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Patient is a 20-year-old gravida 1 para 0 at 12 weeks’ gestation with continuous nausea and continual vomiting x 3 weeks and onset of dizziness, lightheadedness, and difficulty concentrating 2 days ago. Direct admit from office earlier today. History of marijuana/cocaine use until week 6. Smokes half a pack of cigarettes per day. No alcohol. Poor social support; father of the baby not currently involved. History of anxiety/depression controlled by sertraline 50 mg per day.
Orthostatic hypotension. Pulse, respiratory rate, and temperature are stable. Alert and oriented x 4; steady gait. Dry, cracked mucous membranes. S1 S2 with no murmur, rub, or gallop. Lungs clear all fields bilaterally. Spot check of fetal heart tones with Doppler: 156 beats per minute. Point of care random glucose 96. Is down 8 lb from prepregnancy weight. Labs reviewed. 

Assessment: Hyperemesis gravidarum with metabolic disturbance. Intrauterine pregnancy at 12 weeks’ gestation. 

Plan: Change IV fluid hydration to dextrose 5% in lactated Ringer’s at 125 mL/hr. Nothing by mouth. Continue promethazine 25 mg IV every 6 hours as needed for nausea/vomiting. Add ondansetron 4 mg IV every 6 hours as needed for nausea/vomiting. Sertraline 50 mg daily. Social work consult ordered. 

Primary Diagnosis: Hyperemesis gravidarum 

Secondary Diagnosis: Pregnant, 12 weeks’ gestation

I need a nursing diagnosis for this situation and what problems I may encounter providing care for a baptist young women as a male nurse 

 

 

 

 

SCIENCE
HEALTH SCIENCE
NURSING
BSN 225

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