[**These are nursing interventions researched and chosen based upon current best practices. If your facility has Nursing Guidelines/Protocols approved by your Medical Director for nausea and vomiting that differ, then It is important to follow your facility’s guidelines/protocols.]
Initial care for the patient complaining of nausea/ vomiting:
Obtain Vital signs, including orthostatic measures as indicated by patient complaint and condition.
Monitor for signs of fluid loss.
- Early signs include weakness, headache, difficulty concentrating and postural hypotension. Dehydration signs include thirst (first sign), dry mouth and mucus membranes, warm, flushed dry skin, fever, tachycardia, low blood pressure, weight loss, sunken eyeballs, oliguria, dark, concentrated urine, high specific gravity of urine, poor skin turgor, altered LOC (level of consciousness), elevated BUN, serum creatinine, elevated hematocrit.
- Later signs include confusion, oliguria, cool and moist skin, electrolyte imbalance, and chest and abdominal pain.
Contact the provider for any
- abnormal vital signs/vital signs outside of the normal parameters,
- patient showing signs of dehydration,
- pregnant women with nausea and vomiting;
- Temperature > 100.5˚F;
- Nausea/vomiting related to head injury;
- Vomiting is intractable;
- Emesis contains blood;
- Dehydration is evident;
- Severe pain;
- Patient is diabetic.
Clear liquid diet for 24-48 hours
Follow-up in 24 hours for reassessment.
Plan to obtain laboratory studies per provider order.
Plan to medicate patient per provider order. Potential medications – ondansetron, metoclopramide, Compazine or phenergen.
Patient education regarding the maintenance of hydration, the signs and symptoms that must be reported to healthcare staff immediately (coffee-ground emesis, blood in emesis or stool, dizziness, altered level of consciousness), and the expected course of the condition for the patient.
Remember – Nausea and vomiting are common complaints in the correctional environment. Typically the result of gastrointestinal (GI) infections, nausea and vomiting may also be the result of other infections, metabolic disorders, central nervous system disorders, the ingestion of certain drugs, pain, pregnancy and psychiatric disorders. It is important that a thorough history be obtained from the patient. If the patient is experiencing abdominal pain, the nurse should ascertain its location, duration, intensity, exacerbating factors, and mitigating factors. The patient with the symptoms of nausea and vomiting should be questioned about the quality, duration, exacerbation and mitigation of the symptoms. Nursing interventions for the patient with nausea and vomiting include obtaining a complete set of vital signs, monitoring for dehydration, ordering a clear liquid diet, and consultation with a provider should the symptoms warrant. In addition, nursing care may include the administration of anti-emetics and obtaining laboratory studies per the provider’s order. In most cases, episodes of nausea and vomiting are self-limiting and only supportive care is required; however, there is a serious risk of dehydration and so the monitoring of patients with these symptoms is very important.