Vomiting
Vomiting: Excerpt from Signs & Symptoms: A 2-in-1 Reference for Nurses
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 foods or liquids.
History
Ask your 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, page 700.) Explore any 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 assessment
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 assessment, 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 CNS injury, you should quickly check his vital signs. Be alert for widened pulse pressure or bradycardia.
Medical causes
Adrenal insufficiency
Common GI findings associated with adrenal insufficiency include vomiting, nausea, anorexia, and diarrhea. Other findings include weakness; fatigue; weight loss; bronze skin; orthostatic hypotension; and weak, irregular pulse.
Anthrax (GI)
With anthrax, 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
With 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’s 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 women 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 normal 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 ingestion of fatty foods. Other findings in cholelithiasis include abdominal tenderness and guarding, flatulence, belching, epigastric burning, pyrosis, tachycardia, and restlessness.
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.
Escherichia coli 0157:H7
The signs and symptoms of E. coli include vomiting, watery or bloody diarrhea, nausea, fever, and abdominal cramps. In children younger than age 5 and elderly patients, 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. The patient with an ectopic pregnancy may have a tender adrenal mass and a 1- to -2-month history of amenorrhea.
Electrolyte imbalances
Electrolyte imbalances such as hyponatremia, hypernatremia, hypokalemia, and hypercalcemia frequently cause nausea and vomiting. Other effects include arrhythmias, tremors, seizures, anorexia, malaise, and weakness.
Food poisoning
Vomiting is a common finding in food poisoning. Diarrhea, severe, cramping abdominal pain, prostration, and fever also usually occur.
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 occur.
Gastroenteritis
Gastroenteritis causes nausea, vomiting (often 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.
Increased intracranial pressure
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.
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 in labyrinthitis include severe vertigo, progressive hearing loss, nystagmus, and possibly otorrhea.
Ménière’s disease
Ménière’s disease causes sudden, brief, recurrent attacks of nausea and vomiting, dizziness, vertigo, hearing loss, tinnitus, diaphoresis, and nystagmus. Hearing loss may be progressive and tinnitus may persist between attacks.
Mesenteric artery ischemia
Mesenteric artery ischemia is a life-threatening disorder that 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
With mesenteric venous thrombosis, insidious or acute onset of nausea, vomiting, and abdominal pain occurs along with diarrhea or constipation, abdominal distention, hematemesis, and melena.
Metabolic acidosis
Metabolic acidosis may produce nausea, vomiting, anorexia, diarrhea, Kussmaul’s respirations, and decreased LOC.
Migraine headache
Nausea and vomiting are prodromal signs and symptoms of a migraine headache. Fatigue, photophobia, light flashes, increased noise sensitivity, and possibly partial vision loss and paresthesia also occur.
Motion sickness
Rhythmic or erratic motion causes nausea and vomiting that may be accompanied by headache, vertigo, dizziness, fatigue, diaphoresis, and dyspnea.
Myocardial infarction
Nausea and vomiting may occur, but the cardinal symptom of myocardial infarction 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 ingestion of alcohol, caffeine, or aspirin. Attacks are relieved by eating or taking antacids. Hematemesis or melena may also occur.
Peritonitis
With peritonitis, nausea and vomiting usually accompany acute abdominal pain in the area of inflammation. Other findings include high fever with chills; tachycardia; hypoactive or absent bowel sounds; abdominal distention, rigidity, and tenderness; weakness; pale, cold skin; 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.
Renal and urologic disorders
Cystitis, pyelonephritis, calculi, and other renal and urologic disorders 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.
Thyrotoxicosis
With 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.
Ulcerative colitis
Vomiting, nausea, and anorexia may occur, but the most common sign of ulcerative colitis is recurrent diarrhea with blood, pus, and mucus. Fever, chills, and weight loss are other common signs and symptoms.
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 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.
Special considerations
Draw blood to determine fluid, electrolyte, and acid-base balance. (Prolonged vomiting can cause dehydration, electrolyte imbalances, and metabolic alkalosis.) Keep the patient’s 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 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, flatus, and bowel movements carefully because they may slow down GI motility and 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.
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 rate.
Patient counseling
Have the patient breathe deeply to ease his nausea and help prevent further vomiting. Advise him to replace fluid losses to avoid dehydration. A patient suffering from migraine headaches should be advised that vomiting may be a prodromal symptom and antimigraine medication should be taken.
Pictures
Book Source Details
- Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.
More About Chronic digestive diseases
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Medical Books Excerpts
- Vomiting
- "In A Page: Pediatric Signs and Symptoms" (2007)
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- Vomiting
- "Handbook of Signs & Symptoms (Third Edition)" (2006)
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- Vomiting
- "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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- Vomiting
- "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.
» Next page: Regurgitation and Vomiting (The Diagnostic Approach to Symptoms and Signs in Pediatrics)
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