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Lynn Gettrust BSN, RN Alverno College-MSN student Tutorial Project

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2 Lynn Gettrust BSN, RN Alverno College-MSN student Tutorial Project

3 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

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

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

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

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-

8 You Are Correct-Great Start!!! Click arrow to go back

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

10 That’s Right-Way to Go Click to go forward

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

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 ASPAN’S Evidence-Based Clinical Practice Guideline-PONV/PDNV- 2006

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 ASPAN’S Evidence –Based Clinical Practice Guideline- PONV/PDNV-2006

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 ASPAN’S Evidence-Based Clinical Practice Guideline- PONV/PDNV-2006

15 Muscular Contractions Associated with Nausea and Vomiting Copyright 2004, Amdipharm plc, All rights reserved

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 ASPAN’S Evidence-Based Clinical Practice Guideline-PONV/PDNV-2006

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. and vomiting co.uk 2004

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

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

20 Yes, you are correct-vomiting is a reflex not under voluntary control Click to go back

21 Correct, way to go!!! Click to go back

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

23 Correct, you understand the concept!!! Click to go forward

24 Sorry, that is not correct. Nausea and vomiting are physiologic protective mechanisms. Please review content of slide. Click to go back

25 Schematic representation of factors and body systems involved in nausea and vomiting process © Copyright 2004, Amdipharm plc. All rights reserved

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 Mattson-Porth, 2005 MEDULLA

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

28 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

29 Chemoreceptor Trigger Zone located in fourth ventricle brain Chemoreceptor- sensory nerve activated by chemical stimuli Copyright 2004, Amdipharm plc. All rights reserved

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

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

32 Correct, you got it right-way to pay attention! Click to go back

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

34 Sorry, that is not correct. A chemoreceptor is a sensory nerve activated by chemical stimuli Click to go back

35 Yes, you are correct!! Click to go back

36 Yes, that is correct, isn’t pathophysiology interesting? Click to go forward

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

38 Input to vomiting center: GI Tract Input comes from stomach, jejunum, ileumjejunum ileum Input travels on visceral afferent vagus nerve 2004

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

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

41 Input to vomiting center: Cerebral cortex Layer of neurons and synapses (gray matter) on surface of cerebral hemispheres. Mattson-Porth, 2005

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

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. Mattson-Porth, 2005

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

45 That’s correct-way to go Click to go back

46 I’m sorry, that is not correct- mechanoreceptors are tension receptors that respond to touch, pressure and muscular contractions Click to go back

47 Sorry, that is incorrect-input to the CTZ and vomiting center is carried on visceral afferent pathways Click to go back

48 Yes, you are correct, you know your nerve pathways Click to go back

49 Yes, you are correct-the parietal lobe integrates and processes the sensory information Click to go forward

50 Sorry, that is not correct, the parietal lobe integrates and processes the sensory information Click to go back

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 © , WebMD, Inc. All rights reserved Mattson-Porth, 2005

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

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

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

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

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

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

58 That is correct, the vestibular apparatus is associated with balance and position sense Click to go back

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

60 Correct, correct- neurotransmitters are the chemical messengers of the nervous system! Click to go back

61 Sorry, that is not correct- remember, neurotransmitters are chemical messengers in the nervous system Click to go back

62 Correct, now you understand the process- neurotransmitters bind with their receptors to produce a specific physiologic response Click to move forward

63 Sorry, please review your neurotransmitters- remember they bind to a particular receptor site to produce a physiologic response Click to go back

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 Mattson-Porth, 2005

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

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

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

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

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-

70 Yes, you are correct, mask ventilation can increase inflammation in the stomach and upper intestine Click to go back

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

72 Sorry, the hypothalamus controls the release of CRH Click to go back

73 Yes, you are correct, the hypothalamus, not the medulla controls the release of CRH Click to go back

74 Yes, that is right- minimally invasive surgery does decrease the inflammatory response by decreasing wound size Click to move forward

75 Sorry, that is not correct- by reducing wound size, minimally invasive surgery reduces inflammation, tissue catabolism and pain Click to go back

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

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

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 ASPAN’S Evidence-Based Clinical Practice Guideline-PONV/PDNV- 2006

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

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 ASPAN’S Evidence-Based Clinical Practice Guideline-PONV/PDNV- 2006

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

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

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

84 You are correct, polymorphisms are interesting, don’t you agree? Click to go back

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

86 Correct, identification of risk factors preop allows us to decrease the risk of PONV Click to go back

87 Sorry, you are not correct-remember identification of risk factors preop helps to prevent PONV Click to go back

88 Yeah, way to go-let’s prevent PONV!! Click to move forward

89 Sorry, that is not correct, PONV increases patient discomfort, prolongs stay, and increases cost Click to go back

90 ClassificationGenericBrand PhenothiazineProcholoroperazineCompazine AnticholinergicScopolamineIsopto Hyoscine AntihistaminePromethazinePhenergan ButyrophenonesDroperidolInapsine BenzamidesMetoclopromideReglan CorticosteroidsDexamethasoneDecadron 5-HT3 receptor antagonists OndansetronZofran NK1 receptor antagonists AprepitantEmend 8 classifications of medication to treat PONV Rahman, 2004

91 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

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

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

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

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

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

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

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

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

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

101 Sorry, that is not correct, there are actually 8 classifications of meds to treat PONV Click to go back

102 Yes, you’re correct- there are 8 classifications of meds to treat PONV- can you name them? Click to go back

103 Yes, that is correct-way to go – remember your peripheral and central receptors Click to go back

104 Sorry, that is not correct, there are receptors both centrally and peripherally to target in preventing PONV Click to go back

105 That is right-combining or stacking meds to target multiple receptor sites helps to decrease PONV!! Click to move forward

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

107 Fluid abnormalities may be multifactoral Preoperative fasting Surgical preps (bowel preps) Administration/management anesthesia Surgical procedure/associated fluid losses Noble, 2008

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

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

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

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

112 Nursing Activities GI tract Position to prevent aspiration/maintain airway Provide physical support during vomiting (assist person to bend over or support person’s 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

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

114 American Society of Perianesthesia Nurses developed clinical practice guidelines in 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 ASPAN’S Evidence-Based Clinical Practice Guideline-PONV/PDNV- 2006

115 *ASPAN=American Society of Perianesthesia Nurses ASPAN’sASPAN’s Evidence-based Clinical Practice Guideline for the Prevention and/or Management of PONV/PDNVr((2006) Journal of PeriAnesthesia Nursing, 21(4), pp

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

117 Yes, you are correct, greater than 1 liter of fluid in appropriate patients improves recovery! Click to go back

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

119 Yes, that’s right-controlling personal factors targets the cerebral cortex Click to go back

120 Sorry, that is not correct- reducing fear or anxiety that may increase PONV targets the cerebral cortex Click to go back

121 Yes, that’s right-after emesis wait 30 minutes then offer clear liquids, free of carbonation Click to go forward

122 Sorry, please review information-it is important to wait 30 minutes after emesis to avoid a recurrence Click to go back

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

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 ASPAN’S Evidence-Based Clinical Practice Guideline-PONV/PDNV-2006 Nunley, 2008

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

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

127 Click on arrow below question when you are ready for answer 1. What are Melissa’s 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

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

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

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 “I’m going to throw –up” She is handed a basin and has a 100cc emesis

131 Click on arrow below question when you are ready for answer 1. What would be your first steps in treating Melissa’s 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

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

133 Congratulations, you have completed the tutorial, give yourself a round of applause!!

134 ASPAN. (2006). Evidence-Based Clinical Practice Guideline for the Prevention and/or Management of PONV/PDNV. Journal of PeriAnethesia Nurses, 21 (4), pgs Bernard, S. N. (2006). Interethnic Differences in Genetic Polymorphism of CYP2D6 in the US Population: Clinical Implications. The Oncologist, 11: pgs Bulechek, G. B. (2008). Nursing Interventions Classification (NIC). St Louis: Mosby Elsevier. Candiotti, K. B. (2005). The Impact of Pharmacogenics on Postoperative Nausea and Vomiting. Anesthesiology, 102 (3), pgs DiPiro, J. T. (2005). Pharmacotherapy: A Pathophysiologic Approach. New York: McGraw-Hill. Holte, K. (2006). Fluid Therapy and Surgical Outcomes in Elective Surgery: A Need for Reassessment in Fast-Track Surgery. Journal American College of Surgeons, 202 (6), pgs Ide, P. F. (2008). Perioperative Nursing Care of the Bariatric Surgical Patient. American Operating Room Nurse, 88 (1) pgs Ignoffo, R. (2008). Current research on PONV/PDNV: Practical implications for today's pharmacist. American Journal Health-System Pharmacy, 66(1) S Johnson, M. B.-D. (2006). NANDA, NOC, and NIC Linkages. St Louis: Mosby Elsevier

135 Kapoor, R. H. (2008). Comparison of two instruments for assessing risk of postoperative nausea and vomiting. American Journal Health-System Pharmacy, 65: Kloth, D. (2009). New pharmacologic findings in the treatment of PONV and PDNV. American Journal Health-System Pharmacy, 65 (1) S Larzelere, M. J. (2008, july 11). Stress and Health. Retrieved February 23, 2009, from The Clinics: Primary Care: clinics.com Mattson-Porth, C. (2005). Pathophysiology: Concepts of Altered Health States. Philadelphia: Lippincott Williams & Wilkins. Microsoft Clip Art Images. Retrieved March 15, 2009 from en-us/tou.aspx Moorhead, S. J. (2008). Nursing Outcomes Classification (NOC). St Louis: Mosby Elsevier. Nausea and Vomiting-an introduction (2004). Retrieved March 15, 2009 from Noble, K. (2008). Fluid and Electrolyte Imbalance: A Bridge Over Troubled Water. Journal of PeriAnesthesia Nursing, 23 (4), pgs Noble, K. (2008). The Obesity Epidemic: The Impact of Obesity on the PeriAnesthesia Patient. Journal of PeriAnesthesia Nursing, 23 (6), pgs Nunley, C. W. (2008). The Effects of Stimulation of Acupressure Point P6 on Postoperative Nausea and Vomiting: A Review of Literature. Journal of PeriAnesthesia Nursing, 23 (4), pgs

136 Pavlin, J. (2008). Recovery after ambulatory anesthesia. Current opinion in Anaesthesiology, 21(6), pgs Quinn, D. (2004). PeriAnesthesia Nursing Core Curriculum: Preoperative, Phase I and Phase II PACU Nursing. St Louis: Elsevier. Rahman, M. (2004). Post-operative nausea and vomiting. The pharmaceutical Journal, 273, pgs Stevenson, C. (2006, July 19). Drugs for preventing postoperative nausea and vomiting (Review). Retrieved February 23, 2009, from Cochrane Database of Systemic Reviews: cochranelibrary.com Villars, P. V.-M. (2008). Adaptation of the OODA Loop to Reduce Postoperative Nausea and Vomiting in a High-Risk Outpatient Oncology Population. Journal of PeriAnesthesia Nursing, 23 (2) pgs Wender, R. (2009). Do current antiemetic practices result in positive patient outcomes? Results of a new study. American Journal Health System Pharmacy, 6 (1) S3-10. Wilhelm, S. D.-S.-P. (2007, march 21). Prevention of Postoperative Nausea and Vomiting. Retrieved march 4, 2009, from Medscape:


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