Nausea
Nausea: Excerpt from Signs & Symptoms: A 2-in-1 Reference for Nurses
Nausea is a sensation of profound revulsion to food or of impending vomiting. Commonly accompanied by such autonomic signs as hypersalivation, diaphoresis, tachycardia, pallor, and tachypnea, it’s closely associated with both anorexia and vomiting.
Nausea, a common symptom of GI disorders, also occurs with fluid and electrolyte imbalance; infection; and metabolic, endocrine, labyrinthine, and cardiac disorders; and as a result of drug therapy, surgery, and radiation. Nausea is commonly present during the first trimester of pregnancy. It may also arise from severe pain, anxiety, alcohol intoxication, overeating, or ingestion of distasteful food or liquids.
History
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.
Physical assessment
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, vitiligo, depression, and a weak, irregular pulse.
Anthrax (GI)
Initial signs and symptoms of GI anthrax include nausea, vomiting, loss of appetite, and 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 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, 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 typically follows severe right-upper-quadrant pain that may radiate to the back or shoulders, commonly following meals. Associated findings include mild vomiting, flatulence, abdominal tenderness and, possibly, rigidity and distention, 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 ingestion of 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, 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, low-grade fever and, in many cases, a palpable, tender, firm, fixed mass. Signs and symptoms may also include anorexia, bloody stools, and flatulence.
Electrolyte imbalances
Electrolyte imbalances such as hyponatremia or hypernatremia, hypokalemia, and hypercalcemia commonly cause nausea and vomiting. Other effects include cardiac arrhythmias, tremors or seizures, anorexia, malaise, and weakness.
Escherichia coli 0157:H7
Signs and symptoms of E. coli 0157:H7 include nausea, watery or bloody diarrhea, vomiting, fever, and abdominal cramps. In children under age 5 and in elderly people, hemolytic uremic syndrome may develop, which 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, fever, and malaise may also occur.
Gastroenteritis
Usually viral, gastroenteritis causes nausea, vomiting, diarrhea, and abdominal cramping. 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, 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, headache, anorexia, photophobia, pharyngitis, cough, and fever also occur early in the preicteric phase.
Hyperemesis gravidarum
In hyperemesis gravidarum, unremitting nausea and vomiting that persist beyond the first trimester of pregnancy are characteristic. Vomitus ranges from undigested food, mucus, and bile in the early stages of the disorder to a coffee-ground appearance in later stages. Associated findings include weight loss, signs of dehydration, headache, and delirium.
Inflammatory bowel disease
The most common symptom of inflammatory bowel disease is recurrent diarrhea with blood, pus, and mucus. Nausea, vomiting, abdominal pain, and anorexia may also occur. The patient may report abdominal cramps and spasms after meals.
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.
Irritable bowel syndrome
Nausea, dyspepsia, and abdominal distention may occur with irritable bowel syndrome, especially during periods of increased stress. Other findings include lower abdominal pain and abdominal tenderness, which is generally relieved by moving the bowels; diurnal diarrhea alternating with constipation or normal bowel function; and small stools with visible mucus and a feeling of incomplete evacuation.
Labyrinthitis
Nausea and vomiting commonly occur with labyrinthitis (acute inner ear inflammation). More significant findings in this disorder include severe vertigo, progressive hearing loss, nystagmus, tinnitus and, possibly, otorrhea.
Lactose intolerance
Depending on the individual, signs and symptoms of lactose intolerance may include nausea, diarrhea, cramps, bloating, and gas that occurs after eating dairy products. Borborygmi may be heard on auscultation.
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.
Metabolic acidosis
Metabolic acidosis is an acid-base imbalance that may produce nausea and vomiting, anorexia, diarrhea, Kussmaul’s respirations, and decreased level of consciousness. The patient may also exhibit central nervous system depression, drowsiness, lethargy, and stupor.
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. Headache, dizziness, fatigue, diaphoresis, hypersalivation, and dyspnea may also occur.
Myocardial infarction
Nausea and vomiting may occur, but the cardinal symptom of myocardial infarction 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 fever. Tachycardia, restlessness, hypotension, skin mottling, and cold, sweaty extremities may occur in severe cases.
Peptic ulcer
With a 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 ingesting alcohol, caffeine, or aspirin; they’re relieved by eating food or taking an antacid or an antisecretory. Hematemesis or melena may also occur.
Peritonitis
Nausea and vomiting usually accompany acute abdominal pain localized to the area of inflammation. Other findings in peritonitis include high fever with chills; tachycardia; hypoactive or absent bowel sounds; abdominal distention, rigidity, and tenderness (including rebound tenderness); positive obturator sign and obturator weakness; pale, cold skin; diaphoresis; hypotension; shallow respirations; and hiccups.
Preeclampsia
Nausea and vomiting commonly occur with this disorder of pregnancy, along with rapid weight gain, epigastric pain, oliguria, severe frontal headache, hyperreflexia, and blurred or double vision. The classic diagnostic triad of signs includes hypertension, proteinuria, and edema.
Renal and urologic disorders
Cystitis, pyelonephritis, calculi, uremia, and other disorders of the renal system can cause nausea. Related findings reflect the specific disorder.
Rhabdomyolysis
Signs and symptoms of rhabdomyolysis include nausea, vomiting, fever, malaise, and dark urine. The patient may also report tenderness, swelling, and muscle weakness that’s caused by muscle trauma and pressure.
Thyrotoxicosis
With thyrotoxicosis, nausea and vomiting may accompany the classic findings of severe anxiety, heat intolerance, weight loss despite increased appetite, diaphoresis, diarrhea, tremor, tachycardia, and palpitations. Other signs include exophthalmos, ventricular or atrial gallop, and an enlarged thyroid gland.
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 (upon overdose), and nonsteroidal anti-inflammatories.
Radiation and surgery
Radiation therapy can cause nausea and vomiting. Postoperative nausea and vomiting are common, especially after abdominal surgery.
Special considerations
If your 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 the air in his room 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 computed tomography scan, ultrasound, 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, nausea 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.
Patient counseling
Advise the patient to avoid reading because eye movement can aggravate nausea. Also instruct him to avoid sudden position changes. Encourage him to practice good oral hygiene to remove unpleasant tastes and to moisten the mucous membranes. Tell the patient to avoid foods that may aggravate feelings of nausea such as spicy foods.
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.
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Medical Books Excerpts
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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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- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
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- Nausea
- "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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