Nausea, characterized by an uneasy sensation in the throat, upper abdomen, or stomach that may precede vomiting, is a common symptom encountered across various patient populations. While not a disease itself, nausea can significantly impact patient comfort, nutritional status, and overall well-being. It is crucial for nurses to accurately assess, diagnose, and manage nausea to alleviate patient suffering and prevent potential complications.
Nausea can stem from a wide array of underlying causes, including gastrointestinal disorders such as infections, overeating, acid reflux, and bowel obstruction. Furthermore, systemic conditions like anxiety, medication side effects, pregnancy, motion sickness, central nervous system issues, metabolic imbalances, and cardiovascular problems can also trigger nausea. This subjective experience is often accompanied by anorexia or loss of appetite, further complicating patient care. Persistent nausea and vomiting can lead to serious complications such as dehydration, electrolyte imbalances, fluid volume deficit, and even circulatory failure, necessitating prompt and effective nursing interventions.
This comprehensive guide aims to provide nurses with a thorough understanding of nausea, its associated nursing diagnoses, and evidence-based care plans to optimize patient outcomes.
The Nursing Process in Nausea Management
Effective management of nausea necessitates a systematic nursing process that focuses on identifying and addressing the root cause, mitigating complications, and providing symptomatic relief. A meticulous assessment is paramount to pinpoint the etiological factors contributing to the patient’s nausea. In predictable scenarios such as chemotherapy administration, proactive premedication can prevent or minimize discomfort. Moreover, educating patients on non-pharmacological strategies empowers them to actively participate in managing their nausea.
Nursing care plans are indispensable tools for prioritizing nursing diagnoses related to nausea and vomiting. These plans guide the implementation of targeted assessments and interventions, establishing both short-term and long-term goals to optimize patient care and recovery. The following sections will detail specific nursing diagnoses commonly associated with nausea, along with corresponding care plan examples.
Dysfunctional Gastrointestinal Motility
Alterations in gastrointestinal motility, whether increased or decreased, can manifest in a spectrum of symptoms, including nausea, vomiting, dyspepsia, bloating, abdominal cramps, distension, and early satiety.
Nursing Diagnosis: Dysfunctional Gastrointestinal Motility
Related Factors:
- Disease processes affecting the gastrointestinal system
- Psychological factors such as anxiety and stress
- Changes in dietary habits
- Malnutrition
- Unpleasant sensory stimuli (odors, sights, sounds)
- Enteral feedings
- Unsanitary food preparation practices
Evidenced By:
- Food aversion and decreased appetite
- Increased salivation
- Gagging sensation
- Increased swallowing frequency
- Sour taste in the mouth
- Abdominal cramping and pain
- Accelerated or delayed gastric emptying
- Abdominal distension
- Regurgitation
- Altered bowel sounds (hyperactive or hypoactive)
- Nausea and vomiting
Expected Outcomes:
- Patient will demonstrate bowel sounds within normal limits upon auscultation.
- Patient will exhibit normal eating habits without experiencing nausea, vomiting, abdominal discomfort, dyspepsia, bloating, or early satiety.
Nursing Assessment:
1. Investigate causative factors contributing to the patient’s nausea and vomiting.
Rationale: A multitude of factors can disrupt gastrointestinal motility, including gastrointestinal disorders (e.g., gastroparesis, irritable bowel syndrome), food sensitivities or allergies, chronic indigestion, pregnancy-related hormonal changes, central nervous system disorders (e.g., migraines, vestibular neuritis), eating disorders, cancer, medication side effects, and various underlying medical conditions. Identifying potential triggers is essential for guiding targeted treatment and interventions.
2. Evaluate the patient’s dietary intake patterns.
Rationale: Food itself can be a significant precipitant of nausea and vomiting. A detailed dietary history helps to identify specific food triggers, assess past reactions to certain foods, and determine if foodborne illness is a possibility (e.g., if others who consumed the same food are also experiencing similar symptoms).
3. Characterize the patient’s emesis (vomitus).
Rationale: The characteristics of emesis can provide valuable clues about the underlying cause of nausea and vomiting. For instance, emesis containing undigested or partially digested food may suggest gastric outlet obstruction or delayed gastric emptying. The presence of bile in emesis, or a fecal odor after prolonged vomiting, can be indicative of intestinal obstruction distal to the pylorus. Furthermore, the color of the emesis can signal gastrointestinal bleeding (e.g., bright red blood suggests upper GI bleed, coffee-ground emesis suggests digested blood from upper GI bleed).
Nursing Interventions:
1. Maintain NPO status as prescribed.
Rationale: Restricting oral intake (NPO – nil per os) is often necessary for patients experiencing nausea and vomiting until a definitive diagnosis is established. This allows the gastrointestinal tract to rest and facilitates the correction of motility disturbances.
2. Implement nasogastric (NG) tube insertion and securement as indicated.
Rationale: An NG tube may be indicated for gastric decompression in patients with persistent nausea and vomiting, suspected bowel obstruction, or paralytic ileus. Proper securement of the NG tube is crucial to prevent excessive movement within the nasal passages and throat, which can paradoxically stimulate further nausea and vomiting.
3. Administer intravenous (IV) fluids and electrolyte replacement therapy as ordered.
Rationale: Protracted nausea and vomiting can rapidly lead to dehydration and electrolyte imbalances. Dehydration can further exacerbate gastrointestinal motility issues by slowing down intestinal contractions and promoting sluggish bowel function. IV fluid and electrolyte replacement are critical to restore fluid balance and correct electrolyte deficits.
4. Educate the patient to avoid gastric irritants in food and beverages.
Rationale: When oral intake is resumed, patients should be advised to avoid foods and beverages known to irritate the gastric mucosa. Common gastric irritants include caffeine, alcohol, spicy foods, high-fat foods, and acidic foods. These substances can worsen dysfunctional gastrointestinal motility and perpetuate nausea and vomiting.
5. Consult with a registered dietitian for nutritional guidance.
Rationale: A registered dietitian can provide specialized dietary recommendations tailored to the patient’s specific gastrointestinal motility issues. Dietary modifications may vary depending on whether the patient has delayed gastric emptying (gastroparesis) or accelerated gastric motility (dumping syndrome).
Imbalanced Nutrition: Less Than Body Requirements
Nausea frequently impairs nutritional intake, leading to a deficit in essential nutrients. Food aversion and anorexia, common companions of nausea, can reduce both solid food and fluid intake, increasing the risk of dehydration and malnutrition.
Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements
Related Factors:
- Altered taste perception (dysgeusia)
- Food aversion
- Lack of interest in food (anorexia)
- Difficulty swallowing (dysphagia)
Evidenced By:
- Reported food intake consistently below the recommended daily allowance (RDA)
- Nausea and vomiting
- Body weight below the ideal weight range for age and gender
- Hypoglycemia (low blood sugar)
- Lethargy and fatigue
- Pale mucous membranes
- Abdominal discomfort
- Hyperactive bowel sounds (may indicate decreased absorption)
- Abnormal nutritional laboratory values (e.g., low albumin, prealbumin, electrolyte imbalances)
Expected Outcomes:
- Patient will achieve balanced nutrition as evidenced by the absence of malnutrition indicators.
- Patient will regain and maintain an adequate body weight appropriate for age and gender.
Nursing Assessment:
1. Regularly assess and monitor the patient’s weight trends.
Rationale: Unintentional and rapid weight loss is a common consequence of persistent vomiting. Sustained vomiting episodes can deplete the body of vital nutrients and calories, leading to nutritional deficiencies and weight loss.
2. Assess for clinical manifestations of malnutrition.
Rationale: Patients experiencing nausea are at heightened risk for malnutrition due to reduced dietary intake and potential nutrient losses through vomiting. Signs of malnutrition include unintentional weight loss, fatigue, generalized weakness, impaired concentration, brittle hair and nails, muscle wasting, and compromised immune function leading to increased susceptibility to infections.
3. Assess for oral complications such as tooth decay and oral thrush (candidiasis).
Rationale: Frequent nausea and vomiting can expose teeth to gastric acid, increasing the risk of dental erosion and tooth decay. Vomiting can also irritate the oral mucosa, potentially contributing to painful mouth sores and throat irritation. Oral thrush, a fungal infection, can also develop and further compromise oral comfort and nutritional intake.
Nursing Interventions:
1. Offer calorie-dense foods in small, frequent portions.
Rationale: Patients with nausea may only tolerate small quantities of food at a time. Providing calorie-dense options ensures that even small intakes contribute significantly to overall caloric intake. Examples include fortified milkshakes, pudding, yogurt, and nutritional supplements.
2. Cultivate a pleasant and relaxing eating environment.
Rationale: Noxious or strong odors can exacerbate nausea and trigger vomiting. Creating a calm, odor-free environment can promote appetite and improve tolerance to food. Ensure minimal interruptions during meal times and avoid rushing the patient.
3. Administer antiemetic medications prophylactically as prescribed, particularly for patients undergoing chemotherapy or radiation therapy.
Rationale: Chemotherapy and radiation therapy are notorious for inducing nausea and vomiting. Premedication with antiemetics, as ordered, can effectively prevent or minimize these side effects, improving patient comfort and enabling better nutritional intake during treatment.
4. Implement enteral or parenteral nutrition as necessary.
Rationale: For patients unable to maintain adequate oral intake due to intractable nausea, enteral nutrition (tube feeding) or parenteral nutrition (IV nutrition) may be necessary to provide essential nutrients and prevent malnutrition. The route of nutrition support will depend on the patient’s clinical condition and gastrointestinal function.
Impaired Comfort
Nausea is inherently an unpleasant and distressing sensation centered in the abdomen, epigastric region, and throat, causing significant discomfort and the urge to vomit, profoundly impacting patient comfort.
Nursing Diagnosis: Impaired Comfort
Related Factors:
- Underlying disease processes causing nausea
- Sleep disturbances and lack of sleep
- Psychological distress such as anxiety
- Inadequate symptom control
- Noxious environmental stimuli (e.g., unpleasant odors, excessive noise)
Evidenced By:
- Restlessness and agitation
- Verbalization of discomfort and distress
- Expressing psychological distress related to nausea
- Irritable mood and affect
- Reports of altered sleep-wake cycle
- Fatigue and exhaustion
- Reports of hunger but inability to eat due to nausea
- Abdominal discomfort and cramping
- Abdominal pain
- Nausea and vomiting
Expected Outcomes:
- Patient will verbalize at least two effective strategies to reduce nausea and enhance comfort.
- Patient will express improved comfort as evidenced by improved sleep patterns and more positive mood.
Nursing Assessment:
1. Evaluate the persistence, severity, and characteristics of nausea and vomiting.
Rationale: Persistent and severe nausea and vomiting can cause substantial physical and emotional distress. If symptoms impede the patient’s ability to perform daily activities and fulfill role responsibilities, it can significantly diminish their quality of life.
2. Investigate potential underlying causes of nausea and vomiting.
Rationale: Nausea and vomiting are not primary medical conditions but rather symptoms indicative of various underlying health issues. Identifying the root cause—whether it’s a medical condition, food intolerance, eating disorder, psychological stress, pregnancy, medication side effects, or other factors—is crucial for developing a targeted and effective care plan.
3. Assess the patient’s past experiences with discomfort and their usual coping mechanisms.
Rationale: A patient’s perception of comfort and their past experiences with managing discomfort can influence their response to current nausea and vomiting. Understanding their typical coping strategies helps tailor interventions to align with their preferences and enhance their sense of control and comfort during recovery.
Nursing Interventions:
1. Create a tranquil and relaxing environment.
Rationale: Excessive environmental stimulation, such as bright lights and warm temperatures, can exacerbate feelings of nausea. Ensuring a cooler room temperature and dimmed lighting, particularly during meal times, can promote patient comfort and reduce the likelihood of nausea and vomiting. Minimizing strong odors is also essential.
2. Encourage the consumption of ginger or peppermint tea.
Rationale: Ginger is a well-known natural remedy for alleviating nausea and vomiting and promoting overall comfort. It contains anti-nausea compounds like shogaols and gingerols and possesses anti-inflammatory, anti-ulcer, and antioxidant properties. Peppermint tea can also help soothe stomach upset and reduce feelings of nausea due to its calming effect on the gastrointestinal system.
3. Recommend foods with minimal or no odor.
Rationale: Strong food odors can be potent triggers for nausea and vomiting. Suggesting bland foods with little to no aroma, such as plain cereals, crackers, toast, and clear broths, can improve tolerance and reduce nausea.
4. Promote alternative comfort measures to alleviate discomfort.
Rationale: Non-pharmacological techniques such as meditation, deep breathing exercises, listening to calming music, and guided imagery can effectively promote relaxation and significantly reduce discomfort associated with nausea and vomiting. Slow, steady deep breathing can help calm the vagus nerve, easing nausea and fostering mindfulness and comfort.
5. Advise patients regarding over-the-counter (OTC) remedies for nausea and vomiting, when appropriate.
Rationale: OTC antiemetics like dimenhydrinate (Dramamine) can be effective in blocking the vomiting reflex, reducing dizziness, and improving comfort, particularly for motion sickness or mild nausea. It’s important to instruct patients to take these medications proactively, before the onset of nausea, for optimal effectiveness.
6. Apply acupressure techniques.
Rationale: Acupressure at the P6 (Neiguan) point on the inner wrist (located approximately three finger-breadths from the wrist crease, between the two central tendons) is believed to help prevent nausea. Motion sickness acupressure wristbands, readily available OTC, apply continuous pressure to this point and can be worn to prevent or reduce nausea.
Nausea (as primary nursing diagnosis)
While often a secondary symptom, nausea can be a primary focus of nursing care when it significantly impacts patient well-being and requires direct intervention.
Nursing Diagnosis: Nausea
Related Factors:
- Gastrointestinal disorders
- Psychological factors such as anxiety
- Noxious tastes or smells
- Unpleasant sensory stimuli in the environment
- Exposure to toxins or irritants
- Alcohol intoxication
- Medication side effects
- Medical treatments or procedures like chemotherapy or radiation
- Pregnancy-related nausea (morning sickness)
- Motion sickness
- Increased intracranial pressure
- Pain
Evidenced By:
- Verbalization of nausea and the urge to vomit
- Physiological responses such as increased heart rate and respiratory rate
- Cold, clammy skin
- Food aversion and decreased appetite
- Increased swallowing movements
- Increased salivation (ptyalism)
- Sour or metallic taste in the mouth
- Gagging sensation
Expected Outcomes:
- Patient will verbalize relief from nausea and reduced intensity of nausea.
- Patient will be able to demonstrate effective strategies to prevent or manage nausea recurrence.
Nursing Assessment:
1. Determine the potential causes and specific characteristics of the patient’s nausea.
Rationale: The etiology of nausea can be diverse, ranging from treatment-related side effects (e.g., chemotherapy-induced nausea) to physical conditions (e.g., gastroenteritis) or situational triggers (e.g., motion sickness). Establishing the underlying cause is fundamental for developing a targeted and effective management plan.
2. Assess the patient’s hydration status and identify signs of dehydration.
Rationale: Nausea often leads to decreased oral intake of both food and fluids. This aversion, especially when coupled with vomiting, predisposes patients to dehydration due to fluid losses. Assessing hydration status is critical to detect and address fluid deficits promptly.
Nursing Interventions:
1. Provide meticulous routine oral care as needed.
Rationale: Nausea is frequently associated with increased salivation and episodes of vomiting. Regular oral hygiene, including mouth rinsing and brushing teeth, helps remove unpleasant tastes and odors from the mouth, enhancing comfort and reducing nausea triggers.
2. Eliminate or minimize offensive odors from the patient’s environment.
Rationale: Strong or unpleasant odors can significantly worsen nausea. Creating an odor-free environment, through proper ventilation, odor eliminators, and prompt removal of soiled items, can help reduce nausea triggers.
3. Offer ginger ale and dry, bland snacks.
Rationale: Ginger has demonstrated efficacy in settling the stomach and reducing nausea. Ginger ale (real ginger, not just ginger flavoring) and dry, bland snacks like crackers or toast are often well-tolerated and can help prevent nausea associated with an empty stomach.
4. Encourage the patient to consume small, frequent meals and snacks.
Rationale: Patients experiencing nausea may not tolerate large meals. They may also exhibit food selectivity, preferring certain foods over others. Small, frequent meals and snacks can help stabilize blood sugar levels, satisfy hunger pangs without overwhelming the stomach, and provide a consistent intake of nutrients throughout the day.
5. Advise the patient to avoid spicy and greasy foods.
Rationale: Highly seasoned, spicy, and greasy foods can irritate the gastric mucosa and exacerbate nausea. Recommending a bland, low-fat diet can minimize gastric irritation and reduce nausea.
6. Administer prescribed antiemetic medications as indicated.
Rationale: Antiemetic medications, such as ondansetron (Zofran), promethazine (Phenergan), or metoclopramide (Reglan), are effective in treating and preventing nausea by blocking specific receptors in the brain that trigger the vomiting reflex. Administering these medications as prescribed provides pharmacological relief from nausea.
7. Educate patients to avoid taking medications on an empty stomach, if applicable.
Rationale: Certain medications can cause nausea as a side effect, particularly when taken without food. If medication-induced nausea is suspected, instruct patients to try taking their medications with food (unless contraindicated) to minimize gastric irritation and reduce nausea.
Risk for Deficient Fluid Volume
Patients experiencing nausea are at significant risk for developing deficient fluid volume, especially when nausea is accompanied by vomiting. Vomiting leads to direct fluid loss and can disrupt electrolyte balance, further exacerbating fluid volume deficits.
Nursing Diagnosis: Risk for Deficient Fluid Volume
Related Factors:
- Nausea and vomiting leading to fluid loss
- Difficulty meeting increased fluid requirements due to nausea
- Inadequate knowledge about fluid needs and strategies for fluid replacement
- Insufficient oral fluid intake
Evidenced By:
- Risk diagnoses are not evidenced by signs and symptoms because the problem has not yet occurred. Nursing interventions are focused on prevention.
Expected Outcomes:
- Patient will maintain adequate hydration status as evidenced by balanced fluid intake and output, stable vital signs within normal limits, and normal skin turgor.
Nursing Assessment:
1. Regularly assess the patient’s fluid status, monitoring for signs and symptoms of dehydration.
Rationale: Early detection of fluid volume deficit is crucial. Clinical indicators of dehydration include non-elastic skin turgor (tenting), dry skin and mucous membranes, sunken appearance of the eyes, hypotension (low blood pressure), tachycardia (rapid heart rate), concentrated urine and low urine output, and changes in mental status.
2. Accurately monitor and document the patient’s fluid intake and output (I&O).
Rationale: Meticulous monitoring of intake and output provides objective data to assess fluid balance. Comparing fluid intake with output helps determine if the patient is maintaining adequate hydration or experiencing fluid deficits.
3. Continuously assess and monitor vital signs, particularly blood pressure and heart rate.
Rationale: Hypotension is a significant indicator of decreased vascular volume associated with fluid volume deficit. Tachycardia is a compensatory mechanism to maintain cardiac output in the setting of reduced blood volume and blood pressure. Fever can also contribute to dehydration through increased insensible fluid losses.
4. Monitor relevant laboratory values, including electrolytes, hemoglobin and hematocrit, blood urea nitrogen (BUN), and creatinine.
Rationale: Laboratory values provide objective data to assess hydration status and electrolyte balance. Electrolyte imbalances (e.g., hypokalemia, hyponatremia) are common complications of vomiting. Elevated hemoglobin and hematocrit levels may indicate hemoconcentration due to fluid loss. Increased BUN and creatinine levels can signal dehydration and impaired renal function.
Nursing Interventions:
1. Administer intravenous fluids as prescribed and indicated.
Rationale: If oral fluid intake is insufficient to maintain hydration, particularly in patients with persistent nausea and vomiting, intravenous fluid replacement is essential to restore fluid volume and prevent dehydration.
2. Offer foods with high water content to promote fluid intake.
Rationale: In addition to oral fluids, offering foods with high water content can contribute to overall fluid intake. Examples include soups, popsicles, fruit, gelatin (Jell-O), and electrolyte-replacement drinks (e.g., Pedialyte, Gatorade), which not only provide fluids but also replenish electrolytes and glucose.
3. Administer antiemetic medications as prescribed.
Rationale: By suppressing nausea and preventing vomiting, antiemetic medications indirectly reduce fluid losses and help the patient tolerate oral fluid intake, ultimately preventing or mitigating fluid volume deficit.
4. Encourage frequent small sips of clear fluids or ice chips.
Rationale: Patients experiencing nausea may have a strong aversion to large volumes of fluids. However, small, frequent sips of clear fluids or sucking on ice chips are often better tolerated and can contribute to overall fluid intake without exacerbating nausea.
References
(Include references from the original article or add relevant, credible sources for an English-speaking audience. For example, reputable nursing textbooks, medical journals, and organizations like the National Institutes of Health (NIH) or the National Cancer Institute (NCI) for chemotherapy-induced nausea.)
