Date:
Patient:
Room:
Age:
Diagnosis:
BCIT Level 2 Nursing Care Plan
Treatments:
PMHx:
Medications:
Diet:
PRN Medications:
Date of Surgery:
Activity:
Type of Surgery:
Potential Problems
What are the anticipated problems for
this patient and what is potentially
causing these problems. (due to or
related to)
Nausea and/or Vomiting
d/t Anaesthetics
d/t Ingestion of fluids or
food before peristalsis
returns
d/t Chemotherapy
d/t Preoperative
d/t PCA
d/t Bowel
Obstruction/Paralytic
Ileus
d/t lack of food
(increased gastric acid in
stomach may cause N/V)
d/t Narcotics such as
morphine,
hydromorphone (can
cause N/V)
d/t pain (increase in pain
can cause increase in
gastric acid secretion,
which may lead to ulcers.
Sensation of pain could
VALIDATION PROCESS
ASSESSMENT
EVIDENCE
Wednesday PM – How will I assess
each problem?
1. Assess for signs of
gagging and welching,
potentially lying in the
fetal position
2. Assess skin colour,
pale/cool and clammy,
green, temperature and
moisture
3. Assess for loss of or
decreased appetite
4. Assess bowel sounds
x4
5. Assess pt. for
dehydration (ie, skin
integrity, increased thirst,
decreased urine output
of <30cc/hr, increased
respirations and heart
rate, fatigue, dark
coloured urine)
Thursday PM – Data collected to
indicate a valid problem
INTERVENTIONS
Wednesday PM – What will I do for
each of the potential problems – both
nursing interventions and medical
interventions?
1. NPO until BS return
(or full fluids)
2. Start on clear fluid with
IV until patient can
tolerate fluids then
remove IV
3. Administer antiemetic
as prescribed or q4h
Metoclopramide
(maxeran), Gravol,
Prochlorperazine,
Ondanterin
4. Ensure adequate oral
fluid intake if tolerated,
200cc/hr
5. Ensure adequate oral
hygiene and suctioning
6. Offer pt. cold cloth
EVALUATION/FOLLOW
UP
Thursday PM – What will I do Friday
for each valid problem
lead to nausea too)
Pathophysiology:
- Stimulation of the
vestibular
apparatus is
mediated largely
through histamine
and acetylcholine
receptors and can
lead to nausea.
- Stimulation of the
chemoreceptors
and stretch
receptors triggers
nausea and
vomiting via vagal
nerve afferents
and afferent fibres
associated with
the sympathetic
nervous system.
serotonin,
acetylcholine,
histamine, and
substance P are
major
neurotransmitters
involved in
stimulating these
receptors.
- The cerebral
cortex and
associated
structures in the
limbic system
modulate complex
experiences such
6. Assess pt. last dose of
Anti-emetic and route
given
7. Assess if pt. has
excessive saliva due to
nausea
7. Dim the lights to
create a calming
environment
8. Provide ginger ale.
crackers, and/or ice
chips
8. Assess for reports of
nausea
9. Provide basin for
vomiting pt. (followed by
wet cloth and
mouthwash)
pulse rate, >100
beats/min, assess trend
and baseline
10. Refer to dietician
about a more suitable
diet for nauseated pts.
11. Resume oral intake
gradually, start with ice
chips and move to 200cc
q2hr
12. Monitor lab tests for
trend and baseline of
electrolytes
as taste, sight,
and smell as well
as memory
(involved in
anticipatory
nausea) and
emotion
Vomit center in the
medulla of the brain
receives input from the
GI tract, CTZ, vestibular
apparatus, cerebral
cortex, and midbrain
afferents. Pathways can
activate the VC via
cholinergic,
dopaminergic,
histaminergic, or
serotonergic receptors.
Different drugs block
different major
neurotransmitters
involved in the
stimulation of the VC.
5-HT3 receptor
antagonists effect the
CTZ and the afferents at
the GI (Ondanestron).
Phenothiazines: act
primarily via the central
antidopaminergic
mechanism in the CTZ.
Side effects: sedation,
dizziness, and
extrapyramidal
symptoms
(prochlorperazine)
Dopamine antagonist:
dopamine receptors in
the CTZ and VC.
Shortens the bowel
transit time and in high
doses blocks serotonin
receptors
(metoclopramide).
Antihistaminics with
similar effects to the 5HT3 receptor
antagonists. Efficacy is
through high
concentrations of
histamine and muscarnic
cholinergic receptors
within the vestibular
system (dimenhydrinate).