Drugs for Bowel Disorders and. Nausea. Emesis (Vomit) 9/1/2011. Chapter 41

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1 Drugs for Bowel Disorders and other GI Conditions Chapter 41 Nausea Definitions of nausea on the Web: the state that precedes vomiting disgust so strong it makes you feel sick wordnetweb.princeton.edu/perl/webwn comes from the Greek word for ship, naus, which currently can be defined as a queasy or upset stomach. e/lesson/language/origin.htm Emesis (Vomit) Emesis : the reflex act of ejecting the contents of the stomach through the mouth wordnetweb.princeton.ed From the Indo European root wem (to vomit), the source of the words such as emetic and wamble (to feel nauseated). ey=6005 The body s protective mechanism to eject harmful/toxic materials or substances» Adams, P., Holland, L., Urban, C.,

Pathophysiology Vomit Center located in Medulla of Brain. Receives sensory input from G.I., inner ear & Chemoreceptor Trigger Zone (CTZ) in cerebral cortex.

2 Pathophysiology Vomit Center located in Medulla of Brain. Receives sensory input from G.I., inner ear & Chemoreceptor Trigger Zone (CTZ) in cerebral cortex. Noxious stimuli (dizziness, spoiled food, drugs) signal the Vomit Center which in turn stimulates the stomach resulting in nausea &/or vomiting. Antiemetics 1 st Group : Serotonin (5 HT3) Receptor Antagonist Odansetron (Zofran) 4 mg PO/IV Q 4 8 hrs PRN n/v Action: Blocks Serotonin Receptors in CTZ and Vagal Nerve terminals in G.I. Tract. Indications: Post Anesthesia & Chemotherapy Adverse Effects H/A, drowsiness, fatigue, constipation, diarrhea Serious: dysrhythmias, extrapyramidal symptoms (EPS) Pearson Education, Inc. 2008, Wilson B., Shannon, M., Shields, K., 2009 Antiemetics 2 nd Group : Phenothiazines (primary use as an antipsychotic) Action: affects CTZ to inhibit n/v, larger doses inhibit signals to Vomit Center by blocking dopamine receptors Prochlorperazine (Compazine) (prototype drug) 5 10 mg PO TID or QID: mg IV (no more than 5 mg/min), serious adverse effect includes extrapyramidal symptoms (EPS): akathisia or restlessness, dystonia, parkinsonism. Metoclopramide (Reglan) (action unknown) 10mg PO/IV Q6 8h, aids gastric emptying 2

3 Phenothiazines Promethazine (Phenergan) mg PO, PR or IM Q 4 8h PRN (prevents histamine mediated response) Adverse Effects Common: dry mouth & eyes, blurry vision, constipation, drowsiness, photosensitivity Serious: neuroleptic malignant syndrome, EPS, agranulocytosis Pearson Education, Inc Nursing Drug Handbook 2008 Davis Drug Guide 2011 Antiemetics Anticholinergics/ Antihistimines Scopalamine (Hyoscine, Transderm Scop) Transdermal 0.5 mg q 72hrs (usually placed behind the ear) Action: Blocks acetylcholine on postganglionic cholinergic nerves resulting in CNS depression, marked sedation and tranquilizing effects, controls oropharyngeal secretions Adverse Effects: Common: drowsiness, dry mouth, blurred vision, Serious: hypersensitivity reaction, sedation, tremors, seizures, hallucinations, paradoxical excitation (mostly in children), hypotension Pearson Education, Inc Wilson B., Shannon, M., Shields, K., 2009 Diarrhea frequent and watery bowel movements; can be a symptom of infection, food poisoning, colitis or a gastrointestinal tumor wordnetweb.princeton.edu/perl/webwn Diarrhea (from the Greek, διὰρροια meaning "a flowing through"), also spelled diarrhoea, is the condition of having three or more loose or liquid bowel movements per day. It is a common cause of death in developing countries and the second most common cause of infant deaths worldwide.... en.wikipedia.org/wiki/diarrhea 3

Diarrhea Primary Goal: assess and treat the underlying cause of the diarrhea. Recent travel? Immunocompromised? Antibiotic treatment? Dietary Habits? Over the Counter (OTC) Medications? Toxins?

4 Diarrhea Primary Goal: assess and treat the underlying cause of the diarrhea. Recent travel? Immunocompromised? Antibiotic treatment? Dietary Habits? Over the Counter (OTC) Medications? Toxins?/Infections?/Disease? Anti Diarrheal: Opioids Diphenoxylate & Atropine (Lomotil), is a prototype drug. Action: slows peristalsis, allowing water to be reabsorbed from the colon, promoting a more solid stool. Atropine is added to discourage abuse (causes drowsiness, dry mouth, tachycardia). Adverse Effects: no analgesic effect, occasional dizziness or drowsiness. Paralytic ileus with toxic megacolon, respiratory & CNS depression. Pharmacology for Nurses, Adams, Holland & Bostwick Pearson/Prentice Hall 2 nd Ed Anti Diarrheal Miscellaneous Bismuth subsalicylate (Pepto Bismol) Action: antisecretory, anti inflammatory, binds and/or absorbs bacterial and viral enteropathogens. Dosage: Mild nonspecific diarrhea: 30ml or 2 tabs PO q 30 min 1 hr. Max 8 doses for no longer than 2 days. Adverse effects: temporary darkening of tongue & stools, salicylism with high doses Nursing 2008 Drug Book Pearson Education, Inc

Anti Diarrheals Contraindications: Should not be used when patient has a suspicion of or is diagnosed with pseudo membranous colitis (Toxic Megacolon) or severe ulcerative colitis.

5 Anti Diarrheals Contraindications: Should not be used when patient has a suspicion of or is diagnosed with pseudo membranous colitis (Toxic Megacolon) or severe ulcerative colitis. Anti Diarrheals may worsen or mask these conditions. Toxic Megacolon has occurred with patients who have ulcerative colitis who have taken loperamide (Imodium), an opioid antidiarrheal. Constipation Constipation: a common GI complaint 4+ million Americans/yr 2.5 million Dr. s office visits a year, most often are women and adults ages 65 and older, also a common problem following childbirth or surgery. Self treatment of constipation with over thecounter (OTC) laxatives is the most common aid. Around $725 million/yr spent on laxative products in U.S. digestive.niddk.nih.gov/ddiseases/pubs/constipati on/ Cached Similar Laxatives: Bulk Forming Psyllium Mucilloid (Metamucil, etc.) 1 2 tsp in 8 oz water daily prn Action and Use: This Prototype Drug is derived from the seed of the plantain plant. It is an insoluble, indigestible fiber, when taken with enough water, swells to increase the size of the fecal mass, stimulating the defecation reflex. Adverse Effects: rare, produces less cramps than stimulants. If insufficient water is taken, can cause esophageal or intestinal obstruction. Pharmacology for Nurses, Adams, Holland & Bostwick Pearson/Prentice Hall 2 nd Ed

6 Laxatives: Stimulant Bisacodyl (Dulcolax) mg PO daily Action: Unknown. Increases peristalsis probably by direct effect on smooth muscle, either by irritation or stimulation of the colonic intramural plexis. Also promotes fluid accumulation in colon and small bowl. Adverse Effects: GI cramps, n/v/d with high dose, rectal burning with suppository, dependence and/or protein losing enteropathy with long term or excessive use Nursing 2008 Drug Book Laxatives: Saline and Osmotic Magnesium hydroxide (Milk of Magnesia MOM) ml daily PRN Polyethylene glycol (Miralax) sodium 17gm daily in 8 oz liquid x 2 4 days Sodium biphosphate (Fleet Phospho Soda) cc mixed in H2O daily PRN Adverse Effects: Common: Diarrhea, abd. Cramping Serious: Hypermagnesemia with MOM (dysrhythmias, respiratory failure) Laxatives: Stool Softener/Surfactant docusate (Surfak, Colace, Dialose, etc.) mg PO daily Adverse Effects: Abd. Cramping, diarrhea No serious adverse effects Pearson Education, Inc

Laxatives: Miscellaneous Mineral Oil 15 30 ml PO BID Adverse Effects: Diarrhea, nausea Serious: nutritional deficiencies, aspiration pneumonia Pearson Education, Inc.

7 Laxatives: Miscellaneous Mineral Oil ml PO BID Adverse Effects: Diarrhea, nausea Serious: nutritional deficiencies, aspiration pneumonia Pearson Education, Inc Laxatives: Herbal Agent Senna, large genus of flowering plants in the family Fabaceae en.wikipedia.org/wiki/senna_(genus) Cached Similar Action: irritates the wall of the bowl and increases peristalsis Adverse Effects: abdominal cramping and diarrhea, no serious effects. Laxatives Contraindications: Absence of Peristalsis Sudden, unexplained change in bowl pattern esophageal obstruction intestinal obstruction fecal impaction undiagnosed abdominal pain 7

8 Case Study Mrs. P. is an 86 y.o. female admitted to the Medical Unit with the diagnosis of Dehydration and Diarrhea. She has a history of constipation for which she takes OTC laxatives. Admitting VSS: Temp 97.1 HR 104 & thready, RR 18 O2Sat 94 on RA. She complains of feeling weak, tired and has mild abdominal cramping. She states she thinks she had 3 loose BM s today and can not remember how many yesterday. Prior admit to the hospital 3 weeks ago for a Urinary Tract Infection (UTI). Neuman Model What level of Mrs. P. s Lines of Defense are penetrated? What Psychological Variable do you think might be involved? Admission Orders IV D 5 1/2 NS at 100 cc/hr Soft low fiber Diet Up with assistance Labs: CBC and Lytes in the am Urinalysis, Culture and Sensitivity if indicated Stool for Clostridium difficile I & O Tylenol 325 mg PO, 1 for mild pain, 2 for moderate pain 8

9 Clostridium difficile C. difficile toxin, also known as pseudo membranous colitis, is a spore forming gram+ anaerobic bacteria producing toxins A & B, damaging the large intestine, causing diarrhea. Commonly seen in clients following chemotherapy, antibiotic treatment, invasive procedures, or who use stool softeners or laxatives. Most cases reported in clients older than 65. Most common cause of nosocomial infection for hospitalized clients. Black J., & Hawks J., Medical Surgical Nursing 8 th Ed CDC 2010 Nursing Process What Potential/Actual Nursing Diagnosis would apply to Mrs. P? What Goal or Outcome would you expect? Nursing Process Focus: Clients Receiving Antidiarrheal Therapy Potential Nursing Diagnosis Fluid Volume, Imbalanced, Risk for : Less than Body Requirements, related to loss secondary to diarrhea Injury (falls), Risk for, related to weakness, drowsiness secondary to drug therapy Infection, Risk for, related to bacterial, viral, or other infestation in the bowl 9

10 Planning: Client Goals and Expected Outcomes The client will: Report relief of diarrhea VSS and Laboratory values WNL Demonstrate an understanding of the drug s action by accurately describing side effects and precautions. Report persistent diarrhea, constipation, abd. pain, blood in stool, confusion, dizziness, altered body temperature. Implementation (Interventions/Rationales & Client Education/ Discharge Planning Minimize risk of dehydration and electrolyte imbalance (secondary to diarrhea) Encourage PO fluids Instruct client about foods/fluids rich in electrolytes Monitor frequency, character and amount of stool, Perform routine and PRN abdominal assessments Client to report abd. cramping, fevers, increased fatigue and or lethergy Implementation Monitor for dry mouth (side effect of medicine) Hard candy, ice chips, chewing gum Prevent over dosage of medication (can cause constipation). Instruct client/significant other use of dropper/medicine cup, etc. 10

11 Implementation Fall Prevention Instruct client to get up with assistance only call bell in reach, client to use when need to get out of bed Avoid driving/hazardous activities until effects of drugs are known Avoid ETOH and other CNS depressants Implementation Monitor Electrolyte Levels (Imbalances may occur with diarrhea) Monitor lab results Client keep all laboratory appointments Report any unusual muscle cramping or weakness Evaluation of Outcome Criteria Confirm that client goals and outcomes have been met Client reports relief of diarrhea Client demonstrates understanding of drug s action by accurately describing side effects and precautions Client verbalizes signs and symptoms to report to health care provider Pearson Education, Inc

12 Mrs. P. On the second hospital day, Mrs. P. reports she has no abdominal cramping and that her last loose BM was yesterday evening (which you confirmed in your chart review). Her VSS are WNL, she is taking adequate PO fluids, has no N/V, and is making adequate urine. Her IV has been slowed to 75cc s/hr. Both stool for C. difficile & urinalysis to rule out infection resulted negative. New orders: Lomitil 5 mg PO PRN loose stool, max 20 mg/daily. Appetite Suppressants/Anorexiants Drugs used to induce weight loss by suppressing appetite and hunger Obesity defined as 20% above ideal body weight In the U.S. >$33 Billion/yr spent on weightreduction products & services, >1 Million adults using these products are not overweight. Pearson Education, Inc. 2008, Appetite Reduction 1970 s amphetamines/dextramphetamines (Dexadrine): highly addictive Rarely prescribed now 1990 s fenfluramine & phentermine (fen phen): heart valve defects from fenfluramine removed from market 12

13 Appetite Suppressants 2000: phenylpropanolamine (OTC) removed from market due to increased incidence of CVA s and cardiac events 2004: ephedra alkaloids, OTC weight loss products, removed from market increased adverse cardiac events Pearson Education, Inc. 2008, Weight Loss orlistat (Xenical) blocks lipid absorption in the GI Tract by binding to gastric and pancreatic lipases and inactivating them. Also blocks fatsoluble Vitamins and Coumadin. Small result in weight reduction compared to placebo. Side Effects If medicine taken with diet high in fat content: flatus with discharge, oily stool, abd. pain Available by Prescription & OTC Pearson Education, Inc. 2008, AHFS Consumer Medication Information. Copyright, The American Society of Health System Pharmacists, Inc., Rx for Weight Loss Sibutramine (Meridia) Action: Selective Serotonin Reuptake Inhibitor (SSRI) appetite suppressant for short term control ( 1 year ) with 5 10% weight loss. Obesity (BMI >29 or BMI >26 for pt. with hx of HTN, DM, Lipids). 13

14 Sibutramine (Meridia) Adverse Effects: H/A, insomnia, dry mouth. May have weight gain after drug discontinued. Contraindications: Eating disorders, taking Monoamine Oxidase (MAO) Inhibitors. Caution: patients with cardiac history, can cause tachycardia and elevate BP. (other SSRI s: Prozac and Zoloft) Pearson Education, Inc. 2008, Nursing 2008 Drug Book Pancreatic Enzymes Pancrelipase (Pancrease) contains lipase, protease and amylase, of pork origin, to break down lipids, starches and proteins in the gut. Used as replacement therapy for clients with deficient pancreatic exocrine secretions (due to pancreatitis, cystic fibrosis). Adverse Effects: uncommon but can cause N/V/D, hyperuricosuria. Contraindications: allergy to the drug or pork products Pearson Education, Inc Mrs. P. Mrs. P. asks the Nurse to bring her two Dulcolax tablets. Oh, I take them every day. It is the only way I stay comfortable! The nurse asks Mrs. P. how long she has been taking Dulcolax and when was her last dose. As they are speaking, Mrs. P. s son, John, walks into her room. I ve taken my Dulcolax for years, they help keep me regular. I think I took my last dose yesterday morning like always. It becomes evident Mrs. P. had continued to take the Dulcolax after her episodes of diarrhea had occurred, exacerbating her condition. 14

15 Mrs. P. had not been thinking clearly, was forgetful and or did not understand the drug action. John had not been aware of his mothers habits. The nurse instructs and educates the patient and her son that a diet high in fiber (fresh fruits and vegetables, bran), adequate water, and moderate activity, or exercise, as tolerated, can minimize dependence upon laxatives. The nurse instructed them that the use of a laxative should not be taken when diarrhea occurs and that bowel stimulants are for a period of 1 week use only, not every day. Mrs. P. In addition, the nurse explains chronic use of the various bowel stimulants can effect the body s salt balance, causing increased phosphate and Na+, and/ or decreased Ca++, Mg++, and K+. These conditions can cause confusion and disorientation, as well as heart and muscular dysfunction. Mrs. P. and her son John were grateful for the information. John stated he will now be more involved with his mother s care and monitor her more closely now that he better understands her health habits and behaviors. Antiulcer Drugs Indications: Peptic & Duodenal Ulcer Disease, & Gastroesophageal Reflux Disease (GERD) 15

Proton Pump Inhibitors Reduces gastric acid secretion by binding to H+, K+, and ATPase and prevents acid from being secreted. Omeprazole (Prilosec). PO 20 60mg 1 2X daily for 4 8 weeks.

16 Proton Pump Inhibitors Reduces gastric acid secretion by binding to H+, K+, and ATPase and prevents acid from being secreted. Omeprazole (Prilosec). PO 20 60mg 1 2X daily for 4 8 weeks. Onset of action up to 2 hours after taking, duration up to 72 hours. Pantoprazole (Protonix): 40mg PO/IV daily Adverse Effects: H/A, n/d, rash, dizziness; rare serious effects.» Adams, P., Holland, L., Urban, C., 2011 H2 Receptor Antagonists Activation of Histamine2 (H2) results in the secretion of stomach acid. H2 Receptor Antagonists suppress the release of acid by the parietal cells thereby raising the ph of the secretions in the stomach. famotidine (Pepcid): 20 mg PO/IV BID or 40 mg PO QHS Adverse Effects: H/A, nausea, dry mouth. Rare: musculoskeletal pain, tachycardia, blood dyscrasias, blurred vision. Adams, P., Holland, L., Urban, C.,

17 References Adams, P., Holland, L., Urban, C., Pharmacology for Nurses, A Pathophysiological Approach, 2 nd Ed., 2008, 3 rd Ed., 2011, Pearson Education, Inc. Nursing Drug Handbook 2008, Lippincott, Williams & Wilkins Wilson B., Shannon, M., Shields, K., Nursing Drug Guide 2009, Prentice Hall Basic And Clinical Pharmacology 10 th Ed. Katzung, B., 2007 AHFS Consumer Medication Information. Copyright, The American Society of Health System Pharmacists, Inc., Davis s Drug Guide for Nurses 2011, Deglin, J., Vallerand, A., Sanoski, C., F.A. Davis Co., Philadelphia 17

Chapter 41. Media Directory. Lower Digestive Tract. Constipation (continued) Constipation

Chapter 41. Media Directory. Lower Digestive Tract. Constipation (continued) Constipation Chapter 41 Drugs for Bowel Disorders and Other Gastrointestinal Conditions Slide 43 Media Directory Tegaserod Animation Upper Saddle River, New Jersey 07458 All rights reserved. Lower Digestive Tract Figure