Nursing Diagnosis: Nausea
Definition of Nausea
- A subjective unpleasant, wavelike sensation in the back of the throat, epigastrium, or abdomen that may lead to the urge or need to vomit
Defining Characteristics of Nausea
- 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”
Related Factors of Nausea
Biophysical
- Biochemical disorders
- Esophageal disease
- Gastric distention, irritation
- Increased intracranial pressure
- Motion sickness
- Pain
- Pancreatic disease
- Tumors, intra-abdominal or localized tumors
Situational
- Anxiety
- Fear
- Noxious odors, taste, visual stimulation
- Pain
- Physiological factors
Treatment
- Gastric distention, irritation
- Pharmaceuticals
Assessment Focus | Nursing Care Plan for Nausea
Nursing Diagnosis for Nausea | Assessment Focus; Expected Outcomes; Suggested NOC Outcomes
Assessment Focus of Nausea (Refer To Comprehensive Assessment Parameters.)
- Nutrition
- Fluid and electrolytes
- Pharmacological function
- Knowledge
- Comfort
Expected Outcomes | Nursing Diagnosis for Nausea
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 | Nursing Diagnosis for Nausea
Appetite; Comfort Level; Fluid Balance; Hydration; Nausea & Vomiting Control; Nutritional Status: Food & Fluid Intake; Suffering Severity; Symptom Control
Nursing Interventions of Nausea | Nursing Care Plan for Nausea
Nursing Diagnosis for Nausea | Nursing Interventions of Nausea and Rationales; Suggested NIC Interventions
Nursing Interventions of Nausea and Rationales
- 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 information will help in identifying appropriate interventions.
- Monitor direct observation of food and fluid intake to ensure whether or not the patient is receiving adequate nutritional intake.
- 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. Procedures 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 periods of nausea to make it possible to eat. These foods have been found to be effective.
- Administer antinausea medications, as prescribed.
- Teach relaxation techniques and encourage patient to use these techniques during mealtime to reduce stress and divert attention 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.
- 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.
- 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 physician.
- Nausea is a preventable problem and should respond to appropriate measures.
Suggested NIC Interventions | Nursing Diagnosis for Nausea
Diet Staging; Fluid and Electrolyte Management; Fluid Monitoring; Medication Management; Nausea Management Nutritional Management
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