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BC Cancer Professionals' Consensus on Nausea & Vomiting Management in Cancer Treatment, Study notes of Oncology

A consensus statement of BC Cancer professionals regarding current approaches to managing nausea and vomiting during cancer treatment. It includes guidelines for assessing the severity of symptoms, preventive measures, and pharmacological and non-pharmacological interventions.

Typology: Study notes

2021/2022

Uploaded on 09/12/2022

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The information contained in these documents is a statement of co nsensus of BC Cancer professionals regarding their views of currently accepted approaches to tr eatment. Any
clinician seeking to apply or consult these documents is e xpected 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. Page 1 of 8
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
๏‚ทActivity 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
๏‚ทWhen did the nausea and/or vomiting begin?
๏‚ทHow 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
๏‚ทWhat do you believe is causing your nausea?
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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

โ‰ฅ 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 followโ€“up 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)