- Acute pain related to hormonal imbalance as evidenced by appetite change, Nausea and Vomiting
- Deficient fluid Volume related to nausea and vomiting and inadequate fluid and food intake as evidenced by altered skin turgor, dry mucous membranes and weakness
- Deficient Knowledge related to insufficient information and unfamiliarity of condition as evidenced by inaccurate follow-through of instructions and inaccurate statements about the condition
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective Data: -Verbal reports from the patient -Expressions of pain, such as crying -Unpleasant feeling (such as a prick, burn, or ache) Objective Data: -Significant changes in vital signs -Changes in appetite or eating patterns -Changes in sleep patterns -Guarding or protective behaviours | Acute pain related to hormonal imbalance as evidenced by appetite change, Nausea and Vomiting | -Patient will report decreased pain along with manageable nausea and vomiting symptoms. -Patient will perform interventions to help relieve abdominal discomfort, nausea, and vomiting | 1. Encourage small, frequent meals. Patients diagnosed with hyperemesis gravidarum can benefit from eating small, frequent meals of bland and dry foods like toast and crackers, as this can help alleviate gastrointestinal upset and reduce nausea, vomiting, and abdominal pain. 2. Encourage the patient to avoid greasy and spicy foods. Eating spicy and greasy foods can cause further stomach upset and aggravate nausea, vomiting, and abdominal pain in patients diagnosed with hyperemesis gravidarum. 3. Administer medications as indicated. Combining OTC pyridoxine and doxylamine may be effective for nausea during pregnancy. 4. Consider an ultrasound or imaging tests. If abdominal pain is severe or felt in the RUQ, an ultrasound or other imaging test can rule out other causes like appendicitis or gallstones. 5. Encourage non-pharmacological pain interventions. Non-pharmacological pain interventions like relaxation techniques, massage, guided imagery, and heat can help reduce abdominal pain. | Patient reported relief in pain. Patient rated the pain scale lower than the initial rate at a level that is acceptable to them or 0/10. Patient manifested vital signs within normal limits. Patient verbalized regaining appetite and sleep. |
| Subjective Data: -Weakness -Fatigue Objective Data: -Dehydration | Deficient fluid Volume related to nausea and vomiting and inadequate fluid and food intake as evidenced by altered skin turgor, dry mucous membranes and weakness | -Patient will remain adequately hydrated, as evidenced by urine output within normal limits. -Patient will deny the presence of dizziness, weakness, or faintness. | 1. Evaluate and monitor laboratory values. With excessive and prolonged vomiting, fluid loss and electrolyte imbalances occur. When potassium and magnesium are low, complications such as cardiac dysrhythmias and altered kidney function can occur. 2. Administer intravenous fluid replacement as ordered. Intravenous fluid replacement can help manage fluid loss, prevent dehydration, and correct electrolyte imbalances in patients with hyperemesis gravidarum. 3. Provide ice chips. The patient may not be able to tolerate large quantities of food or liquids. Ice chips can feel soothing and support hydration 4. Promote safety. Dehydration can cause feelings of dizziness and fainting. Ensure the pregnant patient’s safety by always assisting with ambulation, encouraging non-slip socks, and keeping bed rails upright. | -Patient’s vital signs remained stable and/or return to patient’s baseline. -Patient’s intake and output is stabilized. -Patient’s lab values returned to baseline. -Patient verbalized measures to take at home to maintain hydration/prevent dehydration. |
| Subjective Data: – Patient verbalize that she is not able to follow through Objective Data: -Inadequate knowledge | Deficient Knowledge related to insufficient information and unfamiliarity of condition as evidenced by inaccurate follow-through of instructions and inaccurate statements about the condition | -Patient will verbalize understanding of the condition, its complications, and the treatment regimen. -Patient will verbalize or demonstrate appropriate interventions to control nausea and vomiting. | 1. Educate the patient about the signs and symptoms of hyperemesis gravidarum. While the exact cause of hyperemesis gravidarum is unknown, it is believed to be due to the rapid increase of HCG and estrogen production during pregnancy. Educating the patient on the signs and symptoms of the condition and controlling fluid loss is important to prevent complications. 2. Use a patient-centered approach to engaging the patient in learning. Various teaching methods are available depending on the patient’s preference and style, ensuring positive teaching outcomes. Utilize printed materials, approved online resources, and verbal education to meet the learning styles of all patients. 3. Request verbalization of teaching. The patient must understand the importance of maintaining hydration and preventing fluid loss that could result in electrolyte imbalances. Ask the patient to teach-back signs and symptoms of dehydration and when to seek medical assistance. 4. Refer the patient to appropriate support and community groups. The patient may benefit from peer support groups where women share their personal experiences. Hearing the stories of other women with hyperemesis gravidarum and how they managed their symptoms can help the pregnant patient feel less alone. | -Patient verbalized that she understood the condition, its complications, and the treatment regimen. -Patient verbalized and demonstrated appropriate interventions to control nausea and vomiting. |