SOAP. – Nausea and Vomiting – SỔ TAY LÂM SÀNG

Nausea and Vomiting

Jill C. Cash and Cheryl A. Glass

Definition

Nausea and vomiting are common symptoms for many conditions and diseases; several terms describe the symptoms (see Table 14.23).

A.Hyperemesis gravidarum is a condition of persistent, uncontrollable vomiting that begins in the first weeks of pregnancy and may continue throughout pregnancy.

B.Chronic nausea and vomiting is defined as at least 1 month in duration.

C.Complications of nausea and vomiting include fluid depletion, hypokalemia, and metabolic alkalosis.

D.Vomiting is also considered a protective mechanism to remove harmful ingested substances.

Incidence

A.Nausea and vomiting are very common, and the etiology is dependent on the disease/condition.

B.During pregnancy, 50% to 95% of women experience nausea and/or vomiting; 50% have both nausea and vomiting. Onset after the initial 9 weeks of pregnancy should direct especially careful evaluation for another cause within the differential diagnoses of nausea and vomiting in nonpregnant patients. Hyperemesis gravidarum occurs in 1 in every 0.5% to 2% of pregnancies. Severe hyperemesis requires hospitalization in 0.3% to 2% of pregnancies.

C.Approximately one third of surgical patients have nausea and/or vomiting after general anesthesia.

D.The incidence of nausea and/or vomiting subsequent to cancer treatment is high.

Pathogenesis

A.Protective mechanisms are activated by numerous gastrointestinal (GI) and non-GI causes. Normal function of the upper GI tract involves an interaction between the gut and the central nervous system (CNS).

B.Nausea and vomiting in pregnancy are related to increased hormones, including human chorionic gonadotropin (HCG), estrogen, and progesterone, as well as decreased gastric motility and relative hypoglycemia that results from a night-long fast.

Predisposing Factors

A.Acute nausea and vomiting.

1.Medications: Digitalis toxicity, opiate use, anesthetic, chemotherapy agents, drug withdrawal, nicotine/nicotine patches, antibiotics, hormones, and antivirals.

2.Ketoacidosis.

3.Pregnancy or hormones.

4.Binge drinking.

5.Hepatitis.

B.Recurrent or chronic nausea and vomiting.

1.Psychogenic vomiting.

2.Metabolic disturbances.

3.Gastric retention.

4.Bile reflux.

5.Pregnancy.

6.Radiation.

7.Gastroparesis.

C.Nausea and vomiting with abdominal pain.

1.Viral gastroenteritis.

2.Acute gastritis.

3.Food poisoning.

4.Peptic ulcer disease (PUD).

5.Acute pancreatitis.

6.Small bowel obstruction.

7.Acute appendicitis.

8.Acute cholecystitis.

9.Acute cholangitis.

10.Acute pyelonephritis.

11.Inferior myocardial infarction (MI).

D.Nausea and vomiting with neurologic symptoms.

1.Increased intracranial pressure.

2.Midline cerebellar hemorrhage.

3.Vestibular disturbances.

4.Migraine headaches.

5.Autonomic dysfunction.

6.Head trauma.

7.Multiple sclerosis.

TABLE 14.23 Definitions of Terminology Used to Describe Nausea and Vomiting

Anorexia	Loss of desire to eat; a true loss of appetite
Early satiety	Fear of being full after eating an unusually small quantity of food
Nausea	The unpleasant sensation of the imminent need to vomit, usually referred to the throat or epigastrium; a sensation that may or may not ultimately lead to vomiting
Regurgitation	The act by which food is brought back into the mouth without the abdominal and diaphragmatic muscular activity that characterizes vomiting
Retching	Spasmodic respiratory movements against a closed glottis with contraction of the abdominal musculature without expulsion of any gastric contents, referred to as “dry heaves”
Rumination	Chewing and swallowing of regurgitated food that has come back into the mouth through voluntary increase in abdominal pressure within minutes of eating or during eating; rumination may be accompanied by weight loss and bulimia
Sitophobia	Fear of eating because of subsequent or associated discomfort
Vomiting	Forceful oral expulsion of gastric contents associated with contraction of the abdominal and chest wall musculature

Common Complaints

A.Queasy sensation.

B.Food aversion.

C.Inability to retain food or liquids.

Other Signs and Symptoms

A.Increased salivation.

B.Bitter taste, acid brash: Indicates ulcer or small bowel obstruction.

C.Weight loss.

D.Dehydration.

E.Sweating.

F.Fast pulse.

G.Pale skin.

H.Rapid breathing.

I.Lightheadedness.

Subjective Data

A.Review onset, duration (acute or chronic problem?), and course of symptoms, including the quality (projectile?) and quantity of emesis. What were the color, taste, and consistency of the emesis? Was blood present?

1.Vomiting bright red blood indicates a hemorrhage—peptic ulcer.

2.Dark red blood indicates a hemorrhage—esophageal or gastric varices.

3.Coffee grounds material is indicative of digested blood from a slowly bleeding gastric ulcer or duodenal ulcer (DU).

4.Vomiting fecal material is a sign of distal small-bowel obstruction and blind-loop syndrome.

5.Explosive projectile vomiting is associated with increased intracranial pressure such as with meningitis.

B.Ask the patient about other symptoms, including pain, fever, diarrhea, and headache.

C.Inquire if other family members are also ill and what their symptoms are.

D.Review the timing of vomiting in relation to meals, time of day, odors, and activity. Does vomiting occur before or after food intake?

E.Ask the patient about medication intake such as antibiotics, chemotherapy, herbals, digitalis, opiates, and birth control pills.

F.Ask about self-image, binge eating, and self-induced emesis.

G.Review any exposure to hepatitis or travel to places with poor sanitation and outbreaks of cholera.

H.Review the patient’s medical history for vertigo, head injury, jaundice, diabetes, hypertension, and pregnancy.

I.Inquire about first day of last period and birth control method used.

J.Establish usual weight. Has there been any recent weight change, how many pounds, and over what period of time?

K.Ask about the patient’s history of diabetes, gallbladder disease, ulcer disease, or cancer.

Physical Examination

A.Check temperature (if indicated), pulse (which should be checked both standing and lying down), respirations, blood pressure, and weight.

B.Inspect:

1.Observe general overall appearance of skin for pallor and signs of dehydration. Tenting of skin when it is rolled between your thumb and index finger may indicate dehydration.

2.Inspect for signs of autonomic insufficiency. Postural hypotension, lack of sweat, or blunted pulse and blood pressure responses to Valsalva’s maneuver suggest autonomic dysfunction and a bowel motility problem as the underlying etiology of nausea and vomiting. Postural hypotension indicates marked volume depletion or circulatory collapse.

3.Oral exam: Inspect mouth, teeth, and gums. Pay particular attention for dental enamel erosion as a sign of bulimia.

C.Palpate:

1.Palpate the abdomen for masses, distension, tenderness, signs of peritonitis, and organomegaly.

2.Palpate the back; note costovertebral angle (CVA) tenderness.

D.Percuss the abdomen.

E.Auscultate:

1.Auscultate the abdomen for bowel sounds in all quadrants.

2.Auscultate the heart and lungs.

F.Perform rectal exam (if indicated).

G.Perform a neurologic examination (if indicated).

Diagnostic Tests

The cause of an acute episode of nausea and vomiting is typically determined through a detailed history and physical examination. Only if the cause is unclear should further diagnostic tests be performed.

A.Urine: Ketones, specific gravity, pregnancy test, culture and sensitivity, if indicated.

B.Serum labs: Multiple chemistry profile, including amylase, electrolytes, BUN, creatinine, glucose, and transaminase.

C.Drug screen.

D.Hepatitis panel.

E.Upper GI.

F.Ultrasonography:

1.Obstetric ultrasound to rule out multiple gestation and/or molar pregnancy if persistent nausea and vomiting, especially after 16 weeks gestation.

2.Upper abdominal ultrasound, if clinically indicated, to evaluate the pancreas and/or biliary tree.

G.Stool for occult blood.

H.Endoscopy.

I.CT scan.

1.Head CT scan, if indicated.

2.Abdominal CT if appendicitis is suspected.

J.Gastric scintigraphy, to rule out gastroparesis if indicated.

K.EKG if chest pain/MI is suspected.

Differential Diagnoses

A.See Predisposing Factors.

Plan

A.General interventions: Assess hydration status. Proceed to IV hydration and antiemetics until ketones clear.

B.Dietary management: See Appendix B, Nausea and Vomiting Diet Suggestions.

C.Pharmaceutical therapy (not an exhaustive list):

1.Antiemetics:

a.Dextrose/fructose/phosphoric acid solution (Emetrol); available over the counter:

i.Adults: 15 to 30 mL by mouth at 15-minute intervals (not to exceed five doses)

ii.Tell the patient not to dilute the drug or take fluids 15 minutes before or after taking the medication.

iii.Diabetics should be instructed not to use without consulting their provider.

iv.If nausea continues despite medication, contact healthcare provider.

b.Promethazine (Phenergan):

i.Drug of choice for gastroenteritis.

ii.Adults: 25 to 50 mg by mouth or per rectum every 4 to 6 hours.

c.Trimethobenzamide (Tigan):

i.Used for gastroenteritis and motion sickness.

ii.Adults: 300 mg orally three or four times daily.

iii.Adults: 200 mg IM three or four times daily.

d.Prochlorperazine (Compazine):

i.Adults: 5 to 10 mg three or four times daily; spansules 15 mg every 12 hours; suppositories 25 mg twice daily.

3.5-hydroxytryptamine (5-HT3, or serotonin) antagonists are utilized for nausea related to chemotherapy therapy and postoperative nausea and vomiting. 5-HT3 drugs are available in oral, IV, and transdermal formulations. Consult a prescribing reference for current dosing/formulations:

a.Ondansetron (Zofran).

b.Granisetron (Sancuso and Kytril).

c.Palonosetron (Aloxi).

d.Dolasetron mesylate (Anzemet).

4.Dronabinol (Marinol), cannabinoid 2.5, 5, and 10 mg capsules are indicated for refractory nausea and vomiting associated with chemotherapy. Therapy is individualized before and after chemotherapy.

Follow-Up

A.Tell the patient to call or visit the office in 24 hours to check response and nutritional intake.

Emergent Issues/Instructions

A.First priority is to rule out acute surgical etiology such as bowel obstruction and peritonitis.

B.If overdose is suspected: Contact 1-800-222-1222, the American Association of Poison Control Centers, the local poison control center, or the emergency department immediately.

Consultation/Referral

A.Consult a physician and hospitalize the patient promptly if there is evidence of bowel obstruction; increased intracranial pressure (ICP); or another GI, neurologic, or metabolic emergency.

B.Hyperemesis gravidarum is the most severe form of nausea and vomiting in pregnancy. Hyperemesis gravidarum may require hospitalization to correct fluid and electrolyte imbalance, and nutritional deficiencies.

C.Call for a psychiatric consultation for suspected psychogenic nausea and vomiting.

D.If postural hypotension occurs, especially in elderly patients, hospital admission for parenteral fluid and electrolyte replacement is indicated.

E.Endocrinologist, gastroenterologist, and surgical consultations for treatment, consideration, and placement of a gastric stimulator for diabetic gastroparesis.

Individual Considerations

A.Pregnancy:

1.Determine whether the woman is ingesting nonfood substances, such as starch, clay, or toothpaste, which would indicate pica.

2.Intractable nausea and vomiting require ultrasonography to rule out hydatidiform mole.

3.Emetrol, promethazine (Phenergan), and prochlorperazine (Compazine) may be used during pregnancy.

4.The only Food and Drug Administration (FDA)-approved drug for treating nausea and vomiting in pregnancy is doxylamine/pyridoxine. Antihistamines, promotility agents (e.g., metoclopramide), Emetrol, promethazine (Phenergan), and prochlorperazine (Compazine) may be used during pregnancy. In cases of refractory to standard therapy, ondansetron and steroids may be considered.

5.Uncorrected hyperemesis gravidarum can result in severe electrolyte imbalance and possible hepatic and renal damage. The major concern for fetal well-being is uncorrected ketosis, which may result in fetal abnormalities or death in early pregnancy.

6.Tell the patient to eat toast or a dry cracker; to eat small, frequent meals and snacks; to drink fluids separately from meals; and to avoid fatty, fried, greasy, or spicy foods and foods with strong odors.

B.Geriatrics:

1.There should be a low threshold for hospitalization of the elderly to treat dehydration and correction of fluid and electrolyte imbalance.

2.Use of the lower dose ranges of an antiemetic is sufficient for most elderly patients due to their susceptibility to hypotension and neuromuscular reactions. osages should be increased more gradually in the elderly.

3.For the older adult with existing nausea and vomiting, NPs should practice special consideration of the following geriatric syndromes:

a.Delirium is a common early sign of acute illness or infection in the elderly. It is more common in patients with existing cognitive impairment. Dehydration is more common in the elderly. Signs of dehydration include: confusion, muscle weakness, fever, dizziness, poor skin turgor, hypotension, and tachycardia. Diminished thirst mechanism and decreased body water exacerbate dehydration.

i.At a minimum, patients and family should be asked if the patient has experienced episodes of altered mental status.

ii.The Brief Confusion Assessment Method (bCAM) is a well-documented assessment for delirium. The bCAM is available at: https://www.mnhospitals.org/Portals/0/Documents/ptsafety/LEAPT%20Delirium/HELP%20Program%20CAM%20Flowsheet.pdf

b.Weight loss/appetite suppression: Weight loss is a predictor of mortality. Clinically significant weight loss is considered to be 5% loss of usual body weight in three months or 10% in six months:

i.Due to GI distress, abdominal discomfort, diarrhea the elderly patient is at increased risk of avoiding eating.

ii.Monitor weight patterns/BMI (Caution: BMI is not used to identify loss of muscle mass)

iii.Monitoring both serum albumin and anemia: hypoalbuminemia and anemia is not necessarily associated with low bodyweight. It can be caused by decreases in liver protein synthesis.

•Serum albumin concentration is commonly recommended.

•Hemoglobin, prealbumin, and transferrin

•Cholesterol

c.Falls: Consistently assess for falls. Discuss the risk of dizziness or lightheadedness when standing.

i.At the minimum, older adults should be asked how many times they have fallen since their last visit. A reported fall should trigger questions about whether the fall led to injury, a visit to urgent care or hospital emergency department, or a hospital admission. Safety measures to reduce falls in the home include removing small area carpets, keeping night lights along the path to the bathroom, installing a toilet seat or nearby grab bars. See Section III: Patient Teaching Guide Safety Issues: Fall Prevention.