Capstone Project: Post-Operative Nausea and Vomiting Among Adult Patients

Abstract

The capstone project is aimed at checking the effectiveness of the application of aromatherapy in combination with anti-emetic drugs compared to simply anti-emetic medication among adult patients experiencing post-operational nausea and vomiting. The project is composed of the following stages: problem statement, solution description, implementation plan, evaluation plan, and the offers devote to results dissemination. Also, the literature review is included to assess the research conducted in the area of study. The problem description is focused on post-operation vomiting and the traditional treatment by means of intravenous injections of anti-emetic drugs. The solution description is focused on aromatherapy as an effective means for dealing with post-operative nausea and vomiting. The conducted research and theoretical achievements in the sphere have been stated. The review of the literature stage is offered to inform about the data in the area of study and confirm that the chosen means for treating post-operative nausea and vomiting is a spread issue. The implementation plan dwells upon the stages of how the project should be implemented. The evaluation assesses the effectiveness of the project results and dissemination plan described the ways how the information is to be delivered. Overall, aromatherapy in combination with anti-emetic medication is considered as an effective tool in coping with post-operative nausea among adults which helps improve the effectiveness of the treatment and reduce the doses of anti-emetic medication (Hunt, Dienemann, Norton, Hartley, Hudgens, Stern, & Divine, 2013).

Problem Description

Defining vomiting as “a complex behaviour composed of three linked activities: nausea, retching, and expulsion of stomach contents” (Moreno-Villares & Segovia, 2009, p. 11), adult patient usually face such problem within 24 hours after operations. Statistically, post-operative nausea and vomiting among adults is a serious problem, which occurs in 20-30% cases within 24 hours (Gibbison & Spencer, 2009). High-risk patients experience nausea and vomiting in 60% case after operations (787.0 Nausea, 2013). The focus of the study is an adult population experiencing post-operative nausea and vomiting immediately after the surgery. The traditional treatment use is anti-emetic medication, intravenous injections offered to patients immediately after they report about the problem or even before it while the surgery. Additionally, the combination of the drugs injections with non-pharmacological strategies is applied. Depending on the severity of nausea, nurses use either drugs or a combination of drugs to assure the immediate or fast remission.

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Gibbison and Spencer (2009) have summarized the most commonly used pharmacological groups for coping with severe nausea and vomiting, hydroxytryptamine antagonists, steroids, antihistamines, phenothiazine’s, benzamide’s, anticholinergic’s, and butyrophenone’s. Additionally to drugs medication, such non-pharmacological treatment is applied as transcutaneous electrical nerve stimulator. The main problem with the traditional medication is that it has numerous limitations. Pharmacological medication is expensive. The refusal from costly pharmacological medication may increase a hospital financial situation. Anti-emetic medication requires nursing interventions; thus, the constant nurses’ presence is necessary. It increases the nursing performance which prevents them from dealing with other more serious issues (Gibbison & Spencer, 2009). Modern research shows that traditional anti-emetic treatment is ineffective in the way as it is expected to be and there is an alternative treatment, which shows more efficiency (Trueman, 2011; Hunt et al., 2013; Hines, Steels, Chang, & Gibbons, 2012; Ferruggiari, Ragione, Rich, & Lock, 2012).

Intravenous injections of the particular drug help cope with nausea and vomiting by means of neurochemical influence. However, this method is used when severe nausea and vomiting is reported. Drugs intravenous injections have numerous limitations, such as painful process. Moreover, scholars do not recommend using Intravenous injections often since liquids in the blood move at a faster speed (Nausea and Vomiting, 2013; Goodina & Cunninghama, 2009; Bhatt et al., 2009). One more problem may appear with the intoxication by any of the medications used for nausea and vomiting treatment, namely hydroxytryptamine antagonists, steroids, antihistamines, phenothiazine’s, benzamide’s, anticholinergic’s, and butyrophenone’s (Gerace, Salomone, Pellegrino, & Vincenti, 2012; Petkovi?, Durendi?-Brenesel, Dolai, & Samojlik, 2011; Nausea and Vomiting, 2012). Intoxication with any of the drugs mentioned above may lead to serious problems. Additionally, vomiting may be a result of overdose (Gerace et al., 2012; Petkovi? et al., 2011; Nausea and Vomiting, 2012). Surgery is a very serious stress for human organism and additional intrusion by intravenous injections may negatively influence human organism. Thus, it may be indicated that post-operative patients with the signs of severe nausea and vomiting should not be subjected to additional interventions, such as anti-emetic drugs injections as having suffered from the surgery, and they may negatively react to this particular medication.

The main purpose of the project is to study the idea that the use of anti-emetic drugs in combination with aromatherapy (oil scent. 70% isopropyl alcohol swab) as an alternative way of dealing with post-operative nausea and vomiting is a more effective therapy compared to only anti-emetic treatment. Much research has already been conducted in direction to consideration of aromatherapy as an effective tool for coping with nausea and vomiting after operation. The research conducted by Hunt et al. (2013) proves that aromatherapy is a very effective means for copying with the problem. The authors of the research also state that using aromatherapy for preventing post-operative nausea immediately after the surgery may reduce the costs on treatment. Moreover, the procedure with aromatherapy involvement does not require professional assistance, which means patients may easily deal with post-operative nausea without outside help. The similar research has been conducted by Hines et al. (2012) who also prove the effectiveness of the method. Comparing isopropyl alcohol and saline placebo in aromatherapy technique while dealing with post-operative nausea the researchers conclude that isopropyl alcohol is more effective. It means that aromatherapy is effective when correctly implemented. However, the same research has not shown the effectiveness in comparison with standard anti-emetic drug. As the study was conducted among 402 patients, its results cannot be generalized. One more research also confirmed the effectiveness of aromatherapy. Ferruggiari et al. (2012) have shown that aromatherapy is an effective measure in dealing with post-operative nausea in South America.

Overall, the problem of nausea and vomiting is very spread among patients. The implementation of the traditional means for treatment requires reconsideration in many reasons. Intravenous injections of a particular group of drugs or sometimes even a combination of these groups require professional knowledge and top care from the side of the nurses. Thus, top professional nurses should be involved, while there are other cases where professional nursing assistance is more important. In conclusion, the standard means for dealing with post-operative nausea require changes. The use of aromatherapy among adult patients in case of post-operative nausea immediately after the surgery is a good decision. The effectiveness of this method has already been proven in several studies (Hunt et al., 2013; Hines et al., 2012; Ferruggiari et al., 2012). The current research will prove that the aromatherapy is more effective than standard means used in the hospital. It will allow to apply the research results in the hospital and to change the existing system of dealing with post-operative nausea immediately after the surgery. Applying the research to the selected population will give way to study the effect of aromatherapy on children, elderly people and pregnant women in the future.

Solution Description

Considering adult patients who experience post-operative nausea immediately after the surgery, two treatments are offered to cope with the problem, any anti-emetic drugs given intravenously individually and a combination of aromatherapy (oil scent. 70% isopropyl alcohol swab) and a reduced number of anti-emetic drugs. This particular comparison is selected in many reasons. Anti-emetic drug is used as a standard means for treating post-operative nausea. The rationale for selection of the aromatherapy as the way to cope with post-operative nausea immediately after the surgery is based on the decision to eliminate the amount of intravenous medicine in healthcare. Aromatherapy is a cheaper way to cope with the problem compared to anti-emetic drug utilization. Utilizing standard anti-emetic drugs, nurses have to participate in the procedure. It is obvious that the cost of the procedure increases. Intravenous injections require professional help. It means that people are dependent on others. This is one more factor, which may be a good reason for people to search for alternative way in dealing with nausea.

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However, there are more valid reasons to utilize aromatherapy as the means for dealing with post-operative nausea. The research conducted by Hunt et al. (2013) proves that aromatherapy is a very effective means for copying with the problem. The authors of the research also state that using aromatherapy for preventing post-operative nausea immediately after the surgery may reduce the costs on treatment. Moreover, the procedure with aromatherapy involvement does not require professional assistance, which means patients may easily deal with post-operative nausea without outside help. The similar research has been conducted by Hines et al. (2012) who also prove the effectiveness of the method. Comparing isopropyl alcohol and saline placebo in aromatherapy technique while dealing with post-operative nausea the researchers conclude that isopropyl alcohol is more effective. It means that aromatherapy is effective when correctly implemented. However, the same research has not shown the effectiveness in comparison with standard anti-emetic drug. As the study was conducted among 402 patients, its results cannot be generalized. One more research also confirmed the effectiveness of aromatherapy. Ferruggiari et al. (2012) have shown that aromatherapy is an effective measure in dealing with post-operative nausea in South America.

Lane, Cannella, Bowen, Copelan, Nteff, Barnes, Poudevigne, and Lawson (2012) have managed to prove the effectiveness of being used in women after C-section. The use of aromatherapy is the best method to help women reduce the level of nausea without having any side effect if compared to traditional medication treatment. Having no opportunity to have any anti-emetic injections (mainly because of breast feeding), aromatherapy is the best way out. Radford, Fuller, Bushey, Daniel, and Pellegrini (2011) have also confirmed that the use of aromatherapy in combination with anti-emetic drugs helps to reduce intravenous injections to minimum. The application of aromatherapy as a means for coping with nausea and vomiting is justified by cognitive and behavioral theories. The choice of these theories is explained by the physiological and pathological nature of vomiting and nausea (Veale, 2009). Nausea is the process which emerges in the brain as various conditions are involved. Being based on various emotional and perceptional aspects, nausea is closely related to brain. Using aromatherapy, nurses provide psychological relaxation effect on human brain affecting perceptions and emotions (Harbord, 2009). The cognitive theory is incorporated in the evidence-based project by means of affecting the human brain and emotions. Referring to the behavioral theory and its incorporation into the study, people experiencing nausea and vomiting refer to rituals or superstitious behaviors to assure the absence of the disturbing symptoms (Veale, 2009).

Aromatherapy brings results within shorter periods of time. Intravenous injections require more time to relieve patients’ condition. Furthermore, drugs are not the best choice after operation as many people have already been subjected to medication. First, patients may develop allergy. Second, the medications used for dealing with post-operative nausea and vomiting may be inconsistent with the previously used drugs, and it may result in ineffectiveness of treatment (people will continue to feel nausea and experience vomiting) or even bring dangerous complications. A number of various studies have already referred to the effectiveness of aromatherapy (Hunt et al., 2013; Radford et al., 2011; Lane et al., 2012). Hunt et al. (2013) have proven the cost effectiveness and time efficiency of aromatherapy, along with the absence of necessity for professional assistance. Hines et al. (2012) have also demonstrated that isopropyl alcohol use for aromatherapy is more effective in comparison with anti-emetic drugs compared to other combinations. This evidence proves the effectiveness of the chosen method. In the case under analysis application of aromatherapy to a greater number of people will allow generalizing the results and refusing from intravenous injections of anti-emetic drugs.

Nausea and vomiting are usually stimulated by particular physiological and psychological factors (Veale, 2009). The reduction of the problem should also be based on the stimuli. Aromatherapy is a procedure, which stimulates various processes in human organism. The senses are stimulated and the brain gets the necessary information. Aromatherapy affects human emotions and improves the work of many systems (Veale, 2009). It is essential to refer to emotions while dealing with nausea. Aromatherapy affects human emotions. The psychological relaxing effect of aromatherapy and supportive oils are effective in dealing with nausea and vomiting. Applying aromatherapy in dealing with the problems under analysis, the cognitive and behavioral theories help model the human actions and predict the effect (Harbord, 2009).

The study is aimed at reducing the role of nurses in post-operative nausea and vomiting treatment. The application of aromatherapy for coping with nausea and vomiting is an effective tool, which is theoretically justified. However, the process of aromatherapy implementation is a very serious and complicated one as implementation of a new treating method always requires much time and effort. Thus, the main idea of the project is to test a new solution to the problem of post-operative nausea and aromatherapy. The solution is aromatherapy, which is approved and justified in the study by means of the cognitive and behavioral theories. Aromatherapy as a new way of treatment is going to assist patients, reduce the number of medication, and limit the nurses’ assistance in the procedure. Also, the financial effect is expected due to the reduction of the cost of the procedure.

Implementation Plan

As it has already been mentioned above, the traditional methods for dealing with nausea and vomiting require changes. Having conducted thorough research and a detailed literature review, it has been noted that aromatherapy is one of the best means of coping with the stated problems (Radford et al., 2011). Using the sample of adult and elderly patients, the evidence-based process improvement will be grounded on implementation of aromatherapy with different oils when dealing with cases of post-operative nausea and vomiting. After the project, a decision will be made about the most effective oil in coping with the problem. Additionally, the project will apply to oil scent 70 % isopropyl alcohol swab. However, it may be possible to refer to patients’ preferences in case the research does not show differences in relation to the choice of oils. Aromatherapy should be assigned to patients for five to ten minutes depending on the severity of vomiting and nausea. The procedure may be repeated after several hours if nausea does not stop. The implementation of this particular method may guarantee the reduction in costs of treatment. Patients may continue treatment after discharged home. The use of aromatherapy requires the minimal professional assistance, which makes the procedure easy to follow at home (Johannessen, 2013).

The materials for evidence-based implementation are delivered to the staff in the form of handouts with the steps necessary for the study to be conducted. Nurses will be informed about the necessary aromatherapy oils and actions. The assessment of effectiveness of the used tools will be made based on the surveys. Patients will report their feelings after two and five minutes from the start of the treatment with aromatherapy. The pretest and posttest assessments of the patients’ condition will be based on the following grading system. The project applies to 4 likert-type scale with 0 indicating no nausea, 1 indicating little nausea, 2 indicating a lot nausea, and 3 indicating severe nausea, to measure the level of nausea before and after the therapy implementation. The evidence-based implementation is deliberated for a year. During this year the data should be gathered from all the patients who receive any of the treatments, either medication or aromatherapy. The information will be analyzed on computers with the use of Microsoft Office software. Using Excel tables, the information will be easily stored, structured and analyzed. The handouts for the nurses do not require many copies. All the information will be presented in the form of a lecture with the most important information noted on paper. The main challenge is to assure the nurses that the study is really necessary for improving the patient’s condition post-operatively for the complaint of nausea and vomiting. Having been presented the evidence gathered from other research supported by convincing arguments and reasonable words, the nurses will understand the necessity for the study and will participate in this research with pleasure.

The evidence-based project is applied in the hospital to the surgical patients who experience post-operative nausea and vomiting. The patients should be adults with no allergy to any medications. The patients will be prescribed five minutes of aromatherapy with the reflection after two and five minutes about the severity of nausea and vomiting. The evidence-based implementation will not interfere with the ordinary workflow of the hospital. The only difference is that nurses, contrary to their ordinary responsibilities of using traditional tools of treating nausea and vomiting, will assist with aromatherapy implementation. The procedure does not require much preparation time. The nurses just need to ask for a feedback. The staff will gather and receive information on necessary actions to be taken. Pre and post treatment questionnaires are important as they are going to be evaluated and on the basis of this evaluation the specific assessment will be done in relation to thee effectiveness of the both methods. The pretreatment evaluation will be based on the patients’ condition, the severity of nausea and vomiting. The evaluation of patients’ condition will be recorded on the fifth and the tenth minutes of the treatment. The aromatherapy treatment will be stopped if after the five minutes the symptoms of nausea will be dismissed. However, in case nausea continues patients will be offered to continue treatment for the next five minutes to have ten minutes of aromatherapy in general. After the five minutes the severity of nausea will be checked with the 4 likert-type scale with 0 indicating no nausea, 1 indicating little nausea, 2 indicating many symptoms of nausea, and 3 indicating severe nausea. The control group of patients who are going to be treated with the help of anti-emetic medication will also have evaluation of the condition on the fifth and the tenth minutes after the treatment.

The project requires the attraction of adults reporting nausea and vomiting after operations. People are going to be assigned to the treatment in a random way. The calculation of the assigned therapies should be done in order to have approximately similar cases of aromatherapy and anti-emetic medications. In both cases nursing assistance is necessary in order to conduct a treatment, but in case with aromatherapy the nursing assistance is reduced to minimum to assure that people can cope with the procedure without outside professional assistance. The process of treatment implementation will be provided in accordance with the following scheme. After a patient reports about post-operative nausea and/or vomiting, he/she will be assigned with the particular treatment. A random choice of either aromatherapy with anti-emetic medication or just the anti-emetic medication will be done. Depending on the chosen treatment, the nurses will have to do the following. If anti-emetic medication is assigned, nurses have to do the traditional and commonly accepted actions. However, they are to conduct a pre and post treatment questionnaires to assess the patients’ condition. If aromatherapy combined with anti-emetic treatment is chosen, nurses should apply to the traditional intravenous injections with the fewer doses of the drug and to use oil scent 70 % isopropyl alcohol swab as aromatherapy.

Evaluation Plan

The evaluation plan is aimed at describing the evidence-based research outcomes from the point of view of their effectiveness (Lavinghouze & Snyder, 2013). The effectiveness allows assessing the credibility and validity of the project outcomes. The limitations of project may be considered with the help of an evaluation plan. The first step in the evaluation plan is to assess the variables, development of the tools necessary for training the participants, and the assessment of the project outcomes from the position of the applied tools (Fineout-Overholt & Johnston, 2007).

The variables that require assessment are the staff attitude to the changes and their perception, patients’ attitude to a new method and their perception, and the time necessary for aromatherapy to relieve the symptoms of patients. The assessment of the nurses’ attitude and perception of a new tool may allow how the staff is going to react to a new intervention.. Attitude and perception of the patients may allow creating a general vision based on the opinion of those who are going to be subjected to the new treatment. The outcomes evaluation based on the patients’ questionnaires allows for assessing the comfort of applying this new treatment. The reflection reports provide the time when aromatherapy became effective. It is the main variable for evaluating the effectiveness of the new treatment for post-operative nausea and vomiting. Nurses’ attitude, patients’ perceptions and the time frames when aromatherapy was effective are also variables being measured for the effectiveness of the project.

The evaluation of the effectiveness of the use of aromatherapy for treating post-operative nausea and vomiting should be based on the staff documentation, patients’ questionnaires and general condition of the patient. The nurses involved in the project should participate in the survey. The main idea of this survey is to get to know personal nurses’ opinion about the procedure, its complications and time consumption. The analysis of these nurses’ surveys will help to evaluate the professional involvement into the procedure and the personal opinion, which is important for project results.

The evaluation of the patients’ self reflection reports before and after the treatment may help in understanding the effectiveness of the treatments. Assessing the self-reflection reports gives an opportunity to evaluate the effectiveness of the treatment compared to the traditional methods. In addition patients will be interviewed on their perceptions regarding comfort/discomfort after the use of aromatherapy. The patients’ will also be asked if they would have preferred medication in the treatment of their nausea and vomiting symptoms. The questionnaires and reports may help in understanding whether the proposed treatment is effective or not based on the results of the participants. The pre and post-treatment questionnaires are helpful in understanding to what extend each of the methods is effective. Thus, the validity of the aromatherapy combined with anti-emetic medication will be assessed and the results of this evaluation may be compared to the effectiveness of the traditional anti-emetic treatment.

Lectures and trainings are going to be used for educating nurses to assure that they are aware of the main aspects of the aromatherapy treatment. Nurses should be informed about the objectives of the procedure and the steps necessary for evidence-based research implementation. Nurses should be aware of the assessment techniques to be able to follow the research procedure and know how to treat patients and how to measure the time of the aromatherapy effectiveness. Having offered the verbal lecture, nurses should receive handouts with the most important stages of the study to assure they remember everything. Such means of education will provide a reference for the nurse to review.

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The Aromatherapy Checklist with the Project Objectives is to be used as the assessment tool for evaluating the project outcomes (Slotterback, Forsyth, Krizek, Johnson, & Pennucci, 2010). Before the project is conducted, specific objectives should be set. After the project is completed, the objectives should be reviewed. Upon review special attention should be paid to whether the objectives were achieved or not. According to Slotterback et al. (2010), a checklist is:

a worksheet for quickly assessing potential health impacts of policies, plans, projects, or programs. It also helps determine whether an additional and more detailed health impact assessment is needed. The tool can be used as a desktop evaluation or in a participatory setting. (p. 4)

The Aromatherapy Checklist with the Project Objectives should contain the following points.

• 1. The involvement of the adults reporting post-operational nausea and vomiting.
• 2. The effective use of a combination of anti-emetic drugs with aromatherapy (oil scent. 70 % isopropyl alcohol swab)
• 3. The effective use of anti-emetic treatment as a comparison.

Dissemination Plan

Having conducted a research, the dissemination of the evidence-based practices should be implemented with the purpose to assure that the study results are incorporated in practice for patient benefit. The main importance in evidence dissemination is the ability to deliver information in a proper manner and to assure the staff that these particular techniques are the best in this case. Paying attention to the specifics of the problem and cases of nausea and vomiting among patients post-operative, the disseminating of the research evidence should be conducted in several ways. The easiest way to inform nurses about the project results is to deliver the special information to the hospitals where surgeries occur. The information should be presented in a form of a direction for nurses, who deal with patients reporting about nausea and vomiting. The direction should be directed at informing the whole staff about the issue. Emails and short briefings should be applied. It will help nurses to get acquainted with the issue and to discuss it with the colleagues. The emails should contain the thesis and some data about the effective confirmation of the thesis. More information may be offered during the briefings in the hospitals.

To begin with, the education and training of staff should take place. Walsh (2010) is sure that time is the main obstacle on the way to disseminating the evidence-based results. Recommending nursing education as the main means for spread of knowledge Walsh (2010) adds that a schedule of necessary trainings should be developed. Teaching nurses to maintain skills and knowledge requires regular professional development. Using training and education technique in implementing newly researched dissemination of the evidence-based practices is one of the best ways to deliver necessary information. Nurses strive for constant personal and professional development; their profession is usually based on new discoveries and developments. Almost all professional nurses are interested in acquiring new knowledge through education and training. Presenting the results of the evidence-based study during such training sessions with the request to implement new knowledge into practice is the best way for disseminating evidence (Walsh, 2010). Therefore, the first step in results dissemination is the organization of the training and learning groups. The information for training and lectures should be concise and full at the same time. The nurses should know what the project purpose is, how this purpose has been achieved, and which results have been obtained. All the additional information will only destruct nurses from acquiring the necessary one.

The National Secondary Transition Technical Assistance Center (NSTTAC) offers numerous ways for disseminating information in respect to evidence-based study results; including “the NSTTAC website”. The “semiannual secondary transition state planning institutes”, “NSTTAC bimonthly newsletter”, “participation in national and regional events”, and “targeted TA and professional development at the state, regional, and district levels” (Mustian, Mazzotti, & Test, 2012, p. 198). The results from this evidence-based project will be published on the internet. Using professional Internet websites, it is possible to get many people acknowledged about the project results and the importance of use of aromatherapy. NSTTAC website suits the best to the purpose of dissemination of the project results. Professional nurses have access to the Internet and spread of the information through the World Wide Web. The Internet is one of the best ways to get information fast and extensively. Nurses can obtain information from subscription to online journals. Moreover, the results may be put in the monthly newsletters and delivered to the professional nurses in the emails, like the information notes.

Local and national presentations with the participation of nurses at times can be mandatory. Nurses’ personal and professional development is usually accompanied by numerous courses and trainings. The information from the latest research may be acquired there (Mustian et al., 2012). As for the results from this project, it is planned to organize several seminars with the presentations based on the project problem, solution and implementation plan with the results stated. The main idea of the project will be to show the project purposes, the implementation plan, and the results obtained. Also, a detailed explanation of the problem solution should be offered in order to assure nurses that they have all the necessary information. The effective use of aromatherapy with the project results confirmed by all the necessary findings may be offered as the addition to any class in the nursing school. Studying there students will get to know about the effectives of aromatherapy before getting down to practice. The projects results may be disseminated among all students in the nursing school. Getting certification or passing through the procedure of being registered, nurses have to listen to a number of lectures. The project results may be included in the program for registered and certificated nurses with the purpose to make those aware about it.

For the use of aromatherapy for post-operative nausea and vomiting, education with the presentation of the research results may be one of the best ways of informing nurses about the types of aromatherapy and its effect on the human body. The use of aromatherapy is not a traditional way of dealing with nausea and vomiting as this issue is only under the research. NSTTAC’s practices may be very useful in respect to disseminating evidence about the use of aromatherapy in the dealing with post-operative nausea and vomiting. Trainings and informing are the most effective means for dealing with the problem dissemination.