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NCP for Vomiting - 6 Nursing Diagnosis and Interventions

Nursing Care Plan for Vomiting

Definition

Vomiting is a complex reflex that is mediated by the vomiting center in the medulla oblongata of the brain.

Vomiting is spending gastric contents exclusively through the mouth with the help of contraction of the abdominal muscles. Necessary to distinguish between regurgitation, rumination, or gastroesophageal reflux.
Regurgitation is the food that was issued back-to-mouth due to esophageal peristaltic movement.
Rumination is perpetually conscious of food expenditure to be chewed and then swallowed back.
Gastroesophageal reflux is the return of stomach contents into the esophagus in a passive way that can be caused by hypotonia spingter lower esophagus, abnormal position of the esophagus connection with cardiac or slow emptying of the stomach contents.


Etiology

Discussion of the etiology of vomiting in infants and children by age is as follows:

Age: 0-2 months:

1. Allergic Colitis
Allergy to cow's milk or formula with a soy-based ingredients. Usually followed by diarrhea, rectal bleeding, and cranky.
2. Anatomic abnormalities of the gastrointestinal tract
Congenital anomalies, including stenosis or atresia. Manifestations of food intolerance in the first few days of life.
3. Esophageal Reflux
Regurgitation often occur immediately after feeding. Very often occur in neonates; Clinically important that this situation causes failure to thrive, apnea, or bronchospasm.
4. Increased intracranial pressure
Fussy or lethargy accompanied by abdominal distension, birth trauma and shaken baby syndrome.
5. Malrotation with volvulus
80% of these cases is found in the first month of life, mostly with biliary emesis.
6. Meconium ileus
Inspissated meconium in the distal colon; can be considered a diagnosis of cystic fibrosis.
7. Necrotizing enterocolitis
It often happens, especially in premature babies, especially if experiencing hypoxia at birth. Can be accompanied by irritability or fuss, abdominal distension and hematochezia.
8. Overfeeding
Regurgitation of milk that can not be digested, wet-burps often in infants with excess weight to excess breast milk given.
9. Stenosis pylorus
Peak at the age of 3-6 weeks of life. The ratio of men compared to women is 5: 1 and this situation often occurs in boys first. The clinical manifestations will progressively worsen, projectiles, and non biliary emesis.

Age: 2 months-5 years

1. Brain tumor
Think especially if it is found that the progressive headache, vomiting, ataxia, and no abdominal pain.
2. Diabetic ketoacidosis
Moderate to severe dehydration, a history of polydipsia, polyuria and polyphagia.
3. Corpus alienum
Associated with the incidence of recurrent choking, coughing occurs suddenly or saliva dripping.
4. gastroenteritis
Very often; often their history of contact with sick people, usually followed by diarrhea and fever.
5. Head trauma
Vomiting often or progressive signifies concussion or intracranial hemorrhage.
6. Incarcerated hernia
Onset of crying, anorexia and scrotal swelling that occurs suddenly.
7. Intussusception
The peak occurs at 6-18 months of life; patients rarely experience diarrhea or fever than children who are suffering from gastroenteritis.
8. Posttusive
Often, children will vomit after coughing or coughing repeatedly imposed.
9. pyelonephritis
High fever, looked ill, dysuria or polacisuria. Patients may have a history of urinary tract infections earlier.

Age: 6 years and older

1. Adhesion
Especially after abdominal surgery or peritonitis.
2. Appendicitis
Clinical manifestations and location of pain varies. Symptoms often include increasing pain, radiating to the right lower quadrant, vomiting preceded by pain, anorexia, fever subfebril, and constipation.
3. cholecystitis
More common in women, especially with hemolytic disease (eg, sickle cell anemia). Characterized by epigastric pain or right upper quadrant occurs suddenly after a meal.
4. Hepatitis
Mainly caused by a viral infection or drug-induced; the patient may have a history of bowel movements such as putty colored or tea-colored urine concentrated.
5. Inflammatory bowel disease
Associated with diarrhea, hematochezia, and abdominal pain. Stricture can cause obstruction.
6. Intoxication
More common in children who are learning to walk and adolescents. Suspected if a history of depression. Can also be accompanied by disturbances in mental status.
7. Migraine
Severe headache; often the presence of an aura before an attack such as scotoma. Patients may have a history of chronic headache or a family history of migraine.
8. Pancreatitis
Risk factors include upper abdominal trauma, history of previous infections or moderate infection, corticosteroid use, alcohol and cholelithiasis.
9. Peptic ulcer
In adolescents, the ratio of female: male = 4: 1. Chronic or recurrent epigastric pain, often worse at night time.


Complication

1. Metabolic Complications
Dehydration, metabolic alkalosis, electrolyte and acid-base disorders, depletion of potassium, sodium. Dehydration occurs as a result of fluid loss through vomiting or inputs that are less because of vomiting. Alkalosis as a result of the loss of stomach acid, it is exacerbated by the influx of hydrogen ions into the cell due to potassium deficiency and reduced extracellular sodium. Potassium can be lost along with the material vomit and out through the kidneys together bicarbonate. Sodium can be lost through vomiting and urine. In the state of severe alkalosis, the pH of urine can be 7 or 8, urine levels of sodium and potassium high despite the depletion of sodium and potassium.
2. Failure growth
Repeated vomiting and severe enough cause nutritional disorders due to intake be greatly reduced and when this happens long enough, there will be a failure of growth and development.
3. Aspiration of gastric contents
Material aspiration of vomit can cause asphyxia. Recurrent episodes of mild aspiration cause recurrent respiratory tract infections. This occurs as a consequence of GERD.
4. Mallory Weiss syndrome
A linear laceration on the border of the esophagus and gastric mucosa. Usually occurs in severe vomiting lasts longer. On endoscopic examination found redness of the lower esophageal mucosa LES area. In a short time will heal. When anemia occurs because of heavy bleeding need blood transfusions.
5. Peptic esophagitis
Due to prolonged reflux in chronic vomiting cause mucosal irritation of the esophagus by stomach acid.


Nursing diagnoses that may arise

Fluid volume deficit related to loss of active liquid.
Imbalanced Nutrition: less than body requirements related to absorption disorders.
Nausea related to gastric irritation.
Ineffective tissue perfusion related to hypovolemia.
Risk for Impaired skin integrity related to disruption of metabolic status.
Anxiety related to changes in health status.


Nursing Care Plan for Vomiting

Nursing Diagnosis 1. Fluid volume deficit related to loss of active liquid.
Goal: fluid and electrolyte deficit is resolved.
Expected outcomes:
signs of dehydration: none,
mucosa of the mouth and lips moist, fluid balance.

Intervention:
  • Observation of vital signs.
  • Observation for signs of dehydration.
  • Measure the input and output of fluid (fluid balance).
  • Provide and encourage the family to drink a lot more than 2000 - 2500 cc per day.
  • Collaboration with physicians in fluid therapy, laboratory tests electrolyte.
  • Collaboration with a team of nutrition in low-sodium fluid administration.


Nursing Diagnosis 2. Imbalanced Nutrition: less than body requirements related to absorption disorders.

Goal: nutrients are met.

Intervention:
1. Assess the extent to which the inadequate nutrition clients.
Rational: analyze the causes implement interventions.
2. Estimate / calculate the calorie intake, keep the comments about the appetite to a minimum.
Rationale: Identifying deficiencies / nutritional needs to focus on the problem and create a negative atmosphere affects the input.
3. Measure the weight as indicated.
Rational: Overseeing the effectiveness in diet.
4. Give eat little but often.
Rational: Do not let boredom and nutrient intake can be increased.
5. Encourage oral hygiene before eating.
Rationale: The mouth of the net increase appetite.
6. Offer a drink.
Rationale: It can reduce nausea and relieve gas.
7. consul of a / dislike of patients who cause distress.
Rational: Involve patients in planning, enables patients to have a sense of control and the drive to eat.
8. Provide a varied diet.
Rationale: The food was varied client can increase appetite.

Risk for Impaired Tissue Integrity related to Graves' Disease


Nursing Diagnosis for Graves' Disease : related to changes in the mechanism of protection of the eyes; damage eyelid closure / exophthalmos.

Goal: Being able to identify measures to provide protection to the eyes and prevention of complications.

Nursing Interventions:

Independent:

1. Observation periorbital edema, eyelid closure disorders, narrow field of vision, excessive tears. Note the presence of photophobia, taste any thing beyond the eyes and eye pain.
R /: general manifestations of excessive adrenergic stimulation associated with thyrotoxicosis who require support to the resolution of crisis intervention can eliminate symptomatology.

2. Evaluation of the sharpness of the eyes, report the presence of blurred vision or double vision (diplopia).
R /: Infiltrative ophthalmopathy (Graves' disease) is the result of an increase in the retro-orbital tissue, which creates exophthalmos and lymphocyte infiltration of the extraocular muscles that cause fatigue. The emergence of visual impairment can worsen or improve the independence of therapy and clinical course of the disease.

3. Instruct the patient to use sunglasses when the patient woke up and cover with a blindfold during sleep as needed.
R /: Protecting corneal damage if the patient can not close their eyes to perfect as edema or fibrosis pads as fat.

4. The head of the bed elevated and limit the use of salt if indicated.
R /: Lowering tissue edema when there are complications such as CHF which can aggravate exophthalmos.

5. Instruct the patient that the extraocular eye muscles if possible.
R /: Improving circulation and maintain eye movements.

6. Give the patient the opportunity to discuss their feelings about the picture changes, body size or shape to improve self-image.
R /: Eyeball rather prominent cause someone unattractive, it can be reduced by using makeup, wearing glasses.

Collaboration:
1. Give the medicine according to the indication.
R /: Awarded to reduce inflammation that develops rapidly.

2. Antithyroid drugs
Can reduce signs / symptoms or prevent the situation getting worse.

3. Diuretics
Can reduce edema in the soft state.

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