Symptom Series: Nausea

By: Jillian Lisiakowski, DNP, FNP-C, ACHPN

Many common symptoms are experienced at the end of life, including nausea, pain, shortness of breath, loss of appetite, weakness, and confusion. Uncontrolled nausea can lead to decreased appetite, loss of muscle mass, and weakness. Chronic uncontrolled symptoms, such as nausea, can also lead to depression in hospice and palliative care patients. While these symptoms can be distressing, a trained hospice and palliative care team can often manage them effectively at home. Treatment for nausea frequently includes both pharmaceutical and non-pharmaceutical therapies and can lead to an increased quality of life for the patient.

What is nausea?

Nausea is an unpleasant, painless sensation that usually precedes the urge to vomit. Vomiting occurs when the contents of the stomach are forced out due to contractions of the stomach muscle. Retching is the contraction of the gastrointestinal tract without vomiting. There are many causes of nausea, including gastrointestinal (GI) causes, drug-induced, metabolic, or endocrine causes, increased pressure around the brain, pharyngeal or vestibular causes, psychological causes, and pain. Examples of the different causes of nausea are listed below. Treatment for each type of nausea can vary based on the cause and can also include non-pharmacological therapies.

Causes of Nausea

Gastrointestinal (GI)

1.      Gastroesophageal reflux (GERD) or acid reflux

2.      Blockage of the intestine

3.      Slowing of the GI tract

4.      Constipation

5.      Inflammation of the pancreas or gallbladder

Drug-Induced

1.      Chemotherapy

2.      Opioid pain medication

3.      Iron supplements

4.      Antibiotics

Metabolic/Endocrine

1.      Diabetes

2.      Dehydration and fluid and electrolyte imbalance

3.      Kidney failure

4.      Infection or sepsis

Increased intracranial pressure (ICP) – or pressure in the brain




1.      Swelling in the brain

2.      Cancer or tumor metastasis to the brain or central nervous system

3.      Bleeding in the brain or skull

4.      Headache or migraine

Pharyngeal/Vestibular- involving the back of the throat and ear




1.      Chronic coughing

2.      Increased or thickened mucous production

3.      Motional sickness

4.      Complications within the ear, such as vertigo and Meniere’s disease

Psychological/Pain

1.      Fear

2.      Anxiety

3.      Pain

 

Treatment options

Medications used to treat nausea will vary based on the suspected cause of nausea as well as the route of administration (oral versus injection). Common medications you may see in the treatment of nausea include ondansetron (Zofran), promethazine (Phenergan), and prochlorperazine (Compazine). These medications are often used for nausea related to medications, post-operatively, and GI irritants. Nausea related to swelling in the brain or other parts of the body may be treated with a corticosteroid such as dexamethasone. Antihistamines such as diphenhydramine (Benadryl) or meclizine may be used for nausea related to motion sickness or inner ear problems.

Nausea related to fear, anxiety, or pain is often treated with both medications and psycho-social services such as chaplain or social worker services. These services allow the patient to explore and discuss the cause of their pain, fears, and anxiety. This could include physical, spiritual, or emotional concerns that present as nausea. Medication such as lorazepam (Ativan) can also assist in lessening anxiety and reducing nausea.

Other treatment options for reducing and managing nausea at home include slowly sipping cold, clear liquids throughout the day and eating smaller snacks instead of large meals. Bland foods such as crackers, pretzels, plain yogurt, or toast are often tolerated well, as are foods without a strong smell. Eating something before taking medications can reduce stomach upset and nausea. Avoid greasy or fried foods. Relaxation techniques such as meditation, music therapy, ginger chews, and the use of aromatherapy with peppermint oil have proven helpful in managing nausea in some patients.

While nausea can be a common, uncomfortable, and sometimes difficult symptom to manage, working with the healthcare team can reduce and control symptoms and improve quality of life. Several therapies may need to be tried to find what works best. Be open to adding both pharmaceutical and non-pharmaceutical therapies to manage nausea. The hospice and palliative care team is ready to ensure symptoms are managed and well-controlled in the home.

 References

Churchill, M. (2020). Chapter 27. In Core curriculum for the hospice and palliative aprn (3rd

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John Hopkins Medicine. (n.d.). Benign paroxysmal positional vertigo (BPPV). Www.hopkinsmedicine.org. https://www.hopkinsmedicine.org/health/conditions-and-diseases/benign-paroxysmal-positional-vertigo-bppv

Johns Hopkins Medicine. (2021). Increased intracranial pressure (ICP) headache. Johns Hopkins Medicine. https://www.hopkinsmedicine.org/health/conditions-and-diseases/headache/increased-intracranial-pressure-icp-headache

National Institute of Health: National Cancer Institute. (2011). https://www.cancer.gov/publications/dictionaries/cancer-terms/def/pharyngeal-cancer. Www.cancer.gov. https://www.cancer.gov/publications/dictionaries/cancer-terms/def/pharyngeal-cancer

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