What should be included in the plan note of a SOAP note for a patient experiencing nausea?

Comprehensive Plan for Nausea in a SOAP Note

The plan section for a patient experiencing nausea should include a thorough assessment of the cause, appropriate antiemetic medication selection based on etiology, and supportive measures to improve patient comfort and quality of life.

Initial Assessment and Management

• Evaluate for specific causes of nausea including medication side effects (especially opioids), constipation, central nervous system pathology, chemotherapy, radiation therapy, hypercalcemia, and gastrointestinal disorders 1
• Review current medications that may be causing nausea, with particular attention to opioids which commonly cause nausea 2, 1
• For opioid-induced nausea, consider prophylactic treatment with metoclopramide 10-20 mg PO every 6 hours or prochlorperazine 10 mg PO every 6 hours for the first few days of opioid therapy 2
• Begin treatment with first-line antiemetics based on suspected cause:
  • Dopamine receptor antagonists: prochlorperazine 5-10 mg every 6-8 hours, metoclopramide 10-20 mg every 6 hours, or haloperidol 0.5-1 mg every 6-8 hours 1, 2
  • Serotonin (5-HT3) receptor antagonists: ondansetron 8 mg PO every 8-12 hours (particularly effective for chemotherapy-induced nausea) 2, 3

Persistent Nausea Management

• If nausea persists despite as-needed regimen, administer antiemetics around the clock for 1 week and then change to as-needed dosing 1
• Consider adding medications with different mechanisms of action:
  • Anticholinergic agents: scopolamine transdermal patch 1 mg/3 days 1
  • Antihistamines: meclizine 25 mg every 6 hours or diphenhydramine 12.5-25 mg every 4-6 hours 2, 1
  • Corticosteroids: dexamethasone 2-8 mg PO or IV daily (particularly useful for chemotherapy-induced nausea) 2, 1
  • Benzodiazepines: lorazepam 1-2 mg every 4-6 hours or alprazolam 0.5-2 mg every 4-6 hours (especially for anticipatory nausea) 2

Specific Nausea Scenarios

Chemotherapy-Induced Nausea and Vomiting

• For highly emetogenic chemotherapy, use a three-drug combination of:
  • NK1 receptor antagonist (aprepitant 125 mg day 1, followed by 80 mg days 2-3)
  • 5-HT3 receptor antagonist (ondansetron 16-24 mg)
  • Dexamethasone (20 mg) 2
• For moderately emetogenic chemotherapy, use a two-drug combination of a 5-HT3 receptor antagonist and dexamethasone 2
• For breakthrough chemotherapy-induced nausea, consider olanzapine 2.5-5 mg PO daily if not used prophylactically 2

Radiation-Induced Nausea

• For high-emetic-risk radiation therapy, use a two-drug combination of a 5-HT3 receptor antagonist and dexamethasone before each fraction and on the day after each fraction 2
• For moderate-emetic-risk radiation therapy, use a 5-HT3 receptor antagonist before each fraction, with or without dexamethasone 2

Opioid-Induced Nausea

• Rule out constipation as a cause of nausea in patients taking opioids 2
• Metoclopramide has both central and peripheral effects and is recommended as first-line for opioid-related nausea 2
• Tolerance to nausea typically develops within a few days; consider prophylactic antiemetics during initial opioid therapy 2
• If nausea persists after trials of several opioids and antiemetics, consider opioid rotation 1

Refractory Nausea Treatment

• Reassess the cause and severity of nausea if initial treatments are ineffective 2
• For chemotherapy-induced nausea refractory to standard therapies, consider cannabinoids such as dronabinol or nabilone 2
• For cyclic vomiting syndrome or cannabis hyperemesis syndrome, consider benzodiazepines (alprazolam 0.5-2 mg) or topical capsaicin 2
• Consider non-pharmacologic approaches such as acupuncture, hypnosis, or cognitive behavioral therapy 1

Supportive Measures

• Ensure adequate hydration and electrolyte replacement 4
• Recommend dietary modifications: small, frequent meals; avoiding trigger foods; consuming clear liquids 4
• For gastroesophageal reflux causing nausea, use proton pump inhibitors or H2 receptor antagonists 1
• For anticipatory nausea, consider behavioral therapy with systematic desensitization 2

Follow-up Plan

• Schedule follow-up to assess response to antiemetic therapy 2
• Document patient's response to antiemetic regimen and any adverse effects 2
• Provide patient education regarding medication side effects and when to contact healthcare provider 2

Special Considerations and Precautions

• Monitor for QT prolongation with serotonin antagonists and some dopamine antagonists 5
• Watch for extrapyramidal side effects with dopamine antagonists, particularly in younger patients 5
• Use antiemetics for the shortest time necessary to control symptoms 4
• For patients with severe hepatic impairment, reduce ondansetron dosing to no more than 8 mg daily 3