Post_Op_N_xV - l ‘ . Muscat and vomit Putting a stop to...

Info iconThis preview shows pages 1–3. Sign up to view the full content.

View Full Document Right Arrow Icon
Background image of page 1

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full DocumentRight Arrow Icon
Background image of page 2
Background image of page 3
This is the end of the preview. Sign up to access the rest of the document.

Unformatted text preview: l ‘ . Muscat and vomit Putting a stop to postop Risk factor assessment and well-chosen drug therapy ’ may prevent or relieve this “big little problem.” For: PATIENTS RECOVERING from surgery, the biggest obstacle isn’t pain, sore throat, or having to de— pend on others for care. It’s postop— erative nausea and vomiting (PONV). A 2001 survey found the average patient would be willing to spend ‘ more than $100 out of pocket to avoid postoperative Gl distress. Despite anesthetic and surgical advances, the estimated incidence of PONV is as high as 30% for low- risk patients and 80% for high-risk patients. New drug therapies show promise in controlling early PONV—~— yet nearly half of patients may ex— perience nausea and vomiting after discharge from ambulatory surgery units. They suffer an uncomfortable recovery and are more likely to re- quire hospitalization. We nurses can help change that. For starters, we can help minimize PONV by identifying high-risk pa- tients preoperativer and implement— ing multimodal therapy based on risk assessment. Plus, we can teach postoperative patients and their farm. ilies strategies to help them cope - with the discomfort and potentially debilitating effects of PONV. Assessing risk PONV is more likely to follow cer- tain types of surgeries—for instance, eye surgery; ear, nose, and throat surgery; gynecologic surgery; and gallbladder surgery. Yet the specific surgery doesn’t predict PONV. On the other hand, having a PONV risk factor independently 10 American Nurse Today W By Susan Fetzer, PhD, RN predicts an untoward event. Strong evidence confirms four patient- related and three anesthesia-related risk factors. By identifying your pa— tient’s risk factors preoperatively and using a simple risk—scoring tool, you can determine the base- line risk for PONV and help devel— op a prophylactic management plan. (See Determining your pa— tient’s risk factors and risk score.) Prophylactic interventions A patient’s PONV risk score deter- mines the number of prophylactic Volume 3, Number 8 interventions required; a high risk score warrants more interventions. (Universal prophylaxis for all elec- tive surgery patients is ineffective and thus not recommended.) Prophylactic interventions include: o minimizing anesthesia factors (such as use of volatile anesthetic. gases) that increase the PONV n'sk - administering prophylactic drugs - optimizing hydration before and during surgery. Research also supports the use of prophylactic complementary in— terventions, such as P6 acupoint stimulation. In this technique, the practitioner stimulates the area be— tween the flexor tendons and three fingerbreadths distal to the hand- wrist crease, using acupuncture needles or acupressure. 'A multimodal approach to pain management, such as use of non- steroidal anti-inflammatory drugs in conjunction with regional analgesia, also reduces the risk of PONV. Prophylactic drugs Antiemetic drugs act on specific re- ceptors in the brain’s chemorecep— tor trigger zone (CT Z) and the nu- cleus tractus solitarius (NTS)-both of which send messages to the vom- iting center in the mid~brainstem. The CTZ contains dopamine, mus— carinic, histamine-1 (H1), serotonin, neurokinin-l (NKI), and opioid re- ceptors. The NTS contains dopa— mine, serotonin, histamine, and muscarinic receptors. For PONV prophylaxis, the pa- tient typically receives drugs that act on several receptor types simul- taneously. For a patient with a PONV risk score abOve 3, the anes— thetist may select multiple drugs, each acting on a different receptor type, for multimodal prophylaxis. Research shows that Hl-receptor blockers, NK—receptor antagonists, serotonin (5—HT3)—receptor antago— nists, and muscarinic-receptor blockers are effective in PONV pro— phylaxis. Dexamethasone also is well established as an effective (and relatively low-cost) prophy— lactic antiemetic, though its exact mechanism is unknown. Drugs that directly increase GI motility, such as metocloprarnide, haven’t been shown to offer effec— tive prophylaxis. Although it’s a dopamine-receptor blocker, meto— Clopramide usually is given in a dosage too low (10 mg I.V.) to af- fect the CT Z. On the other hand, droperidol (also a dopamine-receptor blocker) does have prophylactic antiemetic properties. But the Food and Drug ré‘srtigfaantiémetits“ Administration requires stringent cardiac monitoring during its ad— ministration, so its use in ambulato- ry surgical patients isn’t practical. Adequate hydration Dehydration can play a role in PONV: Low blood pressure com- promises intestinal perfusion and can cause GI intolerance. After con- sulting the anesthetist, inform healthy patients scheduled for elec— tive procedures that they may drink clear fluids up to 2 hours before surgery (unless contraindicated). Additional supplemental IV. fluids can help prevent PONV in high-risk patients. . Rescue treatment Sometimes, even a patient deemed August 2008 at low risk experiences PONV. And high-risk patients receiving multimodal treatment still have a 20% risk of PONV. Both groups require rescue treatment. The first priority is promoting hydration, which active vomiting can further compromise. You can play a role in choosing a specific rescue antiemetic. Find out which prophylactic antiemetics your patient has already received; the rescue antiemetic should be one that affects different receptor sites than the drugs already given. For example, if your patient re- ceived an Hl-receptor blocker be— fore or during surgery, a 5—HT5 an— tagonist might be a good choice for a rescue drug. (See Prophylactic and rescue antiemetics.) American Nurse Today 11 WWW—"m finmhnefinPONVandPDNyl This flowchart shows the timing of symptom onset for the various categories of postoperative nausea and vomiting (PONV) and post- discharge nausea and vomiting (PDNV). Early PONV , Arising 2 to 6 hours after surgery (inpatient) Surgery , I ‘24“hours after .‘LateiPVO‘NV Arising 6 to) Delayed PONV Arising at least i 24 hours after surgery (inpatient) surgery , (inpatient) ‘ ‘.PDNV ‘, Arising within ‘ 24 hours‘ after discharge V Delayed ‘ ‘ PDNV‘ 1‘ Arising at least ‘24 hours after v , discharge ' WWW When nausea and vomiting arise after discharge It’s bad enough when a postopera- tive patient experiences nausea and vomiting in the hospital, where healthcare professionals are avail- able to provide intervention. All too often, though, nausea and vomiting are delayed until after discharge. (See T imelz’ne for PONV and PDNV). High-risk ambulatory surgery pa— tients should be identified and given prophylactic antiemetics. Aprepitant (Emend), the newest antiemetic, was approved in 2007 for surgical outpa— tients. An NKl—receptor antagonist originally developed for chemother— apy-induced nausea, it has shown promise in surgical patients when given as a single oral dose within 5 hours of anesthesia. Prophylactic antiemetics and ad- equate hydration can help ambula— tory surgical patients avoid both early and late postdischarge nausea and vomiting (PDNV). Still, on fol- low-up assessment, many patients report PDNV and delayed PDNV. So during outpatient discharge edu- cation, teach patients and home caregivers how to manage nausea and vomiting. Provide instructions on appropriate food and fluid choices, and encourage frequent intake of clear liquids in small amounts. Advise patients to avoid acidic fruit juices and milk-based products immediately after surgery because these can increase gastric secretions. Caution them not to 12 American Nurse Today drink excessive amounts of carbon- ated beverages, such as soft-drinks, which can distend the stomach. Recommended postop intake “Flat” ginger ale can be helpful in easing PONV. A meta-analysis of five randomized research studies found that 1 g of ginger reduced PONV more effectively than place- bo. Also, animal studies show gin— ger works on serotonin receptors. Recommend popsicles, apple juice, and electrolyte drinks as well. Other nursing interventions Many patients stop taking pain med— ication when they experience PDNV. This can backfire, because pain has an emetic effect. However, opioids may stimulate the vomiting center, so patients with suspected opioid-induced PDNV may need to switch to an anti-inflammatory agent. Be sure to teach your patient not to take anti—inflammatory agents, ' opioids, or antibiotics on an empty stomach. Urge patients to contact the physician or surgical center if PDNV persists. (In a recent survey, fewer than 4% of ambulatory sur- gery patients with significant PDNV said they’d contacted a healthcare provider about the problem.) EX— plain that postdischarge rescue antiemetics can be prescribed for use after discharge. Despite the relatively little re- search done on PONV and PDNV, Volume 3, Number 8 we can offer nursing care consistent with the results of inpatient studies and evidence—based guidelines. With more than 65% of surgeries taking place in outpatient facilities and most patients returning home within 4 hours, PONV and PDNV affect significant numbers. With ef— fective nursing interventions, you can help prevent this “big little problem.” 79: Selected references American Society of PeriAnesthesia Nurses. Evidence—based clinical practice guideline for the prevention and/or management of PONV/PDNV algorithms. fPerianestb Nurs. 2006;21(6):374—576. Chaiyakunapruk N, Kitikannakorn N, Nathisuwan S, et al. The efficacy of ginger for the prevention of postoperative nausea and vomiting: a meta-analysis. Am J Obstet Gynecol. 2006;194:95-99. Fetzer 5, Hand M, Bouchard P, Smith H, Jenkins M. Self-care activities for post dis- charge nausea and vomiting. J Pertanesth Nurs. 2005;20(4):249-254. Gan TJ, Sloan F, Dear GL. How much are patients willing to pay to avoid postopera- tive nausea and vomiting? Anestb Anal. 2001;92:593-400. Golembiewski J, Tokumaru S. Pharmacologi- cal prophylaxis and management of adult postoperative/postdischarge nausea and vom- iting. jPen‘cmestb Nurs. 2006;21(6):585-597. Odom—Forren J, Fetzer S. Moser D. Evidence- based interventions for post discharge nau— sea and vomiting: a review of the literature. Perimzestb Nun. 2006;21(6):411—430. Susan Fetzer is Associate Professor in the Depart- ment of Nursing at the University of New Hampshire in Durham. ...
View Full Document

This note was uploaded on 09/08/2010 for the course NURS 146A at San Jose State.

Page1 / 3

Post_Op_N_xV - l ‘ . Muscat and vomit Putting a stop to...

This preview shows document pages 1 - 3. Sign up to view the full document.

View Full Document Right Arrow Icon
Ask a homework question - tutors are online