Imbalanced Nutrition : less than body requirements related to nausea and vomiting

Nursing Diagnosis : Imbalanced Nutrition : more than body requirements related

Nausea

Nausea is the sensation (feeling) issued a food or want to vomit. Usually accompanied by autonomic signs such as hypersalivation, diaphoresis, tachycardia, pallor, and tachypnea, nausea closely related to anorexia. Nausea caused by distention or irritation in any part of the digestive tract, but can also be stimulated by higher brain centers.

Nausea is a common symptom of digestive disorders, but also may occur in fluid and electrolyte imbalance, infection, metabolic, endocrine, and heart maze. It can also be as a result of drug therapy, surgery, and radiation

Nausea is also common in the first trimester of pregnancy, nausea can arise from intense pain, anxiety, alcohol poisoning, excessive food or digest food or drink that does not taste good.

Vomiting

Vomiting is the way the top of the GI tract to remove the contents when irritated, stretched, or excessive excitability which results in the production of gastric contents or intestines through the mouth with the help ekspulsif abdominal muscles contractions.

Four main areas sender stimulus:

1. Gastrointestinal tract. The role of neurotransmitters serotonin, acetylcholine, histamine, substansia P.
2. Chemoreceptor trigger zone. Primary neurotransmitter is dopamine D2 receptor is activated and activate serotonin 5HT3 receptor.
3. Vestibular apparatus. Stimulus arising from the movement of the body at the time of motoring etc..
4. Cerebral cortex. Stimulus that appears usually in the form of sensory stimuli such as smell something, see something that triggers vomiting etc.

Stimulus that causes vomiting can occur in any part of the digestive tract, while stretching or irritation of the stomach or duodenum gives the strongest stimulus.

Nursing Intervention:

1. Assess the client's nutritional patterns and the changes that occur.
2. Measure weight.
3. Assess the causes of disturbances of nutrition.
4. Perform a physical examination of the abdomen (palpation, percussion and auscultation).
5. Give the diet in warm conditions and small but frequent portions.
6. Collaboration with the team in the determination of nutritional diet.

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Risk for Fluid Volume Deficit related to Vomiting

Vomiting is defined as the discharge of the contents of the stomach up into the mouth by force. Vomiting can be an attempt removing toxins from the gastrointestinal tract such as diarrhea, lower gastrointestinal tract.

Vomiting can be caused by many things such as the following:

• Congenital abnormalities
• Infection of the digestive tract
• Feeding the wrong way
• Poisoned

Complications of vomiting are as follows :

• Dehydration or alkalosis, due to loss of body fluid / electrolyte
• Ketosis from not eating and drinking
• Acidosis caused a sustained ketosis can be a shock even to seizures
• Abdominal muscle tension, conjunctival hemorrhage, esophageal rupture, aspirations, caused by severe vomiting.

Persistent vomiting can lead to complications of dehydration, electrolyte disturbances, rips Mallory Wiess, aspiration of gastric fluid.


Nursing Diagnosis for Vomiting

Risk for Fluid Volume Deficit related to the feeling of nausea and vomiting

Goal: Maintain the balance of fluid volume.

Outcomes: The client does not nausea and vomiting.

Intervention:
1. Monitor vital signs.
Rationale: An early indicator of hypovolemia.

2. Monitor intake and output and urine concentration.
Rationale: Decreased urine output and concentration will improve the sensitivity / sediment as one impression of dehydration and require increased fluids.

3. Give fluid little by little but often.
Rationale: To minimize the loss of fluids.

4. The risk of infection associated with an inadequate immune, characterized by: body temperature above normal. Increased respiratory rate.

Source : http://nurseskomar.blogspot.com/2013/10/nursing-diagnosis-for-vomiting-risk-for.html

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