Nausea – NANDA Diagnoses

NANDA Nursing Diagnose - Nausea

Code: 00134
Domain: Domain 12 - Comfort
Class: Class 1 - Physical comfort
Status: Retired diagnoses

The NANDA-I diagnosis 'Nausea' plays a crucial role in patient care as it encompasses a range of subjective experiences that can significantly impact a patient’s emotional and physical well-being. Recognizing and accurately addressing this diagnosis is essential for nurses, as it not only affects the patient's comfort but can also be indicative of underlying health issues. By understanding the complexities of nausea, nurses can provide tailored interventions that enhance patient outcomes and improve the overall quality of care.

This post aims to explore and elucidate the NANDA-I diagnosis 'Nausea' in detail, focusing on its definition and implications in clinical practice. Key aspects will include defining characteristics such as aversion to food and sensations associated with nausea, as well as various related factors and at-risk populations. Additionally, the discussion will cover associated problems that can arise, providing a comprehensive overview that underscores the significance of effectively managing this common yet often distressing symptom.

Definition of the NANDA-I Diagnosis

Nausea is defined as an unpleasant and subjective sensation typically located in the throat and upper abdomen, characterized by the urge to vomit but not always resulting in actual vomiting. This condition can arise from a wide range of stimuli and factors, both physical and psychological, that trigger an aversive response, leading to feelings of unease regarding the intake of food or fluids. Patients may experience accompanying symptoms such as increased salivation, frequent swallowing, and an unpleasant bitter taste, which can further contribute to their discomfort. Nausea is often associated with various health issues or exposures, including anxiety, adverse reactions to medications, gastrointestinal disturbances, and environmental toxins. Understanding nausea as a distinct nursing diagnosis emphasizes the need for comprehensive assessment and intervention, recognizing its impact on patient well-being and quality of life, particularly in vulnerable populations such as pregnant women and individuals with certain medical conditions.

Defining Characteristics of the NANDA-I Diagnosis

The NANDA-I diagnosis "Nausea" is identified by its defining characteristics. These are explained below:

Aversión hacia los alimentos
The patient's strong aversion to food is a crucial characteristic of nausea. This aversion can manifest as a psychological and physiological response, indicating an underlying discomfort that discourages food intake. Clinically, a persistent aversion may lead to nutritional deficiencies and weight loss, further complicating the patient's health status. In nursing practice, recognizing this aversion is vital, as it may necessitate dietary interventions or alternative nutritional support to ensure the patient’s caloric and nutrient needs are met while minimizing discomfort.
Sentido de náuseas
This defining characteristic encompasses the subjective sensation of discomfort in the upper gastrointestinal tract, often accompanied by a premonition of impending vomiting. It is a direct indicator of the patient’s experience of nausea, providing insight into the severity and potential triggers of the condition. Clinically, healthcare providers can assess the intensity and frequency of this sensation using tools such as the Numeric Rating Scale for nausea, aiding in symptom management. Effective alleviation of this sensation can significantly enhance the patient’s overall quality of life and satisfaction with care.
Aumento de la salivación
Increased salivation is often observed alongside feelings of nausea and can be a physiological response to the gastrointestinal distress the patient is experiencing. Clinically, this characteristic serves as a biological marker of nausea, as the autonomic nervous system may stimulate salivary glands in response to digestive upset. Nurses should monitor this symptom, as it can lead to drooling or discomfort, and may require interventions such as providing tissues or adjusting fluid intake to manage both the nausea and salivation effectively.
Aumento de la deglución
The frequent need to swallow is a common yet often overlooked symptom associated with nausea. This behavior may represent a coping mechanism for the patient, as swallowing may temporarily relieve the discomfort caused by the feeling of nausea. Clinically, it is important to assess the frequency and context of this behavior, understanding that it can contribute to further gastrointestinal irritation if excessive. Additionally, this characteristic can guide nurses in providing strategies that may help alleviate the nausea, such as allowing relaxed environments, promoting small sips of clear liquids, or utilizing antiemetic medications where appropriate.
Sabor amargo
A bitter taste in the mouth is frequently reported by patients experiencing nausea and can serve as a significant indicator of their condition. This characteristic may be attributed to various factors, including metabolic changes, certain medications, or the body’s acute response to gastrointestinal distress. Clinically, acknowledging the presence of this unpleasant taste is essential, as it can further exacerbate the patient’s nausea and affect their willingness to eat or take medications. By addressing this symptom through targeted interventions such as oral rinses, flavor enhancements, or medication adjustments, healthcare providers can play a pivotal role in improving the patient’s overall comfort and willingness to maintain nutrition.

Related Factors (Etiology) of the NANDA-I Diagnosis

The etiology of "Nausea" is explored through its related factors. These are explained below:

Anxiety Anxiety can significantly contribute to the sensation of nausea as it activates the body's stress response. When a person experiences anxiety, it triggers the release of stress hormones such as cortisol and adrenaline. These hormones prepare the body for a 'fight or flight' response, which can alter gastrointestinal motility. The resulting changes in the digestive processes may lead to increased muscle tension in the stomach and can elevate the sensitivity of the gastrointestinal tract, precipitating feelings of nausea. Clinically, it’s crucial to assess the patient's anxiety levels and provide interventions such as relaxation techniques or cognitive-behavioral therapy to manage both anxiety and nausea effectively.
Exposure to Toxins The ingestion or inhalation of noxious substances activates the body's protective mechanisms. When the body detects harmful toxins, it responds by inducing nausea, which serves as a defense mechanism intended to expel the offending substance. Toxins can vary from contaminated food to environmental pollutants, and the mode of exposure can dictate the severity and immediacy of the nausea. Clinically, identifying and removing the source of the toxin is paramount, alongside supportive care to manage nausea through pharmacological interventions as needed. Patient education on avoiding specific toxins and recognizing early signs of exposure can be vital in prevention.
Fear Fear, particularly in stressful situations, can manifest as physiological responses including nausea. This is often due to the activation of the autonomic nervous system, which can induce gastrointestinal distress. For instance, during a traumatic event or situation of perceived danger, the body prepares itself for impending threat, which can disrupt normal digestive function. Clinically, understanding the patient's triggers and providing a safe environment to discuss and process fears can help mitigate the nausea triggered by these stressors. Interventions may involve desensitization techniques or supportive counseling to alleviate fear-based responses.
Unpleasant Tastes Exposure to repugnant or spoiled foods can trigger a conditioned response leading to nausea. The body has evolved mechanisms to reject harmful or spoiled substances through the sensation of nausea, which serves both as a protective reaction and a learned behavior. Clinical implications involve recognizing that sensitivities to specific tastes may vary between individuals, thus necessitating a tailored dietary approach to avoid inducing nausea. Providing education on food safety and the importance of fresh, palatable options can be crucial in management.
Unpleasant Sensory Stimuli Discomfort from loud noises, strong odors, or bright lights can disturb the vestibular system and autonomic nervous system, contributing to feelings of nausea. These overstimulating stimuli can be particularly challenging for patients with underlying conditions such as migraines or vestibular disorders, where sensory input can exacerbate symptoms. Clinicians should assess environmental factors and create a calming atmosphere that minimizes these triggers. Interventions could include providing headphones, adjusting lighting, or guiding breathing techniques to help patients regain a sense of control and relieve nausea.

At-Risk Population for the NANDA-I Diagnosis

Certain groups are more susceptible to "Nausea". These are explained below:

Pregnant Women
During pregnancy, many women experience nausea, particularly in the first trimester. This condition, often referred to as "morning sickness," is primarily attributed to the rapid hormonal changes that occur in a woman's body, including increased levels of human chorionic gonadotropin (hCG) and estrogen. These hormonal fluctuations can affect the gastrointestinal (GI) tract, leading to increased sensitivity and altered motility. Additionally, physical changes such as the growing uterus can exert pressure on the stomach and intestines, exacerbating feelings of nausea. Emotional factors, such as anxiety about pregnancy and changes in lifestyle, may also contribute to nausea. Furthermore, certain dietary preferences or aversions commonly observed in pregnant women can trigger nausea, making this population particularly vulnerable.

Problems Associated with the NANDA-I Diagnosis

The diagnosis "Nausea" can interrelate with other problems. These are explained below:

Gastrointestinal Disorders
- Alteración de los fenómenos bioquímicos - Changes in electrolyte levels and biochemical substances can disrupt normal gastrointestinal functioning, leading to a state of nausea. This biochemical imbalance may arise due to dehydration, renal dysfunction, or metabolic disorders, requiring careful assessment and management in conjunction with nausea to restore homeostasis.
- Irritación gastrointestinal - Conditions such as gastritis or gastrointestinal infections can cause inflammation and irritation, resulting in nausea. The underlying causes often necessitate targeted treatments which may include dietary modifications, medications, or further diagnostic evaluations to alleviate nausea while addressing the root cause.
- Distensión gástrica - Gastric distension from excessive gas or fluid accumulation can trigger nausea through increased pressure within the gastrointestinal tract. This symptom indicates that further evaluation may be needed to identify dietary triggers or gastrointestinal motility issues contributing to the discomfort.
- Enfermedades pancreáticas - Pancreatic disorders can impede digestion, leading to nausea as a primary symptom. Collaborative care among healthcare professionals, including dietary specialists and gastroenterologists, may be necessary for comprehensive management.
Neurological Issues
- Hipertensión intracraneal - Increased intracranial pressure can lead to nausea among other neurological symptoms. It is critical for healthcare providers to assess for potential underlying causes such as tumors or traumatic injuries, as timely intervention is vital for patient safety and symptom relief.
- Laberintitis - Inflammation of the inner ear can disrupt balance and create sensations of dizziness and nausea. This relationship highlights the importance of evaluating vestibular function when assessing nausea, as management may require vestibular rehabilitation or pharmacological interventions.
- Enfermedad de Ménière - This inner ear disorder, characterized by episodes of vertigo, tinnitus, and hearing loss, often presents with nausea. Understanding this relationship necessitates a multifaceted approach to care that may involve audiologists and ENT specialists to appropriately address symptoms.
- Meningitis - The inflammation surrounding the brain can result in nausea, signaling the need for urgent medical attention. The complex relationship warrants thorough assessments including neurological evaluations and possibly imaging studies to ensure prompt and effective treatment.
Psychological and Emotional Factors
- Trastorno psicológico - Conditions like anxiety and depression can manifest with physical symptoms, including nausea. This psychosomatic link necessitates an integrated approach that considers both psychological therapies and management of nausea, as improving mental health can alleviate physical symptoms.
- Mareo por el movimiento - This condition induces nausea in susceptible individuals during movement, such as travel. Assessing the patient's lifestyle and offering coping strategies or preventive measures can be pivotal for improvement.
Pharmacological and Therapeutic Influences
- Preparaciones farmacológicas - Many medications have nausea as a common side effect, which can affect adherence to treatment regimens. It's crucial for healthcare providers to discuss potential side effects with patients and consider alternative medications or adjunctive therapies to mitigate nausea.
- Régimen terapéutico - Treatments like chemotherapy can induce severe nausea, necessitating proactive antiemetic management to ensure patients can continue their cancer treatment successfully. Coordination with oncology teams and symptom management strategies is essential for maintaining quality of life.
Organ-Specific Conditions
- Neoplasia abdominal - Abdominal tumors can obstruct or irritate the gastrointestinal tract, leading to nausea as a presenting symptom. Early recognition and imaging studies are crucial for determining the pathology and initiating appropriate treatment plans.
- Tensión en la cápsula hepática - Liver distension or discomfort may manifest as nausea, indicating possible liver disease or other hepatic conditions requiring diagnostic evaluation and therapeutic measures to address the underlying issues.
- Tensión de la cápsula esplénica - Similar to liver conditions, splenic enlargement may cause nausea, emphasizing the need for careful assessment of the spleen, especially in the context of underlying hematological or infectious diseases.

NOC Objectives / Expected Outcomes

For the NANDA-I diagnosis "Nausea", the following expected outcomes (NOC) are proposed to guide the evaluation of the effectiveness of nursing interventions. These objectives focus on improving the patient's status in relation to the manifestations and etiological factors of the diagnosis:

Nausea Control
This outcome is relevant as it specifically measures the patient's ability to manage and reduce the sensation of nausea. By achieving this outcome, the patient is expected to report a decreased level of nausea on a scale, which is crucial for improving their overall comfort and willingness to participate in daily activities or therapies.
Adverse Effects of Treatment Control
This NOC outcome focuses on monitoring and managing any side effects related to medical interventions that may be contributing to nausea. By ensuring that these adverse effects are controlled, the patient's experience of nausea can be mitigated, thus enhancing adherence to treatment plans and overall patient satisfaction.
Fluid Balance
Maintaining appropriate hydration status is critical for patients experiencing nausea, as it can lead to dehydration if not managed properly. This outcome helps to track the patient's fluid intake and output, ensuring that they are able to maintain hydration, which is essential for overall health and recovery during episodes of nausea.
Nutrition Balance
This outcome addresses the need for proper nutritional intake despite feelings of nausea. It is important to evaluate whether the patient is able to consume and retain adequate nutrition, which is necessary for healing and well-being. Improvement in this area is vital to prevent malnutrition during episodes of nausea.

NIC Interventions / Nursing Care Plan

To address the NANDA-I diagnosis "Nausea" and achieve the proposed NOC objectives, the following nursing interventions (NIC) are suggested. These interventions are designed to treat the etiological factors and manifestations of the diagnosis:

Nausea Management
This intervention includes implementing strategies to alleviate nausea, such as positioning the patient in a comfortable manner, offering clear fluids, and encouraging relaxation techniques. Its purpose is to reduce the sensation of nausea and enhance the patient's overall comfort, which is essential for improving quality of life.
Dietary Management
This intervention focuses on assessing the patient's dietary preferences and tolerances while providing small, frequent meals that are bland and easy to digest. The implementation of an appropriate diet can help manage nausea triggered by certain foods and enhance nutrient intake, promoting better health outcomes.
Medication Administration
Administering prescribed antiemetic medications as indicated helps to control nausea and vomiting. This pharmacological intervention aims to directly address the biochemical signals that trigger nausea, thereby providing symptomatic relief and improving the patient's ability to tolerate oral intake and activities.
Relaxation Therapy
This intervention involves guiding the patient through relaxation techniques such as deep breathing exercises, guided imagery, or mindfulness practices. These techniques can help reduce anxiety and tension, which often exacerbate feelings of nausea, thereby promoting overall emotional well-being and helping patients cope with their symptoms.
Patient Education
Educating the patient about potential triggers of nausea and strategies to avoid them is vital. This includes teaching about the importance of hydration, diet modifications, and recognizing signs that warrant further medical attention. Empowering patients with knowledge can enhance their self-management and reduce the incidence of nausea.

Detailed Nursing Activities

The NIC interventions for the NANDA-I diagnosis "Nausea" are composed of specific activities that nursing staff carry out to provide effective care. Below, examples of activities for the key identified interventions are detailed:

For the NIC Intervention: Nausea Management

Assess the patient's level of nausea by using a standardized nausea scale; this helps to monitor changes and the effectiveness of interventions.
Position the patient in a comfortable sitting position to facilitate relaxation and lessen the sensation of nausea.
Encourage the patient to sip clear fluids such as ginger ale or herbal tea, as these can help soothe the stomach and reduce nausea.
Provide cool compresses to the forehead or the back of the neck to promote physical comfort and alleviate nausea symptoms.

For the NIC Intervention: Dietary Management

Conduct a dietary assessment to identify the patient's preferences and tolerances, ensuring that meals meet their needs and minimize nausea triggers.
Plan and serve small, frequent meals that are bland and easy to digest, such as crackers, rice, or applesauce, to help reduce the risk of exacerbating nausea.
Monitor the patient's food intake and tolerance to assess which foods may be triggering nausea, allowing for timely dietary adjustments.
Provide nutritional education to the patient about the importance of maintaining hydration and identifying foods that can help control nausea.

For the NIC Intervention: Medication Administration

Administer prescribed antiemetic medications according to the physician's orders, ensuring proper dosages and timing for optimal effect.
Educate the patient about the purpose and potential side effects of the antiemetic medications to promote understanding and adherence.
Monitor the patient for adverse reactions or side effects of the medications, including changes in consciousness or potential allergic reactions.
Reassess the patient's nausea level after medication administration to determine effectiveness and the need for adjustments in treatment.

Practical Tips and Advice

To more effectively manage the NANDA-I diagnosis "Nausea" and improve well-being, the following suggestions and tips are offered for patients and their families:

Stay Hydrated

Drink clear fluids such as water, herbal tea, or broth. Staying hydrated can help prevent dehydration, which may worsen nausea. Sip fluids slowly throughout the day to ensure comfort.
Eat Small, Frequent Meals

Instead of three large meals, opt for smaller meals or snacks every 2-3 hours. This can help maintain steady energy levels and reduce the likelihood of nausea by avoiding an empty or overly full stomach.
Avoid Strong Odors

Stay away from strong smells, such as cooking odors or perfumes, which can trigger nausea. Try eating in a well-ventilated space, or use air fresheners to minimize unpleasant scents.
Ginger or Peppermint

Consider consuming ginger tea or peppermint capsules, as both are natural remedies known to alleviate nausea. You can also try ginger candies or infused drinks for added relief.
Rest and Relaxation

Finding a quiet space to rest can help reduce feelings of nausea. Practice deep breathing exercises or mindfulness to calm the mind and body, which may relieve discomfort.
Limit Physical Activity

Avoid strenuous activities and heavy lifting while experiencing nausea. Allow your body to rest and adapt, ensuring that you conserve energy and reduce the risk of worsened symptoms.
Keep a Nausea Diary

Track your symptoms and any potential triggers by keeping a diary. Document what you eat, activities, and feelings to identify patterns and share this information with your healthcare provider for further guidance.

Practical Example / Illustrative Case Study

To illustrate how the NANDA-I diagnosis "Nausea" is applied in clinical practice and how it is addressed, let's consider the following case:

Patient Presentation and Clinical Context

A 30-year-old female, with no significant medical history, presented to the emergency department complaining of severe nausea that started suddenly 2 hours prior to her visit. She reported that the nausea was accompanied by lightheadedness and the sensation of having a lump in her throat. The patient indicated that she had a stressful week at work and had a large meal that included rich foods prior to the onset of symptoms.

Nursing Assessment

During the assessment, the following significant data were collected:

Key Subjective Datum 1: Patient describes the nausea as "persistent and unbearable" and rates it as 8 on a scale of 0 to 10.
Key Subjective Datum 2: Patient reports feeling dizzy and states, "I feel like I'm going to throw up."
Objective Finding 1: Patient appears pale and is diaphoretic.
Objective Finding 2: Vital signs show slight tachycardia (heart rate 110 bpm) and hypotension (blood pressure 90/60 mmHg).

Analysis and Formulation of the NANDA-I Nursing Diagnosis

The analysis of the assessment data leads to the identification of the following nursing diagnosis: Nausea. This conclusion is based on the patient's subjective report of persistent nausea rated at 8/10, associated symptoms of dizziness, and objective findings of pallor and diaphoresis. These defining characteristics indicate an acute episode of nausea likely triggered by stress and dietary factors.

Proposed Care Plan (Key Objectives and Interventions)

The care plan will focus on addressing the "Nausea" diagnosis with the following priority elements:

Objectives (Suggested NOCs)

Symptom relief from nausea as evidenced by a reported decrease in severity.
Increased patient comfort and normal vital sign stability.

Interventions (Suggested NICs)

Symptom Management:
- Provide antiemetic medication as prescribed and educate the patient on its effects.
- Encourage the patient to take slow, deep breaths to help manage the symptoms.
Hydration Management:
- Monitor fluid intake and output, and encourage clear fluids if tolerated.

Progress and Expected Outcomes

With the implementation of the proposed interventions, it is expected that the patient will report a significant decrease in nausea symptoms, ideally to a level of 3 or below on the pain scale within 30 minutes. Additionally, stabilization of vital signs and improvement in overall comfort will indicate progress. Continuous monitoring will allow evaluation of the plan's effectiveness.

Frequently Asked Questions (FAQ)

Below are answers to some frequently asked questions about the NANDA-I diagnosis "Nausea":

What causes nausea?

Nausea can be caused by a variety of factors, including motion sickness, gastrointestinal disorders, medications, pregnancy, and anxiety. Identifying the root cause is essential for effective treatment.

How is nausea diagnosed?

Nausea is typically diagnosed through patient history, a physical examination, and sometimes additional tests to determine any underlying conditions. Nurses assess symptoms and may observe patterns in the patient's experience of nausea.

What treatments are available for nausea?

Treatments for nausea vary depending on the cause but may include dietary changes, medications like antiemetics, and lifestyle adjustments. It's important to consult a healthcare provider for an appropriate treatment plan.

What can I do at home to relieve nausea?

To relieve nausea at home, try sipping clear fluids, eating small and bland meals, and avoiding strong odors. Ginger tea or ginger candies can also help, as ginger is known for its anti-nausea properties.

When should I seek medical help for nausea?

You should seek medical help for nausea if it persists for more than a few days, is accompanied by severe symptoms like vomiting blood, severe abdominal pain, or signs of dehydration, as these may indicate a more serious condition.