Emergency Nurse Protocol

Adult Emergency Nurse Protocol HYPEREMESIS GRAVIDARUM 20XX

Aim:  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:  Positive βHCG (urine or blood)  Vomiting  Nausea  Dehydration (mild-moderate)  Dry mucosa  Dizziness / Lightheadedness Escalation Criteria: Immediate life-threatening presentations that require escalation and referral to a Senior Medical Officer (SMO):  Hemodynamic instability  Severe dehydration  Pregnancy > 20 weeks gestation

 Headache or Visual Abnormalities  Abdominal or Epigastric pain  Fever  Seizure  Chest Pain  Dysponea Primary Survey:  Breathing: resp rate, accessory muscle use, air entry,  Airway: patency SpO2.  Circulation: perfusion, BP, heart rate, temperature  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  Airway – at risk  Breathing – respiratory distress  Circulation – shock / altered perfusion  Partial / full obstruction  RR < 5 or >30 /min  HR < 40bpm or > 140bpm

 SpO2 < 90%  BP < 90mmHg or > 200 mmHg  Disability – decreased LOC  Exposure  Postural drop > 20mmHg  GCS ≤ 14 or a fall in GCS by 2  Temperature <35.5°C or >38.5°C  Capillary return > 2 sec points  BGL < 3mmol/L or > 20mmol/L  Seizure History:  Presenting complaint  Allergies  Medications: Anticoagulant Therapy, Anti-hypertensives, Diabetic meds, Analgesics, Inhalers, Chemotherapy, Non- prescription 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.  Lethargy / fatigue  Nausea / protracted vomiting  Confusion / delirium  Abdominal pain  Muscle weakness / cramps  Hypotension  Proteinuria  Severe headache  Anuria (no urine output)  Cardiac arrhythmias  Severe dehydration  Decreased urine output <80mls over 4 consecutive hours) Investigations / Diagnostics: Bedside: Laboratory / Radiology:

Hyperemesis Gravidarum – Adult Emergency Nurse Protocol Page 1  BGL: If < 3 or > 20mmol/L notify SMO   Pathology: Refer to local nurse initiated STOP  ECG: [as indicated] looks for changes suggesting FBC, UEC, LFTs (moderate-severe dehydration) hypokalaemia or hypocalcemia  Group and Hold (if bleeding suspected) Blood Cultures (if Temp ≤35 or ≥38.5°C)  Urinalysis / MSU (if indicated)  Radiology: Not generally indicated

Hyperemesis Gravidarum – Adult Emergency Nurse Protocol Page 2 Adult Emergency Nurse Protocol HYPEREMESIS GRAVIDARUM 20XX

Nursing Interventions / Management Plan: Resuscitation / Stabilisation: Symptomatic Treatment:  Oxygen therapy & cardiac monitor [as indicated]  Antiemetic: as per district standing order  IV Cannulation (16-18gauge if unstable)  Analgesia: as per district standing order  IV Fluids: Sodium Chloride 0.9% 1 Litre IV stat (discuss  IV Fluids: as per district standing order with SMO)

Supportive Treatment:  Fluid Balance Chart (FBC)  Nil By Mouth (NBM) or  Urinalysis: Ketones and Specific Gravity  Trial of Fluids  Bowel chart [as indicated]  Monitor vital signs as clinically indicated  Consider devices: IDC, Nasogastric tube [as indicated] (BP and postural BP, HR, T, RR, SpO2)  Monitor pain assessment / score Practice Tips / Hints:  Defined as persistent vomiting, volume depletion, ketosis, electrolyte disturbances and weight loss.2  Typical Presentation in weeks 4-7 after LMP2  Concentrations of sodium, potassium and chloride may be reduced from low intake resulting in hypokalemic alkalosis.3  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  ECG changes suggesting Hypocalemia include a prolonged QT interval. The patient may also experience hypotension. 5  Preelampsia exhibits signs and symptoms of headache, visual abnormalities, abdominal pain, epigastric pain, chest pain and dyspnea.  Observe for ketotic (acetone) breath.2  Pregnant women should avoid > 12hrs without meals to avoid hypoglycaemia.3  Delay in treatment in hyperemesis can cause intrauterine growth restriction. 3  Patient education is important as most of the treatment includes dietary changes.  Patient factsheets can be located through the UpToDate website or http://www.uptodate.com/contents/hyperemesis- gravidarum-the-basics?source=search_result&search=hyperemesis+gravidarum&selectedTitle=3%7E73 Further Reading / References: 1. 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-PACE- MgtOfTheDeterioratingAdultMaternityInpatient.pdf. 2. BMJ: http://bestpractice.bmj.com.acs.hcn.com.au/best-practice/monograph/999.html 3. Pillitteri, A. 2003. Maternal & Child Health Nursing: Care of the Childbearing & Childrearing Family, 4th ED. Lippincott Williams & Wilkins, Philadelphia. 4. UpToDate (2013) Clinical Manifestations and Treatment of Hypokalemia. Accessed 2014, from: http://www.uptodate.com/contents/clinical-manifestations-and-treatment-of-hypokalemia? source=search_result&search=hypokalemia&selectedTitle=1%7E150 (2013) 5. UpToDate (2013) Clinical Manifestations of Hypocalcemia. Accessed 2014, from : http://www.uptodate.com/contents/clinical-manifestations-of-hypocalcemia? source=search_result&search=hypocalcemia&selectedTitle=4%7E150 (2013) 6. 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:  Murphy, M (2007) Emergency Department Toolkits. Westmead Hospital, SWAHS  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 Page 3 Hyperemesis Gravidarum – Adult Emergency Nurse Protocol Page 4