Nausea

Nausea

Clinical Findings

Neuro: Dizziness, lightheadedness, anxiety. Resp: Hyperventilation. CV: Hypotension, hypertension, tachycardia, bradycardia. Skin: Cool, pale, diaphoretic, warm and flushed. GI/GU: Nausea, vomiting, diarrhea, constipation. MS:Weakness, fatigue, abdominal pain.

Nursing Interventions

■ Place Pt in position of comfort and provide Pt with an emesis basin. If Pt is unable to protect airway (e.g., clear emesis), place Pt into lateral-lying position to prevent aspiration and be prepared to suction oropharynx to clear emesis if needed. ■ Offer Pt cool compress to forehead or nape of neck. ■ Assess for associated symptoms (chest pain, respiratory distress, cyanosis, decreased LOC, anxiety). ■ Palpate radial pulse for rate and rhythm. If Pt is monitored, assess ECG and manage dysrhythmias per ACLS protocol. ■ Keep Pt NPO until nausea passes or as orders dictate. ■ Obtain and document baseline VS (HR, RR, BP, temp, SpO2). ■ Review medical record (medication, recent labs, and treatments) for possible causes of nausea. ■ Administer p.r.n. antiemetic/antinausea medication if ordered. ■ Notify physician of change in Pt status including pertinent assessment findings and interventions, if any implemented. ■ Consult physician about continued treatment, including antiemetic/ antinausea medication, withholding PO medications or changing them to an alternate route, NPO status, ordering labs, reviewing and changing treatments. ■ Document assessments, any interventions, and outcome. ■ Note: If nausea is reasonably anticipated in relation to Pt’s clinical status, it is not immediately necessary to notify physician, unless there exists a need to order (or clarify an order for) antinausea/antiemetic medication.