Nursing Care Plan Nausea Vomiting PDF

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Lewis: Medical-Surgical Nursing in Canada, 3rd Edition Chapter 44: Nursing Management: Upper Gastrointestinal Problems Care Plans - Customizable NCP 44-1: Nursing Care Plan: Patient With Nausea and Vomiting NURSING DIAGNOSIS: Nausea related to multiple etiologies as evidenced by episodes of nausea and vomiting EXPECTED PATIENT OUTCOMES  Experiences minimal or no nausea  Reports satisfaction with care

NURSING INTERVENTIONS and RATIONALES 

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Assess the duration, frequency, and nature of nausea and vomiting and any aggravating and alleviating factors to plan appropriate interventions. Remove visual stimuli and sources of odours to avoid precipitating triggers of nausea or vomiting. Provide mouth care; change soiled gown and linens to ensure patient comfort. Maintain a quiet environment and avoid unnecessary procedures or activities to minimize triggers of vomiting. Administer antiemetic(s) as ordered. Instruct the patient to take several deep breaths; prevent sudden changes in position; keep the head of the bed elevated to decrease stimulation of the vomiting centre. • Instruct the patient to avoid foods and beverages that stimulate nausea and vomiting.

NURSING DIAGNOSIS: Deficient fluid volume related to prolonged vomiting and inability to ingest, digest, or absorb food and fluids as evidenced by decreased urine output and increased urine concentration, increased pulse rate, hypotension (postural), decreased intake, decreased skin turgor, and dry skin and mucous membranes EXPECTED PATIENT OUTCOMES  Shows no signs of dehydration

NURSING INTERVENTIONS and RATIONALES  

Assess for signs of dehydration to plan appropriate care. Administer and monitor the amount and type of IV fluid to maintain fluid and electrolyte balance.

Copyright © 2014 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

Care Plans - Customizable

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Provide small amounts of clear liquids when vomiting stops to support hydration. Record the amount and frequency of vomitus; maintain accurate intake and output records; weigh daily in acute phase to monitor fluid balance accurately. Monitor laboratory results of serum sodium, potassium, chloride, and bicarbonate as indicators of electrolyte balance.

NURSING DIAGNOSIS: Imbalanced nutrition: less than body requirements related to nausea and vomiting as evidenced by lack of interest in or aversion to food, perceived or actual inability to ingest food, and weight loss EXPECTED PATIENT OUTCOMES  Shows gradual return to usual weight and eating habits

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Assess the patient’s interest in food, ability to ingest food, and weight to determine if a problem is present. Maintain IV fluids or total parenteral nutrition until oral intake is possible to provide necessary fluids, electrolytes, calories, and protein intake. Instruct the patient to resume eating cautiously with bland, nonirritating foods in small amounts to avoid irritating the stomach and initiating a recurrence of nausea and vomiting.

Copyright © 2014 Elsevier Canada, a division of Reed Elsevier Canada, Ltd....