SRI GURU RAM DASS NURSING
INSTITUTE PANDHER, AMRITSAR.
CASE PRESENTATION
ON
HYPEREMESIS
GRAVIDARUM
Submitted To: DR.
Sukhdeep Kaur
(Associate
Professor)
(Head of Deptt.)
OBG. & Gynae
Submitted By: Kartik
Kishore
M. Sc. Nursing
(1st year)
PATIENT'S IDENTIFICATION DATA:
Name of Patient: Mrs. Simranpreet kaur
Age / sex: 27yrs / female
Education: Graduate
Occupation: House wife
Blood Group: B +ve
Marital status: Married
Religion: Sikh
Name of Husband: Mr. Roop Singh
Education: Graduate
Occupation: Self Business
Total Income: 25,000 per month
Address: Amritsar
Date of admission: 20-02-2020
C.R. No.: 65228
I.P.D. No: 202020118
Obstetrical Score: G-2, P-1, A-0, L1
LMP: 07-12-2020
EDD: 14-09-2020
Doctor Incharge: Dr. Raksha Gupta
Diagnosis: Hyper-emesis Gravidarum
CHIEF COMPLAINTS: The chief complaints of the patient are Nausea, vomiting,
dehydration and weight loss since 1 week with pregnancy.
HISTORY OF PRESENT ILLNESS:
1) MEDICAL HISTORY: Patient has admitted in hospital with the chief complaints
of Nausea, vomiting, dehydration and weight loss since 1 week with pregnancy. After
investigations doctor diagnosed her as Hyper-emesis Gravidarum. Now she is under
treatment in Bebe Nanki Hospital, Pandher.
2) SURGICAL HISTORY: No any significant of present surgical history.
HISTORY OF PAST ILLNESS:
PAST MEDICAL HISTORY: No any significant of past medical history.
PAST SURGICAL HISTORY: No any significant of past surgical history.
FAMILY HISTORY: Patient lives in joint family with her husband. All the family
members are good & healthy. No any medical or congenital disorder present in
family.
FAMILY MEMBERS:-
S NAME OF AGE/ RELATIONSHIP EDUCATION Occupation HEALTH
No. FAMILY SEX WITH CLIENT STATUS
MEMBERS
1. Mr. Roop 30y/M Husband Graduate Shopkeeper Healthy
Singh
2. Mrs. 27y/F Patient Graduate Housewife Unhealthy
Simranpreet
Kaur
3. Mst. Ambar 3y/M Son - - Healthy
singh
FAMILY TREE
Mr. Roop Singh Mrs. Simrapreet kaur
30 yrs old 27 yrs old
Mst. Ambar Singh
3 years old
Keys:
Male
Female patient
MENSTRUAL HISTORY:
Age of menarche: 13 years
Duration of cycle: 30 days
Number of days: 5 days
Flow: Normal
Discomfort during menstruation: Mild Dysmenorrhoea
MARITAL HISTORY:
Age of Marriage: 23 years
Nature of marriage: Arranged marriage
OBSTETRICAL HISTORY:
S. Year/ Pregnancy LABOUR Method Puerperium BABY WEIGHT AT
No. Date Event / BIRTH/SEX/DURATION
Delivery OF BREAST FEEDING
1. 2017 About 36 Normal Normal 6 weeks 1) 3 Kg birth weight/
weeks vaginal vaginal (Normal) Male baby/ 1 year
delivery delivery breast feeding
(1st) duration
2. 2020
PRESENT PREGNANCY
Number of living children : 1 Baby
Health status of babies : Healthy
Immunization : Partial
Last Issue : No any last issue
PRESENT OBSTETRICAL DETAILS:
Last menstrual period : 10-01-2020
Expected date of delivery : 17-09-2020
SOCIO-ECONOMIC STATUS:
Type of house : Cemented house
Number of Rooms : 3 rooms
Total income per month : 30,000 from all sources
Latrine facility : Available
Drainage facility : Good
PERSONAL HISTORY:
Sleeping pattern : About 9 hours
Diet Habit : Disturbed due to vomits
Bowel and bladder Habit : Good
Allergic to diet : No any significant
Personal hygiene : Good
Amount of water intake :10-12 glasses per day
PHYSICAL EXAMINATION:
GENERAL APPEARANCE:
Nourishment : Moderate
Body Build : Moderate
Health : Unhealthy
Activity : Dull
VITAL SIGNS:
Temperature : 99 F
Pulse : 86/min
Respiration : 20/min
B.P : 100/60mm (Hg)
MENTAL STATUS:
Consciousness : Conscious
Look : Depressed
POSTURE:
Body curves : Normal
Movement : Allowed
HEIGHT & WEIGHT:
Height : 5’4”
Weight : 58 kg
SKIN CONDITION:
Colour : Fair
Texture : Normal
HEAD:
Hair Colour : Black
Texture of hairs : Rough
Dandruff : Present
Scalp : Clean
EYES:
Eye brows : Symmetrical
Conjunctiva : Normal
Eye Lids : No infection present
Pupillary reaction : Reacting to light
Vision : Normal
Sclera : White
NOSE:
Nasal drainage : Absent
Nostrils : Normal
Epistaxis : Absent
MOUTH:
Lip colour : Pink
Lip Texture : Rough
Teeth : Pale yellow in colour (Normal)
Colour of teeth : Pale yellow
Dental carries : Absent
Gums : No inflammation
TONGUE:
Colour : Pink
Pharynx : Normal
EAR:
Alignment : Normal (Symmetrical)
Discharge : Absent
Hearing : Normal
NECK:
Range of motion : Normal
Lymph nodes : Not palpable
Thyroid glands : Normal, no enlargement
CHEST:
Chest measurement : Normal
Respiratory rate : 24 per minute
Breath sound : Normal, no wheezing sound
Heart sound : S1 and S2 sound present
BREAST:
Shape : Round
Axillary lymph nodes : Not palpable
Nipples : Symmetrical, not cracked and not inverted
Discharge : No any abnormal discharge present
NAILS:
Shape : Round
Texture : Smooth
Colour : Pink
ABDOMEN:
Inspection:
Skin colour : Fair
Linea nigra : Present
Umblicus: Round
Striae gravidarum: Absent
Palpation : Abdominal organs are normal
Auscultation : Normal bowel sound
BACK:
Back ache : Absent
Lesions : Absent
EXTREMITIES:
Deformities : No any deformity present
Edema : Absent
Range of motion : Proper
GENITALIA:
Lesions : Absent
Inguinal lymph node : Present
Anal patency : Good
VITAL SIGNS:
S. VITALS PATIENT NORMAL REMARKS
No VALUE VALUE
1 Temperature 99 F 98.6F Pyrexia
2 Pulse 86/Min 72-80/ Min Tachycardia
3 Respiration 20/min 16-24/ Min Normal
4 B.P 100/60 mm(Kg) 120/80 mm (hg) Hypotension
INVESTIGATIONS:
Ultra sonography (USG): Normal gestational period. Level of AFI is normal.
Liver function test: Elevated liver enzymes and serum amylase.
Serum Electrolyte test: hypokalemia ketones in blood and urine.
Urine analysis: Concentrated urine in small quantities with high specific
gravity with the presence of acetone and with diminished or absent chloride.
LAB INVESATIGATION:
S. NO TEST PATIENT VALUE NORMAL VALUE
1. TLC 10,200/cu mm 4-11000/cu mm
2. DLC :
Polymorph 59% 50-60%
Neutrophils 43% 40-70%
Eosinophil 2% 1-6%
Basophils 1% 0-1%
3. Blood group B +ve -
4. Hb% 10 gm 12-16gm
5. Blood sugar F-90mg/dl 70-130mg/dl
6. Serum 3.2 g 3.5-4.5g
potassium
7. S. Sodium 130 g 135-145mg
(Na+)
8. HIV Negative -
9. HbsAg Negative -
10. Bleeding time 1’-6” min 0-5 min
11. Clotting time 4’-16” min 5-10 min
12. Urine Albumin Nil Nil
13. Urine sugar Nil Nil
SUMMARY:
I have taken the patient Mrs. Simranpreet kaur, 27 years old, diagnosed with
Hyperemesis gravidarum. She came in hospital with the chief complaints of nausea,
vomiting, weakness and weight loss since1 week. Advise is given to take proper rest,
nutritious diet and plenty of fluids.
In this case presentation, I have presented:-
Introduction of patient
Obstetrical history
Menstrual history
Personal history
Physical examination
Investigations
Medications
Disease condition
Nursing diagnosis and
Health education
RECAPITULATION:
After this presentation, group will able to give answers to my questions:
Define Hyperemesis gravidarum?
Explain causes of Hyperemesis gravidarum?
What are the sign and symptoms of Hyperemesis gravidarum?
Explain diagnostic evaluation of Hyperemesis gravidarum?
What are the managements of Hyperemesis gravidarum?
Explain its complications and nursing management?
CONCLUSION
Through this case presentation, Group has learned about Hyperemesis gravidarum, its:
Definition
Causes
Clinical manifestations
Diagnostic evaluations
Managements
Complications and its
Nursing management
Now, they have sufficient knowledge about placenta previa that will helpful for them
in future.
HEALTH EDUCATION:
Regarding Diet:
Instruct the client to take meal thrice in a day.
Instruct the client to avoid more spicy & fatty food.
Instruct the client to take high caloric and iron rich diet.
Take plenty off fluids.
Take small and frequent meals.
Regarding Activity:
Teach the client to take the proper rest & sleep.
Instruct client to avoid heavy weight lifting.
Regarding Hygiene:
Instruct the client & family members to maintain proper personal &
environmental hygiene.
Teach the client & family members about hand washing methods.
Regarding Treatment:
Instruct the client to complete her full course of medications.
Instruct the client about every procedure done on client.
Instruct client about common side effects of medicines.
Regarding Follow-up:
Instruct the client for follow up visits.
Instruct the woman to notify her health care provider if she experiences any
change in health.
BIBLIOGRAPHY:
Dutta DC “A textbook of obstetrics sixth edition” published by –Hiralal
Konar.
William & Wilkins, Lippincott “A textbook of Manuals of Nursing Practice 9th
edition” published by- Wolters Kluwer.
Kumari Neelam, Sharma Shivani, Dr. Gupta Preeti “A text book of Midwifery
and Gynaecological Nursing” Published by Pee Vee.
