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 Reference: Marilyn Doenges, Nurses Pocket Guide 12th Edition, page 545

GOAL After series of nursing intervention, the client will be able to be free of nausea and vomiting completely.

OBJECTIVES 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.

1. May be able to limit or control exposure to situations or take medication prophylactically. Reference: Marilyn Doenges, Nurses Pocket Guide 12th Edition, page 546 2. Suggests severity of effect on fluid and electrolyte balance and nutritional status. Reference: Marilyn Doenges, Nurses Pocket Guide 12th Edition, page

1. Identify situations that perceives as distasteful, anxiety inducing or threatening accordingly? Yes__No__Why?

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. 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, Nurses Pocket Guide 12th Edition, page 547 4. To promote comfort and enhance intake. Reference: Marilyn Doenges, Nurses Pocket Guide 12th Edition, page 547 5. To promote comfort and enhance intake. Reference: Marilyn Doenges, 3. Determine signs of dehydration correctly? Yes__No__Why?

4. Define the benefit of trying dry foods when nausea occurs throughout the day as appropriate.

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. 5. Advise the client to drink liquids 30 minutes before or after meals instead of with meals.

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.

5. Drink liquids 30 minutes before or after meals instead of with meals adequately?

Nurses Pocket Guide 12th Edition, page 547 6. Select from the diet and snacks of preferred or bland foods provided and/or when available. 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) 7. Advise the client to avoid milk/dairy products, overly sweet or fried and fatty foods and gas-forming vegetables (eg. broccoli, cauliflower, cucumbers) 6. To reduce gastric acidity and improve nutrient intake. Reference: Marilyn Doenges, Nurses Pocket Guide 12th Edition, page 547

Yes__No__Why?

6. Select from the diet and snacks of preferred or bland foods provided and/or when available? Yes__No__Why?

7. Avoid milk/dairy products as needed.

7. May increase nausea or be more difficult to digest. Reference: Marilyn Doenges, Nurses Pocket Guide 12th Edition, page 547 8. So stomach does not feel excessively full.

7. Avoid milk/dairy products as needed? Yes__No__Why?

8. Display interest 8. Encourage the on eating small client to eat small meals spaced meals spaced

8. Display interest on eating small meals spaced

throughout the day as needed.

throughout the day instead of large meals.

Reference: Marilyn Doenges, Nurses Pocket Guide 12th Edition, page 547 9. This is to enhance digestion and to promote comfort and enhance intake. Reference: Marilyn Doenges, Nurses Pocket Guide 12th Edition, page 548 10. They may stimulate or worsen nausea. Reference: Marilyn Doenges, Nurses Pocket Guide 12th Edition, page 548

throughout the day as needed? Yes__No__Why?

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. Follow instructions on how to enhance digestion properly? Yes__No__Why?

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. 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, Nurses Pocket Guide 12th Edition, page 548 11. Verbalize understanding of the importance of providing frequent oral care as needed? Yes__No__Why?

12. Practice deep and slow breathing frequently.

12. Teach the client 12. To promote deep and slow relaxation and breathing. refocus attention away from nausea. Reference: Marilyn Doenges, Nurses Pocket Guide 12th Edition, page 548 13. Advise the client to use distraction with music, chatting with 13. To limit dwelling on unpleasant sensation. Reference:

12. Practice deep and slow breathing frequently? Yes__No__Why?

13. Select from different ways to limit dwelling with unpleasant sensation

13. Select from different ways to limit dwelling with unpleasant sensation

accordingly.

family/friends, and watching TV.

Marilyn Doenges, Nurses Pocket Guide 12th Edition, page 548 14. To reduce external pressure on abdomen. Reference: Marilyn Doenges, Nurses Pocket Guide 12th Edition, page 549 15. Promotes relaxation, refocus clients attention, increase sense of control, and decreases feelings of helplessness. Reference: Marilyn Doenges, Nurses Pocket Guide 12th Edition, page

accordingly? Yes__No__Why?

14. Point out the importance of wearing loosefitting clothing as appropriate.

14. Suggest wearing loosefitting clothing.

14. Point out the importance of wearing loosefitting clothing as appropriate? Yes__No__Why?

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. 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, Nurses Pocket Guide 12th Edition, page 548 17. Enhances client safety and effective management of condition. Reference: Marilyn Doenges, Nurses Pocket Guide 12th Edition, page 548 18. Provides necessary information for client to manage own care. Reference: 16. Cooperate upon the schedule of administering antiemetic medications as needed? Yes__No__Why?

17. Adapt to the proper use of antiemetic medications effectively.

17. Instruct in proper use, side effect, and adverse reactions of antiemetic medications.

17. Adapt to the proper use of antiemetic medications effectively? Yes__No__Why?

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. Adhere to the ways of avoiding the problem with nausea efficiently? Yes__No__Why?

Marilyn Doenges, Nurses Pocket Guide 12th 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, Nurses Pocket Guide 12th Edition, page 549 20. Timely recognition and intervention may limit severity and complications. Reference: Marilyn Doenges, Nurses Pocket Guide 12th Edition, p 549 19. Express understanding of the importance of replacing fluids and/or electrolytes as needed? Yes__No__Why?

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. Show interest for monitoring self and for follow-up medications as appropriate? Yes__No__Why?