Mod 3: Lecture 1 Flashcards
Exam 1
Divisions of the GI system
Upper
Lower
Hepatobilliary system
Divisions of the GI system: Upper
Esophagus
Stomach
Small intestine
Divisions of the GI system: Lower
Large intestine (colon)
Appendix
Rectum
Divisions of the GI system: Hepatobilliary system
Liver, gallbladder, pancreas
Neural controls: Sympathetic nervous system- what does it decrease?
Decreases secretion and peristalsis
Neural controls: Parasympathetic nervous system- what nerve
Vagus nerve
Neural controls: Parasympathetic nervous system- does what?
Increases secretion and peristalsis
Tasting food
Neural controls: Sympathetic nervous system- what does it stimulate?
Stimulates vasoconstriction in the mucosa
What stomach enzyme digests proteins?
Pepsin
What does HCI do in the stomach?
HCl acid activates enzymes, breaks up food, kills germs
What protects the stomach walls?
Mucus protects stomach wall
What is an issue with the stomach?
limited absorption
Lower esophageal (cardiac) sphincter is where:
between esophagus and stomach
Pyloric sphincter is where:
between the stomach and duodenum
What protects gut wall of small intestine?
Mucus
What does small intestine do?
Absorbs nutrients and most water
What in small intestine digests proteins, what digests sugars? What digests nucleotides?
Peptidase digests protein
Sucrases digest sugar
Nucleotidases and phosphatases digest nucleotides
What does large intestine do?
Reabsorbs some water and ions
Forms and stores feces
What does rectum do?
Stores feces prior to elimination through anus
What organ completes digestion?
small intestine
Chyme
acid fluid passes partially digested food from stomach to small intestine
What are the digestive juices stomach makes:
Hydrochloric acid ~
Pepsin ~
Gastric lipase ~
Intrinsic factor ~
Mucus ~
How does HCI work?
is secreted by parietal cells,
protein digestion, kills bacteria
What does gastric lipase do?
Gastric lipase ~ fat digestion
What does intrinsic factor do?
Intrinsic factor ~ B12 absorption in small intestine
What is mucus stimulated by?
Mucus ~ Protects stomach lining,
stimulated by prostaglandins,
mucosal barrier, gastric mucosal blood flow
Stomach absorption of nutrient? What is absorbed in the stomach?
No nutrients, only prepares for absorption.
ETOH
Pyloric sphincter- what does it prevent?
Prevents reflux of bile from the small intestines
Pyloric sphincter
a muscular valve at the bottom of the stomach that controls the flow of food from the stomach into the small intestine
What is the initial part of the small intestine?
Duodenum
Emesis- what kind of action?
Involuntary or voluntary
How is emesis protective?
Drug OD
Infection
What is emesis associated with? What are examples?
Association with severe pain
ex;
Migraines
Renal calculi
What does emesis involve coordination with?
Coordination via medulla oblongata
Coordination via medulla oblongata for emesis include what two groups?
- Vomiting center (VC) activation
- Chemoreceptor Trigger Zone (CTZ)
What is needed for Vomiting center (VC) activation?
Direct acting stimuli
What are examples of direct acting stimuli in VC activation?
Fear ~ cerebral cortex
Smell/sight or pain ~ sensory organs
Motion sickness ~ vestibular apparatus of inner ear (cranial nerve VIII)
Fear is involved with what part of the brain?
Fear ~ cerebral cortex
Smell/sight or pain is involved with what part of the brain?
Smell/sight or pain ~ sensory organs
Motion sickness is involved with what part of the brain?
Motion sickness ~ vestibular apparatus of inner ear (cranial nerve VIII)
The Chemoreceptor Trigger Zone (CTZ) requires what kind of stimuli?
Indirect stimuli
Indirect stimuli for the CTZ include what?
Gut activation
Drugs, toxins, chemicals in the blood
Vomitus; What is it and does it aid with?
Contents vomited
Aids w/ ID of underlying cause
Hematemesis:
vomitus with blood
What kind of appearance does vomit with blood have? Why?
Brown, granular appearance ~ coffee grounds
It is Partially digested protein
Why does hematemesis occur?
Blood irritation to GI mucosa –> attempts to expel
Diagnosis is capable of causing upper GI bleed include
Gastric ulcers
Esophageal varices
GIB gastro intestinal bleeding
Bile containing vomitus is what color?
Yellow- or green-colored
Bile containing vomitus
Why does it occur?
Can occur from GI tract obstruction
Liver biliary
Fecal containing vomitus (throwing up poop); how does it appear? Why?
Deep brown color of
May indicate content from lower intestine, possibly fecal
Fecal containing vomitus (throwing up poop) diagnosis include:
Intestinal obstruction
Impacted feces
cancer
Undigested food in vomitus occur because:
Impaired gastric emptying
Pyloric stenosis
Projectile Emesis
Vomitus exits with force
What are qualities of projectile emesis?
Often sudden
Subsequent excessive vomitus with each attack
Are not preceded by nausea
Associated conditions of projectile vomitting? what is the main one?
Intestinal obstructions
Delayed gastric emptying
↑ ICP/Head injury
Poisoning
Overeating
Neurologic lesions – tumors, aneurysms- involving brainstem
Pyloric stenosis
Complications of Emesis include:
Exhaustion
Fluid imbalances
Electrolyte imbalances
Acid–Base imbalances -?
Aspiration
What kind of acid base imbalance from vomitting?
metabolic alkalosis
acidosis for diarrhea
Procedures for management of Emesis may include?
PMH
PE
Blood chem
What are treatment goals for management of emesis?
Cessation of vomiting
Maintaining hydration (PO/IVF)
Restoring acid–base balance
Correcting electrolyte alterations
For cessation of vomiting, what can be given?
Antiemetics
Antiemetics include
5HT antagonists
Metoclopramide
Antihistamines: Dimenhydrinate, Meclizine, Diphenhydramine
Muscarinic antagonist: scopolamine
Best management of motion sickness
Most effective to treat prophylactically
Scopolamine is what kind of drug?
Muscarinic antagonist
How does Scopolamine patch work?
TD patch behind the ear
Apply 4h prior to travel
What are examples of Antihistamines for motion sickness?
Dimenhydrinate & meclizine
Which is most effective for managing motion sickness?
Scopolamine
Receptors & Agents Involved in Emesis
What classes of drugs are involved in emesis control?
- Serotonin antagonists
- Anticholinergics
- Antihistamines
5HT3 receptor Antagonists (serotonin receptor antagonists)- What is the prototype?
Ondansetron (Zofran)
What class in Ondansetron (Zofran)?
Class: Serotonin antagonists
What is the mode of action of Ondansetron (Zofran)?
Blocks type 5HT-3 serotonin receptors in the CTZ & on afferent vagal nerves upper GIT
What is Ondansetron (Zofran) used for?
CINV
Radiation
Anesthesia
How is Ondansetron (Zofran) administered?
PO, IM or IV, ODT
What is Ondansetron (Zofran) augmented with?
Augmentation with GCs
How should Ondansetron (Zofran) for a procedure (chemo)?
Give before to prevent:
CINV 30min prior
Anesthesia 1h prior
Radiation TID
Postop N/V
COmmon adverse effects of Ondansetron (Zofran)?
HA, diarrhea, dizziness
What is a serious adverse effect of Ondansetron (Zofran)?
QT prolongation
↑ risk of torsades de pointes
Avoid in long QT syndrome
When should Ondansetron (Zofran) be avoided?
Avoid in long QT syndrome
What does Ondansetron (Zofran) not cause?
⍉ DA blockade = ⍉ EPS
Precautions to take for Ondansetron (Zofran)?
Electrolyte imbalances
HF
Brady dysrhythmias
QT prolonging drugs
Metoclopramide (Reglan) is what class of drug?
Prokinetic agent/Dopamine antagonist
Since Metoclopramide (Reglan) is a Prokinetic agent/Dopamine antagonist, what does that mean?
Increase GI tone & motility
What is the mode of action of Metoclopramide (Reglan) ?
Blockade of Dopamine & serotonin receptors in CTZ
Increases Ach actions = increase in upper GI motility
Metoclopramide (Reglan) causes Blockade of Dopamine & serotonin receptors in CTZ, what can this be used for?
CINV & post-op N/V
chemotherapy-induced nausea and vomiting
Since Metoclopramide (Reglan) increases acetylcholine actions and increases upper GI motilitywhat does that mean?
Stimulates motility of UGI tract & accelerates gastric emptying (rest & digest)
Metoclopramide (Reglan) Stimulates motility of UGI tract & accelerates gastric emptying (rest & digest); What does this mean it can be used for?
Diabetic gastroparesis
Suppression of gastroesophageal reflux
How is Metoclopramide (Reglan) administered?
PO
IV
When should Metoclopramide (Reglan) be administered for Diabetic gastroparesis ? How?
PO
Diabetic gastroparesis (10mg PO 30 min before meals & HS x 2-8 wks)
When should Metoclopramide (Reglan) be administered for gastroesophageal reflux? How?
PO
Suppression of gastroesophageal reflux (10-15mg PO 30 min before meals & HS for max 12 wks)
What is Metoclopramide (Reglan) given IV for?When?
CINV & post-op N/V ~ 30min prior
Adverse effects of Metoclopramide (Reglan)
Sedation & diarrhea- Common in High Dose therapy
Irreversibletardive dyskinesia
Since Metoclopramide (Reglan) causes tardive dyskinesia, what does this?
Keep TX brief!!!
What is Metoclopramide (Reglan) contraindicated in?
GI obstruction, perforation, or hemorrhage
as per ↑ GI motility
Key Nursing Responsibilities with Metoclopramide Administration:
Assess for Parkinsonian sx – diff speaking, swallowing, loss of balance, pill rolling, rigidity, tremors, dystonia and tardive dyskinesia – uncontrolled rhythmic movements of mouth, face, exts, lip smacking, puffing cheeks
What is the mode of action of scopolamine?
Suppressing nerve communication in neuronal pathway that connects the vestibular apparatus of inner ear to the vomiting center
What is released during vestibular system activation?
Acetylcholine
Vestibular apparatus –> XX inner ear XX –> VC
Scopolamine is used for what?
Most effective drug for preventing motion sickness
End Of Life
Scopolamine > antihistamines
How is Scopolamine administered?
Oral, Sq, transdermal
TD patch applied behind ear
Q72h
Common Adverse effects of Scopolamine?
Dry mouth, blurred vision, drowsiness
What are more severe but less common effects of scopolamine?
Urinary retention, constipation, disorientation
Antihistamine drugs include?
Dimenhydrinate (Dramamine)
Meclizine (Antivert)
Why are antihistamines classified as anticholingerics?
Classified as anticholinergic because block receptors for acetylcholine (muscarinic cholinergic)
Why are antihistamines mode of action?
Blockade of histamine (H1) & muscarinic receptors in the neuro pathway connecting inner ear to VC
What can antihistamines be used for?
Use: motion sickness
What are adverse effects of antihistamines?
H1 blockade
Muscarinic blockade
Adverse effects of antihistamines: H1 blockade means it leads to what symptoms?
Sedation
Adverse effects of antihistamines: muscarinic blockade means it leads to what symptoms??
Dry mouth, confusion, hallucinations
Blurry vision, urinary retention, constipation
Gastritis
Inflammatory disorder of the gastric mucosa lining
What does gastritic do to stomach lining?
Gastric lining red, edematous
What occurs when the stomach lining is damaged?
Ulceration and bleeding when the mucosal barrier is damaged, or circulation compromised
What are common causes of gastritis?
Drugs: *NSAIDs, Glucocorticoids
*H. pylori, physiologic stress-related mucosal changes
Alcohol, metabolic disorders (eg renal failure – uremia)
Symptoms of acute gastritis include?
Sx: vague abd pain, epigastric tenderness, bleeding
Who does Chronic gastritis tend to occur in?
Tends to occur in older adults
What does Chronic gastritis cause?
Causes gastric mucosal atrophy, epithelial changes
What are two types of chronic gastritis?
2 types: immune (T-cell toleranace, auto Abs) vs
non-immune (same causes as acute)
What is immune cause of chronic gastritis?
T-cell toleranace, auto Abs)
What is nonimmune cause of chronic gastritis?
non-immune (same causes as acute)
What does chronic gastritis put you at an increased risk for?
Increased risk of duodenal ulcers, gastric cancer
What is effects with chronic gastritis?
Absorption of nutrients and enzymes are affected
How to treat chronic gastritis without medicine?
Eat small meals, soft, bland diet, avoid etoh & ASA
What is treatment of chronic gastritis?
Tx: GI meds, abx for h.pylori, Vit B12
Helicobacter pylori (H. Pylori) what kind of bacteria?
Gram neg bacteria adapts to acidic stomach by secreting toxins
How does Helicobacter pylori (H. Pylori) survive in the stomach?
Gram neg bacteria adapts to acidic stomach by secreting toxins
What does Helicobacter pylori (H. Pylori) do?
Invades the gastric mucosa lining, causing inflammation.
What is important about the shape of H.pylori?
Spiral shape allows them to penetrate mucosal barrier, where they are protected by mucus, interfering in the immune response so they are not destroyed.
What causes stomach irritation in H.Pylori? What else does it cause?
The combination of stomach acid and H. pylori cause irritation, resulting in sores and ulcerations.
How long is H.pylori in the gut?
Can remain in gut for decades
What are signs and symptoms of Helicobacter pylori (H. Pylori)?
S/sx: Excessive burping, bloating, n/v, anorexia, unexplained weight loss, foul breath
How is H.Pylori assessed?
Tested through stomach lining endoscopic biopsy, breath, serologic, stool tests
What does H.Pylori treatment consist of in general?
Combo of antibiotics prescribed (at least 2) to reduce risk of resistance (10-14 days)
What antibiotics are used to treat H.pylori in combination? - name 4
Proton Pump Inhibitor (PPI) or HR2A blocker
Mucosal protectants
Amoxicillin (Pcn)
Clarithromycin (macrolide)
What antibiotics are used to treat H.pylori in combination? - name 3
Bismuth compounds (bismuth subsalicylate - main ingredient in Pepto-Bismol)
Tetracycline
Metronidazole
What does amoxicillin do to treat H.pylori?
Kills H. pylori by disrupting cell wall, highly sensitive
Where does amoxicillin work highest?
Works highest at a neutral pH
How are amoxicillin effects enhanced?
Effects enhanced by reducing gastric acidity with an antisecretory agent
What is the most common side effect of amoxicillin?
Most common side effect is diarrhea
What does Clarithromycin (macrolide) do for H.pylori treatment?
Suppresses growth of H. pylori by inhibiting protein synthesis
What is the most common side effect of Clarithromycin (macrolide)?
Most common side effects: Nausea, Diarrhea, Distortion of taste
What does Bismuth compounds (bismuth subsalicylate - main ingredient in Pepto-Bismol) do for H.pylori treatment?
Disrupt the cell wall of H. pylori
What does Bismuth compounds (bismuth subsalicylate - main ingredient in Pepto-Bismol) may do to H.pylori?
May inhibit urease activity and may prevent H. pylori from adhering to the gastric surface
What can Bismuth compounds (bismuth subsalicylate - main ingredient in Pepto-Bismol) cause as a harmless effect? **highlighted
Can impart a harmless black coloration to the tongue and stool (melena)
What should be included in patient teaching of Bismuth compounds (bismuth subsalicylate - main ingredient in Pepto-Bismol) use? **highlighted
Long-term therapy: Possible risk of neurologic injury
What does Tetracycline do to H.pylori?
Inhibitor of bacterial protein synthesis
What can happen if tetracycline is used in pregnant/young children?
Use in pregnant patients/young children can stain developing teeth
What is wrong with Metronidazole use for H.pylori?
Over 40% of strains are now resistant
Most common side effects of Metronidazole use for H.pylori?
Most common side effects are nausea and headache
What happens if Metronidazole is used with alcohol
Disulfiram reaction if used with etoh
Peptic Ulcer Disease is what?
Open sores on stomach’s protective mucosal lining or upper duodenum
How can severe erosion in PUD be complicated?
Severe erosion can be complicated by hemorrhage and perforation
How can PUD be?
Can be single, multiple, acute, chronic, superficial, deep
What are causes of Peptic Ulcer Disease (PUD)?
Imbalance between protective mucosal < erosive factors
Most common cause - Infection with H. pylori
Second most common cause - NSAIDs
What is the most common cause of PUD?
highlighted slide
Most common cause - Infection with H. pylori
What are risk factors to peptic ulcer disease?
NSAIDs, H. pylori, stress, etoh, steroids, age, smoking
What are signs and symptoms of Peptic Ulcer Disease (PUD)
epigastric/abd pain, cramps, heartburn, indigestion, CP, N/V, fatigue, unexplained wgt loss, hematemesis & melena (duodenal ulcers)
What are three types of three types of Peptic Ulcers? What is the most common?
Duodenal ulcers (most common)
Gastric ulcers (stomach ulcers)
Stress Ulcers
Types of Peptic Ulcers: What are Duodenal ulcers (most common) characterized by?
Characterized by intermittent pain in the epigastric area
Types of Peptic Ulcers: When does pain associated with Duodenal ulcers occur?
Pain begins 2-3 hours after eating, when stomach empty
Types of Peptic Ulcers: When relieves pain associated with Duodenal ulcers occur?
Relieved by food or antacids
Types of Peptic Ulcers: In duodenal ulcers, increased acid load is caused by?
Increased acid load caused from H. pylori
What does H.pylori do in Duodenal ulcers?
H. Pylori activates immune cells (T&B lymphocytes), cytokines, neutrophils –> damages mucosa
How do Duodenal ulcers heal?
Heal spontaneously but reoccur
Types of Peptic Ulcers: Gastric ulcers (stomach ulcers)
What are they?
A lesion in mucosal wall of stomach breaks down mucosal barrier
Permits H+ ions –> mucosa –> Disrupts cell structure
Where else can gastric ulcers be seen?
Less freq, more deadly, chronic, can be seen in chronic gastritis
What are gastric ulcers seen in chronic gastritis more likely to result in?
more likely to result in obstruction, & increase cancer risk
What does histamines do in gastric ulcers?
Histamine released from the damaged mucosa –> vasodilation and increased capillary permeability –> further secretion of acid and pepsin.
What can gastric ulcers do to the stomach wall?
Can perforate stomach wall gastric contents enter abdominal cavity
What makes pain worse in gastric ulcers?
Pain worse when eating –> anorexia
What are stress ulcers?
Major physiological stressor
severe illness or major trauma
What can cause stress ulcers?
Due to local tissue ischemia (HF, sepsis, burns, shock, anoxia, sympathetic responses)
Complications of all peptic ulcers include?
Complications – GI hemorrhage (hematemesis or melena), obstruction, perforation (destruction of multiple layers), peritonitis, gastric ca
Defense factors of the stomach against H.pylori?
Mucus
Bicarbonate
Blood flow
Prostaglandins
What is bicarbonate secreted from?
Secreted by epithelial cells of stomach and duodenum
What is bicarbonate produced by?
Produced by pancreas, secreted into lumen of duodenum
What does bicarbonate do?
Neutralizes acids
What happens to blood flow is poor in the stomach?
Poor blood flow –> ischemia, cell injury, and vulnerability to attack by acid/pepsin
What do prostaglandins stimulate? What does it promote?
Stimulate the secretion of mucus and bicarbonate, promote vasodilation, maintains submucosal blood flow, suppress gastric acid
Patho of PUD: What are aggressive factors leading to PUD?
H Pylori
NSAIDs
Gastric Acid
Pepsin
Smoking
What do NSAIDs inhibit?
Inhibit PGs
Because NSAIDs inhibit prostaglandins, what does this lead to (having to do with PUD)?
Decrease submucosal blood flow
Suppress mucus/bicarb
Promote gastric acid
Irritant
What does gastric acid do in PUD?
Injures cells of GI mucosa, activates pepsin
What does pepsin do in PUD?
Proteolytic enzyme in gastric juice
Injures gastric mucosa
What does smoking do in PUD?
Delays healing, vasoconstriction
Why does Heartburn & acid regurgitation
occur in GERD?
Chyme periodically backs up from the stomach into the esophagus.
Reflux of bile salts, acid and pepsin from the stomach to the esophagus compromises its defenses causing esophagitis, inflammation, ulceration, precancerous lesions (Barrett esophagus)
Gastroesophageal reflux disease (GERD)- what is it?
Heartburn & acid regurgitation
What would cause GERD?
Abnormalities in LES function, esophageal & delayed gastric motility
What does GERD eventually lead to?
Eventually, fibrosis and strictures develop in the esophagus.
What occurs in GERD that would lead to dysphagia and weightloss?
Edema, strictures, esophageal spasms, decreased esophageal motility –> dysphagia/wgt loss
What has little to no role in GERD?
H. pylori has little to no role
Common predisposing factors to GERD?
Hiatal hernia
Delayed gastric emptying
Vomiting
Coughing
Lifting, bending
Constipation
Foods
Look at slide 36
gastroparesis
What can foods cause that lead to GERD?
Foods like what?
chocolate, peppermint, fatty foods, coffee, and tea decrease lower esophageal sphincter (LES) pressure, predisposing to reflux
What do acidic foods do to cause GERD? Like what?
Acidic foods, such as tomato-based products, orange juice, cola, and red wine, may irritate the esophagus.
What are common causes of GERD?
There is no single cause for GERD.
Incompetent LES:
lower esophageal sphincter (LES)
What does lower esophageal sphincter (LES) do to cause GERD?
An incompetent LES lets gastric contents reflux from the stomach to the esophagus when the patient is supine (lying down on back).
What are clinical manifestations of GERD?
Heartburn/Pain/Dyspepsia
Regurgitation
What is included in heartburn/pain/dyspepsia?
Burning or tight sensation in the chest –> jaw
When does Heartburn/Pain/Dyspepsia
associate with GERD occur?
Usually occurs 60 minutes after eating
Worse at night, rousing from sleep
Sx worse with increased intra-abd pressure
Pain or discomfort centered in the upper abdomen.
Regurgitation in GERD
Hot, bitter, or sour liquid coming into the throat or mouth. This sour taste in the mouth occurs after meals.
What are treatments for GERD?
Tx: PPIs, H2RAs, antacids, prokinetics
Non-Pharm Management for GERD
Smoking cessation
Weight loss
Elevating head of bed
Meal patterns & timing
Avoidance of trigger foods/beverages
Non-Pharm Management for GERD
Increased fluid intake with food consumption alone not adequate
Increase consumption of protein-rich diet
Clothing ~ loose
Proper administration of irritating medications ~ remain upright & plenty H2O
Symptom diary
How should meals be with GERD?
Avoid 2-3h of bedtime/sleep
Smaller meals
What foods/beverages should be avoided with GERD?
Alcohol
Caffeine, chocolate, peppermint
Dietary fat intake
Citrus, oranges, tomatoes, onions & spicy foods, carbonated beverages
Classes of Antiulcer Drugs
Antibiotics
Proton Pump Inhibitors
Histamine2 Receptor Antagonists/Blockers
Gastric Lumen Adherent Cytoprotectives
Antisecretory agents that enhance mucosal defenses
Antacids
Proton Pump Inhibitors PPIs (What do they end in). What are the prototypes?
“zole”
Prototype: Omeprazole (Prilosec), Pantoprazole (Protonix)
What are the most effective drugs for suppression of gastric acid? What do they do?
PPIs
Most effective drugs for suppression of gastric acid, reduce gastric acid by 90%
Fast acting
What is the mode of action of Proton Pump Inhibitors? Where do they work?
Works in parietal cells of stomach
What is the mode of action of Proton Pump Inhibitors? What do they inhibit?
Irreversible inhibition of H+,K+-ATPase (proton pump)
H+,K+-ATPase (proton pump) - what does it do?
This is the enzyme that produces gastric acid
How are Proton Pump Inhibitors PPIs metabolized and excreted?
Hepatic metabolism, renal excretion
How long is the half life, how long do effects persist of Proton Pump Inhibitors PPIs ?
½ life 1 hr but effects persist long after drug leaves body
What do PPIs have to protect against the stomach coating?
Protective EC coated to protect from stomach acid
How is Pantoprazole administered?
Pantoprazole – PO, IV push, IV drip for GIB
How are Proton Pump Inhibitors PPIs used?
Short-term tx of PUD, erosive esophagitis, GERD
How long should Proton Pump Inhibitors PPIs be used?
Limit tx to 4-8wks
Proton Pump Inhibitors PPIs work more effectively and faster than what?
More effective & faster than H2RAs
What do Proton Pump Inhibitors PPIs prevent?
Prevent stress ulcers
Minor adverse effects of Proton Pump Inhibitors PPIs?
Minor: GI ~ n/v/d, CNS ~ headaches, dizziness
Major adverse effects of Proton Pump Inhibitors PPIs?
Major: Pneumonia, osteoporosis, acid rebound upon d/c, HypoMg/Ca by reducing intestinal absorption (↑risk w/diuretics), C.diff
What should you teach patients to report immediately with Proton Pump Inhibitors PPIs use?
Teach pts to report diarrhea immediately
Nursing Implications of PPIs: How should patient take PPI capsules/tablets?
Capsules & tablets should be swallowed intact, not crushed, split or chewed
Nursing Implications of PPIs: When should PPIs be taken?
Depending on PPI may be taken at least an hour to right before meals or just before eating.
Some PPIs taken w/o regard to food
Nursing Implications of PPIs: How are the risks v benefits of PPI use?
Risks > Benefits LT use
Nursing Implications of PPIs: What should you warn patients about with PPI use?
Inform pts about s/sx of resp infection
Nursing Implications of PPIs: What should you encourage patients to maintain while taking PPIs?
Encourage pts to maintain adequate Ca & Vit D intake
Nursing Implications of PPIs: How should patients avoid acid rebound?
Advise pts that acid rebound can be minimized by using lowest dose for shortest time.
Nursing Implications of PPIs: How should patients manage symptoms?
Sx may need to be managed w/H2RA & antacids
Nursing Implications of PPIs: What should you warn patients about?
Inform pts about risk of hypoMg (tremors, muscle cramps, seizures, dysrhythmias)
Nursing Implications of PPIs: What levels may be increased with PPI use?
Serum levels of Digoxin may be slightly increased
Histamine2 Receptor Antagonists (H2RAs): What is the prototypes?
Prototype: Cimetidine (Tagamet), Famotidine (Pepcid), Ranitidine (Zantac)
Histamine2 Receptor Antagonists (H2RAs) MOA: How do histamines act?
Histamine acts through two types of receptors named H1 and H2
Histamine2 Receptor Antagonists (H2RAs) MOA: When histamine stimulates H2 receptors, what happens?
H2 receptors on parietal cells stimulated by histamine –> promote gastric secretion
Histamine2 Receptor Antagonists (H2RAs) MOA: When H2RAs block H2 receptors, what happens?
H2RAs block H2 receptors —> decreased gastric acid secretion & H+ ion concentration
Histamine2 Receptor Antagonists (H2RAs): Is it selective or nonselective?
Selective blockade of H2 receptors
What is the pk of Histamine2 Receptor Antagonists (H2RAs)?
PKs: varies by prototype
How should Histamine2 Receptor Antagonists (H2RAs) be taken? Administration, dose, freq, route?
Administration, dose, frequency, route varies by prototype
May be taken without regard to meals
What is Histamine2 Receptor Antagonists (H2RAs) used for?
Gastric & duodenal ulcers treatment, healing, prophylaxis
GERD
What does ADR of Histamine2 Receptor Antagonists (H2RAs) depend on?
ADRs (depend on prototype)
ADRs of Histamine2 Receptor Antagonists (H2RAs) depend on prototype and include?
Pneumonia (elevation of gastric pH)
Stomach candida
Drug interactions of Histamine2 Receptor Antagonists (H2RAs)
Vary per prototype
Nursing Implications of H2RAs: How should they be taken?
Most H2RAs may be taken without regard to meals
Nursing Implications of H2RAs: When is it best to take H2RAs?
Dosing is @QHS for better suppression of nocturnal acid secretion or BID
QHS= once per day at bed time.
BID= twice per day
Nursing Implications of H2RAs: What should you educate patients about?
Educate pts about s/x GIB
Black tarry stools, coffee-ground emesis Tx should increase gastric pH > 5 & pain relieved
Nursing Implications of H2RAs: What should you warn patients about?
Inform pts about s/sx of resp tract infection
Nursing Implications of H2RAs: How should you take antacids?
Separate from antacids by at least 1 hr
Absorption may be decreased
Sucralfate [Carafate]- What does it do?
important
Creates a protective barrier against acid/pepsin for up to 6 hours
Sucralfate [Carafate]. Creates a protective barrier against acid/pepsin for up to 6 hours- How?
Forms a viscid sticky gel & adheres to ulcer crater
Sucralfate [Carafate].- What does it NOT do?
Does not decrease acid secretion/no acid neutralizing capability
Sucralfate [Carafate].-Therapeutic uses?
Acute ulcers and maintenance therapy
PKs of Sucralfate [Carafate].-absorption and excretion?
Adm orally, minimal systemic absorption
90% of each dose eliminated in feces
Sucralfate [Carafate]- adverse effects?
Constipation (only 2% of patients)
Sucralfate [Carafate]- how can it be taken?
Tx 4-8 wks
Can be halved, broken, or dissolved in 15-30mL H2O to form a slurry
Tablets do not crush well, but you may try splitting tablets.
Sucralfate [Carafate]- Drug interactions
How should antacids be administered with this med? Why?
Antacids may interfere with effects of sucralfate by raising gastric pH >4
Adm 30 min apart
Sucralfate [Carafate]- Drug interactions
may impede absorption of some drugs- what does that mean?
May impede absorption of some drugs, so adm 2h apart
Misoprostol (Cytotec): MOA- what is this med a replacement for?
MOA: Replacement for endogenous prostaglandins
Misoprostol (Cytotec): Uses of med
Uses: prevention of gastric ulcers caused by LT NSAID tx
Misoprostol (Cytotec): ADRs?
diarrhea, abdominal pain
Misoprostol (Cytotec): Contraindicated in?
Contraindicated in pregnancy
Misoprostol (Cytotec): Why is it Contraindicated in pregnancy?
PGs stimulate uterine contractions
Can cause partial/complete expulsion of developing fetus
Women if childbearing age must comply with birth control, be advised on dangers, & have neg pregnancy test within 2 weeks before beginning tx
Misoprostol (Cytotec): What must women of child bearing age have before starting med?
Women if childbearing age must comply with birth control, be advised on dangers, & have neg pregnancy test within 2 weeks before beginning tx
COmbinations of Antacids available?
(Start with aluminum hydroxide)
Aluminum hydroxide + magnesium hydroxide + simethicone (Mylanta)
Aluminum hydroxide + magnesium hydroxide (Maalox)
Combinations of Antacids available?
(Last 2 not including Aluminum hydroxide)
Calcium Carbonate (Tums)
Sodium bicarbonate (Alka-Seltzer)
What are antacids used for?
Used for hyperacidity, indigestion, reflux
Antacids are available in suspensions and tablets, how should they be taken in these forms?
Suspensions - shake well
Chew tablets thoroughly, then H2O or milk
What kind of tablets are Antacids?
Effervescent tablets
Effervescent tablets are designed to release carbon dioxide upon contact with water, promoting their disintegration.
How should antacids be taken?
Taken regularly, not PRN
How should dosing of antacids be? Why?
Short duration of action = frequent dosing
What kind of compounds are antacids? What does this mean they do?
Alkaline compounds that neutralize stomach acid
Reduce destruction of gut wall
What are antacids used for?
Uses: PUD, sx of GERD (no studies demonstrate efficacy)
Can provide prophylaxis against stress-induced ulcers & symptomatic relief, but they do not accelerate healing.
How do antacids effect stomach pH?
Except for sodium bicarbonate, antacids do not alter systemic pH
What has antacid use been replaced by?
H2RAs & PPIs
Who should use antacids cautiously?
Use with caution in patients with renal impairment
Adverse effects of antacids?
Constipation: Aluminum hydroxide
Diarrhea: Magnesium hydroxide
Combinations can minimize bowel effects (Maalox)
Sodium loading
-Caution with HF
What are adverse effects of antacids with Aluminum hydroxide
Constipation
What are adverse effects of antacids with Mg hydroxide
Diarrhea
Drug interactions (due to increased pH)
in antacids would occur why?
(due to increased pH)
Drug interactions (due to increased pH)
Antacids:
Elevation of urinary ph can excrete acidic drugs & delay excretion of basic drugs
The ADRs of antacids for drugs interactions means what?
Allow at least 1 between antacids and other meds (eg ASA)
Antacids: Magnesium Hydroxide [Milk of Magnesia]- what is the most prominent adverse effect?
Most prominent adverse effect is diarrhea
What is Magnesium Hydroxide usually taken with?
aluminum hydroxide
Who should Magnesium Hydroxide [Milk of Magnesia] be avoided in?
Who should it be used cautiously in?
Avoided in patients with undiagnosed abdominal pain
Stimulation of bowel could be dangerous
Use with caution in patients with renal failure- Mg can accumulate to toxic levels (eg CNS depression)
Aluminum Hydroxide- what does it do?
Binds to pepsin, which may facilitate healing
Antacids: What does Aluminum Hydroxide bind with?
Binds with phosphate
When Aluminum Hydroxide binds with phosphate, what does it cause?
Reduce absorption & cause hypophosphatemia
What does Aluminum Hydroxide drug interactions include? What would binding effects be?
Tetracyclines, warfarin, digoxin
Binding may reduce their effects
Calcium Carbonate (Tums)- What do they act as? How long is their duration of action
Also acts as calcium-based phosphate binder
Long duration of action
Principle adverse effects of calcium carbonate (Tums)
Principal adverse effect: Constipation, which can be overcome by combining calcium carbonate with a magnesium-containing antacid (eg, magnesium hydroxide)
Rare side effect of calcium carbonate?
Milk-alkali syndrome
Milk-alkali syndrome
Condition characterized by hyperCa++, met alk, soft tissue calcification, impaired renal function
Taking too many calcium supplements or chronic ingestion
Who should calcium carbonate be used cautiously in?
Caution with renal patients (e.g calcium & phosphate levels)