Nausea and vomiting

Most of the research about nausea and vomiting in advanced disease focuses on cancer. Among patients with advanced cancer, 50% - 90% report nausea and vomiting as a symptom of disease or significant side effect of treatment. In non-cancer advanced disease, nausea occurs less frequently than pain, dyspnea, or constipation.

Prolonged nausea and vomiting can cause serious complications including dehydration, altered electrolyte levels and emotional distress.

The origins and effect of nausea and vomiting are complex, so it can be useful to consider the concept of ‘total nausea’ similar to ‘total pain’. Factors contributing to nausea and/or vomiting include:

• intra-abdominal or gastrointestinal malignancies
• HIV or AIDS
• metabolic imbalance, including hypercalcemia, uraemia, liver failure
• sepsis
• infections such as urinary tract or respiratory
• conditions affecting gastrointestinal motility, including constipation, previous surgery, gastroparesis, or autonomic failure
• reflux or peptic ulcer disease
• medication and treatment side effects, including opioids and other drugs, chemotherapy, and radiotherapy
• anxiety and depression, anticipatory nausea
• inappropriate presentation of food.

Remember to assess nausea and vomiting as separate symptoms.

Ask the person:

• how often they feel sick or are being sick, and how long it lasts for
• whether they feel nauseous or vomit at a certain time of day
• whether nausea is influenced by eating, food preparation or scents/smells such as perfume or deodorant
• if anything makes these symptoms better or worse
• how long they have been experiencing nausea or vomiting
• what medicines they are taking
• what their bowel habit is like
• how much they are managing to eat and drink
• if there are any associated symptoms (e.g. headaches of raised intracranial pressure coincide with vomiting)
• if they have any worries or concerns making them anxious.

Nausea is routinely assessed in Australian palliative care services using Symptom Assessment Scores (SAS).

A physical examination, with the person’s consent, may include the abdomen or the rectum if faecal impaction is considered a possible cause.

Often the cause of nausea and vomiting is multifactorial, requiring multiple interventions concurrently.

Non-pharmacological management

Nurses can support the person with non-pharmacological measures:

• regular mouth care
• regularising bowel habit - constipation may be a relatively common cause of nausea
• a calm and reassuring environment away from the sight and smell of food
• regular small palatable portions of food rather than large meals - be guided by the person as to which foods appeal to them
• avoiding greasy or spicy food
• make sure the person is positioned comfortably, sometimes lying flat can make nausea worse
• encourage the person to move gently as sudden movements like sitting up quickly can make nausea worse
• checking that the person is not becoming dehydrated
• checking the person is taking medications as prescribed
• mouth care after vomiting using one of these methods:
• a teaspoon of baking soda in a glass of warm water, use the solution as a mouth rinse that is spat out
• the person rinses their mouth with water.
• the person brushes their teeth
• acupuncture or acupressure bands
• relaxation techniques.

Certain foods and drinks can be easier to eat and can help with nausea. They include:

• fizzy or flavoured water
• plain-tasting foods, like mashed potato or rice pudding
• dry biscuits, crackers, or toast
• food and drink containing ginger, like ginger ale or ginger biscuits
• boiled sweets and mints, or flavoured ice chips if the person has difficulty swallowing
• cold foods
• salty foods like crisps or salted nuts.

Families are often very worried about nausea and vomiting. Acknowledge their concern. Asking what concerns them most may help relieve their distress.

Families and carers can help by:

• helping with food preparation (appealing foods, small portions, avoiding triggering scents)
• avoiding perfumes or other strong-smelling scents near the person
• keeping a record of when the person feels sick or vomits - this can help the doctor or nurse spot a pattern
• mouth care after vomiting (as above)
• other aspects of care as above.

Pharmacological management

Approaches to care may include the use of anti-emetics. A person may need more than one anti-emetic and it make take a while to find the most appropriate one(s). The choice of anti-emetic will depend on the cause (e.g. gastric irritation, delayed gastric emptying, bowel obstruction, drugs, raised intracranial pressure, vestibular disturbance or anxiety, fear, or anticipation).

Antiemetics can be taken orally, per rectum, subcutaneously with stat doses or continuously through a syringe driver. Antiemetics should be taken regularly, not just as required. They can be stopped if the cause of the nausea has been resolved.

Nausea and vomiting can be a side effect of certain medicines. It may help to ask the doctor or pharmacist to review the person’s medicines.

Nausea is a common side effect of opioid use. To help nausea and vomiting associated with opioids, opioids may be rotated or switched.

If anxiety is a major factor in the person’s nausea and vomiting, they may find talking to a counsellor or psychological therapy helpful.