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The information contained in these documents is a statement of consensus of BC Cancer professionals regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult these documents is expected to use independent medical judgement in the context of individual clinical circumstances to determine any patient's care or treatment. Use of these documents is at your own risk.
Symptom Management Guidelines: Nausea and Vomiting
NCI GRADE AND MANAGEMENT | RESOURCES | CONTRIBUTING FACTORS | APPENDIX
Definition(s)
Nausea: Queasy sensation and/or urge to vomit Vomiting: The forceful expulsion of the contents of the stomach, duodenum, or jejunum through the oral cavity.
Focused Health Assessment
PHYSICAL ASSESSMENT SYMPTOM ASSESSMENT
Vital Signs
โ Frequency โ as clinically indicated
Weight
โ Take current weight and compare to pre โ treatment or last recorded weight
Hydration Status
โ Assess skin turgor, capillary refill, mucous membranes
โ Amount and character of urine (Is
patient urinating less than 400-500 ml per day? Is urine dark?) โ Level of consciousness?
Abdominal Assessment
โ Auscultate abdomen - assess presence and quality of bowel sounds โ Assess for abdominal pain, tenderness, distention
Emesis Examination
โ Inspect emesis for colour, consistency, quantity, odour and blood
Functional Status ๏ท Activity level/ECOG or PPS
*Consider contributing factors
Normal
โ Did you have nausea/vomiting prior to your treatment? โ Are you aware of any medications that you are taking that could cause nausea and vomiting (e.g. antibiotics)
Onset
๏ท When did the nausea and/or vomiting begin? ๏ท How many episodes of vomiting in the last 24 hours?
Provoking / Palliating
โ What brings on the nausea and/or vomiting? โ Is there anything that makes the nausea/vomiting better? Or worse?
Quality
โ Describe the emesis โ Colour: (Visible blood, coffee ground, bile) โ Volume: Large Amount; (2+ cups), moderate amount (ยฝ - 2 cups) small amount; (ยฝ cup or less). โ Odour
Region / Radiation - NA
Severity / other Symptoms
โ How bothered are you by this symptom? (On a scale of 0 โ 10, with 0 being not at all and 10 being the worst imaginable) โ Have you been able to eat in the past 24 hours? โ Have you be able to tolerate fluids in the past 24 hours โ Do you have nausea with or without vomiting? โ Projectile vomiting? โ Have you had any other symptoms such as: Abdominal pain? Headache? Pain elsewhere? โ Passing gas? โ Constipation? - When was your last bowel movement? Blood/mucous in stool? โ Fever? - possible infection โ Dehydration?: Dry mouth, thirst, dizziness, weakness, dark urine?
Treatment
โ What medications or treatments have you tried? Has this been effective?
Value
๏ท What do you believe is causing your nausea?
The information contained in these documents is a statement of consensus of BC Cancer professionals regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult these documents is expected to use independent medical judgement in the context of individual clinical circumstances to determine any patient's care or treatment. Use of these documents is at your own risk.
NAUSEA AND VOMITING GRADING SCALE
NCI CTCAE (Version 4.03)
GRADE 1
(Mild)
GRADE 2
(Moderate)
GRADE 3
(Severe)
GRADE 4
(Life Threatening)
GRADE 5
Nausea Loss of appetite without alteration in eating habits
Oral intake decreased without significant weight loss, dehydration or malnutrition
Inadequate oral caloric or fluid intake; tube feedings, TPN or hospitalization may be indicated
Vomiting 1 - 2 episodes (separated by 5 minutes) in 24 hours
3 - 5 episodes (separated by 5 minutes) in 24 hrs
โฅ 6 episodes separated by 5 minutes) in 24 hrs; tube feeding, TPN or hospitalization indicated
Life-threatening consequences; urgent intervention indicated
Death
*Step-Up Approach to Symptom Management:
Interventions Should Be Based On Current Grade Level and Include Lower Level Grade
Interventions As Appropriate
NORMAL โ GRADE 1 GRADE 2 OR
Nausea and Vomiting NOT resolving after 24
hours
NON โ URGENT
Prevention, support, teaching, & follow-up as clinically indicated
URGENT:
Requires medical attention within 24 hours
Patient Care and
Assessment
โ Provide instructions on how to take antiemetics, including dose and schedule. โ Rule out other causes of nausea and vomiting
Dietary Management Encourage:
โ Eat small, bland meals served cool. ie rice, crackers, toast. โ Sip water and other fluids - Aim for 8-10 glasses/day (coconut water, diluted juice, sports drinks, broth. Suck on ice chips, frozen fruit) โ Maintain oral hygiene โ Restrict fluids with meals
Nausea : try tea/smoothie made with grated ginger root, lemon zest or mint leaves, ginger candies, flat ginger ale.
Vomiting : Avoid solid food for 30-60 minutes after vomiting has passed. Start eating and drinking slowly in this order: 1.Clear liquids (water, ice chips, watered down juice, broth, popsicles) 2. Dry starchy food (crackers, dry toast) 3. Protein rich foods (chicken, fish, eggs) 4. Dairy foods (yogurt, milk, cheese) Avoid: โ alcohol and tobacco โ Avoid lying down after eating-sit upright 30-60 minutes NOTE: If patient unable to tolerate adequate daily fluid intake, IV hydration or hypodermoclysis to replace lost fluid and electrolytes may be required For further Dietary Management See Oncology Nutrition Services in Resource Section
The information contained in these documents is a statement of consensus of BC Cancer professionals regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult these documents is expected to use independent medical judgement in the context of individual clinical circumstances to determine any patient's care or treatment. Use of these documents is at your own risk.
โ Instruct patient/family to call back โ Arrange for nurse initiated telephone followโup or physician follow-up
GRADE 3 - GRADE 4
EMERGENT:
Requires IMMEDIATE medical attention
Patient Assessment โ^ Patients with Grade 3 or 4 nausea and vomiting generally require admission to^ hospital^ โ
notify physician of assessment, facilitate arrangements as necessary โ If patient is on Immunotherapy, remind them to present their Immunotherapy alert card. โ Consult with physician โ To rule out other causes or concomitant causes of nausea and vomiting โ To hold chemotherapy until symptoms resolved โ Lab tests that may be ordered: Complete blood count (CBC), electrolyte profile โ Nursing Support โ Monitor vital signs (as clinically indicated) โ Physical assessment โ Accurate intake and output record, include daily weight โ Pain and symptom assessment and management as appropriate
Dietary Management โ^ IV hydration to replace lost fluids and electrolytes
โ Enteral or parenteral nutrition (TPN) may be indicated for some patients For further Dietary Management See Oncology Nutrition Services in Resource Section
Pharmacological
Management
โ Avoid/discontinue any medications that may cause or exacerbate nausea and vomiting (in consultation with physician and pharmacist) โ Medications that may be prescribed intravenously:
- Ondansetron (Zofran)
- Metoclopramide
- Prochlorperazine (Stemetil)
- Haloperidol
- Nozinan
- Dexamethasone โ Refer to protocol specific algorithm if patient is on Immunotherapy For further Pharmacological Management See Cancer Management Guidelines (Health Professional) and Cancer Drug Manual in Resource Section
Patient Education โ^ Provide support, reinforce to patients/family that nausea and vomiting can be effectively
managed with prompt intervention โ Continue to reinforce self care, review medications, lab /diagnostic testing with patients/family as appropriate โ Discharge teaching as early as possible with patient/family
RESOURCES & REFERRALS
Referrals ๏ท Oncology Nutrition Services
๏ท Home Health Nursing ๏ท Patient Support Centre ๏ท Telephone Care for follow-up ๏ท Pain and Symptom Management/Palliative Care (PSMPC)
Health Professional
Resources
๏ท SCNAUSEA โ Guidelines for preventing and treatment of Chemotherapy-Induced Nausea and Vomiting in Adults
The information contained in these documents is a statement of consensus of BC Cancer professionals regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult these documents is expected to use independent medical judgement in the context of individual clinical circumstances to determine any patient's care or treatment. Use of these documents is at your own risk.
Immunotherapy ๏ท Immunotherapy Alert Card
๏ท Please refer to protocol specific algorithms to guide management of immune mediated side effects.
Patient Education
Resources
๏ท Nausea & Vomiting handout ๏ท Practical tips to help manage nausea handout ๏ท Nutritional Guidelines for Anorexia handout ๏ท Increasing Fluid Intake handout ๏ท Resources about managing anxiety, progressive muscle relaxation, positive thinking, etc http://www.bccancer.bc.ca/health-info/coping-with-cancer/emotional-support/resources
BC Inter-
professional
palliative symptom
management
guideline
๏ท https://www.bc-cpc.ca/cpc/symptom-management-guidelines/
Bibliography List ๏ท http://www.bccancer.bc.ca/health-professionals/clinical-resources/nursing/symptom-
management
Contributing Factors
Cancer Treatments Chemotherapy: For emetogenicity of chemotherapeutic agent, See Appendix A and Cancer Drug Manual in Resources Section
Immunotherapy/Biotherapy
Radiation Therapy:
Surgery/Anesthesia
Medication โ^ Antibiotics โ Opioids &/or Opioid withdrawal โ NSAIDs โ SSRI antidepressants โ Iron supplements โ Anticonvulsants โ Bronchodilators
Cancer Related : โ^ Cancer of the GI tract โ Brain metastases/Increased ICP โ Reduced GI motility, Bowel Obstruction, Chemotherapy induced (e.g. Vincristine) โ Constipation โ Vestibular dysfunction โ Anxiety, anticipatory nausea โ Hypercalcemia, hyperglycemia, hyponatremia โ Gastritis โ Infections โ Uremia โ Pain/Headache
Risk Factors: โ^ Female โ Less than 50 years of age โ Decreased risk for patients with a high chronic alcohol intake Lack of regular alcohol use โ History of motion/morning sickness, chemotherapy induced emesis.
The information contained in these documents is a statement of consensus of BC Cancer professionals regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult these documents is expected to use independent medical judgement in the context of individual clinical circumstances to determine any patient's care or treatment. Use of these documents is at your own risk.
Date of Print: Revised: August 2018 Created: January, 2010
The information contained in these documents is a statement of consensus of BC Cancer professionals regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult these documents is expected to use independent medical judgement in the context of individual clinical circumstances to determine any patient's care or treatment. Use of these documents is at your own risk.
Contributing Authors: Revised by: Jagbir Kaur, RN, MN (2018), Sara Gough, RN, MSN, CON(c) (2018), Ava Hatcher, RN BN (2014) Created by: Vanessa Buduhan, RN MN; Rosemary Cashman, RN MSc(A), MA (ACNP); Elizabeth Cooper, RN BScN, CON(c); Karen Levy, RN MSN; Ann Syme RN PhD(C)
Reviewed by: Karen Huebert, RN BSN CON(c) (2014); Lindsay Van der Meer, BSc RD (2014) Janelle Bellerive, NP (2018)
