Minggu 5 Lp Hiperemesis Gravidarum.docx

INTRODUCTION REPORT HYPEREMESIS GRAVIDARUM 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 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. 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 uterus. 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 tube. 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 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 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 1

Nursing Diagnose

Lack of fluid volume

GOAL

Intervention

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 . 2

Into nutritional imbalance: less than need body

After nursing action 1 x 1) Review the TTV client . 24 hours, maternal R:U to know the 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 activities that are usually done, as evidenced by tolerance of activity, endurance, energy savings, physical fitness, psychomotor energy, and selfcare, ADL. b. Indicates activity tolerance, as evidenced by the following indicators: extreme, heavy, moderate, mild, no interference:  Oxygen saturation during activity  Respiratory frequency during activities  The ability to speak during physical

1) Determine the cause of activity intolerance & determine whether the causes of physical, psychological / motivational. R: Determining causes can help determine intolerance. 2) Assess the suitability of daily client activities & breaks R: Too long bedrest can contribute to activity intolerance. 3) Gradually increase activity, let clients participate can change position, move & selfcare. R: Increased activity helps maintain muscle strength, tone . 4) Make sure the client changes positions gradually. Monitor symptoms of activity intolerance. 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 structure

BIBLIOGRAPY Hartono Andry. ( 1999 ) . Maternity Care Issue 2 . Jakarta: EGC 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 Mansjoer, Arif. (2001). Kapita Selekta Medicine . Jakarta. Erlangga Mochtar, Rustam (1998). Synopsis of Obstetrics . Jakarta. Salemba Medika Nurarif, A, H and Kusuma, H. (2016) . Practical nursing care based on the application of Nanda diagnosis, NIC, NOC in various cases . Yogyakarta Prawirohardjo Sarwono. ( 2002 ) . Midwifery. Jakarta: Trisada Printer Denise's Tiran. ( 2006 ) . Pregnancy Nausea and Vomiting Midwifery Care Series . Jakarta: EGC