Situation #1:

Crystel G1P0 at 23 weeks pregnant was admitted today with chief complaint of nausea and vomiting. Her vital signs are: BP =
130/90, PR = 90/min, T = 36.8. Pt is looking pale and lethargic.
History of Present Illness: 1 day before admission she felt nauseated, she is having headaches and looking lethargic, and then after
an hour the patient vomited constantly. Pt was given fluids from time to time. As verbalized by the pt, “Sumasakit talaga ang ulo ko at
nasusuka talaga ako. Kahit anong kainin ko parati akong nasusuka kaya konti nalang ang nakakain ko.”

BIOGRAPHIC DATA

Name: AREVALO, Crystel G.

Age: 21 years old
Gender: Female
 Status: Married
Religion: R. Catholic
Address: Mercedes, ZC
Chief complaint: Continuous nausea and vomiting
OB Score: G1TPAL
History of Present Illness: Vomiting prior to admission
History of Past Illness: None
Family History: Hypertensive, diabetic
Social History:

Vital Signs:
BP = 130/90
RR = 16/bpm
PR = 90/min
T = 38.8c
General Appearance:
 The patient is conscious, well-oriented of his present condition and showed interest with the interview by answering every
question instantaneously.
 Upon receiving the patient, the patient was pale-looking and lethargic. At the moment, the patient is continuously vomiting.
 The patient is not relaxed due to constant vomiting.
 The patient has facial grimace.

CEPHALOCAUDAL ASSESSMENT
Skin: The client’s skin is uniform in color, although she is looking pale and no presence of any foul odor. Se has a good skin turgor
and skin’s temperature is within normal limit.
Hair: The hair of the client is thick, silky hair is evenly distributed and has a variable amount of body hair. There are also no signs of
infection and infestation observed.
Nails: The client has a light brown nails and has the shape of convex curve. It is smooth and is intact with the epidermis. When nails
pressed between the fingers (Blanch Test), the nails return to usual color in less than 4 seconds.
Head and Face: The head of the client is rounded; normocephalic and symmetrical. The face of the client appeared smooth and has
uniform consistency and with no presence of nodules or masses.
Eye: The Bulbar conjunctiva appeared transparent with few capillaries evident. The sclera appeared white. The palpebral conjunctiva
appeared shiny, smooth and pink. There is no edema or tearing of the lacrimal gland. Cornea is transparent, smooth and shiny and
the details of the iris are visible. The client blinks when the cornea was touched. The pupils of the eyes are black and equal in size.
The iris is flat and round. PERRLA (pupils equally round respond to light accommodation), illuminated and non-illuminated pupils
constricts. Pupils constrict when looking at near object and dilate at far object. Pupils converge when object is moved towards the
nose.
Ear: The Auricles are symmetrical and has the same color with his facial skin. The auricles are aligned with the outer canthus of eye.
When palpating for the texture, the auricles are mobile, firm and not tender. The pinna recoils when folded. During the assessment of
Watch tick test, the client was able to hear ticking in both ears.
Nose and throat: The nose appeared symmetric, straight and uniform in color. There was no presence of discharge or flaring. When
lightly palpated, there were no tenderness and lesions
Mouth: The lips of the client are looking pale and dry.
Chest and lungs: The chest wall is intact with no tenderness and masses. There’s a full and symmetric expansion and the thumbs
separate 2-3 cm during deep inspiration when assessing for the respiratory excursion. The client manifested quiet, rhythmic and
effortless respirations.
Abdomen: The abdomen of the client has an unblemished skin and is uniform in color. The abdomen has a symmetric contour.
There were symmetric movements caused associated with client’s respiration.
Extremities: The muscles are not palpable with the absence of tremors. They are normally firm and showed smooth, coordinated
movements. There were no presence of bone deformities, tenderness and swelling. There were no swelling, tenderness and joints
move smoothly.
GORDON’S 11 FUNCTIONAL PATTERNS

I – Health Perception/Health Management The patient’s current health is that she is unable to digest the food that
she eats and she is in a continuous nausea and vomiting. She
mentioned that she tries to drink fluids in order to cope up the loss that
she had when she was vomiting. The patient is scared to eat again
because she thinks that she will just end up vomiting the food that she
takes in. She does not drink any alcoholic drinks, no signs of smoking,
no consumes drugs. The patient wants to know why she is constantly
vomiting and what she can do to prevent from feeling nauseated and
vomiting.
II – Nutritional – Metabolic Before the confinement, the patient mentioned that she has been
vomiting. Her fluid intake was around 6-8 glasses of water per day.
She tries to avoid food that may trigger her nausea and vomiting such
as spicy food.
During confinement, the patient still feels nauseated and has
continuous vomiting. She continuously drinks 6-8 glasses of water but
averts herself from eating due to fear of vomiting again.
III – Elimination The patient stated that during her confinement for 3 days, she had
normal bowel movements and defecates every morning. In terms of
urinary elimination, it depends upon her liquid intake. Its characteristic
would always be light yellow.
IV – Activity – Exercise The patient stated that she feels weak as of the moment, she feels
nauseated and has the urge to vomit from time to time. She looks
lethargic and was asked by the doctor to have a complete bed rest.

Feeding Grooming

Bathing General Mobility

Toileting Cooking

Bed Mobility Home Maintenance

Dressing Shopping
 The patient has no deficit in hearing, seeing, and touching. The patient
V – Cognitive – Perceptual is well oriented and mentally fit evidenced by her cooperative attitude
during the assessment and interview. Although she is feeling stressed
and anxious at times when she starts to feel nauseated.
VI – Sleep-Rest On pre-confinement the patient is unable to sleep for 6 to 8 hours
straight due to the nausea she is feeling. Every morning she would
rush to the toilet in order to vomit.
During confinement, the patient has only around 4 – 6 hours of sleep.
She has trouble sleeping because she feels nauseated and gets up in
the morning to rush to the toilet to vomit.
VII – Self-Perception/Self-Concept The patient maintains an upright posture and speaks with a soft tone,
she is willing to listen and learn how to alleviate the nausea and
vomiting.
VIII – Role-Relationship The patient has been working as an assistant manager in their family
business. Aside from that she is a loving wife and a waiting mother to
be.
IX – Sexuality-Reproductive Before giving birth to her first baby, the patient was sexually active
since they are trying to have their first child
X – Coping/Stress Tolerance The patient is an optimistic person and tries to look for the solution to
every problem that she encounters in her life. She is the type of
person who is motivated to look for solutions when it comes to her
baby.
XI – Value-Belief She is a devoted Roman-Catholic, she hears the mass every Sunday
and performs the Holy Rosary at night. She has a strong fait to God.

CUES NURSING DIAGNOSIS

Subjective: Imbalanced nutrition: less than body requirements r/t inability to
“Sumasakit and ulo ko at nasusuka talaga ako. Kahit anong digest nutrients (prolonged vomiting)
kainin ko parati akong nasusuka kaya konti nalang ang nakakain
ko” As verbalized by the patient

Objective:
Lethargic
BP = 130/90mmHg
Antihistamines OBJECTIVES CONTENT STRATEGY TIME ALLOTMENT EVALUATION
and other anti-
nausea
medications
Subjective: At the end of the 1 Interactive lectures Instant oral
“Sumasakit and ulo hour session, the with visual images feedback – the
ko at nasusuka patient will be able and demonstration learner will be able
talaga ako. Kahit to: to give feedbacks
anong kainin ko on the topic to be
parati akong The mother will be discussed
nasusuka kaya able to understand What is
konti nalang ang what Hypermesis Hyperemesis 5 minutes Question and
nakakain ko” As Gravidarium is Gravidarium? Answer
verbalized by the -Hyperemesis
patient. The mother will be Gravidarium is
able to learn the extreme, persistent
Objective: different non- nausea and
BP = 130/90mmHg pharmacological vomiting during
PR = 90/min ways on how to pregnancy that
T = 36.8c alleviate nausea persists after the
and vomiting first trimester. It can
lead to dehydration,
weight loss, and
electrolyte
imbalances. Other
common symptoms
may include fatigue,
weakness, and
dizziness.
- It usually occurs
with the first
pregnancy and
commonly affects
pregnant women
with conditions such
as hydatidiform
mole or multiple
pregnancy that
produces a high
level of human
chronic
gonadotropin.

What are the

different non- 15 minutes
pharmacological
ways on how to
alleviate nausea
and vomiting?
DIET
- Eat small meals
often throughout the
day rather than 3
large meals. This
can help keep your
stomach from being
empty.
- Choose food that
are high in
carbohydrates.
Eating foods high in
protein may also
help. Limit greasy or
spicy food.
- Before getting out
of bed, try eating
crackers or dry
toast. This may help
settle your stomach.

- Drink cold, clear

liquids. Drinking
small amounts of
liquids with
electrolytes ie sports
drink may help as
well.
- Remain upright for
45 minutes after
eating to decrease
reflex.
AVOID TRIGGERS
-  One of the most
important
treatments for
pregnancy-related
nausea and
vomiting is to
avoid odors,
tastes, and other
activities that
trigger nausea.
Eliminating food
triggers, like spicy
foods, helps some
women. Other
examples of
triggers include:
stuffy rooms,
odors, heat and
humidity, noise,
visual or physical
motion, and etc.

COMPLEMENTARY
TREATMENTS
- Relaxation
techniques
- Acupuncture and
acupressure
-Hypnosis
- Ginger

What are the 5 minutes

pharmacological
measures that can
be used?
MEDICATIONS
- Vitamin B6 and
doxylamine
- Antihistamines and
other anti-nausea
medications:
Diphenhydramine
(Benadryl),
Meclizine
- Other anti-nausea
medications that are
available by
prescription include:
Promethaizine
(Phenergen),
Metoclopramide
(Reglan),
Ondansetron
(Zofran),
Prochlorperazine
(Compazine),
Corticosteroids, etc.

When do you seek 5 minutes

for help or medical
advice?
Call your medical
provider if any of
these occur:
- Signs of
dehydration: dry
mouth, extreme
thirst, dark urine or
little urine output,
dizziness,
weakness, or
fainting.
- Vomiting that won’t
stop.
- Frequent diarrhea
- Weight loss or no
weight gain over a
2-week period
- Severe constant
pain the lower right
abdomen
- Fever over 100.4
°F (38°C) or higher