diarrhea and nausea/vomiting Flashcards
what is diarrhea? (3)
- increased frequency of bowel movements (more than 3 a day) -increased amount of stool (more than 200g a day)
- altered consistency (increased liquidity of stool)
diarrhea is associated with…
urgency, perianal discomfort, incontinence
any condition that causes….. can produce diarrhea
- decreased intestinal secretions
- decreased mucosal absorption
- altered motility
two underlying potential causes of diarrhea?
inflammatory bowel disease
and
lactose intolerance
acute diarrhea=
infection, self-limiting 7-14 days
chronic diarrhea=
2-3 weeks, may return sporadically
common causes:
-tumours, IBD, AIDs, diabetes, hyperthyroidism, addisons disease
causes of diarrhea? tons
medication (stool softeners, laxatives, thyroid hormone, antibiotics, chemotherapy, antiarrhythmics, antihypertension, magnesium based), tube feed, metabolic and endocrine disorders (addisons, thyroid, diabetes) viral or bacterial infections
-celiac, sphincters defect, zollinger-ellison syndrome, paralytic ileus, obstruction, AIDs)
secretory diarrhea=
high volume, increased production and secretion of water and electrolytes by intestinal mucosa into lumen
-associated with toxins and neoplasms
osmotic diarrhea=
occurs when water is pulled into intestines by osmotic pressure of unabsorbed particles, slowing the reabsorption of water
-caused by lactase deficiency, pancreatic dysfunction, or intestinal hemorrhage
malabsorptive diarrhea=
inhibiting effective absorption of nutritions manifested by marked of malnutrition that include hypoalbuminemia—> low serum albumin and intestinal mucosa swelling, liquid stool
-combines mechanical and biochemical actions
infectious diarrhea=
invade the mucosa, c. diff common
exudative diarrhea=
caused by changes in mucosal integrity, epithelial loss or tissue destruction by radiation or chemo
manifestations
-abdominal cramps, distension, borborygmus, anorexia, thirst
-painful spasmodic contractions of the anus, ineffective straining (tenesmus) may occur
-
nocturnal diarrhea-
diabetic
watery stools=
characteristic of small bowel
loose, semisolid stools=
large bowel
voluminous, greasy stools=
intestinal malabsorption
blood mucus and pus in stool=
suggest inflammatory enteritis or colitis
oil droplets on the toilet water=
indicate pancreatic insufficency
assessment and diagnostics for diarrhea?
- CBC
- serum chemistries
- urinalysis
- stool exam routine and parasitic
- infectious, toxins, blood
- fat electrolytes
- endoscopy or barium enema
complications of diarhea?
- CARDIAC DYSRHYTHMIAS because significant fluid and electrolyte loss (potassium!!)
- urinary output of less than 30ml per hour for 2-3 hours… muscle weakness, paresthesia, hypotension, anorexia
- POTASSIUM LESS THAN 3.5 REPORT
- skin care issues from irritant dermatitis
geri considerations?
- older, dehydrated more quickly, develop lower potassium levels
- muscle weakness, dysrhythmias or decreased peristalsis motility—> paralytic ileus
- if taking digoxin be aware of how quickly dehydration and hypokalemia occur with diarrhea
medical management of diarrhea?
-antibiotics, anti-inflammatory agents, antidiarrheals reduce severity and treat underlying
nursing management/assessments for diarrhea?
-assess and monitor characteristics, pattern, health history, diet, intake
-abd auscultation, palpation, inspection of mucous membranes and skin
-stool samples
-encourage bed rest, avoid caffeine, carbonated beverages, very hot or cold foods (stimulate intestinal motility)
report dysrhythmias or change in LOC
pediatric considerations for GI system?
- mouth is highly vascular, common port for infection
- lower esophageal sphincter prevents regurgitation into esophagus, not fully developed until 1 moth of age… so tend to regurgitate after feeds until 1 year
- childs stomach capacity increases with age (10-20 ml for newborn, 200ml for 2 month, 1500ml for adolescent)
at what age is the gastric contents equal to the adults?
by 6 months
intestinal growth spurts occur…
1-3 years. 15-16 years
clincal manifestations of GI dysfunction in children?
- growth failure
- spitting up or regurgitation
- vomiting, projectile vomiting (vigorous peristalic waves and pyloric stenosis or spasm)
- nausea
- constipation
- encopresis (more water stools)
- diarrhea
- bowel sounds (hypo,hyper,absent)
- abd distension
- pain
- GI bleeding
- jaundice
- dysphagia
- dysfunctional swallowing
- fever
antiemetics=
given to supress nausea and vomiting
emesis=
complex reflex by activating vomiting center, a nucleus of neurons in the medulla or oblongata
-direct stimuli of the vomiting center?
- cerebral cortex (anticipation or fear)
- sensory organs (upsetting sights, noxious odors, pain)
- vestibular apparatus of inner ear
indirect stimuli of vomiting center?
-first activate chemoreceptor trigger zone and vomiting center
-occurs in 2 days:
… by signals from stomach and intestine (vagal afferents)
by direct action of emetogenic compounds (anticancer drugs, opioids, ipecac) that are carried to CTZ in blood
the vomiting center signals…
the stomach, diaphragm and abdominal muscles to expel gastric contents
serotonin receptor antagonists…
ONDANSETRON
…. most effective for nausea and vomiting caused by cisplatin or other emetogenic anticancer drugs, radiation, anesthesia, viral gastritis, pregnncy
ondansetron … tell me about it
- for radiation, anesthesia, childhood viral gastritis, morning sickness
- blocks type 3 serotonin receptors in CTZ and afferent vagal neurons in upper GI
- oral or parenteral
- side effects: headache, diarrhea, dizzy, PROLONG QT INTERVAL life threatening dysrhythmia
- DO NOT GIVE TO PT WITH LONG QT INTERVAL, caution with other GT syndrome, HF, bradyarrhythmias
metoclopramide…. tell me about it
DOPAMINE ANTAGNOIST
(ANOTHER is prochlorperazine)
-suppresses emesis through blockage of dopamine receptors in CTZ. can suppress postop nausea and vomiting as well as emesis caused by antiulcer drugs, opioids, toxins and radiation therapy
-prokinetic agent SO… increase the TONE and MOTILITY of GI TRACT
(indication= gastroesophageal reflux diseae, CINV, diabetic gastroparesis)
-increases upper GI motility!!
-contraindication= GI obstruction, perforation or hemorrhage!!!!
-treatment should be as brief as possible (irreversible dyskinesia is a side effect)
scopolamine… tell me aboutit
- DRUG FOR MOTION SICKNESS
- muscarinic antagonist… most effective drug for prevention and treatment of motion sickness
- suppresses nerve in vestibular appartus of inner ear to vomiting center
- side effects: blurred vision, dry mouth, drowsy, urinary retention, constipation, disoritentation
antihistamines…. tell me about it
DIMENHYDRINATE!!
-MOTION SICKNESS
-block receptor for acetylcholine in addition to receptor for histmaine
-blocks receptor that connects inner ear to vomiting center
-side effects: SEDATION from H1 receptor, dry mouth, blurred vision, urinary retention, constipation (all from blocking muscarinic receptor)
LESS effective than scopolamine for motion sickness
nonspecific antidiarrheal agents?
-opioids (diphenoxylate with atropine)
more effective antidiarheal agents
activate opioid receptors in GI tract—> decrease intestinal motility, slow intestinal transit, allows more time for absorption of fluid and electrolytes
-opioid receptors decrease secretion of fluid into small intestine and increase absorption of fluid and salt
—-> less water in large intestine, volume of stools reduced
ONLY USED FOR DIARRHEA
-ONLY AVAIL with atropine, present to discourage abuse
-NO significant effect on CNS
antidiarrheal medication can change…
change the concentration and availability of medications—> some med binds to the toxins…. so if patients are on other meds, drug-drug interactions….
adsorbents?
an antidiarrheal (ex. bismuth subsalicylate)
- mild cases
- may blacken stools/tongue (activated charcoal!)
- they bind/adhere to toxins that cause diarrhea
- disadvantage: do not address dehydration
bulk forming agents?
an antidiarrheal
- methylcellulose
- causes stools to be less watery
- does not effect volume of stool
- can be used as laxatives
anticholinergics?
ex. atropine
- can relieve cramping
- do not change consistency or volume of stool
- has undesirable side effects….
opioids (ex. diphenoxylate, loperamide)
last resort
- decrease motility and painn
- increase in time stool is in bowel= increased absorption of nutrients, h20, electrolytes
NURSING ASSESSMENTS diarrhea
- NOPQRSTUV for diarrhea
- normal history of bowel habits
- amt consistency and quality of stools
- ins, outs, weights
- signs of dehydration (VS, physical exam, lab work)
NURSING DIANGOSIS: diarrhea
risk of: deficient fluid volume inbalance nutrition acute pain activity intolerance ineffective coping impaired skin integrity electrolyte imbalance
nursing interventions of diarrhea?
- establish cause if possible and treat
- supportive care
- IV fluids
- bland diet with slow advancement
- electrolyte balance
- possible antidiarrheal
- maintain skin integrity
- comfort measures
- psychological support
diphenoxylate vs. atropine
diphenoxylate= opioid, slows peristalsis atropine= anticholinergic, slows peristalsis and reduces gastric secretions SIDE EFFECTS (opioid- constipation and resp depression) assess LOC, vitals (RR, BP)
kidneys in children…
immature until age 2, cannot retain water as well
dehydration in kids…
becomes medical emergency. can lead to kidney failure, cardiac collapse, death
-INFANTS and children become dehydrated fast…. infants can lose 40% ECF in 24 hours
assessments for child with diarrhea? (early)
-dry mouth, decreased urine output, weight loss, what is the childs normal consistency of stool???
assessments for child with diarrhea (LATE SIGNS)
- sunken fontanelles in babies
- loss of tears when crying
- sunken eyes
- rapid, deep respirations (acidosis)
- rapid weak pulse
- cold extremities
- cyanosis
- loss of skin turgor
- COMA
nursing assessments for baby with diarrhea?
similar to adult: IV fluids based on weight, advance diet slowly (yes popsicles count!)
- daily weights
- STRIKT ins and outs, weigh diapers
- PRE and POST feed weights
- little bloodwork
- MOM is hydrated (if breast fed)
what is oral rehydration therapy?
low-tech solution that has saved millions of lives
-oral rehydration solution: boilted water, sugar, salt, orange juice or banana can be addedfor taste
nausea is…. ???? S or O
SUBJECTIVE!!
complications of nausea and vomiting?
- aspiration pneumonia
- dehydration
- malnutrition
- disruption of surgical site
- metabolic disturbances
- increased intracranial pressure
- stress/anxiety
4 pathways to the vomiting center?
- chemoreceptor for trigger zone (CTZ)
- GI tract
- Labyrinth (Inner ear)
- cerebral cortex
GI tract- Triggers of nausea and vomiting?
distension, obstruction, infection
neurotransmitters involved in GI tract?
-serotonin, dopamine, prostaglandins
chemoreceptor trigger zone? (what are the triggers) hint S!!
outside the blood brain barrier
SYSTEMIC triggers of vomiting so… hormones, toxins, metabolic abnormalities
neurotransmitters involved in CTZ?
dopamine, serotonin
vestibular and labyrinth trigger?
stimulated by: motion sickness, vertigo, opioids exert some influence
neurotransmitters in inner ear?
histamines, acetylcholine
cerebral cortex? triggers???
psychological component of nausea
-triggers: emotions, smells, anticipatory nausea, taste, gag reflex
so how do you pick which drugs for nausea and vomiting??
match trigger or cause with right drug or therapy!
- many type of antiemetics
- know your nursing considerations for each
anticholinergics… tell me more connecting with the route etc
BLOCKS acetylcholine receptors in vestibular nuclei an reticular formation!! so used for motion sickness and PONV
-side effects: sedation, dry mouth, constipation, difficult urination, blurred vission
EXAMPLE: scopolamine
antihistamines (H1 receptor antagonist)
mechanism: blocks H1 receptors, preventing Ach from binding to receptor in vestibular nuclei
USE: motion sickness, non-productive cough, sedation, rhinitis, allergies
side effects: sedation, dry mouth, urinary retention, blurred vision
example of a antihistamine???
dimenhydrinate, diphenhydramine
dopamine antagonist (d2 receptor)…. tell me more again
BLOCK DOPAMINE IN CTZ may also block ach, calm CNS
use: n/v from chemo, psychotic disorders, hiccups, radiation
side effects: orthostatic hypotension, extrapyramidal symptoms, tardive dyskinesia, headache, dry eyes, constipation, urinary retention
example of dopamin antagonist
PROCHLORPERAZINE
prokinetics tell me more again please
stimulates peristalsis
blocks dopamine receptors in CTZ, desensitizing to impulses from GI tract
use: delayed gastric emptying, GERD, N/V from chemo, PONV
side effects: ypotension, headache, dystonia, dry mouth, sedation, diarrhea
METOCLOPRAMIDE
serotonin antagonist?
block serotonin receptors in GI, CTZ, VC
- used for chemotherapy nausea or radiation, PONV
- side effects: rash, headache, diarrhea, PROLONGED QT INTERVAL
- ONDANSETRON
THC for n/v???
inhibitory effects on reticular formation, thalamus, cerebral cortex
use for n/v from chemo, stimulate appetite in AIDs, cancer
-side effects: drowsy, dizzy, anxious, confused, euphoria, visual disturbances, dry mouth
WEED
benzodiazepines for nausea????
used as adjunct, depresses CNS to help manage n/v from triggers related to CEREBRAL CORTEX
-side effects: sedation, amnesia
LORAZEPAM!!
corticosteroids for nausea?
usually not given alone but with one or more other category of antiemetic
ADJUNCT for nausea caused by chemotherapy
