Nausea, characterized by an uneasy sensation in the throat, upper stomach, or abdomen, often precedes vomiting, though it can occur independently. It’s a subjective experience, not always culminating in emesis, but consistently unpleasant.
Nausea can stem from a wide array of conditions, notably gastrointestinal issues such as infections, overeating, acid reflux, or bowel obstruction. It also frequently accompanies anxiety disorders, medication side effects, pregnancy, and motion sickness. Furthermore, central nervous system disorders, metabolic imbalances, and cardiovascular problems can manifest as nausea. Often, nausea is accompanied by anorexia, or a diminished appetite. Prolonged episodes of nausea and vomiting pose significant health risks, potentially leading to dehydration, severe electrolyte imbalances, extracellular fluid volume loss, and circulatory failure.
In the realm of nursing, effectively managing nausea involves pinpointing and addressing the underlying cause, mitigating complications, and providing symptomatic relief. A detailed assessment is crucial to identify causative factors. Nurses are proactive in anticipating nausea, particularly in scenarios like chemotherapy, employing premedication to minimize patient discomfort. Educating patients on non-pharmacological strategies for both preventing and treating nausea is also a key nursing intervention.
Nursing care plans are essential tools in managing nausea and vomiting. They guide nurses in prioritizing assessments and interventions, setting both short-term and long-term care goals. The following sections will explore specific nursing diagnoses related to nausea and vomiting, providing examples of nursing care plans to guide effective patient care.
Nursing Care Plans for Nausea and Vomiting
Several nursing diagnoses can be relevant when addressing nausea and vomiting. These include dysfunctional gastrointestinal motility, imbalanced nutrition, impaired comfort, nausea itself, and risk for deficient fluid volume. Each diagnosis necessitates a tailored care plan to address the specific needs of the patient.
Dysfunctional Gastrointestinal Motility
Dysfunctional gastrointestinal motility, characterized by either increased or decreased movement within the digestive system, can manifest in various symptoms, including nausea, vomiting, dyspepsia, bloating, abdominal cramps, distension, and early satiety.
Nursing Diagnosis: Dysfunctional Gastrointestinal Motility
Related to:
- Disease processes
- Anxiety
- Stressors
- Changes in eating habits
- Malnutrition
- Unpleasant sensory stimuli
- Enteral feedings
- Unsanitary food preparation
As evidenced by:
- Food aversion
- Increased salivation
- Gagging sensation
- Increased swallowing
- Sour taste
- Abdominal cramping
- Abdominal pain
- Acceleration of gastric emptying
- Abdominal distension
- Regurgitation
- Altered bowel sounds
- Nausea/vomiting
Expected Outcomes:
- Patient will demonstrate bowel sounds within normal limits.
- Patient will exhibit normal eating habits without experiencing nausea, vomiting, abdominal discomfort, dyspepsia, bloating, and early satiety.
Assessment:
- Assess causative factors contributing to the patient’s nausea and vomiting experience. Identifying potential triggers, such as gastrointestinal disorders, food allergies, pregnancy, medications, or stress, is crucial for targeted interventions.
- Assess the patient’s food intake. Determining specific food triggers, dietary history, and potential foodborne illness is essential in managing nausea related to food.
- Assess the characteristics of the patient’s emesis. The nature of vomit, including content (partially digested food, bile, fecal odor) and color, can provide clues to the underlying cause, such as gastric outlet obstruction or gastrointestinal bleeding.
Interventions:
- Keep the patient NPO (nothing per oral) as ordered. Restricting oral intake allows the gastrointestinal tract to rest and recover, particularly in acute phases of nausea and vomiting.
- Insert and secure a nasogastric tube as indicated. For persistent nausea and vomiting, especially with suspected bowel obstruction or paralytic ileus, a nasogastric tube can decompress the stomach and relieve symptoms.
- Administer IV fluids and electrolyte replacement therapy. Nausea and vomiting can lead to dehydration and electrolyte imbalances, requiring intravenous fluid and electrolyte replacement to maintain physiological balance.
- Encourage the patient to avoid foods and beverages that are gastric irritants. Once oral intake is resumed, advise patients to avoid known gastric irritants like spicy, fatty, or acidic foods to prevent symptom exacerbation.
- Consult with a dietician. A registered dietician can provide tailored dietary recommendations to manage gastrointestinal motility issues and ensure adequate nutrition.
Imbalanced Nutrition: Less than Body Requirements
Persistent nausea often impairs nutritional intake, leading to inadequate nutrient and fluid consumption, potentially resulting in dehydration and malnutrition.
Nursing Diagnosis: Imbalanced Nutrition: Less than Body Requirements
Related to:
- Altered taste perception
- Food aversion
- Inadequate interest in food
- Difficulty swallowing
As evidenced by:
- Food intake less than recommended daily allowance (RDA)
- Nausea and vomiting
- Body weight below ideal weight range for age and gender
- Hypoglycemia
- Lethargy
- Pale mucous membranes
- Abdominal discomfort
- Hyperactive bowel sounds
- Abnormal nutritional lab values
Expected Outcomes:
- Patient will exhibit balanced nutrition as evidenced by the absence of malnutrition.
- Patient will regain and maintain adequate body weight for age and gender.
Assessment:
- Assess and monitor the patient’s weight. Weight loss, especially sudden and unintentional, is a key indicator of nutritional deficit associated with nausea and vomiting.
- Assess and monitor for signs of malnutrition. Recognize signs of malnutrition such as unintentional weight loss, fatigue, weakness, poor concentration, and brittle hair and nails to identify nutritional deficiencies.
- Assess for tooth decay or thrush. Vomiting can contribute to oral health issues like tooth decay and thrush, which can further impair oral intake and comfort.
Interventions:
- Provide calorie-dense foods. For patients with limited appetite, offering calorie-dense, nutrient-rich foods in small portions can maximize caloric intake.
- Create a pleasant environment conducive to eating. Minimize environmental factors that can trigger nausea, such as strong odors, and ensure a calm, unhurried mealtime.
- Premedicate with antiemetics. In situations like chemotherapy-induced nausea, prophylactic antiemetics can improve appetite and nutritional intake.
- Implement tube feedings. If oral intake remains insufficient, enteral or parenteral nutrition may be necessary to meet nutritional requirements.
Impaired Comfort
Nausea significantly impacts patient comfort, causing physical and emotional distress due to the unpleasant sensation and the urge to vomit.
Nursing Diagnosis: Impaired Comfort
Related to:
- Disease process
- Lack of sleep
- Anxiety
- Insufficient control over symptoms
- Noxious environmental stimuli
As evidenced by:
- Restlessness
- Expresses discomfort
- Expresses psychological distress
- Irritable mood
- Reports altered sleep-wake cycle
- Fatigue
- Reports hunger
- Abdominal discomfort
- Abdominal pain
- Nausea and vomiting
Expected Outcomes:
- Patient will verbalize two strategies to reduce nausea and improve comfort.
- Patient will express improved comfort as evidenced by improved sleep and mood.
Assessment:
- Assess the persistence and severity of nausea and vomiting. Understanding the duration and intensity of nausea helps gauge its impact on the patient’s overall well-being and daily life.
- Assess the possible cause of nausea and vomiting. Identifying underlying causes, whether medical conditions, medications, or situational factors, is essential for targeted comfort measures.
- Assess the patient’s history of comfortability and coping strategies. Understanding past coping mechanisms and comfort preferences can inform personalized comfort interventions.
Interventions:
- Create a relaxing environment. Reduce environmental stimuli like bright lights, strong odors, and excessive noise to minimize nausea triggers and promote relaxation.
- Encourage ginger or peppermint tea. These herbal remedies possess antiemetic properties and can soothe gastrointestinal upset.
- Encourage foods that have little to no odor. Mild-smelling foods are less likely to exacerbate nausea. Bland options like crackers and cereals are often better tolerated.
- Encourage alternative ways to alleviate discomfort. Techniques like meditation, deep breathing, music therapy, and guided imagery can help manage nausea and improve comfort.
- Encourage the patient to take OTC remedies for nausea and vomiting. Over-the-counter antiemetics like Dramamine can be effective for certain types of nausea, particularly motion sickness.
- Use acupressure. Applying pressure to the P6 acupressure point on the wrist may help alleviate nausea.
Nausea
Nausea as a primary nursing diagnosis focuses on addressing the symptom itself, often secondary to other underlying conditions.
Nursing Diagnosis: Nausea
Related to:
- Gastrointestinal problems
- Anxiety
- Noxious taste or smell
- Unpleasant sensory stimuli
- Exposure to toxins
- Alcohol intoxication
- Medication side effects
- Treatment or procedure like chemotherapy or radiation
- Pregnancy
- Motion sickness
- Increased intracranial pressure
- Pain
As evidenced by:
- Verbalization of nausea and urge to vomit
- Increased heart rate and respiration
- Cold, clammy skin
- Food aversion
- Increased swallowing
- Increased salivation
- Sour taste
- Gagging sensation
Expected Outcomes:
- Patient will verbalize relief from nausea.
- Patient will be able to demonstrate strategies that prevent nausea.
Assessment:
- Assess the possible causes and characteristics of nausea. Determine if nausea is related to medical treatments, physical conditions, or situational factors to guide appropriate management.
- Assess the patient’s hydration status. Nausea can significantly reduce fluid intake and, if accompanied by vomiting, increase fluid loss, necessitating hydration assessment.
Interventions:
- Provide the patient with routine oral care as needed. Frequent oral care helps remove unpleasant tastes and odors associated with nausea and vomiting, promoting comfort.
- Eliminate offending smells from the room. Minimize exposure to strong odors that can worsen nausea.
- Offer ginger ale and dry snacks. Ginger can help soothe the stomach, and bland, dry snacks like crackers can be easily tolerated.
- Encourage the patient to eat small frequent meals. Smaller, more frequent meals are often better tolerated than large meals when nauseated.
- Encourage the patient to avoid spicy and greasy foods. These foods can irritate the stomach and exacerbate nausea.
- Administer antiemetics as indicated. Prescription antiemetics can effectively manage nausea and vomiting.
- Do not take medications on an empty stomach. If medication-related nausea is suspected, advise taking medications with food, if appropriate.
Risk for Deficient Fluid Volume
Patients experiencing nausea, particularly with vomiting, are at high risk for fluid volume deficit and electrolyte imbalances.
Nursing Diagnosis: Risk for Deficient Fluid Volume
Related to:
- Nausea and vomiting
- Difficulty meeting increased fluid volume requirement
- Inadequate knowledge about fluid needs
- Insufficient fluid intake
As evidenced by:
- Risk diagnoses are not evidenced by existing signs and symptoms but by risk factors. Interventions are aimed at prevention.
Expected Outcomes:
- Patient will maintain hydration as evidenced by adequate intake and output, stable vital signs, and good skin turgor.
Assessment:
- Assess the patient’s fluid status. Monitor for signs of dehydration such as poor skin turgor, dry mucous membranes, sunken eyes, hypotension, and tachycardia.
- Assess and monitor the patient’s intake and output. Accurate intake and output monitoring is crucial for assessing fluid balance.
- Assess and monitor vital signs. Hypotension and tachycardia can indicate fluid volume deficit.
- Monitor lab values. Electrolyte levels, hematocrit, BUN, and creatinine can reflect hydration status and electrolyte imbalances.
Interventions:
- Administer fluids intravenously as indicated. IV fluids may be necessary to correct fluid deficits if oral intake is insufficient.
- Offer high-water content foods. Foods like soups, fruits, and popsicles can contribute to fluid intake and electrolyte replacement.
- Administer antiemetics as indicated. Reducing nausea and vomiting with antiemetics helps prevent further fluid loss.
- Encourage small sips of fluids or ice chips. Even small amounts of fluids, like sips of water or ice chips, can contribute to hydration and may be better tolerated than larger volumes.
References
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