Focus on Nausea and Vomiting (Relates to Chapter 42, “Nursing Management: Upper Gastrointestinal Problems,” in the textbook) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Nausea and Vomiting Vomiting Forceful ejection of partially digested food and secretions (emesis) from the upper GI tract Complex act requiring coordination of several structures Vomiting is a complex act that requires the coordinated activities of several structures: closure of the glottis, deep inspiration with contraction of the diaphragm in the inspiratory position, closure of the pylorus, relaxation of the stomach and lower esophageal sphincter, and contraction of the abdominal muscles with increasing intraabdominal pressure. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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 Psychologic factors: stress Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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 Neural impulses reach the vomiting center via afferent pathways through branches of the autonomic nervous system. Receptors for these afferent fibers are located in the GI tract, kidneys, heart, and uterus. When stimulated, these receptors relay information to the vomiting center, which then initiates the vomiting reflex. {See next slide for figure.} Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Stimuli Involved in Vomiting Stimuli involved in the act of vomiting. CTZ, Chemoreceptor trigger zone; GI, gastrointestinal. 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.

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.

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.

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.

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.

Clinical Manifestations Nausea Subjective complaint Usually accompanied by anorexia Vomiting Dehydration can rapidly occur when prolonged. Water and essential electrolytes are lost. As vomiting persists, severe electrolyte imbalances, loss of extracellular fluid volume, decreased plasma volume, and eventually circulatory failure may occur. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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 Metabolic acidosis is less common than metabolic alkalosis. The threat of pulmonary aspiration is a concern when vomiting occurs in elderly or unconscious patients, or in patients with other conditions that impair the gag reflex. To prevent aspiration, put the patient who cannot adequately manage self-care in a semi-Fowler’s or side-lying position. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Collaborative Care Determine underlying cause and treat Careful history When vomiting occurs Precipitating factors Contents of emesis Differentiate among vomiting, regurgitation, and projectile vomiting Women are more likely to suffer from nausea and vomiting associated with both surgical procedures and motion sickness. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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 Emesis containing partially digested food several hours after a meal is indicative of gastric outlet obstruction or delayed gastric emptying. Example: Vomitus with a “coffee ground” appearance is related to gastric bleeding, where blood changes to dark brown as a result of its interaction with HCl acid. Bright red blood indicates active bleeding. Example: Early-morning vomiting is a frequent occurrence in pregnancy. Emotional stressors with no evident pathologic disorder may elicit vomiting during or immediately after eating. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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. See Table 42-1 for drug information. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Collaborative Care Drug therapy (cont’d) Examples Anticholinergics Scopolamine transdermal (Transderm-Scop) Antihistamines Dimenhydrinate (Dramamine) Promethazine (Phenergan) Meclizine (Antivert) Hydroxyzine (Vistaril) Because many of these drugs have anticholinergic actions, they are contraindicated for the patient with glaucoma, prostatic hyperplasia, pyloric or bladder neck obstruction, or biliary obstruction. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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

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

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Collaborative Care Drug therapy (cont’d) Other drugs with antiemetic properties Benzamides Metoclopramide (Reglan) : may cause tardive diskinesia. Prokinetic drug—increases gastric emptying Serotonin antagonists Ondansetron (Zofran) Dexamethasone (Decadron) Management for chemotherapy-induced emesis Approximately 10% to 20% of patients taking metoclopramide experience CNS side effects ranging from anxiety to hallucinations. Extrapyramidal side effects including tremor and dyskinesias similar to Parkinson’s disease may also occur. Antagonists to specific serotonin (5-HT) receptors act centrally and peripherally to reduce nausea and vomiting. The 5-HT3 receptor antagonists are effective in reducing cancer chemotherapy-induced vomiting caused by delayed gastric emptying and also the nausea and vomiting related to migraine headache and anxiety. Dronabinol (Marinol) is an orally active cannabinoid that is used alone or in combination with other antiemetics for the prevention of chemotherapy-induced emesis. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Collaborative Care Nondrug therapy Acupuncture Acupressure Botanicals Ginger Peppermint oil Breathing exercises Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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 mL fluid every 15 to 20 minutes No extremely hot/cold liquids Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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

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

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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. Coffee, spicy foods, highly acidic foods, and those with strong odors are often poorly tolerated. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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

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.

Nursing Management Nursing Diagnoses Nausea Deficient fluid volume Imbalanced nutrition: Less than body requirements Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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.

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.

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. Until a diagnosis is confirmed, the patient is on nothing-by-mouth (NPO) status and is given IV fluids. An NG tube connected to suction may be necessary for the patient with persistent vomiting, as well as when a bowel obstruction or paralytic ileus is suspected. Secure the NG tube to prevent its movement in the nose and back of the throat because this can stimulate nausea and vomiting. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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.

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. Use of relaxation techniques, frequent rest periods, effective pain management strategies, and diversional tactics also help to prevent nausea and vomiting. When symptoms occur, stop all foods and drugs until the acute phase is over. Some patients are reluctant to resume fluid intake because of fear that nausea will recur; they may need encouragement. You can suggest that it would be helpful to begin with clear liquids or cola beverages, Gatorade, tea or broth, dry crackers or toast, and then plain gelatin. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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.

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 Excessive replacement of fluid and electrolytes may result in adverse consequences for the person who has heart failure or renal disease. The older adult with a decreased level of consciousness may be at high risk for aspiration of vomitus. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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. pH 7.4; PaCO2 40 mm Hg; HCO3- 25 mEq/L 2. pH 7.3; PaCO2 50 mm Hg; HCO3- 20 mEq/L 3. pH 7.6; PaCO2 30 mm Hg; HCO3- 40 mEq/L 4. pH 7.48; PaCO2 40 mm Hg; HCO3- 30 mEq/L Answer: 3 Rationale: Vomiting is a cause of metabolic alkalosis; the arterial blood gases indicate partially compensated metabolic alkalosis. The pH is greater than 7.45 (alkalosis); the HCO3- is above 26 mEq/L (metabolic); and the PaCO2 is less than 35 mm Hg (partially compensated). Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Case Study Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 37

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

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Case Study She states her temperature is “a little higher than normal” at 99.5o F. She has had no recent illnesses. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Discussion Questions What other information should you obtain from her? What remedies could she use to relieve her nausea? Dietary history (and if anyone else has nausea), history of nausea, and discussion of possible pregnancy Breathing exercises and peppermint tea Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Discussion Questions If she started vomiting, would you change your advice? 3. No, unless her vomiting is unremitting or includes blood. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.