Use the navigation arrows at the bottom of a page to move
between pages of the tutorial: Clicking on sends you to the home
page Clicking on sends you to the next page Clicking on sends you
to the previous page
Slide 4
Click on the Emesis Basin to learn about a specific objective
At the end of the tutorial you will know the: Incidence of
postoperative nausea and vomiting (PONV) Pathophysiologic process
involved in the development of PONV Inflammation, stress response,
and genetics in the development of PONV Risk factors associated
with the development of PONV Potential complications of PONV
Medical, nursing and complimentary treatments currently available
to manage PONV Case Study References
Slide 5
PONV occurs in 30% of patients overall, 70% of high risk
patients Patients prioritize vomiting as the top adverse reaction
in anesthesia to avoid PONV is unpleasant and associated with
patient discomfort /dissatisfaction with their perioperative care
30% of ambulatory patients experience post discharge nausea and
vomiting (PDNV) All clipart from microsoft.com unless otherwise
noted Wender, 2009
Slide 6
Financial Impact Average of $618 per patient is incurred today
from a single episode of PONV, even without unplanned admission
Consequences of unplanned admissions Detract from goal-same day
discharge Inconvenience to patients/families Results in lost
wages/missed work time Increases cost to hospital-additional drug
treatment/nursing care Kloth, 2009
Slide 7
Answer True or False to the following questions Click on the
correct answer 1. True or False-Patients prioritize vomiting as the
top adverse reaction in anesthesia to avoid TrueFalse- 2. True or
False-PONV may result in unplanned hospital admission resulting in
lost wages and missed work for patients True False-
Slide 8
You Are Correct-Great Start!!! Click arrow to go back
Slide 9
Sorry, this is incorrect-Patients prioritize vomiting as the
top adverse reaction to avoid, ahead of gagging on the tracheal
tube or incisional pain Click arrow to go back
Slide 10
Thats Right-Way to Go Click to go forward
Slide 11
Sorry, that is incorrect-PONV can result in unplanned hospital
admission, resulting in lost wages for patients, and inconvenience
for patients and families Click to go back
Slide 12
Definitions Nausea is a: Sensation associated with
awareness/urge to vomit Subjective, unpleasant feeling in upper
stomach and/or back of throat Patient descriptors-feel sick to my
stomach, feel queasy, feel squeamish Autonomic symptoms-pallor,
diaphoresis, tachycardia, salivation ASPANS Evidence-Based Clinical
Practice Guideline-PONV/PDNV- 2006
Slide 13
Definition Retching Attempt to vomit without expelling any
material Involves labored spastic respiratory movements against a
closed glottis with rhythmic contractions of the abdominal muscles,
chest wall and diaphragm Retching can occur without vomiting but
normally generates enough pressure to produce vomiting Patients
describe this as dry heaves ASPANS Evidence Based Clinical Practice
Guideline- PONV/PDNV-2006
Slide 14
Definition Vomiting Forceful expulsion GI contents Caused by
powerful, sustained contractions abdominal/ chest wall musculature,
accompanied by descent of diaphragm and opening of gastric
cardiacardia Reflux activity not under voluntary control Autonomic
symptoms-pallor, tachycardia, diaphoresis Patient
descriptors-puking, throwing up, tossing my cookies, barfing ASPANS
Evidence-Based Clinical Practice Guideline- PONV/PDNV-2006
Slide 15
Muscular Contractions Associated with Nausea and Vomiting
Copyright 2004, Amdipharm plc, All rights reserved
Slide 16
PONV is nausea or vomiting that occurs within the first 24 hour
period after surgery 3 phases Early PONV-Occurs within first 2-6
hours after surgery, often in PACU Late PONV-Occurs in 6-24 hour
period after surgery, often after transfer to floor or unit Delayed
PONV-Occurs beyond 24 hours postoperatively in the inpatient
setting ASPANS Evidence-Based Clinical Practice
Guideline-PONV/PDNV-2006
Slide 17
Nausea and vomiting are protective reflexes Physiologic
protective mechanism, limits possibility of damage from ingested
noxious agents by emptying contents of stomach and portions of
small intestine May represent a total body response to a
multiplicity of causes including pregnancy, motion, drugs and
surgery. www.nausea and vomiting co.uk 2004
Slide 18
Answer True or False to the Following Questions Click on the
Correct Answer 1. True or False-Vomiting is a reflex activity under
voluntary control TrueFalse 2. True or False-PONV is divided into
three phases, early, late and delayed TrueFalse 3. True or
False-Nausea and vomiting are physiologic protective mechanisms to
limit damage from toxins TrueFalse
Slide 19
Sorry, that is not correct- vomiting is a reflex activity not
under voluntary control, it causes the rapid and forceful
evacuation of stomach contents up and through the mouth. Click to
go back
Slide 20
Yes, you are correct-vomiting is a reflex not under voluntary
control Click to go back
Slide 21
Correct, way to go!!! Click to go back
Slide 22
Sorry, that is not the correct answer-PONV is divided into an
early, late and delayed phase, please review slide Click to go
back
Slide 23
Correct, you understand the concept!!! Click to go forward
Slide 24
Sorry, that is not correct. Nausea and vomiting are physiologic
protective mechanisms. Please review content of slide. Click to go
back
Slide 25
Schematic representation of factors and body systems involved
in nausea and vomiting process Copyright 2004, Amdipharm plc. All
rights reserved
Slide 26
Vomiting Center controls act of vomiting-located in medulla
oblongata of the brain Medulla is at base of brain, formed by
enlarged top spinal cord Medulla contains cardiac, vasomotor and
respiratory centers of brain www.anomalocaris.net Mattson-Porth,
2005 MEDULLA
Slide 27
Vomiting center- not a discrete anatomical site-represents
nerve network that receives input from different areas in body
Controls vomiting, when activated, sends signals to salivary,
respiratory centers, pharynx, stomach/intestinal muscles Signals
result in vomiting Copyright 2004, Amdipharm plc. All rights
reserved Wilhelm et al, 2007
Slide 28
www.nlm.nih.gov Nerve pathways: Input to vomiting center from
body carried on afferent nerve pathways. Input from vomiting center
to areas that initiate actual vomiting reflex carried on efferent
nerve pathways. www.nauseaandvomiting.co.uk
www.nauseaandvomiting.co.uk 2004
Slide 29
Chemoreceptor Trigger Zone located in fourth ventricle brain
Chemoreceptor- sensory nerve activated by chemical stimuli
Copyright 2004, Amdipharm plc. All rights reserved
www.nauseaandvomiting.co.uk www.nauseaandvomiting.co.uk 2004
Slide 30
Chemoreceptor Trigger Zone (CTZ) Located outside blood brain
barrier Major chemosensory organ for emesis-usually associated with
chemically induced vomiting. Blood-borne/cerebrospinal fluid toxins
have easy access to CTZ. CTZ can be affected by anesthetic
agents/opioids Provides input to vomiting center DiPiro, 2005
Slide 31
Answer True or False to the following questions Click on the
correct answer 1. True or False-The vomiting center in the medulla
controls the act of vomiting TrueFalse 2. True or False-A
chemoreceptor is a sensory nerve activated by movement TrueFalse 3.
True or False-The CTZ is outside the blood-brain barrier and is
usually associated with chemically induced vomiting TrueFalse
Slide 32
Correct, you got it right-way to pay attention! Click to go
back
Slide 33
Sorry, that is not correct-The vomiting center does control the
act of vomiting from input it receives from other parts of the body
Click to go back
Slide 34
Sorry, that is not correct. A chemoreceptor is a sensory nerve
activated by chemical stimuli Click to go back
Slide 35
Yes, you are correct!! Click to go back
Slide 36
Yes, that is correct, isnt pathophysiology interesting? Click
to go forward
Slide 37
Sorry, that is not correct-The CTZ is outside the blood-brain
barrier and is usually associated with chemically induced vomiting
Click to go back
Slide 38
Input to vomiting center: GI Tract Input comes from stomach,
jejunum, ileumjejunum ileum Input travels on visceral afferent
vagus nerve www.nauseaandvomiting.co.ukwww.nauseaandvomiting.co.uk
2004
Slide 39
Two types of receptors in the GI organs are involved in
detecting vomiting producing stimuli Mechanoreceptor Sensory nerve
in muscular wall gut-responds to mechanical stimulation
Examples-touch, pressure, muscular contractions Tension
receptors-send input to vomiting center in response to distention
or contraction
www.nauseaandvomiting.co.ukwww.nauseaandvomiting.co.uk 2004
www.illustrationsof.com
Slide 40
Chemoreceptor Sensory nerve cell activated by chemical stimuli
Located in mucosal layer of GI tract Triggered by noxious
substances in luminal environmentluminal Respond to a variety of
toxins When toxins cause irritation to GI tract, information
travels to CTZ and vomiting center which may initiate vomiting
reflex. www.nauseaandvomiting.co.uk www.nauseaandvomiting.co.uk
2004
Slide 41
Input to vomiting center: Cerebral cortex Layer of neurons and
synapses (gray matter) on surface of cerebral hemispheres.
Mattson-Porth, 2005
Slide 42
Cerebral Cortex Function-to integrate higher mental functions,
general movements, visceral functions, perception, speech and
memory patterns.visceral Higher cortical effects can stimulate or
suppress nausea and vomiting Prefrontal cortex-responsible for
planning, problem solving, intellectual insight, judgment,
expression of emotion. May send input to vomiting center regarding
past memories, fears, anticipation associated with vomiting.
Example-Patient arrives anxious and fearful, states I always vomit
after surgery. Mattson-Porth, 2005
Slide 43
Parietal lobe Integrates/processes sensory information from
various parts bodysensory In parietal lobe sensory experiences
begin to form into cognitions experienced as thinking in frontal
lobes Sensory input from nausea and vomiting integrated here.
www.howstuffworks.com Mattson-Porth, 2005
Slide 44
Answer True or False to the following questions Click on the
correct answer 1. True or False-A mechanoreceptor is a sensory
nerve ending that responds to distention TrueFalse 2. True or
False-Input to the CTZ and vomiting center is carried on visceral
efferent nerve pathways TrueFalse- 3. True or False-The parietal
lobe integrates and processes sensory input TrueFalse
Slide 45
Thats correct-way to go Click to go back
Slide 46
Im sorry, that is not correct- mechanoreceptors are tension
receptors that respond to touch, pressure and muscular contractions
Click to go back
Slide 47
Sorry, that is incorrect-input to the CTZ and vomiting center
is carried on visceral afferent pathways Click to go back
Slide 48
Yes, you are correct, you know your nerve pathways Click to go
back
Slide 49
Yes, you are correct-the parietal lobe integrates and processes
the sensory information Click to go forward
Slide 50
Sorry, that is not correct, the parietal lobe integrates and
processes the sensory information Click to go back
Slide 51
Input to vomiting center: Vestibular apparatus Consists of
peripheral apparatus and CNS connections Peripheral apparatus- 5
parts: three semicircular canals, a utricle and saccule Copyright
1996-2005, WebMD, Inc. All rights reserved Mattson-Porth, 2005
Slide 52
Vestibular apparatus Inner ear structures associated with
balance/position sense-maintains head/body position through reflex
control and stable visual field despite head movements Vestibular
nerve fibers carry information from inner ear to vestibular
nuclei.vestibular Vestibular nuclei has neurons that project to
thalamus and temporal and sensory areas of parietal cortex.
Mattson-Porth, 2005
Slide 53
Thalamic and cortical projections of vestibular apparatus
provide basis for subjective experience of
position/rotation/dizziness. Vestibular system can stimulate PONV
as a result of surgery involving middle ear or postoperative
movement. Sudden head movement after surgery, leads to vestibular
disturbance, and increased incidence of PONV Mattson-Porth,
2005
Slide 54
Neuromediators Neurotransmitters are chemical messenger
molecules of nervous system. Neurotransmission involves
development, storage, and release of a neurotransmitter; reaction
of neurotransmitter with its receptor site, and termination of
receptor action DiPiro, 2005
Slide 55
Numerous neurotransmitters are located in vomiting center, CTZ,
GI tract Examples-cholinergic, histaminic, dopaminergic, opiate,
serotonergic, neurokinin, benzodiazepine receptors Emetic compounds
(chemotherapy drugs, narcotics), theoretically trigger vomiting
process through reaction of emetic compound with its receptor site
Effective antiemetics are able to block or antagonize emetogenic
receptors emetogenic DiPiro, 2005
Slide 56
Chemoreceptor trigger zone and cerebral cortex Vestibular
apparatus Visceral afferent nerves- GI tract Central vomiting
center Salivary center Respiratory center Pharyngeal/GI/ abdominal
muscles VOMITING Diagram representing nausea and vomiting
pathways
Slide 57
Answer True or False to the following questions Click on the
correct answer 1. True or False-The vestibular apparatus is the
inner ear structures associated with balance/position sense True
False- 2. True or False-Neurotransmitters are the chemical
messenger molecules of the nervous system TrueFalse 3. True or
False-Neurotransmitters bind to receptor sites to trigger the
vomiting process TrueFalse
Slide 58
That is correct, the vestibular apparatus is associated with
balance and position sense Click to go back
Slide 59
Sorry, that is not correct, please review. The vestibular
apparatus maintains head and body position with reflex control, and
visual stability despite head movements Click to go back
Slide 60
Correct, correct- neurotransmitters are the chemical messengers
of the nervous system! Click to go back
Slide 61
Sorry, that is not correct- remember, neurotransmitters are
chemical messengers in the nervous system Click to go back
Slide 62
Correct, now you understand the process- neurotransmitters bind
with their receptors to produce a specific physiologic response
Click to move forward
Slide 63
Sorry, please review your neurotransmitters- remember they bind
to a particular receptor site to produce a physiologic response
Click to go back
Slide 64
Inflammation as a cause of PONV Causes of intraabdominal organ
inflammation are multifactoral and may include irritation,
infection, toxin exposures, and surgical procedures and anesthesia
http://digestive.niddk.nih.gov Mattson-Porth, 2005
Slide 65
Anesthesia, surgery and PONV Gastric inflation during mask
ventilation may cause PONV by producing gaseous distention of
stomach/ upper small intestine Nitrous oxide gas diffusion into
spaces of intestinal wall worsens distention Surgical procedures
may produce gastric inflammation- i.e. gastric resection.
Inflammation activates mechanoreceptors which send afferent signals
to vomiting center via vagus nerve Rahman et al, 2004
Slide 66
The corticotropin-releasing factor system Integrator of CNS
response to stress/negative emotion Hypothalamus controls release
of CRHCRH When released during stress, increases transit through
large bowel/delays gastric emptying which may produce PONV
Larzelere, 2008
Slide 67
Activities of brain and gut are highly interrelated, which
accounts for high prevalence of GI symptoms reported by patients in
response to stress Stress may be psychological Psychological stress
may be manifested prior to surgery in nervous patient who is
already experiencing a queasy stomach GI difficulty can impact
mood, behavior, and pain responsiveness Larzelere, 2008
Slide 68
Stress may be physical Surgical trauma stimulates the release
of CRH Increased cytokine production, as a result of stress, can
produce similar physiologic effects (delayed gastric
emptying/increased colonic motility) Minimally invasive surgery
reduces wound size and thereby decreases the undesirable
inflammatory response, pain and catabolism Larzelere, 2008
Slide 69
Answer True or False to the following questions Click on the
correct answer 1. True or False-Mask ventilation may cause PONV by
creating gastric and upper intestinal inflammation TrueFalse 2.
True or False- The medulla controls the release of CRH, which, when
released during stress increases transit through the bowel and
delays gastric emptying. TrueFalse 3. True or False-Minimally
invasive surgery reduces wound size and decreases the undesirable
inflammatory response TrueFalse-
Slide 70
Yes, you are correct, mask ventilation can increase
inflammation in the stomach and upper intestine Click to go
back
Slide 71
Sorry, that is not correct, mask ventilation increases
inflammation in the stomach and upper intestine, nitrous oxide
makes it worse Click to go back
Slide 72
Sorry, the hypothalamus controls the release of CRH Click to go
back
Slide 73
Yes, you are correct, the hypothalamus, not the medulla
controls the release of CRH Click to go back
Slide 74
Yes, that is right- minimally invasive surgery does decrease
the inflammatory response by decreasing wound size Click to move
forward
Slide 75
Sorry, that is not correct- by reducing wound size, minimally
invasive surgery reduces inflammation, tissue catabolism and pain
Click to go back
Slide 76
There are genetic differences in how drugs are metabolized
Genetic information is stored in the structure of DNA Errors in
duplication of DNA may occur producing a mutation Somatic mutation
affects a group of cells that differentiate into one or more of
many tissues of body Somatic mutations that do not have an impact
on health or functioning are called polymorphisms Mattson-Porth,
2005
Slide 77
Majority of drugs are metabolized via microsomal enzymes
localized in liver, and to a lesser extent, small intestine
Activity of many drugs depends on their interaction with enzymes of
P450 (CYP) system More than 5o human CYP isozymes have been
identified, CYP2D6 is best characterized isozyme CYP2D6 metabolizes
approximately 25% of all clinically used medication, including
antiemetics Genetic polymorphisms in drug-metabolizing enzymes are
a major cause of variability in drug metabolism leading to adverse
effects or lack of therapeutic effect Bernard, 2006
Slide 78
Primary purpose of risk factor identification in preoperative
period is to determine potential risk of a patient developing PONV
or PDNV Risk factor tools have been developed to identify patients
at high risk for PONV The simplified tools provide better
discrimination and calibration for prediction of PONVsimplified
ASPANS Evidence-Based Clinical Practice Guideline-PONV/PDNV-
2006
Slide 79
1-2 risk factors=20-40% risk of developing PONV 3-4 risk
factors increase number of patients with PONV to 60-80% Patients
with 20% or greater risk of developing PONV should be considered
high risk and treated prophylactically Appropriate PONV prophylaxis
should reduce need for postoperative treatment and reduce length of
stay in PACU Kapoor, 2008
Slide 80
The following risk factors are supported by strong evidence in
literature Female-two-four fold higher incidence of PONV compared
to males males History PONV and motion sickness-doubles risk
Nonsmoker-doubles risk Postoperative opioids-doubles risk Volatile
Anesthetics Nitrous Oxide ASPANS Evidence-Based Clinical Practice
Guideline-PONV/PDNV- 2006
Slide 81
A risk factor that is supported by conflicting evidence in the
literature is the type of surgery Risk factors increase with
abdominal, gynecologic, orthopedic, ENT surgery Laparoscopic
surgery increases risk because of gas insufflated into abdomen or
pelvis Intubation increases risk due to pharyngeal mechanoreceptor
afferent stimulation Wender, 2009
Slide 82
PONV is a significant concern because It exacerbates patient
discomfort Increases risk for suture dehiscence, esophageal
rupture, aspiration and subcutaneous emphysema Prolonged
postoperative hospital stays Delayed return of patient functional
ability Need for additional drug treatment and nursing care
increases cost of care Kapoor, 2008
Slide 83
Answer True or False to the following questions Click on the
correct answer 1. True or False-Genetic polymorphisms may exist in
the enzymes that metabolize medications leading to adverse effects
(such as PONV) or lack of drug effectiveness True False 2. True or
False-The primary purpose of risk factor identification preop is to
determine the risk for PONV TrueFalse 3. True or False-PONV
increases patient discomfort, prolongs stay and delays return to
patient functional ability True False
Slide 84
You are correct, polymorphisms are interesting, dont you agree?
Click to go back
Slide 85
Sorry, that is not correct, polymorphisms in drug metabolizing
enzymes may cause side effects or a lack of therapeutic effect
Click to go back
Slide 86
Correct, identification of risk factors preop allows us to
decrease the risk of PONV Click to go back
Slide 87
Sorry, you are not correct-remember identification of risk
factors preop helps to prevent PONV Click to go back
Slide 88
Yeah, way to go-lets prevent PONV!! Click to move forward
Slide 89
Sorry, that is not correct, PONV increases patient discomfort,
prolongs stay, and increases cost Click to go back
Target neurotransmitter-receptor sites in brain and
peripherally Anti-emetic may target single or multiple receptors
Each pathway functions independently providing an opportunity to
treat PONV When therapies from multiple drug classes are combined,
targeting multiple receptor systems, increase in antiemetic
efficacy is generally observed. Ignoffo, 2009
Slide 92
Phenothiazines Mainly block dopamine/5HT3 receptors in CTZ Act
against agents that directly stimulate CTZ (opioids/general
anesthesia) Active against emetic stimuli from GI tract Copyright
2004, Amdipharm plc. All rights reserved Rahman, 2004
Slide 93
Anticholinergics Block action of acetylcholine at muscarinic
receptors in vestibular system muscarinic Reduces gastric
motility/afferent stimulation of vomiting center Copyright 2004,
Amdipharm plc. All rights reserved
Slide 94
Antihistamines Block acetylcholine action in vestibular
apparatus Less effect on vomiting induced by direct stimulation CTZ
Copyright 2004, Amdipharm plc. All rights reserved Rahman,
2004
Slide 95
Butyrophenones Block dopamine receptors in CTZ Similar
properties to phenothiazines *Droperidol-monitored patients
only(potential prolong cardiac QT interval) Copyright 2004,
Amdipharm plc. All rights reserved Rahman, 2004
Slide 96
Benzamides Block dopamine receptors in CTZ Block peripheral
dopamine receptors- enhanced gastric/upper intestinal motility
Copyright 2004, Amdipharm plc. All rights reserved Rahman,
2004
Slide 97
Corticosteroids Precise mechanism of action unknown Effects
thought to be mediated by antiinflammatory/ membrane stabilizing
activities peripherally and centrally Copyright 2004, Amdipharm
plc. All rights reserved Kloth, 2009
Slide 98
5HT3 receptor antagonists Block 5HT3 receptors Peripherally in
gut (vagal afferent nerves) Centrally in CTZ Copyright 2004,
Amdipharm plc. All rights reserved Rahman, 2004
Slide 99
Neurokinin-1 receptor antagonists Block substance P
(neurotransmitter) at neurokinin-1 receptors Vomiting center and
CTZ Copyright 2004, Amdipharm plc. All rights reserved Rahman,
2004
Slide 100
Answer True or False to the following questions Click on the
correct answer 1. True or False-There are four classifications of
medication to treat PONV True False 2. True or False-Medications
target receptors peripherally and centrally and some target more
than one site TrueFalse 3. True or False-PONV is decreased by
combining medications that target multiple receptors TrueFalse
Slide 101
Sorry, that is not correct, there are actually 8
classifications of meds to treat PONV Click to go back
Slide 102
Yes, youre correct- there are 8 classifications of meds to
treat PONV- can you name them? Click to go back
Slide 103
Yes, that is correct-way to go remember your peripheral and
central receptors Click to go back
Slide 104
Sorry, that is not correct, there are receptors both centrally
and peripherally to target in preventing PONV Click to go back
Slide 105
That is right-combining or stacking meds to target multiple
receptor sites helps to decrease PONV!! Click to move forward
Slide 106
Sorry, that is not correct- please review this content-
remember targeting multiple receptors with multiple antiemetics
helps to decrease the risk of PONV Click to go back
Slide 107
Fluid abnormalities may be multifactoral Preoperative fasting
Surgical preps (bowel preps) Administration/management anesthesia
Surgical procedure/associated fluid losses Noble, 2008
Slide 108
IV fluid therapy Perioperative fluid administration of greater
than 1L improves recovery after minor to moderate operations Data
does not support choice of one fluid over another IV fluid
generally reduced postoperative drowsiness/dizziness Be
cautious-vulnerable patients-fluid volume overload! Holte,
2006
Slide 109
Nursing diagnosis-Nausea Outcome- Improve or maintain hydration
Intervention-Manage fluid/electrolyte balance Nursing activities
Promote oral intake in absence N/V Set appropriate IV rate,
(consider current IV fluid intake, patient comorbidities) Keep
accurate record I/O Monitor S/S fluid retention (monitor lab
values) Monitor vital signs Assess buccal membranes, sclera, skin
indications altered fluid/electrolyte balance Bulechek, 2008
Moorhead, 2008
Slide 110
Nursing diagnosis-Nausea Outcome-control of nausea and vomiting
Intervention-nausea and vomiting management Nursing activities
Identify risk factors N/V pre and postoperatively Evaluate past
experiences with nausea Complete assessment N/V frequency,
duration, severity, precipitating factors (use tool, i.e. Rhodes
Index of N/V)Rhodes Index of N/V Bulechek, 2008 Moorhead, 2008
Slide 111
Nursing Activities (interrelate with pathophysiology) Cerebral
cortex Control environmental factors aversive smells, sounds,
unpleasant visual stimulation Reduce/eliminate personal factors
that precipitate or increase nausea/vomiting (anxiety, fear,
fatigue, lack of knowledge) Oral hygiene to promote comfort with
nausea/following emesis Clean up after emesis with special
attention to removing odors Teach use of nonpharmacologic
techniques (guided imagery) Bulechek, 2008
Slide 112
Nursing Activities GI tract Position to prevent
aspiration/maintain airway Provide physical support during vomiting
(assist person to bend over or support persons head) Wait at least
30 minutes after emesis, start with fluids that are clear/free of
carbonation-gradually increase fluids if no vomiting in 30 minute
period Monitor for damage esophagus/posterior pharynx from
prolonged retching/vomiting Ensure effective antiemetics given to
prevent N/V- monitor effects vomiting management throughout
Bulechek, 2008
Slide 113
Nursing Diagnosis-Surgery recovery delayed Outcome-decreasing
the severity of nausea and vomiting Interventions-managing nausea
and vomiting Nursing activities All activities as listed for nausea
and vomiting management (please review content as needed) Bulechek,
2008 Moorhead, 2008
Slide 114
American Society of Perianesthesia Nurses developed clinical
practice guidelines in 2006 16 multispecialty, multidisciplinary
experts reviewed/analyzed published data and developed a consensus
for clinical practice recommendations Algorithms developed for
prevention and/or management of PONV/PDNV ASPANS Evidence-Based
Clinical Practice Guideline-PONV/PDNV- 2006
Slide 115
*ASPAN=American Society of Perianesthesia Nurses ASPANsASPANs
Evidence-based Clinical Practice Guideline for the Prevention
and/or Management of PONV/PDNVr((2006) Journal of PeriAnesthesia
Nursing, 21(4), pp 230-250
Slide 116
Answer True or False to the following questions Click on the
correct answer 1. True or False-Perioperative fluid administration
of greater than 1 L improves recovery after minor to moderate
operations TrueFalse 2. True or False-Reducing or eliminating
personal factors (fear/anxiety) that may increase N/V targets the
cerebral cortex True False- 3. True or False-After an emesis it is
important to wait 30 minutes before offering liquids that are clear
and free of carbonation True False
Slide 117
Yes, you are correct, greater than 1 liter of fluid in
appropriate patients improves recovery! Click to go back
Slide 118
Sorry, that is not correct, greater than 1 liter of fluid in
appropriate patients does improve recovery after minor to moderate
operations. Click to go back
Slide 119
Yes, thats right-controlling personal factors targets the
cerebral cortex Click to go back
Slide 120
Sorry, that is not correct- reducing fear or anxiety that may
increase PONV targets the cerebral cortex Click to go back
Slide 121
Yes, thats right-after emesis wait 30 minutes then offer clear
liquids, free of carbonation Click to go forward
Slide 122
Sorry, please review information-it is important to wait 30
minutes after emesis to avoid a recurrence Click to go back
Slide 123
Music therapy-Application of music to influence physical,
mental, emotional functioning. Often used with behavioral
techniques Relaxation-Progressive muscle relaxation to establish a
deep state of relaxation. Focused breathing often used with this
technique Guided imagery-Form a relaxing and pleasing mental image,
often proceeded by relaxation, used with music Quinn, 2004
Slide 124
Distraction-Focus attention on activity unrelated to N/V
Aromatherapy-Use of essential oils combined in a carrier cream.
Used with massage Acupressure-Application of digital pressure or
acustimulation bands in a specific way on designated points on
body. Used to correct imbalances by stimulating/easing energy flow
P6-most common/easily accessible-three finger-widths from wrist
crease ASPANS Evidence-Based Clinical Practice
Guideline-PONV/PDNV-2006 Nunley, 2008
Slide 125
Novel drugs created which target existing receptors, but have
sufficiently different pharmacological properties and different
clinical behaviors Standardization of care for managing PONV/PDNV
More research related to PDNV-Introduction of new prophylactic
modalities that outlast range of traditional antiemetics Wender,
2009
Slide 126
Melissa is a 34 year old female that came to the ER with
abdominal pain/fever/N/V CT scan-indicated acute appendicitis
Transferred to day surgery-prepped for laparoscopic appendectomy.
To be seen by anesthesiologist prior to surgery Pt data- Surgery in
past without N/V History of motion sickness Denies history of heart
disease, kidney disease, diabetes or lung disease
Slide 127
Click on arrow below question when you are ready for answer 1.
What are Melissas identified risk factors for PONV? Female and
positive history motion sickness 2. Is it appropriate to
premedicate Melissa to prevent PONV? Yes. Dr Green gives the nurse
an order to apply a scopalamine patch and give Pepcid 20mg IVP
Slide 128
Melissa arrives in PACU following surgery. It was discovered
that her appendix was ruptured, will need to be admitted for IV
antibiotics. In surgery, received IV propofol for anesthesia,
fentanyl for pain and zofran. EBL minimal, IV intake 500cc Awakens
complaining of pain in her abdomen level 8/10(0 being no pain, 10
worst pain imaginable) PACU nurse gives her 10mg morphine-pain to
level 4 /10 and infuses additional 200cc IV fluid PACU nurse calls
report to floor-vital signs stable, dressings intact, patient is
sleepy, awakens easy, denies nausea
Slide 129
Click on arrow below question when you are ready for answer 1.
Would it be appropriate in PACU to provide an additional
antiemetic? Yes, opioids are a risk for PONV, patient received 10
mg morphine in PACU 2. Could Melissa have received more IV fluids?
Yes, she could have received 1 L of fluid perioperatively for a
moderate operation in a healthy person
Slide 130
Melissa is transported to her fourth floor room Upon arrival,
she is asked to slide from the cart onto the bed Once in bed, she
complains of nausea and states Im going to throw up She is handed a
basin and has a 100cc emesis
Slide 131
Click on arrow below question when you are ready for answer 1.
What would be your first steps in treating Melissas PONV? Determine
what antiemetics she has already received (scopalamine and pepcid
preop, zofran in OR) Based on physiology/pharmacology choose a
medication that acts at a different receptor site from those
already given Infuse IV fluids, and hang second bag
Slide 132
Click on arrow below question when you are ready for answer 1.
Melissa is feeling better now, her nausea and vomiting have not
recurred. How are fluids started and can additional antiemetics be
given if needed? Wait 30 minutes after last emesis and then begin
with sips of clear liquids that are free of carbonation If nausea
and vomiting recur, additional antiemetics may be given targeting a
different receptor site
Slide 133
Congratulations, you have completed the tutorial, give yourself
a round of applause!!
Slide 134
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Slide 136
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