BSN Notes: Common Signs And Symptoms: Vomiting

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VOMITING
·         Most common manifestation of GI disease
·         Nausea: It is a feeling of discomfort in the epigastrium with a conscious desire to vomit.
·         Vomiting: It is the forceful ejection of partially digested food and secretions from the upper GI tract.
Etiology
·         Found in wide variety of GI as well as unrelated to GI diseases        
·         Pregnancy
·         Infectious diseases - Food poisoning 
·         Central nervous system disorders - Meningitis, CNS tumors, head injury
·         Cardiovascular problems - Myocardial infarction, Heart failure
·         Metabolic disorders -  Diabetic mellitus, Addison's disease, uremia
·         Side effects of drugs -  Chemotherapy, opioids, digitalis
·         Psychological factors -  Stress, fear
·         Motion sickness,
·         migraines
·         Overeating
·         Appendicitis 
·         Inflammation of the labyrinth
·         Intestinal obstruction
·         Head injury
Pathophysiology
·         Vomiting is believed to be controlled by two distinct brain centers—the vomiting center and the chemoreceptor trigger zoneboth located in the medulla oblongata. The vomiting center initiates and controls the act of emesis, which involves a series of contractions of the smooth muscles lining the digestive tract.
·         Vomiting center in brainstem receives input from various stimuli.
·         Neural impulses reach the vomiting center via afferent pathways through branches of the autonomic nervous system.
·         Visceral receptors for these afferent fibers are located in the GI tract, kidneys, heart & uterus.  
·         When stimulated, these receptors relay information to the vomiting center and Initiates the vomiting reflex. 
·         Chemoreceptor trigger zone (CTZ) located on the floor of the fourth ventricle in the brain responds to chemical stimuli of drugs and toxins. Labyrinthine stimulation (motion sickness)  
·         Ones stimulated, CTZ transmits impulses directly to vomiting center.
·         Vomiting can also occur when the GI tract becomes overly irritated, excited, or distended.  
·         It can be a protective mechanism to rid the body of spoiled or irritating foods and liquids.
Clinical manifestations
·         Nausea -  a subjective complaint
·         Anorexia -  lack of appetite
·         Dehydration -  if vomiting prolongs  
·         Electrolyte imbalance, Hypotension
·         Weakness, Weight loss
·         Metabolic alkalosis -  loss of gastric HCl
Management Goal:
·         To determine and treat the underlying cause.  
·         To provide symptomatic relief.
History:
·         Frequency, precipitating factors
·         Contents of vomiting - bile,
·         Color of emesis- Coffee ground
·         Type -  projectile vomiting, regurgitation
·         Time -  early morning
Medical management
Drug therapy:
Antiemetic
·         Antihistamine: promethazine (Phenargan)  
·         Phenothiazines: Chlorpromazine
·         Prokinetic: Domperidone, Metoclopramide(Perinorm)
·         Serotonin antagonist: Ondansetron
·         Others: Dexamethasone for cancer chemotherapy induced emesis
Nutrition therapy:
·         For severe vomiting -  fluid therapy with electrolyte and GIucose replacement, NG tube aspiration
·         For improved condition- high carbohydrate and low fat diet. Small and frequent foods
Nursing Management
Assessment
·         Important health information: Past health history, medicines, surgery.
·         Physical examination:
·         General- Lethargy, sunken eyeball,
·         Integumentary - Pallor, dry mucus membrane, poor skin turgor
·         GI -  Amount, frequency, character, content, color of vomitus
·         Urinary -  Decreased output, concentrated urine
Nursing diagnosis
            Deficient fluid volume related to prolonged vomiting and inability to ingest, digest or absorb food and fluids.
Nurses responsibilities
·         Assess duration, frequency and nature of nausea and vomiting.
·         Provide mouth care, Administer & monitor amount & type of IV fluid
·         Provide small amounts of clear fluids,
·         Main I/O chart,
·         Monitor lab reports
·         Instruct patient to resume eating cautiously with bland non-irritating foods in small amounts to avoid irritating the stomach and initiating recurrence of nausea and vomiting.
·         Nausea and vomiting are common complaints and anti-emetics may play an important part in their management, but the primary objective should always be first to identify the underlying cause and if possible treat that primary disorder.



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