiac changes.

                    7.        Patient/Family Education
                              a.      Teach and reinforce:
                                      1)     Measures to minimize nausea and vomiting
                                      2)     Self-care measures
                                      3)     Appropriate dietary choices:
                                             a)      Increased protein, calcium and potassium
                                             b)      Avoid spicy greasy foods
                                      4)     Take small, frequent meals.
                                      5)     Drink fluids between meals.

VII.      Documentation
          Maternity EMR

VIII.     References
          ACOG Practice Bulletin Number 52, April 2004, reaffirmed 2009. Nausea and Vomiting of

          Fell, D.B. , Dodds, L., Joseph, K.S. Allen, V., Butler, B. Risk Factors for hyperemesis
          gravidarum requiring hospital admission during pregnancy. Obstetrics & Gynecology 107 (2 Pt
          1) :277-84, 2006 Feb..

          Lowdermilk, D. Perry, S. 2007. Maternity and Women’s Health Care 9th edition. Pages 842-844.

          Simpson, K.R., & Creehan, P.A. AWHONN Perinatal Nursing 3rd Edition (2008)

          Mosby’s Nursing Skills

Kaleida Health developed these policies and procedures in conjunction with administrative and clinical departments. These documents were
designed to aid the qualified health care team in making clinical decisions about patient care. These policies and procedures should not be
construed as dictating exclusive courses of treatment and/or procedures. No health care team member should view these documents and their
bibliographic references as a final authority on patient care. Variations of these policies and procedures in practice may be warranted based
on individual patient characteristics and unique clinical circumstances. Please contact the print shop regarding any associated forms.

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