Transcript Drugs for Bowl Disorders and other GI Conditions

Drugs for Bowel Disorders and
other GI Conditions
Chapters 40 & 41
1
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.
www.navmetoccom.navy.mil/educate/neptun
e/lesson/language/origin.htm
2
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).
www.medterms.com/script/main/art.asp?articlek
ey=6005
• The body’s protective mechanism to eject
harmful/toxic materials or substances
» Adams, P., Holland, L., Urban, C., 2011
3
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/infection, drugs/anesthesia, pain or
trauma, pregnancy) signals the Vomit Center
which in turn stimulates the stomach resulting
in nausea &/or vomiting.
4
Antiemetics
• 1st 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 General Anesthesia & Chemotherapy
– Adverse Effects
• H/A, drowsiness, fatigue, constipation, diarrhea
• Serious: dysrhythmias, extrapyramidal symptoms
(EPS)
• Pearson Education, Inc. 2008, 2011.
• Wilson B., Shannon, M., Shields, K., 2009
5
Anti-Emetics
• 2nd 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: 2.5-10 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
6
Phenothiazines Continued
Promethazine (Phenergan)
12.5-25mg 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. 2008
Nursing Drug Handbook 2008
Davis Drug Guide 2011
7
Antiemetics
3rd Group: 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. 2008
• Wilson B., Shannon, M., Shields, K., 2009
8
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
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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?
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Anti-Diarrheal: Opioids
• Diphenoxylate 2.5mg & Atropine 0.025mg (Lomotil),
is a prototype drug. 1-2 tabs or 5-10 ml tid-qid
• 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, dry mouth,
nausea, constipation, occasional dizziness or
drowsiness. Serious:Paralytic ileus with toxic
megacolon, respiratory & CNS depression.
– Pharmacology for Nurses, Adams, Holland & Bostwick Pearson/Prentice
Hall 2nd Ed. 2008
– Davis Drug Guide 2011
11
Anti-Diarrheal: Opioids
• loperamide (Imodium): 4 mg PO initially, then
2 mg after each diarrhea episode
• Action: inhibits peristalsis, reduces fecal
volume and loss of fluid and electrolytes
• Adverse Effects: dry mouth, abd pain, n/v,
constipation, dizziness or drowsiness.
• Davis Drug Guide 2011
12
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. 2008
13
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.
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Constipation
• Constipation: a common GI complaint
4+ million Americans/yr
• 2.5 million Dr.’s office visits a year, most often
being female adults 65 yrs & 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
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Laxatives: Bulk Forming
• Psyllium Mucilloid (Metamucil, etc.) 1-2
tsp in 8 oz water followed by 2nd glass 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 2nd Ed. 2008
16
Laxatives: Stimulant
• Bisacodyl (Dulcolax) 10-15 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
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Laxatives: Saline and Osmotic
• Magnesium hydroxide (Milk of Magnesia -MOM)
20-60 ml daily PRN
• Polyethylene glycol (Miralax) sodium 17gm daily
in 8 oz liquid x 2-4 days
• Sodium biphosphate (Fleet Phospho-Soda)
– 15-30 cc mixed in H2O daily PRN
• Adverse Effects:
– Common: Diarrhea, abd. Cramping
– Serious: Hypermagnesemia with MOM (dysrhythmias,
respiratory failure)
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Laxatives: Stool Softener/Surfactant
• docusate (Surfak, Colace, Dialose, etc.)
50-500mg PO daily
– Adverse Effects:
• Abd. Cramping, diarrhea
• No serious adverse effects
• Pearson Education, Inc. 2008
19
Laxatives: Miscellaneous
• Mineral Oil 15-30 ml PO BID
• Adverse Effects:
– Diarrhea, nausea
– Serious: nutritional deficiencies, aspiration
pneumonia
– Pearson Education, Inc. 2008
20
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.
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Laxatives
Contraindications:
Absence of Peristalsis
Sudden, unexplained change in bowl pattern
esophageal obstruction
intestinal obstruction
fecal impaction
undiagnosed abdominal pain
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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 BP 102/55, HR 104 & thready, RR 18,
O2Sat 94 on RA. Weight 40 kg. Ht. 5’ 1”. 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).
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Neuman Model
• What level of Mrs. P.’s Lines of
Defense/Resistance are penetrated?
• What Psychological Variable(s) do you think
might be involved?
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Admission Orders
•
•
•
•
IV D 5 1/2 NS at 75 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
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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 8th Ed. 2009
• CDC 2010
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Nursing Process
• What Potential/Actual Nursing Diagnosis
would apply to Mrs. P?
• What Goal or Outcome would you expect?
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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/electrolyte
depletion
– Infection, Risk for, related to bacterial, viral, or
other infestation in the bowel
– Deficient Knowledge (drug therapy)
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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.
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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
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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.
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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
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Implementation
• Monitor Electrolyte Levels (Imbalances may
occur with diarrhea)
– Monitor lab results
– Client keep all laboratory appointments
– Report any unusual muscle cramping or weakness
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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 proper use, side
effects and precautions
– Client verbalizes signs and symptoms to report to
health care provider
• Pearson Education, Inc. 2008
34
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 50 cc’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.
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Appetite Suppressants/Anorexiants
• Drugs used to induce weight loss by
suppressing appetite and hunger
• Obesity defined as 20% above ideal body
weight determined by BMI (kg Wt/meters Ht)
• 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, 2011.
36
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
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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, 2011.
38
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, 2011.
• AHFS® Consumer Medication Information. © Copyright,
2010. The American Society of Health-System
Pharmacists, Inc.,
39
Rx for Weight Loss
• Sibutramine (Meridia)
–Action: Selective Serotonin Reuptake
Inhibitor (SSRI) appetite suppressant
for short term control (1 year) when
combined with reduced calorie diet
and exercise; results in 5-10% weight
loss. Obesity (BMI >29 or BMI >26 for
pt. with hx of HTN, DM, ↑Lipids).
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Sibutramine (Meridia)
– Initial Dose: 10 mg daily
– 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, 2011.
Nursing 2008 Drug Book
Davis Drug Guide 2011
41
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).
• Dose: 1-3 capsules before/with meals
• Adverse Effects: uncommon but can cause N/V/D,
hyperuricosuria.
• Contraindications: allergy to the drug or pork products
• Pearson Education, Inc. 2008
• Davis Drug Guide 2011
42
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.
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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.
44
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.
45
Antiulcer Drugs
Indications: Peptic & Duodenal Ulcer Disease,
& Gastroesophageal Reflux Disease (GERD)
46
Proton Pump Inhibitors
• Reduces gastric acid secretion by binding to H+,
K+ 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
47
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., 2011
48
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References
• Adams, P., Holland, L., Urban, C., Pharmacology for Nurses,
A Pathophysiological Approach, 2nd Ed., 2008, 3rd 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 10th Ed. Katzung, B., 2007
• AHFS® Consumer Medication Information. © Copyright,
2010. 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
50