Subjective
Date of visit / Postoperative Day (POD)
Reason for encounter (evaluation and management of PONV)
Type of surgery performed
Onset, duration, and frequency of nausea and vomiting
Severity of nausea (using a scoring system like nausea severity score [NSS])
Presence of retching or dry heaves
Associated symptoms (e.g., dizziness, headache, abdominal pain)
Prior history of PONV or motion sickness
Current medications (including antiemetics received)
Objective
Vital signs (temperature, heart rate, blood pressure, oxygen saturation) – assess for dehydration or electrolyte imbalances
Physical exam:
General assessment (hydration status, signs of dehydration)
Abdominal exam (assess for distention, tenderness)
Assessment
Postoperative nausea and vomiting (PONV)
Severity of PONV (mild, moderate, severe) – impacts treatment approach
Consideration of other potential causes of nausea and vomiting (e.g., bowel obstruction, medication side effects)
Plan
Management of PONV:
Antiemetic medications (consider route of administration based on severity – IV, oral, suppository)
Hydration management (intravenous fluids or oral rehydration if tolerated)
Dietary modifications (clear liquids initially, then gradual advancement)
Education
Explain PONV, its causes, and risk factors.
Discuss dietary recommendations and importance of gradual rehydration.
Importance of reporting persistent nausea or vomiting for further evaluation.
Follow-up
Monitor response to treatment (frequency and severity of nausea and vomiting)
Assess for signs of dehydration
Advance diet as tolerated
Consider discharge instructions with emphasis on managing nausea at home (if applicable)
Schedule for follow-up appointment (if needed)
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of postoperative nausea and vomiting