Nursing Care Plan for Nausea and Vomiting

Nausea

Nausea is the sensation (feeling) issued a strong food or want to vomit. Usually accompanied by autonomic signs such as hypersalivation, diaphoresis, tachycardia, pallor, and tachypnea, nausea closely related to anorexia. Nausea caused by distention or irritation in any part of the gastrointestinal tract, but can also be stimulated by higher brain centers.

Nausea is a common symptom of digestive disorders, but may also occur in fluid and electrolyte imbalance, infection, metabolic disorders, endocrine, and cardiac maze. Can also be as a result of drug therapy, surgery, and radiation.

Nausea is also common in the first trimester of pregnancy, nausea can arise from intense pain, anxiety, alcohol poisoning, excessive food or digest food or drinks that do not taste good.


Definition of "Vomit" is a discharge of most or all of the stomach contents food into the stomach occurs after a while, accompanied by contraction of the stomach and abdomen. (Vivian Nanny Lia Dewi, 2010)

In a simple sense of Vomiting is spending the stomach contents through the mouth. Another understanding of the vomiting is a discharge of most or all of the stomach contents food into the stomach occurs after a while, with stomach and abdominal contractions. In the first few hours after birth, the baby may experience vomiting mucus, sometimes with a little blood. Vomiting is not uncommon to settle after breast feeding or food, the situation is probably due to irritation of the gastric mucosa by a number of objects that are ingested during childbirth.

Many causes that can lead to vomiting, namely:

• Virus infection
• Stress
• Gestation
• Drug
• Myocardial infarction
• Uremia
• Other conditions

Therapeutic Intervention

Nausea and vomiting are very few require intervention. However, if left unchecked will lead to dehydration and electrolyte imbalance. Loss of hydrochloric acid from the stomach can cause metabolic alkalosis. Vomiting black, like coffee, showed vomit mixed with blood. Protection of the airway during vomiting are the most important measures to prevent aspiration. Increased risk of aspiration in patients with loss of consciousness, the elderly, and the failure of reflexes. Place the patient in a comfortable position so that vomit out. Beating back while vomiting can lead to aspiration.


Nursing Process in Patients with Nausea and Vomiting

Assessment / data collection

1. Episodes of nausea and vomiting
2. Medical condition
3. Drugs consumed
4. Treatment is being done

Early signs of fluid loss:

1. Weakness
2. Headache
3. Not be able to concentrate
4. Postural hypotension

Further signs of fluid loss:

1. Confused
2. Oliguria
3. Skin cool and moist
4. Chest and abdominal pain

Nursing Diagnosis, Planning, and Implementation

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 :

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

2 . Risk for aspiration related to decreased reflexes or awareness

The desired result :

• Airway and lung sounds clean patient

Iintervention :

1. Assess whether the patient is in the risk for aspiration .
2. Place the patient in a position to prevent aspiration .

3 . Deficient Fluid Volume

The desired result :

• Patient's vital signs within normal limits .

Interventions :

1. Monitor for signs of hypovolemia to prevent any complications that may occur .
2. Measure body weight each day .
3. Monitor intake output , and vital signs , and vital signs , blood pressure ortohstatik .
4. Give fluids by IV .
5. Discharge monitoring during treatment to prevent deficit and excess fluid .

Evaluation

Patients showed no nausea, lung sounds clean and normal vital signs .

Imbalanced Nutrition : less than body requirements related to nausea and vomiting

Risk for Fluid Volume Deficit related to Vomiting