CUES NURSING DIAGNOSIS

ANALYSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective:

- Verbalizes unpleasant sensation at the back of the throat

- Complains sour taste in mouth

- Reports about gagging sensation

Objective:

- Increased swallowing

- Increased salivation

- Client has delayed gastric emptying (gastric distention)

Nausea related to gastric distention as evidenced by increased salivation and swallowing.

Nausea is a subjective unpleasant wavelike sensation at the back of the throat, epigastrium, or abdomen that may lead to the urge to vomit

Reference: Marilyn Doenges, Nurses’ Pocket Guide 12th Edition, page 545

After the nursing intervention, the client will be able to:

Identify situations that perceives as distasteful, anxiety inducing or threatening accordingly.

State if his nausea is potentially self-limiting and/or mild or if severe and prolonged appropriately.

1. Ask the client about the situations that perceives as distasteful, anxiety inducing or threatening.

2. Determine if nausea is potentially self-limiting and/or mild or if severe and prolonged. Explain and give some example of situations to the client.

1. May be able to limit or control exposure to situations or take medication prophylactically.

(Marilyn Doenges, Nurses’ Pocket Guide 12th Edition, page 546)

2. Suggests severity of effect on fluid and electrolyte balance and nutritional status.

(Marilyn Doenges, Nurses’ Pocket Guide 12th Edition, page 547)

After the nursing intervention, the client was able to:

Identify situations that perceives as distasteful, anxiety inducing or threatening accordingly.

State if his nausea is potentially self-limiting and/or mild or if severe and prolonged appropriately.

Determine signs of dehydration correctly.

Define the benefit of trying dry foods when nausea occurs throughout the day as appropriate.

Select from the diet and snacks of preferred or bland foods provided and/or when available.

3. Check vital signs and note signs of dehydration. Explain it to the client.

4. Advise the client to try dry foods such as toast, crackers, dry cereal before arising when nausea occurs within morning or throughout the day.

5. Provide diet and snacks of preferred or bland foods when available

3. Nausea may occur in the presence of postural hypotension and fluid volume deficit.

( Marilyn Doenges, Nurses’ Pocket Guide 12th Edition, page 547)

4. To promote comfort and enhance intake.

(Marilyn Doenges, Nurses’ Pocket Guide 12th Edition, page 547)

5. To reduce gastric acidity and improve nutrient intake.

( Marilyn Doenges, Nurses’ Pocket Guide 12th Edition, page 547)

Determine signs of dehydration correctly.

Define the benefit of trying dry foods when nausea occurs throughout the day as appropriate.

Select from the diet and snacks of preferred or bland foods provided and/or when available.

Follow instructions on how to enhance digestion properly.

Verbalize understanding of the importance of providing frequent oral care as needed.

Compare with the different non pharmacological interventions for managing nausea precisely.

6. Instruct client to eat slowly, chewing food well. Recommend client to remain seated after meal, or with head elevated above feet if in bed.

7. Encourage the client to provide frequent oral care (especially after vomiting)

8. Encourage and explain the use of non pharmacological interventions such as self hypnosis, progressive muscle relaxation, biofeedback, guided imagery,

6. This is to enhance digestion and to promote comfort and enhance intake.

( Marilyn Doenges, Nurses’ Pocket Guide 12th Edition, page 548)

7. To cleanse mouth and minimize “bad tastes”

( Marilyn Doenges, Nurses’ Pocket Guide 12th Edition, page 548)

8. Promotes relaxation, refocus client’s attention, increase sense of control, and decreases feelings of helplessness.

(Marilyn Doenges,

Follow instructions on how to enhance digestion properly.

Verbalize understanding of the importance of providing frequent oral care as needed.

Compare with the different non pharmacological interventions for managing nausea precisely.

Cooperate upon the schedule of administering antiemetic medications as needed.

Adapt to the proper use of antiemetic medications effectively.

Express understanding of the importance of replacing fluids and/or electrolytes as needed.

and systemic desensitization.

9. Administer antiemetic medications on regular schedule as ordered.

10. Instruct in proper use, side effect, and adverse reactions of antiemetic medications.

11. Review signs of dehydration and stress importance of replacing fluids and/or electrolytes.

Nurses’ Pocket Guide 12th Edition, page 548)

9. To prevent or control side effects of medication.

( Marilyn Doenges, Nurses’ Pocket Guide 12th Edition, page 548)

10. Enhances client safety and effective management of condition.

( Marilyn Doenges, Nurses’ Pocket Guide 12th Edition, page 548)

11. Increases likelihood of preventing potentially serious electrolyte depletion.

( Marilyn Doenges, Nurses’ Pocket Guide 12th Edition, page 549)

Cooperate upon the schedule of administering antiemetic medications as needed.

Adapt to the proper use of antiemetic medications effectively.

Express understanding of the importance of replacing fluids and/or electrolytes as needed.