GI drugs Flashcards
What are the antidiarrheals?
pepto-bismol
Diphenoxylate HCL
Loperamide hydroxychloride
What are the different categories of laxatives?
Bulk-forming laxatives
Hyperosmotic cathartics
stool softeners
lubricants
saline laxatives
What are the bulk forming laxatives?
Psyllium
Bisacodyl
What are the hyperosmotic cathartics?
polyethylene glycol - miralax
What are the stool softeners?
docusate sodium
docusate sodium and senna
what are the lubricants?
mineral oil
what are the saline laxatives?
Magnesium hydroxide
Magnesium citrate (Best for Bowel Prep!)
Sodium phosphate
What are the different antiemetics groups?
antihistamines
serotonin receptor antagonist
anticholinergic
phenothiazine
What are the antihistamine antiemetics?
hydroxyzine hydrochloride
mecllizine hydrochloride
dimenhydrinate
What are the serotonin receptor antagonist antiemetics?
zofran
reglan
What are the anticholinergic antiemetics?
scoplamine
What are the phenothiazine antiemetics?
prochlorperazine
promethazine hydrochloride
- Slow and/or inhibit GI motility by acting on nerve endings of the intestinal wall, thereby reducing the volume of stools, increasing viscosity and decreasing fluid and electrolyte loss.
- Used for symptomatic relief of acute nonspecific ______ and _______of inflammatory disease.
action and use for antidiarrheals
diarrhea,
- Shake suspensions well; chew tablets thoroughly
- Stool may appear gray-black (may mask GI bleeding)
- Do not give concurrently with other medications
- Seek medical care if diarrhea persists for more than two days in an adult
- Do not use to treat _____ in children; seek medical attention
- Do not give to clients with C. difficile
administration considerations for antidiarrheals
diarrhea
- Presence of bloody diarrhea, diarrhea associate with pathogens such as E. coli, salmonella or psuedomembranous colitis, or other bacterial toxins
- Avoid use if obstructive bowel disease is suspected
- Avoid bismuth subsalicylate if allergic to aspirin
- Difenoxine/atropine sulfate may cause serious side effects in nursing infants; therefore, should not be used for children under two years of age
contraindications for antidiarrheals
- Allergies to aspirin or other salicylates since bismuth subsalicylate contains salicylate
- Avoid aspirin use as concomitant use with bismuth subsalicylate , which may cause aspirin toxicity
- Bismuth may also decrease tetracycline absorption in the GI tract
- Diphenoxylate/atropine sulfate and difenoxin/atropine may increase the sedative effects of barbiturates, narcotics and alcohol.
- Concomitant use with MAO inhibitors may increase the risk of hypertensive crisis
significant drug interactions with antidiarrheals
are there significant food interactions with antidiarrheals?
no
______ may increase serum amylase levels
Diphenoxylate
- Nausea and vomiting
- Dry mouth, dizziness, drowsiness and constipation
- Temporary darkening of stools and tongue may occur with bismuth salicylate
side effects of antidiarrheals
- Clinical signs and symptoms of overdose include drowsiness, decreased blood pressure (BP), seizures, apnea, blurred vision, dry mouth and psychosis
- Risk of aspirin toxicity with concurrent use of aspirin and bismuth subsalicylate
- Other adverse effects include central nervous system (CNS) depression, respiratory depression, hypotonic reflexes, angioedema, anaphylaxis and paralytic ileus
adverse effects/toxicity for antidiarrheals
- Note allergies
- Document onset, duration, and frequency of symptoms
- Document previous therapies used
- Note current medications
- Identify any causative factors; perform stool analysis if necessary and ordered
- Assess for evidence of dehydration or electrolyte imbalance
- Monitor vital signs and I&O
- Note presence of comorbid conditions
- Check abdomen for tenderness, distention, bowel sounds or masses
- Administer bismuth and tetracycline one hour apart
nursing considerations for antidiarrheals
- Withhold solid food and 24 hours with acute diarrhea
- Foods that aggravate diarrhea include milk products, fruit and fruit juices, coffee, tea with caffeine and chocolate
- Drink fluids to avoid dehydration and alleviate dry mouth
- Follow the BRAT diet-bananas, rice, applesauce, tea/toast-to avoid dehydration if recommended by health care provider (controversial)
- Do not exceed prescribed dose
- Consult health care provider if diarrhea persists over two days
- Use caution in activities requiring alertness if dizziness or drowsiness is present (possible side effects)
- Report fever, nausea, and vomiting, abdominal pain or distention
- Avoid OTC antacids, dairy products, and other foods that aggravate diarrhea
- Use good personal hygiene to avoid skin irritation or breakdown because of diarrhea
- Avoid alcohol ingestion while taking medication
- Notify health care provider if pregnant or breastfeeding
education with antidiarrheals
a. Include nonabsorbable polysaccharide and cellulose derivatives
b. __________ absorb water to increase bulk in fecal mass
c. Peristalsis is stimulated by the increased fecal mass, which decreases bowel transit time
d. They generally produce a laxative effect within 12-14 hours but may require 2-3 days for full effect
e. Are frequently are used to prevent straining with defecation in clients who are post-myocardial infarction or have other conditions in which straining at stool could be harmful
Bulk-forming laxatives action and use
a. Since these agents rely on water to increase their bulk, it is essential that adequate fluids be given for bowel absorption
b. These agents may also cause intestinal and esophageal obstruction when insufficient liquid is administered with the dose
c. Each dose should be given with a full glass of liquid (240 mL)
d. Use sugar-free preparations in clients with phenylketonuria
bulk forming laxatives administration considerations
a. Not recommended for clients with intestinal stenosis, ulceration, or adhesions
b. Use cautiously in clients swallowing difficulties to ensure aspiration does not occur
c. Do not use if fecal impaction is present
contraindications for bulk forming laxatives
: decreased GI absorption may occur with digitalis, anticoagulants, nitrofurantoin and salicylates
significant drug interactions with bulk forming laxatives
a. Dietary management of constipation can be aided by encouraging the intake of fluid and fiber
b. Fiber increases stool bulk and water retention in the bowel
c. A dietary bulk forming nutrient such as bran is an appropriate adjunctive therapy for constipation
d. Bran is only partially fermented by bacteria, resulting in increased stool bulk, accelerated transit time, and promotion of normal defecation
e. Rapid increases in dietary roughage may cause abdominal bloating and flatulence
f. Adequate fluid intake is also necessary in order to prevent fecal impactions
g. Generally 240 to 360 mL of fluid with each tablespoon of bran is sufficient
h. Avoid foods that reduce stool, such as bananas, rice, breads, and cheeses
significant food interactions with bulk forming laxatives
Are there significant laboratory studies reported with bulk forming laxatives?
no
a. abdominal discomfort and/or bloating flatulence
b. Nausea, vomiting, diarrhea
side effects of bulk forming laxatives
a. Rare reports of allergic reactions karaya such as urticaria, rhinitis, dermatitis and bronchospasm
b. Esophageal obstruction, swelling, or blockage may occur when insufficient fluid is used in mixing a bulk-forming laxative
adverse effects/toxicity with bulk forming laxatives
a. Assess degree of abdominal distention, bowel sounds, and bowel elimination patterns
b. Assess swallowing ability, adequately mix agents in liquid and encourage additional fluid intake
c. Monitor for aspiration
d. If administered via feeding tube, it must be a large bore tube, and medication must be adequately dissolved in liquid and given rapidly with adequate flushing
e. Add at least 8 oz (240 mL) of water or juice to drug
f. Separate psyllium administration from digoxin, salicylates and anticoagulants by 2 hours
g. Use sugar free preparations in diabetic clients
nursing considerations with bulk forming laxatives
a. These agents require adequate hydration to be effective
b. Additional fluids and exercise are helpful in aiding bowel elimination
c. Mix powder preparation with at least 8 oz fluid and drink immediately and follow with another 8 oz of fluid
d. Bulk-forming laxatives may decrease appetite if taken before meals
e. Take bulk-forming laxatives 2 hours after meals and any oral medications
f. Use sodium and sugar-free preparations if they are appropriate to individual diet restrictions
g. Full effect of medication not occur for 2-3 days
client education for bulk forming laxatives
adverse effects:
- flatulence
- abdominal cramps
- bloating
- diarrhea
adverse effects for hyper osm cathartics
Dissolve 17 grams Miralax in 8 oz water and use once daily for up to 2 wks; 2 to 4 days for results
Hyperosmotic Cathartics
a. They increase osmotic pressure within the intestinal lumen, which results in luminal retention of water, softening the stool
b. It has been proposed that these organic acids may contribute to the osmotic effect
d. Used for treatment of occasional constipation
e. Used to reduce ammonia levels (Lactulose)
action and use for hyperosmotic cathartics
a. Glycerin is available only for rectal administration (suppository or enema) for treatment of acute constipation; its laxative effect occurs within 15-30 minutes
b. Dissolve 17 grams Miralax in 8 oz water and use once daily for up to 2 weeks; it may take 2 to 4 days for results to occur
administration considerations for hyperosmotic cathartics
Contraindicated in bowel obstruction
contraindications for hyperosmotic cathartics
- Significant drug interactions: antibiotics may decrease laxative effect by elimination of bacteria needed to digest active form
- Significant food interactions: none reported
- Significant laboratory studies: serum electrolyte levels
interactions and lab studies for hyperosmotic
Miralax: flatulence, abdominal cramps and bloating, diarrhea
9. Adverse effects/toxicity: fluid and electrolyte imbalances
side effects and adverse effects/toxicity for hyperosmotics
a. Miralax should always be dissolved in 8 oz of water
b. Monitor frequency and consistency of stools
d. Monitor for electrolyte imbalances, especially in older adults
nursing considerations for hyperosmotics
a. Miralax should be dissolved in 8 oz of water
b. Medication may take 2 to 4 days for effect
c. Contact prescriber if unusual bloating, cramping, or diarrhea occurs
d. Prolonged use may result in electrolyte imbalance and laxative dependence
e. Take medication with juice to improve taste
client education for hyperosmotics
a. Used on a scheduled basis for clients who are likely to become constipated, such as with hospitalization, bed rest, postsurgical status, and for those receiving opioid analgesic medications
b. ______ are often referred to as emollient laxatives
c. They are anionic surfactants that lower the fecal surface tension in vitro by allowing water and lipid penetration
d. Softening of the feces generally occurs after 1 to 3 days
e. Some preparations combine a _________such as docusate sodium with a stimulant, such as casanthranol to make a single combination product (e.g. Pericolace)
f. Used for constipation associated with dry, hard stools and to decrease strain of defecation
Stool softeners action and use
a. Do NOT give with mineral oil
b. Offer fluids after each PO dose
administration considerations for stool softeners or emollient laxatives
a. Contraindicated with any hypersensitivity to the drug
b. Contraindicated with intestinal obstruction undiagnosed abdominal pain, vomiting or other signs of appendicitis, fecal impaction or acute abdomen
c. Docusate sodium should not be used by clients with congestive heart failure (CHF) because of sodium content
contraindications for stool softeners
- Significant drug interactions: may increase absorption of mineral oil
interactions associated with stool softeners or emollient laxatives
Side effects
a. Mild abdominal cramping, diarrhea
b. Dependence with long-term use or excessive use
c. Bitter taste
Adverse effects/toxicity (all rare)
a. Throat irritation has occurred with docusate sodium solution
b. Docusate potassium has been associated with hyperkalemia when used in clients who have renal insufficiency or renal failure
side and adverse effects associated with stool softeners
a. Monitor frequency and consistency of stools
b. Monitor for electrolyte imbalances especially in older adults
nursing considerations with stool softeners
a. Take medication with milk or juice to decrease bitter taste
b. Increase fluid intake if not contraindicated by another condition such as CHF or renal failure
c. It may require 1 to 3 days to soften fecal matter
d. Consult with dietician regarding dietary changes to increase fiber foods
e. Avoid prolonged use
client education for stool softeners
a. Provide lubrication of feces and hinder water reabsorption into the colon
b. Used to treat constipation and prepare client for bowel studies or surgery
action and use for lubricants
Mineral oil is indigestible, and its absorption is limited considerably in the non-emulsified formulation
Onset of action when taken orally is 6 to 8 hours
administration and considerations for stool lubricants
Abdominal pain, nausea, vomiting
Signs and symptoms of appendicitis or acute abdomen, and fecal impaction or bowel obstruction
contraindications for stool lubricants
Stool softeners increase mineral oil absorption
May impair absorption of fat-soluble vitamins (A,D,E,K), anticoagulants, birth control pills, cardiac glycosides, and sulfonamides
contraindications for stool lubricants
- Significant food interactions: do not give with food as it may delay gastric emptying, separate by 2 hour
interactions with lubricants
Side effects:
a. Nausea and vomiting, diarrhea, abdominal cramps
b. Decreased absorption of nutrients
c. Laxative dependence may occur with excessive or long term use
d. Anal pruritis, irritation, and hemorrhoids
Adverse effects/toxicity: aspiration of product may cause lipoid pneumonia
side and adverse effects associated with lubricants
a. Because of possible aspiration and diminished vitamin absorption, do not administer to young children (younger then 6 years of age), pregnant women, older adults and debilitated clients
b. Do not administer the medication at bedtime
c. Avoid administration of drug to clients lying flat in bed because of risk of aspiration
d. Do not give within 2 hours of food because of possible decrease in gastric emptying
e. Cautionary use in older adults because of increased risk of aspiration
f. Monitor medications and alter administration time to avoid decreased absorption caused by mineral oil
nursing considerations with lubricants
a. Avoid chronic use; fat soluble vitamin absorption could be impaired
b. Do not take mineral oil with stool softeners because of risk of toxic levels
c. Mineral oil may leak through the anal sphincter; report side effects to health care provider
d. Do not take medication when lying flat or at bedtime to reduce risk of aspiration of oil droplets
client education with stool lubricants
Magnesium, sulfate, phosphate, and citrate salts are used when rapid bowel evacuation is required, as in bowel evacuation in preparation for procedures or surgery
b. The mechanism of action of these poorly absorbed ions is unclear, but it is believed that they produce an osmotic effect that increases intraluminal volume and stimulates peristalsis
c. Magnesium may cause cholecystokinin release from the duodenal mucosa promoting increased fluid secretion and motility of the small intestine and colon
d. Orally administered magnesium and sodium phosphate salts are effective within 30 minutes to 6 hours
e. Phosphate containing rectal enemas evacuate the bowel within 2 to 15 minutes
action and use for saline laxatives
a. Use magnesium salts cautiously for clients with renal impairment because absorption of magnesium salts may cause hypermagnesemia
b. Use sodium phosphate salts cautiously for clients with CHF when sodium restriction is necessary
administration considerations for saline laxatives
a. ______ agents are not recommended for children under 2 years of age because of the potential for hypocalcemia in this population
b. Abdominal pain, nausea and vomiting, or other signs and symptoms of appendicitis or acute abdomen
c. Intestinal obstruction, edema, CHF, megacolon or impaired renal function
contraindications for saline laxatives
- Significant drug interactions: concomitant use with antacids may inactivate both
interactions associated with saline laxatives
- Side effects: cramping and urgency to defecate
- Adverse effects/toxicity
a. Safe when administered for short-term management
b. They may cause significant fluid and electrolyte imbalances when used for prolonged periods or in certain clients
interactions associated with saline laxatives
a. Dehydration and electrolyte imbalances may occur from repeated administration without appropriate fluid replacement
b. Encourage increased fluid intake
c. Monitor drug effectiveness
nursing considerations for saline laxatives
a. Use appropriate dose and avoid frequent or prolonged use due to risk of laxative dependence
b. Report side effects or lack of effectiveness to health care provider
c. Increase fluid intake as allowed or tolerated
saline laxative client education
- Emesis is a complex reflex brought about by activation of the vomiting center (a nucleus of neurons located in the medulla oblongata)
- Certain stimuli activate the vomiting center directly (e.g. gastrointestinal irritation) while other stimuli (e.g. drugs, toxins, radiation) act within the medulla to stimulate the chemoreceptor trigger zone (CTZ); presumably, it is by altering the function of these neuroreceptors that emetogenic compounds and antiemetic drugs produce their effects
- Receptors involved are influenced by acetylcholine, histamine, serotonin, dopamine, benzodiazepines and cannabinoids
emesis education
suppress emesis by blockade of dopamine receptors in the CTZ
Phenothiazines
Metoclopramide - reglan
_____ are approved to treat nausea and vomiting associated with cancer chemotherapy; mechanism of action is unknown
Cannabinoids
_____: primary effect is suppression of anxiety; most effective for management of cancer chemotherapy-associated nausea and vomiting when combined with metoclopramide and dexamethasone
Benzodiazepines
_______: mechanism for suppression of emesis is unknown, they are effective alone and in combination with other antiemetics in the treatment of emesis associated with cancer chemotherapy
Glucocorticoids
______, anticholinergic effect reducing motion sickness and vomiting
Antihistamines
_____: Blocks serotonin receptors to reduce nausea
Ondansetron
______: a substance P and neurokinin 1 receptor antagonist that does not affect serotonin
Aprepitant
- Frequently, ______ combinations are more beneficial than single-drug treatment, particularly for cancer chemotherapy management of emesis; this may suggest that there is more than one mechanism triggering the emesis
- As a rule, prophylactic drugs are generally given by mouth; however, management of active emesis is usually through parenteral or rectal administration of medication
- Anticipatory nausea and vomiting should be treated 1 hour before meals or treatment
- Parenteral preparations should be given deep IM to avoid leakage of the drug into subcutaneous tissues
antiemetic administration considerations
antiemetic
- Generally contraindicated with CNS depression and coma
- Use cautiously in clients with glaucoma, seizures, intestinal obstruction, prostatic hyperplasia, asthma, and cardiac, pulmonary, or hepatic disease
contraindications for antiemetics
_____ is contraindicated with hypersensitivity, lactation, or concurrent use of pimozide
Use _____ cautiously with warfarin, vinblastine, vincristine, docetaxel ironotecen, imatinib, and paclitaxel
Aprepitant, Aprepitant
do great
:)
______is contraindicated with allergy to sesame oil, or with use of ritanavir, alcohol, sedatives or hypnotics, psychotomimetics, or tricyclic antidepressants
Dronabinol
- Epinephrine including ephedrine, may increase hypertension
- Avoid use with MAO inhibitors
- Antihistamines and CNS depressants may increase CNS depressions
- Levodopa may have decreased action
- Phenytoin may increase toxicity
- Meclizine may mask signs of ototoxicity with such medications aminoglycosides salicyates and loop diuretics
- Glucocorticords cause hyperglycemia
- Rifampin decreases dolasetron levels
significant drug interactions with antiemetics
F. Significant food interactions: none reported
G. Significant laboratory studies
1. Monitor BUN and creatinine (kidney function)
2. May mask response of skin testing; discontinue 4 days prior to testing
3. May cause hyperglycemia, false-positive or false-negative pregnancy test, may increase liver enzyme levels
4. Dexamethasone may increase glucose and cholesterol levels, decrease potassium, calcium and thyroxine levels
significant laboratory studies for antiemetics
H. Side effects
1. Phenothiazines can produce extrapyramidal reactions, anticholinergic effects, hypotension, and sedation; be alert for aspiration
I. Adverse effects/toxicity
Phenothiazines: agranulocytosis, thrombocytopenia
side effects/ adverse effects for antiemetics
- Dronabinol and nabilone have a high potential for misuse
- Check vital signs regularly for risk of hypotension or tachycardia
- Observe for side effects and adverse reactions
- Monitor I & O for urine retention
- Obtain baseline electrocardiogram with dolasetron
- Observe for mood changes or involuntary movements
- Monitor lab values; liver function tests, electrolytes, and renal function (blood urea nitrogen and creatine)
- Store dronabinol in reigerator
- Ensure client safety
- Monitor for anticholinergic effects; dry mouth, constipation, or visual changes
nursing considerations for antiemetics
- Avoid activities that require alertness
- Report adverse effects to health care provider
- Avoid alcohol and CNS depressant drugs
- Diabetic clients need to monitor blood glucose
- Take medications as prescribed
- Avoid excessive sunlight and ultraviolet light because of risk of photosensitivity
- Use sugarless hard candy or ice chips to avoid dry mouth
- Increase fluids and dietary fiber to decrease risk of constipation
- Take medication 30 to 60 minutes before any activity that causes nausea for best effect
client education for antiemetics
- Reduce gastric acid secretion by blocking Histamine H2 in the gastric parietal cells
- Reduce total pepsin output
- Histamine H2 antagonists are used to treat duodenal ulcer, gastric ulcer, hypersecretory conditions such as Zollinger-Ellison syndrome, reflux esophagitis
- Used to prevent stress ulcers in critically ill clients, and as combination therapy to treat Helicobacter pylori infection
action and use for histamine-2 receptor antagonists
- Intravenous administered drugs should not be mixed with other medications
- Avoid antacid use within 1 hour of administration
- May be given as single dose, twice daily, or with meals at bedtime
administration considerations for histamine-2 receptor antagonist antacids
- Hypersensitivity to drug
- Use caution in clients with impaired renal or hepatic function
contraindications for histamine-2 receptor antagonist antacids
E. Significant Drug Interactions
1. Decreased ketoconazole absorption with famotidine
2. Cimetidine: decreased metabolism of beta-adrenergic blockers, phenytoin, lidocaine, procainamide, quinidine, benzodiazepines, metronidazole, tricyclic antidepressants, oral contraceptives, and warfarin causing increased risk of toxicity
3. Cimetidine alters absorption of ketoconazole, ferrous salts, indomethacine and tetracyclines, and may decrease concentration of digoxin
4. Nizatidine may increase salicylate levels with high doses of aspirin
5. Ranitidine may increase diazepam absorption, increase hypoglycemic effects of glipizide, increase procainamide levels and increase warfarin effect
F. Significant Food Interactions: None
interactions associated with histamine-2 receptor antagonists
G. Significant laboratory studies:
1. Ranitidine – false positive urine prolactin
2. Cimetidine: false negative allergen skin test, increased prolactin, alkaline phosphatase and creatinine levels and may alter gastroccult testing caused by blue dye used in tablets
3. Famotidine may cause false negative allergen results and may increase liver enzyme levels
4. Nizatidine may cause false positive urobilinogen
lab studies associated with histamine-2 antagonist antacids
H. Side effects
1. Somnolence, diaphoresis, rash, headache, hypotension
2. Taste disorder, diarrhea, constipation, dry mouth
3. Cardiac dysrhythmias
4. Impotence with cimetidine
I. Adverse Effects/Toxicity
1. Rare but may include agranulocytosis, neutropenia, thrombocytopenia, aplastic anemia, and pancytopenia
2. Anaphylaxis
side effects and adverse effects associated with histamine-2 antagonist antacids
- Reduced dosages usually required for clients with hepatic or renal impairment
- Assess medications for possible interactions
- Evaluate nutritional status and dietary interventions
- Evaluate need for smoking cessation and alcoholic abuse programs
- Give cimetidine with meals and at bedtime
nursing considerations for histamine-2 antagonist antacids
- Block acid production by inhibiting the H+ 2K + ATPase at the secretory surface of the gastric parietal cells, thereby blocking the formation of gastric acid
- Used for treatment of erosive or gastroesophageal reflux disease (GERD) or duodenal ulcers, active benign gastric ulcers, and nonsteroidal anti-inflammatory drug (NSAID) – associated gastric ulcers (short term)
- Used for healing and reduction in relapse rates of heartburn symptoms in erosive or ulcerative GERD (maintenance)
- Used for treatment of pathological hypersecretory conditions such as Zollinger-Ellison syndrome (long term)
action and use of proton pump inhibitors
- May give with antacids
- If unable to swallow capsules, lansoprazole and esomeprazole capsules may be opened and sprinkled on applesauce before taking
- To give per nasogastric (NG) tube, dilute capsule contents in 40 mL juice
- Omeprazole, pantoprazole, and rabeprazole must be swallowed whole
- Pantoprazole IV: should be administered over a period of 15 minutes at a rate not greater than 3mg/min (7mL/min)
- Pantoprazole IV should be administered using the in-line filter provided
administration considerations associated with proton pump inhibitors
D. Contraindications: not recommended in children or nursing mothers
E. Significant Drug Interactions
1. Rabeprazole and pantoprazole may alter absorption of gastric pH dependent drugs such as ketoconazole, digoxin, iron preparations, and ampicillin
2. Esomeprazole may affect drugs metabolized by CYP2C19
3. Lansoprazole may alter theophylline levels; give at least 30 minutes before sucralfate
4. Omeprazole may potentiate diazepam, phenytoin, and warfarin
5. Omeprazole should be taken 30 minutes before sucralfate; it may alter absorption of pH dependent medications
6. Hypoglycemia could occur if rabeprazole is combined with itraconazole or gemfibrozil
7. Esomeprazole increases serum levels and increases risk of toxicity of benzodiazepines
8. Esomeprazole interferes with absorption of ketoconazole, iron salts, and digoxin
F. Significant Food Interactions: None reported but administer before meals
contraindications and interactions associated with proton pump inhibitors
G. Significant laboratory studies:
1. May increase liver enzymes
2. Monitor theophylline levels with lansoprazole (Prevacid)
3. May need to monitor diazepam and phenytoin levels and prothrombin times more frequently with omeprazole (Prilosec)
significant laboratory studies associated with proton pump inhibitors
H. Side Effects
1. Headache, diarrhea, constipation, abdominal pain, nausea, flatulence
2. Rash, hyperglycemia, dizziness, pruritis, dry mouth
3. Injection site reaction with pantoprazole
I. Adverse effects/toxicity
1. Pancreatitis, liver necrosis, hepatic failure, toxic epidermal necrolysis
2. Stevens-Johnson syndrome
3. Agranulocytosis, myocardial infarction (MI), shock, cerebral vascular accident (CVA)
4. GI hemorrhage
side effects and adverse effects associated with proton pump inhibitors
- Dosage should be reduced in severe liver disease
- Document reason for therapy, duration of symptoms, and drug efficacy
- Monitor for side effects
- Monitor laboratory tests results including liver function tests, CBC, and measures of renal function (BUN, Creatinine)
- Review any diagnostic finkings
- Assess for pregnancy or lactation
- Increase water intake to 8 to 10 glasses per day to prevent constipation
nursing considerations for proton pump inhibitors
- Be aware of side effects; report diarrhea
- Take medications as prescribed; do not increase dose
- Follow prescribed diet and activities to decrease symptoms
- Medication is generally for short term therapy; keep health care appointments for treatment of continued signs and symptoms
- Esomeprazole and omeprazole should be taken before meals
- Notify health care provider of any difficulty swallowing since omeprazole, pantoprazole, and rabeprazole must be swallowed whole
- Lansoprazole and esomeprazole capsules may be opened and sprinkled
client education for proton pump inhibitors
Primarily controlled by the vomiting center of the medulla of the brain, which receives sensory signals from the digestive tract, the inner ear, and the ________ in the cerebral cortex
chemoreceptor trigger zone (CTZ)
What are the causes of nausea
Vestibular
Obstruction (Opioids)
Mind (DysMotility)
Infection (Irritation)
Toxins (Tastes and other senses)
Motion and body position are sensed through the _____.
Motion sickness is brought about by the _____
So are, inner-ear diseases, such as Meniere’s disease.
Stimulus of the ______ is mediated largely through histamine and acetylcholine receptors.
Patient will complain of being nauseated with movement of head
vestibular apparatus
What are the preferred meds for vestibular induced nausea?
Promethazine (Suppository)
Scopolamine (Patch or Injection)
Cyclizine (Oral or Injection)
Focus on Anticholinergic/Antihistamine Drugs
Is most common cause of nausea
constipation
Can be caused internally or externally
Internally, could be due to constipation
Externally, an example would be a tumor pushing on outer bowel
May be mediated by both mechano- and chemoreceptors
obstruction
For constipation – use anti-constipation meds like laxatives
For other ______, medication use is controversial
Need to treat cause
obstruction
Caused by something emotional such as anxiety or memories, bad news, nervousness
Very real and often difficult to control
Can manipulate
senses
Can use Lorazepam
Or appetite
stimulants (Megestrol,
Steroids, Cannibinoids)
mind issue nausea
Can be caused by meds that “slow”______:
Opioids
Anticholinergics
Can have upper intestinal dys_____
motility
Treat with Prokinetics
Metoclopramide (Reglan)- upper only
Senna – lower only
dysMotility
Mediated through chemoreceptors: acetylcholine, histamine, serotonin
Gut and/or adjacent organ inflammation can trigger vomiting
infection and irritation
what are used to great GI disorders as a result of infection and irritation?
To treat: anticholinergic and antihistamine like promethazine
A zone in the medulla that is sensitive to certain chemical stimuli. Stimulation of this zone may produce nausea.
chemoreceptor trigger zone
Nausea can be caused via the ______ by:
Biochemical Abnormalities
Hypercalcemia, Hyponatremia, Hepatic Failure, Renal Failure
Sepsis
Drugs
Chemotherapy
Opioids
CTZ
Helps with some Chemotherapy induced vomiting
Example: Ondansetron hydrochloride (Zofran)
Sometimes in
CTZ related nausea where dopamine blockade is contraindicated (Parkinson’s)
Certain GI cases such as Bowel Obstruction or Radiation Enteritis
5HT3 antagonists
Increase in volume of stool and frequency of defecation
Can be due to gastrointestinal disease or a disorder of the bowel
diarrhea
Absorption of water into the intestines is dependent on adequate absorption of solutes. If excessive amounts of solutes are retained in the intestinal lumen, water will not be absorbed and diarrhea will result
A distinguishing feature of ______ is that it stops after the patient stops consuming the poorly absorbed solute
Example: Lactose Intolerance
osmotic diarrhea
Large volumes of water are normally secreted into the small intestinal lumen, but a large majority of this water is efficiently absorbed before reaching the large intestine. Diarrhea occurs when secretion of water into the intestinal lumen exceeds absorption.
secretory diarrhea
Destruction of the epithelium results not only in exudation of serum and blood into the lumen but often is associated with widespread destruction of absorptive epithelium. In such cases, absorption of water occurs very inefficiently and diarrhea results. Examples of pathogens frequently associated with infectious diarrhea include:
Bacteria: Salmonella, E. coli, Campylobacter
Viruses: rotaviruses, coronaviruses, parvoviruses (canine and feline), norovirus
Protozoa: coccidia species, Cryptosporium, Giardia
inflammatory or infectious diarrhea
In order for nutrients and water to be efficiently absorbed, the intestinal contents must be adequately exposed to the mucosal epithelium and retained long enough to allow absorption. Disorders in motility than accelerate transit time could decrease absorption, resulting in diarrhea even if the absorptive process per se was proceeding properly.
diarrhea associated with deranged motility
Normally, waste material travels through the large intestine and water is reabsorbed. If the waste material remains in the colon for too long and too much water is reabsorbed then the stool becomes hard leading to _____.
______ is not a disease, but a symptom of some other underlying cause
constipation
Lack of exercise
Insufficient food intake (fiber)
Insufficient water intake
Diseases that cause constipation:
Hypothyroidism, diabetes, irritable bowel disease
Foods that cause constipation:
Alcoholic beverages, products with high content of refined white flour, dairy products, chocolate
Drugs that reduce intestinal motility:
Opioids, anticholinergics, antihistamines, some antacids, iron supplements are examples
underlying causes of constipation
Dietary changes
Increased water intake
Laxatives
Cathartics
treatment for constipation
Inhibit action of histamines at the H1 Receptor, which results in limited stimulation of the vomiting center
Side Effects: confusion, sedation, dizziness, tinnitus, insomnia, incoordination, fatigue, tremors
Anticholinergic Side Effects of Antihistamine: dry mouth, urinary retention, blurred vision, exacerbation of narrow angled glaucoma
antihistamines
Inhibit action of serotonin at the 5-hydroxytryptamine receptor in the small bowel, vagus nerve, and chemoreceptor trigger zone so, decreases afferent visceral and chemoreceptor trigger stimulation of medullary vomiting center
Choice medication for chemotherapy induced vomiting
Can cause QRS widening and QT prolongation – watch EKGs and what meds are given in conjunction to prevent problems
May see serotonin antagonist used with dexamethasone to treat and prevent postop N/V
serotonin antagonist
Inhibit action of acetylcholine at the muscarinic receptor which results in limited stimulation of the vomiting center
Scopolamine can have effects on the CNS like antihistamines do, but primarily have anticholinergic effects: dry mouth, urinary retention, blurred vision, exacerbation of narrow angled glaucoma
anticholinergics
Actually antipsychotic medication used to treat dizziness and problems with balance, nausea, vomiting, agitation, severe restlessness, schizophrenia
Acts by blocking the action of dopamine on the nervous system of the brain
When given for nausea, give short term
Makes skin more sensitive to sunlight, need sunscreen!
Side effects: dizziness, drowsiness, blurred vision, dry mouth, headache, shakiness, difficulty with temperature regulation, changes in weight, difficulty sleeping, mood changes
prochlorperazine
Can be used for a number of things but used as an antiemetic in postop patients, active prophylactic treatment of motion sickness
DO NOT use in pediatric patients less than 2 years old – can cause respiratory depression
Avoid prolonged exposure to sunlight
Can cause marked drowsiness and impaired mental abilities
No longer recommended IV unless in a central line
promethazine HCl
