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HYPEREMESIS GRAVIDARUM
A. Anatomy
1. External genitals ( external genetalia )
a) Monsveneris
The prominent part includes the symphysis part consisting of fat tissue, this area
is covered in fur during puberty.
b) Vulva
Is the place that empties into the urogenital system. Outside the vulva is circled
by the labio mayora (large lips) which is backward, becomes one and forms the
posterior comic and perineam. Under the skin there is fat tissue like the one in
Mons veneris.
c) Labio mayora
Labio mayora (large lips) are two large folds that limit the vulva, consisting of
skin, connective tissue, fat and sebasca glands. At puberty grow hair on mons
veneris and on the lateral side.
d) Labio Minora
Labio minora (small lips) are two small folds between the labio mayora, with
many sebaceous glands. The gap between the labio minora is the vestibule.
e) Vestibule
The vestibule is a cavity between the small lips (labio minora), then the back is
bordered by the clitoris and perineum, in the vestibule there are estuaries from
the intercourse (vaginal urethral introetus), bartholimi gland and right and left
glands.
f) Himen (hymen)
A thin layer that covers most of the intercourse in the middle is perforated so
that menstrual impurities can flow out, the mouth of the vagina in this part, the
shape is different there is something like a crescent, there is a consistency that is
stiff and soft, the holes are finger tips, there are one finger can pass.
g) Perineum
h) Formed from the perineal corpus, the intersection of the pelvic floor muscles
covered by the perineal skin.
B. Etiology
The cause of hyperemesis Gravidarum is not known with certainty, the incidence incidence
is 3.5 per 1000 pregnancies. The pre- disposition factors that are stated:
1. Organic factors, namely due to the entry of villous khriales in the maternal
circulation and metabolic changes due to pregnancy and resuscitation that decrease
from the mother's side to these changes and the presence of allergies, which is one
of the responses of maternal tissue to the fetus.
2. Psychological factors. This factor plays an important role in this disease. Cracked
households, loss of work, fear of pregnancy and childbirth, fear of dependents as
mothers, can cause mental conflicts that can aggravate nausea and vomiting as an
unconscious expression of unwillingness to become pregnant or as an escape from
life difficulties.
3. Endocrine factors are hi pertiroid, diabetes, elevated levels of HCG and others.
G. Prognosis
The criteria for treatment success can be specified as follows:
1. Rehydration is successful and skin turgor is restored
2. Dieresis increases so much that the ketone objects decrease
3. Seamless good patient awareness that is characterized by increased contact is
assured
4. Jaundice is diminishing
With good handling, the prognosis is very satisfying. However, at a severe level can cause
maternal and fetal death.
H. Diagnostic Check
1. Ultrasound (using the right time): assess the gestational age of the fetus and the
presence of multiple gestations, detect fetal abnormalities, localize the placenta.
2. Urinalysis: culture, detect bacteria, BUN.
3. Liver function check : AST, ALT and LDH levels .
I. Handling
1. Prevention
Prevention of hyperemesis gravidarum is needed by providing application of
pregnancy and childbirth as a physiological process. This can be done by:
a) Providing confidence that nausea and vomiting are physiological symptoms
in young pregnancy and will disappear after 4 months of pregnancy.
b) Mothers are encouraged to change their daily diet with small but frequent
meals.
c) When you wake up in the morning do not immediately get out of bed, but it
is recommended to eat dry bread or biscuits with warm tea. Avoid it, which
is greasy and smells of fat.
d) Eat foods and drinks that are served not too hot or too cold.
e) Try regular defecation.
2. Drug therapy
If the method above complains over the complaints and symptoms are not reduced,
treatment is needed:
a) Do not give teratogenic drugs.
b) Sedetiva which is often given is Phenobarbital.
c) The recommended vitamin is vitamin B1 and B6.
d) Anthistaminics like dramamin, avomin.
e) In severe circumstances, antiemetics such as dicyclomin hydrochloride or
chlorpromasin.
f) Gravidarum level II and III hyperemesis must be hospitalized at the
hospital.
The therapies and treatments provided are as follows:
1) Isolation
Patients are dissociated in quiet, but bright rooms and good blood
circulation. Not too many guests, if only nurses and doctors are allowed
to enter. Sometimes isolation can reduce or eliminate these symptoms
without treatment.
2) Psychological therapy
Give understanding that pregnancy is a natural, normal, and
physiological thing, so there is no need to be afraid and
worried. Convince sufferers that the disease can be cured and eliminated
problems or conflicts that might be the background of this disease.
3) Paretal therapy
Give enough parental fluid electrolytes, carbohydrates, and protein with
5% glukaose in physiological salts as much as 2-3 liters a day. If
necessary, you can add potassium and vitamins, especially complex
vitamin B and vitamin C and if there is a lack of protein, amino acids can
also be given intravenously. Make a list of incoming and excreted fluid
controls. Also give medicines as mentioned above.
4) Termination of pregnancy.
In some cases the situation does not become good, even backwards. Try
to have a medical and psychiatric examination if things get
worse. Delirium, blindness, takhikardi, jaundice, anuria, and bleeding
are manifestations of organic complications. In such circumstances it is
necessary to consider ending the pregnancy. The decision to perform a
therapeutic abotus is often difficult to take, because on one side it should
not be done too quickly, but on the other hand it cannot wait
until irreversible symptoms occur on vital organs.
J. Client Care Plan with Hyperemesis Gravidarum
1. Assessment
a) Break; Systolic blood pressure decreases, pulse increases (> 100 times per
minute) .
b) Ego integrity; family interpersonal conflicts, economic difficulties, changes in
perceptions about conditions, unplanned pregnancies.
c) Elimination; changes in consistency, defecation, increased frequency of
urination. Urinal : increased consistency of urine.
d) Food / liquid; excessive nausea and vomiting (4-8 weeks), epigastric pain,
weight loss (5-10 kg), irritated oral mucous membranes and low red, Hb and
Ht, acetone-smelling breath, reduced skin turgor, sunken eyes and dry tongue
e) Breathing; respiratory frequency increases.
f) Security; the temperature sometimes rises, the body is weak, jaundice, and can
fall into a coma .
g) Sexuality; termination of menstruation, if the mother's condition is dangerous
then therapeutic abortion is performed.
h) Social interaction; changes in health status / pregnancy stressors, role changes,
family members' responses that can vary with hospotalisasi and illness, lack of
support systems.
i) Learning and counseling; everything that is eaten and drunk, especially if it
lasts a long time, weight drops more than 1/10 of the weight of a normal body,
skin turgor, dry tongue, the presence of acetone in the urine.
2. Client identity
3. Main complaint
4. Current disease history
5. Past medical history
6. Daily habits
1) Nutritional pattern
2) Elimination pattern
3) Sleep rest pattern
4) Activity pattern
5) Daily health behavior
6) Personal hygiene
7. Menstrual history
8. Marriage History
9. KB history
10. Physical examination
a) General examination
1) Inspection
2) Palpation
3) Auscultation
4) Examination of vital signs
5) Weight measurement
1.3.3 Planning
1 Lack of fluid volume After nursing the mother 1) Monitor and record the
for 1x 24 hours, TTV every 2 hours or as
the patient's nausea and often as needed to be
vomiting decreased stable. Then monitor and
record TTV every 4
hours .
R : Tachycardia, dyspnea,
or hypotension can
indicate a lack of fluid
volume or electrolyte
imbalance
2) Measure intake and
output every 1 to 4
hours. Record and report
significant changes
including urine, feces,
vomit, wound drainage,
nasogastric drainage,
chest tube drainage, and
other output.
R : Low urine output and
high urine specific gravity
indicate hypovolemia
3) Review and document
skin turgor, condition of
mucous membranes, vital
signs and specific gravity
of urine
R: An accurate
assessment of fluid and
electrolyte status is the
basis for planning and
evaluating interventions
4) Weigh your weight every
day
R: Efforts to improve
electrolyte and fluid
balance and are carried
out through parenteral
therapy to tolerate normal
intake
5) Monitor laboratory values
and report abnormal
values
R : Liquid and electrolyte
balance must be corrected
to prevent severe
complications, such as
metabolic acidosis and
fetal and maternal death .
Hidayati Ratna.( 2009 ) . Physiological Nursing Care in Pregnancy late Pathological d. Jakarta:
Salemba Medika
Lowdermilk, Jensen Bobak. ( 2005 ) . Nursing Maternitas Textbook 4. Edition : Jakarta: EGC
Nurarif, A, H and Kusuma, H. (2016) . Practical nursing care based on the application of Nanda
diagnosis, NIC, NOC in various cases . Yogyakarta
Denise's Tiran. ( 2006 ) . Pregnancy Nausea and Vomiting Midwifery Care Series . Jakarta: EGC