bowel disorder drugs dsn kevin dobi, ms, aprn copyright © 2014 by mosby, an imprint of elsevier...
TRANSCRIPT
BOWEL DISORDER DRUGS
DSN KEVIN DOBI , MS, APRN
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Chapter 51
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Diarrhea
Abnormal passage of stools with increased frequency, fluidity, and weight, or with increased stool water excretion
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Diarrhea (cont’d)
Acute diarrheaSudden onset in a previously healthy
personLasts from 3 days to 2 weeksSelf-limitingResolves without sequelae
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Diarrhea (cont’d)
Chronic diarrheaLasts for more than 3-4 weeksAssociated with recurring passage of
diarrheal stools, fever, loss of appetite, nausea, vomiting, weight loss, and chronic weakness
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Causes of Diarrhea
Acute Diarrhea Chronic Diarrhea
Bacteria TumorsViruses Diabetes mellitusDrug-induced Addison’s disease Nutritional factors Hyperthyroidism Protozoa Irritable bowel
syndromeAIDS
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Goals of Diarrhea Treatment
Stopping the stool frequencyAlleviating the abdominal crampsReplenishing fluids and electrolytesPreventing weight loss and nutritional
deficits from malabsorption
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Antidiarrheals
AdsorbentsAntimotility drugs (anticholinergics and
opiates)Probiotics (bacterial replacement drugs)
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Antidiarrheals: Mechanism of Action
AdsorbentsCoat the walls of the gastrointestinal (GI)
tractBind to the causative bacteria or toxin,
which is then eliminated through the stoolExamples: bismuth subsalicylate (Pepto-
Bismol), activated charcoal, aluminum hydroxide, others
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Antidiarrheals: Mechanism of Action (cont’d)
Antimotility drugs: anticholinergicsDecrease intestinal muscle tone and
peristalsis of GI tractResult: slows the movement of fecal matter
through the GI tractExamples: belladonna alkaloids
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Antidiarrheals: Mechanism of Action (cont’d)
Antimotility drugs: opiatesDecrease bowel motility and reduce pain
by relief of rectal spasmsDecrease transit time through the bowel,
allowing more time for water and electrolytes to be absorbed
Examples: paregoric, opium tincture, codeine, loperamide (over the counter), diphenoxylate
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Antidiarrheals: Mechanism of Action (cont’d)
ProbioticsAlso known as intestinal flora modifiers
and bacterial replacement drugsBacterial cultures of Lactobacillus
organisms work by: Supplying missing bacteria to the GI tract Suppressing the growth of diarrhea-causing
bacteriaExample: L. acidophilus (Bacid)
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Classroom Response Question
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The antidiarrheal drug Lomotil contains both diphenoxylate, a synthetic opiate agonist, and atropine, an anticholinergic. The purpose of the atropine in this combination is to
A. enhance the effects of the diphenoxylate.B. discourage recreational use of the opiate
diphenoxylate.C. counteract the adverse effects of the
diphenoxylate.D. act as an adsorbent for bacteria in the bowel.
Antidiarrheals: Adverse Effects
AdsorbentsIncreased bleeding timeConstipation, dark stoolsConfusionTinnitusMetallic tasteBlue tongue
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Antidiarrheals: Adverse Effects (cont’d)
AnticholinergicsUrinary retention, impotenceHeadache, dizziness, confusion, anxiety,
drowsiness, confusionDry skin, flushingBlurred visionHypotension, bradycardia
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Antidiarrheals: Adverse Effects (cont’d)
OpiatesDrowsiness, dizziness, lethargyNausea, vomiting, constipationRespiratory depressionHypotensionUrinary retentionFlushing
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Antidiarrheals: Interactions
Adsorbents decrease the absorption of many drugs, including digoxin, quinidine, and hypoglycemic drugs
Adsorbents cause increased bleeding time and bruising when given with anticoagulants (warfarin)
Toxic effects of methotrexate are more likely when given with adsorbents
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Antidiarrheals: Nursing Implications
Obtain thorough history of bowel patterns, general state of health, and recent history of illness or dietary changes; assess for allergies
Do NOT give bismuth subsalicylate to children or teenagers with chickenpox or influenza because of the risk of Reye’s syndrome
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Classroom Response Question
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Before administering belladonna alkaloids, it is most important for the nurse to assess the patient for a history of which condition?
A. AnemiaB. Diabetes mellitus C. Myasthenia gravisD. Hypertension
Antidiarrheals: Nursing Implications (cont’d)
Use adsorbents carefully in elderly patients or those with decreased bleeding time, clotting disorders, recent bowel surgery, confusion
Do not administer anticholinergics to patients with a history of narrow-angle glaucoma, GI obstruction, myasthenia gravis, paralytic ileus, and toxic megacolon
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Antidiarrheals: Nursing Implications (cont’d)
Teach patients to take medications exactly as prescribed and to be aware of their fluid intake and dietary changes
Assess fluid volume status, I&O, and mucous membranes before, during, and after initiation of treatment
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Antidiarrheals: Nursing Implications (cont’d)
Teach patients to notify their prescriber immediately if symptoms persist
Monitor for therapeutic effect
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Classroom Response Question
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Which antidiarrheal does the nurse associate with the development of adverse effects of urinary retention, headache, confusion, dry skin, rash, and blurred vision?
A. AnticholinergicsB. Adsorbents C. ProbioticsD. Opiates
Constipation
Abnormally infrequent and difficult passage of feces through the lower GI tract
Symptom, not a diseaseDisorder of movement through the colon
and/or rectumCan be caused by a variety of diseases
or drugs
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Laxatives
Bulk-formingEmollient (stool softeners, lubricant
laxatives)HyperosmoticSalineStimulantPeripherally acting opioid
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Laxatives: Mechanism of Action
Bulk-formingHigh fiberAbsorb water to increase bulkDistend bowel to initiate reflex bowel
activityExamples
psyllium (Metamucil) methylcellulose (Citrucel)
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Laxatives: Mechanism of Action (cont’d)
EmollientStool softeners and lubricantsPromote more water and fat in the stoolsLubricate the fecal material and intestinal
wallsExamples
Stool softeners: docusate salts (Colace, Surfak) Lubricants: mineral oil
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Laxatives: Mechanism of Action (cont’d)
HyperosmoticIncrease fecal water contentResults in bowel distention, increased
peristalsis, and evacuationExamples:
Polyethylene glycol (PEG) Sorbitol, glycerin Lactulose (also used to reduce elevated serum
ammonia levels)
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Laxatives: Mechanism of Action (cont’d)
SalineIncrease osmotic pressure within the
intestinal tract, causing more water to enter the intestines
Results in bowel distention, increased peristalsis, and evacuation
Examples Magnesium hydroxide (Milk of Magnesia) Magnesium citrate (Citroma)
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Laxatives: Mechanism of Action (cont’d)
StimulantIncreases peristalsis via intestinal nerve
stimulationExamples
senna (Senekot) bisacodyl (Dulcolax)
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Peripherally Acting Opioid Antagonists
Treatment of constipation related to opioid use and bowel resection therapy
Block entrance of opioid into bowelStrict regulations for useAllow bowel to function normally with
continued opioid use methylnaltrexone (Relistor) alvimopan (Entereg)
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Laxatives: Indications
Laxative Group UseBulk-forming Acute and chronic
constipation, irritable bowel syndrome, diverticulosis
Emollient Acute and chronicconstipation, fecal impaction,
facilitation of bowel movements in anorectal conditions
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Laxatives: Indications (cont’d)
Laxative Group UseHyperosmotic Chronic
constipation,diagnostic and
surgical prepsSaline Constipation,
diagnostic and surgical preps
Stimulant Acute constipation, diagnostic and
surgical prepsCopyright © 2014 by Mosby, an imprint of Elsevier Inc.
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Classroom Response Question
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A patient is receiving lactulose four times a day but does not have a history of constipation. In fact, he has had bowel movements every day. What is the probable reason for the lactulose?
A. Cleansing the bowel before a procedureB. Removal of helminthsC. Reduction of high ammonia levels associated
with liver failureD. Daily maintenance to prevent constipation
Laxatives: Adverse Effects
Bulk-forming Impaction Fluid overload Electrolyte imbalances Esophageal blockage
Emollient Skin rashes Decreased absorption of vitamins Electrolyte imbalances Lipid pneumonia
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Laxatives: Adverse Effects (cont’d)
Hyperosmotic Abdominal bloating Electrolyte imbalances Rectal irritation
Saline Magnesium toxicity (with renal insufficiency) Cramping Electrolyte imbalances Diarrhea Increased thirst
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Laxatives: Adverse Effects (cont’d)
Stimulant Nutrient malabsorption Skin rashes Gastric irritation Electrolyte imbalances Discolored urine Rectal irritation
All laxatives can cause electrolyte imbalances!
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Laxatives: Nursing Implications
Obtain a thorough history of presenting symptoms, elimination patterns, and allergies
Assess fluid and electrolytes before initiating therapy
Inform patients not to take a laxative or cathartic if they are experiencing nausea, vomiting, and/or abdominal pain
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Laxatives: Nursing Implications (cont’d)
A healthy, high-fiber diet and increased fluid intake should be encouraged as an alternative to laxative use
Long-term use of laxatives often results in decreased bowel tone and may lead to dependency
All laxative tablets should be swallowed whole, not crushed or chewed, especially if enteric coated
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Laxatives: Nursing Implications (cont’d)
Patients should take all laxative tablets with 6 to 8 oz of water
Patients should take bulk-forming laxatives as directed by the manufacturer with at least 240 mL (8 oz) of water
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Laxatives: Nursing Implications (cont’d)
Give bisacodyl with water because of interactions with milk, antacids, and juices
Inform patients to contact their prescriber if they experience severe abdominal pain, muscle weakness, cramps, and/or dizziness, which may indicate possible fluid or electrolyte loss
Monitor for therapeutic effect
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Classroom Response Question
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A 48-year-old patient has been admitted with abdominal pain, and states that she has not had a bowel movement for 4 days. Her abdomen is distended and slightly tender. Which laxative would be appropriate for this patient?A. Milk of magnesiaB. A bulk-forming laxativeC. Mineral oilD. No laxative should be given at this time
Irritable Bowel Syndrome
Chronic intestinal discomfort characterized by cramps, diarrhea, and/or constipation
Patients usually cope with the symptoms by avoiding irritating foods and/or taking over-the-counter (OTC) laxatives and antidiarrheal drugs
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Drugs for Irritable Bowel Syndrome
tegaserod (Zelnorm)lubiprostone (Amitiza) alosetron (Lotronex)
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Drugs for Irritable Bowel Syndrome: Nursing Implications
Perform a general assessment and additional assessment of liver functioning as well as assessment for any underlying cardiac disease
Follow administration guidelinesAssess for therapeutic response
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