Nursing diagnosis – NAUSEA

NAUSEA

DEFINITION

A subjective unpleasant, wavelike sensation in the back of the throat,

epigastrium, or abdomen that may lead to the urge or need to vomit

DEFINING CHARACTERISTICS

• Gagging sensation

• Gastric stasis

• Increased salivation, swallowing

• Sour taste in the mouth

• Uninterested in eating; does not have appetite

• Reports “nausea” or “sick to the stomach”

RELATED FACTORS

Biophysical

Situational

• Biochemical disorders

• Anxiety

• Esophageal disease

• Fear

• Gastric distention, irritation

• Noxious odors, taste, visual

• Increased intracranial pressure

stimulation

• Motion sickness

• Pain

• Pain

• Physiological factors

• Pancreatic disease

Treatment

• Tumors, intra-abdominal or

• Gastric distention, irritation

localized tumors

• Pharmaceuticals

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Nutrition

• Knowledge

• Fluid and electrolytes

• Comfort

• Pharmacological function

EXPECTED OUTCOMES

The patient will

• State reasons for nausea and vomiting.

• Take steps to manage episodes of nausea and vomiting.

• Ingest sufficient nutrients to maintain health.

• Take steps to ensure adequate nutrition when nausea abates.

• Maintain weight within specified limits.

SUGGESTED NOC OUTCOMES

Appetite; Comfort Level; Fluid Balance; Hydration; Nausea & Vom-

iting Control; Nutritional Status: Food & Fluid Intake; Suffering

Severity; Symptom Control

INTERVENTIONS AND RATIONALES

Determine:  Assess for illness, pregnancy, medication use (prescription

and over-the-counter); exposure to tainted foods, chemicals, occupational

hazards; weight (fluctuation in last 6 months); food preferences and usual

dietary patterns; history of gastric/esophageal problems. Assessment infor-

mation will help in identifying appropriate interventions.

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Monitor direct observation of food and fluid intake to ensure

whether or not the patient is receiving adequate nutritional intake.

Perform:  Provide comfort measures (e.g., back massage, warm bath)

to promote feelings of comfort for the patient.

Reduce noise, control odors, and adjust light in the environment

to help the patient relax and to reduce environmental factors that

produce nausea.

Allow periods of uninterrupted sleep between procedures. Proce-

dures and medication administration sometimes trigger periods of

nausea.

Offer small amount of cool liquids or ice chips to provide some

fluid to reduce the possibility of dehydration.

Suggest frequent mouth care to reduce unpleasant taste in the

mouth.

Give dry, bland foods, such as dry toast or crackers, during peri-

ods of nausea to make it possible to eat. These foods have been

found to be effective.

Administer antinausea medications, as prescribed.

Inform:  Teach relaxation techniques and encourage patient to use

these techniques during mealtime to reduce stress and divert atten-

tion from the nausea.

Teach patient how to use food and fluid during periods of nausea

to avoid dehydration and lack of nutrients. Food should be taken in

small, frequent feedings. Avoid drinking with meals.

Attend:  When nausea abates, encourage patient to increase food

intake to assist with adequate intake of nutrients.

Assist patient to make a list of best tolerated and poorly tolerated

foods so he or she can choose quickly and wisely when nausea

abates.

Manage:  If nausea persists, refer patient to a nutritionist to assist

after discharge to ensure that adequate nutrients will be ingested.

Stress the importance of follow-up appointments with the physi-

cian. Nausea is a preventable problem and should respond to appro-

priate measures.

SUGGESTED NIC INTERVENTIONS

Diet Staging; Fluid and Electrolyte Management; Fluid Monitoring;

Medication Management; Nausea Management Nutritional Manage-

ment

Reference

Mamaril, M. E., et al. (2006, December). Prevention and management of

postoperative nausea and vomiting: A look at contemporary techniques.
Journal of Perianesthesia Nursing, 21(6), 404–410.

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