ASSESSING NAUSEA AND VOMITING
In managing nausea and vomiting, nursing assessment is everything. Identify the cause, and you can treat the
symptom more accurately. Assess the treatment’s effectiveness, and you can monitor a pathway towards relief.
Nausea and vomiting commonly occur together, but are also distinct symptoms. Nausea is described as an
unpleasant feeling in the back of the throat and in the stomach that may or may not result in vomiting. Vomiting
is a forceful contraction of the stomach muscles that causes the contents of the stomach to come up through the
mouth. Understanding the many causes of nausea and vomiting in people with advanced disease is essential for
their effective control.
Identify the Cause to Control the Symptom
Remember, there may be multiple causes for these symptoms, often occurring simultaneously. It’s essential in
your assessment of nausea and vomiting to identify the likely source. This information may be gathered from the
referral notes, known history of the patient, and clinical assessment.
Consider the Background
Common causes of nausea and vomiting are listed in Table 1.
Common causes
Radiotherapy
Chemotherapy
Pregnancy including hyperemesis gravidarum
Postoperative
Motion sickness
Drug induced
Other causes
Anxiety
Bulimia nervosa (usually self-induced)
Cough
Fluid and electrolyte imbalance e.g. hypercalcaemia, volume depletion, water
intoxication, adrenocortical insufficiency,metabolic disturbances
Food poisoning (toxins from Bacillus cereus, Staphylococcus aureus, Clostridium
perfringens, etc.)
Gastrointestinal obstruction, ascites
Increased intracranial pressure
Infections (viral gastroenteritis)
Metastasis (brain, meninges, liver)
Peritonitis
Tube feeding
Uraemia
Vestibular problems
Table 1: Common causes of nausea and vomiting
Consider, also, any pre-existing comorbidities such as gastro-oesophageal reflux disease (GORD), gastric
ulcers, and dyspepsia (indigestion). These may not necessarily relate to the advanced disease but could also be
a cause of discomfort.
Many of the medications commonly used in palliative care are known to contribute to nausea and vomiting.
These include opioids (especially morphine), antimicrobials, and antidepressants. It is important to review the
medications being taken by the person in your care. Common medicines that may cause nausea and vomiting
include:
Antibiotics (e.g. erythromycin)
Antidepressants
Antihypertensive agents
Bronchodilators
Bromocriptine
Corticosteroids
Cytotoxic agents
Digoxin
Hormone replacement therapy
Iron preparations
Levodopa
Nicotine (nicotine gum, lozenges)
NSAIDs
Oral contraceptives
Opioids (buprenorphine, codeine, fentanyl, methadone morphine, oxycodone tramadol)
Theophylline
Your patient may also have a number of biochemical disturbances causing these symptoms, including
hypercalcaemia or uraemia. It is essential that these pathology tests are checked and that consultation with
other health professionals is undertaken. Psychological factors may also enhance the risk of nausea and
vomiting. These might include anxiety, fear, and the memory of a previous treatment. Be sure that your
documentation is thorough, as this can help to identify these issues. It may also be worthwhile discussing these
factors with other health professionals, such as psychologists, counsellors, or spiritual carers.
Conduct the Assessment
Examine the mouth and pharynx: look for thrush or ulceration.
Examine the abdomen: observe degree of distension, undertake auscultation for bowel sounds, and palpate for
intra-abdominal masses.
Conduct a rectal examination (with appropriate approval and cultural considerations): observe for
constipation/faecal loading.
Undertake neurological examination, including vestibular function.
Review blood examination: FBC, EUC, LFTs, Se calcium, magnesium, and phosphate if appropriate.
Review films: plain film X-rays of abdomen, CT brain if an increase in intracranial pressure (ICP) is suspected, CT
abdomen if examination indicates progressive disease, obstructive tumours, or lymphadenopathy.
Strategies for Controlling Nausea
In collaboration with your medical colleagues, consider the most appropriate medications and monitor their
effectiveness closely.
The rationale for using medications is to:
Prevent or relieve symptoms.
Prevent complications (dehydration, electrolyte disturbance).
Before starting treatment:
Identify, treat, or remove cause if possible.
Ensure adequate hydration.
Medications
There are a large number of medications that can be used in the short term management of nausea and
vomiting as summarised on Table 3.
Table 3: Some medications that can be used for the management of nausea and vomiting
Class, and Examples Indications Comments Common Side Effects
Dopamine Antagonists
May be used in May cause QT prolongation;
Domperidone Nausea and vomiting Parkinson’s
disease dry mouth, headache
Droperidol Prevention of PONV
Avoid use in
patients with Tardive dyskinesias in older
Nausea and
Parkinson’s
Metoclopramide vomiting; gastric people; akathesia, drowsiness,
disease. Maximum
stasis
dose: 5mg tds for 5 dizziness, headache
days.
Constipation, cardiovascular
Avoid use in
Nausea and patients with and cerebrovascular concerns, drowsiness,
Prochlorperazine
vomiting; vertigo Parkinson’s dizziness, headache,
disease
Parkinsonism, EPSE
5HT3
Agitation, anxiety
Granisetron somnolence, rash,
taste disturbances
Nausea and vomiting
associated with cancer Wafer or orally
Ondansetron chemotherapy, disintegrating Rare side effects
radiotherapy, tablets are available
post-operative
Palonosetron
Abdominal pain,
Tropisetron
fatigue, diarrhoea
Substance P Antagonists
Aprepitant Prevention of nausea
Diarrhoea, fatigue,
and vomiting with
highly or moderate headache, dizziness,
Fosaprepitant emetogenic
weakness, hiccups
chemotherapy
Sedating Antihistamines
Cyclizine PONV
Pheniramine Motion sickness,
nausea and vomiting More effective if Sedation
Promethazine;
Promethazine assoc with vestibular given before travel
theoclate disorders
Anticholinergics
Hyoscine
Motion sickness Dry mouth
hydrobromide
Corticosteroids
PONV adjunct for More effective if
Dexamethasone chemotherapy induced given before induction
nausea and vomiting of anaesthesia
Antipsychotics
Intractable nausea and
vomiting assoc with Only use if other EPSE, Increased risk
Haloperidol
chemotherapy and agents are ineffective of CNS effects
radiotherapy
PONV: post operative nausea and vomiting
EPSE: Extrapyridimal side effects
Medications used in pregnancy: nausea and vomiting are common during the first trimester pregnancy. Drug
treatment should be avoided if possible and emphasis placed on the importance of adequate hydration using ice
chips if necessary. Dietary modification may help. Ginger up to 1 g daily may be useful or pyridoxine (vitamin B6)
25–50 mg up to tds.
If these measures are ineffective, the following medications can be considered: doxylamine (Australian category
A), metoclopramide (Australian category A), promethazine (Australian category C), or prochlorperazine
(Australian category C) orally, if tolerated. In hyperemesis gravidarum IV rehydration is the main treatment.
Metoclopramide, prochlorperazine, or ondansetron (Australian category B1) are used if symptoms are
prolonged and intractable.
Non-pharmacological Interventions
Of course, a number of non-pharmacological strategies can also be used in conjunction with the medications.
Psychoeducational strategies are designed to lessen anxiety and equip patients with tools to help them manage
their emotions. These may include guided imagery, progressive muscle relaxation, music therapy, exercise,
yoga, and massage. If you are not skilled in these approaches, consider the involvement of your allied health
colleagues.
As well as these therapies, dietary modification strategies can be helpful in reducing the risk of vomiting and
nausea while also maintaining nutrition. Strategies could include:
positioning the patient upright while eating and for one hour post-meal
only offering dry foods throughout the day
bland, soft, easily-digestible food for main meals
rinsing patient’s mouth after eating.
Similarly, reducing environmental stimuli may help lessen the risk of external triggers. Strategies include
avoiding cooking aromas, not eating in an overly warm room, and ensuring good ventilation.
Once cause of the nausea or vomiting has been determined, it is possible to approach the problem with targeted
pharmacological and practical solutions in order to provide relief. With careful, ongoing assessment you will be
able to greatly improve the comfort of the patient.
