CUES Subjective: Verbalizes unpleasant sensation at the back of the throat Complains sour taste in mouth Reports about

gagging sensation

NURSING DIAGNOSIS Nausea related to gastric distention as evidenced by increased salivation and swallowing.

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

OBJECTIVES After the nursing intervention, the client will be able to: Identify situations that perceives as distasteful, anxiety inducing or threatening accordingly.

INTERVENTIONS

RATIONALE

EVALUATION After the nursing intervention, the client was 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 prophylacticall y. (Marilyn Doenges, Nurses Pocket Guide 12th Edition, page 546)

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

Objective: Increased swallowing Increased salivation Client has delayed gastric emptying (gastric distention)

State if his nausea is potentially self-limiting 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.

State if his nausea is potentially self-limiting and/or mild or if severe and prolonged appropriately.

(Marilyn Doenges, Nurses Pocket Guide 12th Edition, page 547)

 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. ( Marilyn Doenges, Nurses Pocket Guide 12th Edition, page 547)

Determine signs of dehydration correctly.

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. Provide diet and snacks of preferred or bland foods when available

4. To promote comfort and enhance intake. (Marilyn Doenges, Nurses Pocket Guide 12th Edition, page 547)

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

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

5.

To reduce gastric acidity and improve nutrient intake.

( Marilyn Doenges, Nurses Pocket Guide 12th Edition, page 547)

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

 Follow instructions on how to enhance digestion properly.

6. Instruct client to eat slowly, chewing food well. Recommend client to remain seated after meal, or with head elevated above feet if in bed. 7. Encourage the client to provide frequent oral care (especially after vomiting)

6.

This is to enhance digestion and to promote comfort and enhance intake.

Follow instructions on how to enhance digestion properly.

( Marilyn Doenges, Nurses Pocket Guide 12th Edition, page 548) 7. To cleanse mouth and minimize bad tastes Verbalize understanding of the importance of providing frequent oral care as needed. Compare with the different non pharmacologi cal interventions for managing nausea precisely.

Verbalize understanding of the importance of providing frequent oral care as needed. Compare with the different non pharmacologi cal interventions for managing nausea precisely.

( Marilyn Doenges, Nurses Pocket Guide 12th Edition, page 548) 8. Promotes relaxation, refocus clients attention, increase sense of control, and decreases feelings of helplessness.

8. Encourage and explain the use of non pharmacological interventions such as self hypnosis, progressive muscle relaxation, biofeedback, guided imagery,

(Marilyn Doenges,

and systemic desensitization. Cooperate upon the schedule of administering antiemetic medications as needed. 9. Administer antiemetic medications on regular schedule as ordered.

Nurses Pocket Guide 12th Edition, page 548) 9. To prevent or control side effects of medication. ( Marilyn Doenges, Nurses Pocket Guide 12th Edition, page 548) Cooperate upon the schedule of administering antiemetic medications as needed.

Adapt to the proper use of antiemetic medications effectively.

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

10. Enhances client safety and effective management of condition. ( Marilyn Doenges, Nurses Pocket Guide 12th Edition, page 548) 11. Increases likelihood of preventing potentially serious electrolyte depletion. ( Marilyn Doenges, Nurses Pocket Guide 12th Edition, page 549)

Adapt to the proper use of antiemetic medications effectively.

Express understanding of the importance of replacing fluids and/or electrolytes as needed.

11. Review signs of dehydration and stress importance of replacing fluids and/or electrolytes.

Express understanding of the importance of replacing fluids and/or electrolytes as needed.