N
Nausea
A subjective, unpleasant, wavelike sensation in the back of the throat, epigastrium, or the abdomen that may lead to the urge or need to vomit
Defining Characteristics
Aversion to food; gagging sensation; increased salivation; increased swallowing; report of nausea; sour taste in mouth
Related Factors (r/t)
Biochemical disorders (e.g., uremia, diabetic ketoacidosis, pregnancy); esophageal disease; gastric distention; gastric irritation; increased intracranial pressure; intraabdominal tumors; labyrinthitis; liver capsule stretch; localized tumors (e.g., acoustic neuroma, primary or secondary brain tumors, bone metastases at base of skull); meningitis; Ménière’s disease; motion sickness; pain; pancreatic disease; splenetic capsule stretch; toxins (e.g., tumor-produced peptides, abnormal metabolites due to cancer)
Client Outcomes
Client Will (Specify Time Frame)
Nursing Interventions
Determine cause or risk for N&V (e.g., medication effects, infectious causes, disorders of the gut and peritoneum, central nervous system causes [including anxiety], endocrine and metabolic causes [including pregnancy], postoperative-related status).
Evaluate and document the client’s history of N&V, with attention to onset, duration, timing, volume of emesis, frequency of pattern, setting, associated factors, aggravating factors, and past medical and social histories.
• Document each episode of nausea and/or vomiting separately, as well as effectiveness of interventions.
• Identify and eliminate contributing causative factors. This may include eliminating unpleasant odors or medications that may be contributing to nausea.
Implement appropriate dietary measures such as NPO status as appropriate; small, frequent meals; and low-fat meals. It may be helpful to avoid foods that are spicy, fatty, or highly salty. Reverting to previous practices when ill in the past and consuming “comfort foods” may also be helpful at this time.
Recognize and implement interventions and monitor complications associated with N&V. This may include administration of intravenous fluids and electrolytes.
Administer appropriate antiemetics, according to emetic cause, by most effective route, considering the side effects of the medication, with attention to and coverage for the timeframes that the nausea is anticipated.
• Consider nonpharmacologic interventions such as acupressure, acupuncture, music therapy, distraction, and slow, deliberate movements.
• There are no studies of dietary or other lifestyle interventions with any evidence to support traditional advice and interventions. It is often recommended that the woman eat dry crackers or dry toast in bed before arising and then get up slowly. Additional advice includes eating small frequent meals, drinking small amounts of fluids often, avoid foods with offensive odors, and avoiding preparing food or shopping when nauseated.
Discuss with the primary care practitioner the possibility of using the P6 acupressure point stimulation to help relieve nausea.
Recognize that ginger ingestion may help nausea. Ginger is available in a number of forms including tea, biscuits, and capsules.
Recognize that there are currently no FDA-approved drugs for the treatment of morning sickness, N&V of pregnancy, or hyperemesis gravidarum. There are, however, several pharmacologic treatments outlined by the American College of Obstetrics and Gynecology (ACOG).
Evaluate for risk factors for postoperative nausea and vomiting (PONV). Strong evidence suggests that client-related risk factors such as female gender, history of PONV, history of motion sickness, nonsmoking behavior, and environmental risk factors such as postoperative opioid use, emetogenic surgery (type and duration), and volatile anesthetics may increase the risk for PONV. Prolonged NPO status, more than 6 hours, has been associated with postop nausea.
Medicate the client prophylactically for nausea as ordered, throughout the period of risk.
Alleviate postoperative pain using ordered analgesic agents (refer to care plan for Acute Pain).
• Consider the use of nonpharmacological techniques, such as P6 acupoint stimulation, as an adjunct for controlling PONV, which has been shown to be effective.
• Use of therapeutic suggestions and ginger may not work as effectively in postdischarge nausea and vomiting (PDNV).
• Include client education on the management of PONV for all outpatients and discuss key assessment criteria.
• Perform risk assessment prior to chemotherapy administration. Risk factors include female gender, younger age, history of low alcohol consumption, history of morning sickness during pregnancy, anxiety, previous history of chemotherapy, client expectancy of nausea, and emetic potential of the regimen.
Consult with physician regarding antiemetic strategy, either prophylactic or when N&V occurs.
• Consider teaching your client to learn how to use acupressure for nausea, applying pressure bilaterally at P6 points using fingers or bands to decrease the amount and severity of nausea.
Consider the use of ginger root (Zingiber officinale) to relieve nausea.
There are no specific guidelines that address the prophylaxis of CINV in the elderly. Risk still needs to be assessed, although many elderly clients are often treated with less emetic chemotherapy. Chemotherapy, however, can cause increased toxicity due to age-related decreases in organ function, comorbidities, and drug-drug interactions secondary to polypharmacy. Additionally, adherence may be an issue, due to cognitive decline, impaired senses, and economic issues.
• Previously mentioned interventions may be adapted for home care use.
In hospice care clients, assess for causes of nausea, such as constipation, bowel obstruction, adverse effects of medications, and onset of increased intracranial pressure. Refer the client to a primary care practitioner if needed.
• Assist the client and family with identifying and avoiding irritants in the home that exacerbate nausea (e.g., strong odors from food, plants, perfume, and room deodorizers). All medications except antiemetics should be given after meals to minimize the risk of nausea.
Noncompliance
Behavior of person and/or caregiver that fails to coincide with a health-promoting or therapeutic plan agreed on by the person (and/or family and/or community) and health care professional. In the presence of an agreed-on, health-promoting, or therapeutic plan, person’s or caregiver’s behavior is fully or partially nonadherent and may lead to clinically ineffective or partially ineffective outcomes
Defining Characteristics
Behavior indicative of failure to adhere; evidence of development of complications; evidence of exacerbation of symptoms; failure to keep appointments; failure to progress; objective tests (e.g., physiological measures, detection of physiological markers)
Related Factors (r/t)
Access to care, communication skills of the provider, convenience of care, credibility of provider, difficulty in client-provider relationship, individual health coverage, provider continuity, provider regular follow-up, provider reimbursement, satisfaction with care, teaching skills of the provider
Individual Factors
Cultural influences, developmental abilities, health beliefs; deficient knowledge relevant to the regimen behavior; individual’s value system, motivational forces, personal abilities, significant others, skill relevant to the regimen behavior, spiritual values
Network
Involvement of members in health plan; perceived beliefs of significant others; social value regarding plan
NOTE: The nursing diagnosis Noncompliance is judgmental and places blame on the client. The authors recommend use of the diagnosis Ineffective Self-Health Management in place of the diagnosis Noncompliance. The diagnosis Ineffective Self-Health Management has interventions that are developed by both the health care providers and the client. It is a more respectful and efficacious nursing diagnosis than Noncompliance.
Readiness for enhanced Nutrition
Defining Characteristics
Attitude toward drinking is congruent with health goals; attitude toward eating is congruent with health goals; consumes adequate fluid; consumes adequate food; eats regularly; expresses knowledge of healthy fluid choices; expresses knowledge of healthy food choices; expresses willingness to enhance nutrition; follows an appropriate standard for intake (e.g., the American Diabetic Association guidelines); safe preparation for fluids; safe preparation for food; safe storage for food and fluids
Imbalanced Nutrition: less than body requirements
Defining Characteristics
Abdominal cramping; abdominal pain; aversion to eating; body weight 20% or more under ideal; capillary fragility; diarrhea; excessive loss of hair; hyperactive bowel sounds; lack of food; lack of information; lack of interest in food; loss of weight with adequate food intake; misconceptions; misinformation; pale mucous membranes; perceived inability to ingest food; poor muscle tone; reported altered taste sensation; reported food intake less than RDA (recommended daily allowance); satiety immediately after ingesting food; sore buccal cavity; steatorrhea; weakness of muscles required for swallowing or mastication
Related Factors (r/t)
Biological factors; economic factors; inability to absorb nutrients; inability to digest food; inability to ingest food; psychological factors
Client Outcomes
Client Will (Specify Time Frame)
• Progressively gain weight toward desired goal
• Weigh within normal range for height and age
• Recognize factors contributing to underweight
• Identify nutritional requirements
Nursing Interventions
Use a nutritional screening tool to determine possibility of malnutrition on admission into any health care facility. Watch for recent weight loss of over 10 lb, 10% under healthy weight, not eating for more than 3 days, ½ normal eating for greater than 5 days, and body mass index (BMI) of less than 20, or other reasons why the client may be malnourished, and refer to a dietitian for a complete nutritional assessment.
• Recognize that clients with acute disease or injury-related malnutrition, wounds, recent surgery, trauma, and a fever are using more calories and need increased calories to maintain their nutritional status.
• Recognize that clients with chronic disease-related malnutrition (cancer, rheumatoid arthritis, sarcopenic obesity, organ failure) may need calories to maintain nutritional status.
• Monitor for signs of malnutrition, including brittle hair that is easily plucked, bruises, dry skin, pale skin and conjunctiva, muscle wasting, marked decrease in body fat, smooth red tongue, cheilosis, and a “flaky paint” rash over lower extremities.
• Recognize that severe protein-calorie malnutrition can result in septicemia from impairment of the immune system, and organ failure including heart failure, liver failure, and respiratory dysfunction, especially in the critically ill client.
Note laboratory test results as available: serum albumin, prealbumin, serum total protein, serum ferritin, transferrin, hemoglobin, hematocrit, and electrolytes.
• Weigh the client daily in acute care, weekly to monthly in extended care at the same time (usually before breakfast), with same amount of clothing.
Monitor food intake; record percentages of served food that is eaten (25%, 50%, 75%, 100%). Keep a 3-day food diary to determine actual intake; consult with dietitian for actual calorie count if needed.
• Observe the client’s relationship to food. Attempt to separate physical from psychological causes for eating difficulty.
• Evaluate the intake of the client using the United States Department of Agriculture’s My Tracker online software, available at https://www.choosemyplate.gov/SuperTracker/default.aspx.
• If the client is a vegetarian, evaluate vitamin B12 and iron intake.
• Observe the client’s ability to eat (time involved, motor skills, visual acuity, and ability to swallow various textures). If the client needs to be fed, allocate at least 35 minutes to feeding.
NOTE: If the client is unable to feed self, refer to Nursing Interventions for Feeding Self-Care deficit. If the client has difficulty swallowing, refer to Nursing Interventions for Impaired Swallowing. If the client is receiving tube feedings, refer to the Nursing Interventions for Risk for Aspiration.
• If the client has a minimally functioning gastrointestinal tract and is on clear fluids, consult with dietitian regarding use of a clear liquid product that contains increased amounts of protein and calories such as Ensure Alive, Resource Breeze Fruit Beverage, or citrotein.
• For the client with anorexia, who will not eat foods, consider offering 30 mL of a nutritional supplement in a medication cup every hour, often during medication rounds.
• For the client who is malnourished and can eat, offer small quantities of energy-dense and protein-enriched food, served in an appetizing fashion, at frequent intervals. For the client who is able to eat, but has a decreased appetite, try the following activities:
Offer foods that are familiar to the client and do not offend his/her beliefs.
Avoid interruptions during mealtimes; meals should be eaten in a calm and peaceful environment. Interruptions have a negative effect on client’s nutrition.
Make food available as desired between early evening and breakfast.
Use colored trays to identify clients who need help eating or who are at nutritional risk.
• If the client lacks endurance, schedule rest periods before meals, and open packages and cut up food for the client.
• Watch carefully for signs of infection and maintain every action possible to protect the client from infection.
• Provide companionship at mealtime to encourage nutritional intake.
• Monitor state of oral cavity (gums, tongue, mucosa, teeth). Provide good oral hygiene before each meal.
Administer antiemetics and pain medications as ordered and needed before meals.
• If client is nauseated, remove cover of food tray before bringing it into the client’s room.
• Work with the client to develop a plan for increased activity.
• If the client is anemic, offer foods rich in iron and vitamins B12, C, and folic acid.
• For the agitated, pacing client, offer finger foods (sandwiches, fresh fruit) and fluids
If client has been malnourished for a significant length of time, consult with the dietitian and refeed carefully after correcting electrolyte balance. Watch for heart and respiratory failure.
• Recognize the need to begin enteral feedings within 24 to 48 hours of entrance into the critical care environment, once the client is free of hemodynamic compromise, if the client is unable to eat.
• Recognize that it is important to get the ordered feedings into the client, and that frequently checking for gastric residual, checking placement of the tube, can be a limiting factor to adequate nutrition in the tube-fed client.
• If the client is pregnant, ensure that she is receiving adequate amounts of folic acid by eating a balanced diet and taking prenatal vitamins as ordered.
Utilize a nutritional screening tool designed for nurses such as the Paediatric Yorkhill Malnutrition Score (PYMS) tool, and if the child has a score of 2 or more, make a referral to a dietitian.
• Watch for symptoms of malnutrition in the child including short stature, thin arms and legs, poor condition of skin and hair, visible vertebrae and rib cage, wasted buttocks, wasted facial appearance, lethargy, and in extreme cases, edema.
• Weigh and measure the length (height) of the child and use a growth chart to help determine growth pattern, which reflects nutrition.
Refer to a physician and a dietitian a child who is underweight for any reason.
• Work with the child and parent to develop an appropriate weight gain plan.
• Recognize that a large percentage of girls and teenagers are dieting, which can result in nutritional problems.
• Screen for protein-energy malnutrition in elderly clients regardless of setting. Use a screening tool such as the Mini Nutritional Assessment.
• Screen for dysphagia in all elderly clients.
• Recognize that geriatric clients with moderate or severe cognition impairment have a significant risk of developing malnutrition.
Interpret laboratory findings cautiously. Watch the color of urine for an indication of fluid balance; darker urine demonstrates dehydration.
• Recognize that constipation is a common problem with the elderly; therefore, they avoid many types of food for fear of problems with their bowel regimen.
• Consider using dining assistants, trained non-nursing staff, to provide feeding assistance care in extended care facilities to ensure adequate time for feeding clients as needed.
• Consider offering clients healthy snacks twice a day instead of nutritional supplements.
• Encourage client to increase intake of protein, unless medically contraindicated by organ failure. Aim for 1.5 g of protein per kilogram of body weight.
• Encourage physical activity throughout the day.
• Assess intake of components of bone health: calcium intake; the elderly adult needs 1200 mg of calcium and 800 IU of vitamin D.
• Monitor for onset of depression.
• Provide a restful, homelike environment during meals where clients are treated with respect and are encouraged to maintain autonomy as they are able.
• Recommend to families that enteral feedings may or may not be indicated for clients with dementia; instead use hand-feeding assistance, modified food consistency as needed, or environmental alterations.
NOTE: If the client is unable to feed self, refer to Nursing Interventions for Feeding Self-Care deficit. If client has impaired physical function, malnutrition, depression, and cognitive impairment, please refer to care plan on Adult Failure to Thrive.
• The preceding interventions may be adapted for home care use.
• Screen for malnutrition using the Malnutrition Universal Screen Tool (MUST), which is simple and can be done rapidly.
• Monitor food intake. Instruct the client in intake of small frequent meals of foods with increased calories and protein.
• Assess clients’ willingness to eat; fashion interventions accordingly.
Assess the client for depression. Refer for mental health services as indicated.
• Consider social factors that may interfere with nutrition (e.g., lack of transportation, inadequate income, lack of social support).
Monitor the effect of total parenteral nutrition (TPN) as ordered by physician, and appropriate including weight, blood glucose levels, electrolytes, symptoms of fluid overload or deficit, and symptoms of infection at entry site of catheter.
Client/Family Teaching and Discharge Planning
• Help the client/family identify the area to change that will make the greatest contribution to improved nutrition.
• Build on the strengths in the client’s/family’s food habits. Adapt changes to their current practices.
• Select appropriate teaching aids for the client’s/family’s background.
• Implement instructional follow-up to answer the client’s/family’s questions.
• Recommend that clients utilize dietary supplements such as vitamins and minerals only after consulting with their primary care practitioner.
• Suggest community resources as suitable (food sources, counseling, Meals on Wheels, senior centers).
• Teach the client and family how to manage tube feedings or parenteral therapy at home as needed.
Risk for imbalanced Nutrition: more than body requirements
At risk for intake of nutrients that exceeds metabolic needs
Risk Factors
Concentrating food at the end of day; dysfunctional eating patterns; eating in response to external cues (e.g., time of day, social situation); eating in response to internal cues other than hunger (e.g., anxiety); higher baseline weight at beginning of each pregnancy; observed use of food as comfort measure; observed use of food as reward; pairing food with other activities; parental obesity; rapid transition across growth percentiles in children; reported use of solid food as major food source before 5 months of age
Imbalanced Nutrition: more than body requirements
Defining Characteristics
Concentrating food intake at the end of the day; dysfunctional eating pattern (e.g., pairing food with other activities); eating in response to external cues (e.g., time of day, social situation); eating in response to internal cues other than hunger (e.g., anxiety); sedentary activity level; triceps skin fold greater than 25 mm in women, greater than 15 mm in men, weight 20% over ideal for height and frame
Client Outcomes
Client Will (Specify Time Frame)
• State pertinent factors contributing to weight gain
• Identify behaviors that remain under client’s control
• Design dietary modifications to meet individual long-term goal of weight control
• Lose weight in a reasonable period (1 to 2 lb per week)
• Incorporate increased exercise requiring energy expenditure into daily life
Nursing Interventions
• Ask the client to keep a 1- to 3-day food diary where everything eaten or drunk is recorded.
• Advise the client to measure food periodically. Help the client learn usual portion sizes.
• Help the client determine his or her body mass index (BMI). Use a chart or a website such as http://www.cdc.gov/healthyweight/assessing/bmi/index.html.
• Recommend the client follow the U.S. Dietary Guidelines to determine foods to eat, which can be found at http://www.cnpp.usda.gov/DietaryGuidelines.htm.
• Recommend the client use the Super Tracker, which is available at http://www.choosemyplate.gov/supertracker-tools/supertracker.html, to plan his or her diet, determine the number of calories, evaluate the foods that he/she have eaten, and gain more information on how to eat in a healthy fashion.
• Recommend that clients lose weight slowly, no more than 1 to 2 lb per week, based on a healthy eating pattern and increased exercise.
• Demonstrate the use of food labels to make healthful choices. Alert the client/family to focus on serving size, total fat, and simple carbohydrate. The standardized food label in bold type simplifies the search for information.
• Recommend the client eat a healthy breakfast every morning.
• Recommend the client avoid eating in fast food restaurants.
• Recommend the client learn about and eat a low glycemic diet.
• For information about how to eat healthy and lose weight regarding carbohydrates, protein, and fat, please refer to the care plan Readiness for enhanced Nutrition.
• Encourage the client to increase intake of vegetables and fruits to at least five servings per day, preferably nine servings per day.
• Encourage the client to eat at least three whole grain servings per day, preferably more.
• Encourage the client to stop drinking sugar-sweetened beverages of all kinds, including sodas, lemonade, fruit juice, sweetened tea, vitamin drinks, energy drinks, and sports beverages. Instead encourage the client to drink water, or water with unsweetened fruit in it.
• Evaluate the client’s usual intake of fiber. Recommended intake is 25 g per day for women and 38 g per day for men. Increase intake of whole grains, beans, fruits, and vegetables to obtain needed fiber.
• Discuss the possibility of using a primarily plant-based or vegetarian diet to lose weight.
• Recommend client increase intake of water to at least 2000 mL or 2 quarts per day. A guideline is 1 to 1.5 mL of fluid per each calorie needed, so an average intake would be between 2000 and 3000 mL/day, or at least 8 cups of fluid.
• For more information on healthy eating, refer to Nursing Interventions for Readiness for enhanced Nutrition.
Behavioral Methods for Weight Loss
• Familiarize the client with the following behavior modification techniques:
Self-monitoring of food intake, including keeping a food and exercise diary
Controlling stimuli that cause overeating, such as watching television with frequent food-related commercials
Limiting food intake to one site in the home
Sitting down at the table to eat
Planning food intake for each day
Rearranging the schedule to avoid inappropriate eating
Avoiding boredom that results in eating; keeping a list of activities on the refrigerator
For a party, eating before arriving, sitting away from the snack foods, and substituting lower-calorie beverages for alcoholic ones
Deciding beforehand what to order in a restaurant
Bringing only healthy foods into the house to decrease temptation
Slowing mealtime by swallowing food before putting more food on the utensil, pausing for a minute during the meal and attempting to increase the number of pauses, and trying to be the last one to finish eating
Taking fewer bites of food, and chewing food more thoroughly before swallowing.
Drinking a glass of water before each meal; taking sips of water between bites of food
Making an agreement with oneself or a significant other for a meaningful reward and not rewarding oneself with food
Determine reasons why the client would be unable to participate in an exercise program; refer for evaluation by a primary care practitioner as needed.
• Encourage the client to begin an exercise program, walking, swimming, dancing, running, use of the elliptical machine, and more.
• Recommend the client begin a walking program using a pedometer. For further information on a walking program refer to the care plan Sedentary lifestyle.
• Encourage the client to engage in both aerobic exercise and strength training.
• Work with parents of the overweight child by encouraging the following behaviors:
Emphasize providing good food, not depriving children of food.
Accept the child’s natural size and shape; the child needs the parents’ unconditional love.
Involve the child in helping plan menus, and doing cooking and preparation as appropriate for the child’s age.
• Work with the child and parent to develop an appropriate weight maintenance plan, including behavioral methods of weight loss, as well as increased activity.
• Work with the parent to change the food that is available in the home, eliminating sugary drinks and foods with a high saturated fat or trans fat content.
• Encourage child to increase the amount of walking done per day; if child is willing, ask him or her to wear a pedometer to measure number of steps.
• Recommend that parents do not use food as a reward for good behavior, especially foods that are concentrated sources of sugar or fat.
• Recommend the child decrease television viewing, watching movies, and playing video games. Ask parents to limit television to 1 to 2 hours per day maximum.
• Assess changes in lifestyle and eating patterns.
• Assess fluid intake. Recommend routine drinks of fluids regardless of thirst.
• Observe for socioeconomic factors that influence food choices (e.g., inadequate funds or cooking facilities).
• Recognize that it is generally not appropriate to have an elderly client on a calorie-restrictive diet.
• Recognize that the BMI’s accuracy is different for some ethnic groups.
• Use cultural beliefs, norms, and values of the client when teaching information on nutrition and weight loss.
• Assess for the influence of cultural beliefs, norms, and values on the client’s ideal of acceptable body weight and body size.
• Discuss with the client those aspects of his or her diet that will remain unchanged, and work with the client to adapt cultural core foods.
Client/Family Teaching and Discharge Planning
• Utilize the motivational interviewing technique when working with clients to promote healthy eating and weight loss.
• Inform the client about the health risks associated with obesity, which include cancer, diabetes, heart disease, strokes, hypertension, gastroesophageal reflux, gallstones, osteoarthritis, and venous thrombosis.
• Recommend the client weigh self frequently, ideally every day.
• Inform the client and family of the disadvantages of trying to lose weight by dieting alone, and encourage the client to include exercise in the weight loss plan.