hyperemesis gravidarum - royalberkshire.nhs.uk protocols and...©rbft hyperemesis gravidarum...
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©RBFT Hyperemesis Gravidarum Inpatient ICP (V5.0 June 2019) Page 1 of 14
Hyperemesis Gravidarum In-patient Care Pathway
Likes to be known as
Admission no.
Consultant Expected date of delivery
Named Midwife Gestation at time of referral
Ward Day Assessment Unit Date of discharge
Discharged from Day Assessment Unit Iffley ward
CODE
Midwives responsibility Yellow Admission
TX Doctors responsibility
Version 5.0 June 2019 Review before June 2021
Approval Group Date
Maternity Clinical Governance 7th June 2019
Change History
Version Date Author(s), Job title Reason
Version 3.0 December 2014 Locum Consultant Obstetrician Reviewed
Version 4.0 February 2017 AN Services Manager Reviewed
Version 5.0 February 2019 AN Services Manager Reviewed
©RBFT Hyperemesis Gravidarum Inpatient ICP (V5.0 June 2019) Page 2 of 14
All members of staff who are using this Pathway use black ink and fill in this section. You can then use initials when recording care
Print Name Designation Signature Initials
How to use an Integrated Care Pathway (ICP)
Firstly, if you are going to write in the ICP you need to state your Name, Job Title and give a sample signature and initials on the front of the ICP cover
If you are recording an event which is predicted by the ICP, then you just sign against that predicted intervention in the column provided.
If your intervention is not in line with the pathway, you must record this as a variance in the variance column with the action you will take to try to bring the patient back onto the pathway.
Care given by health care assistants and student nurses must be countersigned by a registered nurse.
There are many ‘NOTES’ pages for you to write free text about the care given to the patient by you. These notes should always be dated and timed.
The ICP has been colour coded to make it easier to document your aspect of care. Black background relates to Doctors, Clear background relates to nurses and grey background relates to PAMS but check the key prior to writing.
All ICPs are chronological so you should be able track the care given very easily
Date
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Admission
Intervention Initial Reason for variance and action
taken Early Late Night
Clinical assessment Clerking completed Yes □ No □
No clinical signs of impaired liver function Yes □ No □ No clinical signs of thyrotoxicosis Yes □ No □ TPR and BP within normal range, recorded on MOWs chart (pg
Yes □ No □
Weight recorded Yes □ No □ No complaints of vomiting Yes □ No □ No complaints of nausea Yes □ No □ IV cannula site observed 4 hourly for swelling and leakage
Yes □ No □
VIP and fluid balance chart commenced (pg Yes □ No □
Investigations Urinalysis performed Ketones present
Yes □ No □ Yes □ No □
Bloods for FBC, U&E, LFT, TSH, Free T4 sent
Yes □ No □
Booking bloods and MSU sent with family origin questionnaire
Yes □ No □
(If first admission) USS requested / performed
Treatment Electrolyte replacement required Yes □ No □
Intravenous cannula sited Yes □ No □
Intravenous fluids prescribed Yes □ No □
Anti-emetics prescribed as per protocol Yes □ No □
(Diabetic women only) Blood biochemistry repeated 12 hourly. Medical staff informed of abnormal results
Yes □ No □
Yes □ No □
Anti-emetics administered Yes □ No □
Route of administration
PO IM PR PO IM PR PO IM PR
DVT prophylaxis given as prescribed Yes □ No □
Consideration given to the administration of Pabrinex and/or hydrocortisone if unable to tolerate oral fluids
Yes □ No □
Activities of daily living E L N Woman tolerating oral fluids
Tolerating usual diet
Passing good volumes of urine
Fluid balance chart in progress
Teaching and support Woman orientated to the ward Yes □ No □
Dietary advice and hyperemesis leaflet reinforced
Yes □ No □
Discharge planning Confirm demographics and existing support arrangements
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Goals for this phase: Woman hydrated, tolerating usual diet and fluids
Date / time Multi-disciplinary free text Initial
Date
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Daily Record – Day 1
Intervention Initial Reason for variance and action
taken Early Late Night
Clinical assessment Reviewed by Obstetric Registrar
FBC, U&Es, LFT’s & TFT’s results within normal range (see page 11)
Yes □ No □
IV fluids to continue Yes □ No □
Anti-emetics reviewed Yes □ No □
TPR & BP (recorded daily) within woman’s normal range
Yes □ No □
No complaints of nausea or vomiting Yes □ No □
DVT risk re assessed and actioned accordingly
Yes □ No □
VIP score 0
Investigations Urinalysis performed Ketones present
Yes □ No □
U&E’s repeated if large amount of ketones or patient still vomiting
Yes □ No □
Treatment (Diabetic women only) Blood biochemistry repeated 12 hourly.
Yes □ No □
Medical staff informed of abnormal results Yes □ No □
Anti-emetics administered regularly Yes □ No □
DVT prophylaxis given as prescribed Yes □ No □
Activities of daily living E L N Increased fluid intake continued
Tolerating usual diet
Has had bowels open since admission
Passing good volumes of urine
Fluid balance chart continued
Hygiene needs have been met
Teaching and support Woman and carer aware of progress plan Yes □ No □
Dietary advice continued Yes □ No □
Woman confirms understanding of future symptoms to observe for /actions to be taken
Yes □ No □
Discharge planning Discharge date and time given to woman as . . . . . . . . . ……………………………………….
Administration TTO’s ordered Yes □ No □
Goals for this phase: Woman hydrated; tolerating good amounts of diet and fluids Date / time Multi-disciplinary free text Initial
Date
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Daily Record – Day 2
Intervention Initial Reason for variance and action
taken Early Late Night
Clinical assessment Reviewed by Obstetric Registrar Yes □ No □
FBC, U&Es, LFT’s & TFT’s results within normal range (see page 11)
Yes □ No □
IV fluids to continue Yes □ No □
Anti-emetics reviewed Yes □ No □
TPR & BP (recorded daily) within woman’s normal range
Yes □ No □
No complaints of nausea or vomiting Yes □ No □
DVT risk re assessed and actioned accordingly
Yes □ No □
VIP score 0
Investigations Urinalysis performed Ketones present
Yes □ No □
U&E’s repeated if large amount of ketones or patient still vomiting
Yes □ No □
Treatment (Diabetic women only) Blood biochemistry repeated 12 hourly.
Yes □ No □
Medical staff informed of abnormal results Yes □ No □
Anti-emetics administered regularly Yes □ No □
DVT prophylaxis given as prescribed Yes □ No □
Activities of daily living E L N Increased fluid intake continued
Tolerating usual diet
Has had bowels open since admission
Passing good volumes of urine
Fluid balance chart continued
Hygiene needs have been met
Teaching and support Woman and carer aware of progress plan Yes □ No □
Dietary advice continued Yes □ No □
Woman confirms understanding of future symptoms to observe for /actions to be taken
Yes □ No □
Discharge planning Discharge date and time given to woman as . . . . . . . . . ……………………………………….
Administration TTO’s ordered Yes □ No □
Goals for this phase: Woman hydrated; tolerating good amounts of diet and fluids Date / time Multi-disciplinary free text Initial
Date
©RBFT Hyperemesis Gravidarum Inpatient ICP (V5.0 June 2019) Page 7 of 14
Daily Record – Day 3
Intervention Initial Reason for variance and action
taken Early Late Night
Clinical assessment Reviewed by Obstetric Registrar Yes □ No □
FBC, U&Es, LFT’s & TFT’s results within normal range (see page 11)
Yes □ No □
IV fluids to continue Yes □ No □
Anti-emetics reviewed Yes □ No □
TPR & BP (recorded daily) within woman’s normal range
Yes □ No □
No complaints of nausea or vomiting Yes □ No □
DVT risk re assessed and actioned accordingly Yes □ No □
VIP score 0
Investigations Urinalysis performed Ketones present
Yes □ No □
U&E’s repeated if large amount of ketones or patient still vomiting
Yes □ No □
Treatment (Diabetic women only) Blood biochemistry repeated 12 hourly.
Yes □ No □
Medical staff informed of abnormal results Yes □ No □
Anti-emetics administered regularly Yes □ No □
DVT prophylaxis given as prescribed Yes □ No □
Activities of daily living E L N Increased fluid intake continued
Tolerating usual diet
Has had bowels open since admission
Passing good volumes of urine
Fluid balance chart continued
Hygiene needs have been met
Teaching and support Woman and carer aware of progress plan Yes □ No □
Dietary advice continued Yes □ No □
Woman confirms understanding of future symptoms to observe for /actions to be taken
Yes □ No □
Discharge planning Discharge date and time given to woman as . . . . . . . . . ……………………………………….
Administration TTO’s ordered Yes □ No □
Goals for this phase: Woman hydrated; tolerating good amounts of diet and fluids Date / time Multi-disciplinary free text Initial
Date
©RBFT Hyperemesis Gravidarum Inpatient ICP (V5.0 June 2019) Page 8 of 14
Daily Record – Day 4
Intervention Initial Reason for variance and action
taken Early Late Night
Clinical assessment Reviewed by Obstetric Registrar Yes □ No □
FBC, U&Es, LFT’s & TFT’s results within normal range (see page 11)
Yes □ No □
IV fluids to continue Yes □ No □
Anti-emetics reviewed Yes □ No □
TPR & BP (recorded daily) within woman’s normal range
Yes □ No □
No complaints of nausea or vomiting Yes □ No □
DVT risk re assessed and actioned accordingly
Yes □ No □
VIP score 0
Investigations Urinalysis performed Ketones present
Yes □ No □
U&E’s repeated if large amount of ketones or patient still vomiting
Yes □ No □
Treatment (Diabetic women only) Blood biochemistry repeated 12 hourly.
Yes □ No □
Medical staff informed of abnormal results Yes □ No □
Anti-emetics administered regularly Yes □ No □
DVT prophylaxis given as prescribed Yes □ No □
Activities of daily living E L N Increased fluid intake continued
Tolerating usual diet
Has had bowels open since admission
Passing good volumes of urine
Fluid balance chart continued
Hygiene needs have been met
Teaching and support Woman and carer aware of progress plan Yes □ No □
Dietary advice continued Yes □ No □
Woman confirms understanding of future symptoms to observe for /actions to be taken
Yes □ No □
Discharge planning Discharge date and time given to woman as . . . . . . . . . ……………………………………….
Administration TTO’s ordered Yes □ No □
Goals for this phase: Woman hydrated; tolerating good amounts of diet and fluids
Date / time Multi-disciplinary free text Initial
Date
©RBFT Hyperemesis Gravidarum Inpatient ICP (V5.0 June 2019) Page 9 of 14
Date / time Multi-disciplinary free text Initial
©RBFT Hyperemesis Gravidarum Inpatient ICP (V5.0 June 2019) Page 10 of 14
Date …….…….
Time …..…..…
of assessment
Pressure relieving equipment Needed / Provided
Date of next planned assessment
Midwife/Nurse Signature
Comments
ADAPTED MATERNITY WATERLOW
PRESSURE ULCER RISK ASSESSMENT
Patient details sticker here
Date
Time
BUILD WEIGHT FOR HEIGHT
Average BMI = 20 - 24.9 Above Average BMI = 25 - 29.9 Obese BMI = > 30 Below Average BMI = < 20
0 1 2 3
MOISTURE DAMAGE Liquor or lochia Visible perspiration
1 1
VISUAL RISK AREAS SKIN TYPE
Healthy Dry/Oedematous Discoloured/Grade 1 Grade2-4
0 1 2 3
MOBILITY
Fully Restricted i.e. PGP/CTG Epidural Spinal
0 3 3 4
HYDRATION RISK FACTORS
In labour Paralytic Ileus Hyperemesis
1 2 3
SPECIAL RISKS
TEDS Gestational Diabetes Smoking Diabetes (type i, type ii) MS/Paraplegia/Motor Sensory HDU (pre-eclampsia/MOH/Sepsis)
1 1 1 5 5 5
MEDICATION Long term/high dose steroids 4
PROLONGED SURGERY On operating table >2hrs 3
SEX AGE
Female 14 - 49
2 1
TOTAL SCORE
MIDWIFE'S INITIALS
10+ = At Risk = Repose Companion 15+ = High Risk = Bi-wave 20+ = Very High Risk = Bi-wave Companion
Date
Time
BUILD WEIGHT FOR HEIGHT
Average BMI = 20 - 24.9 Above Average BMI = 25 - 29.9 Obese BMI = > 30 Below Average BMI = < 20
0 1 2 3
MOISTURE DAMAGE Liquor or lochia Visible perspiration
1 1
VISUAL RISK AREAS SKIN TYPE
Healthy Dry/Oedematous Discoloured/Grade 1 Grade2-4
0 1 2 3
MOBILITY
Fully Restricted i.e. PGP/CTG Epidural Spinal
0 3 3 4
HYDRATION RISK FACTORS
In labour Paralytic Ileus Hyperemesis
1 2 3
SPECIAL RISKS
TEDS Gestational Diabetes Smoking Diabetes (type i, type ii) MS/Paraplegia/Motor Sensory HDU (pre-eclampsia/MOH/Sepsis)
1 1 1 5 5 5
MEDICATION Long term/high dose steroids 4
PROLONGED SURGERY On operating table >2hrs 3
SEX AGE
Female 14 - 49
2 1
TOTAL SCORE
MIDWIFE'S INITIALS
10+ = At Risk = Repose Companion 20+ = Very High Risk = Autologic Mattress
©RBFT Hyperemesis Gravidarum Inpatient ICP (V5.0 June 2019) Page 11 of 14
N.B If the woman develops pressure damage between assessments use the grids above to
record this. If the woman is wearing TED stockings then her heels should be checked daily for
pressure damage. N.B Electronic Clinical Incident to be completed for new/existing
pressure ulcers Grade 2 or above
Please use this assessment in conjunction with Pressure Ulcer Prevention and Management
Care Bundle
C Bell, H Inkster & Amelia Bream
Date and time Clinical Description
Pressure Ulcer Grade (circle)
Signature + Stamp
1 2 3 4
1 2 3 4
1 2 3 4
1 2 3 4
1 2 3 4
Date
©RBFT Hyperemesis Gravidarum Inpatient ICP (V5.0 June 2019) Page 12 of 14
ANTENATAL OBSERVATIONS
Date
Time
40oC
220
39oC
200
38oC
180
37oC
160
36oC
140
35oC
120
Temp º
100
FHR X
80
Pulse
60
BP 40
Resp Rate
Conscious level
Urine - ketones
Urine - glucose
Urine - protein
Blood sugar
Initial box when completed
MOWS Score (Modified Obstetric Warning Score) Resp rate
Pulse
Systolic
Diastolic
Consciousness
Urine Output
Total MOWS
Date
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©RBFT Hyperemesis Gravidarum Inpatient ICP (V5.0 June 2019) Page 14 of 14