Download Diarrhoea and vomiting

Nurse Practitioner – Emergency Services
CLINICAL PRACTICE GUIDELINE
DIARRHOEA +/- VOMITING SYMPTOMS SUGGESTIVE OF
GASTROENTERITIS
Nurse
Practitioner
Medical
Practitioner +/Nurse
Practitioner
Primary Survey
History
Scope
Adults with acute onset of diarrhoea +/- vomiting
Outcomes
Identify patients
suitable for NP
(Emergency) CPG
Underlying medical pathology / complex patient
Chronic onset +/- recent partial treatment
Vomiting of blood or blood in stools
Altered conscious state including effects of drugs/
ETOH
History consistent with collapse
Identify patients
not suitable for NP
(Emergency) CPG
and redirect to
usual ED care +/NP (Emergency) in
team.
Outcomes
Abnormal primary
survey identified →
exit CPG and refer
to EP or SMO
immediately
Assessment & intervention
• Airway
• Breathing
• Circulation
• Disability
• Environment
•
•
•
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•
•
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•
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Signs and symptoms of current illness
Duration of Illness – days and hours
Frequency of vomits, No/day and colour
of vomit
Frequency and volume of stools, No/day
and colour and consistency of stools,
mucus or blood
Oral intake – volume and fluid type,
Urine output
Abdominal Pain
Level of activity – lethargy/ active
Risk factors- recent travel,
immunocompromised, antibiotic
associated (refer to EP)
Allergies
Relevant past medical history /
medication use
Identify patients
not suitable for NP
(Emergency) CPG
→ exit CPG
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Nurse Practitioner – Emergency Services
CLINICAL PRACTICE GUIDELINE
DIARRHOEA +/- VOMITING SYMPTOMS SUGGESTIVE OF
GASTROENTERITIS
Focused clinical
hydration
assessment
•
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Vital Signs including lying and standing
BP if necessary
Urinalysis
General examination
Abdominal examination
Hydration status - Mucous membranes
and appearance, thirst, Urine output,
respirations, heart rate, level of
consciousness, decreased skin turgor
Vomiting with no diarrhoea is not usually
gastroenteritis. Discuss with EP.
Severe
hydration→ exit
CPG
Pain Assessment
•
Pain scale
Determine need
for and type of
analgesia
Analgesia
•
Administration of analgesia (see
medications)
Reduction / relief
of pain.
Imaging
Pathology
Working diagnosis and Investigations
In most circumstances no investigations are
necessary in order to diagnose gastroenteritis or to
manage the patient effectively1.
Imaging not usually required
• Abdominal XR may be requested after
consultation with EP to exclude Bowel
Obstruction or free intra-abdominal gas
• Faecal MC&S required only if there is an
outbreak and public health measures are to
be implemented and where bacterial
infection likely
• Faecal MC & S if Septic and unwell with
bloody stools.
• Faecal testing for occult blood may be
necessary if fever higher than 38.5.
• FBE, U & E, Glucose if the patient is
clinically dehydrated or systemically unwell,
or requires IV fluid therapy
Interpretation of results (diagnostic features) and management
decisions
Imaging
• If taken review in conjunction with
pathology and clinical assessment
Outcomes
Outcomes
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Nurse Practitioner – Emergency Services
CLINICAL PRACTICE GUIDELINE
DIARRHOEA +/- VOMITING SYMPTOMS SUGGESTIVE OF
GASTROENTERITIS
Pathology and
clinical features
Diagnosis mild
dehydration
Tolerating oral
fluids, improvement
in hydration
No signs of sepsis
or indications for
alternate diagnosis
NP (Emergency) review with view to discharge
• Oral hydration as tolerated
• Intravenous hydration if required
• Pt education /health promotion
• Medication prescribed as per formulary
• Follow up appointment with GP
• Referral +/- to services etc
Patient identified
as suitable for NP
(Emergency) CPG
and discharged
safely
Moderate to
NP (Emergency) review in consultation with EP or
Severe
inpatient unit with view to admission
dehydration Not
• Monitor and maintain hydration
tolerating oral fluids,
• Document fluid balance
prolonged vomiting
• Pt education /health promotion
and diarrhoea,
• Medication prescribed as per formulary
requiring significant
• Inpatient team referral
IV fluid replacement,
• Referral to services as required
abnormal pathology
results
Assessment by EP
+/- admission to
ED Obs ward or
inpatient team for
admission and
ongoing
management.
Travellers
Diarrhoea (5)
No high fever, no
peritoneal signs or
focal tenderness, no
blood in stool
Associated Care
eTG recommends
Rx with antibiotics
only for moderate
to severe
NP (Emergency) review with view to discharge
• Rehydration with oral Rehydration solution
• MILD - May benefit from Loperamide
• Moderate to Severe – antibiotics may be
combined with Loperamide (see formulary)
ED NP R/V consider ongoing IV fluids until review
by inpatient unit
Medications
Outcomes
All medication will be stored, labelled and dispensed in accordance with hospital policy and
relevant legislation(3)
Simple analgesia
Paracetamol 500mg: 1 or 2 tablets 4/24 not to
Patients given
S2/4
exceed 8 tablets in 24 hrs.
analgesia
appropriate to
Mild pain
OR
allergies, current
medications and
Instead of Paracetamol, Panadeine Forte: 1 -2
past medical
tablets 4–6/24, not to exceed 8 tablets in 24 hrs.
history.
Analgesia
requirements
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Nurse Practitioner – Emergency Services
CLINICAL PRACTICE GUIDELINE
DIARRHOEA +/- VOMITING SYMPTOMS SUGGESTIVE OF
GASTROENTERITIS
Anti motility S4
Hyoscine Butylbromide: Oral 20mg 6/24
Slow IV 20-40mg
max 100mg/day
Antidiarrhoel S2
Loperamide 2 mg: 2 tablets initially followed by 1
tablet after each unformed stool until diarrhoea
controlled. Max 8 tablets / day.
Antiemetics S4
(Contraindicated in
Parkinson’s
disease)
Metoclopromide hydrochloride: Oral/IM/IV 10mg
8/24 Max 30 mg in 24 hours.
Prochlorperazine:
Oral 5-10mg 8-12/24, initial 10mg po if acute
IM deep 12.5mg 8/24
Antibiotics S4 (4)
In Travellers
Diarrhoea
Azithromycin 1 gm: orally as single dose
OR
Norfloxacin 800 mg: orally as single dose
determined by
ongoing
assessment of
pain and adequate
analgesia
provided.
Patients with
excessive pain or
pain unrelieved by
analgesia need
review by Senior
Doctor
Consider the need to treat for Giardia lambia.
Discuss with EP or SMO
Tinidazole 2 gm orally, as a single dose
Or
Metronidazole 2 gm orally. Daily for 3 days
Intravenous Fluids
When to return
Follow-up
Appointments
0.9% Normal Saline Intravenous fluids: IV 0.9%
Normal Saline 1000 mls titrated to patient
requirements.
Monitor U & Es if requiring significant IV fluid
replacement.
Patient Discharge Education
• Verbal instructions from NP (Emergency) re
need for clinical re assessment if not
tolerating oral fluids, significant increase in
vomiting or diarrhoea, decreased urine
output, increased lethargy or generally more
unwell
• Written patient information
•
Outcomes
Ensure patient
understands
problem,
treatment, follow
up and is safe for
discharge home
Advise patients to see GP in 24 hours, letter
provided
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Nurse Practitioner – Emergency Services
CLINICAL PRACTICE GUIDELINE
DIARRHOEA +/- VOMITING SYMPTOMS SUGGESTIVE OF
GASTROENTERITIS
Discharge
Referrals
•
As appropriate to allied health team
members
Medication
Education
•
•
Verbal instructions from NP (Emergency)
Contact ED Pharmacist to provide
medication education for patient when
available
Certificates
Unexpected
representation
Absence from work certificates
Clinical Audit Evaluative strategies
Emergency Department attendance register and
NP (Emergency) clinical log
References
1. Ginifer, C & Young, S. (2004). Gastroenteritis. In Cameron, Jellinek, Kelly, Murray &
Heyworth(ED.), Textbook
of Adult Emergency Medicine (pp. 311-316). Sydney: Churchill Livingstone.
2. eMIMS 2006. [cited 2007 Nov]; Available from Emergency Department desktop
3. JHC Medication Storage and Administration Policy. Available via Hospital Intranet
4. eTG 2006. cited [2008]. Available from Emergency Department desktop
5. Buttarovoli, P. (2007). Minor Emergencies: Splinters to Fractures. 2nd Ed, Philadelphia:
Mosby.
Author(s) & Endorsement
This CPG was written by:
Bronwyn Nicholson
Terry Jongen
Nurse Practitioner – Emergency Services
Nurse Practitioner – Emergency
Services
Royal Perth Hospital
Joondalup Health Campus
CPG- Clinical Practice Guideline
DVA- Department of Veteran Affairs
EP- Emergency Physician
PS- Pain Score
S1-S4- Schedule of the drug administration act
LMO- Local Medical Officer
MVIT – Motor Vehicle Insurance Trust
NP (Emergency)- Nurse Practitioner –
Emergency Services
OP- Outpatients
WC- Workers Compensation
Date written: April 2008
Review date: April 2011
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