Definition(s) : Symptom Management Guidelines: Nausea and Vomiting
Definition(s) : Symptom Management Guidelines: Nausea and Vomiting
Definition(s) : Symptom Management Guidelines: Nausea and Vomiting
Definition(s)
Nausea: Queasy sensation and/or urge to vomit
Vomiting: The forceful expulsion of the contents of the stomach, duodenum, or jejunum through the oral cavity.
Treatment
● What medications or treatments have you tried? Has this been
effective?
Value
What do you believe is causing your nausea?
The information contained in these documents is a statement of consensus of BC Cancer professionals regarding their views of currently accepted approaches to treatment. Any
clinician seeking to apply or consult these documents is expected to use independent medical judgement in the context of individual clinical circumstances to determine any
patient's care or treatment. Use of these documents is at your own risk.
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NAUSEA AND VOMITING GRADING SCALE
NCI CTCAE (Version 4.03)
Nausea: try tea/smoothie made with grated ginger root, lemon zest or mint leaves, ginger
candies, flat ginger ale.
Vomiting: Avoid solid food for 30-60 minutes after vomiting has passed. Start eating and drinking
slowly in this order: 1.Clear liquids (water, ice chips, watered down juice, broth, popsicles) 2. Dry
starchy food (crackers, dry toast) 3. Protein rich foods (chicken, fish, eggs) 4. Dairy foods (yogurt,
milk, cheese)
Avoid:
● alcohol and tobacco
● Avoid lying down after eating-sit upright 30-60 minutes
NOTE: If patient unable to tolerate adequate daily fluid intake, IV hydration or hypodermoclysis to
replace lost fluid and electrolytes may be required
For further Dietary Management See Oncology Nutrition Services in Resource Section
The information contained in these documents is a statement of consensus of BC Cancer professionals regarding their views of currently accepted approaches to treatment. Any
clinician seeking to apply or consult these documents is expected to use independent medical judgement in the context of individual clinical circumstances to determine any
patient's care or treatment. Use of these documents is at your own risk.
Page 2 of 8
Non-Pharmacological Modify environment (control smells and noise)
Management ● Take a walk outside or breathe in fresh air through an open window
● If anticipatory nausea, consider distraction strategies such as relaxation, music, imagery or
hypnosis (referral to patient and family counselling may be helpful for these interventions)
● Consider acupressure–patient administered or acupressure bracelet. Link:
https://www.mskcc.org/cancer-care/patient-education/acupressure-nausea-and-vomiting
Pharmacological ● Avoid or discontinue any medications that may cause or exacerbate nausea and vomiting (in
Management consultation with physician and pharmacist)
● Refer to protocol specific algorithm if patient is on Immunotherapy
● Instruct patient to initiate or continue medications according to instructions given
● Allow 30-60 minutes post antiemetic before eating
● Antiemetic medications that may be prescribed: Ondansetron, dexamethasone,
metoclopramide, prochlorperazine
● Arpetiant for highly emetogenic chemotherapy
● Haloperidol
● Nozinan
● Dimenhydrinate suppository if unable to take orally
● Lorazepam may be prescribed for anticipatory nausea
For further Pharmacological Management See Cancer Management Guidelines (Health
Professional) and Cancer Drug Manual in Resource Section
OR THIS:
Provide instructions on how to take antiemetic, including dose and schedule
Any unnecessary medications contributing to nausea and vomiting should be discontinued (in
consultation with physician and pharmacist)
Select anti-nausea medication based on the cause of the nausea and vomiting, See Appendix B
Examples:
● High Risk Chemotherapy induced: add Aprepitant. Cannabis for refractory
● Opioid-induced nausea: Metoclopramide/domperidone. May remit w tolerance after 5-7
days..Suggest narcotic rotation and route switching
● Brain metastases: Dexamethasone
● Vestibular causes: Scopolamine, Dimenhydrinate
● Anticipatory: Prevention best option. Lorazepam
Caution:
● Ondansetron and Domperidone: may increase risk of arrhythmia
● Metoclopramide: monitor for neurological/extrapyramidal side effects
● Olanzapine: increased fall risk with sedation and elderly
● Dexamethasone: reflux and insomnia
For further Pharmacological Management See Cancer Management Guidelines (Health
Professional) and Cancer Drug Manual in Resource Section
Patient Education Reinforce importance of accurately recording and reporting the following information:
● Onset and number of emesis occurrences per 24 hours
● Fluid intake per 24 hours
Reinforce with patients when to seek immediate medical attention:
● Temperature greater than or equal to 38° C
● Blood (bright red or black) in emesis, coffee ground emesis
● Severe cramping, acute abdominal pain (+/- nausea & vomiting)
● Dizziness, weakness, confusion, excessive thirst, dark urine.
● Projectile vomiting.
● Nausea and vomiting not improving with recommended strategies
Inform patient that isolation precautions may be required if symptoms worsen or infection
suspected, patient may need to be isolated as per infection control (available to internal PHSA
staff)
Review contact numbers and access to resources
Follow-Up Reassess in 24 hours, if symptoms not resolved provide further recommended strategies and
repeat follow–up assessment within 24 hours.
Follow up options:
The information contained in these documents is a statement of consensus of BC Cancer professionals regarding their views of currently accepted approaches to treatment. Any
clinician seeking to apply or consult these documents is expected to use independent medical judgement in the context of individual clinical circumstances to determine any
patient's care or treatment. Use of these documents is at your own risk.
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● Instruct patient/family to call back
● Arrange for nurse initiated telephone follow–up or physician follow-up
GRADE 3 - GRADE 4
EMERGENT:
Requires IMMEDIATE medical attention
Patient Assessment ● Patients with Grade 3 or 4 nausea and vomiting generally require admission to hospital –
notify physician of assessment, facilitate arrangements as necessary
● If patient is on Immunotherapy, remind them to present their Immunotherapy alert card.
● Consult with physician
● To rule out other causes or concomitant causes of nausea and vomiting
● To hold chemotherapy until symptoms resolved
● Lab tests that may be ordered: Complete blood count (CBC), electrolyte profile
● Nursing Support
● Monitor vital signs (as clinically indicated)
● Physical assessment
● Accurate intake and output record, include daily weight
● Pain and symptom assessment and management as appropriate
Dietary Management ● IV hydration to replace lost fluids and electrolytes
● Enteral or parenteral nutrition (TPN) may be indicated for some patients
For further Dietary Management See Oncology Nutrition Services in Resource Section
Pharmacological ● Avoid/discontinue any medications that may cause or exacerbate nausea and vomiting (in
Management consultation with physician and pharmacist)
● Medications that may be prescribed intravenously:
- Ondansetron (Zofran)
- Metoclopramide
- Prochlorperazine (Stemetil)
- Haloperidol
- Nozinan
- Dexamethasone
● Refer to protocol specific algorithm if patient is on Immunotherapy
For further Pharmacological Management See Cancer Management Guidelines (Health
Professional) and Cancer Drug Manual in Resource Section
Patient Education ● Provide support, reinforce to patients/family that nausea and vomiting can be effectively
managed with prompt intervention
● Continue to reinforce self care, review medications, lab /diagnostic testing with patients/family
as appropriate
● Discharge teaching as early as possible with patient/family
The information contained in these documents is a statement of consensus of BC Cancer professionals regarding their views of currently accepted approaches to treatment. Any
clinician seeking to apply or consult these documents is expected to use independent medical judgement in the context of individual clinical circumstances to determine any
patient's care or treatment. Use of these documents is at your own risk.
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Immunotherapy Immunotherapy Alert Card
Please refer to protocol specific algorithms to guide management of immune mediated side
effects.
Patient Education Nausea & Vomiting handout
Resources Practical tips to help manage nausea handout
Nutritional Guidelines for Anorexia handout
Increasing Fluid Intake handout
Resources about managing anxiety, progressive muscle relaxation, positive thinking, etc
http://www.bccancer.bc.ca/health-info/coping-with-cancer/emotional-support/resources
BC Inter- https://www.bc-cpc.ca/cpc/symptom-management-guidelines/
professional
palliative symptom
management
guideline
Bibliography List http://www.bccancer.bc.ca/health-professionals/clinical-resources/nursing/symptom-
management
Contributing Factors
Cancer Treatments Chemotherapy: For emetogenicity of chemotherapeutic agent, See Appendix A and Cancer Drug
Manual in Resources Section
Immunotherapy/Biotherapy
Radiation Therapy:
Surgery/Anesthesia
Medication ● Antibiotics
● Opioids &/or Opioid withdrawal
● NSAIDs
● SSRI antidepressants
● Iron supplements
● Anticonvulsants
● Bronchodilators
Cancer Related : ● Cancer of the GI tract
● Brain metastases/Increased ICP
● Reduced GI motility, Bowel Obstruction, Chemotherapy induced (e.g. Vincristine)
● Constipation
● Vestibular dysfunction
● Anxiety, anticipatory nausea
● Hypercalcemia, hyperglycemia, hyponatremia
● Gastritis
● Infections
● Uremia
● Pain/Headache
Risk Factors: ● Female
● Less than 50 years of age
● Decreased risk for patients with a high chronic alcohol intake Lack of regular alcohol use
● History of motion/morning sickness, chemotherapy induced emesis.
The information contained in these documents is a statement of consensus of BC Cancer professionals regarding their views of currently accepted approaches to treatment. Any
clinician seeking to apply or consult these documents is expected to use independent medical judgement in the context of individual clinical circumstances to determine any
patient's care or treatment. Use of these documents is at your own risk.
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Appendix A: Emetic Risk of Intravenous Antineoplastic Agents
Adapted from ASCO Guidelines (2011)
* These anthracyclines when combined with cyclophosphamide, are now designated as high
emetic risk
The information contained in these documents is a statement of consensus of BC Cancer professionals regarding their views of currently accepted approaches to treatment. Any
clinician seeking to apply or consult these documents is expected to use independent medical judgement in the context of individual clinical circumstances to determine any
patient's care or treatment. Use of these documents is at your own risk.
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Date of Print:
Revised: August 2018
Created: January, 2010
The information contained in these documents is a statement of consensus of BC Cancer professionals regarding their views of currently accepted approaches to treatment. Any
clinician seeking to apply or consult these documents is expected to use independent medical judgement in the context of individual clinical circumstances to determine any
patient's care or treatment. Use of these documents is at your own risk.
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Contributing Authors:
Revised by: Jagbir Kaur, RN, MN (2018), Sara Gough, RN, MSN, CON(c) (2018), Ava Hatcher, RN BN (2014)
Created by: Vanessa Buduhan, RN MN; Rosemary Cashman, RN MSc(A), MA (ACNP); Elizabeth Cooper, RN BScN, CON(c); Karen
Levy, RN MSN; Ann Syme RN PhD(C)
Reviewed by: Karen Huebert, RN BSN CON(c) (2014); Lindsay Van der Meer, BSc RD (2014)
Janelle Bellerive, NP (2018)
The information contained in these documents is a statement of consensus of BC Cancer professionals regarding their views of currently accepted approaches to treatment. Any
clinician seeking to apply or consult these documents is expected to use independent medical judgement in the context of individual clinical circumstances to determine any
patient's care or treatment. Use of these documents is at your own risk.
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