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?

3. Drink liquids 30 minutes before or after meals instead of with meals adequately. Define the benefit of trying dry foods when nausea occurs throughout the day as appropriate? Yes__No__Why? 5. 4. 4. 5. Explain it to the client. Determine signs of dehydration correctly.547 3. 5. Advise the client to try dry foods such as toast. Reference: Marilyn Doenges. 3. Nurses’ Pocket Guide 12th Edition. Reference: Marilyn Doenges. Check vital signs and note signs of dehydration. crackers. Nausea may occur in the presence of postural hypotension and fluid volume deficit. Reference: Marilyn Doenges. Advise the client to drink liquids 30 minutes before or after meals instead of with meals. page 547 4. Nurses’ Pocket Guide 12th Edition. To promote comfort and enhance intake. dry cereal before arising when nausea occurs within morning or throughout the day. To promote comfort and enhance intake. Determine signs of dehydration correctly? Yes__No__Why? 4. Define the benefit of trying dry foods when nausea occurs throughout the day as appropriate. 3. page 547 5. Drink liquids 30 minutes before or after meals instead of with meals adequately? .

page 547 8. May increase nausea or be more difficult to digest.Nurses’ Pocket Guide 12th Edition. Reference: Marilyn Doenges. 6. cauliflower. cucumbers) 6. Encourage the on eating small client to eat small meals spaced meals spaced 8. overly sweet or fried and fatty foods and gas-forming vegetables (eg. Select from the diet and snacks of preferred or bland foods provided and/or when available. To reduce gastric acidity and improve nutrient intake. Display interest 8. Display interest on eating small meals spaced . 7. broccoli. sherbet or ices. non acidic fruit juice. page 547 Yes__No__Why? 6. Nurses’ Pocket Guide 12th Edition. 7. Nurses’ Pocket Guide 12th Edition. Reference: Marilyn Doenges. Avoid milk/dairy products as needed? Yes__No__Why? 8. Avoid milk/dairy products as needed. skinless cooked chicken) 7. Provide diet and snacks of preferred or bland foods when available (increase bland. gelatin. clear soup broth. Select from the diet and snacks of preferred or bland foods provided and/or when available? Yes__No__Why? 7. page 547 6. caffeine-free non diet carbonated beverages. So stomach does not feel excessively full. Advise the client to avoid milk/dairy products.

chewing food well. perfumes. throughout the day instead of large meals. Recommend client to remain seated after meal. Reference: Marilyn Doenges. Instruct client to eat slowly. page 548 10. Encourage the client to provide peaceful environment and fresh air with fan or open window while at home. This is to enhance digestion and to promote comfort and enhance intake. They may stimulate or worsen nausea. Provide clean. Reference: Marilyn Doenges. such as cooking smells. 9. Advise to avoid offending odors. smoke. page 548 throughout the day as needed? Yes__No__Why? 9. or with head elevated above feet if in bed.throughout the day as needed. peaceful environment and fresh air with fan or open window while at home? Yes__No__Why? . Nurses’ Pocket Guide 12th Edition. Reference: Marilyn Doenges. peaceful environment and fresh air with fan or open window while at home. 10. Nurses’ Pocket Guide 12th Edition. 9. Follow instructions on how to enhance digestion properly. Nurses’ Pocket Guide 12th Edition. Follow instructions on how to enhance digestion properly? Yes__No__Why? 10. and 10. page 547 9. Provide clean.

mechanical emission when possible. Teach the client 12. Advise the client to use distraction with music. To cleanse mouth and minimize “bad tastes” Reference: Marilyn Doenges. Practice deep and slow breathing frequently. Reference: 12. 12. Practice deep and slow breathing frequently? Yes__No__Why? 13. refocus attention away from nausea. Verbalize understanding of the importance of providing frequent oral care as needed. page 548 11. Select from different ways to limit dwelling with unpleasant sensation 13. Encourage the client to provide frequent oral care (especially after vomiting) 11. To promote deep and slow relaxation and breathing. Select from different ways to limit dwelling with unpleasant sensation . page 548 13. 11. chatting with 13. To limit dwelling on unpleasant sensation. Nurses’ Pocket Guide 12th Edition. Verbalize understanding of the importance of providing frequent oral care as needed? Yes__No__Why? 12. Nurses’ Pocket Guide 12th Edition. Reference: Marilyn Doenges. 11.

Reference: Marilyn Doenges. Nurses’ Pocket Guide 12th Edition. To reduce external pressure on abdomen. page 549 15. Suggest wearing loosefitting clothing. Encourage and explain the use of non pharmacological interventions such as self hypnosis. Compare with the different non pharmacological interventions for managing nausea precisely. Nurses’ Pocket Guide 12th Edition. 14. Compare with the different non pharmacological interventions for managing nausea precisely? Yes__No__Why? . biofeedback.accordingly. page accordingly? Yes__No__Why? 14. increase sense of control. refocus client’s attention. 15. Point out the importance of wearing loosefitting clothing as appropriate? Yes__No__Why? 15. 14. and decreases feelings of helplessness. page 548 14. and systemic desensitization. Nurses’ Pocket Guide 12th Edition. Promotes relaxation. Marilyn Doenges. Point out the importance of wearing loosefitting clothing as appropriate. and watching TV. guided imagery. Reference: Marilyn Doenges. progressive muscle relaxation. family/friends. 15.

Instruct in proper use. page 548 18. 17. Adhere to the ways of avoiding the problem with nausea efficiently? Yes__No__Why? . Nurses’ Pocket Guide 12th Edition. Cooperate upon the schedule of administering antiemetic medications as needed. Reference: Marilyn Doenges. Reference: Marilyn Doenges. Adapt to the proper use of antiemetic medications effectively? Yes__No__Why? 18. Administer antiemetic medications on regular schedule as ordered. 18. 18. To prevent or control side effects of medication. 16. page 548 17. Nurses’ Pocket Guide 12th Edition. Adhere to the ways of avoiding the problem with nausea efficiently. and adverse reactions of antiemetic medications. side effect. 17. Enhances client safety and effective management of condition. Provides necessary information for client to manage own care.548 16. 16. Review individual factors or triggers causing nausea and ways to avoid problem. Cooperate upon the schedule of administering antiemetic medications as needed? Yes__No__Why? 17. Adapt to the proper use of antiemetic medications effectively. Reference: 16.

20. Express understanding of the importance of replacing fluids and/or electrolytes as needed? Yes__No__Why? 20. Nurses’ Pocket Guide 12th Edition. Discuss potential complications and possible need for medical follow-up. Review signs of dehydration and stress importance of replacing fluids and/or electrolytes. Timely recognition and intervention may limit severity and complications. Show interest for monitoring self and for follow-up medications as appropriate? Yes__No__Why? . Nurses’ Pocket Guide 12th Edition. page 549 20. Explain to the client the signs that require immediate notification of the health care provider. Show interest for monitoring self and for follow-up medications as appropriate. p 549 19. 20. Express understanding of the importance of replacing fluids and/or electrolytes as needed. 19. Reference: Marilyn Doenges. page 548 19. 19. Nurses’ Pocket Guide 12th Edition. Increases likelihood of preventing potentially serious electrolyte depletion.Marilyn Doenges. Reference: Marilyn Doenges.

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