- Dysfunctional Gastrointestinal Motility related to Unpleasant sensory stimuli and Unsanitary food preparation as evidenced by Gagging sensation, Regurgitation and altered bowel sounds
- Imbalanced Nutrition less than body Requirements related to Inadequate interest in food and Nausea and vomiting as evidenced by Body weight below ideal weight range for age and gender
- Impaired Comfort Related to Insufficient control over symptoms and Noxious environmental stimuli as evidenced by altered sleep-wake cycle and Fatigue
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: Verbalizes vomiting sensation Objective data: -Increased salivation -Gagging sensation -Increased swallowing -Sour taste -Abdominal cramping -Abdominal pain -Acceleration of gastric emptying -Abdominal distention -Regurgitation -Altered bowel sounds | Dysfunctional Gastrointestinal Motility related to Unpleasant sensory stimuli and Unsanitary food preparation as evidenced by Gagging sensation, Regurgitation and altered bowel sounds | Patient will demonstrate bowel sounds within normal limits. Patient will exhibit normal eating habits without experiencing nausea, vomiting, abdominal discomfort, dyspepsia, bloating, and early satiety. | 1. Keep the patient on NPO as ordered. The patient who experiences nausea and vomiting is kept on NPO until a diagnosis is confirmed. This allows the gastrointestinal tract to rest and correct motility problems. 2. Insert and secure a nasogastric tube as indicated. A nasogastric tube is often indicated to help decompress the stomach in patients experiencing persistent nausea and vomiting, possible bowel obstruction, or paralytic ileus. The tube must be secured to prevent it from stimulating nausea and vomiting because of frequent tube movement in the nose and at the back of the throat. 3. Administer IV fluids and electrolyte replacement therapy. Patients who experience nausea and vomiting can experience dehydration along with electrolyte imbalance. Dehydration can cause the gastrointestinal tract to contract slower and the bowels to become slow and sluggish. 4. Encourage the patient to avoid foods and beverages that are gastric irritants. If the patient is allowed to eat, encourage the patient to avoid foods and beverages that are gastric irritants. Gastric irritants can worsen dysfunctional gastrointestinal motility and cause persistent nausea and vomiting. 5. Consult with a dietician. A nutritional consult can offer diet recommendations depending on delayed or increased gastric motility. | Patient demonstrated bowel sounds within normal limits. Patient exhibited normal eating habits without experiencing nausea, vomiting, abdominal discomfort, dyspepsia, bloating, and early satiety. |
| Subjective data: Verbalizes unable to eat Objective data: -Food intake less than recommended daily allowance (RDA) -Nausea and vomiting -Hypoglycaemia -Lethargy -Abdominal discomfort | Imbalanced Nutrition less than body Requirements related to Inadequate interest in food and Nausea and vomiting as evidenced by Body weight below ideal weight range for age and gender | Patient will exhibit balanced nutrition as evidenced by the absence of malnutrition Patient will regain and maintain adequate body weight for age and gender | 1. Provide calorie-dense foods. Patients who can only ingest small amounts of food can benefit from eating foods they prefer that are high in calories to increase overall caloric intake. 2. Create a pleasant environment conducive to eating. Strong and offensive odors can cause nausea and vomiting. Provide uninterrupted time to eat and do not rush. 3. Premedicate with antiemetics. Patients undergoing chemotherapy or radiation may require premedication to prevent the common side effect of nausea. 4. Implement tube feedings. Patients unable to eat due to nausea may require enteral or parenteral nutrition to obtain necessary nutrients. | Patient exhibited balanced nutrition as evidenced by the absence of malnutrition Patient regained and maintained adequate body weight for age and gender |
| Subjective data: -Verbalizes pain, exhaustion, or general unwellness -Expresses feeling stressed or worried -Expresses concern about their health or a procedure -Verbalizes a sense of unease Objective data: -Signs of pain: grimacing, guarding, moaning, diaphoresis -Flat affect -Irritability or restlessness -State of panic or anxiety -Rapid breathing -Increased heart rate | Impaired Comfort Related to Insufficient control over symptoms and Noxious environmental stimuli as evidenced by altered sleep-wake cycle and Fatigue | Patient will verbalize two strategies to reduce nausea and improve comfort. Patient will express improved comfort as evidenced by improved sleep and mood. | 1. Create a relaxing environment. Excessive environmental stimuli like lighting and hot temperatures can aggravate feelings of nausea. Ensure that the environment is cooler and the lights are dimmed during mealtimes to promote the patient’s comfort and reduce the incidence of nausea and vomiting. Strong smells can also be aggravating. 2. Encourage ginger or peppermint tea. Ginger is an effective remedy in alleviating nausea and vomiting and promoting comfort. It has anti-nausea compounds like shogaols and gingerols and anti-inflammatory, anti-ulcer, and antioxidant effects. Peppermint tea can also help soothe stomach upset and reduce feelings of nausea. 3. Encourage foods that have little to no odor. Strong odors can aggravate nausea and vomiting. Foods with little to no odor, like cereals and crackers, should be encouraged. 4. Encourage alternative ways to alleviate discomfort. Meditation, deep breathing exercises, music, and guided imagery enable the patient to relax and significantly reduce discomfort associated with nausea and vomiting. Deep breathing performed slowly and steadily can help ease nausea and promote mindful meditation and comfort. 5. Encourage the patient to take OTC remedies for nausea and vomiting. Dramamine, an anti-nausea medication, is an effective OTC medication that helps block the vomiting reflex, reduce dizziness, and promote comfort. It is important to take these medications before the first bout of nausea. 6. Use acupressure. Pressure to the P6 (Neiguan) point on the wrist (center of wrist, three finger-breadths from the wrist crease) is thought to prevent nausea. Motion sickness bands can be worn on the wrists to avoid nausea. | Patient verbalized two strategies to reduce nausea and improve comfort. Patient expressed improved comfort as evidenced by improved sleep and mood. |