Gastrointestinal patho

Vitamins

• Deficiency occurs as a result of inadequate intake or a disease the prevents absorption of the vitamin
  - Available in foods and OTC as supplements; Commonly “self-prescribed”
  - Fat–soluble (A, D, E, K); should not be taken in excess
  - Water-soluble (B’s, C, Niacin, Folic Acid)
  - DRI – Dietary Reference Intakes
  - Review vitamins Table 35-1
  - Always preferable to obtain vitamins from food sources

• Examples:

- EBP: Folic acid prevents severe birth defects
- Vitamin B12 IM for pernicious anemia (requires lifetime replacement)
- Vitamin K deficiency is associated with bleeding

Minerals

• Large doses of minerals can be toxic

• 22 minerals necessary for human nutrition (Ex: Ca, Ph, Na, K, Mg)

• Multiple functions in the body (e.g. acid-base balance, muscle contraction, Hgb..)

• Review minerals Table 35.4

• Obtained from food or supplements

• Multivitamin-mineral supplements are formulated by age

• Fe supplements are usually temporary (e. g., pregnancy)

• Review use in select population

QSEN: ALL minerals are toxic when ingested in high doses

Iron (Fe)

Examples: PO: ferrous sulfate (P) (Feosol), ferrous gluconate (Fergon)
Pharmacokinetics:

• Oral route is preferred but causes a lot of GI irritation

• Only about ~10-20% of iron is absorbed when taken orally

• Absorption is improved if taken on an empty stomach but increases GI irritation or taken with vitamin c (orange juice)

• Iron is not metabolized; stored in the small intestines

• Fe is recycled in body (1/2 life unknown)

• Excesses of iron are excreted in the stool

Indications

• During instances of increased need (e. g., pregnancy, breastfeeding) Prevent (↑
  need, pregnancy)

• Treat iron deficiency anemia

Adverse Effects of Iron

• GI upset; nausea, diarrhea, constipation

• Black-green stool

• Oral liquid iron may stain the teeth (temporary)

Contraindications of Iron

• Anemias not associated with iron deficiency

• GI diseases such as PUD, colitis

• Disorders in which Fe accumulates in the body

Nursing Implications of Iron

• Take on an empty stomach to increase absorption

• Administer with or after meals with 8oz H2O

• Taking iron supplements with Vitamin improves absorption

• Do not crush/chew sustained-released preparation

• If oral iron solution drink with straw, then rinse

• Oral iron may interfere with absorption of other meds, so take 2-4 hours before or
  after other meds

Parenteral (IV or IM) Iron

• May be given to patients under certain circumstances

• Examples: Iron Dextran injection (InFeD); Iron Sucrose (Venofer)

• IV is preferred parenteral route

• BBW: Risk of anaphylactic reaction/death with iron dextran. Usually a IV test dose
  is done. must be done

• IF given IM Fe dextran MUST be administered using DEEP IM Z-TRACK METHOD (iron in the muscle you must use Z-Track Method)

• With iron sucrose, an anaphylactic reaction may occur but the risk is less than with
  iron dextran

• QSEN: When iron dextran is administered, emergency equipment and medications
  must be available due to the risk of anaphylactic reaction

Hyperkalemia (K+)

• HIgh Potassium = Remove all sources of potassium (know the normal range of potassium)

• Assess potential causes of hyperkalemia i.Withhold all foods/medications that
  contain potassium

• RICK: Remove K sources, Insulin + Glucose, Calcium, Kaexalate

• Calcium gluconate IV slowly (do not use if hypercalcemic), will not lower K+ level

  • helps protect from cardiac dysrythmia

• Insulin + Glucose

- Regular insulin – Causes K+ to move into the cell, thus decreasing extracellular
potassium levels
- Glucose (Dextrose) - prevents hypoglycemia

Sodium polystyrene sulfonate (Kayexalate) = eliminates K+ completely
- Combines with K+ in the colon and eliminated via the stool
- Takes several hours to work
- Can be given PO, via NGT, G-tube, J- tube, retention enema

• Anticipate acidosis, may need IV sodium bicarbonate to treat acidosis

• Anticipate ECG wave elevation/changes (T wave = tall peak)

• QSEN: Do not administer sodium polystyrene sulfonate in sorbitol increased risk of
  intestinal necrosis

Hypokalemia (K+)

• Example: potassium chloride (KCL)

• Indications:

- Prevent or treat hypokalemia
- Prevention with diuretics [covered in cardiac content]

• Adverse Effects: N/V/D, abdominal pain, cardiac dysrhythmias

• Contraindicated: PUSH “Never administer IV PUSH
  - Potassium-sparing diuretics
  - Untreated Addison’s disease
  - Severe renal impairment
  - Hyperkalemia

• Routes: PO or IV
  - PO route is preferred but can cause GI irritation
  - Taking with meals decreases GI effects

IV for Hypokalemia (K+)

• IV: Indicated with severe hypokalemia or if oral route is not an option

• Before giving K+ IV, the nurse must check serum K+ levels AND ensure urine
  output is at least 30ml/hr

• IV route Must Be DILUTED & administered via IV pump

• IV route must be administered SLOWLY: no faster than 10mEq/hr

• May add to continuous IV fluids OR give slow IV intermittent
  - Example IV continuous: 20 mEq KCL added to 1000 mL NS at 125 ml/hr
  - Example IV intermittent: 20mEq KCL/200mL over 2 hours

• Monitor for hyperkalemia after replacement

• QSEN: Never administer IV undiluted potassium

Treatment of Mineral Excess (Chelating Agents)

• Penicillamine (Cuprimine): Indicated to remove excess copper with a rare genetic disease

• Succimer (Chemet): Indicated for lead poisoning

• Deferoxamine (Desferal): Indicated for acute
  iron toxicity

• Deferasirox (Exjade): Indicated for chronic iron overload in adults and children
  who require frequent blood transfusion for chronic anemia

Magnesium Preparations

• Examples:
  o PO: magnesium oxide (Mag-Ox)
  o IV: magnesium sulfate

• Indications: Hypomagnesemia, Convulsions associated with pregnancy, magnesium sulfate is indicated in pregnacny complications

• Depressant effect on CNS, smooth, skeletal, cardiac muscle

• Contraindicated: impaired renal function, comatose

• May cause diarrhea

• The antidote for magnesium toxicity is calcium gluconate

Zinc Preparations

• Examples: zinc sulfate, zinc gluconate

• Dietary supplement, may be used to promote wound healing

• Intranasal zinc preparations are not recommended by the FDA

Multiple Mineral–Electrolyte Preparations

• Example: Pedialyte

• Fluid and electrolyte replacement

• May be used in children with diarrhea to prevent dehydration and electrolyte
  depletion

Nutritional Products

• Patients who are unable to take in, digest, absorb, synthesize, or utilize vitamins, mineral, electrolytes, and/or fluids may need supplements.

• Enteral is a preferred first choice if possible – parenteral nutrition is utilized with GI dysfunction or complicated nutritional needs

Enteral Nutrition

• Numerous formulas are available; typically, 1–2 kcal per ml

• Special formulas are available for specific disease processes such as DM, CKD, liver disease,
  pulmonary disease

• Must have H20 along with enteral feedings

• Caloric needs need to be met if enteral feedings are the only source of nutrition

• Routes: feeding tube (NG tube, G-tube PEG, J-tub)
  - Oral enteral nutrition
  - Intermittent enteral nutrition via feeding tube
  - Continuous enteral nutrition via feeding tube

• Major complication of enteral tube feedings is ASPIRATION

• Adverse Effects: Hypertonicity of the feeding may cause symptoms of fluid volume deficit related to osmotic diuresis such as tachycardia, hypotension, polyuria, and N/V/D

• Assess for therapeutic response / adverse effects

Total Parenteral Nutrition (TPN)

• Is ahighly concentrated/ hypertonic solution of dextrose (e. g., 50%)

• Amino acids, electrolytes, vitamins, minerals, insulin, trace elements are added as per
  patients’ specific nutritional needs

• Only administered via Central Lines
  - CVC – Central Venous Catheters (via subclavian / jugular veins)
  - PICC – Peripherally Inserted Central Catheter

Nursing Interventions for Total Parenteral Nutrition (TPN)

• Verify “right” dose by checking each additive against Provider Order

• MUST be administered via an IV pump

• MUST use sterile technique

• IV Tubing MUST have a filter

• Daily Weights

• Accurate Intake and Output

• Monitor electrolytes

• Monitor glucose

• Monitor nutritional status

• If TPN solution is unavailable, administer 10%-20% dextrose until TPN can be
  obtained

• Remeber: TPN is not compatible with any other IV solution; cannot be infused with other medications

Adverse Effects of Total Parenteral Nutrition (TPN)

• Fluid Overload

• Hyperglycemia

• Electrolyte Imbalances

• Osmotic Diuresis

Pancreatic Enzymes

• Replaces pancreatic enzymes necessary for the absorption of carbs/fats/proteins –
  cystic fibrosis, chronic pancreatitis, pancreatic obstruction

Drugs to Aid Weight Management

• BMI is the best indicator of desirable weight

• Obesity = BMI > greater than 30

• Obesity = CHRONIC DISEASE; many health risks associated with obesity

• 3600 calories = 1lb

• NHLBI [NIH] recommends weight management medications for individuals with BMI ≥30
  with chronic diseases that may improve with weight loss

• Weight loss improves health and decreases need for some medications

• MUST include dietary and lifestyle changes

• Many drugs have been removed from the market as a result of severe adverse effects

Drugs that may cause weight gain

• Antidepressants, Antidiabetics, Antiepileptic, Antihistamines,Antihypertensives, Antipsychotics, Cholesterol-lowering Agents, Corticosteroids, Gastrointestinal Drugs, Hormonal Contraceptives, Mood Stabilizing Agents

Noradrenergic Sympathomimetic Anorexiants

• Appetite Suppressent; Phentermine hydrochloride (P); Schedule IV (risk of substance abuse)

• MOA: inhibits the reuptake of serotonin and norepinephrine, resulting in appetite
  suppression; satiety from the hypothalamic/limbic region (makes your hunger satisfied)

• Indications: Obesity; Short-term use (3 mo or less)

• Adverse Effects: Nervousness, palpitations, hyperactivity, dry mouth, constipation, HTN,impotence, insomnia, unpleasant taste.

• Contraindicated: HTN (mainly), CV disease, hyperthyroidism, pregnancy, history of drug abuse, use cautiously with anxiety and/or agitation

• Nursing Implications
  - Tolerance may develop within 4-6 weeks; drug should be discontinued
  - Take on an empty stomach; if once a day dosing in the early am
  - Assess for therapeutic/adverse effects

Phentermine

• Is a potentially habit-forming and should be taken only as prescribed

• Individuals on phentermine should not operate heavy machinery until knowing how the
  medication specifically affects them

Phentermine & topiramate (Qsymia) extended release

• Combination of phentermine and an antiseizure medication (topiramate)

• Adverse Effects: tachycardia, suicidal thoughts, vision changes

• Pregnancy category X due to risk of cleft lip, cleft palate (exposure to topiramate)

Lipase Inhibitors

• Orlistat (Xenical) (P); Available OTC over the counter

• MOA: decreases absorption of dietary fat from intestines, blocks ≈ 30% of fats from being
  absorbed (block fat from being absorbed)

• No systemic adverse effects as all action occurs in GI tract

• Indications: obesity along with lifestyle changes

• Adverse Effects: Primary disadvantages of medication - abdominal pain, oily spotting, fecal urgency, flatulence, fatty stools, fecal incontinence

• Contraindications: Malabsorption, cholestasis

- Frequent dosing [1 cap with each meal]

- Need multivitamin supplementation

- Monitor for therapeutic/adverse effects

QSEN: May reduce the absorption of fat-soluble vitamins; if patient is on the anticoagulant,
warfarin, management of the anticoagulant doses may be more challenging

Glucagonlike Peptide-1 Receptor Agonists

• Liraglutide (P) Saxenda, semaglutide (Ozempic) GLP1 Agonists

• MOA: slows gastric emptying, results in feelings of fullness and reduced appetite (slows movement of food in body making full feeling for longer)

• Indications: Long-term weight management for BMI

• Adverse Effects: N/V/D, constipation, abdominal pain

• BBW: contraindicated in patients with a history of medullary thyroid cancer, pancreatitis

• Miscellaneous Weight Loss Medications: Bupropion-naltrexone (Contrave)

• Herbal/Dietary Supplement used in Weight Management
  - Glucomannan, guarana, green tea, hydroxycitric acid (garcinia cambogia tree)

Drugs Therapy for Peptic Ulcer Disease (PUD) & Gastroesophageal Reflux Disease
(GERD)

• Drugs that are used in these disorders promote healing and prevent the recurrence of
  gastric lesions by ↑ high gastric cell protection or ↓ low gastric cell destruction

• QSEN: Do not use herbal supplements for ANY type of acid-peptic disorders

Peptic Ulcer Disease (PUD)

• A group of upper GI disorders characterized by ulcer formation due to exposure to gastric acid and pepsin [more common in stomach & duodenum than in the esophagus]

• Two most common causes of PUD: H. pylori and NSAIDs (nonsteroidal anti-
  inflammatory drugs – covered in the neurologic lecture).

• Stress may also contribute to ulceration particularly in critically ill patients

• Smoking also contributes to GI ulceration

• H. pylori, a bacteria found in the gastric mucosa of most patients with chronic gastritis

• Only 10% of the population (50% of people) that harbor H. pylori will develop ulcers

• Gastric acid is ALWAYS present with ulcers; hypersecretion of gastric acids alone is enough to cause ulcers; gastric acid (1) injures the cells of the GI mucosa & (2) activates pepsin]

Gastroesophageal Reflux Disease (GERD)

• Incompetence of lower esophageal sphincter resulting in regurgitation of stomach contacts into the esophagus

• The body’s main defenses against ulcers are: “My Belly’s Basic Protection”

- Mucus [form a barrier to protect cells from acid & pepsin]
- Bicarbonate [neutralizes H+ that penetrate the mucus]
- Blood flow [maintains GI mucosal integrity]
- Protaglandins [stimulate secretion of mucus and bicarbonate, promote vasodilation, & suppress secretion of gastric acid]

• Gastric Acids are necessary to:

- Kill food-borne pathogens

- Absorb substances such as proteins, calcium, Vitamin B12, iron, zinc etc

Antacids

• GOAL: pH 3.5; if pH >5, pepsin action will decrease as well

• MOA: Localized action; React with and neutralizes HCL in the stomach, thus raising the pH

• Indications: PUD, GERD, esophagitis, “heartburn”, gastritis, GI bleed, GI stress ulcers;
  usually taken on an as needed basis

• Contraindications: undiagnosed GI problems (bowel inflammation), s/s appendicitis

• QSEN: Shake liquids/suspensions well before giving

• Assess for therapeutic/adverse response

Antacid Mixtures

• aluminum hydroxide / magnesium hydroxide (P) (Mylanta, Maalox, Gelusil)

• Some antacids contain simethicone, an antiflatulent drugs

• All antacids MUST be taken 1 hour before or 1 hour after other medications

Aluminum Hydroxide Antacids

• Adverse Effects: Constipation; Increased aluminum levels

• Renal Implications: May be used with CKD with hyperphosphatemia

Magnesium Hydroxide Antacids

• Adverse Effects: Diarrhea; Hypermagnesemia

• Renal Implications: *Contraindicated with CKD and with impaired renal function

Calcium Carbonate Antacids

• Adverse effects: Hypercalcemia

• Renal Implications: Indicated with CKD and hyperphosphatemia

Histamine 2 Receptor Antagonist (H2RA)

• “tidine”

• H2 is located in the parietal cells of the stomach and promotes the secretion of gastric acid

• Examples: cimetidine (Tagamet) (P), ranitidine (Zantac), famotidine (Pepcid)

• MOA: inhibits (blocks) the action of H2 receptor, decreasing gastric acids

• Indications: PUD, GERD, esophagitis, GI bleeding, Zollinger-Ellison syndrome, heartburn

• Healing occurs 6-8 weeks with gastric/duodenal ulcers

• IV dose may be used in critically ill patients to PREVENT stress ulcer

• Adverse Effects: rare at therapeutic doses

Contraindications of Histamine 2 Receptor Antagonist

• NONE – use cautiously with children, pregnancy, older adult, renal/hepatic impairment

• Available OTC at lower doses

• Assess for therapeutic/adverse response

• QSEN: Cimetidine (Tagamet) inhibits hepatic metabolism of many drugs (enzyme inhibitor), thus increasing serum blood levels of other drugs; may cause diarrhea, dizziness, drowsiness, HA, confusion, and gynecomastia; increased incidence of confusion in the older adult

Proton Pump Inhibitors (PPIs)

• “prazole'“

• Most potent and effective drugs for suppressing the secretion of gastric acid

• Examples: omeprazole (Prilosec) (P), esomeprazole (Nexium), lansoprazole (Prevacid),
  pantoprazole (Protonix)

• MOA: Irreversibly binds to the enzyme that generates gastric acid [H+, K+ - ATPase];
  prevent “pumping” of gastric acid from parietal cells into stomach

• Indications: PUD, GERD with erosive gastritis, Zollinger-Ellison syndrome, GI bleeding

- Symptoms usually resolve within 1-2 weeks and heal esophagitis within 8 weeks
- IV dose may be used in critically ill patients to PREVENT stress ulcer

Adverse Effects of Proton Pump Inhibitors

• Minimal – nausea, diarrhea, HA; long-term use may impact GI absorption
  of magnesium and vitamin B12

Contraindication of Proton Pump Inhibitors

• Hypersensitivity, during pregnancy

• Be aware that the different types of PPIs have different administration guidelines, these will be applicable when you begin to administer medications in your second semester.

• QSEN: PPIs have pharmacogenomic effects

• Curling’s (Stress) Ulcer Prevention: Anticipate ALL critically ill patients will receive a PPI or H2RA prophylactically

  
  

Helicobacter Pylori Treatment

• Must use combinations to prevent resistance

• Two types of therapy treatment -

• Triple Therapy:

- Acid reducer for 14 days
- Two antibiotics 14 days

- Ex: Omeprazole (Prilosec) 20mg po bid x 14 days; Clarithromycin (Biaxin) 500mg po bid x 14 days; Amoxicillin 1gm po bid x 14 days

• 10-Day Sequential Therapy

- Acid reducer for 10 days
- Different antibiotics sequentially for 5 days each to reduce resistance

- Ex: PPI + amoxicillin for 5 days followed by… PPI + clarithromycin + metronidazole for 5 days

• Effectiveness of treatment is confirmed with an H. pylori urea breath test, stool antigen test, or upper endoscopy test

Prostaglandin E:

• Is produced in the mucosal cells of the stomach/duodenum inhibits gastric acid secretion, increases mucus & bicarbonate production, increases mucosal blood flow

EX: misoprostol (Cytotec)

• Indications: Synthetic prostaglandin is used with NSAIDs to protect gastric mucosa; high
  risk for GI ulceration

• Adverse Effect: Diarrhea in 10%-40% of patients, N/V, vaginal bleeding

• Do not take while pregnant – may cause cramps & miscarriage

• BBW: May cause birth defects – should not be used in women of childbearing age

EX: sulcrafate (Carafate)

• MOA: unclear, thought to act locally on gastric/duodenal mucosa, binding to ulcer and
  forming a protective barrier; 3-5% systemic absorption

• Indications: Treat or prevent GI ulcers

• Adverse Effects: Rare; constipation, dry mouth d/t not absorbed systemically

• Do not administer at the same time as a H2RA, PPI or antacid due to blocking the absorption

Bismuth subsalicylate

• Pepto-bismol, kaopectate

• Contains salicylate which may cause bleeding

• DO NOT administer to children due to risk of Reyes Syndrome

• QSEN: Avoid salicylate products if allergy to aspirin

Antimetics

• Indications: Prevent and treat nausea and vomiting

• Contraindications: Use may prevent or delay diagnosis

• Oral forms preferred for prophylactic use

• Rectal / parenteral forms preferred for therapeutic use

• In general – most effective if administered prophylactically

Phenothiazines

• “azine” P = Psych

• Examples: prochlorperazine (Compazine) (P), promethazine, (Phenergan)

• MOA: CNS depressants; block dopamine receptors in the chemoreceptor trigger zone (CTZ)

• Indications: Prevent and treatment of N/V associated with surgery, anesthesia, migraines, chemotherapy, and motion sickness………

• Adverse Effects: EXANSEDOR: EPS, Anticholinergic, Sedation, Orthostatic
  - Extrapyramidal symptoms (EPS) (such as restlessness, involuntary motor activity,
  involuntary facial movements)
  - Anticholinergic effects (blurred vision, urinary retention, dry mouth),
  - Sedation, cognitive impairment

• BBW: Increased risk of death in older adults with dementia-related psychosis

• Monitor for therapeutic/adverse effects

• IV administration
  

Antihistamines

• Examples: hydroxyzine (P) (Vistaril), dimenhydrinate (Dramamine), meclizine (antivert)

• MOA: block histamine (H1) receptor sites and prevent histamine action; block acetylcholine (aCH) receptors in the brain

• Indications: N/V, motion sickness

• Adverse Effects: Sedation, anticholinergic effects such as dry mouth, blurred vision,
  dizziness, confusion, urinary retention, prolonged QT interval

• Beers Criteria: Inappropriate for use in older adult

• DO NOT give hydroxyzine IV, administer deep IM (intramuscular)

• Meclizine is used for vertigo

• If for motion sickness – take dose 1 hr prior to travel

• AVOID driving or operating machinery with ANY drug that causes sedation

Serotonin Receptor Antagonist [5-Hydroxytryptamine3 Receptor Antagonist] 5-HT3

• “setron”

• Examples: ondansetron (P) (Zofran), granisetron (Kytril), dolasetron (Anzemet)

• MOA: Antagonize serotonin receptors

• Indications: Prevent or treat moderate to severe N/V associated with surgery,
  chemotherapy, etc….

• Adverse Effects: Diarrhea, HA, dizziness, constipation, transient ↑LFT

• Ok for use in children and older adult

• Cautious with hepatic impairment

• Advise against driving

• Max dose on Zofran = 16mg IV; more than 16 mg increases risk of QT prolongation

Substance P / Neurokinin 1 Receptor Antagonist

• Aprepitant (P) (Emend)

• MOA: Blocks activation of Substance P, thus inhibiting perception of nausea

• Indications: Chemotherapy-induced nausea and vomiting (delayed); prevention of
  postop nausea

• Usually given with a 5-HT3 receptor antagonist and corticosteroid as a combination therapy

• Adverse Effects: Typically, well tolerated; fatigue, weakness, dizziness, abnormal heart
  rhythm, HA, hiccups

• Oral dose 1 hour before chemo; then as prescribed

• Note: oral contraceptives are ineffective for ~ 28 days – use another means of birth control “setron”

  
  

Corticosteroids

• Indications: Chemotherapy-induced emesis; post op nausea

• Mild adverse effects with short-term use

Prokinetic Agents

• Examples: metoclopramide (Reglan)

• MOA: Increases GI motility by increasing release of aCH from nerve endings in GI tract;
  antagonizes the action of dopamine results in CNS effects

• Contraindicated: Parkinsons disease

• Adverse Effects: sedation, restlessness, extrapyramidal effects

• Causes extrapyramidal reactions in children in even small doses

• Reduce dosage in patients with renal disease

Marijuana

• 38 states (as of 2/2024) allow the use of medical marijuana for qualifying conditions

• Chemotherapy-induced N/V is a qualifying condition

Scopolamine

• Anticholinergic

• Very effective for motion sickness

• Note: Scop = telescope is used at sea; sea makes you sick

Herbal / Dietary Supplements

• Ginger: Clinical trials demonstrate that ginger is effective in reducing N/V associated with
  motion sickness, pregnancy, and surgery

Nursing Implications for Antiemetics

• Antiemetics are usually ordered as needed (PRN)

• Patients should avoid alcohol, driving, operating machinery

• Assessment for causative factor

• All should be used cautiously with older adults

• Hepatic impairment - ↓ low dose - most are metabolized in the liver

• If used for prevention, most effective is dose is 30 min to 1 hr in advance

• Observe for therapeutic effects/for adverse effects

Laxatives and Cathartics

• Never use laxatives or cathartics in patients with undiagnosed abdominal pain!!!!

• Oral laxatives/cathartics are contraindicated in patients with an intestinal obstruction
  and a fecal impaction

• Classifications: Laxatives, Cathartics, & Miscellaneous agents

• Laxatives: Bulk-forming, Lubricant, Surfactant

• Cathartics: Saline, Stimulant

• Miscellaneous: Chronulac (Lactulose), Linaclotide (Linzess)

Bulk-forming Laxatives

• Examples: psyllium (P) (Metamucil), methylcellulose (Citrucel),

• MOA: These non-digestible agents swell H2O to form a viscous solution that softens and
  increases the bulk of the stool; stimulates peristalsis

• Adverse effects: flatulence, bloating

• Good choice for occasional constipation/bowel irregularity; works in 12-24 hours typically

• Effect is similar to dietary fiber

• May be used long-term, particularly in older adults,

• MUST be taken with at least 8 oz of H2O

• QSEN: Individuals with dysphagia, esophageal stricture, or other narrowing of the GI lumen should not take psyllium

Lubricant Laxative

• Mineral oil – lubricates feces, slows colonic absorption of water

• Most useful as a retention enema; Effects in 6-8 hours

• Oral route has serious adverse effects and is not recommended long-term use

Surfactant Laxatives (Stool Softeners)

• Examples: docusate sodium (Colace), docusate calcium (Surfak); Docusate = Do Cushion Stool

• MOA: Decrease surface tension of fecal mass, allowing water to penetrate the fecal mass-making stools easier to expel

• Used to prevent straining while expelling a stool

Cathartics

What is the strongest and most abused laxative product?

Stimulant Cathartics

• Examples: bisacodyl (P) (Dulcolax), senna (Senokot), Glycerin suppositories

• MOA: Irritate the GI mucosa & pull H2O into the bowel lumen – resulting in a watery stool

• Indications: Constipation, bowel prep before endoscopy procedures or GI surgery, bowel
  program for SCI

• Adverse Effects: Abd pain, GI cramping, nausea, diarrhea, weakness

• Swallow oral tablet whole; Administer at HS to produce an am stool

• QSEN: do not use bisacodyl for longer than 1 week due to risk of electrolyte and acid-base imbalance

Saline Laxatives

• Examples: magnesium citrate, magnesium hydroxide (MOM), polyethylene glycol solution
  (Miralax), polyethylene glycol-electrolyte solution (CoLyte), sodium phosphate (Fleets enema)

• MOA: Increase osmotic pressure in intestinal lumen and cause retention of water – bowels then distend and stimulate peristalsis

• Indications: Short-term treatment of constipation, rapid evacuation of bowel contents,
  prep for endoscopic procedure

• Adverse Effects: dehydration, electrolyte loss

• Contraindicated: Use cautiously with renal impairment

Miscellaneous Laxative

• Ex: chronulac (Lactulose); ChronuLac = Chronic Liver

• MOA: Hypertonic solution that pulls H2O into the intestinal lumen producing semi-formed
  stools

• Indications: Constipation & hepatic encephalopathy – reduces ammonia levels

• Can be mixed with fruit juice, milk, or water

• Ex; lubiprostone (Amitiza); Indications: Used to treat chronic constipation (unknown origin) in adults

Herbal & Dietary Supplements

• Most laxatives are plant based (psyllium, cascara, senna)

• Aloe (oral) is a strong stimulant laxative and can produce severe cramping

Nursing Implications for laxatives and cathartics

• Regular bowel movements are maintained with fluids, high-fiber foods, & exercise

• Laxatives and cathartics should be used temporarily. The best option for long-term use is
  bulk-forming laxatives (psyllium)

• NEVER give laxatives to someone with acute abdominal pain, nausea, vomiting

• Use of laxatives for weight control is inappropriate; individual are at high risk for life-
  threatening fluid/electrolyte imbalances

• Glycerin supp are best choice for children

• Observe for therapeutic/adverse effects

Opiate

• Diphenoxylate (P) (Lomotil)

• Schedule V opioid; contains opioid and atropine

• MOA: Slows peristalsis by acting on smooth muscles in the small and large intestines

• Indications: Moderate to severe diarrhea

• Adverse Effects: Tachycardia, dizziness, HA, flushing, N/V, dry skin, dry mucous
  membranes, urinary retention

• Avoid use in children < 2 yrs

• Contraindicated: diarrhea caused by toxic materials, microorganisms

Loperamide (Imodium)

• OTC over the counter

• Synthetic derivative of meperidine

• MOA: Decreases GI motility; does not penetrate CNS

• Indications: Diarrhea

• Adverse Effects: Generally mild; abd pain, constipation, drowsiness, fatigue, N/V

• BBW: Higher than recommended doses of loperamide may cause life threatening
  cardiovascular effects

Paregoric

• Schedule III or V depending upon formulation (high risk for abuse)

• MOA: Increases muscle tone of intestinal tract thereby inhibiting peristalsis; also used as a cough suppressant

Bismuth subsalicylate (Pepto-Bismol)

• OTC; has antibacterial and antiviral qualities

• Contains salicylates (aspirin)

• DO NOT administer to children due to risk of Reyes Syndrome

• QSEN: Avoid salicylate products if allergy to aspirin

Ocreatide (Sandostatin)

• Somatostatin hormone synthetically derived (will also discuss in the Endocrine lecture)

• MOA: Decreases GI secretion and motility

• Indications: Diarrhea unresponsive to other therapies; HIV/AIDS, carcinoid syndrome,
  intestinal tumors

• Adverse Effects: Diarrhea, HA, cardiac dysrhythmias, injection-site pain

• Psyllium may be used in diarrhea to absorb water and decrease fluidity of the stool

Pancreatic Enzymes

• If diarrhea is caused by a deficit of pancreatic enzymes, then pancreatic enzyme
  replacements are administered

• Steatorrhea

Cholestyramine (Questran)

• Commonly used with diarrhea associated with inflammatory bowel disease

• Inactivates bile salts

• Also lowers LDL – used in hypercholesterolemia

Antibacterial Agents or Antiprotozoal Agents

• Indications: Bacterial enteritis diarrhea > 48 hours or ≥ 6 loose stools in 24 hrs; stool
  contains blood or pus; associated fever

• Regular use of antibacterial agents for “traveler’s diarrhea” may contribute to resistance

• Rifaximin (Xifaxan)
  o Developed specifically for “traveler’s diarrhea”, antibacterial
  o GI effects; not absorbed systemically

• Nitazoxanide (Alinia)
  o Antiprotozoal
  o Diarrhea associated with Giardia lamblia or Cryptosporidium parvum

• 5-HT3 Receptor Antagonist may be used on women with chronic IBS-associated diarrhea not responding to other antidiarrheal therapies

Nursing Implications for antidiarrheal medications

• Monitor closely to prevent electrolyte imbalance/dehydration

• 2-3 L of fluids daily are recommended to prevent fluid deficits

• Maintain bland diet until diarrhea resolves

• Seek healthcare for diarrhea if
  o Accompanied by severe abdominal pain
  o Fever; stool contains blood and/or mucus
  o Lasts more than 3 days

• Indications for antidiarrheal therapy
  o Diarrhea > 2-3 days
  o Chronic inflammatory diseases of the bowel
  o Ileostomies
  o HIV/AIDS associated diarrhea
  o Diarrhea caused by Clostridium deficile = metronidazole (Flagyl)

• Stop antidiarrheals when diarrhea subside