00134 Nausea

Domain 12: comfort
Class 1: physical comfort
Diagnostic Code: 00134
Nanda label: nausea
Diagnostic focus: nausea
Approved 1998 • Revised 2002, 2010, 2017 • Level of evidence 2.1

NANDA Nursing Diagnosis Definition

The Nanda nursing diagnosis « nausea ” is defined as: unpleasant subjective phenomenon in the back of the throat and stomach that may or may not give rise to vomiting.

Definite characteristics

  • Aversion towards food
  • Nausea sensation
  • Increase in salivation
  • Increase in swallowing
  • Bitter taste

Related factors

  • Anxiety
  • Exposure to toxins
  • Fear
  • harmful flavors
  • Unpleasant sensory stimuli

Risk population

  • Pregnant women

Associated problems

  • Abdominal Neoplasia
  • Alteration of biochemical phenomena
  • Esophageal disease
  • Gastric distension
  • Gastrointestinal irritation
  • Intracranial hypertension
  • Labyrintitis
  • Voltage in the hepatic capsule
  • Located tumor
  • Ménière disease
  • Meningitis
  • I dizzy by movement
  • pancreatic diseases
  • Pharmacological preparations
  • Psychological disorder
  • Splenic capsule voltage
  • Therapeutic regime

Suggestions of use

  • This label is suitable for brief episodes of nausea and vomiting (for example, posoperatories). When nausea is serious or prolonged and can put proper nutrition at risk, a risk of nutritional imbalance should be used: intake less than nausea -related needs.

Suggested alternative diagnostics

  • Nutritional imbalance: intake less than needs
  • Volume of liquids, risk of deficit of

NOC Results

  • APETIT: I WISHE TO EAT A SICK PATIENT OR WHO RECEIVES TREATMENT
  • Nausea and vomiting control: personal actions to control the symptoms of nausea, arcades and vomiting
  • Nausea and vomiting: Adverse effect: Gravity of the harmful or reported harmful effects of nausea, arcades, and vomiting, which affect everyday functioning
  • Nausea and vomiting: gravity: severity of the symptoms of nausea, arcades and vomiting

Evaluation objectives and criteria

  • Nausea are reduced as evidenced by a great appetite and proper control of nausea and vomiting
  • demonstrates acceptable levels of nausea and vomiting: adverse effect, as manifested by the following indicators (specify from 1 to 5: severe, substantial, moderate, light or none):
    • Reduction of fluid intake
    • Food intake reduction
    • Urinary elimination reduction
    • Alteration of water balance
    • Alteration of serum electrolytes
    • Alteration of nutritional status
    • Weight loss
  • Other examples

    The patient will be able to:

    • Identify and avoid causal stimuli
    • Indicate a relief of nausea, arcades and vomiting
    • Identify and apply measures that reduce nausea

    NIC Interventions

    • Nausea control: prevention and relief of nausea
    • Vomiting control: prevention and relief of vomiting
    • Medication management: Facilitate the safe and effective use of drugs with and without recipe
    • Management of liquids and electrolytes: regulation and prevention of complications derived from the alteration of water and electrolytic concentrations
    • Management of the environment: manipulation of the patient’s environment to obtain a therapeutic, aesthetic benefit, in addition to psychological well -being
    • Nutrition surveillance: Collection and analysis of patient data to prevent or reduce malnutrition
    • Liquid surveillance: Patient data collection and analysis to regulate water balance

    Nursing Activities

    Valuations

    • Control the subjective symptoms of patient’s nausea
    • Monitor the color, quantity and density of urine
    • Assess the causes of nausea (for example, intestinal obstruction, side effects of medications)
    • (NIC) Nutrition surveillance:
      • Monitor the loss or weight gain trends
      • Monitor energy levels, general discomfort, fatigue and weakness
      • Monitor caloric intake and nutrients
    • (NIC) Liquid management:
      • Monitor the water balance
      • Monitor blood pressure, heart rate and respiratory state
      • Monitor mucous membranes, skin turgidity and thirst

    Patient and family education

    • Explain the causes of nausea
    • If possible, tell the patient the expected duration of nausea
    • Teach the patient to perform intentional swallows or deep breaths to inhibit the reflection of vomit
    • Teach the patient to eat slowly
    • Indicate the patient not to ingest liquids an hour before, an hour later and during meals

    Collaboration activities

    • Administer prescribed antiemetics
    • Consult a doctor to provide medications that control pain properly and that do not cause nausea to the patient
    • (NIC) Liquid management: Manage liquids, as required

    Others

    • Raise the bed header or place the patient on the side to avoid bronchaspiration (in individuals with reduced mobility)
    • Keep the patient and clean bedding when vomiting are presented
    • Immediately eliminate substances with bad smell (urinals or food)
    • Do not schedule painful procedures or that produce nausea near the food schedules
    • Offer oral care after vomiting
    • Apply cold and humid cloths on the dolls, neck and forehead of the patient
    • Offer cold foods and that do not smell bad

    At home

    • Indicate that odors are avoided during the preparation of food at home (for example, that another person prepares food, stay out of the kitchen, go for a walk during food preparation)
    • All the aforementioned interventions can be applied at home

    Babies and Children

    • Babies and children have a higher risk of liquid volume deficit due to nausea, since they usually reject food.

    Older people

    • Carefully monitor the side effects of antiemetics (for example, sedation)
    • Assess whether nausea may have been caused by some NSAIDs that the patient is taking for arthritis