Nursing Management of the Postoperative Patient Experiencing Nausea

Nursing Management of the Postoperative Patient Experiencing Nausea and Vomiting Lynn Gettrust BSN, RN Alverno College-MSN student Tutorial Project Spiritlynnrn@netscape. net

Using Tutorial �Use the navigation arrows at the bottom of a page to move between pages of the tutorial: �Clicking on sends you to the home page �Clicking on sends you to the next page �Clicking on sends you to the previous page

Home Page-Objectives � Click on the Emesis Basin to learn about a specific objective � At the end of the tutorial you will know the: Incidence of postoperative nausea and vomiting (PONV) � � Pathophysiologic process involved in the development of PONV � � Inflammation, stress response, and genetics in the development of PONV � Risk factors associated with the development of PONV � Potential complications of PONV � � Medical, nursing and complimentary treatments currently available to manage PONV � Case Study � References

Incidence �PONV occurs in 30% of patients overall, 70% of high risk patients �Patients prioritize vomiting as the top adverse reaction in anesthesia to avoid �PONV is unpleasant and associated with patient discomfort /dissatisfaction with their perioperative care � 30% of ambulatory patients experience post discharge nausea and vomiting (PDNV) Wender, 2009 All clipart from microsoft. com unless otherwise noted

Incidence �Financial Impact �Average of $618 per patient is incurred today from a single episode of PONV, even without unplanned admission �Consequences of unplanned admissions �Detract from goal-same day discharge �Inconvenience to patients/families �Results in lost wages/missed work time �Increases cost to hospital-additional drug treatment/nursing care Kloth, 2009

Let's Stop for a Review �Answer True or False to the following questions �Click on the correct answer 1. True or False-Patients prioritize vomiting as the top adverse reaction in anesthesia to avoid 2. True or False-PONV may result in unplanned hospital admission resulting in lost wages and missed work for patients

Pathophysiology �Definitions �Nausea is a: �Sensation associated with awareness/urge to vomit �Subjective, unpleasant feeling in upper stomach and/or back of throat �Patient descriptors-feel sick to my stomach, feel queasy, feel squeamish �Autonomic symptoms-pallor, diaphoresis, tachycardia, salivation ASPAN’S Evidence-Based Clinical Practice Guideline. PONV/PDNV-2006

Pathophysiology �Definition �Retching �Attempt to vomit without expelling any material �Involves labored spastic respiratory movements against a closed glottis with rhythmic contractions of the abdominal muscles, chest wall and diaphragm �Retching can occur without vomiting but normally generates enough pressure to produce vomiting �Patients describe this as dry heaves ASPAN’S Evidence –Based Clinical Practice Guideline. PONV/PDNV-2006

Pathophysiology �Definition �Vomiting �Forceful expulsion GI contents �Caused by powerful, sustained contractions abdominal/ chest wall musculature, accompanied by descent of diaphragm and opening of gastric cardia �Reflux activity not under voluntary control �Autonomic symptoms-pallor, tachycardia, diaphoresis �Patient descriptors-puking, throwing up, tossing my cookies, barfing ASPAN’S Evidence-Based Clinical Practice Guideline-PONV/PDNV 2006

Pathophysiology Muscular Contractions Associated with Nausea and Vomiting Copyright 2004, Amdipharm plc, All rights reserved

Pathophysiology �PONV is nausea or vomiting that occurs within the first 24 hour period after surgery � 3 phases �Early PONV-Occurs within first 2 -6 hours after surgery, often in PACU �Late PONV-Occurs in 6 -24 hour period after surgery, often after transfer to floor or unit �Delayed PONV-Occurs beyond 24 hours postoperatively in the inpatient setting ASPAN’S Evidence-Based Clinical Practice Guideline-PONV/PDNV-2006

Pathophysiology �Nausea and vomiting are protective reflexes �Physiologic protective mechanism, limits possibility of damage from ingested noxious agents by emptying contents of stomach and portions of small intestine �May represent a total body response to a multiplicity of causes including pregnancy, motion, drugs and surgery. www. nausea and vomiting co. uk 2004

Let's Stop for a Review �Answer True or False to the Following Questions �Click on the Correct Answer 1. True or False-Vomiting is a reflex activity under voluntary control 2. True or False-PONV is divided into three phases, early, late and delayed 3. True or False-Nausea and vomiting are physiologic protective mechanisms to limit damage from toxins

Pathophysiology Schematic representation of factors and body systems involved in nausea and vomiting process © Copyright 2004, Amdipharm plc. All rights reserved

Pathophysiology Vomiting Center controls act of vomiting-located in medulla oblongata of the brain Medulla is at base of brain, formed by enlarged top spinal cord MEDULLA www. anomalocaris. net Medulla contains cardiac, vasomotor and respiratory centers of brain Mattson-Porth, 2005

Pathophysiology Vomiting center- not a discrete anatomical site-represents nerve network that receives input from different areas in body Controls vomiting, when activated, sends signals to salivary, respiratory centers, pharynx, stomach/intestinal muscles Signals result in vomiting Wilhelm et al, 2007 Copyright 2004, Amdipharm plc. All rights reserved

Pathophysiology Nerve pathways: Input to vomiting center from body carried on afferent nerve pathways. Input from vomiting center to areas that initiate actual vomiting reflex carried on efferent nerve pathways. www. nlm. nih. gov www. nauseaandvomiting. co. uk 2004

Pathophysiology Chemoreceptor Trigger Zone located in fourth ventricle brain Chemoreceptorsensory nerve activated by chemical stimuli www. nauseaandvomiting. co. uk 2004 Copyright 2004, Amdipharm plc. All rights reserved

Pathophysiology � Chemoreceptor Trigger Zone (CTZ) � Located outside blood brain barrier � Major chemosensory organ for emesis-usually associated with chemically induced vomiting. � Blood-borne/cerebrospinal fluid toxins have easy access to CTZ. � CTZ can be affected by anesthetic agents/opioids � Provides input to vomiting center Di. Piro , 2005

Let's Stop for a Review �Answer True or False to the following questions �Click on the correct answer True or False-The vomiting center in the medulla controls the act of vomiting 2. True or False-A chemoreceptor is a sensory nerve activated by movement 3. True or False-The CTZ is outside the blood-brain barrier and is usually associated with chemically induced vomiting 1.

Pathophysiology Input to vomiting center: GI Tract Input comes from stomach, jejunum, ileum Input travels on visceral afferent vagus nerve www. nauseaandvomiting. co. uk 2004

Pathophysiology �Two types of receptors in the GI organs are involved in detecting vomiting producing stimuli �Mechanoreceptor �Sensory nerve in muscular wall gut-responds to mechanical stimulation �Examples-touch, pressure, muscular contractions �Tension receptors-send input to vomiting center in response to distention or contraction www. nauseaandvomiting. co. uk 2004 www. illustrationsof. com

Pathophysiology �Chemoreceptor �Sensory nerve cell activated by chemical stimuli �Located in mucosal layer of GI tract �Triggered by noxious substances in luminal environment �Respond to a variety of toxins �When toxins cause irritation to GI tract, information travels to CTZ and vomiting center which may initiate vomiting reflex. www. nauseaandvomiting. co. uk 2004

Pathophysiology Input to vomiting center: Cerebral cortex Layer of neurons and synapses (gray matter) on surface of cerebral hemispheres. Mattson-Porth, 2005

Pathophysiology �Cerebral Cortex �Function-to integrate higher mental functions, general movements, visceral functions, perception, speech and memory patterns. �Higher cortical effects can stimulate or suppress nausea and vomiting �Prefrontal cortex-responsible for planning, problem solving, intellectual insight, judgment, expression of emotion. May send input to vomiting center regarding past memories, fears, anticipation associated with vomiting. �Example-Patient arrives anxious and fearful , states “I always vomit after surgery. ” Mattson-Porth, 2005

Pathophysiology Parietal lobe Integrates/processes sensory information from various parts body In parietal lobe sensory experiences begin to form into cognitions experienced as thinking in frontal lobes Sensory input from nausea and vomiting integrated here. www. howstuffworks. com Mattson-Porth, 2005

Lets Stop for a Review �Answer True or False to the following questions �Click on the correct answer 1. True or False-A mechanoreceptor is a sensory nerve ending that responds to distention 2. True or False-Input to the CTZ and vomiting center is carried on visceral efferent nerve pathways 3. True or False-The parietal lobe integrates and processes sensory input

Pathophysiology Input to vomiting center: Vestibular apparatus Consists of peripheral apparatus and CNS connections Peripheral apparatus- 5 parts: three semicircular canals, a utricle and saccule Copyright © 1996 -2005, Web. MD, Inc. All rights reserved Mattson-Porth, 2005

Pathophysiology �Vestibular apparatus �Inner ear structures associated with balance/position sense-maintains head/body position through reflex control and stable visual field despite head movements �Vestibular nerve fibers carry information from inner ear to vestibular nuclei. �Vestibular nuclei has neurons that project to thalamus and temporal and sensory areas of parietal cortex. Mattson-Porth, 2005

Pathophysiology � Thalamic and cortical projections of vestibular apparatus provide basis for subjective experience of position/rotation/dizziness. � Vestibular system can stimulate PONV as a result of surgery involving middle ear or postoperative movement. � Sudden head movement after surgery, leads to vestibular disturbance, and increased incidence of PONV Mattson-Porth, 2005

Pathophysiology Neuromediators Neurotransmitters are chemical messenger molecules of nervous system. Neurotransmission involves development, storage, and release of a neurotransmitter; reaction of neurotransmitter with its receptor site, and termination of receptor action Di. Piro , 2005

Pathophysiology �Numerous neurotransmitters are located in vomiting center, CTZ, GI tract � Examples-cholinergic, histaminic, dopaminergic, opiate, serotonergic, neurokinin, benzodiazepine receptors � Emetic compounds (chemotherapy drugs, narcotics), theoretically trigger vomiting process through reaction of emetic compound with its receptor site � Effective antiemetics are able to block or antagonize emetogenic receptors Di. Piro , 2005

Chemoreceptor trigger zone and cerebral cortex Vestibular apparatus Visceral afferent nerves. GI tract Central vomiting center Salivary center Respiratory center VOMITING Pharyngeal/GI/ abdominal muscles Diagram representing nausea and vomiting pathways

Let's Stop for a Review �Answer True or False to the following questions �Click on the correct answer 1. True or False-The vestibular apparatus is the inner ear structures associated with balance/position sense 2. True or False-Neurotransmitters are the chemical messenger molecules of the nervous system 3. True or False-Neurotransmitters bind to receptor sites to trigger the vomiting process

Inflammation as a cause of PONV Causes of intraabdominal organ inflammation are multifactoral and may include irritation, infection, toxin exposures, and surgical procedures and anesthesia Mattson-Porth, 2005 http: //digestive. niddk. nih. gov

Inflammation �Anesthesia, surgery and PONV �Gastric inflation during mask ventilation may cause PONV by producing gaseous distention of stomach/ upper small intestine �Nitrous oxide gas diffusion into spaces of intestinal wall worsens distention �Surgical procedures may produce gastric inflammationi. e. gastric resection. �Inflammation activates mechanoreceptors which send afferent signals to vomiting center via vagus nerve Rahman et al, 2004

Stress Response The corticotropin-releasing factor system Integrator of CNS response to stress/negative emotion Hypothalamus controls release of CRH When released during stress, increases transit through large bowel/delays gastric emptying which may produce PONV Larzelere, 2008

Stress �Activities of brain and gut are highly interrelated, which accounts for high prevalence of GI symptoms reported by patients in response to stress �Stress may be psychological � Psychological stress may be manifested prior to surgery in nervous patient who is already experiencing a queasy stomach � GI difficulty can impact mood, behavior, and pain responsiveness Larzelere, 2008

Stress �Stress may be physical �Surgical trauma stimulates the release of CRH �Increased cytokine production, as a result of stress, can produce similar physiologic effects (delayed gastric emptying/increased colonic motility) �Minimally invasive surgery reduces wound size and thereby decreases the undesirable inflammatory response, pain and catabolism Larzelere, 2008

Let's Stop for a Review � Answer True or False to the following questions � Click on the correct answer 1. True or False-Mask ventilation may cause PONV by creating gastric and upper intestinal inflammation 2. True or False- The medulla controls the release of CRH, which, when released during stress increases transit through the bowel and delays gastric emptying. 3. True or False-Minimally invasive surgery reduces wound size and decreases the undesirable inflammatory response

Genetics � There are genetic differences in how drugs are metabolized � Genetic information is stored in the structure of DNA � Errors in duplication of DNA may occur producing a mutation � Somatic mutation affects a group of cells that differentiate into one or more of many tissues of body � Somatic mutations that do not have an impact on health or functioning are called polymorphisms Mattson-Porth, 2005

Genetics � Majority of drugs are metabolized via microsomal enzymes localized in liver, and to a lesser extent, small intestine � Activity of many drugs depends on their interaction with enzymes of P 450 (CYP) system � More than 5 o human CYP isozymes have been identified, CYP 2 D 6 is best characterized isozyme � CYP 2 D 6 metabolizes approximately 25% of all clinically used medication, including antiemetics � Genetic polymorphisms in drug-metabolizing enzymes are a major cause of variability in drug metabolism leading to adverse effects or lack of therapeutic effect Bernard, 2006

Risk Factors �Primary purpose of risk factor identification in preoperative period is to determine potential risk of a patient developing PONV or PDNV �Risk factor tools have been developed to identify patients at high risk for PONV �The simplified tools provide better discrimination and calibration for prediction of PONV ASPAN’S Evidence-Based Clinical Practice Guideline-PONV/PDNV 2006

Risk factors � 1 -2 risk factors=20 -40% risk of developing PONV � 3 -4 risk factors increase number of patients with PONV to 60 -80% � Patients with 20% or greater risk of developing PONV should be considered high risk and treated prophylactically � Appropriate PONV prophylaxis should reduce need for postoperative treatment and reduce length of stay in Kapoor, 2008 PACU

Risk Factors � The following risk factors are supported by strong evidence in literature � Female-two-four fold higher incidence of PONV compared to males � History PONV and motion sickness-doubles risk � Nonsmoker-doubles risk � Postoperative opioids-doubles risk � Volatile Anesthetics � Nitrous Oxide ASPAN’S Evidence-Based Clinical Practice Guideline. PONV/PDNV-2006

Risk Factors �A risk factor that is supported by conflicting evidence in the literature is the type of surgery �Risk factors increase with abdominal, gynecologic, orthopedic, ENT surgery �Laparoscopic surgery increases risk because of gas insufflated into abdomen or pelvis �Intubation increases risk due to pharyngeal mechanoreceptor afferent stimulation Wender, 2009

Complications � PONV is a significant concern because � It exacerbates patient discomfort � Increases risk for suture dehiscence, esophageal rupture, aspiration and subcutaneous emphysema � Prolonged postoperative hospital stays � Delayed return of patient functional ability � Need for additional drug treatment and nursing care increases cost of care Kapoor, 2008

Let's Stop for a Review � Answer True or False to the following questions � Click on the correct answer 1. True or False-Genetic polymorphisms may exist in the enzymes that metabolize medications leading to adverse effects (such as PONV) or lack of drug effectiveness 2. True or False-The primary purpose of risk factor identification preop is to determine the risk for PONV 3. True or False-PONV increases patient discomfort, prolongs stay and delays return to patient functional ability

You are correct, polymorphisms are interesting, don’t you agree? Click to go back

Medical Management 8 classifications of medication to treat PONV Classification Generic Brand Phenothiazine Procholoroperazine Compazine Anticholinergic Scopolamine Isopto Hyoscine Antihistamine Promethazine Phenergan Butyrophenones Droperidol Inapsine Benzamides Metoclopromide Reglan Corticosteroids Dexamethasone Decadron 5 -HT 3 receptor antagonists Ondansetron Zofran NK 1 receptor antagonists Aprepitant Rahman, 2004 Emend

Medication Pathways �Target neurotransmitter-receptor sites in brain and peripherally �Anti-emetic may target single or multiple receptors �Each pathway functions independently providing an opportunity to treat PONV �When therapies from multiple drug classes are combined, targeting multiple receptor systems, increase in antiemetic efficacy is generally observed. Ignoffo, 2009

Medication Pathway-Compazine Phenothiazines Mainly block dopamine/5 HT 3 receptors in CTZ Act against agents that directly stimulate CTZ (opioids/general anesthesia) Active against emetic stimuli from GI tract Copyright 2004, Amdipharm plc. All rights reserved Rahman, 2004

Medication Pathway-Isopto Hyoscine Anticholinergics Block action of acetylcholine at muscarinic receptors in vestibular system Reduces gastric motility/afferent stimulation of vomiting center Copyright 2004, Amdipharm plc. All rights reserved

Medication Pathway-Phenergan Antihistamines Block acetylcholine action in vestibular apparatus Less effect on vomiting induced by direct stimulation CTZ Rahman, 2004 Copyright 2004, Amdipharm plc. All rights reserved

Medication Pathway-Inapsine Butyrophenones Block dopamine receptors in CTZ Similar properties to phenothiazines *Droperidol-monitored patients only(potential prolong cardiac QT interval) Copyright 2004, Amdipharm plc. All rights reserved Rahman, 2004

Medication Pathway-Reglan Benzamides Block dopamine receptors in CTZ Block peripheral dopamine receptorsenhanced gastric/upper intestinal motility Rahman, 2004 Copyright 2004, Amdipharm plc. All rights reserved

Medication Pathway-Decadron Corticosteroids Precise mechanism of action unknown Effects thought to be mediated by antiinflammatory/ membrane stabilizing activities peripherally and centrally Kloth, 2009 Copyright 2004, Amdipharm plc. All rights reserved

Medication Pathway-Zofran 5 HT 3 receptor antagonists Block 5 HT 3 receptors Peripherally in gut (vagal afferent nerves) Centrally in CTZ Rahman, 2004 Copyright 2004, Amdipharm plc. All rights reserved

Medication Pathway-Emend Neurokinin-1 receptor antagonists Block substance P (neurotransmitter) at neurokinin-1 receptors Vomiting center and CTZ Rahman, 2004 Copyright 2004, Amdipharm plc. All rights reserved

Let's Stop for a Review � Answer True or False to the following questions � Click on the correct answer 1. True or False-There are four classifications of medication to treat PONV 2. True or False-Medications target receptors peripherally and centrally and some target more than one site 3. True or False-PONV is decreased by combining medications that target multiple receptors

Medical Management �Fluid abnormalities may be multifactoral �Preoperative fasting �Surgical preps (bowel preps) �Administration/management anesthesia �Surgical procedure/associated fluid losses Noble, 2008

Medical Management �IV fluid therapy �Perioperative fluid administration of greater than 1 L improves recovery after minor to moderate operations �Data does not support choice of one fluid over another �IV fluid generally reduced postoperative drowsiness/dizziness �Be cautious-vulnerable patients-fluid volume overload! Holte, 2006

Nursing Management �Nursing diagnosis-Nausea �Outcome- Improve or maintain hydration �Intervention-Manage fluid/electrolyte balance �Nursing activities �Promote oral intake in absence N/V �Set appropriate IV rate, (consider current IV fluid intake, patient comorbidities) �Keep accurate record I/O �Monitor S/S fluid retention (monitor lab values) �Monitor vital signs �Assess buccal membranes, sclera, skin indications altered fluid/electrolyte balance Bulechek, 2008 Moorhead, 2008

Nursing Management �Nursing diagnosis-Nausea �Outcome-control of nausea and vomiting �Intervention-nausea and vomiting management �Nursing activities �Identify risk factors N/V pre and postoperatively �Evaluate past experiences with nausea �Complete assessment N/V –frequency, duration, severity, precipitating factors (use tool, i. e. Rhodes Index of N/V) Bulechek, 2008 Moorhead, 2008

Nursing Management �Nursing Activities (interrelate with pathophysiology) �Cerebral cortex �Control environmental factors –aversive smells, sounds, unpleasant visual stimulation �Reduce/eliminate personal factors that precipitate or increase nausea/vomiting (anxiety, fear, fatigue, lack of knowledge) �Oral hygiene to promote comfort with nausea/following emesis �Clean up after emesis with special attention to removing odors �Teach use of nonpharmacologic techniques (guided imagery) Bulechek, 2008

Nursing Management �Nursing Activities �GI tract �Position to prevent aspiration/maintain airway �Provide physical support during vomiting (assist person to bend over or support person’s head) �Wait at least 30 minutes after emesis, start with fluids that are clear/free of carbonation-gradually increase fluids if no vomiting in 30 minute period �Monitor for damage esophagus/posterior pharynx from prolonged retching/vomiting �Ensure effective antiemetics given to prevent N/V- monitor effects vomiting management throughout Bulechek, 2008

Nursing Management �Nursing Diagnosis-Surgery recovery delayed �Outcome-decreasing the severity of nausea and vomiting �Interventions-managing nausea and vomiting �Nursing activities �All activities as listed for nausea and vomiting management (please review content as needed) Bulechek, 2008 Moorhead, 2008

ASPAN algorithm for PONV �American Society of Perianesthesia Nurses developed clinical practice guidelines in 2006 � 16 multispecialty, multidisciplinary experts reviewed/analyzed published data and developed a consensus for clinical practice recommendations �Algorithms developed for prevention and/or management of PONV/PDNV ASPAN’S Evidence-Based Clinical Practice Guideline -PONV/PDNV-2006

*ASPAN=American Society of Perianesthesia Nurses ASPAN’s Evidence-based Clinical Practice Guideline for the Prevention and/or Management of PONV/PDNVr((2006) Journal of Peri. Anesthesia Nursing, 21(4), pp 230 -250

Let's Stop for a Review � Answer True or False to the following questions � Click on the correct answer 1. True or False-Perioperative fluid administration of greater than 1 L improves recovery after minor to moderate operations 2. True or False-Reducing or eliminating personal factors (fear/anxiety) that may increase N/V targets the cerebral cortex 3. True or False-After an emesis it is important to wait 30 minutes before offering liquids that are clear and free of carbonation

Complimentary Treatments �Music therapy-Application of music to influence physical, mental, emotional functioning. Often used with behavioral techniques �Relaxation-Progressive muscle relaxation to establish a deep state of relaxation. Focused breathing often used with this technique �Guided imagery-Form a relaxing and pleasing mental image, often proceeded by relaxation, used with music Quinn, 2004

Complimentary Treatments � Distraction-Focus attention on activity unrelated to N/V � Aromatherapy-Use of essential oils combined in a carrier cream. Used with massage � Acupressure-Application of digital pressure or acustimulation bands in a specific way on designated points on body. � Used to correct imbalances by stimulating/easing energy flow � P 6 -most common/easily accessible-three finger-widths from wrist crease ASPAN’S Evidence-Based Clinical Practice Guideline-PONV/PDNV-2006 Nunley, 2008

Future Trends �Novel drugs created which target existing receptors, but have sufficiently different pharmacological properties and different clinical behaviors �Standardization of care for managing PONV/PDNV �More research related to PDNV-Introduction of new prophylactic modalities that outlast range of traditional antiemetics Wender, 2009

Case Study Melissa is a 34 year old female that came to the ER with abdominal pain/fever/N/V CT scan-indicated acute appendicitis Transferred to day surgery-prepped for laparoscopic appendectomy. To be seen by anesthesiologist prior to surgery Pt data. Surgery in past without N/V History of motion sickness Denies history of heart disease, kidney disease, diabetes or lung disease

Case Study Click on arrow below question when you are ready for answer 1. What are Melissa’s identified risk factors for PONV? Female and positive history motion sickness 2. Is it appropriate to premedicate Melissa to prevent PONV? Yes. Dr Green gives the nurse an order to apply a scopalamine patch and give Pepcid 20 mg IVP

Case Study Melissa arrives in PACU following surgery. It was discovered that her appendix was ruptured, will need to be admitted for IV antibiotics. In surgery, received IV propofol for anesthesia, fentanyl for pain and zofran. EBL minimal, IV intake 500 cc Awakens complaining of pain in her abdomen level 8/10(0 being no pain, 10 worst pain imaginable) PACU nurse gives her 10 mg morphine-pain to level 4/10 and infuses additional 200 cc IV fluid PACU nurse calls report to floor-vital signs stable, dressings intact, patient is sleepy, awakens easy, denies nausea

Case Study Click on arrow below question when you are ready for answer 1. Would it be appropriate in PACU to provide an additional antiemetic? Yes, opioids are a risk for PONV, patient received 10 mg morphine in PACU 2. Could Melissa have received more IV fluids? Yes, she could have received 1 L of fluid perioperatively for a moderate operation in a healthy person

Case Study Melissa is transported to her fourth floor room Upon arrival, she is asked to slide from the cart onto the bed Once in bed, she complains of nausea and states “I’m going to throw –up” She is handed a basin and has a 100 cc emesis

Case Study Click on arrow below question when you are ready for answer 1. What would be your first steps in treating Melissa’s PONV? Determine what antiemetics she has already received (scopalamine and pepcid preop, zofran in OR) Based on physiology/pharmacology choose a medication that acts at a different receptor site from those already given Infuse IV fluids, and hang second bag

Case Study Click on arrow below question when you are ready for answer 1. Melissa is feeling better now, her nausea and vomiting have not recurred. How are fluids started and can additional antiemetics be given if needed? Wait 30 minutes after last emesis and then begin with sips of clear liquids that are free of carbonation If nausea and vomiting recur, additional antiemetics may be given targeting a different receptor site

Congratulations, you have completed the tutorial, give yourself a round of applause!!

References ASPAN. (2006). Evidence-Based Clinical Practice Guideline for the Prevention and/or Management of PONV/PDNV. Journal of Peri. Anethesia Nurses , 21 (4), pgs 230250. Bernard, S. N. (2006). Interethnic Differences in Genetic Polymorphism of CYP 2 D 6 in the US Population: Clinical Implications. The Oncologist , 11: pgs 126 -135. Bulechek, G. B. (2008). Nursing Interventions Classification (NIC). St Louis: Mosby Elsevier. Candiotti, K. B. (2005). The Impact of Pharmacogenics on Postoperative Nausea and Vomiting. Anesthesiology , 102 (3), pgs 543 -549. Di. Piro, J. T. (2005). Pharmacotherapy: A Pathophysiologic Approach. New York: Mc. Graw-Hill. Holte, K. (2006). Fluid Therapy and Surgical Outcomes in Elective Surgery: A Need for Reassessment in Fast-Track Surgery. Journal American College of Surgeons , 202 (6), pgs 971 -989. Ide, P. F. (2008). Perioperative Nursing Care of the Bariatric Surgical Patient. American Operating Room Nurse , 88 (1) pgs 30 -58. Ignoffo, R. (2008). Current research on PONV/PDNV: Practical implications for today's pharmacist. American Journal Health-System Pharmacy , 66(1) S 19 -24. Johnson, M. B. -D. (2006). NANDA, NOC, and NIC Linkages. St Louis: Mosby Elsevier

References Kapoor, R. H. (2008). Comparison of two instruments for assessing risk of postoperative nausea and vomiting. American Journal Health-System Pharmacy , 65: 448 -453. Kloth, D. (2009). New pharmacologic findings in the treatment of PONV and PDNV. American Journal Health-System Pharmacy , 65 (1) S 11 -18. Larzelere, M. J. (2008, july 11). Stress and Health. Retrieved February 23, 2009, from The Clinics: Primary Care: http: //primarycare. the clinics. com Mattson-Porth, C. (2005). Pathophysiology: Concepts of Altered Health States. Philadelphia: Lippincott Williams & Wilkins. Microsoft Clip Art Images. Retrieved March 15, 2009 from http: //office. microsoft. com/ en-us/tou. aspx Moorhead, S. J. (2008). Nursing Outcomes Classification (NOC). St Louis: Mosby Elsevier. Nausea and Vomiting-an introduction (2004). Retrieved March 15, 2009 from http: //www. nauseaandvomiting. co. uk Noble, K. (2008). Fluid and Electrolyte Imbalance: A Bridge Over Troubled Water. Journal of Peri. Anesthesia Nursing , 23 (4), pgs 267 -272. Noble, K. (2008). The Obesity Epidemic: The Impact of Obesity on the Peri. Anesthesia Patient. Journal of Peri. Anesthesia Nursing , 23 (6), pgs 418 -425. Nunley, C. W. (2008). The Effects of Stimulation of Acupressure Point P 6 on Postoperative Nausea and Vomiting: A Review of Literature. Journal of Peri. Anesthesia Nursing , 23 (4), pgs 247 -261. .

References Pavlin, J. (2008). Recovery after ambulatory anesthesia. Current opinion in Anaesthesiology, 21(6), pgs 729 -735. Quinn, D. (2004). Peri. Anesthesia Nursing Core Curriculum: Preoperative, Phase I and Phase II PACU Nursing. St Louis: Elsevier. Rahman, M. (2004). Post-operative nausea and vomiting. The pharmaceutical Journal, 273, pgs 786 -788. Stevenson, C. (2006, July 19). Drugs for preventing postoperative nausea and vomiting (Review). Retrieved February 23, 2009, from Cochrane Database of Systemic Reviews: http: //www. the cochranelibrary. com Villars, P. V. -M. (2008). Adaptation of the OODA Loop to Reduce Postoperative Nausea and Vomiting in a High-Risk Outpatient Oncology Population. Journal of Peri. Anesthesia Nursing , 23 (2) pgs 78 -86. Wender, R. (2009). Do current antiemetic practices result in positive patient outcomes? Results of a new study. American Journal Health System Pharmacy , 6 (1) S 3 -10. Wilhelm, S. D. -S. -P. (2007, march 21). Prevention of Postoperative Nausea and Vomiting. Retrieved march 4, 2009, from Medscape: http: //www. medscape. com