Utilize this comprehensive nursing care plan and management guide to provide effective care for patients experiencing nausea and vomiting. This resource will equip you with knowledge on nursing assessments, interventions, goals, and nursing diagnosis specifically tailored to address and alleviate symptoms of nausea.
Table of contents
What is nausea?
Nausea is a distressing sensation that may or may not lead to vomiting. It can have various causes, including medication side effects, chemical stimulation, gastrointestinal issues, or psychological factors. Pregnancy-related nausea, also known as morning sickness, is a common experience for many women. Nurses play a crucial role in identifying the causes of nausea, administering antiemetic medications, assessing their effectiveness, and communicating relevant information to physicians for necessary treatment adjustments.
Causative Factors
Understanding the underlying causes of nausea is important to identify the appropriate nursing assessments, interventions, and management strategies to alleviate this distressing symptom. Here are common reasons that can cause nausea:
Treatment-related
Nausea can have various causes, including treatment-related factors such as gastric distention, certain medications, postoperative recovery, and tube feeding.
- Gastric distention. Abdominal bloating or swelling, leading to a feeling of fullness and discomfort in the stomach.
- Medications. Certain drugs, such as painkillers, HIV treatment, aspirin, opioids, and chemotherapy agents, can cause nausea as a side effect.
- Postoperative. Nausea experienced after surgery, often due to the effects of anesthesia or the body’s response to the surgical procedure.
- Stomach upset. Discomfort in the stomach caused by factors like alcohol consumption, drug use, gastrointestinal bleeding, or iron supplements.
- Tube feeding. Nausea resulting feeding intolerance when feeding is given too quickly.
Biophysical
Biophysical factors such as bowel obstruction, cardiac pain, gastrointestinal diseases, increased intracranial pressure, infections, and motion sickness can also contribute to nausea.
- Bowel obstruction. Blockage in the intestines that disrupts normal digestion and leads to nausea.
- Cardiac pain. Chest discomfort or angina caused by inadequate blood supply to the heart.
- Cancer. Nausea can be a symptom of cancer, especially in advanced stages or during chemotherapy.
- Cough. Persistent or severe coughing can trigger nausea due to the increased pressure and irritation in the chest and abdomen.
- Gastrointestinal diseases. Various conditions like gastritis, gastroenteritis, or peptic ulcers can cause inflammation in the digestive system and result in nausea.
- Increased ICP. Nausea can be associated with increased intracranial pressure, often caused by conditions like head trauma, brain tumors, or cerebral edema.
- Infections. Nausea can occur as a response to infections, such as viral gastroenteritis or urinary tract infections.
- Motion sickness. Nausea and dizziness caused by the sensory mismatch between what the eyes see and the body feels during motion or travel.
- Peritonitis. Inflammation of the lining of the abdominal cavity, leading to severe abdominal pain, tenderness, and nausea.
- Pregnancy. Nausea and vomiting commonly experienced during early pregnancy, often referred to as morning sickness.
- Uremia. Buildup of toxins in the bloodstream due to kidney dysfunction, leading to nausea and other symptoms.
- Toxins. Ingestion or exposure to harmful substances, such as chemicals or certain foods, can cause nausea.
- Tumors. Nausea can be associated with the presence of tumors in various parts of the body, depending on their location and impact on organ function.
- Vestibular problems. Disorders affecting the inner ear or balance system can result in dizziness and nausea, such as in labyrinthitis or Meniere’s disease.
Signs and symptoms
The nausea is characterized by the following signs and symptoms.
- Allergy to food. Nausea can be a response to an allergic reaction triggered by certain foods, as the body’s immune system releases chemicals that can cause gastrointestinal discomfort.
- Excessive salivation. Excessive salivation, also known as hypersalivation or sialorrhea, can occur as a reflex response to the body’s attempt to protect the digestive tract from potential irritants, contributing to the sensation of nausea.
- Gagging sensation. The sensation of gagging can accompany nausea as the body’s natural defense mechanism to prevent the intake of potentially harmful substances, such as when encountering strong odors or tastes.
- Increased swallowing. Swallowing reflex can be heightened during episodes of nausea as the body attempts to clear the gastric contents and alleviate the discomfort.
- Reports of nausea. Patients experiencing nausea may report a subjective feeling of unease or discomfort in the upper abdomen or throat, indicating the presence of this symptom.
- Sour taste in the mouth. The sensation of a sour taste in the mouth can occur as stomach contents reflux into the esophagus, leading to gastroesophageal reflux disease (GERD) or acid regurgitation, which can be associated with nausea.
Goals and Outcomes
The following are the common goals and expected outcomes for nausea:
- The patient will report decreased severity or elimination of nausea.
- The patient will be able to manage the symptoms effectively and improve the quality of life.
Nursing assessment and rationales
The priority nursing assessment for patients with nausea is essential in understanding the cause, severity, and impact of symptoms, guiding the development of effective care plans, and monitoring the patient’s progress and well-being.
1. 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.
2. Assess nausea characteristics including duration, frequency, severity, precipitating factors, medication history, and previous measures used to relieve the problem.
A thorough assessment and evaluation of nausea can help determine interventions to lessen or ease the problem.
3. Record the patient’s hydration status, daily weights, BP, intake, and output, and assess skin turgor.
Nausea is usually correlated with vomiting which can change a patient’s hydration status because of fluid loss.
4. 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).
5. Review the prenatal vitamins the patient is taking, if pregnant.
Having too much iron may cause nausea, and switching to a different vitamin could help.
Nursing Interventions and Rationales
The priority nursing interventions for patients with nausea focus on symptom management, maintaining fluid and electrolyte balance, providing dietary modifications, educating the patient and family, and collaborating with the healthcare team. The following are the therapeutic nursing interventions for nausea that you can use for your nursing care plans:
1. Provide an emesis basin within easy reach of the patient.
Nausea and vomiting are closely related. Keep the emesis basin out of sight but within the patient’s reach if nausea has a psychogenic component.
2. Educate and assist the patient with oral hygiene.
This is associated with anorexia and excessive salivation. Oral hygiene helps alleviate the condition and facilitates comfort.
3. Eliminate strong odors from the surrounding (e.g., perfumes, dressings, emesis)
Strong and noxious odors can contribute to nausea.
4. 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.
5. Allow the patient to use non pharmacological nausea control techniques such as relaxation, guided imagery, music therapy, distraction, or deep breathing exercises.
These methods have helped patients alleviate the condition but need to be used before it occurs.
6. Apply Acustimulation bands as ordered, or apply acupressure.
Stimulation of the Neiguan P6 acupuncture point on the ventral surface of the wrist has been found to control nausea at some points. This has been found to be helpful for patients who experience motion-related nausea.
7. 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.
8. 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.
- 8.1. Dry food like crackers or toast
Crackers or toast before rising are especially known to be effective for pregnancy-related nausea.
- 8.2. 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.
9. Tell the patient to avoid foods and smells that trigger nausea.
Strong and noxious odors can contribute to nausea.
10. Position the patient upright while eating and for 1 to 2 hours post-meal
This can be helpful in reducing the risk.
11. 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.
12. 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.
13. Evaluate the patient’s response to antiemetics or interventions to alleviate the condition.
This approach is helpful in determining the effectiveness of such interventions.
14. 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.
15. Educate the patient to take prescribed medications as ordered.
Following the prescribed schedule for medications reduces episodes of nausea.
16. Educate the patient about the importance of changing positions slowly and calmly.
Abrupt or gross movements may aggravate the condition.
17. Educate the patient or caregiver on 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.
18. Inform the patient or caregiver to seek medical care if vomiting develops or persists for longer than 24 hours.
Persistent vomiting can result in dehydration, electrolyte imbalance, and nutritional deficiencies.
19. Educate the patient or caregiver on how to apply Acustimulation bands or acupressure.
Patients and caregivers may desire to proceed with intervention if it was found useful and effective.
Recommended Resources
Recommended nursing diagnosis and nursing care plan books and resources.
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Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.
See also
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch. - Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
References and sources
References and sources for this nursing diagnosis:
- 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 Nursing, 23(3), 237-243.