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050125Understanding Nausea and Vomiting in Advanced Cancer

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050125Understanding Nausea and Vomiting in Advanced Cancer CLINICAL knowledge Understanding nausea and vomiting in advanced cancer Author Colin Perdue, Bn, Rgn, dipn, is clinical nurse Definitions specialist in palliative medicine, Morriston Hospital, Nausea and vomiting are often regarded as a single Swansea. entity, but they are separate physiological conditions AbstrAct Perdue, C. (2005) Understanding nausea (Eckert, 2001). Nausea is an unpleasant feeling of the and vomiting in advanced cancer. Nursing Times; 101, need to vomit. It is often accompanied by autonomic 4, 32–35. symptoms such as pallor, cold sweat, salivation and tachy- Nausea and vomiting are commonly experienced by cardia (Yarbro et al, 1999). Retching is a strong involuntary people with advanced cancer. Nausea and vomiting can effort to vomit. It occurs in the presence of nausea and RefeRences have an adverse effect on a patient’s physical, psycho- often culminates in vomiting (Twycross and Back, 1998). logical and social well-being. Knowledge of the physiol- Vomiting (emesis) is the forceful expulsion of gastric con- Allan, S.G. (1999) Nausea and vomiting. ogy of nausea and vomiting will promote a rational tents through the mouth (Twycross and Back, 1998). In: Doyle, D. et al (eds) Oxford Textbook choice of treatment. Nurses also need to be aware of After an episode of vomiting, there may be a post- of Palliative Medicine. Oxford: Oxford non-pharmacological measures that can reduce these ejection phase characterised by weakness, lethargy and University Press. distressing symptoms. shivering (Allan, 1999). Vomiting may ease the sensation Baines, M. (1997) Nausea, vomiting and of nausea. It may serve a protective function by expelling intestinal obstruction. British Medical It is estimated that 20–60 per cent of patients with noxious substances from the gut and stop further ingestion Journal; 315, 1148–1150. advanced cancer will experience nausea and vomiting of such substances (Allan, 1999; Yarbro et al, 1999). (Allan, 1999; Grond et al, 1994; Dunlop, 1989; Baines, Baines, M. (1988) Nausea and vomiting 1988). The patient with advanced cancer may have Physiology in the patient with advanced cancer. several potential causes for nausea and vomiting, Synchronous contractions of the diaphragm and abdominal Journal of Pain and Symptom although it is often possible to identify the primary muscles raise intra-abdominal pressure and compress Management; 3: 2, 81–85. cause. The primary cause, however, may change during the stomach. Atony of the stomach, oesophageal sphinc- the patient’s illness ter and pylorus are associated with retroperistalsis. As a Back, I. (2001) Palliative Medicine Nurses have a significant role in assessing symptoms, result, stomach contents are forced upwards to the Handbook. Cardiff: BPM Books. measuring the response to antiemetics and providing mouth, culminating in the act of vomiting (Yarbro et al, non-pharmacological treatments. Thorough assessment, 1999; Twycross and Back, 1998; Marieb, 1989). knowledge of antiemetics and their mode of action, will Several neural structures and a variety of neurotrans- allow the nurse to provide individualised treatment. mitters and receptors have been identified that relate to Nausea and vomiting can cause dehydration, electrolyte nausea and vomiting. Most of the relevant receptors are imbalance and nutritional deficiencies (Marek, 2003), and excitatory – they induce nausea and vomiting when it can also impact on a patient’s psycho social well-being. stimulated (Twycross and Back, 1998) (Fig 1). They may become withdrawn, isolated and unable to The vomiting centre, sometimes referred to as a cen- perform their usual activities of daily living. The patient’s tral pattern generator, is located within the reticular for- distress often extends to family members. mation of the brain stem and is thought to coordinate the vomiting process. It lies completely within the blood- brain barrier and receives impulses from the chemore- Learning objectives ceptor trigger zone (CTZ), vestibular apparatus (the part of the internal ear concerned with balance) higher corti- each week Nursing Times publishes a guided learning article with reflection cal centres and afferent nerve impulses from the periph- points to help you with your CPd. After reading the article you should be able to: ery (primarily via the vagus nerve, but also the glos- sopharyngeal nerve and sympathetic afferents). The vomiting process is coordinated by efferent impulses from l Understand the physiology behind nausea and vomiting; the vomiting centre to the pharynx, larynx, diaphragm, l Know the link between advanced cancer and nausea and vomiting; intercostal muscles and gut. The CTZ is located within the area postrema (on the l Be familiar with the assessment of nausea and vomiting; floor of the fourth ventricle in the brain). Although ana- tomically close to the vomiting centre, the CTZ lies partly l Know the different medications that can be used to treat nausea and vomiting; outside the blood-brain barrier and is therefore exposed l Understand the connection between nausea and vomiting and chemotherapy. to various noxious agents borne in the blood and cere- brospinal fluid – such as toxins, biochemical products and SPL 32 NT 25 January 2005 Vol 101 No 4 www.nursingtimes.net keywoRds n Cancer care n Nausea n Vomiting Fig 1. simPliFied diAgRAm oF the neURAl emetiC pathwAys RefeRences Dibble, S. et al (2000) Acupressure for Biochemical Toxins/drugs Chemotherapy Anxiety/ Odours nausea: results of a pilot study. disturbance anticipatory Tastes Oncology Nursing Forum; 27: 1: 41–47. Sights Dunlop, G.M. (1989) A study of the relative frequency and importance of Dopamine Serotonin Higher cerebral type 2 D2 5-HT3 intestinal symptoms, and weakness in centres patients with far advanced cancer. Chemoreceptor Palliative Medicine; 4: 37–43. trigger zone CTZ Eckert, R. (2001) Understanding anticipatory nausea. Oncology Nursing Forum; 28: 10, 1553–1558. Motion Chemotherapy Chemotherapy Gastric distension sickness Grond, S. et al (1994) Prevalence and pattern of symptoms in patients with cancer pain: a prospective evaluation of Vagus nerve 1,635 cancer patients referred to a pain Radiotherapy Sympathetic Inner ear clinic. Journal of Pain and Symptom to the gut Afferents Vestibular disorders Management; 9: 6, 372–382. Glossopharyngeal apparatus nerve Marek, C. (2003) Antiemetic therapy in patients receiving cancer chemotherapy. Oncology Nursing Forum; 30: 2, Intestinal obstruction 259–269. Marieb, E. (1989) Human Anatomy and Muscarinic Histamine Serotonin Physiology. Menlo Park, CA: Benjamin cholinergic type 1 H1 5-HT2 Cummings. Vomiting centre Initiation of vomiting drugs (Yarbro et al, 1999; Baines, 1988). Neural path- l Does nausea precede vomiting? ways from the CTZ provide the main stimulus to the l Does vomiting relieve nausea? vomiting centre (Allan, 1999; Baines, 1988). l When did the symptoms start? Did they coincide with The vagus nerve provides the connection between the changes in therapy or medication? gut and the vomiting centre (with some stimulation of l Does anything make the symptoms better? the CTZ). Stimulation of the vagus nerve is thought to l Does anything make the symptoms worse? play a key role in nausea and vomiting induced by chem- l What is the effect of any current or past antiemetic otherapy and radiotherapy. therapy including dose, frequency, duration, effect, route The vomiting centre is also stimulated by impulses of administration? from the vestibular apparatus – motion and labyrinthitis l What are the patient’s current medications/therapies? being the most common to induce nausea and vomiting. l Are there upper gastrointestinal symptoms such as dyspepsia, heartburn, fullness or early satiation? Assessment l Is there any abdominal pain or swelling? The choice of treatment for nausea and vomiting requires l What is the patient’s urine output? a thorough assessment of the primary and subsidiary or l Do they have constipation or diarrhoea? concurrent causes, as well as which receptors and neuro- l Are there signs of infection (for example in the chest transmitters are understood to be involved (Box 1). or urinary tract)? It is insufficient to simply record that a patient ‘has l Is the patient drowsy or confused? This article has been double-blind been sick’. Assessment should address questions such as: l What is the condition of the patient’s oral cavity? peer-reviewed. l Does the patient feel nauseous? Ongoing evaluation of symptoms and interventions is For related articles on this subject l Is the patient vomiting? If so, what is the frequency, equally important. Frequent and regular monitoring ena- and links to relevant websites see volume, content, timing? bles the treatment plan to be adjusted as needed. www.nursingtimes.net NT 25 January 2005 Vol 101 No 4 www.nursingtimes.net 33 knowledge RefeRences Pharmacology spectrum of antiemetic properties. It has an antagonistic Occasionally, assessment will reveal a specific cause of action on D2, H1, Ach m and 5-HT2 receptors (Twycross Perdue, C. (2004) The syringe driver – an nausea and vomiting that is treatable (for example and Back, 1998; Baines, 1997). Dexamethasone also has aid to delivering symptom control. hypercalcaemia). However, antiemetic therapy is nearly anti emetic properties, although its mode of action is Nursing Times; 100: 13, 32–35. always necessary for patients with advanced cancer. uncertain. Many antiemetic drugs are available with varying modes Referral to a specialist palliative care team is recom- Roscoe, J. et
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