Nausea

Definition: A subjective unpleasant, wavelike sensation in the back of the throat, epigastrium,
or abdomen that may lead to the urge or need to vomit

RELATED FACTORS
Treatment
 Gastric irritation [e.g., alcohol, blood]
 Gastric distention
 Pharmaceuticals [e.g., analgesics—aspirin/nonsteroidal anti-inflammatory drugs/opioids,
anesthesia, antiviral for HIV, steroids, antibiotics, chemotherapeutic agents][Radiation therapy/exposure]

Biophysical
 Biochemical disorders (e.g., uremia, diabetic ketoacidosis, pregnancy)
 Localized tumors (e.g., acoustic neuroma, primary or secondary brain tumors, bone metastases
 at base of skull); intra-abdominal tumors
 Toxins (e.g., tumor-produced peptides, abdominal metabolites due to cancer)
 Esophageal/pancreatic disease; liver/splenetic capsule stretch
 Gastric distention [e.g., delayed gastric emptying, pyloric intestinal obstruction, external
 compression of the stomach, other organ enlargement that slows stomach functioning
 (squashed stomach syndrome)]
 Gastric irritation [e.g., pharyngeal and/or peritoneal inflammation]
 Motion sickness; Meniere’s disease; labyrinthitis
 Increased intracranial pressure; meningitis
Situational
 Noxious odors/taste; unpleasant visual stimulation
 Pain
 Psychological factors; anxiety; fear

Subjective data
Report of nausea

Objective data
Aversion toward food
Increased salivation; sour taste in mouth
Increased swallowing; gagging sensation

Expected outcome:

NURSING OBJECTIVES INTERVENTIONS RATIONALE

ASSESSMENT DIAGNOSIS

Nausea The patient 1. Assess nausea characteristics 1. A comprehensive assessment of the

Subjectiv related to will report nausea can help to determine
e data gastric diminished interventions
irritatiion severity of 2. Assess the patients hydration 2. Nausea is often associated with
Objective nausea status by easuring BP, IOchart and vomiting that can alter a patient’s
data skin turgor. hydration status.

 Aversion 3. Review medication regimen, 3. Polypharmacy with drug interaction can

toward
food
especially in elderly client on cause gastric irritation
 Increased multiple drugs.
salivation; 4. Keep an emesis basin within easy 4. To avoid the soliling of the cloth or
sour taste reach of the patient. rushing to the toilet
in mouth
 Increased 5. Offer or assist with oral hygiene 5. Oral hygiene helps to promotecomfort
swallowin
g; gagging
every 2 to 4 hrs if tolerated.
sensation
6. Remove noxious odours from the 6. Strong noxios odour
room contributes to nausea
7. Offer frequent small amount of
foods that appeal to the patient 7. Patient may not feel
a. Dry foods or bland dkiet nauseated.
b. Offer cold water or ice
chips
8. Elevate head of bed or have client 8. To reduce the feeling of
sit upright after meals nausea to promote digestion
by gravity and
9. Avoid sudden changes in position. 9. eliminate feeling of fullness
 10. Apply cool cloth to face and neck. 10. It may increase nausea
11. Encourage slow, deep breathing. 11. To promote relaxation
Use such distraction techniques as
guided imagery, music therapy 12. To reduce nausea and
12. Administer antiemetics as ordered. prevent vomiting.
Patient reports diminished severity or elimination of nausea.

Risk for deficient Fluid Volume

Definition: At risk for experiencing vascular, cellular, or intracellular dehydration

RISK FACTORS

Excessive losses through normal routes (e.g., diarrhea, vomiting)

Deviations affecting access, intake, or absorption of fluids (e.g., physical immobility
Factors influencing fluid needs (e.g., hypermetabolic states)
Medications (e.g., diuretics)
Extremes of age/weight
Loss of fluid through abnormal routes (e.g., indwelling tubes)
Knowledge deficiency

Expected outcome

• Identify individual risk factors and appropriate interventions.

• Demonstrate behaviors or lifestyle changes to prevent development of fluid volume deficit

Assessment Nursing Diagnosis objective Interventions Rationale

 Risk for deficient The patient will 1. Assess for the possible causes 1. To plan proper interventions
Subjective data fluid volume maintain
related to fever, normovolemia or 2. Assess skin turgor/oral mucous 2. To check the severity of
Objective data diarrhea, balanced fluid membranes for signs of fluid loss
nausea/vomiting; volume. dehydration
 Excessive irritable
3. Evaluate nutritional status, noting
losses through bowel syndrome, 3. It can negatively affect fluid
current food intake, type of diet
normal routes draining wounds, intake
(e.g., client is NPO or is on a
(e.g., diarrhea, dementia, restricted/pureed diet)
vomiting) depression, eating
 Deviations disorders
affecting 4. Monitor vital signs 4. to check fluid loss
access, intake,
or absorption of 5. Calculate pulse pressure
5. Pulse pressure often widens before
fluids (e.g., systolic BP drops in response to
physical fluid loss
immobility
 Factors 6. Monitor I/O chart 6. to monitor fluid balnace
influencing
fluid needs
(e.g., 7. Weigh client and compare with 7. fluid loss may cause drastic
hypermetabolic recent weight history. changes in weight
states)
 Medications 8. to promote adequate
(e.g., diuretics) 8. Encourage oral intake hydration
 Extremes of
9. Offer fluids between meals and
age/weight 9. to promote hydration
regularly throughout the day.
 Loss of fluid
through 10. Allow adequate time for eating 10. To prevent fluid loss . to
abnormal and drinking at meals. stop/limit fluid losses
routes (e.g.,
indwelling
tubes) 11. Limit fluids that tend to exert a 11. To identify fluid loss at
 Knowledge diuretic effect (e.g., caffeine, earlier
alcohol
 deficiency
12. Administer medications as
appropriate (e.g., antiemetics,
antidiarrheals, antipyretics)
13. Encourage client/caregiver to
maintain diary of food/fluid
intake, number and amount of
14. voidings, and estimate of other
fluid losses

3. Disturbed body image

Definition: Confusion [and/or dissatisfaction] in mental picture of one’s physical self

RELATED FACTORS

Biophysical; illness; trauma; injury; surgery; [mutilation, pregnancy]

Illness treatment [change caused by biochemical agents (drugs), dependence on machine]
Psychosocial
Cultural; spiritual
Cognitive; perceptual
Developmental changes; [maturational changes]
[Significance of body part or functioning with regard to age, gender, developmental level
Subjective data

 Verbalization of feelings that reflect an altered view of one’s body (e.g., appearance, structure,
 function)
 Verbalization of perceptions that reflect an altered view of one’s body in appearance
 Verbalization of change in lifestyle
 Fear of rejection/reaction by others
 Focus on past strength/function/appearance
 Negative feelings about body (e.g., feelings of helplessness, hopelessness, or powerlessness);
 [depersonalization/grandiosity]
 Preoccupation with change/loss
 Refusal to verify actual change
 Emphasis on remaining strengths; heightened achievement
 Personalization of part/loss by name
 Depersonalization of part/loss by impersonal pronouns

Objective data

 Behaviors of acknowledgment of one’s body; avoidance of one’s body; monitoring one’s body
 Nonverbal response to actual/perceived change in body (e.g., appearance, structure,
  function)
 Missing body part
 Actual change in structure/function
 Not looking at/not touching body part
 Trauma to nonfunctioning part
 Change in ability to estimate spatial relationship of body to environment
 Extension of body boundary to incorporate environmental objects
 Intentional/unintentional hiding/overexposing of body part
 Change in social involvement
 [Aggression; low frustration tolerance level

Expected outcome

Client Will

• Verbalize acceptance of self in situation (e.g., chronic progressive disease, amputee,

decreased independence, weight as is, effects of therapeutic regimen).

• Verbalize relief of anxiety and adaptation to actual/altered body image.

• Verbalize understanding of body changes.

• Recognize and incorporate body image change into self-concept in accurate manner without
negating self-esteem.

• Seek information and actively pursue growth.

• Acknowledge self as an individual who has responsibility for self.

• Use adaptive devices/prosthesis appropriately

Assessment Nursing objective Interventions Rationale
Diagnosis

Disturbed body The patient will 1. Assess mental/physical influence 1. Emotional changes may indicate
Subjective image related to verbalize of illness/condition on the level of anxiety and need for
data illness; trauma; acceptance of client’s emotional state intervention to lower anxietye.
injury; surgery self in situation
or understands 2. Evaluate level of client’s 2. It interferes with ability to
body changes. knowledge of and anxiety related engage in therapy and indicate
to situation. need to provide interventions to
deal
3. Recognize behavior indicative of 3. with concern before beginning
overt preoccupation with body therapy
and its processes.
4. Establish therapeutic nurse-client 4. Conveys an attitude of caring
relationship. and develops a sense of trust

Objective data 5. Provide assistance with self-care 5. Client needs support to achieve
needs/measures, as necessary, the goal of independence and
while promoting individual positive return to managing own
abilities/independence life.

6. Acknowledge and accept feelings 6. Conveys a message of

of dependency, grief, and understanding
hostility.

7. Encourage client to look at/touch 7. Acceptance will enhance self-

affected body part to begin to esteem and enable client to
incorporate changes into body move forward in a positive
image.
8. Provide accurate information, as 8. Accurate knowledge helps client
desired/requested. Provides make better decisions for the
early/ongoing sources of support future
 9. Provide rehabilitation services or 9. to promote rehabilitation in a
do required referral services. timely manner

10. Observe emotional changes. 10. to promote better living

conditions

DEFICIENT KNOWLEDGE

Definition:

 Absence or deficiency of cognitive information related to specific topic . [Lack of specific information necessary for
clients/SO(s) to make informed choices regarding condition/treatment/lifestyle changes]

RELATED FACTORS:

 Lack of exposure/recall
 Information misinterpretation; [inaccurate/incomplete information presented]
 Unfamiliarity with information resources
 Cognitive limitation
 [Development of preventable complicationLack of interest in learning; [request for no information]

Subjective
 Verbalization of the problem
 [Request for information]
 [Statements reflecting misconceptions]
Objective
 Inaccurate follow-through of instruction/performance of test
 Inappropriate or exaggerated behaviors (e.g., hysterical, hostile, agitated, apathetic]

EXPECTED OUTCOME / GOAL:

Client Will (Include Specific Time Frame)
• Participate in learning process.
 • Identify interferences to learning and specific action(s) to deal with them.
• Exhibit increased interest/assume responsibility for own learning by beginning to look for
information and ask questions.
• Verbalize understanding of condition/disease process and treatment.
• Identify relationship of signs/symptoms to the disease process and correlate symptoms
with causative factors.
• Perform necessary procedures correctly and explain reasons for the actions.
• Initiate necessary lifestyle changes and participate in treatment regimen.

ASSESSMEN NURSING GOAL PLANNING RATIONALE

T DIAGNOSIS
OBJECTIVE DEF ICIENT Client Will 1. Ascertain level of knowledge, 1. Client may or may not ask for
DATA: KNOWLEDGE Participate in including anticipatory needs. information or may express
RELATED TO learning Learning needs can include many inaccurate perceptions of health
 Inaccurate Lack of process things (e.g., disease cause and status and needed behaviours to
follow- exposure/recall. process, factors contributing to manage self care.
through of symptoms, procedures for symptom
instruction control, needed alterations in
/performan lifestyle, ways to prevent
ce of test complication. 2. Conveys expectation of
 Inappropri 2. Engage in Active-listening. confidence in client’s ability to
ate or determine learning needs and best
exaggerate ways of meeting them
d
behaviors 3. Determine client’s ability/readiness 3. Client may not be physically,
(e.g., and barriers to learning emotionally, or mentally capable at
hysterical, this time and may need time to work
hostile, through and express
agitated,
apathetic] 4. Be alert to signs of avoidance 4. May need to allow client to suffer
the consequences of lack of
knowledge before client is ready
to accept information
5. Identify family members requiring 5. Providing appropriate
information. information to others can provide
reinforcement for learning, as
everyone will understand what is
to be expected.
6. Note personal factors (e.g., 6. Affects ability and desire to
age/developmental level, gender, learn/assimilate new information,
social/cultural influences, religion, take control of situation, accept
life experiences, level of education, responsibility for change.
emotional stability] .
7. Determine blocks to learning,
including (1) language barriers (e.g., 7. Many factors affect the client’s
can’t read or write, ability and desire to learn, and his
speaks/understands a different or her expectations of the learning
language than that spoken by process must be addressed if
teacher); (2) physical factors (e.g., learning is to be sucessful.
cognitive impairment, sensory
deficits [e.g., aphasia, dyslexia,
hearing or vision impairment]); (3)
physical constraints (e.g., acute
illness, activity intolerance, impaired
thought processes); (4) complexity of
material to be learned (e.g., caring for
colostomy giving own insulin
injections); (5) forced change in
lifestyle (e.g., stopping smoking); or
(6) have stated no need/desire to
learn.

8. Assess the level of the client’s 8. May need to assist caregivers to

capabilities and the possibilities of the learn by introducing one new idea,
situation. by building on previous
information, or by finding pictures
to demonstrate an idea, etc., to
adapt teaching to client’s
9. Identify motivating factors for the 9. Provides information that can
individual (e.g., client needs to stop guide
smoking because of
10. advanced lung cancer, or client wants 10. content specific to client’s
to lose weight because family situation and motivations.
member died of complications of
obesity). Motivation may be negative
(e.g., smoking caused lung cancer) or
positive (e.g., client wants to promote
health/prevent disease).

11. Provide information relevant only to 11. Reducing the amount of

the situation. information at any one given time
helps to keep the client focused
and prevents client from feeling
overwhelmed.
12. Provide positive reinforcement rather 12. Enhances cooperation and
than negative reinforcers (e.g., encourages continuation of efforts.
criticism and threats).

13. Discuss client’s perception of need. 13. Takes into account the client’s
personal desires/needs and
values/beliefs, providing a basis
for planning appropriate care.

14. Identify information that needs to be 14. Enhances possibility that

remembered (cognitive) at client’s information will be heard and
level of development and education. understood.

15. Determine client’s/SO’s method of 15. Using multiple modes of

accessing information and preferred instruction facilitates
learning mode (e.g., auditory/visual, learning/enhances retention,
kinesthetic; group classes, one-to-one especiallywhen faced with a
instruction, online) and include in stressful situation, illness/new
teaching plan. treatment regimen
16. Involve with others who have same 16. Group presentations, support
problems/needs/concerns. Use team groups provide role models and
and group teaching as appropriate. opportunity for sharing of
information to enhance learning.
17. Provide written
information/guidelines and self- 17. Reinforces learning proces
learning modules for client to refer to
as necessary.

18. Pace and time learning sessions and 18. Client statements, questions,
learning activities to individual’s comments provide feedback about
needs. Involve and evaluate ability to grasp information being
effectiveness of leaning activities presented
with client.

19. Provide an environment that is 19. To limit distractions and allow

conducive to learning. client to focus on the material
presented.
20. Be aware of factors related to teacher 20. may affect client’s reaction to
in the situation (e.g., vocabulary, teacher/ability to learn from this
dress, style, knowledge of the subject, individual.
and ability to impart information
effectively).

21. Begin with information the client 21. Can arouse interest/limit sense of
already knows and move to what the being overwhelmed.
client does not know, progressing
from simple to complex.

22. Provide active role for client in 22. Promotes sense of control over
learning process, including questions situation.
and discussion

23. Have client paraphrase content in 23. to enhance internalization of

own words, perform return material and to evaluate learning.
 demonstration, and explain how
learning can be applied in own
situation.

24. Provide for feedback (positive 24. . Validates current level of

reinforcement) and evaluation of understanding and identifies areas
learning/acquisition of Skills. requiring follow UP.

25. Be aware of informal teaching and 25. Answering specific

role modeling that takes place on an questions/reinforcing previous
ongoing basis. teaching during routine
contacts/care