NURSING DIAGNOSIS
Nausea related to gastric distention as evidenced by increased salivation and swallowing. Cues: S – Client reports nausea and vomiting - Verbalizes unpleasant sensation at the back of the throat - Complains sour taste in mouth - Reports about gagging sensation O – Aversion toward food - Increased swallowing - Increased salivation - Client has delayed gastric emptying (gastric distention)
ANALYSIS
Nausea is a subjective unpleasant wavelike sensation at the back of the throat, epigastrium, or abdomen that may lead to the urge to vomit
GOAL
OBJECTIVES
After series of nursing intervention, the client will be able to be free of nausea and vomiting completely.
After the nursing intervention, the client will be able to: 1. Identify situations that perceives as distasteful, anxiety inducing or threatening accordingly.
INTERVENTIONS
RATIONALE
EVALUATION
After the nursing intervention, was the client able to:
1. Ask the client about the situations that perceives as distasteful, anxiety inducing or threatening.
Reference: Marilyn Doenges, Nurses’ Pocket th
Guide 12 Edition, page 545
1. May be able to limit or control exposure to situations or take medication prophylactically. Reference: Marilyn Doenges,
1. Identify situations that perceives as distasteful, anxiety inducing or threatening accordingly? Yes__No__Why?
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Guide 12 Edition, page 546 2. State if his nausea is potentially selflimiting and/or mild or if severe and prolonged appropriately.
2. Determine if nausea is potentially selflimiting and/or mild or if severe and prolonged. Explain and give some example of situations to the client.
2. Suggests severity of effect on fluid and electrolyte balance and nutritional status. Reference: Marilyn Doenges, Nurses’ Pocket th
Guide 12 Edition, page
2. State if his nausea is potentially selflimiting and/or mild or if severe and prolonged appropriately? Yes__No__Why?
547 3. Determine signs of dehydration correctly.
3. Check vital signs and note signs of dehydration. Explain it to the client.
3. Nausea may occur in the presence of postural hypotension and fluid volume deficit. Reference: Marilyn Doenges,
3. Determine signs of dehydration correctly? Yes__No__Why?
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Guide 12 Edition, page 547 4. Define the benefit of trying dry foods when nausea occurs throughout the day as appropriate.
5. Drink liquids 30 minutes before or after meals instead of with meals adequately.
4. Advise the client to try dry foods such as toast, crackers, dry cereal before arising when nausea occurs within morning or throughout the day.
4. To promote comfort and enhance intake. Reference: Marilyn Doenges,
5. Advise the client to drink liquids 30 minutes before or after meals instead of with meals.
5. To promote comfort and enhance intake. Reference: Marilyn Doenges,
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Guide 12 Edition, page 547
4. Define the benefit of trying dry foods when nausea occurs throughout the day as appropriate? Yes__No__Why?
5. Drink liquids 30 minutes before or after meals instead of with meals adequately?
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Yes__No__Why?
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Guide 12 Edition, page 547 6. Select from the diet and snacks of preferred or bland foods provided and/or when available.
7. Avoid milk/dairy products as needed.
8. Display interest on eating small meals spaced
6. Provide diet and snacks of preferred or bland foods when available (increase bland, caffeine-free non diet carbonated beverages, clear soup broth, non acidic fruit juice, gelatin, sherbet or ices, skinless cooked chicken)
6. To reduce gastric acidity and improve nutrient intake. Reference: Marilyn Doenges,
7. Advise the client to avoid milk/dairy products, overly sweet or fried and fatty foods and gas-forming vegetables (eg. broccoli, cauliflower, cucumbers)
7. May increase nausea or be more difficult to digest. Reference: Marilyn Doenges,
8. Encourage the client to eat small meals spaced
8. So stomach does not feel excessively full.
6. Select from the diet and snacks of preferred or bland foods provided and/or when available? Yes__No__Why?
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Guide 12 Edition, page 547
7. Avoid milk/dairy products as needed? Yes__No__Why?
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Guide 12 Edition, page 547 8. Display interest on eating small meals spaced
throughout the day as needed.
throughout the day instead of large meals.
Reference: Marilyn Doenges,
throughout the day as needed? Yes__No__Why?
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Guide 12 Edition, page 547 9. Follow instructions on how to enhance digestion properly.
9. Instruct client to eat slowly, chewing food well. Recommend client to remain seated after meal, or with head elevated above feet if in bed.
9. This is to enhance digestion and to promote comfort and enhance intake. Reference: Marilyn Doenges,
9. Follow instructions on how to enhance digestion properly? Yes__No__Why?
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Guide 12 Edition, page 548 10. Provide clean, peaceful environment and fresh air with fan or open window while at home.
10. Encourage the client to provide peaceful environment and fresh air with fan or open window while at home. Advise to avoid offending odors, such as cooking smells, smoke, perfumes, and
10. They may stimulate or worsen nausea. Reference: Marilyn Doenges, Nurses’ Pocket th
Guide 12 Edition, page 548
10. Provide clean, peaceful environment and fresh air with fan or open window while at home? Yes__No__Why?
mechanical emission when possible. 11. Verbalize understanding of the importance of providing frequent oral care as needed.
11. Encourage the client to provide frequent oral care (especially after vomiting)
11. To cleanse mouth and minimize “bad tastes”
Reference: Marilyn Doenges,
11. Verbalize understanding of the importance of providing frequent oral care as needed? Yes__No__Why?
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Guide 12 Edition, page 548 12. Practice deep and slow breathing frequently.
12. Teach the client deep and slow breathing.
12. To promote relaxation and refocus attention away from nausea. Reference: Marilyn Doenges,
12. Practice deep and slow breathing frequently? Yes__No__Why?
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Guide 12 Edition, page 548 13. Select from different ways to limit dwelling with unpleasant sensation
13. Advise the client to use distraction with music, chatting with
13. To limit dwelling on unpleasant sensation. Reference:
13. Select from different ways to limit dwelling with unpleasant sensation
accordingly.
family/friends, and watching TV.
Marilyn Doenges,
accordingly? Yes__No__Why?
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Guide 12 Edition, page 548 14. Point out the importance of wearing loosefitting clothing as appropriate.
14. Suggest wearing loosefitting clothing.
14. To reduce external pressure on abdomen. Reference: Marilyn Doenges,
14. Point out the importance of wearing loosefitting clothing as appropriate? Yes__No__Why?
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Guide 12 Edition, page 549 15. Compare with the different non pharmacological interventions for managing nausea precisely.
15. Encourage and explain the use of non pharmacological interventions such as self hypnosis, progressive muscle relaxation, biofeedback, guided imagery, and systemic desensitization.
15. Promotes relaxation, refocus client’s
attention, increase sense of control, and decreases feelings of helplessness. Reference: Marilyn Doenges, Nurses’ Pocket th
Guide 12 Edition, page
15. Compare with the different non pharmacological interventions for managing nausea precisely? Yes__No__Why?
548 16. Cooperate upon the schedule of administering antiemetic medications as needed.
16. Administer antiemetic medications on regular schedule as ordered.
16. To prevent or control side effects of medication. Reference: Marilyn Doenges,
16. Cooperate upon the schedule of administering antiemetic medications as needed? Yes__No__Why?
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Guide 12 Edition, page 548 17. Adapt to the proper use of antiemetic medications effectively.
17. Instruct in proper use, side effect, and adverse reactions of antiemetic medications.
17. Enhances client safety and effective management of condition. Reference: Marilyn Doenges,
17. Adapt to the proper use of antiemetic medications effectively? Yes__No__Why?
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Guide 12 Edition, page 548 18. Adhere to the ways of avoiding the problem with nausea efficiently.
18. Review individual factors or triggers causing nausea and ways to avoid problem.
18. Provides necessary information for client to manage own care. Reference:
18. Adhere to the ways of avoiding the problem with nausea efficiently? Yes__No__Why?
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Guide 12 Edition, page 548 19. Express understanding of the importance of replacing fluids and/or electrolytes as needed.
19. Review signs of dehydration and stress importance of replacing fluids and/or electrolytes.
19. Increases likelihood of preventing potentially serious electrolyte depletion. Reference: Marilyn Doenges,
19. Express understanding of the importance of replacing fluids and/or electrolytes as needed? Yes__No__Why?
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Guide 12 Edition, page 549 20. Show interest for monitoring self and for follow-up medications as appropriate.
20. Explain to the client the signs that require immediate notification of the health care provider. Discuss potential complications and possible need for medical follow-up.
20. Timely recognition and intervention may limit severity and complications. Reference: Marilyn Doenges, Nurses’ Pocket th
Guide 12 Edition, p 549
20. Show interest for monitoring self and for follow-up medications as appropriate? Yes__No__Why?
