Nausea
Nausea: Excerpt from Professional Guide to Signs & Symptoms (Fifth Edition)
Nausea is a sensation of profound revulsion to food or of impending vomiting. Often accompanied by autonomic signs, such 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. Often 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 this endocrine disorder 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 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 this disease, nausea often follows severe right-upper-quadrant pain that may radiate to the back or shoulders, often 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 this disease, 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 often a palpable, tender, firm, fixed mass.
Ectopic pregnancy
Nausea, vomiting, vaginal bleeding, and lower abdominal pain occur in this potentially life-threatening disorder. Suspect ectopic pregnancy in a female of childbearing age with a 1- to 2-month history of amenorrhea.
Electrolyte imbalances
Such disturbances 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 O157:H7
Signs and symptoms include nausea, watery or bloody diarrhea, vomiting, fever, and abdominal cramps. In children younger than age 5 and in the elderly, hemolytic uremic syndrome may develop in which red blood cells are destroyed, which may ultimately lead to acute renal failure.
Gastric cancer
This rare cancer may produce vague GI symptoms—mild nausea, anorexia, upper abdominal discomfort, and chronic dyspepsia. Fatigue, weight loss, weakness, hematemesis, melena, and altered bowel habits are also common.
Gastritis
Nausea is common with this disorder, 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, this disorder 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
This disorder 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
Unremitting nausea and vomiting that persist beyond the first trimester are characteristic of this 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, headache, and delirium.
Infection
Acute localized or systemic infection typically produces nausea. Other common findings include fever, headache, fatigue, and malaise.
Inflammatory bowel disease
The most common symptom is recurrent diarrhea with blood, pus, and mucus. Nausea, vomiting, abdominal pain, and anorexia may also occur.
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 this 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 this acute inner ear inflammation. More significant findings include severe vertigo, progressive hearing loss, nystagmus, tinnitus and, possibly, otorrhea.
Lactose intolerance
Depending on the individual, signs and symptoms may include nausea, diarrhea, cramps, bloating, and gas, and they occur after eating dairy products.
Listeriosis
Signs and symptoms include nausea, vomiting, diarrhea, fever, myalgias, and abdominal pain. If the infection spreads to the nervous system and causes meningitis, signs and symptoms include fever, headache, nuchal rigidity, and change in level of consciousness.
Ménière’s disease
This disease causes sudden, brief, recurrent attacks of nausea, vomiting, vertigo, tinnitus, diaphoresis, and nystagmus. It also causes hearing loss and ear fullness.
Mesenteric artery ischemia
With this condition, nausea and vomiting may accompany 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
Insidious or acute onset of nausea, vomiting, and abdominal pain occurs, with diarrhea or constipation, abdominal distention, hematemesis, and melena.
Metabolic acidosis
This acid-base imbalance may produce nausea and vomiting, anorexia, diarrhea, Kussmaul’s respirations, and decreased level of consciousness.
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 this disorder, 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 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.
Norovirus infection
Acute gastroenteritis from noroviruses commonly causes infected individuals to experience nausea. Frequent accompanying symptoms include vomiting, diarrhea, and abdominal pain or cramping. Less commonly, individuals may develop low-grade fever, headache, chills, muscle aches, and generalized tiredness. These viruses are carried in the stool or vomit of infected individuals, and are often spread through contaminated food or water. Duration of illness is brief, with healthy individuals recovering in 24 to 60 hours.
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 this disorder, nausea and vomiting may follow attacks of sharp or gnawing, burning epigastric pain. Attacks typically occur when the stomach is empty, or after ingestion of 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 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 include hypertension, proteinuria, and edema.
Q Fever
Signs and symptoms include nausea, vomiting, diarrhea, fever, chills, severe headache, malaise, and chest pain. Fever may last up to 2 weeks, and in severe cases, the patient may develop hepatitis or pneumonia.
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 include nausea, vomiting, muscle weakness or pain, 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 the myoglobin from the bloodstream.
Thyrotoxicosis
With this disorder, 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.
Typhus
An abrupt onset of nausea, vomiting, fever, and chills follows the initial symptoms of 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-inflammatories.
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 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 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 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. Often 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: Professional Guide to Signs & Symptoms (Fifth Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Professional Guide to Signs & Symptoms (Fifth 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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