Nurse Practitioner

CLINICAL PROTOCOL
Diarrhoea & Vomiting suggestive of gastroenteritis
INTRODUCTION: Gastroenteritis outbreaks are common in settings where people are in
close contact, including residential aged care facilities. Elderly people are particularly
susceptible to the more severe complications of gastroenteritis. There are many causes of
infectious gastroenteritis, including contact with other infected persons, eating contaminated
foods, and antibiotic associated diarrhoea. Elderly residents may also have symptoms that
can mimic gastroenteritis which are due to chronic bowel disease or problems or certain
medicines, but are not the result of an infection. These non-infectious illnesses do not
usually occur in several residents at the same time.
EPIDEMIOLOGY:
Viral gastroenteritisnoroviruses and rotaviruses that are spread from one infected person
to another. Norovirus is the most common cause of outbreaks in aged care homes.
Norovirus outbreaks can be recognised in that: of those affected, 50% will vomit, illness
usually lasts less than 2 days, and staff becoming affected. Viral outbreaks usually last
longer than a week. Where a facility is affected by an outbreak of suspected viral
gastroenteritis the main focus should be on enhancing infection control.
Bacterial gastroenteritis gastroenteritis in residents may also be due to several different
bacteria, such as Salmonella, Campylobacter and Shiga toxin producing E. coli (STEC).
Bacterial gastroenteritis is usually more severe and may be caused by contaminated food
served to residents. Outbreaks of bacterial gastroenteritis may be recognised in that: of
those affected, 10-50% of people vomit and illness usually lasts longer than two days.
Bacterial outbreaks may last for up to two weeks. Sometimes people may experience blood
in their faeces. If bacterial gastroenteritis is suspected then the main focus should be on a
search for potential food sources, and should be discussed with your State/Territory Public
Health Unit or Health Department urgently.
Toxin producing bacteriasome bacteria, such as Clostridium perfringens or Staphylococcus
aureus, produce toxins that cause gastroenteritis in residents. Toxin-associated
gastroenteritis is usually of short duration and may be caused by contaminated food served
to residents. Outbreaks of toxin-associated gastroenteritis may be recognised in that: most
people have diarrhoea and less than 15% of people vomit, and illness usually lasts less than
24 hours. Toxin-based outbreaks are usually over within a couple of days. If toxinassociated gastroenteritis is suspected then the main focus should be on a search for
potential food sources, and should be discussed with your State/Territory Public Health Unit
or Health Department urgently.
Antibiotic-associated diarrhoeagastroenteritis in residents may also be due to bacteria that
cause diarrhoea in people who have recently received antibiotics. Antibiotics can alter the
bacteria normally found in the gut and allow bacteria, such as Clostridium difficile, to grow
and produce toxin. Outbreaks of antibiotic associated diarrhoea cannot be distinguished from
other causes of gastroenteritis based on symptoms alone, and can only be diagnosed after
specific testing at a pathology laboratory. As with all cases of gastroenteritis, monitoring of
hydration is important.

Nurse Practitioner
CLINICAL PROTOCOL
Diarrhoea & Vomiting suggestive of gastroenteritis
DIFFERENTIAL DIAGNOSIS:

Bowel obstruction

Severe infection

Poisoning (e.g. food)

Various drugs

AMI

CLINICAL PRACTICE GUIDELINE

Nurse
Practitioner
Medical
Practitioner
+/Nurse
Practitioner

Scope
Adults with an acute onset of vomiting +/diarrhoea.
Vomiting of blood or melena.
Hx. of collapse.
Alteration
in
conscious
state
including effects of ETOH / drugs.
Chronic onset.
Underlying medical pathology.

Outcomes
Identify pts. suitable for NP CP
Identify pts. not suitable for NP
CP and refer to current GP.

Initial Assessment and Interventions

Patient history 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
Allergies
Relevant past medical history incl current
medications.

Outcomes
Identify pts. not suitable for NP
CP and refer to current GP.

Physical
examination
and hydration
assessment

In cases of severe dehydration;

exit CP and refer to current GP.

Vital signs (lying and standing BP if

required.)
Urinalysis.
General and abdominal examination.
Assess hydration state: thirst, urine

Nurse Practitioner
CLINICAL PROTOCOL
Diarrhoea & Vomiting suggestive of gastroenteritis

Pain
assessment

output, mucous membranes,

decrease skin turgor, conscious
level.
NB: vomiting in the absence of diarrhoea is
not generally gastroenteritis.
Asses pain with appropriate pain scale.

Investigations
In the majority of cases, investigations are
not required to effectively manage/diagnose
gastroenteritis.
Faecal MC&S if an outbreak at RACF
noted or bacterial infection is
suspected.
Faecal MC&S if pt. is septic and has
blood in the stool.
FBE, U&E, BGL if pt. clinically
dehydrated, systemically unwell or
IV fluid replacement required.
Imaging
Not generally required.
Abdominal XR may be required by
GP to exclude bowel obstruction or
free intra-abdominal gas.
Patient Education / Follow-up
Follow up
If required after 24 hours.
appointment
Patient
Verbal instruction to return for
Education
reassessment if not tolerating oral
fluids, any significant increase in
vomiting/diarrhoea, decrease urine
output, or if generally unwell.
Medication
Verbal/written instructions from
instructions
NP/GP

Determine need for analgesia

and most appropriate type.
Outcomes

Pathology

Certificates
Letter

Absence from work certificates

Certificate of attendance
Copy of notes to GP / Specialist or
acute care facility

Interpretation of results and management decisions

Outcomes

Pt. understands their diagnosis,

treatment plan and reason for
follow up if required.
Ensure patient understands
problem, treatment and follow
up
Ensure appropriate
documentation completed
Ensure continuity of care and
referral to health care team
GP hospital admission
Outcome

All medications will be stored, labelled and dispensed in accordance with hospital policy and relevant legislation

Mild dehydration
Improvement in
hydration state

Oral fluid as tolerated

Pt. education
Medication as per formulary

Pt. identified as suitable for NP

CP

Nurse Practitioner
CLINICAL PROTOCOL
Diarrhoea & Vomiting suggestive of gastroenteritis
with oral fluid, no
sign of
sepsis/alternate
diagnosis.
Moderate
severe
dehydration
Not tolerating oral
fluid, prolonged
vomiting/diarrhoea,
abnormal pathology
result, requires IV
fluid.

Refer to current GP for possible

admission for rehydration.

Pt. referred to current GP for

possible admission for IV
rehydration

Goals of Treatment
Relief of symptoms

Eradication of infection

Prevention of recurrence

Prevention of complications

Drug Formulary

FORMULARY
PARACETAMOL / PANADEING FORTE

HYOSCINE BUTYLBROMIDE

Drug (generic name): paracetamol (with added codeine)

Drug (generic name): Hyoscine Butylbromide

Therapeutic class: analgesics and antipyretics, non-opioid

Poisons schedule: S2

analgesic.

Dosage range: 10-20mg (max 100mg/day)

Dosage range: 500mg-1g

Route: oral

Route: oral/rectal

Frequency of administration: 3-4 times daily

Frequency of administration: 4- 6 hourly

Duration of order: as required max 100mg / day

Duration of order: as required max 4g daily

Actions: Smooth muscle relaxant reduces GI motility and

Actions: inhibition of prostaglandin synthesis

spasm.

Indications for use: mild-moderate pain, migraine, headache,

Indications for use: GI spasm, renal and biliary spasm

fever, muscular pain

Adverse reactions: urinary retention, dry mouth, blurred vision,

Contraindications for use: nil caution for resident with liver

dry eyes, arrhythmias, fever.

Nurse Practitioner
CLINICAL PROTOCOL
Diarrhoea & Vomiting suggestive of gastroenteritis
disease.
Adverse drug reactions: (rare) rash, drug fever, mucosal
lesions, neutro/pancyto/thrombocytopenia

LOPERAMIDE

METOCLOPROMIDE

Drug (generic name): Loperamide

Drug (generic name): Metoclopramide

Poisons schedule: S2

Poisons Schedule: S4

Dosage range: 4mg initially, then 2mg after each loose bowel

Dosage range: 10mg

motion.

Route: Oral / IM

Route: Oral

Frequency of administration: 8 hourly

Frequency of administration: After each loose bowel motion.

Duration of order: as required. Max 30mg / day

Duration of order: as required, max 16mg / day

Actions: Dopamine antagonist. Stimulates upper GIT,

Actions: Activation of opioid receptors in the wall of the gut,

increases gastric emptying rate and decreases small intestine

decreasing bowel motility and increasing fluid absorption.

transit time.

Indications for use: Diarrhoea (generally short term).

Indications for use: Nausea and vomiting, gastric stasis.

Adverse reactions: Abdominal pain, bloating, nausea and

vomiting.

Adverse reactions: restlessness, drowsiness, dizziness,

headache. Extrapyramidal effects (acute dystonic reactions
and tardive dyskinesia.
Care: Should not be used in pts. with Parkinsons disease as
symptoms may worsen. Long term use can cause tardive
dyskinesia in elderly people these effects are rarely
reversible.

PROCHLOPERAZINE
Drug (generic name): Prochloperazine
Poisons schedule: S4
Dosage range: 5-10mg PO, 12.5mg IM
Route: Oral / Deep IM
Frequency of administration: Oral: 8-12 hrly. IM: 8 hourly
Duration of order: As required
Actions: phenothiazine derivative. Blocks dopamine receptors
centrally.
Indications for use: Nausea, vomiting, vertigo

Nurse Practitioner
CLINICAL PROTOCOL
Diarrhoea & Vomiting suggestive of gastroenteritis
Adverse reactions: constipation, dry mouth, drowsiness,
parkinsonism, blurred vision, akathisia. Rare: prolonged QT
interval, tardive dyskinesia.
CARE: Risk of tardive dyskinesia increases with cumulative
dose, use short term only. Can potentiate CNS depression.

Unexpected
representation
NP Clinical
Practice

Evaluative strategies
Review Patient Notes. Full audit of clinical
events.
NP Clinical Practice/Medical Report Audit

Key Terms
NP Nurse Practitioner
CP Clinical Protocol
GP General Practitioner
S4 Schedule of the drug administration
act

References
1. Australian Government, Department of health and Ageing (2011). Gastroenteritis Kit
for Aged Care. Accessed 28 Nov 2011 at:
www.health.gov.au/internet/main/publishing.nsf/Content/ageing-publicat-gastrokit.htm
2. Australian Medicines handbook (2011). Australian Medicines Handbook Pty Ltd, SA;
2011
3. etg complete (internet). Melbourne: Therapeutic Guidelines Limited; 2011 Nov.
Accessed 2011 Nov 25 at http://etg.tg.com.au/ref/ref
4. Murtagh, J. (2005). General Practice Companion Handbook, 3rd edition. McGraw
Hill, NSW.

Nurse Practitioner
CLINICAL PROTOCOL
Diarrhoea & Vomiting suggestive of gastroenteritis
Authorship, Endorsement and acknowledgement
This CP was originally written by:
Reviewed and authorised by:
Carol Jones
Nurse Practitioner
Dr. Frank Reedman Jones
Murray Medical Centre Mandurah
MBBCh, DCH, DRCOG, FRACGP, FACRRM

Murray Medical Centre: Primary Care

Physician

We acknowledge the input of: Joondalup

Health Campus Nurse Practitioner
Emergency Services CPG diarrhoea +/vomiting symptoms suggestive of
gastroenteritis.

Date Written: November 2011

Dr. Eileen Bristol

MBChB,MRCGP,DRCOG,FRACGP
Murray Medical Centre: Primary Care
Physician

Carol Jones
RN, RM, PGradDipNursePractitioner, NP
Nurse Practitioner

Review Date: November 2013