Pain Management

Symptom Management
Common Symptoms:
Bowel Management
Nausea and Vomiting
Terminal Phase
Changing Awareness
Altered Elimination
Respiratory Changes
Agitation or Restlessness
Signs of Impending Death
Caregiver Support

Common Symptoms and
Management in Advanced Disease

Nausea and Vomiting

Nausea and vomiting are symptoms experienced by approximately 40% to 60% of cancer patients, especially those with breast or stomach cancer. Nausea and vomiting are also often a consequence of chemotherapy treatments, and can be a temporary side effect when initiating opioid therapy. Quality of life and the ability to perform activities of daily living are significantly impacted by nausea and vomiting, and treatment should be directed at the cause as well as the symptoms themselves.

Nausea is a subjective experience, influenced by past experiences, emotions, expectations and other contributing factors. The sensation of nausea can range from stomach discomfort that comes and goes in waves, to painful cramping, to an urgent need to vomit, depending on the patient. Nausea can occur without vomiting and is more common than vomiting.

Vomiting is the “forceful ejection of the stomach or intestinal contents” and is controlled by the vomiting or emetic center in the brain stem. Several central and peripheral nerve pathways stimulate the vomiting center: through the cortex and the limbic system which is activated by certain smells, or remembered sensory experiences; the chemoreceptor trigger zone in the medulla oblongata which responds to chemical changes in the cerebrospinal fluid; the peripheral nerve pathways, which are stimulated by chemical changes in the blood and viscera; and the vestibular apparatus in the middle ear that responds to changes in position of the patient (Haughney, 2004). Vomiting can be a sudden occurrence and may or may not occur with nausea.

Causes of nausea and vomiting

Treatment of nausea and vomiting
Treatment of nausea and vomiting can be challenging.

Modifying the diet
Modifying the diet can help to decrease nausea and vomiting. Begin by eliminating spicy, fatty, or overly sweet foods. Bland foods such as rice, potatoes, crackers, dry toast etc. should be encouraged. Small frequent meals that are room temperature (warm foods may have a stronger odor) are recommended.

Monitor and treat for dehydration.

Discontinue as many of the patient’s other medications as possible.

Drug Therapy
Drug therapy is most likely to work if started prophylactically; the oral route is preferred if there has been no vomiting.

Start with a metoclopramide around the clock. for nausea and vomiting caused by gastric stasis, ascites, hepatomegaly, and tumor infiltration. If not effective, assess mechanism of nausea and vomiting:
Nausea and vomiting that is secondary to opioid therapy, uremia, liver metastases add: haloperidol or chlorpromazine;
If secondary to brain metastases add: dexamethasone

Antihistamines such as hydroxyzine, promethazine, or diphenhydramine may be added if nausea and vomiting are not fully controlled.

Ondansetron (Zofran) may be added if nausea is due to chemotherapeutic agents such as cisplatin.

If Due To Anxiety
Nausea and vomiting due to anxiety can also be treated with antihistamines or anticholinergics such as scopalomine.

Relaxation and breathing techniques, techniques such as Therapeutic Touch, spiritual counseling, and life review are also very useful to relieve nausea caused in part by anxiety. These techniques should be initiated along with conventional pharmacological treatments for a more comprehensive plan of care.