Vomiting
Vomiting: Excerpt from Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series
Vomiting is the forceful expulsion of gastric contents through the mouth. Characteristically preceded by nausea, vomiting results from a coordinated sequence of abdominal muscle contractions and reverse esophageal peristalsis.
A common sign of GI disorders, vomiting also occurs with fluid and electrolyte imbalances, infections, and metabolic, endocrine, labyrinthine, central nervous system (CNS), and cardiac disorders. It can also result from drug therapy, surgery, or radiation.
Vomiting occurs normally during the first trimester of pregnancy, but its subsequent development may signal complications. It can also result from stress, anxiety, pain, alcohol intoxication, overeating, or ingestion of distasteful food or liquid.
Act Now: Immediate action is required if the patient’s vomiting has lead to dehydration or is resulting in significant blood loss. Immediate response includes instituting I.V. fluid or blood replacement. Obtain blood samples to assess electrolyte level, renal studies, liver function tests, and a complete blood count. Assess the patient’s vital signs frequently until he’s stable. Administer an antiemetic as ordered. Offer supportive care during vomiting episodes, and provide meticulous mouth care afterward.
Assessment
History
Ask the patient to describe the onset, duration, and intensity of his vomiting. What started the vomiting? What makes it subside? If possible, collect, measure, and inspect the character of the vomitus. (See Vomitus: Characteristics and causes.) Explore associated complaints, particularly nausea, abdominal pain, anorexia and weight loss, changes in bowel habits or stools, excessive belching or flatus, and bloating or fullness.
Obtain a medical history, noting GI, endocrine, and metabolic disorders; recent infections; and cancer, including chemotherapy or radiation therapy. Ask about current medication use and alcohol consumption. If the patient is a female of childbearing age, ask if she is or could be pregnant. Ask which contraceptive method she’s using.
Physical examination
Inspect the abdomen for distention, and auscultate for bowel sounds and bruits. Palpate for rigidity and tenderness, and test for rebound tenderness. Next, palpate and percuss the liver for enlargement. Assess other body systems as appropriate.
During the examination, keep in mind that projectile vomiting unaccompanied by nausea may indicate increased intracranial pressure (ICP), a life-threatening emergency. If this occurs in a patient with a CNS injury, you should quickly check his vital signs. Stay alert for widened pulse pressure or bradycardia.
Pediatric pointers
In a neonate, pyloric obstruction may cause projectile vomiting, whereas Hirschsprung’s disease may cause fecal vomiting. Intussusception may lead to vomiting of bile and fecal matter in an infant or toddler. Because an infant may aspirate vomitus as a result of his immature cough and gag reflexes, position him on his side or abdomen and clear any vomitus immediately.
Geriatric pointers
Although elderly patients can develop several of the disorders mentioned earlier, always rule out intestinal ischemia first — it’s especially common in patients of this age-group and it has a high mortality.
Medical causes
Adrenal insufficiency
Common GI findings with adrenal insufficiency include vomiting, nausea, anorexia, and diarrhea. Other findings include weakness, fatigue, weight loss, bronze skin, orthostatic hypotension, and a weak, irregular pulse.
Anthrax (GI)
Initial signs and symptoms after eating contaminated meat from an infected animal include vomiting, loss of appetite, nausea, and fever. Signs and symptoms may progress to abdominal pain, severe bloody diarrhea, and hematemesis.
Appendicitis
Vomiting and nausea may follow or accompany abdominal pain. Pain typically begins as vague epigastric or periumbilical discomfort and rapidly progresses to severe, stabbing pain in the right lower quadrant. The patient generally has a positive McBurney sign — severe pain and tenderness on palpation about 2" (5 cm) from the right anterior superior spine of the ilium, on a line between that spine and the umbilicus. Associated findings usually include abdominal rigidity and tenderness, anorexia, constipation or diarrhea, cutaneous hyperalgesia, fever, tachycardia, and malaise.
Bulimia
Most common in females ages 18 to 29, bulimia is characterized by polyphagia that alternates with self-induced vomiting, fasting, or diarrhea. It’s commonly accompanied by anorexia. The patient typically weighs less than what is considered healthy but has a morbid fear of obesity. Self-induced vomiting may be evidenced by calloused knuckles.
Cholecystitis (acute)
With acute cholecystitis, nausea and mild vomiting commonly follow severe right upper quadrant pain that may radiate to the back or shoulders. Associated findings include abdominal tenderness and, possibly, rigidity and distention, fever, and diaphoresis.
Cholelithiasis
Nausea and vomiting accompany severe unlocalized right upper quadrant or epigastric pain after eating fatty foods. Other findings include abdominal tenderness and guarding, flatulence, belching, epigastric burning, pyrosis, tachycardia, and restlessness.
Cholera
Signs and symptoms include vomiting and abrupt watery diarrhea. Severe water and electrolyte loss leads to thirst, weakness, muscle cramps, decreased skin turgor, oliguria, tachycardia, and hypotension. Without treatment, death can occur within hours.
Cirrhosis
Insidious early signs and symptoms of cirrhosis typically include nausea and vomiting, anorexia, aching abdominal pain, and constipation or diarrhea. Later findings include jaundice, hepatomegaly, and abdominal distention.
O157:H7. The signs and symptoms of E. coli O157:H7 infection include vomiting, watery or bloody diarrhea, nausea, fever, and abdominal cramps. In children younger than age 5 and in elderly people, hemolytic uremic syndrome may develop in which the red blood cells are destroyed, and this may ultimately lead to acute renal failure.
Ectopic pregnancy
Vomiting, nausea, vaginal bleeding, and lower abdominal pain occur in ectopic pregnancy, a potentially life-threatening disorder.
Electrolyte imbalances
Such disturbances as hyponatremia, hypernatremia, hypokalemia, and hypercalcemia commonly cause nausea and vomiting. Other effects include arrhythmias, tremors, seizures, anorexia, malaise, and weakness.
Food poisoning
Vomiting is a common finding in food poisoning, caused by preformed toxins produced by bacteria typically found in foods, such as
Bacillus cereus, Clostridium, and
Staphylococcus. Diarrhea and fever also usually occur.
Gastric cancer
This rare cancer may produce mild nausea, vomiting (possibly of mucus or blood), anorexia, upper abdominal discomfort, and chronic dyspepsia. Fatigue, weight loss, melena, and altered bowel habits are also common.
Gastritis
Nausea and vomiting of mucus or blood are common with gastritis, especially after ingestion of alcohol, aspirin, spicy foods, or caffeine. Epigastric pain, belching, and fever may also occur.
Gastroenteritis
Gastroenteritis causes nausea, vomiting (commonly of undigested food), diarrhea, and abdominal cramping. Fever, malaise, hyperactive bowel sounds, and abdominal pain and tenderness may also occur.
Heart failure
Nausea and vomiting may occur, especially with right-sided heart failure. Associated findings include tachycardia, ventricular gallop, fatigue, dyspnea, crackles, peripheral edema, and jugular vein distention.
Hepatitis
Vomiting commonly follows nausea as an early sign of viral hepatitis. Other early findings include fatigue, myalgia, arthralgia, headache, photophobia, anorexia, pharyngitis, cough, and fever.
Hyperemesis gravidarum
Unremitting nausea and vomiting that last beyond the first trimester characterize hyperemesis gravidarum, a disorder of pregnancy. Vomitus contains undigested food, mucus, and small amounts of bile early in the disorder; later, it has a coffee-ground appearance. Associated findings include weight loss, headache, and delirium. Thyroid dysfunction may be associated with this condition.
Increased ICP
Projectile vomiting that isn’t preceded by nausea is a sign of increased ICP. The patient may exhibit a decreased level of consciousness (LOC) and Cushing’s triad (bradycardia, hypertension, and respiratory pattern changes. He may also have headache, widened pulse pressure, impaired motor movement, vision disturbances, pupillary changes, and papilledema.
Infection
Acute localized or systemic infection may cause vomiting and nausea. Other common findings include fever, headache, malaise, and fatigue.
Intestinal obstruction
Nausea and vomiting (bilious or fecal) are common with intestinal obstruction, especially of the upper small intestine. Abdominal pain is usually episodic and colicky but can become severe and steady. Constipation occurs early in large intestinal obstruction and late in small intestinal obstruction. Obstipation, however, may signal complete obstruction. In partial obstruction, bowel sounds are typically high pitched and hyperactive; in complete obstruction, hypoactive or absent. Abdominal distention and tenderness also occur, possibly with visible peristaltic waves and a palpable abdominal mass.
Labyrinthitis
Nausea and vomiting commonly occur with labyrinthitis, an acute inner ear inflammation. Other findings include severe vertigo, progressive hearing loss, nystagmus and, possibly, otorrhea.
Listeriosis
After eating food contaminated with the bacterium
Listeria monocytogenes, vomiting, fever, myalgia, abdominal pain, nausea, and diarrhea occur. If the infection spreads to the nervous system, meningitis may develop. Signs and symptoms may include fever, headache, nuchal rigidity, and change in the patient’s LOC. The food-borne illness primarily affects pregnant females, neonates, and those with weakened immune systems.
Ménière’s disease
Ménière’s disease causes sudden, brief, recurrent attacks of nausea and vomiting, dizziness, vertigo, hearing loss, tinnitus, diaphoresis, and nystagmus.
Mesenteric artery ischemia
A life-threatening disorder, mesenteric artery ischemia may cause nausea and vomiting and severe, cramping abdominal pain, especially after meals. Other findings include diarrhea or constipation, abdominal tenderness and bloating, anorexia, weight loss, and abdominal bruits.
Mesenteric venous thrombosis
An insidious or an acute onset of nausea, vomiting, and abdominal pain occur with mesenteric venous thrombosis and may be accompanied by diarrhea or constipation, abdominal distention, hematemesis, and melena.
Metabolic acidosis
Metabolic acidosis is an imbalance that may produce nausea, vomiting, anorexia, diarrhea, Kussmaul’s respirations, and a decreased LOC.
Migraine headache
Nausea and vomiting are prodromal signs and symptoms, with fatigue, photophobia, light flashes, increased noise sensitivity and, possibly, partial vision loss and paresthesia.
Motion sickness
Nausea and vomiting may be accompanied by headache, vertigo, dizziness, fatigue, diaphoresis, and dyspnea.
Myocardial infarction
Nausea and vomiting may occur, but the cardinal symptom is severe substernal chest pain, which may radiate to the left arm, jaw, or neck. Dyspnea, pallor, clammy skin, diaphoresis, and restlessness also occur.
Pancreatitis (acute)
Vomiting, usually preceded by nausea, is an early sign of pancreatitis. Associated findings include steady, severe epigastric or left upper quadrant pain that may radiate to the back, abdominal tenderness and rigidity, hypoactive bowel sounds, anorexia, vomiting, and fever. Tachycardia, restlessness, hypotension, skin mottling, and cold, sweaty extremities may occur in severe cases.
Peptic ulcer
Nausea and vomiting may follow sharp, burning or gnawing epigastric pain, especially when the stomach is empty or after the ingestion of alcohol, caffeine, or aspirin. Attacks are relieved by eating or taking antacids. Hematemesis or melena may also occur.
Peritonitis
Nausea and vomiting usually accompany acute abdominal pain in the area of inflammation. Other findings include abdominal distention, rigidity, and tenderness as well as high fever with chills, tachycardia, hypoactive or absent bowel sounds, weakness, and pale, cold skin. The patient may also experience diaphoresis, hypotension, signs of dehydration, and shallow respirations.
Preeclampsia
Nausea and vomiting are common with preeclampsia, a disorder of pregnancy. Rapid weight gain, epigastric pain, generalized edema, elevated blood pressure, oliguria, severe frontal headache, and blurred or double vision also occur.
Q fever
Signs and symptoms of Q fever, a rickettsial infection, include vomiting, fever, chills, severe headache, malaise, chest pain, nausea, and diarrhea. Fever may last up to 2 weeks. In severe cases, the patient may develop hepatitis or pneumonia.
Renal and urologic disorders
Cystitis, pyelonephritis, calculi, and other disorders of this system can cause vomiting. Accompanying findings reflect the specific disorder. Persistent nausea and vomiting are typical findings in patients with acute or worsening chronic renal failure.
Rhabdomyolysis
Signs and symptoms of rhabdomyolisis include vomiting, muscle weakness or pain, fever, nausea, malaise, and dark urine. Acute renal failure is the most commonly reported complication. It results from renal structure obstruction and injury during the kidney’s attempt to filter myoglobin from the bloodstream.
Thyrotoxicosis
Nausea and vomiting may accompany the classic findings of severe anxiety, heat intolerance, weight loss despite increased appetite, diaphoresis, diarrhea, tremors, tachycardia, and palpitations. Other findings include exophthalmos, ventricular or atrial gallop, and an enlarged thyroid gland.
Typhus
Typhus is a rickettsial disease transmitted to humans by fleas, mites, or body lice. Initial symptoms include headache, myalgia, arthralgia, and malaise, followed by an abrupt onset of vomiting, nausea, chills, and fever. A maculopapular rash may be present in some cases.
Ulcerative colitis
Vomiting, nausea, and anorexia may occur, but the most common sign is recurrent diarrhea with blood, pus, and mucus. Fever, chills, and weight loss are also common.
Other causes
Drugs
Drugs that commonly cause vomiting include antineoplastics, opiates, ferrous sulfate, levodopa, oral potassium, chloride replacements, estrogens, sulfasalazine, antibiotics, quinidine, anesthetics, and overdoses of cardiac glycosides and theophylline. Syrup of ipecac, a mixture of ipecac fluid extract, glycerin, and syrup, is used to treat overdoses by inducing vomiting.
Radiation and surgery
Radiation therapy may cause nausea and vomiting if it disrupts the gastric mucosa. Postoperative nausea and vomiting are common, especially after abdominal surgery.
Nursing considerations
Draw blood to determine fluid, electrolyte, and acid-base balance. (Prolonged vomiting can cause dehydration, electrolyte imbalances, and metabolic alkalosis.) Have the patient breathe deeply to ease his nausea and help prevent further vomiting. Keep his room fresh and clean smelling by removing bedpans and emesis basins promptly after use. Elevate his head or position him on his side to prevent aspiration of vomitus. Continuously monitor his vital signs and intake and output (including vomitus and liquid stools). If necessary, administer I.V. fluids or have the patient sip clear liquids to maintain hydration.
Because pain can precipitate or intensify nausea and vomiting, administer pain medications promptly. If possible, give these by injection or suppository to prevent exacerbating associated nausea. If an opioid is used to treat pain, monitor bowel sounds and flatus and bowel movements carefully because they slow down GI motility and may exacerbate vomiting. If you administer an antiemetic, be alert for abdominal distention and hypoactive bowel sounds, which may indicate gastric retention. If this occurs, insert a nasogastric tube.
Patient teaching
Advise the patient to replace fluid losses to avoid dehydration. Inform the patient suffering from migraine headaches that vomiting may be a prodromal symptom; advise him to take antimigraine medication should vomiting occur.
Pictures
Book Source Details
- Book Title: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, Copyright © 2007 Lippincott Williams & Wilkins.
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Medical Books Excerpts
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- "In A Page: Pediatric Signs and Symptoms" (2007)
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- "Handbook of Signs & Symptoms (Third Edition)" (2006)
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- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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- Nausea and Vomiting
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
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- Vomiting
- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
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- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
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- Vomiting
- "Nursing: Interpreting Signs and Symptoms" (2007)
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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