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NAUSEA Nursing Care Plan

Nausea
NANDA-I Definition
A subjective phenomenon of an unpleasant feeling in the back of
the throat and stomach that may or may not result in vomiting
Defining Characteristics*
Aversion toward food Increased swallowing
Gagging sensation Reports nausea
Increased salivation Reports sour taste in mouth
Related Factors
Biopathophysiologic
Related to tissue trauma and reflex muscle spasms secondary to:
Acute gastroenteritis
Peptic ulcer disease
Irritable bowel syndrome
Pancreatitis
Infections (e.g., food
poisoning)
Drug overdose
Renal calculi
Uterine cramps associated
with menses
Motion sickness

Treatment Related
Related to effects of chemotherapy, theophylline, digitalis, antibiotics,
iron supplements
Related to effects of anesthesia
Situational (Personal, Environmental)*
Anxiety
Noxious odors, taste
Fear
Pain
Psychologic factors
Unpleasant visual stimulation
Goal
The client will report decreased nausea as experienced by the following
indicators:
• Name foods or beverages that do not increase nausea.
• Describe factors that increase nausea.
Interventions
Take Measures to Prevent Treatment-Related Nausea
• Aggressive management before, during, and after chemotherapy
can prevent nausea (Yarbro, Wujcik, & Gobel, 2011).
• Aggressively prevent nausea and vomiting in those with risk
factors (Pasero & McCaffery, 2011):
• Female gender
• Nonsmoker
• History of motion sickness/postoperative nausea/vomiting
• Use of volatile anesthetics within 0–2 hours, Nitrous oxide
and or intraoperative and postoperative opioids.
• Duration of surgery
• Type of surgery (e.g., laparoscopic, ENT, neurosurgery,
breast, plastic surgery)
• Consult with specialist to prevent postoperative nausea and vomiting
intraoperatively and postoperatively

• Use multimodal analgesics to reduce the dose of opioids to
lowest possible.
• Use multimodal antiemetics preinduction and at the end of
surgery.
Promote Comfort During Nausea and Vomiting
• Protect those at risk for aspiration (immobile, children).
• Address the cleanliness of the client and environment.
• Provide an opportunity for oral care after each episode.
• Apply a cool, damp cloth to the client’s forehead, neck, and
wrists.
Reduce or Eliminate Noxious Stimuli
Pain
• Plan care to avoid unpleasant or painful procedures before
meals.
• Medicate clients for pain 30 min before meals according to
physician/NP’s orders.
• Provide a pleasant, relaxed atmosphere for eating (no bedpans
in sight, do not rush); try a “surprise” (e.g., flowers with meal).
• Arrange the plan of care to decrease or eliminate nauseating
odors or procedures near mealtimes.
Fatigue
• Teach or assist the client to rest before meals.
• Teach the client to spend minimal energy preparing food (cook
large quantities and freeze several meals at a time, request
assistance
from others).
Odor of Food
• Teach the client to avoid cooking odors—frying food, brewing
coffee—if possible (take a walk; select foods that can be eaten
cold).
• Suggest using foods that require little cooking during periods
of nausea.
• Suggest trying sour foods.
Decrease Stimulation of the Vomiting Center
• Reduce unpleasant sights and odors. Restrict activity.
• Provide good mouth care after vomiting.
• Teach the client to practice deep breathing and voluntary swallowing
to suppress the vomiting reflex.
• Instruct the client to sit down after eating, but not to lie down.
• Encourage the client to eat smaller meals and to eat slowly.
• Restrict liquids with meals to avoid overdistending the stomach;
also, avoid fluids 1 hour before and after meals.

Loosen clothing.
• Encourage the client to sit in fresh air or use a fan to circulate air.
• Advise the client to avoid lying flat for at least 2 hours after
eating. (A client who must rest should sit or recline so that the
head is at least 4 inches higher than the feet.)
• Advise the client to listen to music.
• Offer small amounts of clear fluids and foods and beverages
with ginger.
• Offer muscle relaxation and distraction techniques to adult
cancer patients.
• If qualified, use acupressure at pressure points post operatively.
Maternal Interventions
Teach That Various Interventions Have Been Reported to Help
Control Nausea During Pregnancy
• Assure her that nausea is common during pregnancy (Pillitteri,
2010).
• Avoid fatigue and sudden movements.
• Avoid greasy, high-fat foods and strong odors.
• Eat high-protein meals and a snack before retiring.
• Chew gum or suck hard candies.
• Eat carbohydrates (e.g., crackers, toast, sour ball candy) on
arising; Delay eating breakfast until nausea passes.
• Eat immediately when hungry.
• Do not go longer than 12 hours without eating.
• If nauseated, sip/consume carbonated beverages (e.g., Coke
syrup, orange juice, ginger ale, and herbal teas such as ginger).
• Try deep breaths of fresh air
• Lie down to relieve symptoms.
Instruct the Pregnant Woman to Try One Food or Beverage Type
at a Time (e.g., High-Protein Meals/Bedtime Snack)
• If nausea is not relieved, try another measure.
• Explain the use of acupressure and acupuncture. Refer to
resources.

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