Situation-Specific Evaluation, SBAR Reporting, and Management

Nausea / Vomiting

Causes

  • Common:  Constipation, fecal impaction, gastroenteritis, gastroparesis, medications
  • Less common:  Obstruction, diverticulitis, cholecystitis, pancreatitis, ulcers,food poisoning, kidney stones, UTI, kidney failure, metabolic derangement, liver failure, cancer, increased intracranial pressure, pneumonia

Goal is to identify and treat the underlying cause of the nausea / vomiting.

Vital Signs

Temperature:________                       Heart Rate: ________                                   Blood Pressure lying: _____________         

Respiratory Rate:______                     Oxygen Saturation: _______                         Blood Pressure standing: ____________

Evaluate Symptoms and Signs

  • Acute mental status change
  • Not eating or drinking as much as usual
  • Acute decline in ADL abilities
  • Jaundice
  • Fainting, dizziness or lightheadedness when standing up
  • Signs of dehydration
  • Diaphoresis: Cold, clammy, pale skin
  • Respiratory: New cough, abnormal lung sounds
  • Cardiovascular:  Chest pain, new irregular pulse, cyanosis, mottling, edema
  • GI: Nausea, vomiting, diarrhea, constipation, abdominal distention or tenderness, rebound tenderness, bowel sounds
  • GU: New or worsened incontinence, pain with urination, blood in urine, scrotal pain, urinary retention / Bladder scan
  • Neurologic  changes: consciousness/alertness, orientation, weakness
  • Appearance of any vomited material, presence of occult blood
  • Rectal check for impaction, appearance of stool
  • Tube feeding residual measurement
  • Fingerstick glucose (patients with diabetes)

Persistent or recurrent (two or more episodes within 12 hours) vomiting, OR vomiting with bleeding, abdominal distention, or fever

Notify the medical staff & Designated Representative immediately.

New persistent nausea or vomiting  impacting po intake

Notify medical staff & Designated Representative within the next 16 hours.

Intermittent recurrent nausea, or isolated episode of vomiting

Notify medical staff on the next business day

Continued on Next Page

Nausea / Vomiting  Continued

SBAR Report

Situation:  "(Nausea) (Vomiting), associated with:" (fever) (other acute symptoms)

Background:

        Report…

  • Reason the patient is in the nursing home (rehab for___, long term care for __).
  • When the symptoms started, vomiting frequency and amount, getting worse or staying the same, alleviating or aggravating factors, what treatments have been used.
  • Abnormal Vital Signs based on patient’s previous values
  • MOLST / Advance Directives
  • Recent illness, surgery, antibiotics, medication changes, falls
  • General observation of patient condition
  • Appearance of vomited material, presence of blood
  • Bowel record for the last week, including prn medication use
  • Diet restrictions, Fluid restriction, thickened liquids
  • Similar symptoms in other patient(s) on unit or in facility
  • Tube feeding rate,  water flush orders, residual measurements, recent changes
  • Availability of IV or clysis hydration (i.e., PICC line)

        Have Available…

  • Chart / logged in to Electronic Medical Record
  • MAR
  • Recent medical problems & order changes
  • Major diagnoses
  • Allergies
  • Recent lab results & previous results if abnormal
  • Intake record
  • Bowel record
  • List of emergency medications available in the facility

Assessment: I think the problem is:  __________

I am concerned about: __________

Recommendations/Requests:

  • Labs: CBC with manual diff, Lactic Acid, CMP/Chem14, Amylase, Lipase, Drug levels
  • X-ray abdomen or free air series
  • Ultrasound abdomen
  • Start or stop a medication
  • IV or SC (clysis) fluids
  • Straight catheterization for urine sample for urinalysis and culture (unless patient is able to collect clean-catch, midstream urine)
  • Stool for occult blood testing
  • Diet change
  • Other:
  • Nausea Medication
  • Laxative Medication, tap water enema
  • “Hold” parameters for medicines that lower blood pressure

Clarify expectations for care, interventions, and illness course/prognosis. Repeat any telephone orders back to the provider to ensure that they are correct and complete

Management

  • Monitor vital signs, fluid intake/urine output every 4-8 hrs for 2-3 days
  • Offer fluids frequently if nausea/vomiting allow
  • Place on Intake & Output monitoring
  • Place on 24-hour report for 2-3 days
  • Record all episodes of vomiting or diarrhea
  • Obtain lab results (if ordered), and notify medical as needed of:
  • Significantly abnormal values in lab tests (refer to appropriate Situation)
  • WBC > 12,000 or neutrophils > 90%
  • Abnormal X-ray results
  • Urine results suggest infection and symptoms or signs present (Refer to “UTI” Situation)
  • Monitor meal acceptance
  • Assure bowel regularity
  • Clear liquid diet
  • Resume normal diet and discontinue prn nausea medications when symptoms are resolved
  • Implement infection control measures if indicated
  • Update care plan regarding  fall risk, pressure ulcer prevention, assistance needed with ADLs, supervision for safety, restorative needs
  • Review status and plan of care with designated representative daily

2016-01-30           © www.ssesbar.org