Focus on Nausea and Vomiting Relates to Chapter

Nausea and Vomiting Most common manifestations of GI diseases Nausea § Feeling of discomfort

Nausea and Vomiting § Forceful ejection of partially digested food and secretions (emesis) from

Etiology and Pathophysiology Occurs from § GI disorders § Pregnancy § Infectious diseases §

Etiology and Pathophysiology Nausea § Usually occurs before vomiting § Related to slowing of

Stimuli Involved in Vomiting Fig. 42 -1. Stimuli involved in the act of vomiting.

Etiology and Pathophysiology Chemoreceptor trigger zone (CTZ) § Responds to chemical stimuli of drugs

Etiology and Pathophysiology Vomiting also can occur when the GI tract becomes irritated, excited,

Etiology and Pathophysiology Before act of vomiting, person becomes aware of the need. Autonomic

Etiology and Pathophysiology Parasympathetic stimulation § Relaxes lower esophageal sphincter § Increase in gastric

Clinical Manifestations Nausea § Subjective complaint § Usually accompanied by anorexia Vomiting § Dehydration

Clinical Manifestations Vomiting (cont’d) § Metabolic alkalosis—from loss of gastric HCl § Metabolic acidosis—from

Collaborative Care Determine underlying cause and treat § Careful history When vomiting occurs Precipitating

Collaborative Care Regurgitation § Partially digested food slowly brought up into stomach Projectile vomiting

Collaborative Care Fecal odor and bile indicate a lower intestinal obstruction. Color of emesis

Collaborative Care Drug therapy § Drug therapy depends on cause of problem. § Antiemetics

Collaborative Care Drug therapy (cont’d) § Examples Anticholinergics Scopolamine transdermal (Transderm-Scop) Antihistamines Dimenhydrinate (Dramamine)

Collaborative Care Drug therapy (cont’d) § Examples (cont’d) Phenothiazines Prochlorperazine (Compazine) Chlorpromazine (Thorazine) Copyright

Collaborative Care Drug therapy (cont’d) § Common side effects include Dry mouth Hypotension Sedative

Collaborative Care Drug therapy (cont’d) § Other drugs with antiemetic properties Benzamides Metoclopramide diskinesia.

Collaborative Care Nondrug therapy § Acupuncture § Acupressure § Botanicals Ginger Peppermint oil §

Collaborative Care Nutritional therapy § IV fluids to replace fluids and electrolytes, glucose §

Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 23

Collaborative Care Nutritional therapy (cont’d) Room-temperature carbonated beverages without carbonation okay Warm tea May

Collaborative Care § Use Gatorade, broth with caution because of high salt intake. §

Collaborative Care Nutritional therapy (cont’d) § Fluids between meals instead of with meals—to avoid

Nursing Management Assessment All patients with history of prolonged N/V require a thorough assessment.

Nursing Management Nursing Diagnoses Nausea Deficient fluid volume Imbalanced nutrition: Less than body requirements

Nursing Management Planning Patient goals § Experience minimal or no nausea and vomiting. §

Nursing Management Implementation Acute intervention § Usually managed at home § Persistent vomiting—hospitalization with

Nursing Management Implementation Acute intervention (cont’d) § NG tube may be used for possible

Nursing Management Implementation Ambulatory and home care § Education—patient/family How to manage sensation of

Nursing Management Implementation Keep environment quiet, well ventilated, free of noxious odors. Avoid sudden

Nursing Management Evaluation Expected outcomes § Be comfortable with minimal or no nausea and

Nursing Management Gerontologic Considerations More likely to have cardiac or renal insufficiency § Increased

Audience Response Question A patient with persistent vomiting of 3 days’ duration is seen

Case Study Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier

Case Study A young woman calls a triage hotline complaining of severe nausea for

Case Study She states her temperature is “a little higher than normal” at 99.

Discussion Questions 1. What other information should you obtain from her? 2. What remedies

Discussion Questions 3. If she started vomiting, would you change your advice? Copyright ©

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Nausea and Vomiting Most common manifestations of GI diseases Nausea § Feeling of discomfort in the epigastric area with a conscious desire to vomit Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 2

Nausea and Vomiting § Forceful ejection of partially digested food and secretions (emesis) from the upper GI tract § Complex act requiring coordination of several structures Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 3

Etiology and Pathophysiology Occurs from § GI disorders § Pregnancy § Infectious diseases § CNS disorders § Cardiovascular problems § Metabolic disorders : DM, addisons disease, renal failure § Side effects of drugs: chemo, opioids, digitalis Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 4

Etiology and Pathophysiology Nausea § Usually occurs before vomiting § Related to slowing of gastric motility and emptying Vomiting center in the brainstem § Coordinates events related to vomiting § Receives input from various stimuli Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 5

Stimuli Involved in Vomiting Fig. 42 -1. Stimuli involved in the act of vomiting. CTZ, Chemoreceptor trigger zone; GI, gastrointestinal. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 6

Etiology and Pathophysiology Chemoreceptor trigger zone (CTZ) § Responds to chemical stimuli of drugs and toxins § Located in the fourth ventricle § Site of action of drugs used to induce vomiting : Ipecac § Plays a role in vomiting due to labyrinthine stimulation : motion sickness. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 7

Etiology and Pathophysiology Vomiting also can occur when the GI tract becomes irritated, excited, or distended. Vomiting can be a protective mechanism. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 8

Etiology and Pathophysiology Before act of vomiting, person becomes aware of the need. Autonomic nervous system activated —stimulating SNS and PNS Sympathetic activation—tachycardia, tachypnea, and diaphoresis Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 9

Etiology and Pathophysiology Parasympathetic stimulation § Relaxes lower esophageal sphincter § Increase in gastric motility and salivation Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 10

Clinical Manifestations Nausea § Subjective complaint § Usually accompanied by anorexia Vomiting § Dehydration can rapidly occur when prolonged. § Water and essential electrolytes are lost. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 11

Clinical Manifestations Vomiting (cont’d) § Metabolic alkalosis—from loss of gastric HCl § Metabolic acidosis—from loss of bicarbonate if the contents from the small intestine are vomited Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 12

Collaborative Care Determine underlying cause and treat § Careful history When vomiting occurs Precipitating factors Contents of emesis Differentiate among vomiting, regurgitation, and projectile vomiting Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 13

Collaborative Care Regurgitation § Partially digested food slowly brought up into stomach Projectile vomiting § Forceful expulsion of stomach contents without nausea Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 14

Collaborative Care Fecal odor and bile indicate a lower intestinal obstruction. Color of emesis aids in determining presence and source, if bleeding. Time of day occurring : pregnancy Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 15

Collaborative Care Drug therapy § Drug therapy depends on cause of problem. § Antiemetics act on CNS in CTZ to block chemicals that trigger nausea and vomiting. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 16

Collaborative Care Drug therapy (cont’d) § Examples Anticholinergics Scopolamine transdermal (Transderm-Scop) Antihistamines Dimenhydrinate (Dramamine) Promethazine (Phenergan) Meclizine (Antivert) Hydroxyzine (Vistaril) Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 17

Collaborative Care Drug therapy (cont’d) § Examples (cont’d) Phenothiazines Prochlorperazine (Compazine) Chlorpromazine (Thorazine) Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 18

Collaborative Care Drug therapy (cont’d) § Common side effects include Dry mouth Hypotension Sedative effects Rashes GI disturbances Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 19

Collaborative Care Drug therapy (cont’d) § Other drugs with antiemetic properties Benzamides Metoclopramide diskinesia. Prokinetic (Reglan) : may cause tardive drug—increases gastric emptying Serotonin antagonists Ondansetron (Zofran) Management for chemotherapy-induced emesis Dexamethasone (Decadron) Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 20

Collaborative Care Nutritional therapy § IV fluids to replace fluids and electrolytes, glucose § NG tube suction to decompress stomach § Clear liquids started first 5 to 15 m. L fluid every 15 to 20 minutes No extremely hot/cold liquids Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 22

Collaborative Care Nutritional therapy (cont’d) Room-temperature carbonated beverages without carbonation okay Warm tea May advance to dry toast, crackers Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 24

Collaborative Care § Use Gatorade, broth with caution because of high salt intake. § Advance to high carbohydrate, low fat next, because it is easier to digest. Baked potato, plain gelatin, cereal with milk § Eat slowly and in small amounts. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 25

Collaborative Care Nutritional therapy (cont’d) § Fluids between meals instead of with meals—to avoid overdistention § Dietitian may be helpful with appropriate foods with adequate nutritional value. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 26

Nursing Management Assessment All patients with history of prolonged N/V require a thorough assessment. Need basic understanding of common causes Table 42 -2 presents data to be obtained from patient. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 27

Nursing Management Planning Patient goals § Experience minimal or no nausea and vomiting. § Have normal electrolyte levels and hydration status. § Return to a normal pattern of fluid balance and nutrient intake. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 29

Nursing Management Implementation Acute intervention § Usually managed at home § Persistent vomiting—hospitalization with IV fluids and NPO status Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 30

Nursing Management Implementation Acute intervention (cont’d) § NG tube may be used for possible obstruction. § Record I & O. § Monitor VS. § Assess for dehydration. § Maintain quiet, odor-free environment. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 31

Nursing Management Implementation Ambulatory and home care § Education—patient/family How to manage sensation of nausea Methods of preventing nausea/vomiting Strategies to maintain fluid/nutritional intake Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 32

Nursing Management Implementation Keep environment quiet, well ventilated, free of noxious odors. Avoid sudden changes in position/activity. Use relaxation techniques. Cleanse face/hands with a cool washcloth. Provide mouth care between episodes. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 33

Nursing Management Evaluation Expected outcomes § Be comfortable with minimal or no nausea and vomiting. § Maintain body weight. § Have electrolyte levels within normal range. § Be able to maintain adequate intake of fluids and nutrients. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 34

Nursing Management Gerontologic Considerations More likely to have cardiac or renal insufficiency § Increased risk for life-threatening fluid/electrolyte imbalances Increased susceptibility to CNS side effects of antiemetic drugs Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 35

Audience Response Question A patient with persistent vomiting of 3 days’ duration is seen at the urgent care center because of increasing weakness. Intravenous therapy with lactated Ringer’s solution is started, and arterial blood gases (ABGs) are ordered. Which of the following ABGs results would the nurse expect? 1. p. H 7. 4; Pa. CO 2 40 mm Hg; HCO 3 - 25 m. Eq/L 2. p. H 7. 3; Pa. CO 2 50 mm Hg; HCO 3 - 20 m. Eq/L 3. p. H 7. 6; Pa. CO 2 30 mm Hg; HCO 3 - 40 m. Eq/L 4. p. H 7. 48; Pa. CO 2 40 mm Hg; HCO 3 - 30 m. Eq/L Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 36

Case Study A young woman calls a triage hotline complaining of severe nausea for the past 6 hours. She denies any emesis, but is unable to obtain any relief from her nausea. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 38

Discussion Questions 1. What other information should you obtain from her? 2. What remedies could she use to relieve her nausea? Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 40