Ch.14

Ch. 14: Simplified Key Terms (The "Need to Knows")

• Antacid: Neutralizes stomach acid (HCl) to stop heartburn.

• Antidiarrheal: Stops loose, watery stools.

• Antiemetic: Prevents and treats nausea and vomiting (N/V).

• Cannabinoids: Man-made or natural THC that stops N/V.

• Cytoprotective drugs: Puts a protective coating over the stomach lining to prevent damage from acid.

• Histamine H2-receptor blocker: Turns down the amount of acid the stomach makes.

• IBS (Irritable Bowel Syndrome): Chronic belly pain mixed with diarrhea, constipation, or both.

• Laxatives: Stimulates the bowels to help the patient poop.

• Proton-pump inhibitors (PPIs): Completely blocks the stomach from secreting acid.

• Serotonin (5-HT3) receptor antagonists: A heavy-duty antiemetic that stops N/V by blocking serotonin signals.

Section 1: The Digestive System

• Learning Objective: Summarize the structure and function of the digestive system.

• Nurse Translation: The GI tract is essentially one long tube from the mouth to the anus. Its job is to break down food, absorb nutrients, and excrete waste. Because it is open to the outside world, it is highly prone to infections and irritation.

• Key Pathophysiology: The stomach uses hydrochloric acid (HCl) to break down food. To protect itself from this acid, the body produces prostaglandins which create a thick, gel-like mucus shield.

Section 2: Antiemetic Drugs

• Learning Objective: Determine the nursing care of patients receiving antiemetic drugs.

• Nurse Translation: Vomiting occurs when the "vomiting center" in the brain is triggered. This can happen directly (fear, pain, motion sickness) or indirectly via the Chemoreceptor Trigger Zone (CTZ) (triggered by chemotherapy, opioids, or spoiled food).

• Safety Priority: Patients who are vomiting are at high risk for dehydration and electrolyte imbalances. Always monitor their fluid intake, output, and laboratory values.

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Medication Breakdown: Serotonin (5-HT3) Receptor Antagonists

  - Learning Objective: Describe the pharmacology, nursing implications, and patient teaching for this drug class.   - PAMPS Breakdown:     - P - Pathophysiology: Antiemetic (specifically a Serotonin (5-HT3) Receptor Antagonist).     - A - Antidote: N/A (Treatment for overdose is supportive care; manage symptoms).     - M - Management: Best given before nausea starts (e.g., right before chemotherapy or surgery).     - P - Purpose: To reduce or completely halt severe nausea and vomiting.     - S - Safety: Monitor for central nervous system (CNS) side effects (dizziness, drowsiness) as they present a fall risk! Monitor hydration status due to previous vomiting.

Pharmacology Concept Map Format

  - Medication Classification: Antiemetic (Serotonin 5-HT3 Receptor Antagonist)
  - Mechanism of Action: Blocks serotonin receptors in the gut and the brain's CTZ, preventing the brain from receiving signals to induce vomiting.   - Side Effects: CNS depression (dizziness, headache, drowsiness). Other side effects may include taste changes, heartburn, or bowel changes.   - Contraindications/Considerations: Observe for severe dizziness. Check laboratory values for electrolytes lost due to prior vomiting.   - Nursing Interventions: Administer proactively. Assess the severity of nausea/vomiting before and after administering the medication. Implement fall precautions if dizziness occurs.   - Client Education (Patient Teaching): Instruct patients to call for assistance before getting out of bed due to potential dizziness/drowsiness.

• Mnemonics & Memory Joggers:   - The “-SETRON” trick: All Serotonin (5-HT3) receptor antagonists end in the suffix -setron.
    - Example: Ondansetron (Zofran).
    - Mnemonic: “Setron stops you from tossing and turnin’ (vomiting).” Or, “Setron blocks Serotonin.”

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General Nursing Rules for All Antiemetics (Box 14.1)

  - Learning Objective: Understand general nursing considerations for antiemetic drug therapy.   - Simplified Key Terms (Definitions):     - Emesis: Medical term for vomit.
    - Neutropenia: Dangerously low white blood cell count (high risk for infection).   - Nurse Translation (Top Interventions):     - Assess first: Check vital signs (VS) and level of consciousness (LOC) before administering medications.     - Be proactive: Administer medications before the patient vomits.     - Hydration: Nausea/vomiting causes severe fluid loss. Monitor Intake & Output (I&O), skin turgor, and electrolytes.     - Red Flags: If vomitus appears like "coffee grounds" or contains blood, notify the provider immediately; this indicates a potential gastrointestinal bleed. Severe abdominal pain may signify infection or bowel tear.     - Safety Priority: Always provide the patient with their call light. These drugs may cause dizziness/drowsiness, posing a risk of falls.

• ## Medication Breakdown: Substance P/NK1 Receptor Antagonists   - Learning Objective: Describe the pharmacology, nursing implications, and patient teaching for Substance P/NK1 receptor antagonists.   - ## Pharmacology Concept Map Format     - Medication Classification: Antiemetic (Substance P/NK1 Receptor Antagonist).
      - Example: Aprepitant (Emend).     - Mechanism of Action: Blocks the “Substance P” chemical in the brain's trigger zone (CTZ) to prevent the body from inducing vomiting.     - Side Effects: Fatigue, diarrhea, headache, dizziness, hiccups.     - Contraindications/Considerations: Neutropenia (low WBCs), respiratory depression, angioedema.     - Nursing Interventions: Do NOT shake liquid suspensions—swirl them gently! Verify protocols; usually administered 1-2 hours before chemotherapy. Monitor CBC labs.     - Client Education (Patient Teaching): Store mixed liquid in the refrigerator (good for 30 days). Avoid alcohol consumption.

  - PAMPS Breakdown:     - P - Pathophysiology: Aprepitant (Emend).     - A - Antidote: N/A (provide supportive care).     - M - Management: Swirl liquid; do not shake. Administer before chemotherapy.     - P - Purpose: Prevents immediate and delayed nausea/vomiting from chemotherapy or surgery.     - S - Safety: Monitor for signs of infection (neutropenia) and respiratory depression.

• Mnemonics & Memory Joggers:   - Mnemonic: “A prepitant helps you prep for chemo by stopping the nausea.” Or, “Substance P prevents Puking.”

• ## Medication Breakdown: Phenothiazines   - ## Pharmacology Concept Map Format     - Medication Classification: Antiemetic (Phenothiazine / Dopamine Antagonist).     - Examples: Prochlorperazine (Compazine), Promethazine (Phenergan).     - Mechanism of Action: Blocks dopamine (D2) receptors in the brain's trigger zone.     - Side Effects: Drowsiness, dizziness.     - Contraindications/Considerations: Extrapyramidal symptoms (EPS) like Parkinson's-like tremors or muscle spasms. Risk of Neuroleptic Malignant Syndrome (NMS).     - Nursing Interventions: Administer IM injections deeply into a large muscle mass. Monitor motor movements and check temperature frequently.     - Client Education (Patient Teaching): Advise patients to change positions slowly to avoid orthostatic hypotension.

  - PAMPS Breakdown:     - P - Pathophysiology: Promethazine (Phenergan).     - A - Antidote: N/A.     - M - Management: Administer via deep IM injection.     - P - Purpose: Treats severe nausea/vomiting or motion sickness.     - S - Safety: Watch for a sudden high fever (sign of NMS) and muscle twitching/tremors; high fall risk due to blood pressure drops.

  - Mnemonics & Memory Joggers:     - Mnemonic: “Phenergan makes you Phall (orthostatic hypotension) and Phreeze (tremors/motor issues).”

• ## Medication Breakdown: Cannabinoids   - ## Pharmacology Concept Map Format     - Medication Classification: Antiemetic (Cannabinoid).     - Example: Dronabinol (Marinol).     - Mechanism of Action: Man-made THC that binds to cannabinoid receptors in the brain to stop N/V.     - Side Effects: Confusion, sedation, euphoria (a "high" feeling).     - Contraindications/Considerations: Worsening mental status.     - Nursing Interventions: This is considered a heavy-hitter, reserved for patients who do not respond to other antiemetics. Dose is calculated using Body Surface Area (BSA). Use an oral syringe for precise measuring.     - Client Education (Patient Teaching): Advise patients to avoid other sedatives/alcohol. Reassure them that the "high" or confused feeling usually recedes after a few days.

  - PAMPS Breakdown:     - P - Pathophysiology: Dronabinol (Marinol).     - A - Antidote: N/A.     - M - Management: Calculate the exact dose using BSA. Administer 1-3 hours prior to chemotherapy.     - P - Purpose: Last-resort drug for severe N/V when all else fails.     - S - Safety: Monitor mental status closely (confusion, extreme sedation).

  - Mnemonics & Memory Joggers:     - Mnemonic: “Dronabinol makes you feel like a drone (sedated and spaced out).”

• ## Medication Breakdown: Promotility Drugs   - ## Pharmacology Concept Map Format     - Medication Classification: Promotility Drug.     - Example: Metoclopramide (Reglan).     - Mechanism of Action: Blocks dopamine, promoting contraction of the upper GI tract and accelerating stomach emptying.     - Side Effects: Restlessness, mood swings.     - Contraindications/Considerations: Risk of orthostatic hypotension.     - Nursing Interventions: Monitor BP closely. Administer IM injections in a large muscle mass.     - Client Education (Patient Teaching): Instruct patient to request assistance before getting out of bed due to low BP risk.

  - PAMPS Breakdown:     - P - Pathophysiology: Metoclopramide (Reglan).     - A - Antidote: N/A.     - M - Management: Regularly assess BP.     - P - Purpose: Speeds up the gut to treat or prevent postoperative nausea/vomiting.     - S - Safety: Monitor for orthostatic hypotension and unexpected mood changes.

  - Mnemonics & Memory Joggers:     - Mnemonic: “Reglan makes the gut run regularly and fast.”

PIMPS Breakdown for General Nausea/Vomiting

• P - Pathophysiology: Nausea and Vomiting (N/V). The brain's trigger zone is activated by chemotherapy, medications, or gastrointestinal irritation.

• I - Intervention: Administer prescribed antiemetics before vomiting starts or exacerbates, remove strong odors from the environment.

• M - Management: Monitor I&O, skin turgor, and electrolyte lab values. Provide clear liquids or ice chips once vomiting ceases.

• P - Priority: Prevent severe dehydration and airway aspiration.

• S - Safety: Implement fall precautions due to dizziness from medications or dehydration. Assess emesis for blood ("coffee grounds").

Section: Peptic Ulcer Disease (PUD) & GERD

• Learning Objective: Determine the nursing care of patients receiving medications for peptic ulcer disease or gastroesophageal reflux disease.

• Nurse Translation: Though the stomach is designed to endure strong acid, the esophagus and intestines are not. If the protective mucus layer in the stomach fails, acid can damage the lining (PUD). If this acid splashes back into the unprotected esophagus, it leads to severe heartburn and injury (GERD).

• Simplified Key Terms:   - Peptic Ulcer Disease (PUD): Painful, bleeding lesions in the stomach or duodenal lining attributed to excessive acid or insufficient mucus protection.   - GERD (Gastroesophageal Reflux Disease): Acid reflux wherein stomach contents flow backward into the esophagus.   - H. pylori: A bacterium that incites many peptic ulcers. Treatment involves a robust combination of a PPI and 2-3 antibiotics over 10-14 days.   - Prostaglandins: Beneficial substances that ensure blood flow to the stomach lining to maintain its health. Note: NSAIDs (like ibuprofen) disrupt prostaglandins, thus promoting stomach ulcers!

PIMPS Breakdown: PUD & GERD

• P - Pathophysiology: PUD (stomach ulcers) and GERD (acid reflux). Both conditions entail damage to tissues caused by stomach acid (HCl).

• I - Intervention: Administer medications that neutralize acid, inhibit acid production, or coat the stomach.

• M - Management: Monitor for gastrointestinal bleeding and assess pain levels. Educate the patient to avoid trigger foods (e.g., alcohol, spicy foods) and refrain from NSAIDs.

• P - Priority: Prevent ulcer perforation (creating a full hole through the stomach) and cease any gastrointestinal bleeding.

• S - Safety: Watch for signs of "coffee ground" emesis or black, tarry stools, which indicate an active, bleeding ulcer!

Drug Class: Antacids

• Learning Objective: Describe the pharmacology, nursing implications, and patient teaching for antacids (initiation of this section).

• Pharmacology Concept Map:
    - Classification: Antacid.
    - Mechanism of Action: Functions akin to a fire extinguisher. It does not inhibit acid production; it simply neutralizes existing hydrochloric acid (HCl) and raises the gastric pH to reduce irritation.   - Considerations: This class commonly comprises calcium, magnesium, or aluminum.

• PAMPS Breakdown:
    - P - Pathophysiology: Antacid.
    - A - Antidote: N/A.
    - M - Management: Utilize to efficiently douse the "fire" of heartburn.
    - P - Purpose: Alleviates symptoms of indigestion and heartburn by decreasing gastric acidity.
    - S - Safety: (Additional safety information forthcoming on the following pages!)

• Mnemonic: "Antacids are Anti-Acids. They neutralize the burn."

Box 14.2: General Nursing Rules for PUD & GERD

• Lifestyle changes: Instruct patients to quit smoking (nicotine raises stomach acid!), consume smaller meals, and avoid eating within 3 hours of bedtime to reduce nighttime reflux.

• The "2-Week Rule": Patients should refrain from using over-the-counter (OTC) H2-blockers or PPIs for over 2 weeks without consulting a healthcare provider as prolonged use can obscure serious issues like stomach cancer or active bleeding.

• Red Flags: Alert provider for severe dizziness, dramatic drops in BP, increases in heart rate, or black stools—these are all classic indicators of an internal GI bleed!

• Older Adults: Maintain close monitoring for confusion and restlessness, as these drugs can significantly raise fall risks in elderly patients.

Drug Class: Antacids (Continued)

• Expected Side Effects: Dependent on the active ingredients!
    - Magnesium-based (e.g., Milk of Magnesia): May cause diarrhea.
    - Calcium/Aluminum-based (e.g., Tums): May lead to constipation.

• Adverse/Contraindications: Avoid high-sodium antacids in patients with heart failure. Monitor for electrolyte imbalances (hypercalcemia, hypermagnesemia) which can lead to kidney stones or cardiac arrhythmias.

• M - Management (Timing is critical!): Antacids may impede the absorption of nearly all other medications. Administer antacids one hour prior to or two hours following other medications.

• Client Education: Instruct patients to thoroughly chew chewable tablets and follow with a full glass of water. Shake liquid formulations well before serving.

Drug Class: Histamine H2-Receptor Blockers

• Learning Objective: Describe the pharmacology, nursing implications, and patient/family teaching for histamine H2-receptor blockers.

• Pharmacology Concept Map:
    - Classification: Histamine H2-Receptor Blocker.
    - Examples: Famotidine (Pepcid), Nizatidine (Axid).   - Mechanism of Action: Inhibits H2 receptors in the stomach to reduce baseline acid and nighttime acid production.   - Side Effects: Headache, nausea, mild confusion (particularly in older adults).
    - Contraindications/Adverse Effects: Rare blood disorders, dysrhythmias. Can elevate pneumonia risk.   - Nursing Interventions: Assess CBC labs for signs of unusual bleeding/infection. Monitor mental status in elderly patients.   - Client Education: Most effective when taken with meals or once daily at bedtime. Note that smoking diminishes the drug's effectiveness.

• PAMPS Breakdown:
    - P - Pathophysiology: Famotidine (Pepcid).     - A - Antidote: N/A.
      - M - Management: Preferably taken at bedtime to alleviate nighttime acid reflux.
      - P - Purpose: Prevents and treats PUD and occasional heartburn.
      - S - Safety: Watch for signs of confusion/dizziness in elderly patients (fall risk!).   

• Mnemonic: "Tie down the acid with a -tidine." (All generic H2-blockers end in -tidine).

Drug Class: Proton-Pump Inhibitors (PPIs)

• Learning Objective: Describe the pharmacology, nursing implications, and patient/family teaching for proton-pump inhibitors.

• Pharmacology Concept Map:
    - Classification: Proton-Pump Inhibitor (PPI).
    - Examples: Omeprazole (Prilosec), Pantoprazole (Protonix).   - Mechanism of Action: Fully inhibits the acid secretory "pump" inside stomach cells, effectively shutting down acid production.   - Side Effects: Headache, gastrointestinal upset (flatulence/diarrhea), photosensitivity (sun sensitivity).   - Contraindications/Adverse Effects: Long-term usage (> 1 year) can result in Vitamin B12 deficiency, low magnesium, and decreased calcium absorption (potentially leading to osteoporosis and fractures). Increased risk of C. difficile infections.   - Nursing Interventions: Timing is crucial! Must be administered 30–60 minutes prior to the first meal of the day.   - Client Education: Advise wearing sunscreen. Relief may take 1-3 days to manifest. If prescribed for H. pylori, it will be given alongside antibiotics—stress the importance of completing the full prescription!

• PAMPS Breakdown:
    - P - Pathophysiology: Omeprazole (Prilosec).
    - A - Antidote: N/A.
    - M - Management: Administer 30-60 minutes BEFORE breakfast.
    - P - Purpose: Heals severe gastric ulcers, serious GERD, and treats H. pylori infections.   - S - Safety: Monitor bone density and encourage Calcium/Vitamin D supplements for long-term users.

• Mnemonic: "PPIs block the pump and end in -prazole."

Drug Class: Cytoprotective Drugs

• Learning Objective: Describe the actions, uses, dosing, and nursing implications of cytoprotective drugs. (Note: These drugs function differently, so it's best to memorize them individually!)

1. Sucralfate (Carafate)
      - Action/Purpose: Functions as a liquid band-aid. It adheres directly to the ulcer, shielding it from acid to facilitate healing.
      - Management: Administer one hour before meals and at bedtime. Avoid administering antacids within 30 minutes before or 1 hour after.    - Nurse Trick: If the patient struggles to swallow the large pill, dissolve it in 10 mL of water to form a slurry.    - Mnemonic: "Sucralfate sucks and sticks to the ulcer."

2. Bismuth subsalicylate (Pepto-Bismol)
      - Action/Purpose: Coats the stomach; also indicated for diarrhea.
      - Safety: Instruct the patient that this medication may darken their stools to a brown or black color (normal side effect, not an indicator of a GI bleed!).
      - Warning: Contains aspirin (salicylate), hence watch for aspirin toxicity symptoms.

3. Misoprostol (Cytotec)
      - Action/Purpose: A synthetic prostaglandin administered to patients taking heavy NSAIDs to prevent NSAID-induced ulcers.
      - Safety/Critical Warning: NEVER give to pregnant women, as it induces severe uterine contractions and will result in miscarriage.

New Section Intro: Drugs for Constipation and Diarrhea

• Learning Objective: Determine the nursing care of patients receiving drugs for constipation or diarrhea.

• Memory Jogger: Signs of Constipation:
    - Fewer than 3 bowel movements per week.
    - Sudden decrease in frequency.
    - Hard, dry stools.
    - Straining, feeling bloated, or the sensation of incomplete defecation.

Section: Drugs for Diarrhea

• Nurse Translation: Diarrhea arises when the intestines fail to reabsorb enough fluid, leading to loose, watery stools. It is often a symptom of other conditions such as infections, food poisoning, or adverse effects of medications like antibiotics or chemotherapy.

• The Golden Rule of Diarrhea: If diarrhea is caused by an infectious agent (bacteria/parasite), do NOT administer an antidiarrheal immediately. The body is attempting to eliminate the pathogen! Slowing down the gut can retain the infection inside.

PIMPS Breakdown: Diarrhea

• P - Pathophysiology: Condition resulting from fluid imbalance in the intestines, leading to loose, watery stools. Can be acute (< 14 days) or chronic (> 2-4 weeks).

• I - Intervention: Keep the patient hydrated. Apply barrier creams to the perianal area to prevent skin breakdown.

• M - Management: Strictly monitor Intake & Output (I&O). Assess stool volume, frequency, and consistency.

• P - Priority: Prevent severe dehydration and electrolyte disturbance (notably low potassium levels).

• S - Safety: Implement fall precautions as severe dehydration can cause dizziness and hypotension.

Drug Class: Synthetic Opioid Agonists (Antidiarrheals)

• Pharmacology Concept Map:
    - Classification: Synthetic Opioid Agonist (Antidiarrheal).
    - Examples: Loperamide (Imodium), Diphenoxylate with Atropine (Lomotil).   - Mechanism of Action: Binds to opioid receptors in the gut to slow GI motility, allowing more time for water reabsorption.   - Side Effects: Constipation (if overused), dry mouth, blurred vision.   - Contraindications/Adverse Effects: Sedation; may interact with other CNS depressants.   - Nursing Interventions: Observe for constipation. Offer ice chips or sugar-free candy for dry mouth.

• PAMPS Breakdown:
    - P - Pathophysiology: Diphenoxylate with Atropine (Lomotil).
    - A - Antidote: N/A.
    - M - Management: Discontinue the drug promptly once diarrhea subsides to avoid severe constipation.
    - P - Purpose: Halts severe diarrhea.
    - S - Safety: Diphenoxylate combines with atropine to deter abuse for a "high"; atropine causes undesirable side effects (dry mouth and tachycardia) at high doses.

Drug Class: Antispasmodics & Anticholinergics (Antidiarrheals)

• Examples: Dicyclomine (Bentyl), Atropine, Hyoscyamine.

• Mechanism: Blocks acetylcholine, relaxing the GI tract smooth muscle and ceasing spasms/cramps.

• Safety/Management:
    - Do not administer within 2 hours of an antacid.
    - May cause profound dry eyes (advice patients not to wear contact lenses!).
    - Monitor heart rate closely (risk of tachycardia or bradycardia).
    - Exercise caution in older adults due to heightened confusion risks.

Section: Drugs for Constipation (Laxatives)

• Learning Objective: Describe the pharmacology, nursing implications, and patient teaching for laxatives.

• Nurse Translation: Laxatives promote defecation by various means; they are categorized into five primary types based on their mechanism of action.

Laxative Type 1: Bulk-Forming Drugs

• Examples: Psyllium (Metamucil), Methylcellulose (Citrucel).

• Mechanism: Absorbs water in the GI tract to form bulky stool; the increased bulk stimulates intestinal peristalsis. Takes 12 hours - 3 days to take effect.

• Purpose: The safest laxative, ideal for routine constipation prevention.

• Safety/Critical Warning: Must be mixed with a minimum of 8 oz of liquid and consumed immediately. Insufficient fluid can cause it to inflate in the throat, leading to esophageal obstruction.

• Management: Monitor patients with diabetes, as some bulk-forming powders are high in sugar.

Laxative Type 2: Emollients / Stool Softeners

• Example: Docusate (Colace).

• Mechanism: Acts as a wetting agent; reduces stool surface tension, allowing water and fats to mix in and soften the hard mass. Takes 1-3 days to work.

• Purpose: Preventative, ideal for postoperative patients or those advised against straining (e.g., hernias or recent heart attacks).

• Client Education: Inform patients that docusate may alter urine color to pink-red or yellow-brown (normal).

Laxative Type 3: Lubricants

• Example: Mineral Oil.

• Mechanism: Coats stool and colon walls, sealing in moisture to facilitate easy elimination.

• Safety: May inhibit absorption of fat-soluble vitamins. Lipid Pneumonia Risk: Avoid giving at bedtime or to patients at risk for aspiration, as inhalation can cause severe pneumonia.

Laxative Type 4: Osmotic (Saline) Laxatives

• Examples: Polyethylene glycol (Miralax), Lactulose, Sodium phosphate (Fleet Enema).

• Mechanism: Rapidly draws water into the intestines for flushing. Takes effect within 30 mins - 6 hours.

• Purpose: Typically used to cleanse the bowel before a colonoscopy or gastrointestinal surgery.

• Specific Drug Highlights:
    - Lactulose: An adjunct use—binds to ammonia, pulling it into the stool, utilized for patients with liver failure to decrease ammonia levels and improve confusion.
    - Fleet Enemas: High sodium content; avoid use in sodium-restricted patients (such as those with heart failure).

• Safety: Heightened risk of severe fluid and electrolyte imbalances; ensure the patient has a commode immediately accessible.

Laxative Type 5: Stimulant (Irritant) Laxatives

• Example: Bisacodyl (Dulcolax).

• Mechanism: Harshly irritates the nerve fibers in the intestinal mucosa, inducing peristalsis.

• Purpose: Used for acute or stubborn constipation or bowel prep; oral form works in 6-12 hours; suppositories in 15 mins - 1 hour.

• Safety: Avoid frequent use! Overuse may lead to muscle weakness and hypokalemia (low potassium).

Crucial Safety Rules for Constipation & Diarrhea

• Box 14.4 (Laxative Red Flag): NEVER administer any laxative to patients with severe abdominal pain, N/V, or fever without prior assessment from a provider. These are classic symptoms of appendicitis, and laxatives could result in appendiceal rupture.

• Box 14.5 (Diarrhea Rules): Always employ hand hygiene and wear gloves. Accurately track I&O and investigate stool for blood or mucus. Inform patients that many OTC drugs and antibiotics may induce diarrhea as a side effect.

Section: Drugs for Irritable Bowel Syndrome (IBS)

• Learning Objective: Determine the nursing care of patients receiving medication for irritable bowel syndrome.

• Nurse Translation: IBS is a frustrating, chronic condition where the bowel becomes easily irritated, resulting in abdominal pain and unpredictable bowel habits. It manifests as:   - IBS-C: Constipation-predominant (hard, lumpy stools).   - IBS-D: Diarrhea-predominant (loose, watery stools).

Drugs for IBS-C (Constipation)

1. Chloride Channel Activators
      - Pharmacology Concept Map:
        - Classification: Chloride Channel Activator.
        - Example: Lubiprostone (Amitiza).      - Mechanism of Action: Activates chloride channels in the gut, increasing fluid flow into the bowel lumen. This leads to softer stools and augmented motility.      - Side Effects: Nausea, mild diarrhea, headache, gas.      - Contraindications/Adverse Effects: Severe diarrhea.      - Nursing Interventions: Administer orally twice a day with food/water to minimize nausea. Instruct patient to swallow capsules whole (do not chew/break!).

   - PAMPS Breakdown:
     - P - Pathophysiology: Lubiprostone (Amitiza).
     - A - Antidote: N/A.
     - M - Management: Administer with food/water; swallow whole.      - P - Purpose: Treats IBS-C and chronic/opioid-induced constipation.      - S - Safety: Monitor/report severe diarrhea.    - Mnemonic: "Lube-iprostone lubes up the dry intestines."

2. Guanylate Cyclase-C Agonists
      - Pharmacology Concept Map:
        - Classification: GC-C Agonist.
        - Example: Linaclotide (Linzess).      - Mechanism of Action: Elevates intestinal fluid and motility while ameliorating abdominal pain and inflammation.      - Side Effects: Diarrhea, mild abdominal pain, gas.      - Contraindications/Adverse Effects: Not suitable for children. Avoid post-high-fat breakfast (can result in explosive loose stools!).      - Nursing Interventions: Administer orally at least 30 mins before the first meal of the day. Capsules may be opened and sprinkles on applesauce if swallowing difficulties arise.

   - PAMPS Breakdown:
     - P - Pathophysiology: Linaclotide (Linzess).
     - A - Antidote: N/A.
     - M - Management: Administer on an empty stomach, 30 mins before breakfast.      - P - Purpose: Treats IBS-C.      - S - Safety: Observe for signs of severe diarrhea or bowel obstruction.    - Mnemonic: "Linzess gives the bowels a clean-zess before breakfast."

3. Serotonin 5-HT4 Receptor Agonists
      - Pharmacology Concept Map:
        - Classification: 5-HT4 Agonist.
        - Example: Tegaserod.      - Mechanism of Action: Stimulates peristalsis in the GI tract. Approved only for females younger than 65 years.      - Side Effects: Diarrhea (generally resolves in 1-2 weeks).      - Contraindications/Adverse Effects: Considerable cardiovascular risk flags (stroke, myocardial infarction) and suicidal ideation.      - Nursing Interventions: Give 30 minutes prior to meals.

   - PAMPS Breakdown:
     - P - Pathophysiology: Tegaserod.
     - A - Antidote: N/A.
     - M - Management: Administer 30 mins before meals; females < 65 only.      - P - Purpose: Treats IBS-C.      - S - Safety: Immediate medical attention is necessary for symptoms of chest pain, arm weakness, facial drooping, or sudden depression/suicidal thoughts.

Drugs for IBS-D (Diarrhea)

1. Opioid Agonists (Specifically for IBS-D)
      - Pharmacology Concept Map:
        - Classification: Opioid Agonist for IBS-D.
        - Example: Eluxadoline (Viberzi).      - Mechanism of Action: Binds to specific opioid receptors in the gut to reduce GI motility without inducing euphoria.      - Side Effects: Nausea, mild abdominal pain, dizziness, mild constipation.      - Contraindications/Adverse Effects: Bronchospasm, pancreatitis, and severe constipation.      - Nursing Interventions: Administer orally twice a day with food. Closely monitor bowel habits to avoid excessive slowing of the gut.

   - PAMPS Breakdown:
     - P - Pathophysiology: Eluxadoline (Viberzi).
     - A - Antidote: N/A.
     - M - Management: Administer with food twice daily. Avoid OTC medications unless approved by a pharmacist (due to numerous interactions).      - P - Purpose: Treats IBS-D.      - S - Safety: Monitor for severe constipation (could lead to hospitalization) and abdominal pain indicating pancreatitis.    - Mnemonic: "Eluxadoline is a luxury for IBS-D (stops the diarrhea)."

Final Updates for Eluxadoline (Viberzi) Flashcard

• Client Education & Safety Red Flags:
    - Administer orally with meals twice a day (usually breakfast and dinner).
    - NO ALCOHOL: Concurrent use significantly heightens the risk of pancreatitis.
    - Discontinue use and contact a provider immediately if severe abdominal pain radiates to the back or shoulder occurs; this is a classic sign of pancreatitis.   

Chapter 14 Mastery Checklist: Drugs for GI Problems

• Digestive System Basics: Can you summarize how the GI tract operates and why stomach acid necessitates prostaglandins for lining protection?

• Antiemetics (Nausea/Vomiting):
    - Serotonin (5-HT3) Antagonists (the "-setrons"): Inhibit N/V by blocking serotonin. Monitor for dizziness.
    - Substance P/NK1 Antagonists: Prepares for chemotherapy-induced N/V. Do not shake liquid forms!
    - Phenothiazines: Block dopamine; administer deep IM injections. Monitor for EPS/tremors.
    - Cannabinoids: Medical THC for severe N/V; monitor for sedation/spaced out state.
    - Promotility: Accelerates gut movement; monitor for low BP.

• Peptic Ulcer Disease (PUD) & GERD:
    - Antacids: Neutralize the acid—administer 1 hour before or 2 hours after other drugs.
    - Histamine H2-Blockers (the "-tidines"): Diminish acid levels. Administer at bedtime.
    - Proton-Pump Inhibitors (the "-prazoles"): Disrupt the acid production system. Administer 30-60 minutes before breakfast.
    - Cytoprotective: Functions as a liquid band-aid (sucralfate) or coating agent.

• Constipation & Diarrhea:
    - Antidiarrheals: Decelerate GI transit (opioid agonists, anticholinergics). Refrain from use if infection is suspected!   - Laxatives: Facilitate bowel movements (Bulk-forming, softeners, lubricants, osmotic, stimulants). Ensure adequate hydration with bulk-forming agents!

• Irritable Bowel Syndrome (IBS):
    - IBS-C (Constipation): Chloride channel activators, GC-C agonists; enhance fluid availability in gut.   - IBS-D (Diarrhea): Opioid agonists (eluxadoline); slow down motility. Watch for pancreatitis!