Nausea Nursing Diagnosis and Care Plans
Nausea Nursing Diagnosis and Care Plans

Nausea: An unpleasant, wavelike sensation in the back of the throat, epigastrium, or throughout the abdomen that may or may not lead to vomiting.

The NANDA nursing diagnosis Nausea is described as an unpleasant sensation in the back of the throat and in the stomach that may or may not result in vomiting. 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.

Related Factors

Here are some factors that may be related to nursing diagnosis Nausea:

Treatment-related:

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  • 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

Defining Characteristics

The nursing diagnosis is characterized by the following signs and symptoms:

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

Goals and Outcomes

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

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

AssessmentRationale
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 Nausea

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

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Nursing InterventionsRationale
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-mealThis 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.

Sources and References

References and sources for this nursing diagnosis:

  • Carpenito-Moyet, L. J. (Ed.). (2006). Nursing diagnosis: Application to clinical practice. Lippincott Williams & Wilkins. [Link]
  • 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 cancerCancer Nursing23(3), 237-243.
Nausea Nursing Diagnosis and Care Plans
Nausea Nursing Diagnosis and Care Plans
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