Nursing Diagnosis and Interventions for Nausea and Vomiting


Nausea and Vomiting

Nausea is a sensation of unease and discomfort in the upper stomach with an involuntary urge to vomit. It occasionally precedes vomiting. A person can suffer nausea without vomiting. When prolonged, it is a debilitating symptom.

Nausea is a non-specific symptom, which means that it has many possible causes. Some common cause of nausea are motion sickness, dizziness, migraine, fainting, gastroenteritis (stomach infection) or food poisoning. Nausea is a side effect of many medications including chemotherapy, nauseants or morning sickness in early pregnancy. Nausea may also be caused by anxiety, disgust and depression.

Vomiting , also known as emesis, throwing up, among other terms, is the involuntary, forceful expulsion of the contents of one's stomach through the mouth and sometimes the nose.

Vomiting can be caused by a wide variety of conditions; it may present as a specific response to ailments like gastritis or poisoning, or as a non-specific sequela of disorders ranging from brain tumors and elevated intracranial pressure to overexposure to ionizing radiation. The feeling that one is about to vomit is called nausea, which often precedes, but does not always lead to, vomiting. Antiemetics are sometimes necessary to suppress nausea and vomiting. In severe cases, where dehydration develops, intravenous fluid may be required.


Nursing Diagnosis and Interventions for Nausea and Vomiting


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


2. Risk for aspiration related to decreased reflexes or penuruanan awareness

The desired result :
  • Airway and lung sounds clean.

Iintervention :
  • Assess whether the patient is in the risk for aspiration.
  • Place the patient in a position to prevent aspiration.


3. Deficient Fluid Volume

The desired result :
  • Patient's vital signs within normal limits.
Interventions :
  • Monitor for signs of hypovolemia to prevent any complications that may occur.
  • Measure body weight each day.
  • Monitor intake output, and vital signs.
  • Give fluids by IV.
  • Discharge monitoring during treatment to prevent deficit and excess fluid.

Sumber :
http://www.nandahealth.com/2013/10/nursing-care-plan-for-nausea-and.html

Nursing Care Plan for Hypertensive Heart Disease : Acute Pain


Hypertensive heart disease includes a number of complications of high blood pressure that affect the heart. While there are several definitions of hypertensive heart disease in the medical literature, the term is most widely used in the context of the International Classification of Diseases (ICD) coding categories. The definition includes heart failure and other cardiac complications of hypertension when a causal relationship between the heart disease and hypertension is stated or implied on the death certificate.

The symptoms and signs of hypertensive heart disease will depend on whether or not it is accompanied by heart failure. In the absence of heart failure, hypertension, with or without enlargement of the heart (left ventricular hypertrophy) is usually symptomless. Symptoms and signs of chronic heart failure can include:
  •     Fatigue
  •     Irregular pulse or palpitations
  •     Swelling of feet and ankles
  •     Weight gain
  •     Nausea
  •     Shortness of breath
  •     Difficulty sleeping flat in bed (orthopnea)
  •     Bloating and abdominal pain
  •     Greater need to urinate at night
  •     An enlarged heart (cardiomegaly)
Patients can present acutely with heart failure and pulmonary edema due to sudden failure of pump function of the heart. Acute heart failure can be precipitated by a variety of causes including myocardial ischemia, marked increases in blood pressure, or cardiac dysrhythmias, especially atrial fibrillation. Alternatively heart failure can develop insidiously over time.(wikipedia).


Nursing Care Plan for Hypertensive Heart Disease : Acute Pain

Acute Pain (headache) related to increased cerebral vascular pressure.


Goal :

    Client reported pain / discomfort disappeared / controlled .


Interventions and Rationale :

1. Maintain bed rest during the acute phase.

2. Give non-pharmacological measures to eliminate headaches eg, a cold compress on the forehead, back and neck massage, quiet, dim the room lights room lights, relaxation techniques (manual imagination, disktraksi) and leisure time activities.

3. Eliminate / minimize vasoconstriction activity that can increase headache eg, straining during defecation, coughing and bending length.

4. Assist patients in ambulation as needed.

5. Give liquids, soft foods, regular oral care in the event of bleeding nose or nasal pack has been done to stop the bleeding.

Rationale:

1. Minimize stimulation / promote relaxation.

2. Actions that reduce cerebral vascular pressure and the slow / block sympathetic response is effective in relieving headaches and complications.

3. Activities that increase vasoconstriction causing headaches in an increase in cerebral vascular pressure.

4. Dizziness and blurred vision often associated with pain kepala.pasien can also experience episodes of postural hypotension.

5. Increase the general comfort, compress the nose can interfere with swallowing or breathing requires mouth, causing stagnation oral secretions and mucous membranes dry out.

Source :
http://www.nurseskomar.com/2013/11/acute-pain-nursing-care-plan-for.html

Nanda Nursing Diagnoses : Definitions and Classification (2015-17, 2012-14, 2009-11, 2007-08, 2005-06, 2003-04, 2001-02)

Nursing Diagnoses: Definitions and Classification, 2001-2002 1st Edition



Pocket-sized outline addressing the development and classification of nursing diagnoses. New nursing diagnoses, as of April 2000, include: risk for falls, risk for powerlessness, risk for relocation stress syndrome, risk for situational low self-esteem, risk for suicide, self-mutilation and wandering. Bulleted-outline format. Previous edition: c1999. Softcover.

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Nanda Nursing Diagnoses 2003-2004: Definitions and Classification

Brandon/Hill Nursing List first-purchase selection (#223). Annual pocket reference addresses the development and classification of nursing diagnoses. Contains 12 new diagnoses and three new revisions. Each diagnosis is listed alphabetically by diagnostic concept. Bulleted-outline format. Softcover.

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Nanda Nursing Diagnoses: Definitions and Classification 2005-2006



Changes in this new edition include 5 new diagnoses, , three revised diagnoses, and placement of the NANDA International diagnoses within the NNN Taxonomy of Nursing Practice.

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Nursing Diagnoses: Definitions & Classification, 2007-2008



Nursing Diagnoses: Definitions & Classification contains 25 new nursing diagnoses, 16 revised nursing diagnoses and a revised procedure to appeal aDDC decision on diagnosis review. There are also 4 articles demonstrating the value of nursing diagnoses in administration, education, electronic health records and research.

Nursing Diagnoses: Definitions & Classification, 2007-2008




Nursing Diagnoses 2009-2011: Definitions and Classification (NANDA NURSING DIAGNOSIS) 2nd Edition



A nursing diagnosis is defined as a clinical judgement about individual, family or community responses to actual or potential health problems or life processes which provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable. Accurate and valid nursing diagnoses guide the selection of interventions that are likely to produce the desired treatment effects and determine nurse-sensitive outcomes. Nursing diagnoses are seen as key to the future of evidence-based, professionally-led nursing care - and to more effectively meeting the need of patients and ensuring patient safety. In an era of increasing electronic patient health records standardized nursing terminologies such as NANDA, NIC and NOC provide a means of collecting nursing data that are systematically analyzed within and across healthcare organizations and provide essential data for cost/benefit analysis and clinical audit. 'Nursing Diagnoses: Definitions and Classification' is the definitive guide to nursing diagnoses worldwide. Each nursing diagnoses undergoes a rigorous assessment process by NANDA-I with stringent criteria to indicate the strength of the underlying level of evidence. Each diagnosis comprises a label or name for the diagnosis and a definition. Actual diagnoses include defining characteristics and related factors. Risk diagnoses include risk factors. Many diagnoses are further qualified by terms such as effective, ineffective, impaired, imbalanced, readiness for, disturbed, decreased etc. The 2009-2011 edition is arranged by concept according to Taxonomy II domains (i.e. Health promotion, Nutrition, Elimination and Exchange, Activity/Rest, Perception/Cognition, Self-Perception, Role Relationships, Sexuality, Coping/ Stress Tolerance, Life Principles, Safety/Protection, Comfort, Growth/Development). The book contains new chapters on 'Critical judgement and assessment' and 'How to identify appropriate diagnoses' and core references for all nursing diagnoses. A companion website hosts NANDA-I position statements, new PowerPoint slides, and FAQs for students.* 2009-2011 edition arranged by concepts* New chapters on 'Critical judgement and assessment' and 'How to identify appropriate diagnoses'* Core references for new diagnoses and level of evidence for each diagnosis* Companion website available

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Nursing Diagnoses 2012-14: Definitions and Classification 9th Edition



A nursing diagnosis is defined as a clinical judgment about individual, family or community responses to actual or potential health problems or life processes which provide the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability (NANDA-I, 2009). Accurate and valid nursing diagnoses guide the selection of interventions that are likely to produce the desired treatment effects and determine nurse-sensitive outcomes. Nursing diagnoses are seen as key to the future of evidence-based, professionally-led nursing care -- and to more effectively meeting the need of patients. In an era of increasing electronic patient health records, standardized nursing terminologies such as NANDA-I, NIC and NOC provide a means of collecting nursing data that are systematically analysed within and across healthcare organizations and provide essential data for cost/benefit analysis and clinical audit. Nursing Diagnoses: Definitions and Classification is the definitive guide to nursing diagnoses, as reviewed and approved by NANDA-I. Each nursing diagnosis undergoes a rigorous assessment process by NANDA-I's Diagnosis Development Committee, with stringent criteria used to indicate the strength of the underlying level of evidence. Each diagnosis comprises a label or name for the diagnosis, a definition, defining characteristics, risk factors and/or related factors. Many diagnoses are further qualified by terms such as risk for, effective, ineffective, impaired, imbalanced, self-care deficit, readiness for, disturbed, decreased, etc. The 2012-2014 edition is arranged by concept according to Taxonomy II domains, i.e. Health promotion, Nutrition, Elimination and exchange, Activity/Rest, Perception/Cognition, Self-perception, Role relationships, Sexuality, Coping/ Stress tolerance, Life principles, Safety/protection, Comfort, and Growth/development. The 2012-2014 edition contains revised chapters on NANDA-I taxonomy, and slotting of diagnoses into NANDA & NNN taxonomies, diagnostic reasoning & conceptual clarity, and submission of new/revised diagnoses. New chapters are provided on the use of nursing diagnoses in education, clinical practice, electronic health records, nursing & health care administration, and research . A companion website hosts related resources. Key features 2012-2014 edition arranged by diagnostic concepts Core references and level of evidence for each diagnosis New chapters on appropriate use of nursing diagnoses in clinical practice, education, administration and electronic health record 16 new diagnoses 11 revised diagnoses Aimed at students, educators, clinicians, nurse administrators and informaticians Companion website available, including a video on assessment, clinical reasoning and diagnosis

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Nursing Diagnoses 2015-17 : Definitions and Classification 10th Edition



Nursing Diagnoses: Definitions and Classification is the definitive guide to nursing diagnoses, as reviewed and approved by NANDA-I. The 2015–2017 edition of the classic and internationally recognised text has been rigorously updated and revised, and now provides more linguistically congruent diagnoses as a result of the Diagnostic Development Committee’s attentiveness to understanding the translation of the diagnostic label, definition, defining characteristics, related factors, and risk factors. Each of the 235 diagnoses presented are supported by definitions as well as defining characteristics and related factors, or risk factors. Each new and revised diagnosis is based on the latest global evidence, and approved by expert nurse diagnosticians, researchers, and educators.

New to this edition:
  • 26 brand new nursing diagnoses and 13 revised diagnoses
  • Updates, changes, and revision to the vast majority of the nursing diagnosis definitions, in particular the Health Promotion and Risk Diagnoses
  • A standardization of diagnostic indicator terms (defining characteristics, related factors, and risk factors) to further aid clarity for readers and clinicians
  • All introductory chapters are written at an undergraduate nursing level, and provide critical information needed for nurses to understand assessment, its link to diagnosis, and the purpose and use of taxonomic structure for the nurse at the bedside
  • A new chapter, focusing on Frequently Asked Questions, representing the most common questions received through the NANDA-I website, and at global conferences
  • Five nursing diagnoses have been re-slotted within the NANDA-I taxonomy, following a review of the current taxonomic structure
  • Coding of all diagnostic indicator terms is now available for those using electronic versions of the terminology
  • Companion website featuring references from the book, video presentations, teaching tips, and links to taxonomy history and diagnosis submission/review process description www.wiley.com/go/nursingdiagnoses

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Comprehensive Toxicology, Second Edition





An explosive increase in the knowledge of the effects of chemical and physical agents on biological systems has led to an increased understanding of normal cellular functions and the consequences of their perturbations. The 14-volume Second Edition of Comprehensive Toxicology has been revised and updated to reflect new advances in toxicology research, including content by some of the leading researchers in the field. It remains the premier resource for toxicologists in academia, medicine, and corporations.

Comprehensive Toxicology Second Edition provides a unique organ-systems structure that allows the user to explore the toxic effects of various substances on each human system, aiding in providing diagnoses and proving essential in situations where the toxic substance is unknown but its effects on a system are obvious. Comprehensive Toxicology Second Edition is the most complete and valuable toxicology work available to researchers today.
  • Contents updated and revised to reflect developments in toxicology research
  • Organized with a unique organ-system approach
  • Features full color throughout
  • Available electronically on sciencedirect.com, as well as in a limited-edition print version

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