Nausea Nanda-NIC-NOC 2017
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| Nausea: Nanda-NIC-NOC 2017 |
The related Factore
Related treatment
- Gastric irritation (aspirin, medicine nonstedoid bitter taste, steroid, antibiotic)
- Distensi hull
- Pharmacological agents
- Toxin
The biophysical
- Biochemical disorders
- Esophageal diseases or pancreatitis
- Distensi hull
- Stomach irritation
- Intra abdominal tumor
- Kapsula heart stretch or nodes
- Local tumors such as neuroma abdomen, primary or secondary brain tumors
- Drunk motion, mneiere disease or labirinitis
- Pain
- Physical factors such as intracranial emphasis and meningitis
- Toxin
Situational
- Psychological factors such as pain, fear, ansietas, etc.
Restriction characteristics
- Subjective
- Avoid foods
- The sensation of wanting to vomit
- Increased production of saliva
- Improvement of swallowing
- Reported nausea
- A sour taste in the mouth
Objective (Non nanda)
- Pale skin
- Cold, wet
- Flutter
- Static gastristik
- Vomiting
Results & NOC
NOC:
Appetite; the desire to eat while in a State of pain or are currently undergoing treatment
Level of comfort; the perception of the degree of posistif of physical and psychological comfort
Hydration; keadekuatan fluid adekuat in the intrasel and ekstrasel body compartment
Controlling nausea-vomiting; individual actions to control nausea and vomiting
Nausea and vomiting: effects of disturbance; the severity of the interference effects observed or reported due to nausea, vomiting, and want to throw up on everyday functions
The severity of nausea and vomiting; the severity of nausea, vomiting and want to vomit
Status of nutrition: dietary intake and fluid; the amount of food and liquid into the body within 24 hours
Objectives and evaluation criteria
Nausea will be evidenced by reduced appetite, comfort levels, Hydration, control nausea-vomiting, nausea and vomiting: the effect of disturbance, the severity of nausea and vomiting, adekuat nutrition Status
Shows the effects of disturbances nausea and vomiting that can be accepted, as evidenced by the
following indicators:
- very heavy
- the weight of the
- is being
- light
- do not experience
| Indicator |
1
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2
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3
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4
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5
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Decrese your intake of fluids
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Adecrease in food intake
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Decreased urine output
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Fluid balance disorder
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Serum electrolyte disorders
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Impaired nutritional status
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Weight loss
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shows hydration, which is evidenced by the following indicators:
- eksterm disorders
- the weight of the
- is being
- light
- no distractions
| Indicator |
1
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2
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3
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4
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5
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An increase in the hematokrit
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Mucous membrane moist
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An increase in the hematokrit
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The thirst
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Sunken eye balls and moist
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A decrease in blood pressure
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Rapid and weak pulse
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The patient will:
- report free of nausea
- identify and take actions that can decrease nausea
NIC Interventions
The study of- Subjective symptoms monitor nausea in patients
- Monitor color, weight, type and quantity of urine
- Review the causes of nausea
- Monitoring of nutrition (NIC):
- Monitor the tendency of increase or decrease in weight
- Monitor the presence of dry skin and chapped accompanied depigmentation
- Monitor turgorkulit if necessary
- Monitor the presence of swelling or softening, depreciation and increased bleeding in the gums
- Monitor energy levels, malaise, tiredness and weakness
- Monitor your calorie intake and food
- Fluid Management (NIC):
- Maintain the accuracy of the recording of intake and urinary haluaran
- Monitor TTV if necessary
- Monitor food and liquids consumed and calculate your calorie intake per day, if necessary
- Monitor hydration status, if necessary
Counseling for patients and families
Explain the causes of nausea
- Apaila permits, tell patients how long the possibility of mua will occur
- Teach the patient to consciously swallowing or deep breath to suppress gag reflex
- Taught to eat slowly
- Teach to limit drink 1 hour before, 1 hour after, and during the meal
- Antiemetic drugs provided as recommended by
- Consult your doctor to prescribe a pain control adekuat and does not cause the mua in patients
- Fluid Management (NIC): give therapy IV, in accordance with the advice of
- Elevate the head of the bed or change the position of the patient's lateral to prevent aspiration
- Maintain the cleanliness of the client and the bed in the event of vomiting
- The move immediately objects that cause the smell
- Do not menjadwakan actions that cause pain or nausea before or after eating
- Give oral care after vomiting
- Give it a cool wet cloth dipergelangan hands, neck and forehead of the patient
- Offer food and other food with minimal scent
- Monitoring of nutrition (NIC): note significant changes nutritional ststus and as soon as do the handling, if necessary
- Instruct the client to avoid odors from food prepared at home
- All of the above interventions can be made for treatment at home
- Infants and children at risk of experiencing a lack of fluid volume as a result of the mua because usually refused to be fed
For the elderly
- Monitor carefully antiemetic medication side effects
- Examine whether likelihood of nausea caused by nonsteroidal anti-inflammatory drugs that are taken by the patient
Written by Unknown
File Entry Pendidikan Berbagi Ilmu Akademi Keperawatan ,Akademi Kebidanan Serta Pendidikan Sekolah Secara Gratis Dengan Ikhlas.
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