Download Hyperemesis Gravidarum

Adult Emergency Nurse Protocol
20XX
HYPEREMESIS GRAVIDARUM
Aim:
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Early identification and treatment of hyperemesis gravidarum and escalation of care for patients at risk.
Early initiation of treatment / clinical care and symptom management within benchmark time.
Assessment Criteria: On assessment the patient should have one or more of the following signs / symptoms:
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Positive βHCG (urine or blood)
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Vomiting
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Nausea
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Dehydration (mild-moderate)
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Dry mucosa
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Dizziness / Lightheadedness
Escalation Criteria: Immediate life-threatening presentations that require escalation and referral to a Senior Medical
Officer (SMO):
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Hemodynamic instability
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Severe dehydration
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Pregnancy > 20 weeks gestation
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Headache or Visual Abnormalities
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Abdominal or Epigastric pain
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Fever
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Seizure
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Chest Pain
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Dysponea
Primary Survey:
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Airway: patency
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Circulation: perfusion, BP, heart rate, temperature
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Breathing: resp rate, accessory muscle use, air entry,
SpO2.
Disability: GCS, pupils, limb strength
Notify CNUM and SMO if any of the following red flags is identified from Primary Survey and Between the Flags
criteria1
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Airway – at risk
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Breathing – respiratory distress
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Circulation – shock / altered perfusion
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Partial / full obstruction
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RR < 5 or >30 /min
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HR < 40bpm or > 140bpm
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SpO2 < 90%
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BP < 90mmHg or > 200 mmHg
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Disability – decreased LOC
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Exposure
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Postural drop > 20mmHg
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GCS ≤ 14 or a fall in GCS by 2
points
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Temperature <35.5°C or >38.5°C
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Capillary return > 2 sec
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BGL < 3mmol/L or > 20mmol/L
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Seizure
History:
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Presenting complaint
Allergies
Medications: Anticoagulant Therapy, Anti-hypertensives, Diabetic meds, Analgesics, Inhalers, Chemotherapy, Nonprescription meds, Any recent change to meds
Past medical, past surgical history and pregnancy history
Last ate / drank (and what diet has been tolerated) & last menstrual period (LMP) or βHCG result
Events and environment leading to presentation
Associated signs / symptoms: urine output, headaches, dizziness and pain, muscle weakness / cramps
History: previous pregnancies (hyperemesis), family, trauma and travel (gastroenteritis & infectious colitis)
Systems Assessment:
Inspection: general appearance, mucosa, eyes (sunken), pallor.
Palpation: peripheral pulse, skin temperature, turgor, blood pressure.
Notify CNUM and Senior Medical Officer (SMO) if any of following red flags is identified from History or Systems
Assessment.
 Nausea / protracted vomiting
 Confusion / delirium
 Lethargy / fatigue
 Abdominal pain
 Proteinuria
 Cardiac arrhythmias
 Muscle weakness / cramps
 Severe headache
 Severe dehydration
 Hypotension
 Anuria (no urine output)
 Decreased urine output <80mls over
4 consecutive hours)
Investigations / Diagnostics:
Bedside:
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BGL: If < 3 or > 20mmol/L notify SMO 
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ECG: [as indicated] looks for changes suggesting
hypokalaemia or hypocalcemia 
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Urinalysis / MSU (if indicated)
Hyperemesis Gravidarum – Adult Emergency Nurse Protocol
Laboratory / Radiology:
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Pathology: Refer to local nurse initiated STOP
FBC, UEC, LFTs (moderate-severe dehydration)
Group and Hold (if bleeding suspected)
Blood Cultures (if Temp ≤35 or ≥38.5°C)
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Radiology: Not generally indicated
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Adult Emergency Nurse Protocol
20XX
HYPEREMESIS GRAVIDARUM
Nursing Interventions / Management Plan:
Resuscitation / Stabilisation:
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Oxygen therapy & cardiac monitor [as indicated]
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IV Cannulation (16-18gauge if unstable)
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IV Fluids: Sodium Chloride 0.9% 1 Litre IV stat (discuss
Symptomatic Treatment:
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Antiemetic: as per district standing order
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Analgesia: as per district standing order
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IV Fluids: as per district standing order
with SMO)
Supportive Treatment:
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Nil By Mouth (NBM) or
Trial of Fluids
Monitor vital signs as clinically indicated
(BP and postural BP, HR, T, RR, SpO2)
Monitor pain assessment / score
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Fluid Balance Chart (FBC)
Urinalysis: Ketones and Specific Gravity
Bowel chart [as indicated]
Consider devices: IDC, Nasogastric tube [as indicated]
Practice Tips / Hints:
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Defined as persistent vomiting, volume depletion, ketosis, electrolyte disturbances and weight loss.2
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Typical Presentation in weeks 4-7 after LMP2
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Concentrations of sodium, potassium and chloride may be reduced from low intake resulting in hypokalemic alkalosis.3
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ECG changes suggesting Hypokalaemia include; ST segment depression, decrease in amplitude of T wave and
increase in amplitude in U wave. Arrhythmias may also be present.4
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ECG changes suggesting Hypocalemia include a prolonged QT interval. The patient may also experience
hypotension. 5
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Preelampsia exhibits signs and symptoms of headache, visual abnormalities, abdominal pain, epigastric pain, chest
pain and dyspnea.
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Observe for ketotic (acetone) breath.2
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Pregnant women should avoid > 12hrs without meals to avoid hypoglycaemia.3
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Delay in treatment in hyperemesis can cause intrauterine growth restriction. 3
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Patient education is important as most of the treatment includes dietary changes.
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Patient factsheets can be located through the UpToDate website or http://www.uptodate.com/contents/hyperemesisgravidarum-the-basics?source=search_result&search=hyperemesis+gravidarum&selectedTitle=3%7E73
Further Reading / References:
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SESLHD Patient with Acute Condition for Escalation (PACE): Management of the Deteriorating Adult and
Maternity Inpatient SESLHD/PR283.
http://www.seslhd.health.nsw.gov.au/Policies_Procedures_Guidelines/Clinical/Other/SESLHDPR283-PACEMgtOfTheDeterioratingAdultMaternityInpatient.pdf.
BMJ: http://bestpractice.bmj.com.acs.hcn.com.au/best-practice/monograph/999.html
Pillitteri, A. 2003. Maternal & Child Health Nursing: Care of the Childbearing & Childrearing Family, 4th ED.
Lippincott Williams & Wilkins, Philadelphia.
UpToDate (2013) Clinical Manifestations and Treatment of Hypokalemia. Accessed 2014, from:
http://www.uptodate.com/contents/clinical-manifestations-and-treatment-ofhypokalemia?source=search_result&search=hypokalemia&selectedTitle=1%7E150 (2013)
UpToDate (2013) Clinical Manifestations of Hypocalcemia. Accessed 2014, from :
http://www.uptodate.com/contents/clinical-manifestations-ofhypocalcemia?source=search_result&search=hypocalcemia&selectedTitle=4%7E150 (2013)
UpToDate (2013) Pre-eclampsia, clinical features and diagnosis. Accessed 2014, from:
http://www.uptodate.com/contents/preeclampsia-clinical-features-and-diagnosis?source=see_link (2014)
Acknowledgements: SESLHD Adult Emergency Nurse Protocols were developed & adapted with permission from:
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Murphy, M (2007) Emergency Department Toolkits. Westmead Hospital, SWAHS
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Hodge, A (2011) Emergency Department, Clinical Pathways. Prince of Wales Hospital SESLHD.
Revision & Approval History
Date
Revision No.
Author and Approval
Hyperemesis Gravidarum – Adult Emergency Nurse Protocol
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