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: Issued: 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 NYS: Federal: 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 Pharmacists 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 dehydration. 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 11/15/10 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, droperidol) 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 11/15/10 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 Pregnancy 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. Mosby. 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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