Today we continue our discussion of the patient presenting with nausea and vomiting, In our last post, we discussed the importance of obtaining a thorough history from our patient.
Nausea is an unpleasant sensation vaguely referred to the epigastrium and abdomen, with a tendency to vomit. Nausea may be a symptom of a variety of disorders, ranging from benign to serious. Nausea is usually felt when nerve endings in the stomach and other parts of the body are irritated. The irritated nerves send messages to the center in the brain that controls the vomiting reflex. When the irritation gets to a certain level, vomiting results. Because the nausea-vomiting mechanism is part of the autonomic nervous system, nausea and vomiting may be instigated from nerve signals in many different parts of the body. The North American Nursing Diagnosis Association (NANDA) defines nausea as “an unpleasant, wave-like sensation in the back of the throat or epigastrium, or throughout the abdomen that may or may not lead to vomiting”.
Vomiting is defined as the forcible voluntary or involuntary emptying of the contents of the stomach through the mouth.
There are many potential causes of nausea and vomiting. Below find a grid of potential causes, typical signs and symptoms, and examples.
Infection
S/S: Abrupt onset, spontaneous vomiting, often accompanied by fever, malaise, and diarrhea
Gastroenteritis (viral and bacterial), hepatitis, pelvic inflammatory disease, viral syndrome, upper respiratory infection
Food Poisoning
S/S: Symptoms occur hours to days after exposure, severe nausea and vomiting often with diarrhea, neurological symptoms, liver involvement
Bacterial sources – clostridium botulinum, staphylococcus
Non-bacterial sources – mushrooms, poisonous plants, fish, chemicals
Gastrointestinal Obstruction
S/S: Emesis containing undigested food, upper or lower abdominal pain and tenderness, absent bowel sounds, x-ray or computed tomography showing bowels loops, ileus, mass, stricture.
Gastric outlet obstruction related to peptic ulcer disease, gastroesophageal reflux disease, malignancy, esophageal stricture, pyloric stenosis, or intestinal obstruction related to malignancy, intussusception, adhesions, and motility disorders.
Medication
S/S: Symptoms may be from central trigger zone stimulation or irritation to the gastric mucosa.
Reactions to medication generally cause a persistent nausea.
If from gastric irritation, the nausea will worsen soon after medication administration.
With trigger zone stimulation, nausea is often delayed.
If related to cardiac medicines or bronchodilators, there may be changes in heart rate and EKG readings.
Cardiac medicines, especially digitalis and quinidine; anti-hypertensives; antibiotics; bronchodilators, especially aminophylline; antineoplastic drugs; NSAIDs; monoamine oxidase (MAO) inhibitors; antidepressants; anti-retrovirals; oral hyper-glycemics.
Metabolic Disorders
S/S: Mild nausea rarely accompanied by vomiting, muscle cramping, skin changes, hypotension or hypertension, neuropathic changes, abnormal renal or endocrine laboratory studies.
Renal disease with uremia, hyperglycemia, ketoacidosis, Addison’s Disease, hyperthyroidism
Central Nervous System Disorders
S/S: Central nervous system-related vomiting is often projectile and not preceded by nausea. Vomiting caused by space-occupying lesion is often worse when arising due to an increase in intracranial pressure when lying down. Depending upon the cause, accompanying symptoms include headache, visual disturbances, nystagmus, ataxia, and in meningitis, nuchal rigidity.
Meningitis, increased intracranial pressure, migraines, space-occupying lesion or fluid, Meniere’s Disorder, cerebellar disorders
Cardiac Disease
S/S: Often nausea only, but vomiting may occur in myocardial infarction with severe pain.
In congestive heart failure, the nausea is vague and persistent, accompanied by pain, diaphoresis, shortness of breath, edema.
Myocardial infarction, congestive heart failure
Pregnancy
S/S: Typically nausea without emesis, often in the morning but may present with persistent or intermittent vomiting, misses or irregular menses, positive HCG test.
Due to either hormonal or emotional changes.
Psychogenic
S/S: Usually promptly follows eating, may stop on hospitalization, more common in young women.
Anorexia, bulimia, anxiety
Cholecystitis/Pancreatitis
S/S: Nausea and vomiting are intermittent and usually accompanied by right upper quadrant pain or epigastric pain.
Due to infection, inflammation, or obstruction of the pancreas or gall bladder
This information is taken from The Correctional Nurse Educator series on Abdominal Assessment. In our next post we will review the components of an abdominal assessment.
Please share your experience with patients experiencing nausea and vomiting below.