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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