In managing nausea and vomiting, nursing assessment is everything. Identify the cause, and you can treat the symptom more accurately. Assess the treatment’s effectiveness, and you can monitor a pathway towards relief.
Nausea and vomiting commonly occur together, but are also distinct symptoms. Nausea is described as an unpleasant feeling in the back of the throat and in the stomach that may or may not result in vomiting. Vomiting is a forceful contraction of the stomach muscles that causes the contents of the stomach to come up through the mouth. Understanding the many causes of nausea and vomiting in people with advanced disease is essential for their effective control.
Identify the Cause to Control the Symptom
Remember, there may be multiple causes for these symptoms, often occurring simultaneously. It’s essential in your assessment of nausea and vomiting to identify the likely source. This information may be gathered from the referral notes, known history of the patient, and clinical assessment.
Consider the Background
Common causes of nausea and vomiting are listed in Table 1.
Table 1: Common causes of nausea and vomiting
Consider, also, any pre-existing comorbidities such as gastro-oesophageal reflux disease (GORD), gastric ulcers, and dyspepsia (indigestion). These may not necessarily relate to the advanced disease but could also be a cause of discomfort.
Many of the medications commonly used in palliative care are known to contribute to nausea and vomiting. These include opioids (especially morphine), antimicrobials, and antidepressants. It is important to review the medications being taken by the person in your care. Common medicines that may cause nausea and vomiting include:
- Antibiotics (e.g. erythromycin)
- Antihypertensive agents
- Cytotoxic agents
- Hormone replacement therapy
- Iron preparations
- Nicotine (nicotine gum, lozenges)
- Oral contraceptives
- Opioids (buprenorphine, codeine, fentanyl, methadone morphine, oxycodone tramadol)
Your patient may also have a number of biochemical disturbances causing these symptoms, including hypercalcaemia or uraemia. It is essential that these pathology tests are checked and that consultation with other health professionals is undertaken. Psychological factors may also enhance the risk of nausea and vomiting. These might include anxiety, fear, and the memory of a previous treatment. Be sure that your documentation is thorough, as this can help to identify these issues. It may also be worthwhile discussing these factors with other health professionals, such as psychologists, counsellors, or spiritual carers.
Conduct the Assessment
- Examine the mouth and pharynx: look for thrush or ulceration.
- Examine the abdomen: observe degree of distension, undertake auscultation for bowel sounds, and palpate for intra-abdominal masses.
- Conduct a rectal examination (with appropriate approval and cultural considerations): observe for constipation/faecal loading.
- Undertake neurological examination, including vestibular function.
- Review blood examination: FBC, EUC, LFTs, Se calcium, magnesium, and phosphate if appropriate.
- Review films: plain film X-rays of abdomen, CT brain if an increase in intracranial pressure (ICP) is suspected, CT abdomen if examination indicates progressive disease, obstructive tumours, or lymphadenopathy.
Strategies for Controlling Nausea
In collaboration with your medical colleagues, consider the most appropriate medications and monitor their effectiveness closely.
The rationale for using medications is to:
- Prevent or relieve symptoms.
- Prevent complications (dehydration, electrolyte disturbance).
Before starting treatment:
- Identify, treat, or remove cause if possible.
- Ensure adequate hydration.
There are a large number of medications that can be used in the short term management of nausea and vomiting as summarised on Table 3.
Table 3: Some medications that can be used for the management of nausea and vomiting
|Class, and Examples||Indications||Comments||Common Side Effects|
|Domperidone||Nausea and vomiting||May be used in Parkinson’s disease||May cause QT prolongation; dry mouth, headache|
|Droperidol||Prevention of PONV|
|Metoclopramide||Nausea and vomiting; gastric stasis||Avoid use in patients with Parkinson’s disease. Maximum dose: 5mg tds for 5 days.||Tardive dyskinesias in older people; akathesia, drowsiness, dizziness, headache|
|Prochlorperazine||Nausea and vomiting; vertigo||Avoid use in patients with Parkinson’s disease||Constipation, cardiovascular and cerebrovascular concerns, drowsiness, dizziness, headache, Parkinsonism, EPSE|
|Granisetron||Nausea and vomiting associated with cancer chemotherapy, radiotherapy, post-operative||Agitation, anxiety somnolence, rash, taste disturbances|
|Ondansetron||Wafer or orally disintegrating tablets are available||Rare side effects|
|Tropisetron||Abdominal pain, fatigue, diarrhoea|
|Substance P Antagonists|
|Aprepitant||Prevention of nausea and vomiting with highly or moderate emetogenic chemotherapy||Diarrhoea, fatigue, headache, dizziness, weakness, hiccups|
|Pheniramine||Motion sickness, nausea and vomiting assoc with vestibular disorders||More effective if given before travel|
|Promethazine; Promethazine theoclate|
|Hyoscine hydrobromide||Motion sickness||Dry mouth|
|Dexamethasone||PONV adjunct for chemotherapy induced nausea and vomiting||More effective if given before induction of anaesthesia|
|Haloperidol||Intractable nausea and vomiting assoc with chemotherapy and radiotherapy||Only use if other agents are ineffective||EPSE, Increased risk of CNS effects|
PONV: post operative nausea and vomiting
EPSE: Extrapyridimal side effects
Medications used in pregnancy: nausea and vomiting are common during the first trimester pregnancy. Drug treatment should be avoided if possible and emphasis placed on the importance of adequate hydration using ice chips if necessary. Dietary modification may help. Ginger up to 1 g daily may be useful or pyridoxine (vitamin B6) 25–50 mg up to tds.
If these measures are ineffective, the following medications can be considered: doxylamine (Australian category A), metoclopramide (Australian category A), promethazine (Australian category C), or prochlorperazine (Australian category C) orally, if tolerated. In hyperemesis gravidarum IV rehydration is the main treatment. Metoclopramide, prochlorperazine, or ondansetron (Australian category B1) are used if symptoms are prolonged and intractable.
Of course, a number of non-pharmacological strategies can also be used in conjunction with the medications. Psychoeducational strategies are designed to lessen anxiety and equip patients with tools to help them manage their emotions. These may include guided imagery, progressive muscle relaxation, music therapy, exercise, yoga, and massage. If you are not skilled in these approaches, consider the involvement of your allied health colleagues.
As well as these therapies, dietary modification strategies can be helpful in reducing the risk of vomiting and nausea while also maintaining nutrition. Strategies could include:
- positioning the patient upright while eating and for one hour post-meal
- only offering dry foods throughout the day
- bland, soft, easily-digestible food for main meals
- rinsing patient’s mouth after eating.
Similarly, reducing environmental stimuli may help lessen the risk of external triggers. Strategies include avoiding cooking aromas, not eating in an overly warm room, and ensuring good ventilation.
Once cause of the nausea or vomiting has been determined, it is possible to approach the problem with targeted pharmacological and practical solutions in order to provide relief. With careful, ongoing assessment you will be able to greatly improve the comfort of the patient.
[show_more more=”Show References” less=”Hide References” align=”center” color=”#808080″]
- EMIMs Cloud 2015 http://www.emims.com.au/
- Glare P et al, 2008. ‘Treatment of nausea and vomiting in terminally ill cancer patients’, Drugs, 68(18), pp.2575-2590.
- Keely PW, 2007. ‘Nausea and vomiting.’ Medicine, 36(2), pp.75-77.
- National Cancer Institute, 2011. www.cancer.gov Accessed 17/7/2015.
- KOncology Nursing Society, 2008. www.ons.org Accessed 17/5/2015.
- Rossi S (Ed). 2015 Australian Medicines Handbook. Adelaide
- Therapeutic Guidelines writing committee. 2015 Gastrointestinal in eTG, Therapeutic Guidelines Ltd Melbourne
- Yates P, 2012. ‘Nausea and vomiting in palliative care nursing.’ Palliative Care Nursing. A Guide to Practice. 3rd Edition. pp.167-177. Ausmed Publications: Melbourne.
NB: Brand names have been removed as there are many generic products
John Rosenberg is a Registered Nurse with a clinical background in community-based palliative care. He has worked as an educator and researcher in care of people at the end of life. John was responsible for the development of the postgraduate Chronic Disease Management and Palliative Care suite of courses at the University of Queensland School of Nursing and Midwifery. He is a co-author of the Framework of Competency Standards for Specialist Palliative Care Nursing Practice. John is the immediate past President of Palliative Care Nurses Australia Inc., the peak body for nurses in Australia caring for people at the end of life. He was the inaugural Director of the Calvary Centre for Palliative Care Research in Canberra with the Australian Catholic University. John currently works as a Research Fellow in the Centre for Research Excellence in End of Life Care at Queensland University of Technology.