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I. Reviuw the Concept of Anatomical Reproductive System Physiology

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

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.

2. Internal genitals ( internal genetalia)

a) Vagina
The tube, which is coated with a membrane of a type of striped epithelium, is
specially drained with many blood vessels and nerve fibers. The length from
the vestibule to the uterus is 7½ cm. Is a link between the vaginal and uterine
introitus. The front wall of the vagina (9 cm) is shorter than the back wall. At
the top of the inner vaginal fold is called rugae.
b) Uterus
c) The thick, muscular pear-shaped organ, located in the pelvis between the
rectum behind and the bladder in front, is called the myometrium. The uterus is
floating in the pelvis with connective tissue and ligaments. The length of the
uterus 7½ cm, width  5 cm, 2 cm thick . Weighs 50 grams, and weighs 30-60
grams. The uterus consists of:
1) Fundus uteri (uterine base)
The uterine part is located between the base of the oviduct. On a
pregnancy examination, touching the uterine fundus can estimate
gestational age.
2) Korpus uteri
The largest part of the uterus in pregnancy, this part functions as a place
where the fetus develops. The cavity in the corpus uteri is called the
uterine cavity or uterine cavity.
3) Uterine cervix
The tip of the cervix that leads to the top of the vagina is called the
portion, the relationship between the uterine cavity and the cervical
canal is called the internal uterine ostium.
Uterine layers, including:
a. Endometrium
b. Myometrium
c. Parametrium

4) Ovary
It is a walnut-shaped gland, located left and right of the uterus under the
uterine tube and is bound to the back by the broad ligament of the
5) Fallopian tube
The fallopian tube is lined with ciliated epithelium arranged in many
folds, which slows ovum's journey into the uterus. Some tubal cells
secrete serous fluid which provides nutrients to the ovum. The fallopian
tube is also called the oviduct, there are 2 left and right oviducts. The
length is approximately 12 cm but does not run straight. Then at the
ends there is a fimbria, to hug the ovum during ovulation to enter the

II. Concept of Hyperemesis Gravidarum

A. Definition
Hyperemesis Gravidarum is excessive nausea and vomiting in pregnant women until it
interferes with daily work because the condition generally becomes bad , due to
dehydration (Tiran, 2009)
Nausea and vomiting that occurs in pregnant women in the first trimester and second
trimester for a long time which can last up to 4 months which can interfere with the
general condition of everyday pregnant women is called hyperemesis gravidarum
(Prove rawati, 2009).
Hyperemesis gravidarum is vomiting that occurs up to 20 weeks' gestation, so great that
everything that is eaten and drunk is vomited so that it affects the general condition and
daily work, decreased weight, dehydration, there is acetone in the urine, not because of
illness (Maidun, 2009).
Hiperemisis gravidarum is excessive nausea and vomiting so menggang g u daily work
dehydration and penurunanan appetite during pregnancy. If pregnant women who
experience these things do not handle properly can cause other problems, namely
increased stomach acid and can later become grastitis. Increased gastric acid will further
aggravate hyperemisis gravidarum (Maulana, 2008).

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.

C. Signs and symptoms

How many nausea and vomiting is called hyperemesis gravidarum there is no
agreement. Some say, if more than 10 times throw up. However, if the general condition
of the affected mother is considered hyperemesis gravidarum, hyperemesis gravidarum
according to the severity of the symptoms is divided into three levels, namely:
1. Level I (Lightweight)
a) Nausea persistent vomiting that affects the general condition of the patient.
b) Mother feels weak.
c) There is no appetite.
d) Decreased body weight.
e) Feeling pain in the epigastrium.
f) Pulse increased by around 100 per minute.
g) Decreased blood pressure.
h) Reduced skin turgor.
i) Sunken eyes.
2. Level II (Medium)
a) Patients appear weak and apathetic.
b) Skin turgor starts to get worse.
c) The tongue dries and looks dirty.
d) Pulse is small and fast.
e) Body temperature rises (dehydration).
f) The eyes begin to jaundice
g) Weight loss and sunken eyes.
h) Down tension, hemoconcentration, oliguria, and constipation.
i) Acetone is smelled from breathing air and acetonuria occurs.
3. Level III (Weight)
a) General condition is more severe (consciousness decreases from somnolence
to coma).
b) Severe dehydration.
c) Pulse is small, fast and smooth.
d) Temperature rises and tension drops.
e) fatal complications in the nervous system known as wernicke
encephalopathy , with symptoms of nigtasm , diplopia and mental decline.
f) Jaundice arises which shows the presence of heart failure.

D. Pathophysiology
Feelings of nausea are the result of increased estrogen levels that usually occur in the first
trimester. If it occurs continuously, it can lead to dehydration and electrolyte balance with
hypochloremic alkalosis.
This hyperemesis gravidarum can cause carbohydrate and fat reserves to be used up for
energy purposes. Because of incomplete fat oxidation , ketosis occurs with accumulation
of aco-acetic acid, bitychic hydroxide acid, and acetone in the blood. Vomiting causes
dehydration, so the extracellular fluid and plasma are reduced. Sodium and chloride
blood drop. In addition, dehydration causes homoconcentration, resulting in reduced
blood flow. This causes the amount of food substances and tissue oxygen to decrease as
well as the accumulation of toxic metabolic substances.Besides dehydration and
disturbances in electrolyte balance, tears can occur in the esophageal and gastric mucous
membranes ( mollary-weiss syndrome ), with the result of gastrointestinal bleeding.
E. Pathway

Source: Nurarif, A, H and Kusuma , H 2016

F. Complications
Complications that occur due to hyperemesis gravidarum alntara others
1. Mild complications: weight loss, dehydration, acidosis from malnutrition,
alkalosis, hypokalemia, muscle weakness, abnormal electrocardiographic, tetany,
and psychological disorders.
2. Life-threatening complications: Oesophageal rupture is associated with severe
vomiting, wernicke's encephalophaty, pontine myelinolysis, retinal haemorage,
renal damage, spontaneous pneumomediastinum, growth retardation in the uterus,
and fetal death.

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
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
b) Mothers are encouraged to change their daily diet with small but frequent
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
f) Gravidarum level II and III hyperemesis must be hospitalized at the
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
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

K. Nursing diagnoses that may appear

Diagnosis 1: Lack of fluid volume
1. Definitions
Decreased intravascular, interstitial and / or intracellular fluid. This refers to
dehydration, fluid loss.
2. Characteristic limits
 Changes in mental status
 Decrease in blood pressure
 Decreased pulse pressure
 Decreased pulse volume
 Decreased skin turgor
 Weight loss
 Increased body temperature
 Pulse rate increase
 Dry mucous membranes
3. Related factors
 Inadequate fluid intake marked by nausea and vomiting
 Loss of active fluid volume

Diagnosis 2 : Into nutritional imbalance: less than need body

1. Definition
Nutritional intake is not enough to meet metabolic needs
2. Characteristic limits
 Lack of interest in food
 Weight loss with adequate food intake
 Pale mucosal membranes
 Decreased muscle tone
3. Related factors
 Biological factor
 Inability to absorb nutrients
 Inability to digest food
 Psychological factors

Diagnose 3: Activity Intolerance

1. Definition
Insufficient physiological or psychological energy to continue or complete daily
activities that you want or need to do.
2. Characteristic limits
 Discomfort or dyspnea during activities
 Report verbal fatigue and weakness
 Heart frequency and blood pressure are abnormal in response to activity .
 Ecg changes that indicate arrhythmia or ischemia.
3. Related factors
 Bed rest and immobility
 General weakness
 An imbalance between oxygen supply and needs .
 A sedentary lifestyle

1.3.3 Planning

No Nursing Diagnose GOAL Intervention

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
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
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
R: Efforts to improve
electrolyte and fluid
balance and are carried
out through parenteral
therapy to tolerate normal
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 .

2 Into nutritional After nursing action 1 x 1) Review the TTV client .

imbalance: less than
24 hours, maternal R:U to know the
need body
nutritional needs are general condition of the
fulfilled with patient .
the patient's outcome 2) Weigh and record the
criteria saying increased patient's weight at the
appetite . same time every day .
R:To get the most
accurate reading .
3) Monitor patient intake
and output
R : Because weight can
increase as a result of
liquid retention .
4) Assess and record the
bowel sounds of the
patient one each time
each task is maintained.
R : To control the
increase and decrease
5) Auscultation and record
the patient's breathing
sounds every 4 hours .
R : To monitor
aspirations .
6) To consult in preparing a
menu arrangement plan
that meets nutritional
needs during pregnancy .
R : Adequate maternal
nutrition is very
important for maternal
health. Starting oral
administration .
7) Discuss the importance
of adequate nutrition
R : Arrange an
appointment with a
dietitian and the growth
and development of the
fetus .
8) Monitor client weight
R: Knowing fetal and
maternal development
3 Activity Intolerance a. Tolerate 1) Determine the cause of
activities that are activity intolerance &
usually done, as determine whether the
evidenced by causes of physical,
tolerance of psychological /
activity, motivational.
endurance, R: Determining
energy savings, causes can help
physical fitness, determine
psychomotor intolerance.
energy, and self- 2) Assess the suitability of
care, ADL. daily client activities &
b. Indicates activity breaks
tolerance, as R: Too long bedrest
evidenced by the can contribute to
following activity intolerance.
indicators: 3) Gradually increase
extreme, heavy, activity, let clients
moderate, mild, participate can change
no interference: position, move & self-
 Oxygen care.
saturation R: Increased activity
during helps maintain
activity muscle strength,
 Respiratory tone .
frequency 4) Make sure the client
during changes positions
activities gradually. Monitor
 The ability to symptoms of activity
speak during intolerance.
physical R: Bedrest in a supine
activity position causes
c. Demonstrating plasma volume →
energy savings, postural hypotension
as evidenced by & syncope.
the following 5) When helping clients
indicators: never, stand up, observe
rarely, intolerance symptoms
sometimes, often, such as nausea, pallor,
always: dizziness, awareness
 Realizing the disorders & vital signs.
limitations of R: TV & HR
energy response to
 Balance orthostasis is very
activity and diverse .
rest 6) Perform ROM exercises
 Set an if the client cannot
activity tolerate the activity.
schedule to R: Inactivity
save energy. contributes to muscle
strength & joint

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