Download NAUSEA AND VOMITING

CHAPTER 12
NAUSEA AND VOMITING
Theresa Clifford, MSN, RN, CPAN
CHAPTER 12
OVERVIEW
Purpose: The perianesthesia nurse will demonstrate knowledge of physiology, symptomatology,
influencing factors, and detrimental effects of nausea and vomiting, identify appropriate nursing
interventions to attenuate nausea and vomiting, and intervene to provide an acceptable level of comfort
for the patient.
Competency Statement: Provide perianesthesia management of postoperative nausea and vomiting (PONV).
Criteria:
1. Identify key components of the pathophysiology of nausea and vomiting.
• Vomiting center (VC) is located in lateral reticular formation of medulla
• VC receives impulses from the gastrointestinal (GI) tract, brain cortex, vestibular apparatus and
chemoreceptor trigger zone (CTZ)
• CTZ has four (4) major receptors: dopaminergic, histaminic, muscarinic (cholinergic), and
seratonergic
• Nausea: subjective experience of unpleasant flushing or pallor, swallowing, tachycardia, an urge to
vomit
• Vomiting: objective experience which includes contraction of abdominal muscles, descent of
diaphragm, opening of gastric cardia, expulsion of stomach contents through mouth
CHART I
• Factors influencing nausea and vomiting are either central or peripheral in origin
o Central factors are those elements that excite the vomiting center directly. These elements can be
chemical materials carried through the blood stream, such as narcotics and other medications, and
anesthetic and inhalation agents, especially nitrous oxide. Central factors also include a prior
history of nausea and vomiting, and motion sickness
o Peripheral factors are elements that trigger nausea and vomiting outside of direct influence on the
vomiting center. Vagal afferent nerves transmit impulses from the periphery toward the central
nervous system. These factors include major intra-abdominal or pelvic surgery, including any
laparoscopic procedure in which there is insufflation of the abdomen, manipulation of the eye,
manipulation of the glossopharyngeal nerve (i.e., tonsillectomy), pain, and premature oral intake
of fluids
ASPAN 2009 Edition
381
CHAPTER 12
CHART 2
2. Identify consequences of postoperative nausea and vomiting.
Factors associated with the risks and complications of nausea and vomiting include:
• Aspiration
• Dehydration
• Electrolyte imbalance (metabolic alkalosis, hyponatremia, hypokalemia)
• Disruption of surgical incisions, formation of hematoma, increased ICP
• Esophageal rupture
• Increased costs (increased length of stay, unanticipated admission)
• Side effects of antiemetics including increased anxiety, pain, and/or sedation
• Delayed oral intake
3. Identify patients at risk for nausea and vomiting.
Factors influencing nausea and vomiting which place the perianesthesia patient at risk are:
• Overall incidence of nausea and vomiting is 25 – 30%
• Age: children are at higher risk with the peak incidence between age 11 and 14
• Gender: females have a 2 – 3 times higher incidence
• Gender difference not seen in prepubertal children or in elderly suggesting that variations in serum
gonadotropin or other hormonal levels may influence the higher incidence of emesis in women
• Obesity: the obese have a larger gastric volume and may swallow more air during mask ventilation
(anesthetic agents are lipid soluble and the fat cells serve as a reservoir)
• Gastroparesis such as with diabetic neuropathy, chronic cholecystitis, small bowel obstruction, gastroesophageal reflux disorders
• Full stomach
• Anxiety which produces a high level of circulating catecholamines and increased gastric volumes
• History of motion sickness or otherwise sensitive vestibular system (up to three times more likely)
• History of nausea and vomiting after previous anesthesia and surgical procedures (anticipatory)
• Type of surgery: laparoscopic, major intra-abdominal procedures, ear nose and throat (ENT), eye,
gynecological procedures, lithotripsy
• Type of anesthesia:
o General anesthetics irritate the lining of the stomach and distend air containing spaces, particularly
the use of volatile anesthetics as well as nitrous oxide
382
A Competency Based Orientation and Credentialing Program for the Registered Nurse in the Perianesthesia Setting
CHAPTER 12
•
•
•
•
•
•
o Circulating chemical agents (i.e., Ketamine and Etomidate) cross the blood brain barrier of the
CTZ stimulating the vomiting center in the medulla
Length of surgery
Tactile stimulation of posterior pharynx (i.e., endotracheal tubes, airways, and nasogastric tubes)
Pre- or postoperative medications, especially narcotics
Pain, motion, and early oral intake
Postoperative hypotension and hypoxemia, as well as undiagnosed hypoglycemia from prolonged
fasting
Nonsmokers
4. Identify factors that stimulate the vomiting center of the brain.
Factors that stimulate the vomiting center of the brain are as follows:
• Hypotension
• Hypoxia
• Anxiety or stress
• Increased intracranial pressure (ICP)
• Anesthetic agents
• Narcotics
• Chemotherapeutic agents
• Other medications
• Fluid/electrolyte imbalance
• Dehydration, hypovolemia, and hypotension simulating dizziness or motion
• Noxious sights, smells, and sounds
• Abdominal distention
• Pain, especially visceral or pelvic
• Increased oral secretions
5. Identify prophylactic measures for the prevention of PONV.
• Use a simplified risk factor identification tool to identify the baseline risk for PONV
• Consider the baseline PONV risk in the selection of the number and type of prophylactic
interventions
• Consider additional interventions in the case of increased surgical risks associated with PONV
• Recommended prophylactic interventions include:
o Anesthesia considerations
• Total intravenous anesthesia (TIVA)
• Consider non-steroidal anti-inflammatory drugs
• Regional blocks
o Pharmacologic
• Dexamethasone
• 5-HT3 receptor antagonists
• H1 receptor blockers (antihistamines)
• Scopolamine patch
• Droperidol (currently has a “Black Box” warning from the United States Food and Drug
Administration (FDA), because the drug can prolong the QT interval. This prolongation has
been associated with fatal cardiac dysrhythmias when given at the upper end of the
recommended dose limits)
New drug class: Neurokinin-1 (NK1) antagonists
o Therapeutic interventions
• Hydration
• Encourage healthy patients undergoing elective procedures to drink clear fluids up to two
ASPAN 2009 Edition
383
CHAPTER 12
hours before surgery (verify facility/Anesthesia department policy related to NPO status)
• Administer supplemental intravenous fluids in high-risk, ASA I-II patients with insensible
losses if there is not a concern of fluid volume overload. Intravenous fluid doses ranging from
15 to 40 ml/kg of lactated ringers have been shown to decrease PONV in this population
o Pain management:
• Use a multimodal approach to pain management
• Consider the use of non-steroidal anti-inflammatory drugs
• Consider the use of regional analgesia
o Complementary interventions
• The perianesthesia nurse may consider educating the patient regarding the acquisition and use
of over-the-counter acupressure and acustimulation devices in high-risk patients or patients
expressing concern over experiencing PONV
• P6 acupressure stimulation
6. Identify pharmacologic and nonpharmacologic interventions for nausea and vomiting
postoperatively.
• Assess for postoperative nausea on admission, discharge, and more frequently as indicated (high-risk
patient, after administration of an opioid or antiemetic, etc.)
• If nausea is present, quantify the severity of the nausea using a verbal descriptor scale (VDS) or
visual analogue scale (VAS)
• Select and administer appropriate rescue antiemetics
o 5-HT3 receptor antagonists
o H1 receptor blockers (antihistamines)
o Droperidol (currently has a “Black Box” warning from the United States Food and Drug
Administration (FDA), because the drug can prolong the QT interval. This prolongation has been
associated with fatal cardiac dysrhythmias when given at the upper end of the recommended dose
limits)
384
A Competency Based Orientation and Credentialing Program for the Registered Nurse in the Perianesthesia Setting
CHAPTER 12
o Late considerations may include:
• Metoclopramide
• Low-dose promethazine
• Prochlorperazine
• New drug class: Neurokinin-1 (NK1) antagonists
• Consider additional therapeutic modalities to manage nausea and vomiting:
o Consider aromatherapy
o Apply acupressure techniques
o Offer music therapy
o Provide supplemental oxygen
o Provide perioperative bolus of intravenous fluids to appropriate patients with no contraindications
o Offer modified preoperative fasting protocols
7. Discuss additional nursing interventions for the patient experiencing PONV.
A. Monitor BP, HR, R and SpO2.
• Obtain baseline vital signs to establish reference point
• Anxiety and discomfort will release circulating catecholamines, which will increase BP, heart rate
and respirations
• Stimulation of the parasympathetic system through nausea with retching (vagal stimulation) may
produce bradycardia and hypotension
B. Position patient to ensure protection of the airway.
• If the patient is unconscious or there is a possibility of a compromised airway or loss of protective
reflexes, position head down and body in left lateral position during active retching and vomiting
ASPAN 2009 Edition
385
CHAPTER 12
to facilitate drainage of contents from oral cavity, decreasing the possibility of aspiration
• Left lateral positioning further decreases the possibility, as it protects the vulnerable right
mainstem bronchus
• If patient has abdominal distention or history of esophageal reflux, elevate head of bed 30 – 45
degrees
C. Auscultate breath sounds and encourage deep breathing.
• Assess after vomiting for possible aspiration
• If adventitious sounds are audible and there is a decrease in the SpO2, aspiration should be
suspected
• Deep breathing facilitates the elimination of inhaled anesthetic agents, minimizes nausea and
vomiting, and is a method of distraction
D. Perform oral/tracheal suctioning to remove vomitus and clear airway.
• Removal of oral/tracheal contents by suctioning decreases potential for aspiration of contents
E. Support or splint surgical wound during active retching and vomiting.
• Supporting the surgical wound limits incisional pain and decreases potential for rupture
(dehiscence) of the suture line
F. Provide psychological support, including application of cool, moist cloths to face/neck, and
provision of oral care.
• The nurse’s presence and emotional support offer psychological comfort and encouragement
• A cool, moist cloth is soothing and refreshing to the vasodilated vessels
• Rinsing of oral cavity refreshes and removes noxious odors and taste. Water is preferable to
flavored mouthwashes
G. Assess patency and securement of tubes, catheters, and intravenous lines.
• A functional nasogastric tube prevents abdominal distention from gas and accumulated fluids
• Foley catheter output informs the nurse of hydration status, as dehydration is a contributing factor
to nausea and vomiting
• Intravenous lines permit administration of antiemetics, analgesics, and hydration
H. Report excessive or prolonged nausea and vomiting.
• Promotes investigation for other possible disease processes or treatment modalities
I. Judiciously advance oral fluids, beginning with ice chips and sips of water.
• Premature intake of oral fluids is an influencing factor for nausea and vomiting
• Auscultate for presence of bowel sounds prior to providing oral intake
• Provide adequate intravenous/oral fluids to replace fluid deficit resulting from NPO status and
surgical events
8. Communicate and document all pertinent information per facility/unit specific policy/protocol.
• Facilitate a collaborative effort to maintain quality patient care through communication of pertinent
data
• Documentation will include assessment, interventions and outcomes of nursing management for
nausea and vomiting
386
A Competency Based Orientation and Credentialing Program for the Registered Nurse in the Perianesthesia Setting
CHAPTER 12
TRIGGER SITES
Vagal
Visceral
Afferent
Sympathetic
Visceral
Afferent
Cerebral Cortex
CLINICAL PRESENTATION
Hypotension
Hypoxia
Bradycardia
Abdominal distention
Increased secretions
Increased peristalsis
Decreased peripheral
vascular resistance
Vasoconstriction
Increased peripheral
vascular resistance
Pallor
Sweating
Tachycardia
Increased glucose level
Increased muscle strength
Increased respiratory rate
and depth
Bladder distention
Decreased gastric motility
Decreased digestive
gland secretions
Pain
Emotions: anxiety, depression,
fear, and stress
Hypotension
Hypoxia
CTZ
Vestibular
Cerebellar
Afferent
Abdominal Contents
Pain
Sensory – sight, smell, sound
Increased intracranial pressure
Inhalation/Intravenous anesthetic agents
Narcotics
Hypovolemia
Fluid/Electrolyte imbalance
Chemotherapeutic agents
Circulating drugs – Ergotrates,
cardiac, glycosides, amphetamines
Inhalation/intravenous
anesthetic agents
History of motion sickness
Ocular procedures
ENT procedures
Motion
Tremors
Narcotics (especially Meperidine)
Decreased gastric emptying
Gastric irritants – blood,
chemicals, anesthetic agents
MANAGEMENT
Rapid infusion of intravenous fluids
Administration of supplemental oxygen
If symptomatic, administer anticholinergic
(atropine, glycopyrrolate)
Elevate head of bed, insert nasogastric tube
Suction oral cavity and trachea as needed
Maintain cool environment, apply cool,
moist cloth
Refresh skin with cool, moist cloths
Monitor
Monitor
Encourage slow, deep breathing
Empty bladder
Administer Gastrokinetic (Metoclopramide)
Position for comfort, administer analgesics
Education, psychological support, positive
reinforcement, distraction and relaxation
techniques, administer tranquilizer, anxiolytic
Rapid infusion intravenous fluids
Administer supplemental oxygen, encourage
deep breathing
Position for comfort, administer analgesia
Remove/eliminate noxious stimulus
Elevate head of bed if not contraindicated
Administer antiemetic
Administer antiemetic
Intravenous fluid replacement
Monitor labs, replace fluid and electrolytes
Administer antiemetic
Administer antiemetic
Administer antiemetic
Administer antiemetic
Administer antiemetic
Administer antiemetic
Position, transfer, move gently and slowly
Warm, psychological support, Meperidine IV
Administer antiemetic with narcotic
Administer Gastrokinetic (Metoclopramide)
Expect emesis, support with comfort
measures and psychological support
The ASPAN Clinical Guideline for Postoperative Nausea and Vomiting/Postdischarge Nausea and Vomiting (PONV/PDNV), found online at
www.aspan.org, was developed as a practical bedside guide for the healthcare practitioner.
ASPAN 2009 Edition
387
CHAPTER 12
Bibliography
American Society of Health-System Pharmacists, Inc. ASHP Therapeutic Guidelines on the
Pharmacologic Management of Nausea and Vomiting in Adult and Pediatric Patients Receiving
Chemotherapy or Radiation Therapy or Undergoing Surgery. 1999; 56: 729-764.
American Society of PeriAnesthesia Nurses. ASPAN Clinical Guideline for Postoperative Nausea and
Vomiting/Postdischarge Nausea and Vomiting (PONV/PDNV). In: 2008-2010 Standards of
PeriAnesthesia Nursing Practice. Cherry Hill, NJ: ASPAN; 2008.
Couture DJ, Maye JP, O’Brien D, Smith AB. Therapeutic Modalities for the Prophylactic Management
of Postoperative Nausea and Vomiting. JOPAN. 2006; 21(6): 398-403.
Drain CB, Odom-Forren J, eds. Perianesthesia Nursing: A Critical Care Approach. 5th ed. St. Louis,
MO: Saunders; 2009.
Kovac AL. Postoperative Nausea and Vomiting: New Advances with Serotonin Receptor Antagonists.
Kansas City, KS: Department of Anesthesiology, University of Kansas Medical Center; 2000.
Kovac AL. Prevention and treatment of postoperative nausea and vomiting. Drugs 2000. 2000; 59(2):
213-243.
Mamaril M, Windle PE, Burkard JF. Prevention and Management of Postoperative Nausea and
Vomiting: A Look at Complementary Techniques. JOPAN. 2006; 21(6): 404-410.
Merritt BA, Okyere CP, Jasinski. Isopropyl alcohol (IPA) inhalation: alternative to treatment of
postoperative nausea and vomiting. Nurs Res 2002. 2002; 51(2): 125-128.
Murphy MJ, Hooper VD, Sullivan E, Clifford T, Apfel C. Identification of Risk Factors for
Postoperative Nausea and Vomiting in the Perianesthesia Adult Patient. JOPAN. 2006; 21(6): 377-384.
Quinn DM, Schick L. PeriAnesthesia Nursing Core Curriculum: Preoperative, Phase I and Phase II
PACU Nursing Core Curriculum. Philadelphia, PA: WB Saunders; 2004.
388
A Competency Based Orientation and Credentialing Program for the Registered Nurse in the Perianesthesia Setting
CHAPTER 12
QUESTIONS:
NAUSEA AND VOMITING COMPETENCY
1. Factors influencing nausea and vomiting are either peripheral or central in origin.
Which of the following are peripheral factors?
a. Major intra-abdominal surgery and premature oral intake of fluids
b. Anesthetic inhalation agents, especially nitrous oxide
c. Prior history of nausea and vomiting, motion sickness
d. None of the above.
2. The chemoreceptor trigger zone-vomiting center of the brain is located in the medulla.
a. True
b. False
3. Which of the following affect the chemoreceptor trigger zone-vomiting center of the brain?
a. Anesthetic agents, opioids, neuromuscular blockade
b. Anesthetic agents, opioids, pain, motion
c. Premature intake of oral fluids
d. All the above
4. The best position for the prevention of aspiration is:
a. Head of bed elevated 30 to 35 degrees
b. Turn head to either side
c. Head down and left lateral
d. Lateral or prone
5. Ondansetron, a serotonin antagonist, is best described as:
a. Accelerating gastric emptying
b. An antiemetic that may cause headache and sedation
c. A CNS depressant, anticholinergic, antispasmodic
d. None of the above
6. Every patient receiving anesthetic agents should also receive antiemetic prophylaxis.
a. True
b. False
7. Complications associated with nausea and vomiting include:
a. Dehydration
b. Electrolyte imbalance
c. Increased length of stay
d. All of the above
ASPAN 2009 Edition
389
CHAPTER 12
KEY:
NAUSEA AND VOMITING COMPETENCY QUESTIONS
1. Factors influencing nausea and vomiting are either peripheral or central in origin.
Which of the following are peripheral factors?
a. Major intra-abdominal surgery and premature oral intake of fluids
b. Anesthetic inhalation agents, especially nitrous oxide
c. Prior history of nausea and vomiting, motion sickness
d. None of the above.
2. The chemoreceptor trigger zone-vomiting center of the brain is located in the medulla.
a. True
b. False
3. Which of the following affect the chemoreceptor trigger zone-vomiting center of the brain?
a. Anesthetic agents, opioids, neuromuscular blockade
b. Anesthetic agents, opioids, pain, motion
c. Premature intake of oral fluids
d. All the above
4. The best position for the prevention of aspiration is:
a. Head of bed elevated 30 to 35 degrees
b. Turn head to either side
c. Head down and left lateral
d. Lateral or prone
5. Ondansetron, a serotonin antagonist, is best described as:
a. Accelerating gastric emptying
b. An antiemetic that may cause headache and sedation
c. A CNS depressant, anticholinergic, antispasmodic
d. None of the above
6. Every patient receiving anesthetic agents should also receive antiemetic prophylaxis.
a. True
b. False
7. Complications associated with nausea and vomiting include:
a. Dehydration
b. Electrolyte imbalance
c. Increased length of stay
d. All of the above
390
A Competency Based Orientation and Credentialing Program for the Registered Nurse in the Perianesthesia Setting
ASPAN 2009 Edition
Independent
Date__________________________
Performs
with
Assistance
Preceptor Signature____________________________________________________
Observed
Retake &
Date
Date__________________________
Discusses
with
Preceptor
Pass & Date
(90%)
Date____________________
Provide perianesthesia management of postoperative nausea and
vomiting (PONV).
CRITERIA:
1. Identify key components of the pathophysiology of nausea and
vomiting.
2. Identify consequences of postoperative nausea and vomiting.
3. Identify patients at risk for nausea and vomiting.
4. Identify factors that stimulate the vomiting center of the brain.
5. Identify prophylactic measures for the prevention of PONV.
6. Identify pharmacologic and non-pharmacologic interventions for
nausea and vomiting postoperatively.
7. Discuss additional nursing interventions for the patient experiencing
PONV.
8. Communicate and document all pertinent information per facility/unit
specific policy/protocol.
Meets Criteria
Does Not Meet Criteria
Re-Validate – Meets Criteria
Employee Signature____________________________________________________
NAUSEA & VOMITING
Competency Criteria can be validated by discussion, or by
performance, or both. If an item is not appropriate for each
column, please indicate with “N/A.”
Competency Statement
Written Competency Test
Competency Based Orientation for the Perianesthesia Nurse
Name_______________________________________________________
CHAPTER 12
391