1. Prepared by: Gertrudo L. Catolico Jr. RN., BSN.
Controlling Post-Operative Nausea and Vomiting Using Aromatherapy in Outpatient Orthopedic Ambulatory Surgery Center
Prepared by: Gertrudo L. Catolico Jr. RN., BSN.

2. Postoperative Nausea and Vomiting
Introduction and Problem to know
Definition
Facts and Complication Associated with PONV
PONV the least preferred by patient
Physiology
Risk Factors
Preventive Steps
Prevention and Management
Methodology
Procedure
Findings
Conclusion
References

3. Introduction
Since 1848, Post-Operative Nausea and Vomiting (PONV) has been identified as a surgical problem (Tinsley & Barone, 2015). One of the unpleasant side effect and the most common problem that can result to a very serious complications like pulmonary aspiration, dehydration, and dysrhythmias secondary to electrolyte imbalances. With 20% to 30% of patient experience moderate to severe symptoms of N/V after using gas or inhaled anesthesia (Cochrane, 2012) (Tinsley & Barone, 2015). In a post-anesthesia care unit (PACU) about 10% of surgical patients develop this symptom. Within the first 24 hours there are more 30% patient surgically developed problem which can poses risk for outpatient client experience after patient is discharged home from surgery center.

4. Problem to know
The incidence of vomiting is as high as 60% when older inhalation of anesthetic agent such as ether and cyclopropane were commonly used.
Patients rank PONV as one of the most unpleasant memories associated with their hospital stay.
Patients satisfaction with anesthetic is highly linked to their experience (or lack) of PONV. In survey, many state they prefer to experience pain than nausea and vomiting.
When severe it can prolonged hospital stay due to increased in bleeding, incisional hernias and sometimes leading to life threatening like aspiration pneumonia.
In spite of years of advancement in surgical and anesthetic technique, effective, prevention, and treatment of PONV has been elusive.

5. Background
Aromatherapy is a non-pharmacologic antiemetic medicine that can alternate to a very expensive antiemetic drugs in the market. My intention is to compare the effectiveness of aromatherapy by preventing postoperative problem to patient undergoing surgery at the ambulatory center making them recover without complications or problems.

6. Statement of the Problem
One of the major problems that causes of the delayed to discharge the patient from PACU is due to postoperative nausea and vomiting (PNOV) resulting to patient frustration on their recovery (Gundzik, 2008). Treatment and control to prevent PONV using Aromatherapy can help (Buckle, 2015). These treatments are inexpensive compared to pharmacologic agents which is non- invasive and normally has decreased the adverse side effects causes by anesthesia medication. In the ambulatory orthopedic center PONV is one of the most common problems. Due to this problem it initiate to identify this project to help the patient recovered well.

7. Purpose Statement
The purpose of this study is to identify and treat those patients at risk of PONV to alternate with antiemetic medication for best result that are available in the market.
To determine the outcome of aromatherapy on postoperative patient including good and worst possible side effect if this aromatherapy can be helpful (Gundzik, 2008).
Nurses will be more knowledgeable about the benefits of aromatherapy to their patient and they are in prime position to make patient reduce PONV leading to a well recovery resulting to good patient satisfaction, improve quality outcome and less medical bill incurred by clients (Tinsley & Barone, 2016) (Gundzik, 2008).

8. Objectives of the Study
The objective of this study is to determine whether aromatherapy can be very effective and safe for postoperative ambulatory care patients undergoing surgery similar to the standard antiemetic’s medication.
To give a clear understanding on the effectiveness of aromatherapy because it can greatly impact patient recovery leading to improved patients satisfaction and have a quality outcome after under the influence of anesthesia medication (Gundzik, 2008) (Reilly & Schachtman, 2009).

9. Definition
Vomiting – is a forceful expulsion of gastric content from the mouth associated with contraction of abdominal and chest wall musculature.
Nausea – is a subjective and unpleasant sensation of imminent need to vomit usually felt at the back of the throat and epigastrium.
Retching – is a rhythmic and spasmodic contractions of the respiratory muscles, diaphragm, chest wall, and abdominal muscles, without the expulsion of gastric contents.

10. Facts:
Postoperative N/V leads to increase cost like time spent in recovery, needs for nurses, need to admit overnight. More than 30% of patient report experience PONV reaching numbers as high as 80% for high risk populations.
PONV has a negative effect`s on patients quality of life and delays the discharge time from the PACU which negatively affect`s patient satisfaction.

11. Complications associated with PONV:
In addition to dehydration and electrolyte disturbances that can lead to cardiac dysrhythmias, complications of PONV include transient changes in intraocular pressure that can impair vision. (Report these changes to the anesthesia provider.)
Pulmonary complications are often due to aspiration, and are commonly seen in patients are unable to protect their airway. Position the patient in Fowler or semi-Fowler position (unless contraindicated) to reduce the risk of aspiration. If the patient can't sit up, position him or her on one side to prevent aspiration.

12. Complications associated with PONV
PONV can also lead to wound dehiscence or ruptured after surgery. Patients should be taught to splint their wounds when coughing, retching, or vomiting.
Severe PONV can cause hematoma development, especially in patients undergoing thyroidectomy. Monitor the surgical site for edema and airway compression (difficult breathing). Administer prophylactic antiemetic's as prescribed, to help the patient avoid retching and vomiting.

13. Postoperative Outcomes Least Preferred by Patients
Postoperative Outcomes Least Preferred by Patients. Vomiting/Emesis is the most least preferred by patients.
Rank
Postoperative Outcome 1
Vomiting 2
Gagging on endotracheal tub 3
Incisional pain 4
Nausea 5
Recall without pain 6
Residual weakness 7
Shivering 8
Sore throat 9
Somnolence
Data from a survey of adult patients (N= 101) conducted at Stanford University Medical Center. Patient were eligible if they were schedule to undergo surgery at the center. Patients were asked to rank order 10 possible postoperative outcomes from the most to least desirable. F-test <0.01).

14. Emesis can be divided into three phases
The preejection phase is characterized by the symptom of nausea as well as the autonomic signs of increased salivation, swallowing, pallor, diaphoresis, and tachycardia.
The ejection phase consists of retching and vomiting.
The postejection phase consists of relaxation of respiratory and abdominal muscles and cessation of nausea.

15. Physiologic events involved in vomiting
The vomiting center can be stimulated by several sources. These include afferent neurons from the pharynx, GI tract, and mediastinum, as well as afferents from the higher cortical centers (including the visual center and the vestibular portion of the eighth cranial nerve). Rapid position changes and motion in patients with vestibular disturbances can trigger vomiting and can be a profound problem in any PACU setting, but especially in the ambulatory care setting.

16. Physiologic events involved in vomiting
Another cause of vomiting is the chemoreceptor trigger zone (CTZ) at the base of the fourth ventricle in the area postrema, a medullary structure in the brain. The CTZ is highly vascularized; the vessels terminate in fenestrated capillaries surrounded by large perivascular spaces. Without an effective blood-brain barrier, the CTZ can be stimulated by chemicals received in the blood (such as drugs) and cerebrospinal fluid. However, direct electrical stimulation of the CTZ doesn't result in vomiting.

17. Physiologic events involved in vomiting
The vomiting center can also be activated indirectly when afferent pathways are stimulated by specific neurotransmitters- dopamine, serotonin, acetylcholine, and histamine-that activate the CTZ. Antiemetic drugs that block specific neurotransmitter receptors are used to prevent or treat PONV.

18. Physiologic events involved in vomiting
Lastly, the practice of fasting a patient overnight before surgery may lead to dehydration, and in combination with anesthetic agents and surgical blood loss can cause a state of transient ischemia in the GI system due to mesenteric hypoperfusion, one of the identified causes of PONV.

19. Risk Factor for PONV The four important risk factors: A) Gender
B) Non-smokers
C) History of PONV/ Motion sickness
D) Use of medication or postoperative opioids
Other risk factor include:
A) Age
B) Obesity
C) Type of surgery
D) Length of surgery

20. Risk Factor for PONV
Note: A patient with one risk factor has a 10% to 21% chance of developing PONV, compared with an 80% chances in patient with two or more risk factors.

21. Preventive Steps:
Early and effective management of PONV is critically important for many reasons, such as patient satisfaction, safety, improved surgical outcomes, and reducing medical costs. If the patient is at risk for PONV, here are some steps for reducing that risk:

22. Preventive Step to Combat PONV
Independent Nursing Intervention to Prevent PONV once the patient arrive at PACU
A) Let the patient wake-up slowly.
B) Take out oral airway as soon as possible.
C) Avoid irritation of upper airway as possible.
D) Proper positioning of patient for drainage purposes.
E) Be aware of patient V/S.
F) Start slowly of oral intake.
G) Give O2 as needed and encouraged deep breathing.
H) Slowly raise the head of bed and encourage minimal movement.
I) Give pain medication as needed.
J) Provide comfort and relaxing atmosphere.

23. Preventive and Management
NON-PHARMACOLOGIC INTERVENTION
A) Acupressure – wrist bands have shown to be effective when applied before anesthesia. Found that these techniques were similar to pharmacologic agents in preventing early and late vomiting.
B) P6 or Median Nerve stimulation.
- Research revealed that P6 stimulation aid and managed in reducing PONV.

24. Non-Pharmacologic Intervention
C) Aromatherapy
- Dates back as far as 2800 B.C
- Herbal preparation and plant extracts
- Use scent of ginger, peppermint, lavender and alcohol as prophylactic therapy. The scent thought to affect the neurotransmitter that activate the CTZ. Study showed great promise.
- Quease Ease – commercially prepared aromatherapy product that are available in the market. Over the counter (OTC).

25. Non-Pharmacologic Intervention
D) Mind-Body Therapy – Because the mechanism of PONV are triggered by neurochemicals, there`s a strong mind-body link and non-drug therapy works well with anxious patient.

26. Preventive and management
PHARMACOLOGIC AGENTS
A) Droperidol (Inaspine)
- a centrally acting anti-dopaminergic agent, prevents PONV and treats opioid- induced nausea and vomiting, and is as effective as ondansetron and promethazine with no significant differences related to adverse events. However, use of droperidol has significantly decreased since 2001, when the FDA issued a black box warning about the drug's potential for causing prolonged QT intervals and potentially fatal cardiac dysrhythmias such as torsades de pointes.
- Block dopamine-2 receptors in the CTZ and area of postrema.
- More effective for nausea than vomiting.
- Risk for cardiac patient.
- Adverse effects : sedation, dizziness, anxiety, hypotension, and extrapyramidal side effects.

27. Pharmacologic Agent B) Metoclopramide
-acts centrally in the CTZ and peripherally in the GI tract to increase lower esophageal sphincter tone and promote gastric motility. The drug is as effective as ondansetron in treating postoperative nausea but isn't as effective with postoperative vomiting. Metoclopramide crosses the blood-brain barrier and has centrally mediated adverse effects causing somnolence, reduced mental acuity, anxiety, depression, and EPS in young children and older adults
- Blocks dopamine-2 receptors in the CTZ and vomiting.
- Prokinetic properties that quicken esophageal clearance, enhance gastric emptying, and shorten bowel-transit time.
- Adverse effects: sedation, hypotension, restlessness, and extrapyramidal symptoms.

28. Pharmacologic Agent Promethazine (Phenergan)
- are more effective than ondansetron in preventing postoperative nausea, but no difference was noted in the treatment of vomiting.
- Blocks dopamine-2 receptors in the CTZ and other areas of the brain.
- Also blocks histamine 1 receptors and muscarinic-1 receptors.
- Adverse effects: hypotension, and extrapyramidal symptoms.

29. Pharmacologic Agent Scopolamine
-Anticholinergic agents which block muscarinic receptors in the vestibular system, also can be used to treat PONV. Scopolamine is available as a transdermal patch that should be applied the night before surgery (onset of action is 2 to 4 hours) and should remain in place for at least 24 hours postoperatively. Scopolamine is contraindicated in patients with angle-closure glaucoma.

30. Pharmacologic Agent Dexamethasone
- Corticosteroid has been successfully used to manage PONV, and administering it during anesthesia induction may delay PONV. Few studies have focused on combination therapy for PONV, but the combination of dexamethasone and a selective 5-HT3 antagonist has been found more effective than the use of either agent alone.
- Antiemetic action not fully understood. Thought to work by inhibition of prostaglandin
- Side effects: flushing and perineal itching.

31. Pharmacologic Agent Aprepitant
- Newest class of antiemetic. the first substance P and neurokinin-1 receptor antagonist approved by the FDA for prevention of PONV.
Is an oral drug administered 3 hours before induction of general anesthesia.
Aprepitant also is used to treat nausea and vomiting associated with chemotherapy.

32. Methodology
A clinical study of aromatherapy at outpatient orthopedic surgery center undergoing procedure who will meet the criteria of adult that show sign and symptoms of nausea and vomiting and no allergy to aromatherapy. A pre-op protocol tool question need to be completed by a pre-op nurse as well as a post-op after surgery. Prior to surgery demographic and risk factor are collected including PONV prophylaxis agent given at pre-op (Hunter, et. al., 2008).

33. Procedure
During recovery phase 1 in-time and out-time are recorded including how many antiemetic agents given pre-op and intra-op. Patient who experience nausea level 1-3 on a verbal descriptive scale 0-3 received aromatherapy to inhale 3 times deeply. A repeat reassessment of nausea (0-3) was measured again in 5 minutes. A follow PONV rescue medication ordered by a physician can be given if patient is not relieved from aromatherapy. Aromatherapy will then be used as complementary therapy (Hunter, et. al., 2008).

34. Findings of Effectiveness of Aromatherapy
According to study client remained to received saline improvement over time comparable to patient obtain an active drugs (Kwekkeboom, 1997)

35. Conclusion
Patient got an aromatherapy where less likely to receive rescue dose for nausea which are more promising study because it decrease the severity and incidence of the problem (Hunter et. al., 2008) (SD, 2016) (Scott, 2015).
Aromatherapy offer a beneficial therapeutic choice as a budget readily available treatment (Newsom, 2014). In an event that common antiemetic medication is not available to give to patient like contraindication or client’s refusal aroma inhalation could be an alternative choice.

36. Conclusion
Nausea and vomiting are unpleasant symptoms that extremely affect client’s recovery and patient satisfaction for their experience during recovery. The nurse has an essential role in recognizing patients at risk and managing this problem when it occurs. They can greatly help in preventing unwarranted symptoms by treating them with medication or alternative therapies. The primary goal is to prevent the symptom rather than treating the problem. By recognizing earlier for those patients at higher risk and immediate intervening throughout their ambulatory surgery stay can significantly increase patient outcomes and improves patient satisfaction.

37. References
Altaf, W., Hakak, S., (2010). PONV anesthesia management. Health and medicine. Retrieved fromhttp://
Anderson, L. A., & Gross, J. B., (2004). Aromatherapy with peppermint, isopropyl alcohol, or placebo is equally effective in relieving postoperative nausea. PubMed. Retrieved from
Gundzik, K., (2008). Nausea and vomiting in ambulatory setting. ProQuest Central. Retrieved from
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Kwekkeboom, K. L. (1997). The placebo effect in symptom management. Oncology Nursing Forum, 24(8),
Tinsley, M., & Barone, C., (2015). Preventing postoperative nausea and vomiting. OR Nurse.
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Vyas, P., (2009). Postoperative nausea and vomiting. Health and medicine. Retrieved from

38. Gertrudo L. Catolico Jr. RN, BSN, (Student) N599 Nursing Capstone
Thank you and God Bless
Gertrudo L. Catolico Jr. RN, BSN, (Student)
N599 Nursing Capstone