Pharmacology, Intravenous Therapy & Nutrition

Question 1

What are antacids

Answer 1

Antacids commonly prescribed have at least one of the following elements as their main ingredient:
1. Aluminum salts
2. Calcium carbonate
3. Magnesium salts

The ingredient alginate is not an antacid but may provide barrier protections

Are available OTC

Question 2

What is the mechanism of action of antacids

Answer 2

1. Antacids have no direct effect on gastric acid secretin and do not coat or protect the mucous lining.
2. Instead, antacids neutralize gastric acid, reducing the total acid load in the GI tract and leading to a transient rise of gastric pH.
3. This decreases pepsin activity because pepsin is rendered inactive in alkaline conditions.
4. It also increases LES tone, reducing reflux
5. Aluminum ions inhibit smooth muscle contraction and gastric emptying. This action is counterproductive because in gastroesophageal reflux disease (GERD), prompt gastric emptying is beneficial

Question 3

What are the indications for antacids

Answer 3

Antacids are indicated in the treatment of:
1. Hyperacidity—heartburn (pyrosis)
2. Gastroesophageal reflux disease (GERD)
3. Acid indigestion
4. Hyperacidity associated with peptic ulcer disease
- Research studies demonstrate that antacids are clearly superior to placebos in healing gastric ulcers

Because antacids leave the stomach rapidly, they are best used for intermittent symptoms.
Taken on an empty stomach, the effects of antacids last less than 1 hour.
After meals, the buffering effect may last as long as 3 hours
For optimal effect, antacids should be given about 1 hour after meals or feedings and during periods of acid rebound

Question 4

What are adverse effects of antacids

Answer 4

1. Prolonged use of magnesium or calcium containing antacids may cause systemic absorption of toxic quantities of these ions.
2. Excessive use of aluminum containing antacids my lead to hypophosphatemia
3. Aluminum and calcium preparations tend to be constipating, whereas magnesium preparations tend to produce a laxative effect
4. In chronic patients with renal failure, administration of aluminum-containing antacids is best at mealtime
5. Antacids containing sodium can precipitate edema in patients with cirrhosis, hypertension, or renal or congestive heart failure

Question 5

What are contraindications of use of antacids

Answer 5

1. In patients taking tetracycline, iron, or H2-receptor antagonists
   —Calcium binds and prevents absorption of tetracycline, whereas antacids decrease the absorption of iron and H2blockers
2. Magnesium containing antacids can precipitate hypermagnesemia in patients with chronic renal failure and should be avoided in these patients, as central nervous system depression, skin irritation, and rarely, muscle paralysis with respiratory failure can occur

Question 6

What are examples of antacids

Answer 6

1. Aluminum hydroxide gel
2. Calcium carbonate (Alkaline-Seltzer, Tums)
3. Magnesium hydroxide (Milk of Magnesia)
4. Gaviscon, Gelusil, Maalox, Mylanta, Rolaids
5. Pepto-Bismol

Question 7

What are antibiotics

Answer 7

1. May be prescribed for pediatric and adult patients
2. The nurse needs to have a basic knowledge of mechanism of action, antimicrobial spectrum, typical uses, and toxicity of commonly used antibiotics
3. Cost and dosing schedules must be considered in the decision-making process when prescribing, in order to enhance patient compliance
4. Knowledge of patient drug allergies, recommended dosages, and bacterial taxonomy is of critical importance for GI nurses in order to provide safe medical care and promote patient and family education

Question 8

What is the mechanism of action for antibiotics

Answer 8

1. Antibiotics are antimicrobial agents
2. The specific antibiotic drug selection depends on the pathogen, drug adverse-effect profile, patient drug allergies, age of the patient, and any comorbid illness

Question 9

What are the indications for antibiotics

Answer 9

For infectious agents found in the GI tract

1. Mouth infections
2. Gastroenteritis
3. Traveler’s diarrhea
4. Severe diarrhea
5. Diverticulitis
6. Gastritis and ulcers

Question 10

What are indications of using antibiotics for prophylaxis

Answer 10

1. Prosthetic cardiac valves, including trans catheter implanted prostheses and homografts
2. Prosthetic material used for cardiac valve repair such as annuloplasty rings and chords
3. previous IE (infectious endocarditis)
4. Unrepaired cyanotic congenital heart disease or repaired congenital heart disease with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or prosthetic device
5. Cardiac transplant with valve regurgitation due to a structurally abnormal valve

Question 11

What are adverse effects of antibiotics

Answer 11

1. Side effects may vary depending on agent given and can include nausea, vomiting, diarrhea, rash, urticaria, headache, and anaphylaxis
2. The administering provider should be familiar with the medication, its potential side effects and their contraindications prior to drug administration

Question 12

What are contraindications of antibiotics

Answer 12

Contraindications include a known sensitivity to the antibiotic agent

Question 13

What are examples of antibiotics

Answer 13

1. Clindamycin
2. Ampicillin
3. Tetracycline
4. Ciprofloxacin
5. Levofloxacin
6. Moxifloxacin hydrochloride
7. Metronidazole
8. Azithromycin
9. Clarithromycin
10. Trimethoprim-sulfamethoxazole (TMP-SMX)
11. Vancomycin

Question 14

What are Anticholinergic

Answer 14

Substances that block the action of the neurotransmitter called acetycholine at synapses in the central and peripheral nervous system

Question 15

What is the mechanism of action for Anticholinergic drugs

Answer 15

1. Inhibit gastric acid secretions at its source by blocking the acetylcholine receptor on gastric parietal cells
2. Decrease the output of pepsin and block vagal stimulation of the smooth muscle, thus decreasing GI tone and motility
3. They also decrease gastric emptying tome, presumably through their inhibition of vagal and cholinergic-mediated motility

Question 16

What are indications for Anticholinergic medications

Answer 16

In treatment for:

1. Diffuse esophageal spasm
2. Peptic ulcer disease
3. IBS
4. Diverticulitis
5. Hypermotility disorders
6. Ulcerative colitis

Can be use to relived the gastric distress caused by gastric spasms, hyperperistalsis, and rapid emptying of the stomach

Because of their side effects they are primarily used as an adjunctive therapy for peptic ulcer disease in combination with antacids or H2 blockers

Best given approximately 1 hour after meals, when food-stimulated acid is at its peak
Their effects persist for 4-5hours

Question 17

What are adverse effects of Anticholinergics

Answer 17

1. Dry mouth, nose and throat
2. Hoarseness
3. Tachycardia
4. Blurred vision
5. Urinary hesitancy or retention
6. Flushing of the skin
7. Constipation

Question 18

What are contraindications of anticholinergics

Answer 18

In patients who experience bleeding or who have tachycardia, closed angle glaucoma, Achalasia, obstruction, or suspected toxic mega colon

Question 19

What are examples of Anticholinergic drugs

Answer 19

1. Atropine sulfate
2. Hyoscyamine
3. Dicyclomine hydrochloride (Bentyl)
4. Lomotil

Question 20

What are cholinergic drugs

Answer 20

Mimic the action of acetycholine and/or butrylcholine

Question 21

What is the mechanism of action for cholinergic drugs

Answer 21

1. In contrast to Anticholinergic agents, they increase GI tone and motility
2. Produce the same effects as stimulation of the parasympathetic nervous system, thereby stimulating GI secretion and motility

Question 22

What are indications for the use of cholinergic drugs

Answer 22

1. Bethanechol may be used to increase LES pressure in patients suffering from GERD
   
   • also used in children with GERD who are unresponsive to metoclopramide (reglan)
2. Domperidone is a peripheral dopamine antagonist that has a safety profile similar to reglan, used to enhance gastric emptying. - not FDA approved in the US
3. Cisapride used to relieve symptoms of reflux esophagitis by increasing contractions in the stomach to improve stomach emptying - removed from the market in late 2000

Question 23

What are adverse effects of cholinergic medications

Answer 23

Cause the same parasympathetic symptoms as anticholinergics, which may include diaphoresis and bladder contractions

Question 24

What are contraindications of cholinergic medications

Answer 24

Peptic ulcers or possible GI obstruction

Question 25

What are examples of cholinergic medications

Answer 25

Bethanechol (urecholine, duvoid)

Question 26

What are antidiarrheals

Answer 26

Agents used for symptomatic relief of diarrhea

Question 27

What is the mechanism of action for antidiarrheals

Answer 27

Include drugs that decrease intestinal motility and drugs that decrease the fluid content of the stool or inhibit intestinal secretions

Question 28

What are indications for antidiarrheals

Answer 28

Opium alkaloids may be used as antidiarrheal agents in addition to anticholinergics to inhibit intestinal motility

Bismuth subsalicylate is useful for mild diarrhea and upset stomach; may be used in combination with an antibiotic for the treatment of H.pylori

Question 29

What are adverse effects of antidiarrheals

Answer 29

Continued use of antidiarrheal agents over an extended period of time is not recommended. If it is not possible to control diarrhea promptly, diagnostic tests should be ordered.

Because opium alkaloid drugs may be habit-forming patients must be cautioned not to exceed the recommended dosage

Question 30

What are contraindications of antidiarrheals

Answer 30

1. Fever, or bloody diarrhea or in patients younger than 2
2. Agents that inhibit intestinal motility may cause toxic mega colon in patients suffering from pseudomemranous enterocolitis, acute dysentery, and acute ulcerative colitis
3. Should be used in acute exacerbation of IBD only after an infectious cause for the symptoms has been ruled out
4. Opium alkaloids are contraindicated in patients with toxic causes of diarrhea and should be used cautiously by patients with asthma, liver disease, prostatic hypertrophy and narcotic dependence

Question 31

What are examples of antidiarrheals

Answer 31

1. Lomotil
2. Pepto-bismol
3. Imodium
4. Acidophilus

Question 32

What are antiemetics

Answer 32

Produce symptomatic relief of nausea and vomiting

Question 33

What is the mechanism of action for antiemetics

Answer 33

1. Phenothiazines - appear to exert their effects on the cells of the chemoreceptor trigger zone (CTZ) located in the medulla of the brain stem, preventing vomiting center from being activated
2. Certain antihistamines - act on the CTZ to suppress centrally mediated nausea and vomiting
3. Trimethobenzamide hydrochloride - has a mechanism of action that is unknown, but it may act on the CTZ
4. Ondansetron is a selective 5-HT3 antagonist antiemetic, a subtype of serotonin receptor capable of controlling nausea and vomiting by acting on receptors within the vagus nerve and CTZ, without the sedation that accompanies phenothiazines
5. Reglan may also be considered an antiemetic drug as a result of its antagonism of central and peripheral dopamine receptors

Question 34

What are indications for antiemetics

Answer 34

1. Phenothiazines—effective in relieving vomiting associated with gastroenteritis, radiation sickness, and drug therapy, but they do not relieve motion sickness
2. Antihistamine—suppresses nausea and vomiting associated with motion sickness, drug or radiation therapy, or following surgery
3. Trimethobenzamide hydrochloride—effective for the treatment of postoperative nausea and vomiting and nausea associated with gastroenteritis
4. Ondansetron—a preferable choice for long term use such as chemotherapy

Question 35

What are adverse effects of antiemetics

Answer 35

1. Phenothiazines—sedation, hypotension, restlessness, dry mouth, blurred vision, constipation, and muscle twitching, they should be used only when non-drug antiemetic measures or other drugs fail
2. Antihistamines—drowsiness
3. Trimethobenzamide hydrochloride—dizziness, headache, rash, Parkinson-like symptoms, muscle cramps and seizures
4. Ondansetron—headache, drowsiness, diarrhea, fatigue, dystonia, hypotension, cardiac arrhythmias, atrioventricular (AV) block, and Steven-Johnson syndrome
5. Metoclopramide has been associated with an increased risk of extrapyramidal movement disorders such as tardive dyskinesia

Question 36

What are contraindications of antiemetic drugs

Answer 36

1. Phenothiazine—asthma, benzyl alcohol hypersensitivity, phenothiazine hypersensitivity, sulfate hypersensitivity, CNS depression, leukopenia, seizure disorder, tardive dyskinesia, a history of urinary retention, and previous coronary disease, liver disease, or pulmonary disease
2. Antihistamine—renal and liver disease, a history of urinary retention, coronary disease, hypertension, seizure disorder, narrow angle glaucoma, bowel obstruction, hyperthyroidism, asthma or COPD
3. Trimethobenzamide hydrochloride—renal failure and impairment, hepatic disease, pregnancy, breastfeeding, encephalopathy, fever, Reye’s syndrome, or in geriatric or pediatric populations
4. Ondansetron—hepatitis, liver disease, phenylketonuria, GI obstruction, coronary artery disease, electrolyte imbalance, alcoholism, bradycardia, or hypertension
5. Metoclopramide—CHF, seizure disorder, tardive dyskinesia, Parkinson’s disease, GI bleeding, hypertension, pheochomocytoma, G6PD deficiency, or breast cancer (prolactin is increased by metoclopramide which may enhance tumor growth)

Question 37

What are examples of antiemetic drugs

Answer 37

1. Phenothiazines—chlorpromazine, thioridazine, fluphenazine, promazine
2. Antihistamine—diphenhydramine
3. Trimethobenzamide hydrochloride—Tigan
4. Ondansetron

Question 38

What are antiflatulent medications

Answer 38

Used to relieve painful symptoms of excess gas in the GI tract

Question 39

What is the mechanism of actin for antiflatulent medication

Answer 39

These agents act by dispersing and preventing the formation of mucus-surrounded air or gas pockets in the GI tract

Question 40

What are indications for antiflatulent medications

Answer 40

Relieve gas that may be caused by
1. Air swallowing
2. Postoperative gaseous distention
3. Peptic ulcer
4. Spastic or irritable colon
5. Diverticulosis
6. Infantile colic

Question 41

What are adverse effects of antiflatulent medications

Answer 41

1. Stool discoloration
2. Diarrhea
3. Nausea

Question 42

What are contraindications of antiflatulent medications

Answer 42

Simethicone should not be taken with oral thyroid medications, as simethicone chelates with oral thyroid medications reducing thyroid absorption in the GI tract

Patients with phenylketouria must check for the presence of aspartame in the chosen drug preparation

Question 43

What are examples of antiflatulent agents

Answer 43

Simethicone

Question 44

What are antiparasitic agents

Answer 44

Combat the effects of intestinal parasites

Question 45

What is the mechanism of action for antiparasitic agents

Answer 45

Metronidazole demonstrates antimicrobial activity with antibacterial, antiprotozoal, and anti inflammatory effects against a wide variety of bacterial and protozoan infections

Question 46

What are indications for antiparasitic medications

Answer 46

1.Metronidazole is effective in treating bacterial and protozoan infections, including Bacterioides fragils (B.fragilis) infections and C.Diff-associated colitis, and as surgical prophylaxis.
2. Indications for uses of metronidazole in Crohn’s disease include perianal disease, Crohn’s colitis and sulfasalazine intolerance or allergy
3. Metronidazole has shown no benefit in the therapy of Ulcerative Colitis
4. Nitazoxanide (Alinia) is another drug effective in the treatment of Cryptosporidiosis or giardiasis caused by cryptosporidium parvum or Giardia lamblia. It has been used effectively for rotavirus, C.Diff and the eradication of H.pylori

Question 47

What are adverse effects of antiparasitic agents

Answer 47

1. Nitazoxanide—headache, nausea, diarrhea, abdominal pain, and sinus tachycardia
2. Metronidazole—headache, nausea, Pruritus, candidia, Stevens-Johnson syndrome, seizures, elevated liver function tests (LFTs) and cardiac arrhythmias

Question 48

What are contraindications of antiparasitic agents

Answer 48

1. Metronidazole—us with caution in patients with liver and renal failure and a history of alcoholism or in patients on corticosteroid therapies. Patients with a history of CAD, arrhythmia, electrolyte imbalance, sodium restriction, and newly diagnosed primary malignancy should be monitored carefully
2. Nitazoxanide—use with caution in patients with renal and hepatic or biliary disease. Insufficient data is available regarding use in pregnancy, breastfeeding, and pediatric and geriatric populations

Question 49

What are some examples of antiparasitic agents

Answer 49

1. Metronidazole
2. Nitazoxanide

Question 50

What are antifungal agents

Answer 50

They combat the effects of fungal infections

Question 51

What are indications of antifungal agents

Answer 51

Effective against
1. Oropharynx
2. Esophageal
3. Vaginal

Fungal infections

Patients may be predisposed due to disease and drugs

Question 52

What are some examples of antifungal agents

Answer 52

1. Nystatin—available as an oral tablet or suspension and topical cream, powder, or ointment
2. Clotrimazole—available OTC as topical cream or solution, oral lozenge, or vaginal cream
3. Ketoconazole—available as an oral tablet and topical cream, foam, gel, or shampoo
4. Itraconazole—available as an oral solution or tablet
5. Amphotericin-B—available as an injectable
6. Fluconazole—available as an oral table or suspension

Question 53

What are anti-ulcer agents

Answer 53

The classes of drugs used as antiulcer agents include:
1. Antacids
2. Anticholinergics agents
3. H2 blockers
4. Sucralfate (Carafate)
5. Prostaglandins
6. Proton Pump Inhibitors (PPIs)

Question 54

What is the mechanism of action for anti-ulcer agents

Answer 54

Promote healing by reducing gastric acid secretion, buffering secreted gastric acid, and/or enhancing intrinsic mucosal defenses

1. H2 blockers—reduce the secretion of gastric acid by blocking histamine’s action on the H2 receptors in the parietal cells
2. Sucralfate (Carafate)—is a basic aluminum salt of sucrose octasulfate, which forms a viscous adhesive gel that adheres to the ulcer crater, preventing further digestive action by both acid and pepsin
3. Synthetic prostaglandins have both antisecretory and cytoprotective effects
4. Proton Pump Inhibitors (PPIs)—provide more complete control of acid than H2 blockers. PPIs are prodrugs and need to be administered 30 minutes prior to eating in order to maximally activate proton pump blockade

Question 55

What are the indications for antiulcer agents

Answer 55

1. H2 Blockers—reduce the secretion of gastric acid and may also be used to reduce gastric acidity in patients with upper GI bleeding that stems from a peptic ulcer
2. Sucralfate—has been approved for the treatment of duodenal ulcers but not for gastric ulcers
3. Prostaglandins—may be used to prevent the gastric ulcers and mucosal injury that have been associated with the use of non steroidal anti-inflammatory drugs (NSAIDs)
4. PPIs—are the most effective agents in the therapy of GERD. Use of these agents is indicated for the treatment of patients with erosive esophagitis or active duodenal ulcers. Long-term treatment may be indicated in some hypersecretory conditions such as Zollinger-Ellison syndrome, systemic mastocytosis, chronic erosive esophagitis, and Barrett’s esophagus
   - omeprazole and Lansoprazole may be used in combination with Clarithromycin and amoxicillin in patients with positive H.pylori infection

Question 56

What are adverse effects of anti-ulcer agents

Answer 56

1. H2 blockers—the most common side effects of H2 blockers are diarrhea, headaches, dizziness, fatigue, muscle pain, rash, impotence, mild gynecomastia, leukopenia, and thrombocytopenia
2. Sucralfate—the main side effect of sucralfate is constipation, which occurs in approximately 2% of patients who take this drug. Other rare side effects include dizziness, vertigo, sleepiness, dry out, skin rashes, Pruritus, back pain, diarrhea, nausea, gastric discomfort and indigestion
3. Prostaglandins—the most common side effect of prostaglandins is diarrhea, followed by abdominal pain
4. PPIs—patients taking anticoagulants, anticonvulsants, or diazepam along with a PPI will require special monitoring because of potential drug-drug interactions
   - adverse reaction to PPIs may include—abdominal pain, asthenia, constipation, diarrhea, nausea, vomiting and headaches
   -although rare—several severe adverse reactions have been attributed to long term use and include an increased risk of fractures, hypomagnesemia, thrombocytopenia, vitamin B12 deficiency (especially in patients with Ellison-Zollinger Syndrome), interstitial nephritis, enteric infections (including C.Diff) and neoplasm
   -there is some concern that prolonged use may contribute to increased cardiovascular risk and dementia

Question 57

What are contraindications for the use of anti-ulcer agents

Answer 57

1. Increases in H2 blocker drug therapy may increase or produce a confused state in women who are breastfeeding, patients with renal and hepatic disease, and the geriatric population
2. Sucralfate is contraindicated in patients with renal failure and in patients with dysphagia where aspiration is a potential risk. It should be used with caution in patients with diabetes due to the glucose content of the drug
3. Because of its abortifacients properties, Misoprostol is contraindicated in pregnant women and generally is not recommended for women of child-bearing age
4. PPIs should be used with caution in patients with known liver disease, osteoporosis, vitamin B12 deficiency and hypomagnesemia

Question 58

What are examples of anti-ulcer agents

Answer 58

1. H2 blockers—cimetidine (Tagamet HB), famotidine (Pepcid, Pepcid AC), Nizatidine (Axid AR), and ranitidine (Zantac) depending on the drug they are available OTC or at prescription doses
2. Sucralfate (Carafate)
3. Prostaglandins —Misoprostol (cytotec)
4. Proton Pump Inhibitors (PPIs)—omeprazole (Prilosec), Lansoprazole (Prevacid), Pantoprazole (Protonix), Rabeprazole (AcipHex), Esomeprazole (Nexium), and Dexlansoprazole (Dexilant). Many of these PPIs are now available OTC

Question 59

What are corticosteroids

Answer 59

Are used in gastroenterology practice primarily for their anti-inflammatory properties

Question 60

What are indications for corticosteroids

Answer 60

1. Treatment of inflammatory conditions, such as IBD, autoimmune hepatitis, collagenous sprue, severe cases of celiac disease, collagenous colitis, and radiation injury
2. Possible relief of dysphagia in patients with benign esophageal strictures of various causes following intralesional injection therapy
3. Crohn’s disease, including proctitis or distal colitis

Question 61

What are adverse effects of corticosteroids

Answer 61

1. Patients on prolonged corticosteroid therapy should be monitored for signs of Cushing’s syndrome, which is characterized by rapidly developing adipose deposition of the face, neck and trunk; kyphosis; hypertension; diabetes mellitus; amenorrhea, hypertrichosis; impotence; osteoporosis, bruising, mood alteration; insomnia; muscular wasting and weakness
2. Because of the immunosuppressive nature of corticosteroids, patients must be monitored for infection and cautioned to avoid exposure to infectious disease. The physician should be notified of such exposures (such as chicken pox). The physician should be consulted before the patient considers receiving immunizations prepared with live virus (e.g., measles, mumps, rubella, varicella, and oral polio vaccines and nasal flu vaccine)

Question 62

What are contraindications of corticosteroids

Answer 62

1. Should not be used in patient with concurrent bacterial or viral infection, communicable disease (varicella, measles, tuberculosis), myasthenia gravis, or recent acute myocardial infarction, or while on anticholinesterase agents

Question 63

What are examples of corticosteroids

Answer 63

1. Hydrocortisone
2. Prednisone
3. Synthetic analogs such as prednisolone and methylprednisolone (Medrol, Solu-Medrol injectable, Depo-Medrol injectable, and Medrol oral tabs)
4. Triamcinolone acetonide (Kenalog, Trisence injectable) and triamcinolone hexacetonide (Aristospan)

Question 64

What are immunomodulators

Answer 64

Medications used to regulate or normalize the immune system in an effort to promote disease control or remission

They are immunosuppressants that weaken the immune response, which appears to be overactive in patients with IBD

Question 65

What is the mechanism of action for immunomodulators

Answer 65

1. Have a “steroid sparing” effect, allowing the patient to eventually discontinue the use of corticosteroids

Question 66

What are the indications for use of immunomodulators

Answer 66

1. Used in IBD when the patient is unable to wean or discontinue corticosteroids without exacerbation symptoms
2. Cyclosporine has a more rapid onset of action Than Mercaptopurine or Azathioprine. Tacrolimus and cyclosporine have been effective in treating severe ulcerative colitis until either one of the slower immunomodulators begins to work or surgery is performed
3. Tacrolimus is often used in Crohn’s disease when corticosteroids proved ineffective or fistula development is present

Question 67

What are adverse effects of immunomodulators

Answer 67

1. Because of the tendency for immunomodulator medications to suppress bone marrow activity, it is vital that patients be instructed to keep all follow-up appointments with their physician and to have laboratory studies drawn when requested
2. Patients on an immunomodulator regimen should avoid exposure to communicable illness and should see a physician promptly when ill. Annual flu shots are a must for people who take these medications. Other immunizations should be discussed with the physician because immunizations prepared with live virus should be avoided. Parents who are taking immunomodulators should check with their child’s pediatrician before their child receives oral polio vaccine because the virus is shed in stool and urine for a period of time following immunization

Question 68

What are contraindications of immunomodulators

Answer 68

1. Some immunomodulator agents have a teratogenic effect
2. Women considering pregnancy should consult their physician while taking these drugs

Question 69

What are examples of immunomodulator agents

Answer 69

1. Mercaptopurine
2. (6-MP, Purinethol)
3. Azathioprine (Imuran)
4. Cyclosporine
5. Methotrexate
6. Tacrolimus (Prograf)

Question 70

What are agents used in diagnostic tests

Answer 70

A number of different pharmacological agents may be used in the diagnosis of GI disorders

Question 71

What is the mechanism of action of agents used in diagnostic tests

Answer 71

These agents are used in a variety of ways to improve data collection and visualization during the diagnostic and therapeutic exams

Question 72

What are indications for agents used in diagnostic tests

Answer 72

1. Penagastrin - stimulates gastric acid secretion
2. Secretin (chirhostim-secretin) stimulates pancreatic secretions to aid in the diagnosis of pancreatic exocrine dysfunction. It can be used to stimulate gastric secretions to aid in the diagnosis of Gastrinomas
3. Edrophonium chloride (Enron injectable), a cholinergic agent, is used for provocative testing in patients with non cardiac chest pain
4. Glucagon is used in diagnostic tests and therapeutic procedures, primarily to reduce GI motility
5. Sincalide (Kinevac), the GI hormone cholecystokinin, is given by exogenous administration and may be used in diagnostic procedures in which gallbladder contraction is desired

Question 73

What are adverse effects of agents used in diagnostic tests

Answer 73

Adverse effects vary by medication

1. Pentagastrin—often produces nausea, vomiting, increased gastric distress, and abdominal cramping
2. Secretin—nausea, vomiting, GI distress, and flushing
3. Edrophonium—watery eyes, muscle twitching, nausea, vomiting, and diarrhea
4. Glucagon—rash, urticaria, and respiratory distress
5. Sincalide—cramping, nausea, headache, shortness of breath, and flushing

Question 74

What are contraindications of agents used in diagnostic tests

Answer 74

1. Pentagastrin—concurrent medication use, especially antacids, anticholinergics, H2-receptor antagonist, or PPIs and acute bleeding peptic ulcer
2. Secretin—patients with a history of liver disease, as they may be hyper reactive to secretin. Patients with a history of IBD or vagotomy may be hyporeactive to secretin, giving a false positive to testing. Alternative diagnostic testing should be considered
3. Edrophonium—bowel or urinary obstruction, narrow angle glaucoma, and pyloric stenosis
4. Glucagon—Insulinoma and pheochromocytoma
5. Sincalide—Cholelithiasis, as this can lead to common bile duct (CBD) obstruction

Question 75

What are gallstone therapeutic agents

Answer 75

1. Ursodexycholic acid or ursodiol (Actigall, Urso 250, Urso Forte) is an agent that may dissolve cholesterol gallstones
2. Urso 250 and Urso Forte oral tabs are available in different strengths

Question 76

What is the mechanism of action for gallstone therapeutic agents

Answer 76

1. Ursodiol decreases the rate of secretion of cholesterol into bile, thus causing the bile to become desaturated with cholesterol
2. This unsaturated bile dissolves cholesterol molecules from gallstones and holds them in micellar or vesicular solution until gallbladder contraction discharges them into the duodenum
3. Therapy must be continued until the stones dissolve completely, typically in 6-24 months

Question 77

What are indications for gallstone therapeutic agents

Answer 77

1. The efficacy of medical dissolution therapy differs according to the size of the gallstone and length of therapy
2. Studies show the disappearance of stones with a diameter of less than 5mm in about 90% of cases, whereas the chance of dissolution is approximately 40-50% for larger or multiple stones
3. Ursodeoxycholic acid studies have shown clinical significance in treatment of postcholecystectomy microlithiasis, also referred to as sludge, biliary San, and biliary sediment, and reversible Cholelithiasis
4. Clinical conditions associated with the formation of microlithiasis are prolonged fasting, total Parenteral nutrition (TPN), rapid weight loss, pregnancy, and chronic illness

Question 78

What are adverse effects to gallstone therapeutic agents

Answer 78

1. Abdominal pain
2. Diarrhea
3. Headache
4. Fatigue

Question 79

What are contraindications of gallstone therapeutic agents

Answer 79

1. Ursodiol is contraindicated for patients without patent cystic ducts
2. Women who are or may be pregnant
3. Patients with radiopaque(pigment) stones
4. Cholangitis
5. Biliary obstruction
6. Biliary-gastrointestinal fistula
7. Stones that are larger than 15mm in diameter

Question 80

What are laxatives

Answer 80

Laxatives are classified into six primary categories
1. Bulk
2. Stool softener
3. Osmotic
4. Saline
5. Enema
6. Stimulant

Question 81

What is the mechanism of action for bulking agent laxatives

Answer 81

1. Hold on to water and soften stool, making it easier to pass, which is particularly important in patients with Anorectal disorders
2. These agents are also used to relieve chronic constipation
3. The best example of a bulking agent is the nonabsorbable complex carbohydrate called fiber
4. Other examples including bulking agents that contain processed husk glom psyllium (Metamucil, Konsyl); agents based on methylcellulose, a synthetic fiber (e.g. Citrucel); and a complex nonabsorbable starch-calcium polycarbophil (Fibercon)
5. The addition of natural fiber from fruits and vegetables to the diet has the same bulking effect

Question 82

What is the mechanism of action for stool softener and emollients

Answer 82

Lubricating agents prevent the stool from becoming compacted and dry by:
1. Lowering the surface tension, thus allowing the fecal mass to be penetrated by intestinal fluid
2. Acting as surfactants that soften the fecal mass by facilitating the mixture of aqueous and fatty substances
3. Inhibiting fluid and electrolyte reabsorption by the intestine
4. Increasing the secretion of water, both in the small bowel and the colon

These agents include mineral oil, docusate sodium (colace) and a combination of fiber and mineral oil in emulsion form (Kondremul)

The absorption of the fat-soluble vitamins A,D,E, and K appear to be moderately reduced with prolonged use of mineral oil, but there appears to be no significant clinical significance when used in limited quantities as directed

Question 83

What is the mechanism of action for osmotic laxatives

Answer 83

1. Osmotic laxatives are largely nonabsorbable sugars, thus making sugar a high concentration in the bowel
2. Water from the tissues moves into the bowl to equalize the osmotic pressure and increase the bulk
3. This results in increased colonic peristalsis
4. Types of osmotic laxatives include:
   - lactulose (enulose, kristalose)—most osmotic laxatives are disaccharides
   - sorbitol—a non-soluble sugar
   - sodium phosphate mono basic mono hydrate (osmo-prep)—often referred to as the pill prep. It lost favor because of documented cases of renal failure associated with its use
   -Glycerin—a naturally occurring trivalent alcohol suppository that acts via hyperosmotic action and a local irritation and lubrication
   - Polyethylene glycol (CoLyte, GoLytely, NyLytely)—an example of a polyethylene glycol 3350 (PEG-3350) and electrolytes colon lavage preparation that may be administered orally or by nasogastric tube infusion. Miralax, Plenvu, and MoviPrep also contain PEG-3350
   - Sodium sulfate, potassium sulfate, and magnesium sulfate (Suprep)—an osmotic laxative intended for cleansing the colon prior to colonoscopic exam
   - Clenpiq (sodium picosulfate, magnesium oxide, and anhydrous citric acid) oral solution—a stimulant and osmotic laxative intended for colon preparation prior to procedure

Question 84

What is the mechanism of action for saline laxatives

Answer 84

1. Increase the intraluminal pressure by attracting and retaining water in the small intestine and colon and inducing contractions
2. The most common saline laxative is magnesium salts—magnesium hydroxide (milk of magnesia) and magnesium citrate
3. Magnesium hydroxide also stimulates the release of cholecystokinin, which increases intestinal secretion and stimulates peristalsis and transit

Question 85

What is the mechanism of action of enemas

Answer 85

1. Primarily work by inducing evacuation as a response to colonic distention and by lavage
2. They soften the stool by preventing colonic reabsorption of fecal fluid resulting from creation of a barrier between the feces and the colon
3. They also have a lubricant effect that eases the passage of feces through the intestines
4. Mineral oil retention enemas also work by lubricating the rectum and colon
5. Soap sud enemas provide an irritant action that stimulates peristalsis

Question 86

What is the mechanism of action of stimulant laxatives

Answer 86

1. Work by directly signaling the muscles and nerve plexus of the intestines to contract and expel their content
2. These laxatives include:
   - a derivative of the senna leaf (Senokot)
   - alkaloid chemicals such as bisacodyl (Ducolax)
   - a combination of sodium picosulfate, magnesium oxide, and anhydrous citric acid (Prepopik), an oral stimulant laxative intended for the preparation of the colon prior to a diagnostic exam

Question 87

What are the indications for use of laxatives

Answer 87

Laxatives vary in indication. They may be used to:
1. Cleanse the bowel before Radiographic examination, colonoscopy, flexible or rigid sigmoidoscopy, or surgery
2. Eliminate a substance from the GI tract
3. Prevent straining
4. Obtain a stool specimen
5. Treat constipation

For patients who experience irritable bowel syndrome with constipation (IBS-C) and for whom laxatives and bulking agents are ineffective, medications such as linaclotide(Linzess) may be trialed.

Linaclotide is a guanylate cyclase-C agonist

Question 88

What are adverse effects of laxatives

Answer 88

1. None of the bulking or lubricating agents or osmotic laxatives carries long-term side effects. Results vary from 5 minutes to several days
2. Side effects of osmotic preparations include headache, nausea, vomiting, bloating, electrolyte imbalance, and dehydration
3. Stimulant laxatives may be habit forming, necessitating increasingly higher doses to produce the same stimulation effect
4. Side effects of Prepopik include headache, nausea, vomiting, bloating, electrolyte imbalance, and dehydration
5. The most significant side effect of Linaclotide is diarrhea

Question 89

What are contraindications of laxatives

Answer 89

1. Stimulant laxatives are contraindicated in the presence of obstruction or peritonitis or immediately after bowel surgery
2. Prepopik should be used with caution in patients with known renal insufficiency
3. Linaclotide is contraindicated in children under 6 years of age and for those with known or suspected bowel obstruction

Question 90

What are narcotics

Answer 90

1. Narcotics, including meperidine (Demerol) and fentanyl (Sublimaze), are used in gastroenterology
2. Other narcotics include tramadol and morphine

Question 91

What is the mechanism of action for narcotics

Answer 91

1. Overall, narcotic painkillers work by reducing nerve excitability that leads to the sensation of pain
2. Narcotics bind to special receptors in the brain (central nervous system) and in other areas of the body (peripheral nervous system, including the gastrointestinal tract) called opioid receptors
3. The receptors block the release of neurotransmitters involved with pain sensation

Question 92

What are indications for the use of narcotics

Answer 92

1. Narcotic analgesics, particularly meperidine and fentanyl, may be used for premedication of patients undergoing endoscopic procedures.
2. They may also be used for postoperative pain relief

Question 93

What are adverse effects to narcotics

Answer 93

1. Narcotics should be used sparingly because they tend to mask symptoms and complications and may cause physical and psychological dependence
2. Abrupt discontinuance of the drug may precipitate withdrawal symptoms, including convulsions and a decrease in bowel motility
3. Fentanyl appears to spur less emetic activity than either morphine or meperidine. In addition, clinically significant histamine release rarely occurs with fentanyl
4. The most dangerous side effect of narcotic medications is respiratory depression. Respiratory depression, sedation, and hypotension can be reversed by administration of naloxone, which is thought to antagonize the opioid effects by competing for the same receptor sites

Question 94

What are contraindications of narcotics

Answer 94

1. Morphine should not be given to patients with biliary or pancreatic problems, either preoperatively or postoperatively, because it may increase smooth muscle spasm
2. Meperidine is usually the drug of choice for these patients
3. Morphine must also be restricted in patients with severe liver disease

Question 95

What are sclerosing agents

Answer 95

1. Sclerotherapy is rarely used anymore
2. Endoscopic variceal banding is the recommended treatment to stop bleeding from varices
3. For recurrent gastric varices, beta blockers, Transjugular intrahepatic portosystemic shunt (TIPS), and tissue adhesives are used to create hemostasis

Question 96

What is the mechanism of action for sclerosing agents

Answer 96

1. Sclerosing agents such as sodium tetradecyl sulfate (Sotradecol), Ethanolamine oleate (Ethamolin), and 100% Ethan all are injected intravariceally or paravariceally to promote intima inflammation and thrombus formation in patients with esophageal varices.
2. The subsequent formation of fibrous tissue results in partial or complete vein obliteration
3. Vasoactive medications are recommended in the treatment of acute variceal bleeding and have shown to reduce the mortality and re-bleeding rates
4. The two classes of vasoactive drugs—vasopressin, including terilpressin, and somatostatin—and their respective analogues octreotide and vapreotide can be highly effective for prolonged hemostasis control

Question 97

What are the indications for the use of sclerosing agents

Answer 97

Sclerotherapy is used to stop bleeding from esophageal varices or to obliterate varices that previously bled

Question 98

What are adverse effects of sclerosing agents

Answer 98

1. Potential post-procedure complications for sclerotherapy may be various degrees of bleeding, esophageal ulcers, esophageal perforation, esophagopleural fistula, and sepsis
2. Sclerotherapy also may precipitate or increase hepatic encephalopathy

Question 99

What are contraindications for the use of sclerosing agents

Answer 99

1. Sclerosing agents are pregnancy category C, meaning that there is unknown risk to pregnant women and their unborn children
2. There is a risk of fatal anaphylaxis for larger than normal dose administration

Question 100

What are sedatives and antagonists

Answer 100

1. The use of sedatives to achieve moderate sedation requires the gastroenterology nurse to complete specialized training and competency
2. Patients require uninterrupted monitoring throughout the procedure once moderate sedation is initiated, once the desired sedation level is achieved, and until sedation is resolved
3. Resuscitative equipment must be readily available
4. When using sedatives, the individual administering the drug must have no duty other than patient monitoring and muscle be capable of full cardiopulmonary rescue

Question 101

What is the mechanism of action for sedatives and antagonists

Answer 101

1. Propofol (Diprivan) works by increasing gamma-aminobutyric acid (GABA)-mediated inhibitory tone in the central nervous system

Question 102

What are indications for the use of sedatives and antagonists

Answer 102

1. Sedatives and anti anxiety agents such as diazepam (Valium) and midazolam are used in the practice of gastroenterology primarily to medicate patients before and during endoscopic or invasive procedures
2. They may be used to relieve pre-procedure anxiety and tension and to decrease the recall of the procedure.
3. Sedatives are most commonly used to achieve moderate sedation for patients during an endoscopic examination
4. Propofol is given for deep sedation or monitored anesthesia care (MAC)
5. In most states, only licensed anesthesia providers can administer propofol.
6. Propofol is administered via slow IV push and is titration according to need

Question 103

What are adverse effects of sedatives and antagonists

Answer 103

1. The most serious side effect of moderate sedation with midazolam or propofol is centrally mediated respiratory depression
2. Apnea is associated with rapid IV injection of either drug
3. The extent of respiratory depression depends on the dosage, rate of administration, and individual susceptibility
4. Sedative effects are accentuated by the concomitant administration of other central nervous system depressants such as opiates, barbiturates, or alcohol
5. Midazolam is more potent, is faster-acting, and has a greater amnesiac effect than propofol
6. Propofol is associated with more injection site complications such as thrombophlebitis
7. During MAC with propofol, hypotension, oxyhemoglobin desaturation, obstruction, and apnea may occur

Question 104

What are contraindications of sedatives and antagonists

Answer 104

1. Allergy to eggs and soy are contraindications to propofol use
2. Contraindications to moderate sedation include sensitivity to the anesthetic agent; previous complications with sedation, including airway difficulty, morbid obesity, history of sleep apnea, and a compromised cardiovascular state
3. The inability to effectively communicate with the physician or nurse may be taken into consideration

Question 105

What are reversal agents

Answer 105

Reversal agents include medications to reverse the effects of benzodiazepines and opioids

Question 106

What is the mechanism of action of reversal agents

Answer 106

The purpose of reversal agents is to shorten or reverse the action of the narcotic or benzodiazepine administered

Question 107

What is the indication for reversal agents

Answer 107

1. Benzodiazepine reversal—Flumazenil may reverse the sedative effects of benzodiazepines (midazolam, propofol) but not the resulting respiratory depression. Flumazenil is given intravenously in individual doses of 02.mg/min, not to exceed 1mg at a time and not more than 3mg/hr. The drug acts in minutes, but its duration is considerably shorter than that of the benzodiazepines. Careful monitoring for resedation must be carried out
2. Opioid reversal—naloxone reverses both sedation and respiratory depression associated with administration of opioids. As with Flumazenil, multiple doses may be necessary because the drug’s duration is shorter than that of the opioid. Careful monitoring for resedation must be carried out

Question 108

What are adverse effects of reversal agents

Answer 108

1. When given a reversal agent, outpatients in the endoscopy unit should not be discharged home until the gastroenterology nurse is reasonably certain that the effect of the reversal agent has worn off (usually a minimum of 1 hour) and the institutional guidelines for discharge have been met

Question 109

What are contraindications of reversal agents

Answer 109

1. Contraindications include hypersensitivity to the drug
2. Reversal agents should be used with caution in patients with known cardiovascular disease or in patients with known addiction, as rapid reversal can precipitate an acute withdrawal syndrome

Question 110

What is the mechanism of action of smooth muscle relaxants

Answer 110

These agents have a direct relaxant effect on the smooth muscle fivers of the LES

Question 111

What are indications for smooth muscle relaxants

Answer 111

1. Smooth muscle relaxants can alleviate esophageal symptoms of achalasia and diffuse esophageal spasm in some patients
2. Sublingual isosorbide dinitrate (Dilatrate-SR oral tab; Isordil oral tab) can improve symptoms and radionuclide transit time
3. Calcium channel blockers such as nifedipine (Procardia) also have recognized relaxant effects on LES muscle

Question 112

What are adverse effects of smooth muscle relaxants

Answer 112

Adverse effects of smooth muscle relaxants include hypotension, flushing, tachycardia, syncope, nausea, vomiting, and rash

Question 113

What are contraindications of smooth muscle relaxants

Answer 113

1. Smooth muscle relaxants are contraindicated in patients with hypotension, hypovolemia, cardiomyopathy, closed angle glaucoma, and hepatic disease
2. Safety during pregnancy and breastfeeding and use in children is not established

Question 114

What is the mechanism of action for topical anesthetics

Answer 114

Topical sprays and gels work by reversibly blocking nerve conduction responsible for pain

Question 115

What are the indications for the use of topical anesthetics

Answer 115

1. Topical anesthetics such as benzocaine (Cetacaine) and lidocaine (xylocaine) are used in gastroenterology to suppress the gag reflex and control pain for upper GI endoscopic procedures

Question 116

What are adverse effects of topical analgesics

Answer 116

1. Common adverse effects of topical anesthetics include contact dermatitis, localized swelling, and edema
2. On rare occasions, methemoglobinemia has been reported in connection with use of benzocaine-containing products

Question 117

What are contraindications of topical anesthetics

Answer 117

1. Benzocaine should never be used near the eyes, in any large denuded area, or in patients with a cholinesterase deficiency
2. Lidocaine should not be used in patients with G6PD deficiency, an amide allergy, or significantly impaired lung function

Question 118

What is 5-aminosalicylic acid (5-ASA)

Answer 118

1. The clinical response of 5-ASA is thought to be due to a localized effect
2. Preparations are designed to deliver drug to the large intestine where its therapeutic action is driven by intestinal lumen absorption
3. 5-ASA absorption is variable and depends on disease activity and colonic pH
4. Medications containing 5-ASA include mesalamine, osalazine and sulfasalazine

Question 119

What is Mesalamine

Answer 119

1. Mesalamine (Rowasa) may be administered in the form of a suspension retention enema for patients with distal ulcerative colitis, proctosigmoiditis or proctitis, and radiation enteritis and colitis
2. Research has demonstrated that some forms of mesalamine (Asacol, Pentasa) are effective when disease is proximal to the colon

Question 120

What are adverse effects of Mesalamine

Answer 120

1. The mesalamine suspension enema slow contains potassium metabisulfite, which may cause life-threatening allergic reactions in patients with sulfite sensitivity
2. Epinephrine is the preferred treatment for serious allergic of emergency situations
3. Other side effects include nausea, headache, diarrhea, worsening or ulcerative colitis symptoms, and renal impairment

Question 121

What are contraindications of mesalamine

Answer 121

1. 5-ASAs are contraindicated in patients with a salicylate hypersensitivity and those with renal impairment
2. The Rowasa brand of rectal suspension may produce an allergic response in patients with a sulfite allergy because it contains potassium bisulfite
3. The Apriso brand tablets contain aspartame, which is contraindicated in patients with phenylketonuria

Question 122

What is sulfasalazine

Answer 122

1. Sulfasalazine (Azulfidine) is a complex of sulfapyridine and 5-ASA.
2. It is effective in the maintenance of clinical remission and in the treatment of mildly to moderately severe attacks of ulcerative colitis
3. It is also effective in active Crohn’s colitis and ileocolitis, although it does not appear to be as effective in ileitis alone

Question 123

What are adverse effects of Sulfasalazine

Answer 123

1. Side effects are common and include nausea, vomiting, headache, rash and skin sensitivity to sun exposure
2. Temporary male infertility may also result

Question 124

What are contraindications of Sulfasalazine

Answer 124

1. Sulfasalazine should be used with caution in patients with hypersensitivity to salicylate 5-ASA, carbonic anhydride inhibitor, sulfonamide, sulfonylurea or thiazide diuretic and patients with G6PD deficiency
2. Safety is not established in pregnancy, breastfeeding, and in children
3. It should be used with caution in patients with chronic or recurrent infections, as immunosuppression can lead to sepsis and death

Question 125

What is the mechanism of action for Thiopurines

Answer 125

1. Azathioprine and 6-Mercaptopurine are immunosuppressive immunomodulators (acting on isolated genes)
2. They deactivate the T lymphocytes responsible for inflammation
3. They often take months to be effective

Question 126

What are indications for Thiopurines

Answer 126

Thiopurines are often employed when 5-ASA therapy along with two course of steroids have failed

Question 127

What are adverse effects of Thiopurines

Answer 127

Common side effects
1. Fatigue
2. Malaise
3. Flu like symptoms
4. Nausea
5. Lymphopenia
6. Neutropenia
7. Liver toxicity
8. Pancreatitis

Question 128

What are contraindications of Thiopurines

Answer 128

Should not be used in patients with pre-existing liver or pancreatic disease

Question 129

What is the mechanism of action for Tumor necrosis factor (TFN) blockers

Answer 129

1. Adalimumab (Humira), infliximab (Remicade), golimumab, (Simpomi), vedolizumab (Entyvio) and certolizumab pegol (Cimzia) are TNF blockers
2. Vedolizumab is a monoclonal antibody that specifically targets alpha4beta7

Question 130

What are indications for Tumor necrosis factor (TNF) blockers

Answer 130

1. TNF blockers are used to reduce the signs and symptoms of moderate to severe Crohn’s disease and/or ulcerative colitis in adults
2. Some TNF blockers also may be used to treat other autoimmune disorders such as rheumatoid arthritis
3. Golimumab is used to treat ulcerative colitis in patients who have not responded to 5-ASA, corticosteroids, and immunomodulators such as 6-MP
4. Vedolizumab is used to treat both Crohn’s disease and ulcerative colitis

Question 131

What are adverse effects of Tumor necrosis factor (TFN) blockers

Answer 131

1. Patients taking TNF blocker are at increased risk for developing serious opportunistic infections, including tuberculosis, fungal infections, histoplasmosis, coccidioidomycosis, legionellosis and others
2. Live vaccines are not recommended in this population
3. Patient education regarding preventative health care, annual screenings, open communication with providers, and participation in care is strongly encouraged during therapy
4. Prior to starting therapy with TNF blockers, hepatitis B and varicella serologies, PPD testing, and a chest X-ray are required.
5. These should then be repeated annually while on therapy
6. Adalimumab, infliximab, certolizumab pegol, and vedolizumab require monitoring of liver function and hematology tests, as these drugs can affect immune and liver function
7. Often C-reactive protein (CRP) is monitored to determine the effect on inflammation
8. Dosage for infliximab is weight-based, so weight must be taken on each medical visit

Question 132

What are contraindications for tumor necrosis factor (TNF) blockers

Answer 132

1. Active disease, including viral infections, upper respiratory infections, or other illness is a contraindication to TNF therapy
2. Patient with mild to moderate heart failure are not suitable candidates for treatment
3. Patients with pre-existing demyelinating disease are at greater risk for developing muscular sclerosis or optic neuritis if treated with TNF blockers
   / 4. Any previous acute reaction to an infusion is a contraindication to proceed with further treatment

Question 133

What are Biosimilars

Answer 133

1. A bio similar drug is one that is highly similar to its reference drug in terms of structure, purity, safety and efficacy, biological activity, receptor binding, and potency
2. They are FDA-approved drugs that perform identically to their reference drug
3. These drugs differ in their inactive compounds and the number of Phase III trials required by the FDA
4. Biosimilars are medications contained under the Biologics Price Competition and Innovation Act of 2009
5. The goal of this law is to promote access to medication that is otherwise too costly
6. Reflexis (infliximab-abda) is one such drug. It carries all the same prescribing, dosing, and side effect information as its originator drug

Question 134

What is the mechanism of action for Pancrelipase

Answer 134

1. Pancrelipase, which includes Creon and Zenpep, is a combination of digestive enzymes, including lipase, protease and amylase

Question 135

What are indications for Pancrelipase

Answer 135

1. Pancrelipase is used to decrease the number of bowel movements and improve stool consistency in patients with pancreatic exocrine insufficiency, cystic fibrosis, steatorrhea, and other disorders of fat metabolism

Question 136

What are adverse effects of Pancrelipase

Answer 136

1. In patients with cystic fibrosis or malabsorption syndrome, high doses of pancreatic enzymes containing 20,000USP units of lipase per capsule may increase the risk of strictures in the ileocecal region and/or ascending colon
2. Other side effects may include constipation, diarrhea and abdominal pain

Question 137

What are contraindications of Pancrelipase

Answer 137

1. In patients with acute pancreatitis and hypersensitivity to pork protein
2. It should be used with caution in patients with asthma and gout

Question 138

What is the mechanism of action for Cholestyramine

Answer 138

1. Cholestyramine is an anion exchange resin
2. It absorbs and combines with bile acids in the intestine to form an insoluble complex that is excreted in the feces
3. This increased fecal loss of bile acids leads to an increased oxidation of cholesterol to bile acids, a decreased in plasma low-density lipoproteins (LDLs), and a decrease in serum cholesterol

Question 139

What are indications for Cholestyramine

Answer 139

1. Cholestyramine is used to lower plasma cholesterol levels
2. In patients with partial biliary obstruction, the reduction of serum bile acid levels reduces excess bile acids deposited in the skin, resulting in a decrease in Pruritus

Question 140

What are adverse effects of Cholestyramine

Answer 140

The most common adverse reactions are constipation, abdominal discomfort and nausea

Question 141

What are contraindications to Cholestyramine

Answer 141

Cholestyramine is contraindicated in patients with complete biliary obstruction

Question 142

What is the mechanism of action of Penicillamine

Answer 142

1. Penicillamine (Cuprimine) chelates to copper, which is the excreted in the urine
2. Trientine may also be used as a chelating agent

Question 143

What are indications for Penicillamine

Answer 143

1. Penicillamine is the drug of choice for patients with Wilson’s disease, which is a hereditary disorder of copper metabolism
2. Patients with Wilson’s disease must be committed to lifelong administration of a daily dose of Penicillamine or Trientine
3. Complete reversal or improvement of hepatic, neurological and psychiatric abnormalities can be expected in most patients
4. Other medications used to treat Wilson’s disease include GABA antagonists, anticholinergics, baclofen, CNS depressants, and levodopa to treat dystonia and accompany tremors; antiepileptics to manage seizures, other neuroleptics to manage psychiatric symptoms; and lactulose to treat hepatic encephalopathy

Question 144

What are adverse effects of Penicillamine

Answer 144

A small portion of patients develop serious toxic reactions to Penicillamine and may require administration of an alternative chelating agent

Question 145

What are contraindications of Penicillamine

Answer 145

1. Use of Penicillamine is contraindicated during pregnancy, and women should not breastfeed while on therapy
2. Penicillamine also is contraindicated in patients with a history of Penicillamine-related aplastic anemia or agranulocytosis

Question 146

What is the mechanism of action for neomycin and lactulose

Answer 146

1. Neomycin acts by reducing the production of the nitrogenous breakdown products that cause encephalopathy
2. Rifaximin (Xifaxan), a non-aminoglycoside and non-systemic antibiotic, is a derivative of rifampin and is often better tolerated than neomycin for hepatic encephalopathy
3. Bacterial breakdown of lactulose acidifies the colonic contents, resulting in the retention of ammonia in the colon and a concomitant reduction in blood ammonia levels

Question 147

What are indications for neomycin and lactulose

Answer 147

1. Neomycin, rifaximin, and lactulose are used in the treatment of hepatic encephalopathy
2. Rifaximin is also used at lesser doses to treat IBS-D and traveler’s diarrhea

Question 148

What are adverse effects of neomycin and lactulose

Answer 148

1. Nausea
2. Dizziness
3. Abdominal pain
4. Peripheral edema
5. Myalgias

Question 149

What are contraindications for neomycin and lactulose

Answer 149

1. Rifaximin is contraindicated in patients with a hypersensitivity to rifamycin
2. Safety and effectiveness have not been established in pediatric and geriatric populations
3. Use during pregnancy or lactation is not recommended
4. Teratogenic effects on animals were established, but no human studies have been completed

Question 150

What is the mechanism of action for Hepatitis C medications

Answer 150

1. Interferon, such as interferon Alfa-2B (Intron A), works against HCV by:
   - preventing the virus from entering into cells
   - interfering with the virus’s ability to make the proteins it needs to thrive
   - stimulating the production of other immune system defenders
   - increasing the immune system’s ability to recognize viral cells so that it can destroy them
2. Ribavirin is an oral antiviral agent that is used in combination with interferon.
   - ribavirin is a nucleotide analogue that does not work when used alone against HCV
3. The length of treatment course for HCV depends on the viral genotype
4. Both interferon and ribavirin can cause side effects
   - some more common side effects include nausea, vomiting, diarrhea, headache, fatigue, mood changes, thrombocytopenia and anemia
5. Research into antiviral drug therapy for HCV has resulted in a growth in therapies
   - there are a variety of therapies based on genotype and comorbidity

Question 151

Antiviral drug therapy for HCV based on genotype

Answer 151

Genotype Drugs. Length of treatment
1,3. Daklinza (daclatasvir) with Savoldi (sofosbuvir); sometimes with ribavirin. 12 weeks
1,2,3,4,5,6. Epclusa (sofosbuvir/velpatasvir); only given with ribavirin in cases of 12 weeks
Decompensated (advanced) cirrhosis
1,4,5,6. Harvoni (ledipasvir/sofosbuvir); sometimes given with ribavirin 8,12 or 24 weeks, depending
On type
1. Olysio (simeprevir) plus Sovaldi (sofosbuvir); sometimes given with ribavirin 24 weeks
1. Viekira Pak(dasabuvir/ombitasvir/paritaprevir/ritonavir) combo pack; given. 12-24 weeks
With ribavirin if genotype 1a
1. Viekira X-RAY (dasabuvir/ombitasvir/paritaprevir/ritonavir) extended release. 24 weeks
Formula; given with ribavirin if genotype 1a
1,4. Zepatier (elbasvir/grazoprevir); sometimes given with ribavirin. 12-24 weeks
2,3,4. Savoldi (sofosbuvir); often given with ribavirin. 12-24 weeks
4. Technivie (ombitasvir/paritaprevir/ritonavir) plus ribavirin. 12 weeks
1,2,3,4,5,6. Vosevi (sofosbuvir/velpatasvir/voxilaprevir) not taken with ribavirin 12 weeks

Question 152

What is performed in the assessment step of IV therapy

Answer 152

1. Assessment is the first step and includes assessing the patient’s knowledge and experiences with IV therapy
   - the patient’s diagnosis
   - co-morbid conditions
   - activity level
   - mental state
   -duration and type of therapy

Question 153

What is performed in the planning step of IV therapy

Answer 153

1. Planning includes identification of the appropriate person to place the vascular access device (VAD)
   - the type of VAD
   - the dressing necessary for the VAD
   - the assessment for the best site to place the VAD

Question 154

What is performed during the implementation step of IV therapy

Answer 154

1. Implementation includes preparing the patient, the environment, and the equipment and placing the VAD

Question 155

What is performed in the evaluation and assessment step of IV therapy

Answer 155

1. Includes determining the patient’s response or outcome to the IV therapy administered and revising the plan of care to achieve desirable outcomes

Question 156

What are the competencies in the IV therapy for the gastroenterology nurse should include

Answer 156

1. Knowledge of the types of VADs
2. Skill in performing the procedure competently and safely
3. Skill in inspection and assessment of the insertion site
4. Ability to problem-solve as necessary
5. Ability to monitor the patient’s condition and report changes
6. Skills for proper VAD documentation and record-keeping
7. Knowledge of medication and fluids infused via VAD

Question 157

What are the Gastroenterology Nurse’s responsibilities for IV therapy

Answer 157

1. Identify the right patient
2. Verify the prescription and the right medication. Check the infusion fluid, drug, and container for any obvious faults or contamination
3. Confirm the right dosage
4. Ensure administration of the prescribed drug or fluid via the right route. Establish that the VAD is patent and comfortable for the patient
5. Verify the right times and frequency for the medication
6. Maintain appropriate documentation. Monitor the condition of the patient and report any changes
7. Verify the rationale for the medication delivered
8. Monitor the condition of the patient to determine if the medication has led to the desired effect. Report any changes

Question 158

What are body fluids composed of

Answer 158

Electrolytes
1. Electrically charged and dissociate into ions—cations and anions—when placed in solution
2. Electrolytes account for 95% if the solute molecules in body water
3. Cations are ions with a positive charge and include sodium (the predominant extra cellular cation), potassium (the predominant intracellular cation), calcium, and magnesium
4. Anions are ions with a negative charge and include chloride, phosphate, and sulfate
5. These electrolytes help to maintain osmotic pressure within cells

Nonelectrolytes
1. Glucose, urea, bile salts, creatinine, and cholesterol, do not dissociate in water into ions, but they do addiction the acid-base balance and osmotic pressure gradients

Question 159

What is maintenance therapy

Answer 159

1. Meets the patient’s standard needs by providing approximately 3,000mL if fluid per 24 hours, along with added electrolytes, nutrients, and vitamins
2. For maintenance therapy, a balanced hypotonic electrolyte solution with the addition of 5% dextrose for calories is ideal.
3. This balanced electrolyte solution typically contains sodium, potassium, magnesium, chloride and acetate
4. These solutions are available in concentrations appropriate for pediatric and adult patients

Question 160

What is replacement therapy

Answer 160

1. Restores lost fluids on a volume-to-volume basis, often in excess of 3,000ml of fluid per 24 hours.
2. The electrolyte concentration of replacement therapy is generally equal to the concentration of electrolytes in the extra cellular fluid
3. Ideally, replacement therapy solutions should contain ions in the same composition as that of the plasma and interstitial fluid
4. Depending on the caloric and fluid needs of the patient, 5% dextrose may or may not be included
5. In patients with preserved renal function who have NPO status, replacement potassium should be provided in IV fluids to prevent hypokalemia, as the kidneys routinely excrete potassium

Question 161

What are different types of vascular access devices

Answer 161

1. Steel,Winged infusion sets (butterfly’s)
2. Peripheral short IV catheters (angiocaths)
3. Peripheral long or midline catheters
4. Peripherally inserted central catheter (PICC)
5. Non-tunneled central venous catheters (CVC)
6. Tunneled central venous catheters
7. Totally implanted devices or ports

Question 162

What equipment is needed for IV therapy

Answer 162

1. IV fluid containers
2. IV tubing
3. Intermittent infusion sets
4. Filters
5. Tourniquets
6. Transparent semipermeable membrane dressings
7. Antiseptic agents
8. IV stands/poles
9. Infusion controllers

Question 163

What are the steps for inserting an IV

Answer 163

1. Prepping the selected site with the organizationally approved antiseptic agent and permit it to air dry
2. Using topical anesthetics to numb the insertion site, especially in children, according to organizational policies and procedures
3. Applying a tourniquet above the intended insertion site
4. Using the smallest gauge and length of angiocatheter capable of accommodating the prescribed treatment
5. For peripheral insertion, holding the skin taut and anchoring the vein with the thumb below the insertion site. Insert the needle slowly into the vein until blood return is noted, then advance the needle or catheter, and release the tourniquet
6. Connecting the primed tubing and running the fluid at a fast rate to flush blood from the tubing. Once blood is cleared, regulate the IV drip at the prescribed rate
7. Stabilizing the cannula so it does not interfere with assessment and monitoring of the IV site or impede delivery of the prescribed therapy
8. Applying a sterile gauze or transparent, semipermeable membrane dressing. All edges of the dressing should be securely taped. An armboard or handboard may be used if the cannula is placed to close to an area of flexion
9. Looping a 3-6inch portion of tubing and securing it near the insertion site. The loop allows some slack to prevent dislodgement of the catheter caused by tension on the line
10. Documenting all pertinent information

Question 164

What steps do you take to remove a peripheral line

Answer 164

1. Clamp the tubing
2. Remove the securement device from the skin
3. Slowly and smoothly withdraw the needle or catheter
4. Maintain pressure with a gauze pad at the insertion site after withdrawal of the VAD until bleeding stops
5. Apply a dry, sterile bandage
6. Inspect the removed VAD for appropriate length and any defects

Question 165

What are the possible causes; signs and symptoms and interventions of infiltration

Answer 165

Possible Causes
1. Puncture of the vein wall
2. Needle or cannula slipping out of the vein

Signs and Symptoms
1. Coolness, blanching, edema, pain, burning
2. No blood return
3. Leakage at the venipuncture site

Interventions
1. Discontinue infusion
2. Remove cannula
3. Restart IV at a different, more proximal location
4. Elevate the affected part
5. Apply heat or cold compression based on infiltrated solution

Question 166

What are the possible causes; signs and symptoms and interventions of extravasation

Answer 166

Possible Causes
1. Administration of drugs into the tissue

Signs and Symptoms
1. Redness along with blistering
2. Tissue necrosis and ulceration
3. Burning, stinging pain, swelling, leakage

Intervention
1. Requires immediate physician notification
2. Do not pull IV catheter—treatment should be determined prior to catheter removal, as some vesicants require drugs to be infused directly into the extravasation site via the IV

Question 167

What are the possible causes; signs and symptoms and interventions for a hematoma at the IV site

Answer 167

Possible Causes
1. Unsuccessful attempt at venipuncture
2. Infiltration of a blood transfusion

Signs and Symptoms
1. Painful, raised area, with blue or purplish coloring

Intervention
1. Remove needle or cannula
2. Apply pressure and cold compresses

Question 168

What are the possible causes; signs and symptoms and interventions of phlebitis, with or without clot formation

Answer 168

Possible Causes
1. Vein irritation and inflammation
2. May occur post-infusion

Signs and Symptoms
1. Redness with or without edema along the affected vein
2. Sore, hard, cordlike, warm vein

Interventions
1. Discontinue infusion
2. Remove cannula
3. Apply warm, moist compresses
4. Notify the physician

Question 169

What are possible causes; signs and symptoms and interventions for pyrogenic reactions

Answer 169

Possible causes
1. Contaminated equipment or solutions

Signs and Symptoms
1. Fever, chills, nausea and vomiting, backache, malaise

Interventions
1. Discontinue infusion
2. Record lot number of solution
3. Culture cannula and solution
4. Notify the physician

Question 170

What are possible causes, signs and symptoms and interventions of air embolisms

Answer 170

Possible Causes
1. Air in tubing
2. Loose connections allowing air to enter tubing

Signs and Symptoms
1. Hypotension
2. Cyanosis
3. Heart murmur
4. Tachycardia
5. Syncope
6. Vascular collapse
7. Loss of consciousness

Interventions
1. Place the patient in the left lateral decubitus position
2. Notify the physician
3. Check the system for leaks and clamp line proximal to any leaks or breaks noted

Question 171

What are possible causes; signs and symptoms and interventions of catheter embolism

Answer 171

Possible Causes
1. Portion of the plastic cannula breaks off and flows into the vascular system
2. Attempting to retread the catheter with a needle
3. Unsecured catheter

Signs and Symptoms
1. Vein discomfort
2. Cyanosis
3. Decreased blood pressure
4. Weak, rapid pulse
5. Loss of consciousness

Interventions
1. Discontinue infusion
2. Apply tourniquet above insertion site
3. Notify the physician
4. Per physician order, x-ray film is taken to locate fragment

Question 172

What are possible causes, signs and symptoms and interventions of pulmonary edema

Answer 172

Possible causes
1. Circulatory overload
2. Excessive infusion flow rate

Signs & Symptoms
1. Headache
2. Venous dilation
3. Hypertension
4. Coughing
5. Dyspnea
6. Tachycardia
7. Coarse crackles auscultated in lung fields

Interventions
1. Stop infusion until patient can be assessed
2. Elevate the head of the bed and lower the patient’s legs to dependent position
3. Notify the physician

Question 173

What are possible causes, signs & symptoms and interventions of speed shock/overload

Answer 173

Possible causes
1. Too-rapid administration of solutions and medications

Signs & Symptoms
1. Shock
2. Syncope
3. Cardiac arrest

Interventions
1. Slow infusion to keep-open rate
2. Resuscitate
3. Notify the physician

Question 174

What are the possible causes; signs&symptoms and interventions of nerve injury

Answer 174

Possible causes
1. Puncture of the nerve during venipuncture

Signs & Symptoms
1. Immediate “electric shock” sensation radiating to the thumb and index finger when the catheter is inserted
2. Can result in complex regional pain syndrome

Interventions
1. Immediately remove angiocath
2. Place dry, sterile dressing

Question 175

What kind of patient education needs to be performed prior to IV therapy

Answer 175

1. The purpose of the therapy
2. An estimate of the duration of therapy
3. Patient mobility
4. Avoiding pressure to the IV site
5. Keeping the site dry
6. Maintaining the fluid container at an appropriate height
7. Not adjusting the flow rate (for optimal patient safety)
8. Instructions to notify the gastroenterology nurse in the case of pain, burning, redness, or swelling a the IV site or other complications or concerns

Question 176

What is the documentation required for IV insertion

Answer 176

1. Date and time of initiation
2. Amount and type of solution used
3. Type and length of needle or catheter, and its gauge
4. Number of venipuncture attempts
5. Location of the venipuncture site
6. Type of dressing and any stabilization devise used
7. Infusion devices, if used
8. Rate of flow recorded in milliliters per hour (ml/hr)
9. Any complications, anxiety, or untoward reactions on the part of the patient, along with nursing interventions taken
10. Patency during therapy
11. Site condition during infusion therapy and following removal of the VAD

Question 177

What needs to be done prior to medication administration

Answer 177

1. The physician’s or other provider’s written order for the IV medication
2. The dose, route, and rate of the medication ordered
3. The label on the medication against the order on the patient medication record and against the physician’s order
4. The appropriateness of the prescribed therapy
5. The patient’s age and condition
6. Any patient medication allergies
7. The medication’s indications, actions, side effects, and the appropriate nursing interventions in the event of adverse reactions
8. The drug compatibility with the solution before adding any drug to an IV solution
9. The expiration date of solutions and medications
10. The patient’s identity

Question 178

What are the different ways that IV medications can be delivered

Answer 178

1. Continuous infusions
2. Piggyback method
3. Intermittent infusion sets
4. IV push or IV bolus route

Question 179

What is Factor VIII given to treat

Answer 179

Used to treat moderate to severe factor VIII deficiency (hemophilia A)

Question 180

What is Factor IX used to treat

Answer 180

Hemophilia B (Christmas disease), with the treatment regimen based on severity and type of bleeding

Question 181

Autologous transfusion

Answer 181

Can be performed using the patient’s own blood. The blood for autologous transfusion can be obtained by preoperative donation or by postoperative salvage via the operative site

Autologous transfusion eliminates the risk of incompatibility reactions (except those due to clerical error) and the risk of blood-borne virus exposure

GI endoscopy produces do not allow for salvage of blood for autologous transfusion due to the contaminants in the GI tract

Question 182

What equipment is needed for a blood transfusion

Answer 182

1. Ordered blood component
2. Standard blood infusion set with an inline filter
3. Micro aggregate filter for RBC administration
4. 0.9% NaCl flush IV bag
5. Proper gauge needle or catheter access
6. Infusion equipment
7. Portable infusion stand

Question 183

What are the nurse’s responsibilities in the administration of blood and blood components

Answer 183

1. Confirm the informed patient consent, verbal and/or written, as required by state law
2. Provide patient education
3. Inspect the blood product
4. Verify the product expiration date
5. Verify the blood component administration order
6. Confirm crossmatch and compatibility between the patient recipient and the donor unit
7. Adhere to aseptic technique
8. Begin the transfusion
9. Monitor the patient and vital signs at 15 minutes after administration and at completion of transfusion, or per organizational policy
10. Identify any immediate and delayed reactions
11. Intervene in the case of adverse reactions
12. Discontinue the completed transfusion
13. Complete written documentation

Question 184

What are possible transfusion reactions

Answer 184

1. Circulatory overload — when the amount of fluid administered exceeds the pumping capacity of the heart
   - patient findings include—dyspnea, hypertension, JVD, bounding pulse, tachycardia, tachypnea, cough, confusion, restlessness and pulmonary congestion
   - the nurse should slow the transfusion, elevate the head of the patient’s bed, notify the physician, and administer oxygen and diuretics as ordered
2. Bacterial sepsis—caused by bacterial contamination of blood product
   
   • patient findings—rapid onset of chills, high fever, abdominal cramping, vomiting, diarrhea, and profound hypotension
     - the nurse should stop the transfusion, maintain IV access, and contact the physician for further orders
3. Allergic reaction—cause by a blood product recipient being allergic to a protein or antigen in the donors blood
   - symptoms range from local erythema, hives, and urticaria to cough, respiratory distress, hypotension, loss of consciousness, and possible cardiac arrest
   - the nurse should stop the transfusion, maintain IV access, and contact the physician
   - treatment includes—antihistamines, and possibly corticosteroids or epinephrine, depending o the severity of the reaction
4. Hemolytic reactions—occur as a result of the infusion of ABO-incompatible RBCs,
   - symptoms evident within 5-15 minutes of transfusion. Fever, increased heart rate, chills, low back pain, headache, nausea, chest pain, dyspnea, and hypotension, from hemolysis the patient might develop acute renal failure
   - the nurse must immediately stop the transfusion, maintain IV access, and contact the physician. Vitals should be monitored every 15 minutes
5. HBV,HCV,HIV
6. Other transfusion-retaliated infectious agents—(viral, bacterial, parasitic) have been reported
7. Citrate toxicity —may develop with large volumes of FFP, whole blood, or platelets are transfused rapidly in patients with liver disease or those with circulatory collapse. Citrate is an anticoagulant added to blood products to prohibit clotting of the product and is rapidly metabolized by a healthy liver
   - symptoms develop from hypocalcemia that occurs, ventricular dysrhythmias can develop and the patient may also experience parenthesis, muscle cramps, fasciculations, spasms, nausea and hyperventilation

Question 185

What is the transfusion documentation that the nurse needs to complete

Answer 185

1. Verification of the correct unit for the correct patient
2. Type of blood product administered, unit number, and blood type
3. Date and start time of the transfusion, and the completion time
4. Pre-transfusion vital signs, vital signs at 15 minutes, and vital signs at the completion of transfusion per organizational policy
5. Total fluid volume infused, including saline flush and blood component volume
6. Any reaction noted during the transfusion
   - time and date of the reaction
   - type and amount of transfused blood or blood products
   - clinical signs of the transfusion reaction in order of occurrence
   - the patient’s vital signs
   - any specimens that were sent to the laboratory
   - any treatment, and the patient’s response to treatment
   - completion of a transfusion reaction form, if required by the organization

Question 186

What are the ingested forms of carbohydrates

Answer 186

1. Polysaccharides —mainly starch
2. Disaccharides—sucrose and lactose
3. Monosaccharides—glucose, fructose, galactose

Question 187

In order for the body to utilize carbohydrates they must be

Answer 187

Hydrolyzed or broken down to monosaccharides by a chemical process that involves the splitting of a bond by the addition of water molecules

Question 188

What is the end product of carbohydrate catabolism

Answer 188

Glucose

Question 189

What do lipids consist of

Answer 189

1. Triglycerides
2. Phospholipids
3. Sterols
4. Sphingolipids
5. Terpenes

Question 190

What do the the compounds of lipids serve as a source of

Answer 190

1. Energy
2. Thermal insulation
3. Precursors for steroid hormones
4. Structural components of cell membranes
5. Carriers of essential nutrients

Question 191

What diseases could cause fat malabsorption

Answer 191

1. Crohn’s disease
2. Chronic pancreatitis
3. Cystic fibrosis

Question 192

Out of the 22 recognized amino acids how many are considered essential

Answer 192

9

Our bodies cannot synthesize them so they must be consumed through diet

Question 193

What contributes to the nitrogen balance

Answer 193

1. In a healthy adult, protein synthesis is equal to protein degradation and the individual is said to be in nitrogen balance
2. Positive nitrogen balance occurs when protein synthesis exceeds protein degradation. This state is normal and to be expected in children, pregnant women, and people recovering from an injury who are building new tissue. In adults, it may signify a rebuilding of wasted tissue
3. Negative nitrogen balance occurs when protein loses are greater than protein intake. It indicates that protein breakdown exceeds protein synthesis

Question 194

Where does metabolism of ingested protein begin

Answer 194

1. It begins in the stomach
2. Where pepsin in the presence of hydrochloric acid, hydrolyzes proteins into amino acids and polypeptides of varying lengths
3. Then in the duodenum and jejunum, pancreatic enzymes reduce these products to their basic peptides and amino acids
4. In the lower jejunum and ileum, the remaining peptides are hydrolyzed into amino acids and absorbed
5. Protein absorption may be reduced by disorders that reduce gastric hydrochloric acid secretion or impair production of proteolytic enzymes, by duodenal or jejunal inflammation or infection, or by gastric or intestinal resection

Question 195

What are the fat-soluble vitamins

Answer 195

1. A
2. D
3. E
4. K

Absorbed with dietary fats and tend to be stored in the body in moderate amounts

Question 196

What are water-soluble vitamins

Answer 196

1. C
2. All the B vitamins (thiamine B1, riboflavin B2, niacin B3, pantothenic acid B5, Pyroxidine B6, cobalamin B12)
3. Folic acid
4. Biotin

They are excreted in urine and are not stored in the body in appreciable amounts

Question 197

What are the major minerals found in the body

Answer 197

1. Calcium
2. Chloride
3. Sodium
4. Magnesium
5. Potassium
6. Sulphur
7. Phosphorus

Question 198

What are the trace minerals found in the human body

Answer 198

1. Chromium
2. Cobalt
3. Copper
4. Fluorine
5. Iodine
6. Iron
7. Manganese
8. Molybdenum
9. Selenium
10. Zinc

Question 199

What foods need to be avoid when patients are taking warfarin

Answer 199

Foods containing vitamin K

1. Dark green leafy vegetables
2. Kale
3. Broccoli
4. Brussels sprouts
5. Green onions
6. Parsley
7. Spinach
8. Chard

Patients should also avoid cranberry juice and cranberry products because the flavonoids in cranberries may inhibit cytochrome P450 system activity and predispose patients to hemorrhage

Question 200

What should patients avoid while they are taking methylprednisone, prednisolone, or prednisone

Answer 200

In patients who develop hyperglycemia
1. Limit consumption of carbohydrates
2. Avoid foods high in simple carbohydrates
- sugared breakfast cereal
- canned fruit in syrup
- sugared flavorings
- sugar
- syrups
- jams
- jellies
- candy
- honey
- regular soft drinks

Patients who develop hypertension
1. Reduce sodium intake by limiting the consumption of food high in sodium
- croissants
- bagels
- biscuits
- baked beans
- canned or creamed corn
- scalloped potatoes
- canned mushrooms
- sauerkraut
- marinara sauce
- canned vegetables
- vegetable juice
- cheese (especially feta)
- miso
- pickles
- soy and soy sauce
- barbecue sauce
- table salt
- ketchup
- teriyaki sauce

Question 201

What foods should be limited when taking potassium sparing diuretics

Answer 201

In potassium sparing diuretics potassium is not excreted through urine and levels may rise

Foods that contain potassium
1. Fruits
2. Vegetables
3. Dairy
4. Meats
5. Legumes

Patients need to be seen by a registered dietician to avoid overconsumption

Question 202

What are the steps of a nutritional assessment

Answer 202

1. A health and dietary history, including a report of any recent weight gain or loss; recurrent nausea, vomiting or diarrhea; any chronic illnesses; all medications, over-the-counter drugs and supplements; possible dysphagia; poor dentition; food allergies or intolerances; psychosocial issues; and changes in appetite associated with current nutrition status
2. A physical examination, including height, weight, body mass index, mid-arm circumference, and skin fold thickness. Signs of nutritional deficiency (edema, loss of subcutaneous fat, and muscle wasting, for example) and compromised skin integrity (such as decubiti) should be noted
   - in pediatric patients, the child’s height, weight, and head circumference should be correctly plotted on a standardized growth chart
3. Diagnostic studies, including laboratory tests for serum albumin, transferrin, prealbumin, retinol-binding protein, and nitrogen balance calculations

Question 203

What is used to calculate energy requirements

Answer 203

Harris-Benedict equation for basal energy expenditures

W=the patient’s actual or usual weight in kilograms
H=the height in centimeters
A=the age in years

Question 204

What is the formula for women when calculating their basal energy expenditures

Answer 204

BEE=655+(9.6’W)(1.8’h)-(4.7’A)

Question 205

What is the formula for men when calculation the basal energy expenditures

Answer 205

BEE=66+(13.7’W)(5’H)-(6.8’A)

Question 206

Who is recommended to be on a high-fiber diet and what does it consist of

Answer 206

1. The high-fiber diet id recommended as an aid in the prevention of constipation and diverticulosis and has been associated with a decreased risk of colon and breast cancer
2. Food sources of insoluble fiber include—whole-grain breads and cereals and fresh fruits and vegetables
3. The recommended intake for fiber is 25-38 grams (25 grams in females and 38 grams in males for ages 18-50 and 21g in females and 30g in males for ages 50+)

Question 207

Who is recommended to be on a low-fiber diet and what does it consist of

Answer 207

1. Recommended for those with inflammatory bowel disease, diverticulitis and acute ulcerative colitis or Crohn’s disease
2. Reduction of intake of whole grains, fruits and vegetables
3. The nutritional implications of a low-fiber diet are that it may provide an inadequate amount of many vitamins and minerals, and patients adopting this may require supplementation

Question 208

What food need to be avoided on a gluten-free diet

Answer 208

1. Obvious sources of gluten, including baked goods, cereals, pastas, and soups containing wheat, barley, rye and oats (that are not labeled gluten free0
2. Less obvious sources of gluten, including wheat and it derivatives that are used as an extender in processed foods and beverages such as ice-cream, salad dressings, soy sauce, canned foods, ketchup, mustard, candy bars and instant coffee
3. Foods containing modified food starch, hydrolyzed vegetable protein, and malt

Question 209

Who is it suggested to be on a low-lactose diet and what does it consist of

Answer 209

1. In the treatment for
   - short bowel syndrome or dumping syndrome
   - IBS
   - during the acute phase of diarrheal illness in which intestinal transit is rapid or lactase deficiency is transient as in:
   
   • acute gastroenteritis, ulcerative colitis or Crohn’s disease
2. Foods to limit
   - milk and milk products
   - ice cream, cheeses and butter

Question 210

Who is recommended to be on low-protein diets and what does it entail

Answer 210

Those with end-stage liver disease who are at risk for portosystemic encephalopathy
Patients with chronic renal failure (pre-dialysis) to delay the progression of renal failure and the need for dialysis

Limiting intake of milk, cheese, meat, fish, poultry, and eggs; focusing on high-fiber foods like vegetables and eating small frequent meals

Question 211

When are low-fat diets used for

Answer 211

To control symptoms of GI disease, particularly steatorrhea and diarrhea

Indicated in all acute and chronic diseases that impair the functions of lipolysis, micellar solubilization, mucosal absorptions transport out of the absorptive cell or transport in the lymphatic system

Question 212

What is the framework used to target therapies aimed at improving GI functioning

Answer 212

1. What does this patient need to have removed (e.g. pathogenic growth in the intestinal tract, allergenic foods in the diet) for healthy GI function
2. What does this patient need to have replaced (e.g. stomach acid, digestive enzymes) to support improved GI function
3. What does this patient need to support and/or reinoculate a healthy balance of micro flora? That is, does he or she require probiotic reinoculation and.or prebiotic support
4. What does this patient to need to support the regeneration of the mucosal layer. That is, does he or she require a targeted nutritional support for GI barrier regeneration

Question 213

What are the different types of enteral formulas

Answer 213

1. Polymeric formulas contain intact mixtures of proteins, fats, and carbohydrates. Polymeric formulas are used when GI function is normal or near normal. They are available in fiber-containing and low-residue formulations. In a variety of protein levels; in formulations specialized for renal disease, pulmonary disease, and diabetes mellitus; and in formulations for those under high metabolic stress (e.g. trauma)
2. Monomeric formulas, called elemental or semi-elemental, are predigested formulas composed of hydrolyzed starch, peptides or amino acids, and LCTs and MCTs. These are nutritionally complete, low-residue, and relatively non-stimulating to pancreatic, biliary, and GI secretions. Elemental diets are used for patients with definite evidence of impaired digestion of malabsorption
3. Disease-specific formulas are designed for special nutritional needs of patients with conditions such as renal disease, respiratory disease, diabetes and hepatic failure
4. Modular formulas contain only one nutritional component (fats, proteins, or carbohydrates). Modular preparations may be added to formulas to increase calories or protein to meet specific nutritional or metabolic needs of patients

Question 214

What are potential gastrointestinal complications of enteral feedings

Answer 214

1. Nausea vomiting, or cramping may be caused by delayed gastric emptying due to medications
2. Constipation may result from dehydration or inadequate fiber intake
3. Abdominal distention may be the result of GI ileus, obstruction, or ascites
4. Diarrhea is commonly caused by medications such as antibiotics, sorbitol-containing elixirs, or infections such as C.Diff
5. Dumping syndrome may be due to rapid infusion of a high volume of formula
6. Malabsorption and maldigestion may result from Crohn’s disease, diverticular disease, radiation enteritis, fistulas, and pancreatic insufficiency

Question 215

What are potential mechanical complications of enteral feedings

Answer 215

1. Tube placement can cause tracheal perforation, respiratory complications, or GI tract perforation leading to abscess formation and peritonitis
2. Presence of feeding tubes can cause pharyngeal discomfort; nasal or pharyngeal irritation; or necrosis, fistulas, and cellulites
3. Tube obstruction and clogging, common in concentrated and fiber-containing formulas, can be prevented by frequent flushing of tube
4. Aspiration is the most common complication and may be minimized by placing nasojejunal or jejunostomy tubes well beyond the ligament of Treitz and by elevating the patient’s head and shoulders 30-45 degrees

Question 216

What are potential metabolic complications of enteral feedings

Answer 216

1. Fluid and electrolyte imbalances—hypo or hypernatremia, hypo- or Hyperkalemia, overhydration, hypertonic dehydration, and hyperglycemia
2. Trace elements, vitamin, and mineral deficiencies
3. Excessive carbon dioxide production
4. Refeeding syndrome

Question 217

What is the nursing care required for enteral feedings

Answer 217

1. Frequent monitoring is necessary to reduce complications associated with feeding that result in compromised nutritional status. Monitoring may include the following
2. Gastric residuals every 4 hours. All aspiration secretions should be returned to the stomach because they contain nutrients, electrolytes, and digestive enzymes. In general, if gastric residuals are greater than 150 ml for PEG feedings or greater than 200ml from a NG tube, feedings are held for about 2 hours and residuals are checked prior to resuming feeding. The American Society of Parenteral and Enteral Nutrition (ASPEN) guidelines state that gastric residual volumes should not be used as part of routine care to monitor ICU patients receiving enteral nutrition
3. Daily weight to detect fluid shifts, and daily intake and output (I&O)
4. Consistency, volume, and frequency of bowel movements
5. Signs and symptoms of intolerance such as abdominal distention, vomiting, nausea, diarrhea, and constipation
6. Daily electrolyte levels, BUN, and creatinine until the goal rate is achieved and, thereafter, two to three times per week. Minerals and a weekly blood count may be ordered
7. Inspection of tube site for placement, patency or infection

Question 218

For what patients might Parenteral nutrition be ordered for

Answer 218

1. For patients with GI disorders such as radiation enteritis, mesenteric ischemia, small bowl obstruction, acute pancreatitis, and short bowel syndrome
2. In preoperative preparation of malnourished patients who cannot tolerate enteral feedings
3. For patients with postoperative surgical complications, particularly fistulas or paralytic ileus
4. In postoperative care of neonates who cannot tolerate enteral feeding
5. For infants with intractable diarrhea

Parenteral neutrino is usually not used if oral or enteral nutrition is possible

Question 219

What are potential infection and sepsis complications of total Parenteral nutrition

Answer 219

1. Catheter contamination during insertion
2. Long-term indwelling catheter
3. Catheter seeding from bloodborne or distant infection
4. Contaminated solution

Question 220

What are potential metabolic complications of total Parenteral nutrition

Answer 220

1. Dehydration, hypovolemia
2. Bone demineralization
3. Hyperglycemia, rebound hypoglycemia
4. Hyperosmolar hyperglycemic nonketotic syndrome
5. Azotemia
6. Electrolyte disturbances, include Hypocalcemia, hypophosphatemia, hyperphospatemia, hypokalemia and hypomagnesemia
7. Deficiencies of essential fatty acids, trace elements, vitamins and minerals
8. Altered acid-base balance
9. Elevated liver enzymes, hepatomegaly, fatty liver, and cholestasis
10. Fluid overload

Question 221

What are potential mechanical complication related to catheterization for total Parenteral nutrition

Answer 221

1. Catheter misplacement
2. Hemothorax (blood in the chest)
3. Pneumothorax (air or gas in the chest)
4. Hydrothorax (fluid in the chest)
5. Hemomediastinum (blood in the mediastinal spaces)
6. Subcutaneous emphysema
7. Hematoma
8. Arterial puncture
9. Myocardial perforation
10. Catheter embolism
11. Cardiac dysrhythmia
12. Air embolism
13. Endocarditis
14. Nerve damage at the insertion site
15. Laceration of lymphatic duct, chylothorax and lymphatic fistula
16. Thrombosis