Nausea / Vomiting

Also Consider:  Abdominal Discomfort, Appetite Diminished, Constipation, Diarrhea, Rectal Bleeding, Vomiting Blood 

1. Take Vital Signs

• Temperature:

• Blood Pressure:

• Heart Rate: 

• Respiratory Rate:

• Oxygen Saturation:

2. 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)

3. Take Action using SBAR Report:

• Presence of other, significant symptoms or signs of illness 

  • Refer to appropriate Situation-Specific Evaluation for the identified symptoms and signs.

• Immediately notify the medical staff & resident representative

  • Persistent or recurrent (two or more episodes within 12 hours) vomiting, OR 

  • Vomiting with bleeding, abdominal distention, or fever

• Notify medical staff & resident representative within the next 16 hours. 

  • New persistent nausea or vomiting  impacting po intake

• Notify medical staff on the next business day 

  • Intermittent recurrent nausea, or isolated episode of vomiting

4. Implement Management Plan

• 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

2025-04-27