Nausea
Nausea: Excerpt from Handbook of Signs & Symptoms (Third Edition)
Nausea is a sensation of profound revulsion to food or of impending vomiting. Typically accompanied by autonomic signs, such as hypersalivation, diaphoresis, tachycardia, pallor, and tachypnea, it’s closely associated with anorexia and vomiting.
Nausea, a common symptom of GI disorders, also occurs with fluid and electrolyte imbalance; infection; metabolic, endocrine, labyrinthine, and cardiac disorders; and as a result of drug therapy, surgery, and radiation. Commonly present during the first trimester of pregnancy, nausea may also arise from severe pain, anxiety, alcohol intoxication, overeating, or ingestion of distasteful food or liquids.
History and physical examination
Begin by obtaining a complete medical history. Focus on GI, endocrine, and metabolic disorders; recent infections; and cancer and its treatment. Ask about drug use and alcohol consumption. If the patient is a female of childbearing age, ask if she is or could be pregnant. Have the patient describe the onset, duration, and intensity of the nausea as well as what causes or relieves it. Ask about related complaints, particularly vomiting (color, amount), abdominal pain, anorexia and weight loss, changes in bowel habits or stool character, excessive belching or flatus, and a sensation of bloating.
Inspect the skin for jaundice, bruises, and spider angiomas, and assess skin turgor. Next, inspect the abdomen for distention, auscultate for bowel sounds and bruits, palpate for rigidity and tenderness, and test for rebound tenderness. Palpate and percuss the liver for enlargement. Assess other body systems as appropriate.
Medical causes
Adrenal insufficiency
Common GI findings in adrenal insufficiency include nausea, vomiting, anorexia, and diarrhea. Other findings include weakness; fatigue; weight loss; bronze skin; hypotension; a weak, irregular pulse; vitiligo; and depression.
Anthrax (GI)
Initial signs and symptoms include nausea, vomiting, loss of appetite, and a fever. Signs and symptoms may progress to abdominal pain, severe bloody diarrhea, and hematemesis.
Appendicitis
With acute appendicitis, a brief period of nausea may accompany the onset of abdominal pain. Pain typically begins as vague epigastric or periumbilical discomfort and rapidly progresses to severe stabbing pain localized in the right lower quadrant (McBurney’s sign). Associated findings usually include abdominal rigidity and tenderness, cutaneous hyperalgesia, a fever, constipation or diarrhea, tachycardia, anorexia, moderate malaise, and positive psoas (increased abdominal pain occurs when the examiner places his hand above the patient’s right knee and the patient flexes his right hip against resistance) and obturator signs (internal rotation of the right leg with the leg flexed to 90 degrees at the hip and knee with a resulting tightening of the internal obturator muscle that causes abdominal discomfort).
Cholecystitis (acute)
With acute cholecystitis, nausea commonly follows severe right upper quadrant pain that may radiate to the back or shoulders, usually following meals. Associated findings include mild vomiting, flatulence, abdominal tenderness and, possibly, rigidity and distention, a fever with chills, diaphoresis, and a positive Murphy’s sign.
Cholelithiasis
With cholelithiasis, nausea accompanies attacks of severe right upper quadrant or epigastric pain after eating fatty foods. Other associated findings include vomiting, abdominal tenderness and guarding, flatulence, belching, epigastric burning, tachycardia, and restlessness. Occlusion of the common bile duct may cause jaundice, clay-colored stools, a fever, and chills.
Cirrhosis
Insidious early signs and symptoms of cirrhosis typically include nausea and vomiting, anorexia, abdominal pain, and constipation or diarrhea. As the disease progresses, jaundice and hepatomegaly may occur with abdominal distention, spider angiomas, palmar erythema, severe pruritus, dry skin, fetor hepaticus, enlarged superficial abdominal veins, mental changes, and bilateral gynecomastia and testicular atrophy or menstrual irregularities.
Diverticulitis
Besides nausea, diverticulitis causes intermittent crampy abdominal pain, constipation or diarrhea, a low-grade fever, and commonly a palpable, tender, firm, fixed mass.
Escherichia coli O157:H7
Signs and symptoms include nausea, watery or bloody diarrhea, vomiting, a fever, and abdominal cramps. In children younger than age 5 and in the elderly, hemolytic uremic syndrome — in which red blood cells are destroyed — may develop. This may ultimately lead to acute renal failure.
Gastritis
Nausea is common with gastritis, especially after ingestion of alcohol, aspirin, spicy foods, or caffeine. Vomiting of mucus or blood, epigastric pain, belching, a fever, and malaise may also occur.
Gastroenteritis
Usually viral, gastroenteritis causes nausea, vomiting, diarrhea, and abdominal cramping. A fever, malaise, hyperactive bowel sounds, abdominal pain and tenderness, and possible dehydration and electrolyte imbalances may also develop.
Heart failure
Heart failure may produce nausea and vomiting, particularly with right-sided heart failure. Associated findings include tachycardia, a ventricular gallop, profound fatigue, dyspnea, crackles, peripheral edema, jugular vein distention, ascites, nocturia, and diastolic hypertension.
Hepatitis
Nausea is an insidious early symptom of viral hepatitis. Vomiting, fatigue, myalgia and arthralgia, a headache, anorexia, photophobia, pharyngitis, a cough, and a fever also occur early in the preicteric phase.
Hyperemesis gravidarum
Unremitting nausea and vomiting that persist beyond the first trimester are characteristic of hyperemesis gravidarum, a pregnancy disorder. Vomitus ranges from undigested food, mucus, and bile early in the disorder to a coffee-ground appearance in later stages. Associated findings include weight loss, signs of dehydration, a headache, and delirium.
Intestinal obstruction
Nausea commonly occurs, especially with high small-intestinal obstruction. Vomiting may be bilious or fecal; abdominal pain is usually episodic and colicky, but can become severe and steady with strangulation. Constipation occurs early in large-intestinal obstruction and later in small-intestinal obstruction; obstipation may signal complete obstruction. Bowel sounds are typically hyperactive in partial obstruction and hypoactive or absent in complete obstruction. Abdominal distention and tenderness occur, possibly with visible peristaltic waves and a palpable abdominal mass.
Labyrinthitis
Nausea and vomiting commonly occur with labyrinthitis, an acute inner ear inflammation. More significant findings include severe vertigo, progressive hearing loss, nystagmus, tinnitus and, possibly, otorrhea.
Listeriosis
Signs and symptoms include nausea, vomiting, diarrhea, a fever, myalgia, and abdominal pain. If listerosis spreads to the nervous system and causes meningitis, signs and symptoms include a fever, a headache, nuchal rigidity, and a change in the level of consciousness (LOC).
Gender Cue:Listeriosis infection during pregnancy may lead to premature delivery, infection of the neonate, or still birth.
Ménière’s disease
Ménière’s disease causes sudden, brief, recurrent attacks of nausea, vomiting, vertigo, tinnitus, diaphoresis, and nystagmus. It also causes hearing loss and ear fullness.
Mesenteric venous thrombosis
An insidious or acute onset of nausea, vomiting, and abdominal pain occurs, with diarrhea or constipation, abdominal distention, hematemesis, and melena.
Metabolic acidosis
Metabolic acidosis is an acid-base imbalance that may produce nausea and vomiting, anorexia, diarrhea, Kussmaul’s respirations, and a decreased LOC.
Migraine headache
Nausea and vomiting may occur in the prodromal stage, along with photophobia, light flashes, increased sensitivity to noise, light-headedness and, possibly, partial vision loss and paresthesia of the lips, face, and hands.
Motion sickness
With motion sickness, nausea and vomiting are brought on by motion or rhythmic movement. A headache, dizziness, fatigue, diaphoresis, hypersalivation, and dyspnea may also occur.
Myocardial infarction
Nausea and vomiting may occur, but the cardinal symptom is severe substernal chest pain that may radiate to the left arm, jaw, or neck. Dyspnea, pallor, clammy skin, diaphoresis, altered blood pressure, and arrhythmias also occur.
Pancreatitis (acute)
Nausea, usually followed by vomiting, is an early symptom of pancreatitis. Other common findings include steady, severe pain in the epigastrium or left upper quadrant that may radiate to the back; abdominal tenderness and rigidity; anorexia; diminished bowel sounds; and a fever. Tachycardia, restlessness, hypotension, skin mottling, and cold, sweaty extremities may occur in severe cases.
Peptic ulcer
With peptic ulcer, nausea and vomiting may follow attacks of sharp or gnawing, burning epigastric pain. Attacks typically occur when the stomach is empty or after the ingestion of alcohol, caffeine, or aspirin; they’re relieved by eating food or taking an antacid or antisecretory. Hematemesis or melena may also occur.
Peritonitis
Nausea and vomiting usually accompany acute abdominal pain localized to the area of inflammation. Other findings include a high fever with chills; tachycardia; hypoactive or absent bowel sounds; abdominal distention, rigidity, and tenderness (including rebound tenderness); a positive obturator sign and obturator weakness; pale, cold skin; diaphoresis; hypotension; shallow respirations; and hiccups.
Preeclampsia
Nausea and vomiting commonly occur with preeclampsia — a pregnancy disorder — along with rapid weight gain, epigastric pain, oliguria, a severe frontal headache, hyperreflexia, and blurred or double vision. The classic diagnostic triad of signs include hypertension, proteinuria, and edema.
Q Fever
Signs and symptoms include nausea, vomiting, diarrhea, a fever, chills, a severe headache, malaise, and chest pain. The fever may last up to 2 weeks, and in severe cases, the patient may develop hepatitis or pneumonia.
Rhabdomyolysis
Signs and symptoms include nausea, vomiting, muscle weakness or pain, a fever, malaise, and dark urine. Acute renal failure is the most commonly reported complication of the disorder. It results from renal structure obstruction and injury during the kidneys’attempt to filter myoglobin from the bloodstream.
Typhus
An abrupt onset of nausea, vomiting, a fever, and chills follows the initial symptoms of a headache, myalgia, arthralgia, and malaise.
Other causes
Drugs
Common nausea-producing drugs include antineoplastics, opiates, ferrous sulfate, levodopa, oral potassium chloride replacements, estrogens, sulfasalazine, antibiotics, quinidine, anesthetics, cardiac glycosides, theophylline (overdose), and nonsteroidal anti-inflammatory drugs.
Herb Alert
Herbal remedies, such as ginkgo biloba and St. John’s wort, can produce adverse reactions, including nausea.
Radiation and surgery
Radiation therapy can cause nausea and vomiting. Postoperative nausea and vomiting are common, especially after abdominal surgery.
Special considerations
If the patient is experiencing severe nausea, prepare him for blood tests to determine fluid and electrolyte status and acid-base balance. Have him breathe deeply to ease his nausea; keep his room air fresh and clean-smelling by removing bedpans and emesis basins promptly after use and by providing adequate ventilation. Because he could easily aspirate vomitus when in a supine position, elevate his head or position him on his side.
Because pain can precipitate or intensify nausea, administer pain medications promptly, as needed. If possible, give medications by injection or suppository to prevent exacerbating nausea. Be alert for abdominal distention and hypoactive bowel sounds when you administer an antiemetic: these signs may indicate gastric retention. If you detect these, immediately insert a nasogastric tube, as required.
Prepare the patient for such procedures as a computed tomography scan, an ultrasound scan, endoscopy, and colonoscopy. Consult the nutritionist to determine the patient’s metabolic demands such as total or partial parenteral nutrition.
Pediatric pointers
Nausea, commonly described as stomachache, is one of the most common childhood complaints. Typically the result of overeating, it can also occur as part of diverse disorders, ranging from acute infections to a conversion reaction caused by fear.
Geriatric pointers
Elderly patients have increased dental caries; tooth loss; decreased salivary gland function, which causes mouth dryness; reduced gastric acid output and motility; and decreased senses of taste and smell — any of which can contribute to nonpathologic nausea.
Book Source Details
- Book Title: Handbook of Signs & Symptoms (Third Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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