Nausea, Nursing Assessment for Nausea, Nursing Interventions for Nausea, and 5 Nursing Care Plans for Nausea

Nausea, Nursing Assessment for Nausea, Nursing Interventions for Nausea, and 5 Nursing Care Plans for Nausea

This guide is about Nausea, Nursing Assessment for Nausea, Nursing Interventions for Nausea, and 5 Nursing Care Plans for Nausea. It can be followed when preparing educational nursing care plans for Nausea.

Nausea

Nausea, Nursing Assessment for Nausea, Nursing Interventions for Nausea, and 5 Nursing Care Plans for Nausea
Nausea

What is Nausea?

Nausea is the sensation of an urge to vomit. Nausea can be acute and short-lived, or it can be prolonged. When prolonged, it is a debilitating symptom. Nausea (and vomiting) can be psychological or physical in origin. Nausea is a queasy sensation that may include or not include an urge to vomit. It is a common and distressing indication with multiple causes, including chemical stimulation of the vomiting center by certain medications, chemotherapy, intracranial lesions, ingestion of toxins, inhalation of anesthetic gases, mucosal diseases, gastrointestinal obstruction, or microorganisms in the gastrointestinal tract.
Other physiological factors include decreased motility, delayed gastric emptying time, and decreased peristalsis. It may also have psychogenic origins such as gastroparesis in which the stomach cannot empty itself of food in a normal fashion. Carsickness or seasickness are also some factors for most causes of nausea. Nausea during pregnancy is commonly one of the most experienced and complained about symptoms that women report. Up to 70 percent of expectant mothers experience this at some point during early pregnancy but this subsides by their second trimester although sometimes even longer.

Nurses are responsible for assessing the causes of nausea and vomiting, administering appropriate antiemetic agents, evaluating the outcomes of the agents, and communicating data and information to physicians when changes in treatment are indicated.

What Causes Nausea?

Here are common reasons that can cause nausea:

Treatment-related:

  • Gastric distention
  • Medications like analgesics, HIV treatment, aspirin, opioids, radiotherapy, or chemotherapy agents
  • Postoperative
  • Stomach upset due to alcohol, drugs, blood, or iron
  • Tube feeding

Biophysical:

  • Bowel obstruction
  • Cardiac pain
  • Cancer
  • Cough
  • Gastrointestinal diseases
  • Increased ICP
  • Infections
  • Motion sickness
  • Peritonitis
  • Pregnancy
  • Uremia
  • Toxins
  • Tumors
  • Vestibular problems

Situational:

  • A reaction to smells and odors
  • Bulimia
  • Fear
  • Noxious stimuli
  • Overeating
  • Pain

What are the Signs and Symptoms of Nausea?

The nausea is characterized by the following signs and symptoms. Look for these nursing assessment cues to help you diagnose:

  • Allergy to food
  • Excessive salivation
  • Gagging sensation
  • Increased swallowing
  • Reports of nausea
  • Sour taste in the mouth

What are the Goals and Outcomes for Nursing Diagnosis of Nausea?

The following are the common goals and expected outcomes for Nausea nursing diagnosis:

  • Patient reports decreased severity or elimination of nausea.

Nursing Assessment for Nausea

How do you access for Nausea?

Nausea, Nursing Assessment for Nausea, Nursing Interventions for Nausea, and 5 Nursing Care Plans for Nausea
Nursing Assessment for Nausea

The following nursing assessments are done for the nursing diagnosis Nausea:

Assessment Rationale
Determine causes of nausea. Assessing the patient with the causes of nausea will guide the choice of interventions to be used. Treatment may not be needed if the stimulus is eliminated.
Assess nausea characteristics: 

  • History
  • Duration
  • Frequency
  • Severity
  • Precipitating factors
  • Medications
  • Measures used to alleviate the problem
A thorough assessment and evaluation of nausea can help determine interventions to lessen or ease the problem.
Record the patient’s hydration status, daily weights, BP, intake and output, and assessing skin turgor. Nausea is usually correlated with vomiting that can change a patient’s hydration status because of fluid loss.

Nursing Interventions for Nausea

What are the Nursing Interventions for Nausea?

Nausea, Nursing Assessment for Nausea, Nursing Interventions for Nausea, and 5 Nursing Care Plans for Nausea
Nursing Interventions for Nausea

The following are the therapeutic nursing interventions for Nausea nursing diagnosis that you can use for your nursing care plans:

Nursing Interventions Rationales
Provide an emesis basin within easy reach of the patient. Nausea and vomiting are closely related. Keep emesis basin out of sight but within the patient’s reach if nausea has a psychogenic component.
Educate and assist patient about oral hygiene. This is associated with anorexia and excessive salivation. Oral hygiene helps alleviate the condition and facilitates comfort.
Assist the patient in diagnostic testing preparation. A series of tests may be used to determine the contributing factor (e.g., upper gastrointestinal tract study, abdominal computed tomography scan, ultrasonography.)
Eliminate strong odors from the surrounding (e.g., perfumes, dressings, emesis) Strong and noxious odors can contribute to nausea.
Maintain fluid balance in patients at risk. Sufficient hydration before surgery or chemotherapy has been shown to reduce the risk of nausea in these situations.
Allow the patient to use nonpharmacological nausea control techniques such as relaxation, guided imagery, music therapy, distraction, or deep breathing exercises. These methods have helped patients alleviate the condition but needs to be used before it occurs.
Apply acustimulation bands as ordered, or apply accupressure. Stimulation of the Neiguan P6 acupuncture point on the ventral surface of the wrist has been found to control nausea in some points. This has been found to be helpful for patients who experience motion-related nausea.
Introduce cold water, ice chips, ginger products, and room temperature broth or bouillon if tolerated and appropriate to the patient’s diet. These aid hydration. Ginger helps relieve nausea whether in ginger ale, ginger tea, or chewed as crystallized ginger. Fluids that are too cold or hot may be difficult to tolerate.
Give frequent, small amounts of foods that appeal to the patient. This approach will help maintain nutritional status. For some patients, an empty stomach exacerbates nausea.
  • Dry food like crackers or toast
Crackers or toast before rising are especially known to be effective for pregnancy-related nausea.
  • Bland, simple foods like broth, rice, bananas, or Jell-O
Patients may endure these types of foods. They should attempt to consume more when nausea is absent.
Tell patient to avoid foods and smells that trigger nausea. Strong and noxious odors can contribute to nausea.
Position the patient upright while eating and for 1 to 2 hours post-meal This can be helpful in reducing the risk.
Review about the prenatal vitamins the patient is taking, if pregnant. Having too much iron may cause nausea, and switching to a different vitamin could help.
Administer antiemetics as ordered. Most antiemetics work by increasing the threshold of the chemoreceptor trigger zone to stimulation. Drugs with antiemetic actions include antihistamines, anticholinergics, dopamine antagonists, serotonin (5-HT3) receptor antagonists, and benzodiazepines. Glucocorticoids and cannabinoids are useful to treat chemotherapy-induced nausea and vomiting. For the preoperative patient, administration of antiemetics prior to surgery has been shown to reduce postoperative nausea and vomiting.
Keep rooms well-ventilated. If possible, assist the patient to go outside to get some fresh air. A well-ventilated room or having a fan close by promotes easier breathing.
Educate the patient or caregiver about appropriate fluid and dietary options for nausea. Patients and caregivers can promote adequate hydration and nutritional status by acknowledging dietary points to consider when nauseated.
Educate the patient to take prescribed medications as ordered. Following the prescribed schedule for medications reduces episodes of nausea.
Education the patient about the importance of changing positions slowly and calmly. Abrupt or gross movements may aggravate the condition.
Educate patient or caregiver the use of nonpharmacological nausea control techniques such as relaxation, guided imagery, music therapy, distraction, or deep breathing exercises. Teaching the patient and caregiver methods to control nausea increases the sense of personal efficacy in managing nausea.
Evaluate the patient’s response to antiemetics or interventions to alleviate the condition. This approach is helpful in determining the effectiveness of such interventions.
Inform the patient or caregiver to seek medical care if vomiting develops or persists longer than 24 hours. Persistent vomiting can result in dehydration, electrolyte imbalance, and nutritional deficiencies.
Educate the patient or caregiver how to apply accustimulation bands or accupressure. Patients and caregivers may desire to proceed with intervention if it was found useful and effective.

5 Nursing Care Plans for Nausea

What are the Nursing Care Plans for Nausea?

Nursing Care Plan 1

Cancer with Ongoing Chemotherapy

Nursing Diagnosis: Nausea and Vomiting related to chemotherapy status secondary to cancer as evidenced by reports of nausea, vomiting, and gagging sensation.

Desired Outcome: The patient will manage chronic nausea, as evidenced by maintained or regained weight.

Intervention Rationale
Assess the extent of nausea, vomiting, and limited food and fluid intake. To provide baseline data and determine the need for hydration and nutritional support.
Encourage to try dry foods (crackers, toast) when nausea occurs. To decrease discomfort and enhance intake.
Encourage ice chips, sips of cold water and ginger products when nauseous. To promote hydration and decrease the discomfort associated with nausea.
Promote a bland diet and decrease intake of greasy and spicy food and caffeinated beverages. Avoid milk/dairy products, overly sweet, fried, and fatty foods To reduce gastric acidity, improve nutrient intake, and prevent further nausea and vomiting.
Administer antiemetics regularly before, during, and after administration of antineoplastic agents. To prevent and control side effects of the antineoplastic medications, including but not limited to nausea and vomiting.
 Monitor weight regularly. To monitor nutritional status throughout the chemotherapy, and address malnutrition and dehydration if present.
Discuss possible complications with the healthcare team. Timely recognition of possible complications leads to timely solutions.
Educate patient to avoid foods and smells that trigger nausea. To decrease the occurrence of nausea and vomiting.
Advise the patient on nonpharmacologic ways to reduce nausea, such as guided imagery, deep breathing exercises, and relaxation. To control and manage nausea, and to promote independence.
Inform the patient and the caregiver to seek professional assistance if vomiting persists for more than 24 hours. Persistent vomiting has serious consequences. Timely assessment may prevent complications brought about by this condition, i.e. dehydration, electrolyte imbalance, and nutritional deficiencies.

Nursing Care Plan 2

Gallbladder Disease

Nursing Diagnosis: Nausea and Vomiting related to intestinal blockage secondary to gallbladder disease and intestinal obstruction as evidenced by nausea, vomiting, and gagging sensation.

Desired Outcome: The patient will be free of nausea.

Intervention Rationale
Prepare the patient for diagnostic testing. To determine the etiology of the nausea and vomiting.
Maintain oral hydration and start intravenous hydration as ordered. To prevent dehydration and hypovolemia.
Encourage to try dry foods (crackers, toast) when nausea occurs. To decrease discomfort and enhance nutritional intake.
Encourage ice chips, sips of cold water and ginger products when nauseous. To promote hydration and decrease the discomfort associated with nausea.
Promote a bland diet and decrease intake of greasy and spicy food and caffeinated beverages. Avoid milk/dairy products, overly sweet, fried, and fatty foods To reduce gastric acidity, improve nutrient intake, and prevent further nausea and vomiting.
Advise the patient on nonpharmacologic ways to reduce nausea, such as guided imagery, deep breathing exercises, and relaxation. To control and manage nausea, and to promote independence.
Administer antiemetics as needed, as ordered by the healthcare provider. To halt vomiting and prevent further vomiting episodes.
Administer pain medications as needed, as ordered by the healthcare provider. Pain may exacerbate vomiting episodes. Administering pain medications decreases the risk of further episodes.
Monitor the patient for signs and symptoms of complications. Timely recognition of complications leads to timely solutions.
Educate patient to avoid foods and smells that may trigger nausea. To decrease the occurrence of nausea and vomiting.
Prepare the patient for pharmacologic and/or surgical interventions. To effectively alleviate the nausea and vomiting being experienced by the patient.
Maintain the patient on a low-fat diet. Preventing gallstone formation prevents further episodes of nausea and vomiting due to gallbladder disease.

Nursing Care Plan 3

Food Poisoning

Nursing Diagnosis: Nausea and Vomiting related to irritation of the gastrointestinal system as evidenced by abdominal cramping and abdominal pain secondary to food poisoning

Desired Outcome: The patient will be able to state relief of nausea and will be able to explain methods that can be used to decrease nausea and vomiting

Intervention Rationale
Determine the cause of nausea and vomiting (e.g., food poisoning). Determine the food source that caused nausea and vomiting Nausea and vomiting are clinically identifiable symptoms, it is essential for the cause to be determined and appropriate plan and interventions be developed
Document each episode of nausea and/or vomiting separately, as well as the effectiveness of interventions. Use of an assessment tool is needed for the consistency of evaluation A systematic approach can provide consistency, accuracy, and measurement needed for the direction of care. It is important to recognize that nausea is an experience that is subjective.
Identify and eliminate contributing causative factors. This would include the elimination of the food source that has been identified as the cause of the nausea and vomiting Elimination of these contributing causative factors may provide the patient relief from stimulus that causes the nausea and vomiting
Implement appropriate dietary measures such as nothing by mouth (NBM or NPO) status when appropriate; instituting small frequent meals; and implementing low-fat meals. It is beneficial to avoid foods that are spicy, fatty, or highly salty. Implementing an NPO status gives the gastrointestinal system of the patient time to recover from nausea and vomiting and implementation of the different feeding arrangements ensure adequate nutritional status of the patient
Recognize and implement interventions and monitor complications associated with nausea and vomiting. This may include the administration of intravenous fluids and electrolytes Recognizing the complications of nausea and vomiting is critical in the prevention and management of the complications of dehydration, electrolyte imbalance, and malnourishment. Adequate hydration also corrects imbalances and reduces further emesis
Administer appropriate antiemetics, according to emetic cause, by most effective route, with a consideration of the side effects of the medication, and with attention to and coverage for the timeframes that the nausea and vomiting is anticipated Antiemetic drugs are effective at different receptor sites and treat the different causes of nausea and vomiting. A combination of medications may be more effective than a single drug.

Nursing Care Plan 4

Pregnancy

Nursing Diagnosis: Nausea and vomiting related to pregnancy as evidenced by aversion to food and gagging sensation

Desired Outcome: The patient will be able to state relief of nausea and be able to explain methods the patient can use to decrease the incidence of nausea and vomiting

Intervention Rationale
Early recognition of pregnancy induced nausea and vomiting Early recognition and conservative measures are recommended for the successful management of nausea and vomiting caused by pregnancy, and to prevent the progression to hyperemesis gravidarum.
Implement dietary and lifestyle modifications first before the implementation of pharmacological interventions The fetus is highly sensitive to pharmacological interventions. Dietary and lifestyle options should be tried first.
Avoidance of aversive odors or foods is recommendedTo avoid the stimulation of nausea and vomitingEating multiple small meals per dayTo ensure adequate nutrition and to have food in the stomach at all times, thereby preventing hypoglycemia and gastric overdistentionDrinking smaller volumes of liquids at multiple times throughout the dayEnsures adequate hydration without the stimulation of nausea and vomitingAssess and manage symptoms of heartburn, belching, and indigestionDue to the high incidence of coexisting gastroesophageal reflux disease (GERD) during pregnancy, it is important to manage these symptoms should they occurTesting for Helicobacter pyloriHelicobacter pylori is associated with hyperemesis gravidarum. It is recommended to test for Helicobacter pylori if there are persistent symptoms of nausea with pregnancy, prolonged symptoms of GERD, or a previous history of Helicobacter pylori infectionTimely diagnosis and treatment of anxiety and depressionCoexisting psychosocial factors may also influence the severity of nausea and vomiting during pregnancy. Symptoms of anxiety and depression can occur in early pregnancy, especially when the nausea and vomiting is severe and this can make the treatment of nausea and vomiting more challenging and even ineffective
Administration of oral pyridoxine hydrochloride and doxylamine succinate This combination is the first-line treatment for nausea and vomiting of pregnancy

Nursing Care Plan 5

Gastroenteritis

Nursing Diagnosis: Nausea and vomiting related to active fluid volume loss secondary to gastroenteritis

Desired Outcome: The patient will be able: to maintain a urine output of 0.5 mL/kg/hour or at least more than 1300 mL/day; maintain normal blood pressure, heart rate, and body temperature; maintain elastic skin turgor, moist tongue, and mucous membranes, and orientation to person, place, and time.

Intervention Rationale
Watch for early signs of hypovolemia, including thirst, restlessness, headaches, and inability to concentrate Thirst is often the first sign of dehydration. Heart rate increases due to fluid restriction along with increased urine specific gravity, darker urine color, and increased thirst. Decreased alertness, increased sleepiness, fatigue, and confusion is also experienced
Recognize symptoms of cyanosis, cold clammy skin, weak thready pulse, confusion, and oliguria as late signs of hypovolemia These symptoms occur after the body has compensated for fluid loss by removing fluid from the interstitial space into the vascular compartment
Monitor pulse, respiration, and blood pressure of patients with deficient fluid volume every 15 minutes to 1 hour for unstable patients and every 4 hours for stable patients Changes in vital signs seen with fluid volume deficit include tachycardia, tachypnea, decreased pulse pressure, hypotension, decreased pulse volume, and decreased or increased body temperature
Check orthostatic blood pressure with the patient standing, sitting, and lying. A decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within 3 minutes of standing compared with blood pressure from the sitting position is considered as orthostatic hypotension
Note the skin turgor over bony prominences such as the hand or shin For the assessment of the level of dehydration
Weigh the patient daily and watch for sudden decreases, especially in the presence of decreasing urine output or active fluid loss Body weight changes of 1 kg represent a fluid loss of 1 L
Monitor total fluid intake and output every 4 hours or every hour for unstable patients. To monitor the patient’s hydration status
Provide fresh water and oral fluids preferred by the patient To promote hydration
Administer pharmacologic interventions such as antibiotics, antivirals, antidiarrheals, and antiemetics as ordered and appropriate To treat the cause of the gastroenteritis

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.

Carpenito-Moyet, L. J. (Ed.). (2006). Nursing diagnosis: Application to clinical practice. Lippincott Williams & Wilkins.

Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier.

Grealish, L., Lomasney, A., & Whiteman, B. (2000). Foot massage: a nursing intervention to modify the distressing symptoms of pain and nausea in patients hospitalized with cancer. Cancer Nursing23(3), 237-243.

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.

Nausea, Nursing Assessment for Nausea, Nursing Interventions for Nausea, and 5 Nursing Care Plans for Nausea

 

 

"Looking for a Similar Assignment? Order now and Get a Discount!

Place New Order
It's Free, Fast & Safe

"Looking for a Similar Assignment? Order now and Get a Discount!

Want Someone to Write Your Paper For You
Order Now & Get 15% off your first purchase

X
Scroll to Top