Module 2 Part 1- Nausea, Vomiting, and Diarrhea Flashcards
when is it considered to be ‘diarrhea’
- increased frequency of BM (more than 3 per day)
- increased amount of stool (more than 200g/day)
- altered consistency (increased liquidity)
what is diarrhea associated with
urgency, perianal discomfort, incontinence or combination of these
what can produce diarrhea
any condition that causes increased intestinal secretions, decreased mucosal absorption or altered motility
list some common underlying diseases that cause diarrhea
IBS, IBD, and lactose intolerance
T or F: diarrhea is chronic
FALSE. It can be acute OR chronic
how long does acute diarrhea last for
7-14 days
how long does chronic diarrhea last for
longer than 2-3 weeks and may return sporadically
what can be the potential cause of chronic diarrhea
certain medications, certain tube-feeding formulas, metabolic and endocrine disorders, and viral/bacterial infectious processes
what are other disease processes that are associated
include nutritional and malabsorptive disorders (eg. Celiac disease), anal sphincter defect, Zollinger-Ellison syndrome, paralytic ileus, intestinal obstruction, and AIDS
what are the 5 types of diarrhea
- secretory
- osmotic
- malabsorptive
- infectious
- exudative
describe secretory diarrhea
usually high volume, often associated with bacterial toxins and neoplasms and caused by increased production and secretion of water/electrolytes by the intestinal mucosa into the intestinal lumen
describe osmotic diarrhea
occurs when water is pulled into the intestines by the osmotic pressure of unabsorbed particles, slowing the reabsorption of water. Can be caused by lactase deficiency, pancreatic dysfunction or intestinal hemorrhage
describe malabsorptive diarrhea
combines mechanical and biochemical actions, inhibiting effective absorption of nutrients manifested by markers of malnutrition that include hypoalbuminemia. Low serum albumin levels lead to intestinal mucosa swelling and liquid stool
describe infectious diarrhea
results from infectious agents invading the intestinal mucosa. C-diff is most commonly identified agent in antibiotic-associated diarrhea in hospital
describe exudative diarrhea
caused by changes in mucosal integrity, epithelial loss, or tissue destruction by radiation or chemo
list the mnfts (theres alot)
• Abdominal cramps
• Distention
• Intestinal rumbling (borborygmus)
• Anorexia
• Thirst
• Painful spasmodic contractions of anus and ineffective straining may occur with defecation
• Other symptoms depend on cause/severity but are r/t dehydration and to fluid/electrolyte imbalances
• Watery stools are a characteristic of disorders of small bowel
• Loose, semisolid stools are associated with large bowel usually
• Voluminous, greasy stools suggest intestinal malabsorption
• Presence of blood, mucus, pus in stools suggests inflammatory enteritis or colitis
• Oil droplets on toilet water almost always mean pancreatic insufficiency
-Nocturnal diarrhea may be a mnft of diabetic neuropathy
Dx testings for diarrhea
- CBC
- serum chemistries
- urinalysis
- routine stool exam
- endoscopy or barium enema may assist in identifying the cause
what would you look for in a stool exam
infectious or parasitic organisms, bacterial toxins, blood, fat, electrolytes, and WBCs
what are complications for diarrhea
- potential for cardiac dysrhythmias (b/c of fluid loss and electrolyte loss)
- urinary output less than 30mL per house for 2-3 consecutive hours
- muscle weakness
- paresthesia
- hypotension
- anorexia
- drowsiness (with K+ less than 3.5 must be reported)
- chronic diarrhea (results in skin care issues r/t irritant dermatitis)
what are gerontologic considerations for diarrhea
- older patients become dehydrated quickly and develop low potassium levels
- nurse observes for muscle weakness, dysrhyth., decreased peristaltic motility
- older patient taking digitalis (digoxin) must be aware of how quickly dehydration and hypokalemia can occur
Tx for diarrhea (non pharm)
- controlling symptoms
- preventing complications
- eliminating or treating the underlying disease
Tx for diarrhea (pharm)
- antibiotics
- anti-inflm
- anti-diarrheals (loperamide, diphenoxylate)
is loperamide or diphenoxylate preferred?
loperamide is the medication of choice because it has fewer side effects than diphenoxylate
what is the nursing management for diarrhea
- assessing and monitoring characteristics and patterns of diarrhea
- obtain stool samples for testing
- encourage bed rest, liquids and foods low in bulk until acute attack subsides
- recommend bland diet of solid and semisolid foods
- avoid caffeine and carbonated drinks, and very hot/cold
- administer anti-diarrheals
- monitor serum electrolytes closely
what are the major functions of the GI system
break down and digest foods so that the nutrients may be absorbed through the digestive tract and waste products may be eliminated
what happens with the GI system during fetal development
GI system begins to form during the fourth week of the embryonic stage, starting with the mouth and anal tube
define growth failure
weight consistently below the third percentile,BMI below the fifth percentile, or a decrease from established growth pattern
define spitting up or regurgitation
passive transfer of gastric contents into the esophagus or mouth
define encopresis
involuntary overflow of incontinent stool causing soiling or incontinence secondary to fecal retention or impaction
describe adsorbents: Bismuth, subsalicylate, activated charcoal
- bind to toxins that cause diarrhea
- does not stop dehydration
- for more mild cases
- may blacken stools/tongue
describe bulk forming agents (methyl cellulose)
- causes stools to be less watery
- does not effect volume of stool
describe anticholinergics (atropine)
- can relieve cramping
- does not change the consistency or volume of stool
- undesirable side effects
describe opioids (diphenoxylate)
- last resort
- decrease motility and pain
- increase in time in stool is in the bowel=increased absorptive nutrients, H2O, electrolytes
what is the MOA, use, side effects of a serotonin antagonist (5-HT3 receptor)? and give an example
• Mechanism: block serotonin receptor in the GI, CTZ, and VC
• Use: N/V from chemotherapy or radiation, PONV
• Side effects: headache, diarrhea, rash, prolonged QT interval
Example: ondansetron
what is the MOA, use, side effects of a benzodiazepine with example
• Mechanism: depress CNS
• Use: as adjunct. Can be used to help manage N/V from triggers related with the cerebral cortex
• Side effects: sedation, amnesia
Example: lorazepam
what is the MOA, use, side effects of a dopamine antagonist (D2 receptor) with example
• Mechanism: block dopamine in the CTZ and may also block Ach. Calms CNS
• Use: N/V from chemo, radiation, psychotic disorders, intractable hiccups
• Side effects: orthostatic hypotension, extrapyramidal symptoms, tardive dyskinesia, headache, dry eyes/mouth, constipation, urinary retention, akathisia (restlessness)
Example: prochlorperazine
what is diphenoxylate? and what is atrophine?
- diphen: an opioid and helps to slow peristalsis
- atro: anticholinergic and slows peristalsis and reduces gastric secretions
what is the MOST COMMON drug for motion sickness
scopolamine (anticholinergics)
what is the MOA, use, side effects of anticholinergics with example
• Mechanism: block acetylcholine (Ach) receptors in the vestibular nuclei and in the reticular formation
• Use: motion sickness and PONV
• Side effects: sedation, dry mouth, constipation, difficult urination, blurred vision
Example: scopolamine
what is the MOA, use, side effects of antihistamines (H1 Receptor Antagonist) with example
• Mechanism: blocks H1 receptors, preventing Ach from binding to receptor in the vestibular nuclei (labyrinth)
• Use: motion sickness, non productive cough, sedation, rhinitis, allergies
• Side effects: sedation, dry mouth, urinary retention, blurred vision
Example: dimenhydrinate (Gravol), diphenhydramine
what is the MOA, use, side effects of prokinetics with example
• Mechanism: stimulates peristalsis. Blocks dopamine receptors in the CTZ, desensitizing it to impulses from the GI tract
• Use: delayed gastric emptying, GERD, N/V from chemotherapy, PONNV
• Side effects: hypotension, sedation, headache, dystonia, dry mouth, diarrhea
Example: metoclopramide
what is the MOA, use, side effects of THC with example
• Mechanism: inhibitory effects on the reticular formation, thalamus and cerebral cortex
• Use: N/V from chemotherapy, stimulates appetite in patients with AIDS, cancer
• Side effects: drowsiness, dizziness, anxiety, confusion, euphoria, visual disturbances, dry mouth
Example: marijuana
how are corticosteroids used
- Usually not given alone but with one or more other category of antiemetic
- Used as adjunct for nausea caused by chemotherapy
what is the term related to nausea and vomiting in pregnancy
Hyperemesis Gravidarum (HG)
describe HG
• Severe, debilitating N/V
• Greater than 5% weight loss in early pregnancy
• Usually during first trimester only
• HG effects women in many aspects of their lives
-Unknown cause, a theory is it is d/t high HCG levels
symptoms of HG
• Dehydration • Malnutrition • Metabolic disorders • Stress and extreme fatigue • Fetal growth restriction DVT
list holisitc interventions for HG
• May need to be hospitalized
• Therapeutic communication and active listening
• Reduce odours, noises, fresh air, encourage woman to move slowly
• Important to avoid isolation/depression
-Monitor weight and electrolytes, nutritional status
Tx for HG
- IV rehydration: Electrolytes especially Na, K; B1 (thiamine), B6 (pyridazine) added. May require enteral feeding, TPN in severe cases
- Medication: Antiemetics, Folic acid, thiamine, LMWH
whats the Et of HG
- No conclusive pathogenesis
- Maternal genetics
- Placental factors (hCG, estrogen, progesterone etc)
- increased placental mass and elevated hCG levels
- hCG (stimulates upper GI secretory processes)
- estrogen (delayed gastric emptying)
Dx of HG
typical presentation and exclusion of other causes of N+V
S+S of HG
- Persistent N&V
- Dehydration
- Ketonuria
- Weight loss of 5% or more of body weight
- Negatives psychosocial effects
- Decreased QOL
- Increased cost: lifestyle modifications, prescribed therapies, complementary and alternative therapies
complications of HG
- Hyponatremia
- Central pontine myelinolysis
- Vitamin B6
- Vitamin B12 deficiency
- Mallory weiss tears
- Venous thromboemolism
- Retinal detachment
- Esophageal rupture
- Pneumomediastinum
- Splenic avulsion
risk factors for HG
- Gestational trophoblastic disease
- Female fetal sex
- Multifetal pregnancy
- Conceived with assisted reproductive technologies
- Hx of HG
- Gestational trophoblastic disease
- Helicobacter pylori
- Maternal family hx
- Allergies and restrictive diets = longer duration of symptoms
- Maternal age of >30yrs and smoking = decreased risk
list associated co-morbidities with HG
- Psychiatric illness
- Migraines
- Asthma
- Pre-existing diabetes
- Hyperthyroid disorders
- Gastrointestinal disorder
what are the maternal outcomes for HG
- May protect the mother and fetus from food-borne pathogens
- Decreased risk of miscarriage
- Psychological morbidity
- Postpartum period, posttraumatic stress and breast-feeding self-care
- Fears of pregnancy
offspring outcomes for HG
• Low birth rate • Born preterm • Small for gestational age • Anomalies: (Undescended testicles, Hip dysplasa, Trisomy 21, CNS, Skeletal anomalies)
what is the explanation for a 6 month old baby who isn’t crying?
wont hear crying because infant is too dehydrated and fatigued
what is normal number of stools for an infant
approx. 10-15 soft/pasty small amounts of stool per day
what are the most common causes of acute diarrhea
- Drugs
- Infection- bacteria, virus, protozoa
- Nutritional factors
Why would you avoid giving antidiarrheals if the suspected cause is infection?
Your normal body mechanisms would try to flush out bacteria on own and can cause infectious diarrhea if you treat it with antidiarrheals
what do you have to watch for with someone taking anti-diarrheals and why??
all anti-diarrheals don’t prevent dehydration so you need to watch for this with labs***
what type of assessment would you take for someone experiencing diarrhea
• Think OPQRSTUV but for diarrhea
• Thorough history of normal bowel habits
• Amount, consistency and “quality” of stool
• Ins/outs and weights
• Signs of dehydration
○ VS
○ Physical exam
○ Lab work (electrolytes (Na, K), hematocrit, WBC’s, CBC’s with differentials
• For pediatrics the most accurate way to determine how much fluid is lost, you weigh them**
-Ask if they’ve changed their diet
list nursing diagnoses for someone with diarrhea
• Risk of: ○ Deficit fluid volume ○ Imbalanced nutrition ○ Acute pain ○ Activity intolerance ○ Ineffective coping ○ Impaired skin integrity Electrolyte imbalance
what are the top three interventions for a child with diarrhea?
- rehydration*** golden rule
- treat cause
- treat electrolyte imbalance
what are given to rehydrate a child?
ORS (oral rehydration solutions) or IV fluids
what is a side effect you’d expect to see with Diphenoxylate and Atropine and what is this significance
○ Constipation, respiration depression, if pt has delirium, check LOC*. Is it the drug causing more delirium or the diarrhea etc
what is the significance of children with immature kidneys
children under age of 2 cannot retain water as well as adults
do children or adults have a greater body surface area? what does this mean
CHILDREN DO. they have greater insensible losses (more likely for diarrhea)
what can dehydration in children lead to?
kidney failure, cardiac collapse, death
what are early assessment findings for children
• Dry mouth
•
what are late assessment findings for children
• Sunken fontanelles in babies • Loss of tears when crying • Sunken eyes • Rapid, deep respirations (acidosis) • Cold extremities • Rapid weak pulse • Cyanosis • Loss of skin turgor -Coma
what is nursing care for child with diarrhea
• IV fluids are based on weight
• Advance diet slowly (yes popsicles count)
• Daily weights
• Strict intake and output (weight diapers)
• Pre and post feed weights
• Bloodwork done as little as possible
-Nurses must make sure the mother is well hydrated if the baby is breast fed
is nausea subjective or objective
subjective
-Subjective sensations of feeling like you’re going to puke
what is vomiting
its the defence mechanism to get rid of toxic mechanisms in body
what is nausea the result from
result from stimulation of the vomiting centre (VC) in the medulla
complications of N+V
• Aspiration pneumonia (unconscious, stroke, seizures, MS/ALS, dysphagia patients)
• Dehydration
• Malnutrition (of electrolytes and PO intake is limited/no PO d/t N+V)
• Disruption of the surgical site (dehiscence, or evisceration if really bad N+V)
• Metabolic disturbances
• Increased intracranial pressure
-Stress/anxiety
what are the 4 pathways to the vomiting centre (VC)
- Chemoreceptor trigger zone (CTZ)
- GI tract
- Labyrinth (inner ear)
- Cerebral cortex
describe the first pathway chemoreceptor trigger zone (CTZ) and what are the neurotransmitters
• Outside the BBB (blocking all toxins before it reaches CNS so they can’t enter)
• CTZ located under the medulla oblongata and activated when there are any toxic substances/hormones that can harm the region
• Site of ‘systemic’ triggers of vomiting
• Triggers: drugs, hormones, toxins, metabolic abnormalities
Neurotransmitters: dopamine, serotonin
describe the second pathway GI tract and what are the neurotransmitters
• Some triggers of N+V
○ Distention (overeating, indigestion, chronic small bowel obstruction)
○ Obstruction
○ Infection
Neurotransmitters: serotonin, dopamine, PG’s
describe the third pathway vestibular and labyrinth (inner ear) and what are the neurotransmitters
• Stimulated by:
○ Motion sickness (d/t labyrinth stimulation that activates CTZ and then experience N+V), vertigo
○ Opioids exert some influence on this route
• Fluid in inner ear causes dizziness in elevators
Neurotransmitters: histamines, acetylcholine
describe the fourth pathway cerebral cortex
• Psychological component of nausea
• Triggers:
○ Emotions
○ Smells
○ Anticipatory nausea
○ Taste
-Gag reflexwhat is the implementation for vomiting (pharmaceutical modalities)
• Match the trigger or cause with the right drug or therapy
• Many types of antiemetics (gravol, ondansetron)
• Know your nursing considerations with each medication
-Often given IM, IV, or rectal suppository route as PO may be ineffective
what is the implementation for vomiting (holistic and alternative modalities)
• Gentle diet (BRAT-Bananas Rice Applesauce Toast)
• Ginger, peppermint
• Relaxation, music, distraction
• Cool cloths
• Positioning (side lying if they prefer to lay down**)
• TENS (transcutaneous electrical nerve stimulation-they use low voltage for pain relief), acupressure, acupuncture
-Aromatherapy
what is the MOA, use and SE of ondansetron
MOA: Serotonin antagonist-block serotonin in the GI, CTZ and in VC
use: Nausea from chemo, radiation, PONV *HG (after other preferred meds)
SE: Headache, diarrhea/constipation, prolonged QT interval
what is the MOA, use and SE of dimenhydrinate
MOA: Antihistamine-blocks receptors, preventing ACh from binding to receptor in the vestibular nuclei
use: Motion sickness, vertigo
SE: Sedation, dry mouth, urinary retention, blurred vision
what is the best route to give dimenhydrinate
IM, subQ
what is the MOA, use and SE of scopolamine
MOA: Anticholinergic-potent effects on vestibular nuclei
use: Motion sickness, PONV
SE: Sedation, dry mouth, constipation, difficult urination, blurred vision
what is the MOA, use and SE of prochlorperazine
MOA: Antidopaminergic-block dopamine in CTZ and may also block Ach
use: Can be used for many types of nausea, chemo, radiation, PONV
SE: Orthostatic hypotension, extrapyramidal symptoms, tardive dyskinesia, headache, dry eyes/mouth, constipation, urinary retention
