NURSING CARE PLAN 2

NURSING CARE PLAN 2
1.      Nausea and vomitting related to side effects of PCA(Patient-Controlled Analgesia) as evidenced by patient keep vomits.

Goal: Patient will reports diminished nausea and vomitting.

No.	Nursing Interventions	Rationales
1.	Assess the cause of nausea and vomiting.	Determining the cause of nausea and vomiting will guide the choice interventions to be used.
2.	Monitor nausea and vomiting characteristics such as duration, frequency, severity and precipitating factors.	A comprehensive assessment of the nausea and vomiting can help determine interventions to minimize the problems.
3.	Assist with oral hygiene every 2 to 4 hours if tolerated.	Nausea is often associated with anorexia and increased salivation. Oral hygiene will help promote comfort.
4.	Remove noxious odors from the surroundings such as perfumes or smelly odors.	Strong or noxious odors can contribute to nausea.
5.	Maintain fluid balance of patient in 2000 ml to 3000 ml of plenty water.	Adequate hydration has been shown to reduce the risk of nausea.
6.	Offer frequent, small amounts of foods that appeal to the patient.	This approach will help maintain nutritional status and for some patient, an empty stomach exacerbates the nausea.
7.	Encourage the patient to use non pharmacological nausea control techniques such as relaxation, music therapy or deep breathing.	These techniques have helped patient manage their nausea but they need to be used before nausea occurs or increases.
8.	Administer antiemetic such as Maxolon as ordered by doctor.	Most antiemetic act by raising the threshold of the chemoreceptor trigger zone to stimulation.
9.	Teach the patient to change positions slowly.	Sudden or gross movement may increase nausea.
10.	Teach patient to use PCA when the pain is feel.	Overdose uses of PCA may increase the severity of nausea.

Evaluation: Patient reports eliminations of nausea and vomiting.