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Patterns of Nausea and Vomiting in Antineoplastic Postchemotherapy Patients

Verna A. Rhodes, Phyllis M. Watson, and Mary H. Johnson

p bATTERNS of nausea and vomiting occur- rence and distress are not well documented

for single antineoplastic chemotherapeutic agents and drug combinations. The purpose of this study, using self-regulation theory, was to describe pat- terns of nausea and vomiting that occurred during six consecutive cycles of initial selected chemo- therapy regimens. A stratified sample of patients (N = 309), 21 to 85 years old, was selected from multiple geographic sites within two Midwestern states. The Rhodes Index of Nausea and Vomiting (INV) Form 2 was used to measure nausea and vomiting every 12 hours for 48 hours. Nonpara- metric analysis of variance and cluster analysis methods were used to determine the patterns of postchemotherapy nausea and vomiting. Findings revealed that 84% of the sample had their vomiting well controlled during the 48 hours posttherapy, while 71% had little or no nausea (i.e., minimal pattern). In the remaining sample, three distinct antiemetic drug-resistant patterns emerged for each of the dyad symptoms. The drug-resistant patterns of symptom experience, symptom occurrence, and symptom distress were (a) peak, (b) latent, and (c) sustained patterns (Rhodes & Watson, 1987a; Rhodes, Watson, Johnson, Madsen, & Beck, 1987). Additional findings were as follows:

1. Statistically significant relationships between postchemotherapy symptom experience and the antineoplastic drug protocols. The three most emetic chemotherapy drug protocols were cyclo-

From the University of Missouri-Columbia, and Lakeland Regional Medical Center, Lakeland, FL.

Supported by U.S. Public Health Service Grant No. 5 ROI NUO1154-02.

Verna A. Rhodes, EdS, RN: Associate Professor of Nursing, Univesity of Missouri-Columbia: Phyllis M. Watson, PhD, RN: Vice President for Nursing, Lakeland Regional Medical Cen- ter, Lakeland, FL: Mary H. Johnson, MSN, RN: Clinical Nurse 1, Adult Oncology, Division of Nursing Services, Uni- versity of Missouri, Columbia Hospital and Clinics, Columbia.

Address correspondence to Verna A. Rhodes, EdS, RN, $314 School of Nursing, University of Missouri-Columbia, Colum- bia, MO 65211.

© 1988 by W.B. Saunders Company. 0897-1897/88/0103-000955.00/0

phosphamide (Cytoxan) and doxorubicin (Adri- amycin), platinum and doxorubicin (Adriamycin), and platinum alone or with less emetic drags.

2. Cycle 1 posttherapy vomiting scores pre- dicted vomiting scores in cycles 2 through 6.

3. Cycle l posttherapy nausea scores predicted nausea scores in cycles 2 through 6.

4. Total symptom experience did not increase with each successive cycle of therapy. However, symptom experience at 12 hours posttherapy showed a statistically significant pattern of in- crease with each successive cycle.

These findings have implications for the educa- tion and practice of oncology nurses and the de- velopment of effective nursing interventions to re- duce symptom distress, enhance self-care abilities, and improve patient coping with symptom occur- rence. Patients can not only distinguish between the individual symptoms of nausea, vomiting, and retching but differentiate between the components of each (i.e., frequency, amount, duration, and distress).

The varied patterns of nausea and vomiting ex- perience repeatedly illustrate the need for careful assessment of the specific symptom occurrence and distress and for the prescription and implemen- tation of antiemetie interventions over 48 hours and longer. Posttherapy antiemetic drug adminis- trations are most frequently administered within the first 12 hours and then as needed (prn). Until findings of studies of specific antiemetics that use reliable and valid measurement tools are available, nurses can encourage regular dosage rather than prn, start medications the day before, and continue their use for 48 hours or longer. Nausea was a more frequent symptom than vomiting; over 25% of the individuals indicated that nausea never went away. Since nausea is an unobservable symptom, nurses need to use reliable and valid assessment tools to assess the symptoms and to measure the effectiveness of their interventions. When inter- viewing or questioning patients about symptoms, caution must be taken to use language that is mean- ingful to the patient. In an earlier study (Rhodes, Watson, & Johnson, 1984) the term "nausea" was not understood by two thirds of the patients. The

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phrase "sick at stomach" was the most common description of this term. Most patients did not know the meaning of "emesis ." Vomiting was most clearly understood as "throw up."

According to self-regulation theory (Leventhall & Johnson, 1983; Rhodes & Watson, 1987a; Rhodes, Watson, Johnson, Madsen, & Beck, 1987) and in view of the predominate pattern of symptom experience, patients on similar antineo- plastic and antiemetic regimens should be told to expect little or no nausea and vomiting postther- apy. Thus, caution must be taken to .avoid inform- ing patients of every possible side effect. It is es- sent ia l to d i f f e r e n t i a t e i n fo rm ed consen t procedures from the procedures designed to pre- pare patients for chemotherapy.

Although total symptom experience did not in- crease with each successive cycle, contrary to common thought, symptom experience 12 hours posttherapy increased with each successive cycle. Strategically timed nursing interventions should be planned to prevent or alleviate this discomfort. Practicing oncology nurses should make every ef-

RESEARCH BRIEFS

fort to provide proactive interventions to alleviate symptom distress prior to, during, and following the first cycle of chemothe rapy , since the cycle/symptom experience for both nausea and

- "vomiting is predictive for cycles 2 through 6. In summary, our practice has most frequently

focused on the presence or absence of signs and symptoms rather than on the patient's response to the occurrence of the symptoms. The amount of mental or physical anguish or upset (distress) the patient perceives or feels must be assessed. A ma- jor function of nursing practice is to assist patients in coping with symptom distress. Quality of life is dependent upon the degree to which this is accom- plished. Assessment tools that measure symptom occurrence and symptom distress separately should be used in nursing practice to inform us of the patient's response to the occurrence (Rhodes & Watson, 1987b). Future experimental research of nursing interventions should be conducted to en- hance coping behaviors to reduce distress and to promote self-care.

REFERENCES

Leventhall. H., & Johnson, J.E. (1983). Laboratory and field experimentation: Development of a theory of self- regulation. In Woolridge, Schmitt, Skipper, & Leonard (Eds.), Behavioral science and nursing theory (pp. 189-262). St. Louis: C.V. Mosby.

Rhodes, V.A., & Watson, P.M. (1987a). Final report of U.S. Public Health Service Grant No. 5 R01 NU01154-02.

Rhodes, V.A., & Watson, P.M. (1987b). Symptom dis-

tress--The concept: Past and present. Seminars in Oncology Nursing, 3, 242-247.

Rhodes, V.A., Watson, P.M., & Johnson, M.H. (1984). Development of reliable and valid measures of nausea and vom- iting. Cancer Nursing, 7(I), 33-41.

Rhodes, V.A., Watson, P.M., Johnson, M.H., Madsen, R.W., & Beck, N.C. (1987). Patterns of nausea, vomiting, and distress in patients receiving antineoplastic drug protocols. On- cology Nurshzg Forum, 14(4), 35-43.