Nurse Practitioner Emergency Services CLINICAL PRACTICE GUIDELINE DIARRHOEA +/- VOMITING SYMPTOMS SUGGESTIVE OF

GASTROENTERITIS

Nurse Practitioner

Scope Adults with acute onset of diarrhoea +/- vomiting

Outcomes Identify patients suitable for NP (Emergency) CPG Identify patients not suitable for NP (Emergency) CPG and redirect to usual ED care +/NP (Emergency) in team. Outcomes Abnormal primary survey identified exit CPG and refer to EP or SMO immediately Identify patients not suitable for NP (Emergency) CPG exit CPG

Medical Practitioner +/Nurse Practitioner

Underlying medical pathology / complex patient Chronic onset +/- recent partial treatment Vomiting of blood or blood in stools Altered conscious state including effects of drugs/ ETOH History consistent with collapse Assessment & intervention Airway Breathing Circulation Disability Environment Signs and symptoms of current illness Duration of Illness days and hours Frequency of vomits, No/day and colour of vomit Frequency and volume of stools, No/day and colour and consistency of stools, mucus or blood Oral intake volume and fluid type, Urine output Abdominal Pain Level of activity lethargy/ active Risk factors- recent travel, immunocompromised, antibiotic associated (refer to EP) Allergies Relevant past medical history / medication use

Primary Survey

History

Nurse Practitioner Emergency Services CLINICAL PRACTICE GUIDELINE DIARRHOEA +/- VOMITING SYMPTOMS SUGGESTIVE OF
GASTROENTERITIS

Focused clinical hydration assessment

Pain Assessment

Vital Signs including lying and standing BP if necessary Urinalysis General examination Abdominal examination Hydration status - Mucous membranes and appearance, thirst, Urine output, respirations, heart rate, level of consciousness, decreased skin turgor Vomiting with no diarrhoea is not usually gastroenteritis. Discuss with EP. Pain scale

Severe hydration exit CPG

Determine need for and type of analgesia Reduction / relief of pain. Outcomes

Analgesia

Administration of analgesia (see medications)

Imaging

Pathology

Working diagnosis and Investigations In most circumstances no investigations are necessary in order to diagnose gastroenteritis or to manage the patient effectively1. Imaging not usually required Abdominal XR may be requested after consultation with EP to exclude Bowel Obstruction or free intra-abdominal gas Faecal MC&S required only if there is an outbreak and public health measures are to be implemented and where bacterial infection likely Faecal MC & S if Septic and unwell with bloody stools. Faecal testing for occult blood may be necessary if fever higher than 38.5. FBE, U & E, Glucose if the patient is clinically dehydrated or systemically unwell, or requires IV fluid therapy

Interpretation of results (diagnostic features) and management decisions Imaging If taken review in conjunction with pathology and clinical assessment

Outcomes

Nurse Practitioner Emergency Services CLINICAL PRACTICE GUIDELINE DIARRHOEA +/- VOMITING SYMPTOMS SUGGESTIVE OF
GASTROENTERITIS

Pathology and clinical features Diagnosis mild dehydration Tolerating oral fluids, improvement in hydration No signs of sepsis or indications for alternate diagnosis

NP (Emergency) review with view to discharge Oral hydration as tolerated Intravenous hydration if required Pt education /health promotion Medication prescribed as per formulary Follow up appointment with GP Referral +/- to services etc

Patient identified as suitable for NP (Emergency) CPG and discharged safely

Moderate to NP (Emergency) review in consultation with EP or Severe inpatient unit with view to admission dehydration Not Monitor and maintain hydration tolerating oral fluids, Document fluid balance prolonged vomiting Pt education /health promotion and diarrhoea, Medication prescribed as per formulary requiring significant Inpatient team referral IV fluid replacement, Referral to services as required abnormal pathology results Travellers Diarrhoea (5) No high fever, no peritoneal signs or focal tenderness, no blood in stool Associated Care NP (Emergency) review with view to discharge Rehydration with oral Rehydration solution MILD - May benefit from Loperamide Moderate to Severe antibiotics may be combined with Loperamide (see formulary) ED NP R/V consider ongoing IV fluids until review by inpatient unit

Assessment by EP +/- admission to ED Obs ward or inpatient team for admission and ongoing management.

eTG recommends Rx with antibiotics only for moderate to severe

Medications Outcomes All medication will be stored, labelled and dispensed in accordance with hospital policy and relevant legislation(3) Simple analgesia Paracetamol 500mg: 1 or 2 tablets 4/24 not to Patients given S2/4 exceed 8 tablets in 24 hrs. analgesia appropriate to Mild pain OR allergies, current medications and Instead of Paracetamol, Panadeine Forte: 1 -2 past medical tablets 46/24, not to exceed 8 tablets in 24 hrs. history. Analgesia requirements

Nurse Practitioner Emergency Services CLINICAL PRACTICE GUIDELINE DIARRHOEA +/- VOMITING SYMPTOMS SUGGESTIVE OF
GASTROENTERITIS

Anti motility S4

Hyoscine Butylbromide: Oral 20mg 6/24 Slow IV 20-40mg max 100mg/day Loperamide 2 mg: 2 tablets initially followed by 1 tablet after each unformed stool until diarrhoea controlled. Max 8 tablets / day.

Antidiarrhoel S2

determined by ongoing assessment of pain and adequate analgesia provided. Patients with excessive pain or pain unrelieved by analgesia need review by Senior Doctor

Antiemetics S4 (Contraindicated in Parkinsons disease) Antibiotics S4 (4) In Travellers Diarrhoea

Metoclopromide hydrochloride: Oral/IM/IV 10mg 8/24 Max 30 mg in 24 hours. Prochlorperazine: Oral 5-10mg 8-12/24, initial 10mg po if acute IM deep 12.5mg 8/24 Azithromycin 1 gm: orally as single dose OR Norfloxacin 800 mg: orally as single dose Consider the need to treat for Giardia lambia. Discuss with EP or SMO Tinidazole 2 gm orally, as a single dose Or Metronidazole 2 gm orally. Daily for 3 days

Intravenous Fluids

When to return

0.9% Normal Saline Intravenous fluids: IV 0.9% Normal Saline 1000 mls titrated to patient requirements. Monitor U & Es if requiring significant IV fluid replacement. Patient Discharge Education Verbal instructions from NP (Emergency) re need for clinical re assessment if not tolerating oral fluids, significant increase in vomiting or diarrhoea, decreased urine output, increased lethargy or generally more unwell Written patient information Advise patients to see GP in 24 hours, letter provided

Outcomes Ensure patient understands problem, treatment, follow up and is safe for discharge home

Follow-up Appointments

Nurse Practitioner Emergency Services CLINICAL PRACTICE GUIDELINE DIARRHOEA +/- VOMITING SYMPTOMS SUGGESTIVE OF
GASTROENTERITIS

Discharge Referrals Medication Education

As appropriate to allied health team members Verbal instructions from NP (Emergency) Contact ED Pharmacist to provide medication education for patient when available

Certificates

Absence from work certificates Clinical Audit Evaluative strategies Emergency Department attendance register and NP (Emergency) clinical log

Unexpected representation

References 1. Ginifer, C & Young, S. (2004). Gastroenteritis. In Cameron, Jellinek, Kelly, Murray & Heyworth(ED.), Textbook of Adult Emergency Medicine (pp. 311-316). Sydney: Churchill Livingstone. 2. eMIMS 2006. [cited 2007 Nov]; Available from Emergency Department desktop 3. JHC Medication Storage and Administration Policy. Available via Hospital Intranet 4. eTG 2006. cited [2008]. Available from Emergency Department desktop 5. Buttarovoli, P. (2007). Minor Emergencies: Splinters to Fractures. 2nd Ed, Philadelphia: Mosby. Author(s) & Endorsement This CPG was written by: Bronwyn Nicholson Terry Jongen Nurse Practitioner Emergency Services Nurse Practitioner Emergency Services Royal Perth Hospital Joondalup Health Campus CPG- Clinical Practice Guideline DVA- Department of Veteran Affairs EP- Emergency Physician PS- Pain Score S1-S4- Schedule of the drug administration act LMO- Local Medical Officer MVIT Motor Vehicle Insurance Trust NP (Emergency)- Nurse Practitioner Emergency Services OP- Outpatients WC- Workers Compensation Date written: April 2008

Review date: April 2011