Nausea & Vomiting Nursing Diagnosis & Care Plan

Nausea and vomiting wreck a patient's comfort fast, and they tip you off to something bigger going on underneath. Your job is to find the cause, control the symptom, protect the airway and fluid status, and keep the provider informed. This guide covers the assessment, diagnoses, goals, and interventions you actually use at the bedside.

What is Nausea and Vomiting?

Nausea is the distressing urge that may or may not end in vomiting. It comes from medication side effects, chemical stimulation, GI problems, or psychological triggers. Pregnancy-related nausea (morning sickness) is one of the most common forms. You identify the cause, give antiemetics, judge whether they work, and report back so the provider can adjust treatment.

Vomiting (emesis) is the forceful expulsion of gastric and intestinal contents through the mouth. Triggers include chemotherapy, toxins, viruses, fungi, food poisoning, radiation, medications, and motion. Vomiting often comes with nausea, but not always.

Causative Factors

Pin down the cause and the right interventions follow. Common drivers fall into two groups.

Treatment-related:

• Gastric distention. Bloating and fullness from a distended stomach.
• Medications. Painkillers, HIV drugs, aspirin, opioids, and chemotherapy agents all list nausea as a side effect.
• Postoperative. Anesthesia and the surgical stress response trigger nausea after surgery.
• Stomach upset. Alcohol, drugs, GI bleeding, or iron supplements irritate the stomach.
• Tube feeding. Feeding given too fast produces feeding intolerance and nausea.

Biophysical:

• Bowel obstruction. A blockage disrupts digestion and triggers nausea.
• Cardiac pain. Angina from inadequate coronary blood supply.
• Cancer. Especially in advanced stages or during chemotherapy.
• Cough. Severe coughing raises chest and abdominal pressure enough to provoke nausea.
• GI disease. Gastritis, gastroenteritis, or peptic ulcers inflame the digestive tract.
• Increased ICP. Head trauma, brain tumors, or cerebral edema raise intracranial pressure.
• Infections. Viral gastroenteritis, urinary tract infections, and others.
• Motion sickness. Sensory mismatch between what the eyes see and the body feels.
• Peritonitis. Inflammation of the abdominal lining brings severe pain, tenderness, and nausea.
• Pregnancy. Common in early pregnancy.
• Uremia. Toxin buildup from kidney dysfunction.
• Toxins. Ingested or inhaled chemicals or contaminated food.
• Tumors. Depending on location and effect on organ function.
• Vestibular problems. Labyrinthitis, Meniere's disease, and other inner-ear disorders.

Nursing Problem Priorities

1. Fluid and electrolyte imbalance. Prolonged vomiting causes dehydration and electrolyte loss. Keeping balance is the top priority.
2. Deficient nutrition. Poor intake leads to malnutrition. Address it with diet changes or alternative feeding.
3. Risk of aspiration. Frequent vomiting risks aspiration pneumonia. Position, suction, and monitor respiratory status.
4. Client and caregiver education. Teach causes, triggers, and symptom management.

Nursing Assessment

Assessment tells you the cause, severity, and impact, and it guides the plan. Watch for these signs and symptoms.

• Food allergy. An allergic reaction releases chemicals that cause GI discomfort and nausea.
• Excessive salivation. Hypersalivation (sialorrhea) is a reflex to protect the digestive tract from irritants.
• Gagging. A defense reflex against harmful substances, strong odors, or tastes.
• Increased swallowing. Heightened as the body tries to clear gastric contents.
• Reports of nausea. The patient describes unease or discomfort in the upper abdomen or throat.
• Sour taste. Gastric contents reflux into the esophagus, linked to GERD and acid regurgitation.

Nursing Diagnosis

After assessment, form nursing diagnoses using clinical judgment and the patient's specific picture. Their use varies by setting. Examples for nausea:

• Nausea related to excessive gastric secretions as evidenced by vomiting, queasiness, and pallor.
• Nausea related to pain as evidenced by the patient verbalizing nausea during episodes of severe pain.
• Nausea related to opioid analgesic use as evidenced by reports of nausea and vomiting after medication administration.

Nursing Goals

• The client will report decreased severity or elimination of nausea and vomiting.
• The client will manage symptoms effectively and improve quality of life.
• The client will avoid complications such as aspiration and dehydration.
• The client will improve nutritional intake and gain or maintain appropriate weight.

Nursing Interventions and Actions

Interventions center on symptom control, fluid and electrolyte balance, diet, education, and collaboration with the team.

1. Assessment for Nausea and Vomiting

Good assessment drives everything else. It sets the urgency of interventions and tracks progress over time.

1. Determine the cause. The cause guides the intervention, and removing the stimulus may be all that's needed. The differential is broad and spans pathological, anatomic, and metabolic disorders.
2. Check vital signs. A postural drop in blood pressure with a rise in pulse on standing points to significant dehydration. A drop in blood pressure with no pulse change suggests autonomic neuropathy.
3. Auscultate the abdomen. Increased bowel sounds suggest obstruction, absent sounds suggest ileus. A succussion splash over the epigastrium while rocking the abdomen side to side suggests gastroparesis or gastric outlet obstruction.
4. Assess nausea characteristics: duration, frequency, severity, precipitating factors, medication history, and what has helped before. With most chemotherapy agents the acute phase starts 1 to 2 hours after IV administration, peaks over the next 8 hours, then eases. Delayed nausea and vomiting can hit 24 hours or more after chemotherapy.
5. Record hydration status, daily weights, intake and output, and skin turgor. Vomiting shifts hydration status through fluid loss. Severe vomiting causes symptomatic dehydration and electrolyte abnormalities. Chronic vomiting causes undernutrition, weight loss, and metabolic derangement.
6. Prepare the client for diagnostic testing. Workup may include upper GI study, abdominal CT, or ultrasonography. Every female of childbearing age gets a urine pregnancy test. Severe vomiting, vomiting lasting over one day, or signs of dehydration warrant electrolytes, BUN, creatinine, glucose, urinalysis, and liver function tests.
7. Review prenatal vitamins if pregnant. Too much iron can cause nausea. Pregnant women should stop iron-containing supplements in the first trimester and switch to folic acid or low-iron vitamins.
8. Review the client's medications. Several dopamine agonists used for schizophrenia, Parkinson's disease, ADHD, depression, and restless leg syndrome cause nausea and vomiting. Cholinesterase inhibitors, which block acetylcholine metabolism, also provoke vomiting.
9. Do a brief neurological exam as appropriate. Check cranial nerves (ocular movements, pupillary light response, nystagmus) and observe gait. Cranial nerve abnormalities or long tract signs point to a CNS cause. Brainstem tumors can present with vomiting plus long tract or cranial nerve signs.
10. Review serum drug levels. Levels may show toxicity in clients on digoxin, theophylline, or salicylates, or recreational drug use such as opiates or cannabis.
11. Evaluate for an eating disorder. When history, exam, and testing find no cause and symptoms persist, screen for an eating disorder. Higher-risk clients include young women, competitive athletes, those with a first-degree relative with an eating disorder, and those with significant anxiety, depression, or body image concerns.

2. Managing Chronic and Acute Nausea and Vomiting

Chronic nausea and vomiting last 4 weeks or longer. Acute nausea and vomiting last 7 days or less. The distinction matters: most acute cases are transient, self-limited, or a medication side effect.

1. Keep an emesis basin within reach. If nausea has a psychogenic component, keep it out of sight but reachable. A basin contains vomit and makes cleanup easier.
2. Assist with oral hygiene. Nausea brings anorexia and excessive salivation, and emesis is acidic enough to erode enamel. Regular oral care removes acidic residue, prevents decay, and clears the unpleasant taste and smell.
3. Eliminate strong odors (perfumes, dressings, emesis). The chemoreceptor trigger zone is sensitive to strong odors and connects directly to the vomiting center in the brainstem.
4. Maintain fluid balance in at-risk clients. Adequate hydration before surgery or chemotherapy lowers nausea risk. Perioperative fluid status is a key risk factor for postoperative nausea and vomiting, and a carbohydrate beverage before laparoscopic cholecystectomy lowered postoperative vomiting.
5. Offer nonpharmacological techniques: relaxation, guided imagery, music therapy, distraction, or deep breathing. These work best when used before nausea hits. Complementary therapies are increasingly used for refractory symptoms or by clients who want to avoid standard treatment.
6. Introduce cold water, ice chips, ginger products, and room-temperature broth or bouillon if tolerated. Ginger relieves nausea through its constituents gingerol, shogaol, and zingerone, which act on serotonin and NK1 receptors. Fluids that are too cold or too hot are harder to tolerate.
7. Give frequent, small amounts of appealing foods. For some clients an empty stomach worsens nausea. Crackers or toast before rising help with pregnancy-related nausea. Bland foods (broth, rice, bananas, gelatin) are easier to keep down, and clients should eat more when nausea is absent.
8. Have the client avoid trigger foods and smells. Intense odors overwhelm the olfactory system and can trigger nausea, more so in clients sensitive to strong smells.
9. Position upright while eating and for 1 to 2 hours after. Gravity keeps food and liquids moving down, lowering aspiration and reflux risk.
10. Keep rooms well ventilated. Get the client outside for fresh air when possible. Ventilation clears odors, airborne particles, allergens, and pollutants, which matters most for immunocompromised clients.
11. Administer antiemetics as ordered. Most raise the threshold of the chemoreceptor trigger zone. Classes include antihistamines, anticholinergics, dopamine antagonists, serotonin (5-HT3) receptor antagonists, and benzodiazepines. Glucocorticoids and cannabinoids help with chemotherapy-induced nausea and vomiting. Giving antiemetics before surgery reduces postoperative nausea and vomiting.
12. Evaluate the response to antiemetics and interventions. Transdermal scopolamine helps some clients with chronic nausea but causes visual changes and dry mouth. It can slow gastric emptying through its antimuscarinic effect and should be avoided in gastroparesis.
13. Apply acustimulation bands or acupressure as ordered. Stimulating the Neiguan P6 point on the ventral wrist controls nausea in some clients, especially motion-related nausea.

For clients with gastrointestinal disorders

1. Identify medications to discontinue and refer to the provider. Stop drugs that slow GI motility: opioids, dopamine agonists, calcium channel blockers, alpha2-adrenergic blockers, and muscarinic cholinergic antagonists. In diabetic gastroparesis, avoid pramlintide and GLP-1 analogs, which slow gastric emptying. Stop NSAIDs and aspirin in clients with esophagitis, gastritis, or peptic ulcer found on endoscopy.

2. Provide adequate oral nutrition. Poor intake causes deficits in calories, vitamins, and minerals. The stomach empties at up to 2.5 kcal/min. Clients with gastroparesis need small, frequent meals low in fat and fiber, since both delay gastric emptying. Blenderized solids or nutrient liquids work because liquid emptying is usually preserved.

3. Keep the client NPO as indicated. Acute gastritis calls for no food or fluids by mouth for a few days until symptoms subside, letting the gastric mucosa heal. Then offer ice chips followed by clear liquids.

4. Have the client avoid caffeine and alcohol, and promote smoking cessation. Caffeine stimulates the CNS and increases gastric activity and pepsin secretion. Smoking and alcohol delay GI transit, and nicotine cuts pancreatic bicarbonate, which impairs neutralization of gastric acid in the duodenum.

5. Monitor intake and output. Watch for early dehydration (minimal fluid intake 1.5 liters per day, minimal urine output 0.5 mL/kg/hour). If food and oral fluids are withheld, IV fluids are usually ordered, and a record of intake plus caloric value is kept.

6. Recommend ginger. Ginger in any form (powder, oil, tea, candied, crystallized, pickled) has long been used for nausea and vomiting. Used alongside other antiemetics, it adds some relief.

7. Administer enteral nutrition as indicated. When small bowel function is normal, jejunal feeding improves symptoms and reduces hospitalizations. Enteral feeding beats parenteral nutrition on complications, cost, and ease.

8. Treat the underlying disorder. A broad range of agents treat GI-related nausea and vomiting, most of the evidence coming from gastroparesis studies.

   • Prokinetics increase GI contractility. Erythromycin works best on gastric emptying; erythromycin and domperidone both improve overall symptoms.
   • Dopamine receptor antagonists theoretically speed gastric emptying. Metoclopramide is the only FDA-approved drug for gastroparesis and comes in tablet, orally disintegrating, liquid, injectable, and nasal spray forms. Domperidone matches metoclopramide but can cause prolonged QTc, cardiac arrhythmias, and sudden cardiac death.
   • Motilin receptor agonists. Macrolide antibiotics stimulate enteric cholinergic neurons and smooth muscle directly. Erythromycin and azithromycin stimulate gastric emptying and antral pressure activity.
   • Antiemetics include phenothiazines, antihistamines, and 5-HT3 receptor antagonists. Scopolamine blocks muscarinic acetylcholine receptors and has central sedative, antiemetic, and amnestic effects, but avoid it in gastroparesis because it slows gastric emptying.

9. Manage pain as appropriate. Abdominal pain hits 90% of clients with gastroparesis and feeds the nausea and vomiting. Mirtazapine eases symptoms, especially nausea and vomiting, in diabetic and non-diabetic gastroparesis. Low-dose gabapentin can improve visceral pain and nausea in some clients.

10. Prepare for surgical intervention. Correct mechanical or anatomical causes surgically. A client with persistent symptoms, gastroparesis, and resistance to all standard and experimental therapy may benefit from total gastrectomy.

11. Assist with NG tube insertion for decompression. For gastric outlet obstruction, an NG tube decompresses the stomach first. A residual over 400 mL on aspiration suggests obstruction.

12. Prepare for gastric electrical stimulation as indicated. Low-frequency stimulation normalizes gastric dysrhythmias and accelerates emptying with minimal effect on nausea and vomiting. High-frequency stimulation uses short pulses, less energy, and significantly reduces nausea and vomiting in gastroparesis.

3. Interventions for Pregnant Clients

Nausea and vomiting in pregnancy range from mild to severe. Severe cases are the second most common reason for pregnancy hospitalization and are considered pathological. Symptoms usually peak between 10 and 16 weeks and resolve on their own.

1. Monitor symptoms with a validated tool. The Pregnancy-Unique Quantification of Emesis and Nausea (PUQE) score tracks severity and correlates with quality-of-life measures.

2. Provide small, frequent meals. Small meals every 1 to 2 hours avoid a full stomach. Tell the client to eat when hungry, regardless of clock time, as long as it isn't a full meal.

3. Avoid spicy and fatty foods. Protein meals relieve pregnancy nausea better than carbohydrate or fatty foods. Bland or dry foods also help.

4. Recommend acupuncture or acupressure. Both act on the PC-6 (Neiguan) acupoint, located two cm above the wrist crease between the tendons. Acupuncture inserts needles there; acupressure applies pressure to stimulate the median nerve.

5. Promote ginger. Ginger stimulates GI movement and the flow of saliva, bile, and gastric secretions. 1000 mg of ginger per day for 4 days improves nausea and vomiting in pregnancy.

6. Start IV rehydration for hyperemesis gravidarum (HG). IV fluids are recommended for HG with severe dehydration or ketonuria. Rapid hydration relieves many HG symptoms, and glucose saline may outperform normal saline in moderate to severe cases.

7. Provide prenatal vitamin and mineral supplementation. Women taking a multivitamin around conception were less likely to need medical attention for vomiting. Starting supplements one month before pregnancy can lower the incidence and severity of nausea and vomiting.

8. Discontinue iron therapy. Per ACOG, pregnant women should stop iron-containing supplements in the first trimester and switch to folic acid or low-iron vitamins. Most women who stopped iron reported improvement.

9. Administer pharmacologic treatment as prescribed. Combining antiemetics with different mechanisms improves the effect.

   • Ondansetron, a selective 5-HT3 receptor antagonist, is approved for pregnancy-related nausea and vomiting, with no increased rate of major congenital malformations in meta-analysis.
   • Pyridoxine relieves nausea severity in early pregnancy. Combined with metoclopramide, it beats either drug alone.
   • Promethazine is mainly antihistaminergic with weak dopamine antagonism. It works but carries maternal side effects: dystonia, sedation, and decreased seizure threshold.

10. Provide enteral tube nutrition as recommended. When antiemetics and fluids aren't enough, ketonuria persists, and intake can't improve, add nutritional therapy. Tube feeding is preferred for long-term needs and can be given by gastric or jejunal tube.

4. Managing Postoperative Nausea and Vomiting

Postoperative nausea and vomiting (PONV) is common and distressing, and routine perioperative opioids are a major contributor. It's usually self-limiting but takes a real toll on nutrition and quality of life.

1. Identify PONV risk. Patient risk factors include female sex, a history of PONV or motion sickness, nonsmoking status, and young age. Higher-risk surgeries include laparoscopic, bariatric, gynecological, and cholecystectomy. Use risk factors to guide management.

2. Place the client side-lying. At the first sign of nausea, turn the client fully to one side to promote drainage and prevent aspiration, which can cause asphyxiation and death.

3. Offer an aromatherapy inhaler. Client-controlled aromatherapy is an effective nonpharmacologic option for postoperative nausea.

4. Suggest chewing gum with provider or surgeon consent. One pilot study found gum was not inferior to ondansetron for PONV in women after laparoscopic or breast surgery under general anesthesia.

5. Initiate IV fluid therapy. Adequate hydration lowers PONV risk. Minimize fasting time or use supplemental IV fluid for euvolemia. Supplemental crystalloids reduce early and late PONV and the need for rescue antiemetics.

6. Administer medications as indicated. Many drugs control PONV without oversedation, given during surgery and in the PACU.

   • Metoclopramide stimulates gastric emptying and increases GI transit; give at the end of the procedure.
   • Prochlorperazine controls severe nausea and vomiting via oral, sustained-release, rectal, IM, and IV routes.
   • Dimenhydrinate prevents nausea, vomiting, and vertigo of motion sickness.
   • Hydroxyzine controls nausea and vomiting and serves as an analgesia adjunct to lower opioid dosage.
   • Scopolamine prevents and controls nausea and vomiting from motion sickness and surgical recovery.
   • Ondansetron prevents PONV with few side effects and is often the drug of choice.

7. Avoid opioids when appropriate. Opioid-free anesthesia and analgesia eliminate opioid-related adverse events, including PONV.

5. Care for Chemotherapy-Induced Nausea and Vomiting

Nausea and vomiting are common side effects of cytotoxic chemotherapy, with the emetic action starting in the GI tract.

1. Encourage relaxation activities (acupuncture, acupressure). Relaxation controls all types of chemotherapy-induced nausea and vomiting (CINV), not just anticipatory CINV, and acupuncture is gaining ground as an option.

2. Recommend medicinal plants with provider approval. Citrus aurantium, Hypericum perforatum, Achillea millefolium, and Zingiber officinale have treated CINV, with Zingiber officinale (ginger) coming out on top. Ginger may also improve CINV-related quality of life and reduce fatigue.

3. Encourage adequate intake, avoiding oily and fatty foods. Nausea is linked to oils. The American Cancer Society recommends bland foods such as dry toast and crackers; avoiding fatty, fried, spicy, or very sweet foods; using butter, oils, syrups, sauces, and milk to add calories; and eating food cold or at room temperature to cut its smell and taste.

4. Offer small, frequent meals. Smaller meals keep the stomach from overfilling. Non-greasy, easy-to-digest foods reduce GI irritation.

5. Administer antiemetic agents as prescribed. As single agents, only 5-HT3 receptor antagonists and NK1 receptor antagonists show marked activity against highly emetogenic chemotherapy.

   • 5-HT3 receptor antagonists are the most effective family for acute emesis, blocking serotonin type 3 receptors mainly through peripheral blockade in the small intestine. Early agents include ondansetron, granisetron, and dolasetron.
   • NK1 receptor antagonists added to a standard regimen improve control of acute and delayed CINV. These include aprepitant, fosaprepitant, and rolapitant.
   • Corticosteroids have moderate efficacy and should be used as single agents only for mildly emetogenic chemotherapy. Use caution in clients with diabetes or other conditions predisposing them to steroid complications.
   • Olanzapine reduces delayed and breakthrough nausea and vomiting. Its major side effect is sedation, which is common and can be severe.

6. Client and Caregiver Education

Teaching the client and family lets them take part in care and make informed decisions.

1. Teach fluid and dietary options for nausea. Good hydration and nutrition depend on knowing what to eat when nauseated. Chemotherapy clients develop early satiety, so maintain nutrition by the oral route whenever possible.
2. Teach the client to take medications as ordered. Following the schedule cuts nausea episodes. Drugs fall into antiemetics (suppress nausea centrally) and prokinetics (modulate GI motility peripherally).
3. Teach the client to change positions slowly. Standing quickly shifts blood pressure abruptly, worsening dizziness, lightheadedness, and nausea. A gradual change lets the body adjust.
4. Teach nonpharmacological control techniques: relaxation, guided imagery, music therapy, distraction, aromatherapy, or deep breathing. These build the client's sense of control. A client-controlled aromatherapy inhaler works well for postoperative nausea.
5. Tell the client to seek care if vomiting develops or persists longer than 24 hours. Prolonged vomiting causes dehydration and electrolyte imbalances (potassium, sodium, chloride) that affect heart function, muscle contraction, and fluid balance.
6. Teach how to apply acustimulation bands or acupressure. The most-used point for pregnancy nausea is pericardium 6 (PC6), four fingerbreadths from the wrist crease between two tendons, where acupressure wristbands sit.