Clinical Findings

Neuro: Anxiety from prospect of vomiting.

Resp: Coughing, risk for aspiration.

CV: Tachycardia, bradycardia.

Skin: Diaphoresis, pallor.

GI/GU: Sensation/urge to vomit, drooling, abdominal pain, decreased or high-pitched bowel sounds; small or large amounts of emesis.

MS: Weakness, fatigue.

Possible Causes: Gastroenteritis, appendicitis, bowel obstruction, other GI disorder, vascular headache, head injury, meningitis, other neurological cause, pregnancy, drug side effect, infection, pain, motion sickness, stress, chemotherapy.

Collaborative Management

Call for STAT 12-lead if associated with CP, SOB, slow, fast, or irregular HR.

• Position Pt upright to prevent aspiration and respiratory compromise—or turned to one side if altered LOC, debilitated, or inadequate gag reflexes.
• Provide emesis basin, and offer a cool compress to forehead or nape of neck.
• Keep NPO, and assess onset of symptoms and associated events (e.g., eating, medication, activity).
• Assess VS and hydration status (orthostatic hypotension, skin turgor, mucous membranes, recent I&O).
• Assess abdomen for distention and tenderness.
• Monitor for CP, SOB, HA, and visual disturbances.
• Establish IV, and administer IVF as ordered.
• Administer antiemetic medication as ordered.
• Determine if nausea or vomiting is an anticipated side effect of treatment (anesthesia, chemotherapy.
• Check MAR for prn antiemetic; administer if clinically indicated.
• If nausea is not expected given Pt’s clinical problem, notify HCP.
• Clarify whether to withhold PO medication or give by alternate route.
• Monitor serial electrolytes, nutritional status, and UO.
• Insert NGT if bowel obstruction is present.
• Monitor and record I&O.
• Monitor laboratory tests for electrolyte imbalances (from loss of fluid) or metabolic alkalosis (from loss of gastric acid).
• Inspect emesis for color, odor, amount, and contents.
• Note if vomiting is projectile.