• Use findings from the history, examination, and investigations to try to identify the cause of the nausea and vomiting and assess the person's clinical state.
• Consider whether treatment of the cause is appropriate, or whether the emphasis should be on treatment of symptoms.
• Take the following factors into account:
• The stage of illness and the person's prognosis.
• The person's wishes and those of carers and family.
• The cause of the person's nausea or vomiting and whether it is reversible or untreatable.
• The severity of nausea or vomiting and the presence of complications.
• The urgency with which treatment is required.
• The input of the multidisciplinary team.

In depth

• Features:
• Nausea: onset, frequency, intensity, relieving and exacerbating factors, relationship to vomiting.
• Vomiting: onset, frequency, quantity, force, colour, timing, and pattern.
• Other symptoms:
• Dyspepsia, heartburn, fullness, early satiety, constipation, diarrhoea, flatus, cough, headache, confusion.
• Treatments:
• Simple measures.
• Current medication including chemotherapy and anti-emetics.
• Radiation.
• Medical history.
• Effect on nutrition.
• Effect on quality of life.
• For more information, see Features indicating a cause.

In depth

• Perform an appropriate examination for the stage of the person's illness to determine, if possible, the cause of the nausea or vomiting:
• Perform a general examination (e.g. for signs of dehydration, infection, confusion, drowsiness, weakness).
• Assess the condition of the oral cavity.
• Examine the abdomen for tenderness, swelling, or distension; signs of intestinal obstruction; or constipation.
• Perform a rectal examination if faecal impaction is suspected.
• Check the fundi for papilloedema if increased intracranial pressure is a possibility (absence of papilloedema does not exclude intracranial pathology).
• Determine whether anxiety could be contributing to the person's symptoms.

In depth

• The choice of diagnostic tests should be based on the stage of disease, the person's prognosis, the risk-to-benefit ratio of the investigation, and the wishes of the person and their family.
• Blood tests to exclude hypercalcaemia or uraemia are among the most useful investigations in all people with nausea or vomiting in a palliative care situation in primary care.
• Other investigations are more appropriately done in secondary care (e.g. abdominal radiography to exclude constipation, ultrasonography to detect ascites), but the primary care team may also be able to arrange these and receive the results.

In depth