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Nursing Care Plan: Nausea and Vomiting
Assessment
Subjective data:
Patient report of nausea: onset, duration, frequency, severity (use 0–10 scale), triggers, relation to meals or medications, associated symptoms (dizziness, abdominal pain, headache, photophobia, anxiety).
History of recent illness, chemotherapy, radiation, motion exposure, pregnancy, post-operative state, migraine, gastroenteritis, food intake, alcohol use, medication changes, or substance use.
Past medical history: GI disorders (GERD, peptic ulcer disease, gastroparesis), neurologic conditions, metabolic disorders, vestibular disorders.
Objective data:
Vital signs: blood pressure, heart rate, respiratory rate, temperature, oxygen saturation.
Hydration status: mucous membranes, skin turgor, capillary refill, urine output and color, daily weights.
Abdominal assessment: bowel sounds, distention, tenderness, surgical wounds if applicable.
Neurologic signs: altered mental status, focal deficits, nystagmus.
Labs and diagnostics: electrolytes (Na+, K+, Cl-, HCO3-), BUN/creatinine, glucose, pregnancy test, H. pylori testing if indicated, imaging results.
Emesis characteristics: amount, color, presence of blood (hematemesis), undigested food, bile, odor.
Medication review for emetogenic agents (opioids, antibiotics, chemo agents, anesthesia).
Nursing Diagnoses (examples)
Nausea related to physiologic effects of illness/medication/treatment as evidenced by patient report of nausea score 7/10 and recurrent retching.
Risk for deficient fluid volume related to vomiting and decreased oral intake.
Imbalanced nutrition: less than body requirements related to persistent nausea and reduced oral intake.
Electrolyte imbalance risk related to repeated vomiting.
Anxiety related to persistent nausea and fear of vomiting.
Impaired oral mucous membrane integrity related to repeated vomiting and dehydration.
Goals/Expected Outcomes
Patient will report decreased nausea (e.g., <3/10) within 30–60 minutes of intervention.
Patient will maintain adequate hydration as evidenced by stable vital signs, urine output ≥30 mL/hr (adult guideline), moist mucous membranes, and stable daily weight.
Patient will tolerate small, bland oral intake without emesis within 24–48 hours.
Patient’s electrolyte values will remain within normal limits or correct toward baseline.
Patient will demonstrate effective coping measures and decreased anxiety related to nausea.
Nursing Interventions and Rationales
Assessment and monitoring
Continuously assess nausea severity using a standardized scale and document response to interventions. Rationale: Quantifies symptom and evaluates effectiveness of treatments.
Monitor vital signs, intake and output, daily weights, and lab values (electrolytes, BUN/creatinine). Rationale: Detects dehydration, hemodynamic instability, and electrolyte disturbances.
Observe emesis characteristics (color, amount, presence of blood). Rationale: Helps identify complications and need for urgent intervention (e.g., GI bleed).
Pharmacologic management (implement per provider orders)
Administer antiemetics as prescribed (e.g., ondansetron, promethazine, metoclopramide, prochlorperazine, or NK1 antagonists for chemo-induced nausea). Rationale: Reduces nausea and prevents vomiting by acting on CNS and GI receptors.
Assess for contraindications and side effects (e.g., QT prolongation with ondansetron, extrapyramidal symptoms with metoclopramide). Rationale: Minimizes adverse effects and ensures safe use.
Consider adjunct medications for underlying causes (IV fluids, proton-pump inhibitors, antibiotics for gastritis). Rationale: Treats precipitating cause to reduce symptoms.
Fluid and electrolyte management
Initiate/maintain IV fluids for moderate to severe vomiting or inability to tolerate PO. Choose appropriate fluid type (e.g., isotonic crystalloid). Rationale: Restores circulating volume and corrects dehydration.
Replace electrolytes as indicated based on labs (e.g., potassium replacement for hypokalemia). Rationale: Prevents complications from electrolyte depletion.
Monitor urine output and specific gravity. Rationale: Assesses renal perfusion and hydration status.
Nutrition and oral care
Offer small, frequent sips of clear liquids or oral rehydration solutions once vomiting subsides; progress to bland, low-fat, low-spice foods (toast, crackers, rice, applesauce) as tolerated. Rationale: Reduces gastric load and risk of recurrent vomiting
Nursing Care Plan: Nausea and Vomiting
Assessment
Subjective data:
Patient report of nausea: onset, duration, frequency, severity (use 0–10 scale), triggers, relation to meals or medications, associated symptoms (dizziness, abdominal pain, headache, photophobia, anxiety).
History of recent illness, chemotherapy, radiation, motion exposure, pregnancy, post-operative state, migraine, gastroenteritis, food intake, alcohol use, medication changes, or substance use.
Past medical history: GI disorders (GERD, peptic ulcer disease, gastroparesis), neurologic conditions, metabolic disorders, vestibular disorders.
Objective data:
Vital signs: blood pressure, heart rate, respiratory rate, temperature, oxygen saturation.
Hydration status: mucous membranes, skin turgor, capillary refill, urine output and color, daily weights.
Abdominal assessment: bowel sounds, distention, tenderness, surgical wounds if applicable.
Neurologic signs: altered mental status, focal deficits, nystagmus.
Labs and diagnostics: electrolytes (Na+, K+, Cl-, HCO3-), BUN/creatinine, glucose, pregnancy test, H. pylori testing if indicated, imaging results.
Emesis characteristics: amount, color, presence of blood (hematemesis), undigested food, bile, odor.
Medication review for emetogenic agents (opioids, antibiotics, chemo agents, anesthesia).
Nursing Diagnoses (examples)
Nausea related to physiologic effects of illness/medication/treatment as evidenced by patient report of nausea score 7/10 and recurrent retching.
Risk for deficient fluid volume related to vomiting and decreased oral intake.
Imbalanced nutrition: less than body requirements related to persistent nausea and reduced oral intake.
Electrolyte imbalance risk related to repeated vomiting.
Anxiety related to persistent nausea and fear of vomiting.
Impaired oral mucous membrane integrity related to repeated vomiting and dehydration.
Goals/Expected Outcomes
Patient will report decreased nausea (e.g., <3/10) within 30–60 minutes of intervention.
Patient will maintain adequate hydration as evidenced by stable vital signs, urine output ≥30 mL/hr (adult guideline), moist mucous membranes, and stable daily weight.
Patient will tolerate small, bland oral intake without emesis within 24–48 hours.
Patient’s electrolyte values will remain within normal limits or correct toward baseline.
Patient will demonstrate effective coping measures and decreased anxiety related to nausea.
Nursing Interventions and Rationales
Assessment and monitoring
Continuously assess nausea severity using a standardized scale and document response to interventions. Rationale: Quantifies symptom and evaluates effectiveness of treatments.
Monitor vital signs, intake and output, daily weights, and lab values (electrolytes, BUN/creatinine). Rationale: Detects dehydration, hemodynamic instability, and electrolyte disturbances.
Observe emesis characteristics (color, amount, presence of blood). Rationale: Helps identify complications and need for urgent intervention (e.g., GI bleed).
Pharmacologic management (implement per provider orders)
Administer antiemetics as prescribed (e.g., ondansetron, promethazine, metoclopramide, prochlorperazine, or NK1 antagonists for chemo-induced nausea). Rationale: Reduces nausea and prevents vomiting by acting on CNS and GI receptors.
Assess for contraindications and side effects (e.g., QT prolongation with ondansetron, extrapyramidal symptoms with metoclopramide). Rationale: Minimizes adverse effects and ensures safe use.
Consider adjunct medications for underlying causes (IV fluids, proton-pump inhibitors, antibiotics for gastritis). Rationale: Treats precipitating cause to reduce symptoms.
Fluid and electrolyte management
Initiate/maintain IV fluids for moderate to severe vomiting or inability to tolerate PO. Choose appropriate fluid type (e.g., isotonic crystalloid). Rationale: Restores circulating volume and corrects dehydration.
Replace electrolytes as indicated based on labs (e.g., potassium replacement for hypokalemia). Rationale: Prevents complications from electrolyte depletion.
Monitor urine output and specific gravity. Rationale: Assesses renal perfusion and hydration status.
Nutrition and oral care
Offer small, frequent sips of clear liquids or oral rehydration solutions once vomiting subsides; progress to bland, low-fat, low-spice foods (toast, crackers, rice, applesauce) as tolerated. Rationale: Reduces gastric load and risk of recurrent vomiting
