• State relief of nausea

• Explain methods clients can use to decrease nausea and vomiting (N&V)

• There are no studies of dietary or other lifestyle interventions with any evidence to support traditional advice and interventions. It is often recommended that the woman eat dry crackers or dry toast in bed before arising and then get up slowly. Additional advice includes eatingt small frequent meals, drinking small amounts of fluids often, avoid foods with offensive odors, and avoiding preparing food or shopping when nauseated. These are traditional strategies for alleviating nausea during pregnancy and are considered expert opinion (Festin, 2009).

s. Discuss with the primary care practitioner the possibility of using the P6 acupressure point stimulation to help relieve nausea. EB: A systematic review showed that using P6 acupressure during early pregnancy reduced the proportion of women reporting nausea and vomiting compared to control and is therefore likely to be beneficial (Festin, 2009). It is still unclear whether acupuncture is a helpful intervention (Festin, 2009).

s. Recognize that ginger ingestion may help nausea. Ginger is available in a number of forms including tea, biscuits, and capsules. There are scant randomized controlled clinical trials for use of ginger in pregnancy, with two RCTs showing inconsistent resultsCEB & EB: It is reported that ginger may reduce nausea and vomiting in pregnancy when compared with placebo in early pregnancy; however, effectiveness for ginger in treating hyperemesis gravidarum is still unknown (Ding, Leach, & Bradley, 2012; Festin, 2009; Matthews et al, 2010).

s. Recognize that there are currently no FDA-approved drugs for the treatment of morning sickness, N&V of pregnancy, or hyperemesis gravidarum. There are, however, several pharmacological treatments outlined by the American College of Obstetrics and Gynecology (ACOG). A stepwise, cost-effective strategy may be helpful in approaching nausea with pregnancy. Considerable N&V with associated dehydration may require intravenous antiemetics, hydration, and/or parenteral nutrition (Festin, 2009; Reichmann & Kirkbride, 2008).

s. Evaluate for risk factors for postoperative nausea and vomiting (PONV). Strong evidence suggests that client-related risk factors such as female gender, history of PONV, history of motion sickness, nonsmoking behavior, and environmental risk factors such as postoperative opioid use, emetogenic surgery (type and duration), and volatile anesthetics may increase the risk for PONV. Prolonged NPO status, more than 6 hours, has been associated with postop nausea (Makic, 2011). It is important to determine this risk in the preoperative period, to better plan interventions (Ignoffo, 2009).

s. Medicate the client prophylactically for nausea as ordered, throughout the period of risk. EB: Antiemetic medications can reduce the incidence of PONV, and use of combination treatment such as 5-HT₃ antagonist plus dexamethasone is more effective than monotherapy (Ignoffo, 2009).

s. Alleviate postoperative pain using ordered analgesic agents (refer to care plan for Acute Pain). Pain is known to be a factor in the development of PONV.

• Consider the use of nonpharmacological techniques, such as P6 acupoint stimulation, as an adjunct for controlling PONV, which has been shown to be effective. EB: Acupuncture and acustimulation have been studied with the most consistent results, similarly effective across methods of stimulation (acupuncture or noninvasive with acupressure or wrist-like electrical stimulation) (Kranke & Eberhart, 2011; Lee & Fan, 2009).

• Use of therapeutic suggestions and ginger may not work as effectively in postdischarge nausea and vomiting (PDNV) (Kranke & Eberhart, 2011).

• Include client education on the management of PONV for all outpatients and discuss key assessment criteria (Ignoffo, 2009).

• Perform risk assessment prior to chemotherapy administration. Risk factors include female gender, younger age, history of low alcohol consumption, history of morning sickness during pregnancy, anxiety, previous history of chemotherapy, client expectancy of nausea, and emetic potential of the regimen. It is important to recognize the many risk factors individual clients may have and tailor the antiemetic strategy accordingly. Far too often, the degree of N&V is underestimated by health care providers (Hawkins & Grunberg, 2009).

s. Consult with physician regarding antiemetic strategy, either prophylactic or when N&V occurs. Preventing N&V is important; one failure in antiemetic therapy can result in anticipatory nausea for the remainder of the client’s treatments, and interventions are less likely to be effective (Hawkins & Grunberg, 2009; Ryan, 2010).

• Consider teaching your client to learn how to use acupressure for nausea, applying pressure bilaterally at P6 points using fingers or bands to decrease the amount and severity of nausea. EBN & EB: Finger acupressure can be effective to relieve chemotherapy-induced nausea (Lee et al, 2008). Use of acupressure bands yielded negative results (Lee et al, 2008). Research supports the use of acupressure as an adjunct to pharmacological interventions. Acupressure is a safe, inexpensive, noninvasive technique that has promise for CINV (Lee et al, 2008).

s. Consider the use of ginger root (Zingiber officinale) to relieve nausea. EB: A large study showed that three different daily doses of ginger in capsules with liquefied ginger reduced acute CINV, compared to placebo. In this study clients began the ginger 3 days before chemotherapy and took the ginger in combination with the standard 5-HT₃ antagonist antiemetic and dexamethasone (Ryan et al, 2009).

• Consider massage for symptom relief of nausea. EB, EBN, & CEB: Two systematic reviews of massage in cancer clients show suggestion of benefit in the reduction of nausea; however, the variability of areas massaged and the poor quality of studies make it difficult to draw definitive conclusions (Ernst, 2009; Wilkinson, Barnes, & Storey, 2008). An additional small RCT showed significant reduction in nausea, compared to control (Billhult, et al, 2007).

• Consider the use of yoga for CINV. CEB: A small study in breast cancer clients showed a significant decrease in postchemotherapy nausea frequency, nausea intensity, and intensity of anticipatory N&V compared to a control group. This may be a possible stress-reduction technique in conjunction with antiemetics to decrease CINV (Raghavendra et al, 2007).

Geriatric:

Pediatric:

Home Care:

Client/Family Teaching and Discharge Planning:

• Explain how to eat according to the U.S. Dietary Guidelines

• Design dietary modifications to meet individual long-term goal of health, using principles of variety, balance, and moderation

• Maintain weight within normal range for height and age

• Encourage the client to decrease intake of sugars, including intake of soft drinks, desserts, and candy. Limit sugar intake to 6.5 teaspoons of added sugars for women and 9.5 teaspoons of added sugar for men daily.

• Share with client the names of sugars include glucose, dextrose, corn syrup, maple syrup, brown sugar, molasses, evaporated cane juice, sucrose, honey, orange juice concentrate, grape juice concentrate, apple juice concentrate, brown rice syrup, high-fructose corn syrup, agave, and fructose (Nutrition Action, 2012). Sugar predisposes to type 2 diabetes, heart disease, high blood pressure, high triglycerides, gout, and weight gain. EB: Studies comparing sugary and diet drinks demonstrated that sugary drinks increase visceral fat which expands waistlines and drives insulin resistance, predisposing to type 2 diabetes and heart disease (Hu & Malik, 2010; Odegaard et al, 2012).

• Limit intake of fruit juice to 1 cup per day. EB: Studies have shown that people who drank more fruit juice had a greater risk of type 2 diabetes or weight gain (Odegaard et al, 2010; Pan et al, 2012).

• Recommend the client eat whole grains whenever possible, and explain how to find whole grains using the food label. EB: A review of studies found strong evidence that eating whole grains is associated with a decreased BMI and reduced the risk of being overweight (Williams, Grafenauer, & O’Shea, 2008). Intake of whole grains has been shown to decrease the incidence of heart failure (Nettleton et al, 2008) and, when eaten with other healthier foods, resulted in lower incidence of diabetes in a multiethnic study (Nettleton et al, 2008).

• Evaluate the client’s usual intake of fiber. Recommended intake is 25 g per day for women and 38 g per day for men. Increase intake of whole grains, beans, fruits, and vegetables to obtain needed fiber. Wheat bran is an excellent source of fiber, but cannot be tolerated by all people; beans are the second-best source of fiber (Nutrition Action, 2011). In general, high-fiber foods take longer to eat, increase satiety, and contain fewer calories than most other foods (Slavin, 2008).

• Recommend the client eat five to nine fruits and vegetables per day, with a minimum of two servings of fruit and three servings of vegetables. Encourage client to eat a rainbow of fruits and vegetables because bright colors are associated with increased nutrients. Both fruits and vegetables are excellent sources of vitamins and also phytochemicals that help protect from disease, strokes, some kinds of cancer, and possibly macular degeneration (Liebman & Hurley, 2009). EB: A study done on older men found that if they ingested increased foods high in vitamin C, it resulted in decreased thickening of the carotid arteries (Ellingsen et al, 2009).

• Recommend the client limit intake of saturated fats and avoid trans fatty acids completely; instead increase intake of vegetable oils such as polyunsaturated and monounsaturated oils. EB: A Cochrane study showed that decreasing intake of saturated fats, replacing them with unsaturated oils, was effective in decreasing cardiovascular risk (Hooper, 2001). Intake of both saturated fat and trans fatty acids raises the low-density lipoprotein (LDL) level, which predisposes to atherosclerosis with cardiovascular disease (Zelman, 2011).

• Recommend client use low-fat choices when selecting and cooking meat, and also when selecting dairy products.

• Recommend that the client eat cold-water fish such as salmon, tuna, or mackerel at least two times per week to ensure adequate intake of omega-3 fatty acids. If unwilling to eat fish, suggest sources such as flaxseed, soy, or walnuts. Note: Fish oil capsules should be taken cautiously; some brands can be contaminated with mercury or pesticides. Intake of excessive omega-3 fatty acids can result in bleeding. Ingestion of omega-3 fats results in lower triglycerides and total cholesterol and also decreases the risk of heart disease and stroke (Neville, 2009). CEB: The intake of omega-3 fatty acids by eating fish or fish oil capsules results in decreased incidence of sudden cardiac death (von Schacky, 2007).

• Recommend the client decrease intake of red meat and processed meats, instead eat more poultry, fish, soy, and dairy sources of protein. EB: Red and processed meat intakes were associated with increases in mortality for cancer, and cardiovascular disease (Sinha et al, 2009).

• Recommend the client eat meatless meals at intervals and try alternative sources of protein, including nuts, especially almonds (one handful), and nut butters. EB: Consumption of nuts and peanut butter was shown to decrease the incidence of cardiovascular disease in women with type 2 diabetes (Li et al, 2009). A study found that diabetic people who ate walnuts regularly had improved endothelial function, and healthier blood vessels, and also lower low-density lipoproteins and total cholesterol (Ma et al, 2010).

• Recommend the client eat beans and soy as an alternative to animal proteins at intervals. Introduce the client to soy products such as flavored soy milk and tofu. Note: Women with diagnosed estrogen-dependent cancer of the breast should generally avoid eating soy foods. EB: Research has shown that intake of soy foods as a child may cut the incidence of breast cancer by half, and may protect women from breast cancer in a Chinese study, but further research is needed (Welland, 2007).

• Recommend the client choose and prepare foods with less salt, aiming for a maximum of 2,300 mg per day (Harvard Health Letter, 2012). The CDC (2009) recommends that all salt-sensitive Americans, including everyone 40 years or older, should decrease daily sodium intake. EB: A study found that decreased sodium intake helped lower blood pressure, as well as increase flexibility in blood vessels, improving the health of the blood vessels (CDC, 2009).

• If the client drinks alcohol, encourage him or her to drink in moderation—no more than one drink per day for women and two drinks per day for men. EB: A study found an increased incidence of cancer of the upper gastrointestinal tract, liver cancer, and also renal cancer (Thygesen et al, 2009).

• Recommend client increase intake of water, to at least 2000 mL or 2 quarts per day. A guideline is 1 to 1.5 mL of fluid for each calorie needed, so an average intake would be between 2000 and 3000 mL/day, or at least 8 cups of fluid. EB: The adequate intake recommendation is 3 L for the 19- to 30-year-old male and 2.2 L for the 19- to 30-year-old female. Water balance studies suggest that adult men require 2.5 L per day (Institute of Medicine, 2004).

• Recommend that clients utilize dietary supplements such as vitamins and minerals only after consulting with their primary care practitioner (Mayo Clinic Health Letter, 2012). EB: A large study performed on women found that those who took more supplements had an increased risk of death, especially with intake of multivitamins, vitamin B₆, folic acid, iron, magnesium, zinc, and copper. Calcium seemed to decrease the risk of death (Mursu et al, 2011). CEB: A review of 14 randomized trials demonstrated that intake of antioxidant supplementation did not prevent gastrointestinal (GI) cancers, and intake seemed to increase mortality (Bjelakovic et al, 2004).

Pediatric:

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