Care plan question?

RNstudent13renee · Oct 1, 2013

I think your wording would be fine, but are you sure that nausea would be the priority for post-op anesthesia? What do they usually monitor after surgery? In my experience respirations/O2 sats are bigger priorities than nausea. Even pain management would be more of a priority, but that one is my opinion. I don't know your patient though. :) Try looking in a nursing diagnosis handbook, I use Ackley and I just looked up nausea and there are great explanations in there. NANDA is a great resource as well.

nurseprnRN, BSN, RN · Oct 2, 2013

NANDA-I is the ONLY authoritative resource. :) All the others are able to quote parts of the NANDA-I work (for a price, and I have had to negotiate with their publisher for a deal so we could quote them extensively in a book). However, NANDA-I does not give permission to quote the whole of their work, for obvious reasons. Therefore, if you do not at least refer to the original work, you do not get all the information you need. Specifically, you will probably not get all the defining characteristics and related-to (causes) for the diagnoses, leaving you to fake it. It is not OK for you to sit there and think and think and try to come up with a cause on your own. You have to identify one from the approved (research-based) list.

So, with that in mind, let's pull out the handy-dandy NANDA-I 2012-2014 to see what's in there about nausea.

Nausea: 00134. Domain 12, comfort; class 1, physical comfort

Definition: A subjective phenomenon of an unpleasant feeling in the back of the throat and stomach that may or may not result in vomiting.

Defining characteristics: aversion towards food; gagging sensation; increased salivation; increase swallowing; reports nausea; reports sour taste in mouth

Related factors (causes):

Biophysical (there is a list of 17 of those, including biochemical disorders (e.g., uremia, DKA), increased ICP, liver capsule stretch, motion sickness, pregnancy, toxins, and more. Some of those may have occurred with the surgery, for example.

Situational: Anxiety; fear; noxious odors; noxious taste;pain;psych factors; unpleasant visual stimulation

Treatment: Gastric distension; gastric irritation; pharmaceutical agents

So, knowing that, and seeing nothing that says "postoperative," your choice of "effects of general anesthetic" is good to go, because that would fall under "pharmaceutical agents," and depending on what surgery was done, there could be other causes. YOu would say, "Nausea, related to pharmaceutical agents (general anesthesia) and gastric distension (or whatever), as evidenced by (pick the defining characteristic(s) that apply to THIS patient)."

Once you have those, you can see your way clear to finding out what to do to make the nausea better. HINT: Although we are legally bound to implement some parts of the medical plan of care (such as give medications, IVs, and administer prescribed treatments, for example), a nursing plan of care does not properly include those. What NURSING measures, monitoring, and teaching will you do, independent of a medical plan of care, for a patient with the NURSING DIAGNOSIS of nausea, and put into a NURSING plan of care to deliver or delegate?

Esme12, ASN, BSN, RN · Oct 3, 2013

Hi there, I have a quick question. I have come up with the priority nursing diagnosis of nausea (it is post-operative nausea) and I am wondering if this is acceptable wording:
nausea R/T effects of general anesthetic.
Input, comment, feedback?
Thank you!

Your patient has just had surgery and this is the only ND you have? Nursing diagnosis is all about the assessment of the patient...there is not enough information about this patient to know if this is OK or not.

Tell us about your patient.