NAUSEA Nursing Care Plan

Mr. Holme, 48 years old, embalmer recently diagnosed with lung cancer and still have undergoing chemotherapy. Because of Mr. Holme's chemotherapy, he experience unwanted nausea and very stressful for him. He can't do his task properly and he have difficulty in traveling even in a short distance. That nausea bothers him a lot. Below is a nursing care plan about nausea of Mr. Holme.

 

Assessment:

Subjective: "I always feel like to vomit." As verbalized by the patient.

Objectives:

- Gagging sensation reports nausea
- Increased salivation reports sour taste in mouth

Diagnosis:

Nausea related to chemotherapy secondary to increased salivation reports sour taste in mouth.

 

Planning:

After 4 hours of nursing intervention, the patient will report decreased nausea as experienced. The patient will identify foods or beverages that do not increase nausea. The patient will describe factors that increase nausea.

Interventions:

- Take measures to prevent treatment-related nausea of Mr. Holme. Aggressive management before, during, and after his chemotherapy can prevent nausea. Aggressively prevent nausea and vomiting in those with risk factors in female gender, non-smoker, history of motion sickness/postoperative nausea/vomiting. Use volatile anesthetics within 0–2 hours, Nitrous oxide and or intraoperative and postoperative opioids.

- Promote comfort during nausea and vomiting of Mr. Holme. Protect him at risk for aspiration if Mr. Holme is immobile. Address the cleanliness of Mr. Holme and environment. Provide an opportunity for oral care after each episode. Apply a cool, damp cloth to Mr. Holme's forehead, neck, and wrists.

- Teach or assist Mr. Holme to rest before meals. Teach him to spend minimal energy preparing food like cook large quantities and freeze several meals at a time, request assistance from others. Teach Mr. Holme 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 to Mr. Holme after vomiting. Teach him to practice deep breathing and voluntary swallowing to suppress his vomiting reflex. Instruct him to sit down after eating, but not to lie down. Encourage Mr. Holme to eat smaller meals and to eat slowly. Restrict liquids with meals to avoid over-distending his stomach; also, avoid fluids 1 hour before and after meals.

- Encourage Mr. Holme to sit in fresh air or use a fan to circulate air. Advise him to avoid lying flat for at least 2 hours after eating. He must rest should sit or recline so that his head is at least 4 inches higher than his feet. Advise Mr. Holme to listen to his music. Offer small amounts of clear fluids and foods and beverages with ginger. Offer muscle relaxation and distraction techniques to Mr. Holme. If qualified, use acupressure at pressure points post operatively.

 

Evaluation:

After 4 hours of nursing intervention, the patient was reported decreased nausea as experienced. The patient was identified foods or beverages that do not increase nausea. The patient was described factors that increase nausea.

 

For more samples of nursing care plan you are free to check it out in our NCP LIST page.