1. JUST NAUSEA ? Symptom management

2. JUST NAUSEA ? OBJECTIVES Identify the effects of Nausea on daily life Identify those palliative patients at greatest risk of Nausea Describe the assessment of GI distress and nausea Describe nursing interventions to limit or prevent Nausea Identify Pharmacological and non pharmacological treatments

3. WHAT IS NAUSEA? A Subjective symptom report by the individual often described as a distressing feeling in the stomach, verbalized as rolling, squeezing, churning. Often of varying intensity Increased intensity frequently proceeds vomiting Side effect of many medical treatments Symptom of disease process Body response to change in equilibrium

4. WHAT IS NAUSEA? Nausea and vomiting are controlled by stimulation of the vomiting center The vomiting center is located medulla oblongata, near the origin of the vagus nerve The chemoreceptor trigger zone located near the floor of the 4th ventricle reacts to chemicals mediators in the blood stream and relays information to the vomiting center to induce nausea The vomiting center also receives descending impulses from higher centers in the brain. Ascending impulses from GI Tract via the vagus, glossopharyngeal, and splanchnic nerves.

5. QUALITY OF LIFE Physical Decrease appetite and food intake Fatigue Weight loss Limits activity Over sensitivity to smells Over reaction to motion or light Psychological Fear of vomiting Depression Fear of leaving home Spiritual/ Social Isolation Inability to enjoy meals Avoidance of social engagements Loss of work Loss of income

6. CHRONIC VS. ACUTE Metastatic cancers of colon Elevated ICP Poor perfusion of GI tract in vascular disease End stage Lung disease or cancer End stage liver or renal disease Pregnancy Motion sickness Viral infections Food reactions Medication reactions

7. CONSTIPATION

8. CHEMO THERAPY Radiation therapy

9. INTRACTABLE COUGHING Hiccups

10. METABOLIC CAUSES Hyperkalemia, uremia, infection, drug reactions

11. VESTIBULAR DISTURBANCE

12. ASSESSMENT

13. Medical history, physical exam, pattern of symptoms, Relieving and aggravating factors, medication history

14. PERSON AT RISK

15. PREVENTION

16. TREATMENT CORRECT THE UNDERLYING PROBLEM

17. DOPAMINE, SEROTONIN, HISTAMINE, AND CHOLINERGIC PATHWAYS DRUG THEREPY

18. PHARMACOLOGIGIC MEASURES METOCLOPRAMIDE ( D2) DRUG OF CHOICE FOR GASTROPARESIS, OFTEN OPIOID INDUCED NOT FOR USE IN BOWEL OBSTRUCTION HALOPERIDOL (D2) ALTERNATIVE TO METOLOPRAMIDE EFFECTIVE FOR OPIOID RELATED NAUSA Effective for metabolic induced nausea Multiple routes of administration

19. PHARMACOLOGIGIC MEASURES DIPHENHYDRAMINE (H1) HYDROXYZINE Antihistamine Useful in cough related nausea Reduces secretions Reduces anxiety Promote rest SCOPALAMINE TRANSDERMAL PATCH Effective for 3 days ease of dosing useful in patients unable to take oral meds Reduces secretions May cause increase delirium

20. PHARMACOLOGIGIC MEASURES PROMETHAZINE (H1) Commonly used for all causes Can be given rectally Less sedating than chlorpromazine ONDANSETRON (5-HT3) First choice for Chemo related nausea Used for acute nausea post op May decrease GI motility Not good choice for opioid induced nausea

21. PHARMACOLOGIGIC MEASURES CORTICOSTEROIDS/DEXAMETHASONE Reduce tumor swelling Helpful in GI Obstruction Reduce ICP Use lowest dose effective and consider tapering Effectiveness may be time limited by disease process

22. PHARMACOLOGIC MEASURES HYCOSDINE (ARC) Reduce GI spasm and cramping Limits interstitial swelling Useful in obstructions OTHER ADJUVANTS : Proton pump inhibitors H2 receptor antagonist Anti-acids Simethicone Ativan/ Xanax

23. NON PHARMACOLOGICAL MEASURES DIET Small meals Cool foods, no extremes Space out solids and fluids Limits foods that trigger patient specific reactions Assess reactions to smells, and texture when planning meals ENVIROMENT Limit noise or light Keep room cool may need fan for personal space Keep HOB elevated Assess aspiration risk if vomiting present.

24. NON PHARMACOLOGICAL MEASURES INVASIVE TREATMENTS Naso- gastric tube Decompress GI tract NGT limited to In-patient use is most cases, increased risk of aspiration peg tube to gravity or suction more easily managed in home. higher risks with placement/ site infection COMPLIMENTARY THERAPIES Acupuncture Massage Reki Reflexology Music therapy Aromatherapy

25. CASE STUDY Mr. Hayes is 47 year-old with widely metastatic colon cancer. He arrives on your unit with chief complaint of intractable nausea and vomiting for 24 hours. He states he is barley able to manage any activities of daily living. Mr. Hayes has been found to have a non- resectable partial bowel obstruction. Discussion questions: 1. describe your assessment 2. what Nursing DX. Do you identify 3. what treatments so you expect/ plan 4. discuss the Suffering of Mr. Hayes

26. Q AND A

29. AGNES PELOSA RN, CHPN RNAdvantage1 @gmail.com

30. THANK YOU