Nausea and vomiting are unpleasant and potentially distressing symptoms that are commonly experienced by patients. This is especially the case for individuals on the perioperative care continuum, during pregnancy and childbirth, patients receiving chemotherapy and patients in the advanced stages of a disease or at the end of life (Vidall, 2011; Kelly and Ward, 2013; Dye, 2017; Leach, 2019). Nausea and vomiting can also be a sign of more serious impairment, emotional distress or an adverse reaction to therapeutic treatments (Keeley, 2019).
The potential impact of nausea and vomiting on an individual's wellbeing and quality of life can vary and will depend on the length and severity of the specific episodes, but in some cases can be so severe that individuals may decide to stop treatment (Brooker and Waugh, 2013; Kelly and Ward, 2013).
Prolonged nausea and vomiting can result in physiological complications, psychological changes and social difficulties that could have short- or long-term consequences for health. The most frequent and severe effects include dehydration, nutritional deficiencies and electrolyte and acid-base imbalance (Table 1) (Brooker and Waugh, 2013; Patton and Thibodeau, 2018).
| Physical |
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| Psychological |
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| Social |
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Terminology
An understanding of the medical terminology associated with nausea and vomiting is important for reliable and effective assessment and management of patients' symptoms (Table 2) (Waugh and Grant, 2018). However, although this is vital when working collaboratively with other health professionals, when communicating with patients it beneficial to have an awareness of some of the more colloquial language people might use to describe how they are feeling, ie ‘barf’ and ‘hurl’, to accurately interpret their symptoms.
| Nausea |
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| Retching |
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| Emesis |
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| Vomiting |
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| Emetic symptoms |
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| Emetogenic potential |
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| Antiemetics |
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| Projectile vomiting |
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| Chemotherapy-induced nausea and vomiting |
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| Anticipatory nausea and vomiting |
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Anatomy and physiology
The act of emesis is associated with the initiation of the vomiting centre of the brain (Dougherty et al, 2015). This can be activated by a variety of receptors (ie histamines, acetylcholine, dopamine and 5-hydroxytryptamine) in the gastrointestinal tract, cerebral cortex, vestibular apparatus and chemoreceptor trigger zone, which respond to stimuli such as drugs and toxins, pain and fear, or movement and injury (Brooker and Waugh, 2013) (Table 3).
| Vestibular system | Chemoreceptor trigger zone | Gastrointestinal tract | Cerebral cortex |
|---|---|---|---|
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In some cases, the cause of nausea and vomiting and the specific aetiology may be multifactorial, ie chemotherapy treatment, memory and anxiety—this is because more than one type of receptor and pathway have initiated the vomiting centre (Collis, 2015).
Assessment strategies
Before nausea and vomiting can be treated or the cause reversed, there needs to be a comprehensive assessment of a patient's symptoms, and specific clinical features must be examined to find which branch of the emetic pathway has triggered the physiological response (Collis, 2015; Leach, 2019).
To assess patients with emetic symptoms a variety of assessment tools/scales is available to ascertain the severity or intensity of emetic symptoms. These can include numerical rating scales, which are often incorporated in analgesia infusion charts, and nausea, retching and vomiting questionnaires, which are used to obtain more in-depth insight into the person's emetic symptoms and their biopsychosocial impact on the individual.
However, although these tools are beneficial, a holistic patient assessment should also include a review of precipitating and relieving factors (ie movement, food/fluids, hunger, aromas), characteristics (ie duration, frequency), as well as visual inspection of the vomit (ie volume, colour, odour, consistency and presence of blood), and, if required, physical examination (ie oral, rectal, abdominal, vital observations) (Dye, 2017; Keeley, 2019).
Assessments can also be undertaken in a preventive capacity, whereby the risk of developing nausea and vomiting are examined and calculated to prophylactically manage anticipatory nausea and vomiting (Dougherty et al, 2015). These risk assessments are not only beneficial for individualised patient assessments, but have also been shown to allow for targeted management strategies, reducing the incidence of postoperative and chemotherapy-induced nausea and improving patient satisfaction (Vidall, 2011; Smith and Ruth-Sahd, 2015). Examples of factors that might be taken into account include age, gender, history of motion sickness, history of previous postoperative or chemotherapy-induced nausea and vomiting, smoking status, type and length of the surgical procedure, and type of anaesthetic or analgesic agent (Dougherty et al, 2015; Smith and Ruth-Sahd, 2015; Phillips and Perriman, 2017).
Management strategies
Effective management of nausea and vomiting not only influences a patient's symptom response, it also improves patient compliance with therapeutic treatments. However, because there is a vast array of possible management strategies, depending on the quality of the assessment and the resources available, it is essential that health professionals involve the patient in the decision process, and use a multimodal approach that incorporates both pharmacological and non-pharmacological management methods (Collis, 2015; Dougherty et al, 2015; Dye, 2017).
Pharmacological management
The most common intervention used in today's healthcare system is the administration of medication because it is often a safe and effective way of managing many signs and symptoms of diseases (National Institute for Health and Care Excellence (NICE), 2015).
Concerning the nausea and vomiting, antiemetics (anti-sickness) medication should be prescribed only when the specific cause of nausea and vomiting are known, because antiemetics vary in their mechanism(s) of action (Table 4) and will depend on the cause and which receptor has initiated the emetic response (British National Formulary, 2020). For example, an anti-emetic medication that is effective in the management of chemotherapy-induced nausea and vomiting may have no role in the prevention and treatment of emetic symptoms due to other causes, eg motion sickness (Neal, 2012).
| Types of antiemetics and examples of medications | Uses |
|---|---|
| Antihistamines |
Wide variety of uses, including motion sickness and vertigo |
| Phenothiazines and related drugs |
Phenothiazines are dopamine antagonists that act centrally by blocking the chemoreceptor trigger zone. |
| Domperidone and metoclopramide |
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| Dexamethasone | A steroid used to manage nausea and vomiting during chemotherapy |
| 5HT3-receptor antagonists |
Therapy to prevent postoperative nausea and vomiting include 5HT3-receptor antagonists. A combination of these medications can be used with choice based on the assessed risk of postoperative nausea and vomiting in each patient. 5HT3-receptor antagonists are often used with dexamethasone |
| Neurokinin 1-receptor antagonists |
Administered alongside 5HT3-receptor antagonist to prevent chemotherapy-induced nausea and vomiting |
| Nabilone | Nabilone is a synthetic cannabinoid that can be considered as an add-on for treating nausea and vomiting. Cannabinoids are used as a last resort when other antiemetics have failed to control nausea and vomiting caused by chemotherapy |
| Hyoscine | Hyoscine should be given to prevent motion sickness and should, therefore, be administered before vomiting has started |
Antiemetic medication can also be administered via multiple routes (ie intravascular, oral, rectal), so it is important to consider which is the most appropriate approach for each patient. Additionally, because there may be more than one cause, individuals may require two or more antiemetics to achieve adequate symptom control (Dye, 2017).
Non-pharmacological
Although antiemetics are used worldwide to manage nausea and vomiting, pharmacological management is only partially effective, and for some individuals can cause side-effects (ie sedation, headache, constipation, and fatigue). Alternative strategies may therefore also need to be employed (Lee and Fan, 2015; Yang et al, 2019).
Acupressure
Acupoints are located at specific places on imaginary lines ‘meridians’ throughout the human body (Byju et al, 2018) and acupressure of the P6 point, which lies 4 cm proximal (three fingers) to the wrist crease of the dominant arm, has proven helpful to some patients in controlling nausea and vomiting, with, minimal side-effects (Lee and Fan, 2015).
Ginger
Ginger is a herb belonging to the Zingiberaceae family, which has been shown to block the actions of serotonin and acetylcholine that stimulate the vomiting reflex and trigger involuntary stomach contractions in the body (Lete and Allué, 2016; Stanisiere et al, 2018).
Its use as an adjuvant therapy or as a complementary natural alternative for alleviating symptoms of nausea and vomiting (Tóth et al, 2018) has been researched extensively within pregnancy, chemotherapy, postoperative nausea and vomiting, and motion sickness (Stanisiere, et al, 2018)— it is now regarded as just as effective as pharmacological therapies, with fewer potential side-effects (Lete and Allué, 2016).
Nursing care
As well as the use of complementary therapies, to ensure adequate holistic management, there are additional nursing considerations that need to be addressed when caring for patients experiencing nausea and vomiting (Table 5), especially in relation to assisting patients with activities of living and biopsychosocial wellbeing:
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Mouth care
Following episodes of vomiting, bile and acids from the stomach can cause damage to teeth, gums and throat, and result skin irritation around the mouth. To ensure that the structures and tissues of the mouth remain healthy it is essential to assist patients with oral mouth care and ensure that they have access to equipment to perform oral hygiene (Burns et al, 2019). Removing the taste through oral hygiene can also help with reducing nausea (Nicol et al, 2012).
Privacy and dignity
Close curtains to provide privacy and promote comfort by keeping clothes clean and ensure that tissues and vomit bowls are easily accessible (Nicol et al, 2012; NICE, 2016).
Fluid balance
Vomiting and nausea can change a patient's hydration status, putting them at risk of dehydration. It is therefore important to keep an accurate record of the patient's fluid balance and, if possible, encourage oral intake or administer intravenous fluids (Dougherty et al, 2015).
Environment
Following episodes of vomiting, it is important to consider the stimulation of the vomiting centre via the cerebral cortex, because smells can trigger further episode. To reduce the stimulus, strong odours should be avoided by moving the patient or opening windows because fresh cool air can help alleviate symptoms of nausea (NICE, 2016).
Diet and nutrition
Nausea and vomiting can lead to a reduction in appetite and/or cause a patient to stop eating. Consequently, food charts should be used and patients should be encouraged to eat small, frequent meals, consisting of bland, non-spicy, non-fatty foods (NICE, 2016).
Conclusion
Pirri et al (2013) state that it is imperative that health professionals take multimodal approaches to the assessment and management of nausea and all its associated symptoms, including preventative risk assessments and pharmacological, as well as non-pharmacological, treatments. However, this can only be achieved effectively and efficiently by working in partnership with the patient and ensuring that up-to-date evidenced-based approaches are used to underpin decisions on which assessments to use, how risks are identified and what management strategies are employed (Nursing and Midwifery Council, 2018).