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PHRM 504 > Lecture 15: Nausea/Vomiting/Diarrhea > Flashcards

Lecture 15: Nausea/Vomiting/Diarrhea Flashcards

1
Q

Nausea

A

Inclination to vomit or as a feeling in the throat or epigastric region alerting an individual that vomiting is imminent

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2
Q

Retching

A

Involuntary, rhythmic diaphragmatic and abdominal contractions

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3
Q

Vomiting

A

Forceful ejection or expulsion of gastric contents through the mouth

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4
Q

Physiology

A

Central nervous system (CNS) and gastrointestinal tract (GIT)
- Medulla oblongata (vomiting center) gets input from:

  • Cerebral cortex
    • Sensory input – anticipation, memory, sight, smell
  • Chemoreceptor trigger zone
    • Bloodstream or cerebrospinal fluid
  • Vestibular apparatus
    • Motion and body position
  • Visceral GIT afferent nerves
    • GIT mechanoreceptors and chemoreceptors
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5
Q

Pathophysiology – Primary Causes

* important ones that we can treat with self-care*

A
  • Motion Sickness
  • Food poisoning, Acute Viral gastroenteritis- an inflammation, swelling, and irritation of the inside lining of your gastrointestinal tract (stomach and small intestines)
  • Generally self-limiting
  • Caused by norovirus and rotavirus
  • Pregnancy- 70-80% incidence (most commonly early pregnancy through week
    22)
  • Overeating
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6
Q

Rotavirus

A

very contagious virus that causes severe, watery diarrhea and vomiting in infants and young children.

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7
Q

Norovirus

A

common virus that can cause gastroenteritis

- Norovirus is the most common cause of vomiting, diarrhea, and foodborne illness.

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8
Q

Complications

A 
§ Aspiration
§ Dehydration
§ Diaphragmatic herniation
§ Electrolyte or acid-base abnormalities
§ Esophageal tears
§ Malnutrition
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9
Q

Clinical Presentation - Dehydration for Adults

A 
§ Decreased skin turgor
§ Dizziness
§ Dry mouth
§ Excessive thirst
§ Fainting
§ Lightheadedness
§ Little or no urination
§ Reduced blood pressure
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10
Q

Clinical Presentation - Dehydration for Infants/Children

A 
§ Absence of tears when crying
§ Body is “floppy”
§ Dark urine
§ Decreased skin turgor
§ Decreased urine output
§ Difficulty waking up
§ Dry mouth and tongue
§ Fast heartbeat
§ Lightheadedness
§ Sunken and/or dry eyes
§ Sunken fontanelle
§ Thirst
§ Unusual lethargy, sleepiness,
decreased alertness, or irritability
§ Weight loss
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11
Q

Exclusions to Self-Care – Adults

A

§Too severe self-care cause
• Pregnancy with severe symptoms or breastfeeding
• Suspected food poisoning that does not clear in 24 hours

Associated symptoms
§ Blood in vomit
§ Fever and/or diarrhea
§ Head injury with N/V, blurry vision, or numbness and tingling
§ Severe abdominal pain, particularly right quadrants
§ Stiff neck with/without headache

Signs of complications
§ Urine ketones/high blood glucose (DKA/HHS) with signs of
dehydration in patients with diabetes
§ Yellow skin or eye discoloration and dark urine

Patient factors
§ Asthma; BPH; chronic bronchitis; emphysema; glaucoma

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12
Q

Other causes of Nasua, Vomting and Diarrhea

A
  • Anorexia or bulimia; CNS, endocrine, GI, or serious metabolic disorders; gastroesophageal reflux disease (GERD); gastroparesis with DM
  • Cancer treatment – chemotherapy or radiation
  • Drug-induced – antibiotics, digoxin, estrogen, ethanol, lithium, NSAIDs, opioids, theophylline
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13
Q

Exclusions to Self-Care – Infants/Children

A

Caregiver unable/unwilling to manage at home

Associated symptoms
< 6 months old or weight < 8 kg, vomited clear fluids 3 times, watery diarrhea
§ Lack of urination in past 8-12 hours
§ Lethargic, unusually sleepy, listless, or crying
§ Refusal to drink liquids
§ Suspected poisoning
§ Stiff neck
§ Vomiting/Vomitus
• Contains red, black, or green fluid
§ Following head or abdominal injury
§ Plus diarrhea, distended abdomen, fever, or severe headache
§ Repeatedly projectile and/or continues > 8 hours
§ With each feeding
§ With recurrent, severe, acute abdominal pain

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14
Q

Goals of Self-Treatment

A
  1. Provide symptomatic relief
  2. Identify and correct underlying cause
  3. Prevent and correct complications
  4. Prevent and manage unwanted effects of medications
  5. Prevent future occurrences
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15
Q

Cerebral cortex

A

Sensory input – anticipation, memory, sight, smell

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16
Q

Chemoreceptor trigger zone

A

Bloodstream or cerebrospinal fluid

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17
Q

Vestibular apparatus

A

Motion and body position

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18
Q

Visceral GIT afferent nerves

A

GIT mechanoreceptors and chemoreceptors

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19
Q

Non-pharmacologic therapy are used mostly to

A

correct dehydration and electrolyte imbalances

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20
Q

Pharmacologic non-prescription options are limited

A 
Target to appropriate pathway
§ Antacids
§ Antihistamines
§ Bismuth subsalicylate
§ H2RAs
§ Phosphorated carbohydrate solution (PCS)
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21
Q

Antihistamines Agents

A
  • Dimenhydrinate (Dramamine)
  • Diphenhydramine (Benadryl)
  • Meclizine (Bonine, Dramamine Less Drowsy)
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22
Q

Antihistamines MOA

A

Compete with histamine at central and peripheral H1-receptor sites to prevent histamine-receptor interaction and resulting mediator release

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23
Q

Antihistamines Contraindications

A

Breastfeeding
hypersensitivity
MAOI use
narrow angle glaucoma

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24
Q

Antihistamines Precautions/Warnings

A

Asthma
BPH
chronic bronchitis
emphysema

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25
Q

Antihistamines Adverse Effects

A

Blurred vision; constipation; dry eyes; dry mucous membranes;
incoordination; reflex tachycardia; sedation; urinary
hesitancy/retention
May cause paradoxical excitation: insomnia; irritability; nervousness

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26
Q

Antihistamines Drug Interactions

A

Alcohol
Anticholinergics
Sedatives

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27
Q

Dimenhydrinate Adult dosing

A

50-100 mg every 4-6 hours

MDD: 400mg

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28
Q

Dimenhydrinate 6-12 dosing

A

25-50 mg every 6- 8 hours

MDD: 150 mg

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29
Q

Dimenhydrinate 2-6 dosing

A

12.5-25 mg every 6-8 hours

MDD: 75 mg

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30
Q

Diphenhydramine adult dosing

A

25-50 mg every 6- 8 hours

MDD: 300 mg

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31
Q

Diphenhydramine 6-12 dosing

A

12.5-25 mg every 6-8 hours

MDD: 150 mg

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32
Q

Diphenhydramine 2-6 years old dosing

A

Not

recommended

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33
Q

Meclizine adult dosing

A

25-50 mg one hour prior to travel

MDD: 50 mg

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34
Q

Meclizine 2-12 years old

A

Not recommended

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35
Q

Antihistamines Patient Education

A

Take at least 30-60 minutes before travel, then take continuously for duration of travel

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36
Q

Phosphorated Carbohydrate Solution Products

A

Emetrol- Phosphoric acid/dextrose/fructose

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37
Q

Emetrol MOA

A

Direct local action on GIT wall to decrease smooth muscle contraction and delay gastric emptying time

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38
Q

Emetrol Contraindications

A

Hereditary fructose intolerance; hypersensitivity

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39
Q

Emetrol Precautions/Warnings

A

Diabetes

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40
Q

Emetrol Adverse Effects

A

Diarrhea; stomach pain

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41
Q

Emetrol Dosing adult

A

15-30 mL by mouth every 15
minutes until distress subsides
Max 5 doses/1 hour

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42
Q

Emetrol Pediatric 2-12 yrs old

A

5-10 mL by mouth every 15
minutes until distress subsides
Max 5 doses/1 hour

43
Q

Complementary Medicine

A
  • Ginger
  • Pyridoxine (vitamin B6)
  • Acupressure
44
Q

Ginger

A
  • Used in motion sickness, pregnancy, surgery

- Adverse Effects: mild GI – belching, discomfort, heartburn

45
Q

Pyridoxine (vitamin B6)

A

First-line treatment for pregnancy N/V (nausea/vomiting) per American College of
Obstetricians and Gynecologists (ACOG)
- Adverse Effects: well tolerated
- High doses (> 200 mg/day) may lead to lethargy,
neuropathy, and weakness

46
Q

Acupressure

A
  • Used in motion sickness and pregnancy
  • Direct pressure on pericardium-6 point on wrist
  • BioBand, ReliefBand NST, Sea-Band
47
Q

Treating Complications – Dehydration

A

Oral Rehydration Solutions (ORS)

48
Q

Oral Rehydration Solutions (ORS)

A
  • Rehydrate and correct electrolyte imbalances
  • Preferred sugar to sodium ratio of 3:1
    • Too much sugar can draw water into GIT and increase dehydration
    • Cola, ginger ale, fruit juice, and sports drinks may have too much sugar

Examples: Enfalyte, Pedialyte

49
Q

Treating Complications – Dehydration adults

A

Gauge need according to thirst

- Replace 30-50% fluid lost within 24 hours

50
Q

Treating Complications – Dehydration Pediatrics

A

Minimal dehydration

  • < 10 kg: 60-120 mL ORS after each vomiting episode
  • ≥ 10 kg: 120-240 mL ORS per episode

Mild-moderate dehydration
• 50-100 mL/kg ORS over 3-4 hours

51
Q

For severe dehydration->

A

Refer for emergency department in IV rehydration

52
Q

Treatment for Food Poisoning/Viral Gastroenteritis

Non-pharmacologic methods

A
  • Eliminate contaminated food
  • Bland diet (BRAT diet)
  • Explain signs/symptoms of dehydration
  • May initiate ORS
  • For excessive vomiting and at patient’s request, refer for
    prescription antiemetic
  • Reassess in 24 hours
53
Q

BRAT method

A

Banana
Rice
Apple juice
Toast

54
Q

Treatment – Motion Sickness

A
  • Acupressure
  • Avoid excess food or alcohol before and during extended flights
  • Avoid reading during travel
  • Avoid strong odors
  • Drive the vehicle, if possible
  • Focus the line of vision straight ahead
  • Stay where motion is least expected
55
Q

Motion Sickness Pharmacologic options

A

Antihistamines

56
Q

Treatment – Overeating

Non-pharmacologic options

A

Limit disagreeable options – alcohol, caffeine, dairy, smoking
- Remote offending food items

57
Q

Treatment – Overeating

Pharmacologic options

A

Antacids
§ Bismuth subsalicylate
§ H2RAs
§ PCS

58
Q

Treatment – Pregnancy

Non-Pharmacologic Methods

A
  • Before getting out of bed and eating breakfast, eat several dry
    crackers or toast
  • Do not overeat and avoid greasy/fatty foods
  • Eat 4-5 small meals per day instead of 3 large meals
  • Relax in bed for 10-15 minutes upon waking and get out of bed
    slowly
  • Sleep in an area with a fresh air source
  • Try small sips of carbonated beverages or fruit juice
59
Q

Treatment Pregnancy- Pharmacologic Options

A
  • Doxylamine – antihistamine used off-label

- Complementary medicine – ginger, pyridoxine

60
Q

For pregnancy, you must refer

A

If no relief after 1 week, refer

61
Q

Diarrhea

A
  • Abnormal increase in stool frequency, liquidity, and/or
    weight
    -Frequency changes with the patient
  • > 3 bowel movements per day considered abnormal
62
Q

Acute diarrhea

A

Acute: < 14 days
§ May be caused by intolerance of certain foods, medications, poisoning,
various non-GI acute or chronic illnesses
§ Managed with fluid/electrolyte replacement, dietary interventions, and
non-prescription therapy

63
Q

Persistent diarrhea

A

14 days to 4 weeks

64
Q

Chronic diarrhea

A

> 4 weeks

65
Q

Pathophysiology

A

Infectious Diarrhea/Gastroenteritis
Bacterial, protozoal, viral
§ Norovirus most common cause in adults
§ Rotavirus most common cause in infants/young children
§ Increased risk
§ Acquired immunodeficiency syndrome (AIDS), diverticulitis
§ Consumption of unsafe foods (raw or undercooked eggs, meat, shellfish)
§ Living/working environment: caregivers, congregate living conditions
(multifamily dwellings, nursing homes, prisons), daycare centers, food
handlers

66
Q

Traveler’s Diarrhea

A

Acquired through ingestion of contaminated food or water

  • Fruits, hot sauces, ice, raw meats, seafood, vegetables, water
  • 3-8 watery stools per day associated with at least one additional GI symptom – abdominal pain, nausea, vomiting
  • Symptoms usually subside over 3-7 days
67
Q

Food-Induced

A

Food intolerances

  • Allergy
  • Ingestion of excessive fat, fiber, seeds, spice
  • Lactose intolerance
68
Q

Clinical Presentation of Diarrhea

A

> 3 bowel movements per day
-Stool characteristics provide information about
pathophysiology
§ Black, tarry: upper GI bleeding
§ Red
§ Ingestion of red foods (beets) or drugs (rifampin)
§ Lower bowel or hemorrhoidal bleeding
Undigested food particles: disease of small intestine
§ Yellow: bilirubin or potentially serious liver pathology
§ White: fat malabsorption disease

69
Q

Black tarry stool means

A

upper GI bleeding

70
Q

Red stool means

A

Ingestion of red foods (beets) or drugs (rifampin)

§ Lower bowel or hemorrhoidal bleeding

71
Q

Undigested food particles means

A

disease of small intestine

72
Q

Yellow stool

A

bilirubin or potentially serious liver pathology

73
Q

White

A

fat malabsorption disease

74
Q

Exclusions to Self-Care Associated symptoms

A 
High output, including frequent and substantial volumes of
diarrhea
- Persistent fever
- Persistent vomiting
- Visible blood, pus, or mucus in stool
75
Q

Exclusions to Self-Care: Signs of complications (severe dehydration)

A

Children showing behavioral/mental changes (apathy, irritability,
lethargy, unconscious)
- Children who have no tears when crying
- Children who have not urinated in 8 hours
- Orthostatic hypotension

76
Q

Orthostatic hypotension

A

decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within three minutes of standing when compared with blood pressure from the sitting or supine position

77
Q

Exclusions to Self-Care: Patient Factors

A
  • Pregnancy
  • Risk for significant complications including chronic medical conditions or concurrent illness
  • Diabetes
  • Immunocompromised patients: AIDS, cancer, chemotherapy, frail patients
    ≥ 65 years, organ transplant recipients)
  • Renal disease
  • Severe cardiovascular disease
  • Young age (age < 6 months or weight < 8 kg)
78
Q

Exclusions to Self-Care: Too severe or long-lasting

A

Chronic or persistent diarrhea

§ Suboptimal response to already administered ORS

79
Q

Goals of Self-Treatment

A
  1. Prevent or correct fluid/electrolyte loss and acid-base
    disturbance
  2. Control symptoms
  3. Identify and treat the cause
  4. Prevent acute morbidity and mortality
  5. Prevent and manage unwanted effects of medications
80
Q

Non-Pharmacologic Therapy

Fluid and electrolyte management

A
  • Rehydration and maintenance
  • Preferred: ORS
  • Household items (juices, soups, sports drinks) may have high carbohydrate and/or low sodium
81
Q

Non-Pharmacologic Therapy: Diarrhea

Dietary management

A

Withhold food no longer than 24 hours

  • Reintroduce normal, age-appropriate diet once rehydrated
  • BRAT diet NOT recommended
  • Avoid caffeine, fatty foods, simple sugars (gelatin, juices, soft drinks), spicy foods
82
Q

Pharmacologic Therapy: Diarrhea

A
  • Evidence lacking to show agents other than loperamide or bismuth subsalicylate reduce stool frequency or duration of disease in adults
  • No antidiarrheals shown to significantly improve clinical outcomes < 5 years of age
  • Consider digestive enzymes (alpha-galactosidase or lactase)
    for food-induced diarrhea
83
Q

Loperamide Brand Name

A

Imodium (2 mg caplets; 1 mg/7.5 mL oral liquid)

84
Q

Loperamide MOA

A

Stimulates peripheral micro-opioid receptors on the intestinal circular muscles to slow intestinal motility and allow absorption of
electrolytes and water.
This reduced fecal volume, increased viscosity,
reduced fluid/electrolyte loss

85
Q

Loperamide Contraindications

A
  • Abdominal pain without diarrhea; acute ulcerative colitis
  • Bacterial enterocolitis
  • Children < 2years
  • Hypersensitivity
  • Pseudomembranous colitis associated with antibiotic use
86
Q

Loperamide Adverse Effects

A

Constipation

Dizziness

87
Q

Loperamide Dosing Adults

A

Adults ≥ 12 years
- 4 mg by mouth initially followed by 2 mg by mouth after each loose stool
MDD 8 mg

88
Q

Loperamide Dosing Children

A

2 mg by mouth initially followed by 1 mg by mouth after each loose stool
§ 9-11 years (60-95 lb): MDD 6 mg
§ 6-8 years (48-59 lb): MDD 4 mg

89
Q

Loperamide Special Pops

A

Breastfeeding: likely compatible
Pregnancy: exclusion to self-care

90
Q

Loperamide Concerns

A

Increasing number of individuals are taking extremely high doses to self-manage opioid withdrawal or achieve a euphoric high

91
Q

Loperamide Toxicity symptoms

A
  • Anxiety
  • Cardiac arrest
  • Decreased consciousness
  • Dyspnea
  • Generalized weakness
  • Nausea and vomiting
  • New-onset or recurrent syncope
  • Palpitations
  • Presyncope
  • Seizure-like activity
92
Q

Solid forms of Loperamide

A

Unit-dose packaging only

Maximum of 24-count (48 mg)

93
Q

Liquid products of Loperamide

A

4 ounce and 8 ounce sizes only

Maximum of 32 mg in 8 fluid ounces

94
Q

Bismuth Subsalicylate Brand Name

A

Kaopectate
Pepto-Bismol

262 mg caplets/tablets

262 mg/15 mL,
525 mg/15 mL oral liquids

95
Q

Bismuth Subsalicylate MOA

A

Salicylate provides antisecretory effect; bismuth exhibits antimicrobial effects directly against bacterial and viral gastrointestinal pathogens

96
Q

Bismuth Subsalicylate Contraindications

A

Hypersensitivity

Pregnancy

97
Q

Bismuth Subsalicylate Precautions/Warnings

A

Bleeding disorders
children
pregnancy
renal failure

98
Q

Bismuth Subsalicylate Adverse Effects

A 
Fecal discoloration (gray-black)
tongue discoloration (darkening)
99
Q

Bismuth Subsalicylate Dosing Adults

A

262-525 mg by mouth every 30 mins- 1 hour as needed

MDD 8 doses (262 mg)
4 doses (525 mg
100
Q

Bismuth Subsalicylate Pediatrics

A

Not recommended: Risk of Ryes syndrome

101
Q

Bismuth Subsalicylate Special Pops

A
  • Breastfeeding: avoid
  • Pediatrics: do not use < 12 years (Reye’s syndrome)
  • Pregnancy: contraindicated
102
Q

Patient Education: What you say when your advising a patient on a specific medication

A

Most acute diarrheal episodes end within 48 hours
§Non-pharmacologic measures: Prevent and correct dehydration

Pharmacological options
- Medication name and indication
- Administration and dosing
§ Potential side effects and how to manage
§ Warnings
§ Follow-up
103
Q

Evaluation of Patient Outcomes

A

§Most acute diarrheal episodes end within 48 hours
§ Dietary supplementation
§ Increased appetite, return to normal diet
§ Oral rehydration
§ Body weight, mental alertness, vital signs
§ Pharmacologic agents
§ Improved stool consistency, reduced stool frequency

104
Q

Refer if:

A
  • Bloody or mucoid stools
  • diarrhea continuing > 48 hours
  • high fever
  • worsening illness

PHRM 504 (22 decks)

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