Nursing Diagnosis and Interventions for Nausea and Vomiting

Nausea and Vomiting

Nausea is a sensation of unease and discomfort in the upper stomach with an involuntary urge to vomit. It occasionally precedes vomiting. A person can suffer nausea without vomiting. When prolonged, it is a debilitating symptom.

Nausea is a non-specific symptom, which means that it has many possible causes. Some common cause of nausea are motion sickness, dizziness, migraine, fainting, gastroenteritis (stomach infection) or food poisoning. Nausea is a side effect of many medications including chemotherapy, nauseants or morning sickness in early pregnancy. Nausea may also be caused by anxiety, disgust and depression.

Vomiting , also known as emesis, throwing up, among other terms, is the involuntary, forceful expulsion of the contents of one's stomach through the mouth and sometimes the nose.

Vomiting can be caused by a wide variety of conditions; it may present as a specific response to ailments like gastritis or poisoning, or as a non-specific sequela of disorders ranging from brain tumors and elevated intracranial pressure to overexposure to ionizing radiation. The feeling that one is about to vomit is called nausea, which often precedes, but does not always lead to, vomiting. Antiemetics are sometimes necessary to suppress nausea and vomiting. In severe cases, where dehydration develops, intravenous fluid may be required.


Nursing Diagnosis and Interventions for Nausea and Vomiting


1. Nausea related to various causes

The desired result :
  • Patients expressed no nausea and vomiting.
  • Odor-free environment, clean so it does not cause nausea.

Interventions :
  • Give anti- emetic.
  • Oral care, to reduce emesis and increased comfort.
  • Explained to the patient to avoid foods that cause or may cause vomiting.


2. Risk for aspiration related to decreased reflexes or penuruanan awareness

The desired result :
  • Airway and lung sounds clean.

Iintervention :
  • Assess whether the patient is in the risk for aspiration.
  • Place the patient in a position to prevent aspiration.


3. Deficient Fluid Volume

The desired result :
  • Patient's vital signs within normal limits.
Interventions :
  • Monitor for signs of hypovolemia to prevent any complications that may occur.
  • Measure body weight each day.
  • Monitor intake output, and vital signs.
  • Give fluids by IV.
  • Discharge monitoring during treatment to prevent deficit and excess fluid.

Source :
http://www.nandahealth.top/2013/10/nursing-care-plan-for-nausea-and.html

Nursing Care Plan for Hypertensive Heart Disease : Acute Pain

Hypertensive heart disease includes a number of complications of high blood pressure that affect the heart. While there are several definitions of hypertensive heart disease in the medical literature, the term is most widely used in the context of the International Classification of Diseases (ICD) coding categories. The definition includes heart failure and other cardiac complications of hypertension when a causal relationship between the heart disease and hypertension is stated or implied on the death certificate.

The symptoms and signs of hypertensive heart disease will depend on whether or not it is accompanied by heart failure. In the absence of heart failure, hypertension, with or without enlargement of the heart (left ventricular hypertrophy) is usually symptomless. Symptoms and signs of chronic heart failure can include:
  •     Fatigue
  •     Irregular pulse or palpitations
  •     Swelling of feet and ankles
  •     Weight gain
  •     Nausea
  •     Shortness of breath
  •     Difficulty sleeping flat in bed (orthopnea)
  •     Bloating and abdominal pain
  •     Greater need to urinate at night
  •     An enlarged heart (cardiomegaly)
Patients can present acutely with heart failure and pulmonary edema due to sudden failure of pump function of the heart. Acute heart failure can be precipitated by a variety of causes including myocardial ischemia, marked increases in blood pressure, or cardiac dysrhythmias, especially atrial fibrillation. Alternatively heart failure can develop insidiously over time.(wikipedia).


Nursing Care Plan for Hypertensive Heart Disease : Acute Pain

Acute Pain (headache) related to increased cerebral vascular pressure.


Goal :

    Client reported pain / discomfort disappeared / controlled .


Interventions and Rationale :

1. Maintain bed rest during the acute phase.

2. Give non-pharmacological measures to eliminate headaches eg, a cold compress on the forehead, back and neck massage, quiet, dim the room lights room lights, relaxation techniques (manual imagination, disktraksi) and leisure time activities.

3. Eliminate / minimize vasoconstriction activity that can increase headache eg, straining during defecation, coughing and bending length.

4. Assist patients in ambulation as needed.

5. Give liquids, soft foods, regular oral care in the event of bleeding nose or nasal pack has been done to stop the bleeding.

Rationale:

1. Minimize stimulation / promote relaxation.

2. Actions that reduce cerebral vascular pressure and the slow / block sympathetic response is effective in relieving headaches and complications.

3. Activities that increase vasoconstriction causing headaches in an increase in cerebral vascular pressure.

4. Dizziness and blurred vision often associated with pain kepala.pasien can also experience episodes of postural hypotension.

5. Increase the general comfort, compress the nose can interfere with swallowing or breathing requires mouth, causing stagnation oral secretions and mucous membranes dry out.

Source :
http://www.nurseskomar.xyz/2013/11/acute-pain-nursing-care-plan-for.html