Nursing Care Plan Anxiety
- 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”
Biophysica & Situational
- Biochemical disorders
- Esophageal disease
- Gastric distention, irritation
- Noxious odors, taste, visual
- Increased intracranial pressure
- Motion sickness
- Physiological factors
- Pancreatic disease
- Tumors, intra-abdominal or
- Gastric distention, irritation
- Fluid and electrolytes
- 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.233 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
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.