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Chapter 046

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11/04/2014

Chapter 46

DRUGS FOR GASTROINTESTINAL TRACT DISORDERS

Elsevier items and derived items © 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc.

1

Drugs for the Gastrointestinal Tract

Gastrointestinal disorders
   

Vomiting Toxic substance ingestion Diarrhea Constipation

Elsevier items and derived items © 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc.

2

Vomiting

Cerebral centers affecting vomiting

The chemoreceptor trigger zone and vomiting center.
Elsevier items and derived items © 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc. 3

Antiemetics

Nonpharmacologic measures
   

Weak tea Gatorade Crackers Toast

Elsevier items and derived items © 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc.

4

Antiemetics (cont’d)

Nonprescription antiemetics

Antihistamines • Dimenhydrinate (Dramamine) • Diphenhydramine (Benadryl) • Side effects (similar to anticholinergics)

Drowsiness, dry mouth, constipation

Bismuth subsalicylate (Pepto-Bismol) • Action

Acts directly on gastric mucosa to suppress vomiting

Elsevier items and derived items © 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc.

5

Antiemetics (cont’d)

Prescriptive antihistamines
  

Hydroxyzine (Vistaril) Promethazine (Phenergan) Acts on VC, decreases stimulation of CTZ Scopolamine (Transderm-Scop) Acts on VC, decreases stimulation of CTZ

Anticholinergic
 

Dopamine antagonists

Phenothiazines • Promethazine (Phenergan)

Elsevier items and derived items © 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc.

6

Antiemetics (cont’d)

Promethazine (Phenergan)
 

Action • Inhibit CTZ, blocks H1 receptor sites Side effects • Drowsiness, dry mouth, blurred vision, tachycardia,
constipation, urinary retention, photosensitivity, EPS (tardive dyskinesia, acute dystonia, akathisia)

Elsevier items and derived items © 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc.

7

Antiemetics (cont’d)

Dopamine antagonists

Butyrophenones • Haloperidol (Haldol), Droperidol (Inapsine) • Action

Blocks dopamine (D2) receptors in CTZ EPS, hypotension

• Side effects

Metoclopramide (Reglan) • Action

Blocks D2 receptors in CTZ
Sedation, diarrhea, EPS
8

• Side effects

Elsevier items and derived items © 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc.

Antiemetics (cont’d)

Benzodiazepines

Lorazepam (Ativan) • Use
• Used in combination with a glucocorticoid and
serotonin 5-HT3 receptor antagonist

Cancer chemotherapy

Elsevier items and derived items © 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc.

9

Antiemetics (cont’d)

Serotonin receptor antagonist

Ondansetron (Zofran) • Action

• Use
 

Blocks serotonin receptors in CTZ and afferent vagal nerve terminals in UGI Cancer chemotherapy Headache, diarrhea, dizziness, fatigue

• Side effects

Elsevier items and derived items © 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc.

10

Antiemetics (cont’d)

Glucocorticoids
 

Dexamethasone (Decadron) Methylprednisolone (Solu-Medrol) • Use: cancer chemotherapy Dronabinol (Marinol) • Side effects

Cannabinoids

Drowsiness, dizziness, dry mouth, impaired thinking, euphoria, mood changes, headaches, confusion, depersonalization, nightmares, incoordination, memory lapse, anxiety

Elsevier items and derived items © 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc.

11

Antiemetics (cont’d)

Miscellaneous
 

Diphenidol (Vontrol) Trimethobenzamide (Tigan) • Action
• Side effects
 

Suppress impulses to CTZ Drowsiness, dry mouth, tachycardia, urine retention, constipation, diarrhea, blurred vision, hypotension, EPS

Elsevier items and derived items © 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc.

12

Antiemetics (cont’d)

Nursing interventions
     

Provide mouth care Monitor vital signs, bowel sounds Monitor for dehydration Warn not to consume alcohol when taking an antiemetic Warn pregnant females to avoid antiemetics Avoid driving motor vehicles

Elsevier items and derived items © 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc.

13

Emetics

Ipecac (OTC)
  

Action • Stimulates CTZ & acts directly on gastric mucosa Use • Induces vomiting after toxic substance Caution • Avoid vomiting if substance is caustic or petroleum • If vomiting contraindicated, activated charcoal is
given

Elsevier items and derived items © 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc.

14

Emetics (cont’d)

Ipecac

Administration • Use ipecac syrup, not ipecac fluid extract • Take with a glass of water or fluid, not with milk or
carbonated beverage • Vomiting occurs in 15 to 30 minutes • If vomiting does not occur, give activated charcoal • Gastric lavage may be needed if vomiting does not occur

Elsevier items and derived items © 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc.

15

Diarrhea

Causes
     

Spicy or spoiled foods Bacteria (Escherichia coli), virus, toxins Drug reactions Fecal impaction, laxative abuse Malabsorption disorders, bowel tumor, inflammatory bowel disease Stress, anxiety

Elsevier items and derived items © 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc.

16

Antidiarrheals

Purpose

Decrease hypermotility Should not be used for more than 2 days or if fever is present Opiates and opiate-related agents Somatostatin analog Adsorbents

Caution

Types
  

Elsevier items and derived items © 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc.

17

Antidiarrheals (cont’d)

Opiates and opiate-related agents
  

Paregoric (camporated opium tincture) Diphenoxylate with atropine (Lomotil) Loperamide (Imodium) • Opiates decrease GI motility • Opiates may cause respiratory depression
• May cause physical dependence • Atropine contraindicated in glaucoma

Especially children and elderly

Elsevier items and derived items © 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc.

18

Antidiarrheals (cont’d)

Somatostatin analog

Octreotide (Sandostatin) • Use: for severe diarrhea from cancer

Adsorbents
 

Bismuth salts (Pepto-Bismol) Kaolin-pectin (Kaopectate) • Action: coats GI tract, absorbs bacteria or toxins Parepectolin (paregoric, Kaolin-pectin)

Combination agents

Elsevier items and derived items © 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc.

19

Antidiarrheals (cont’d)

Nursing interventions
      

Monitor BP, R Report more than 10-15 mmHg decrease in BP Monitor frequency of bowel movements and bowel sounds Assess for evidence of dehydration Monitor electrolytes Avoid fried foods, milk, and sedatives If diarrhea persists after 48 hrs, notify MD

Elsevier items and derived items © 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc.

20

Constipation

Causes
    

Bowel obstruction, fecal impaction Chronic laxative use, ignoring urge to defecate Neurologic disorders Side effect of drugs Lack of exercise, fiber, water

Elsevier items and derived items © 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc.

21

Constipation (cont’d)

Laxatives
  

Laxatives: promote soft stool Cathartics: soft to watery stool with cramping Purgatives: watery stool with cramping Osmotic (saline) Stimulant (irritants) Bulk-forming Emollient (stool softeners)

Types of laxatives
   

Elsevier items and derived items © 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc.

22

Osmotic (Saline) Laxatives
  

Polyethylene glycol (GoLYTELY) Lactulose (Chronulac) Action

Hyperosmolar salts pull water into colon, increase water in feces to increase bulk, which stimulates peristalsis Fluid and electrolyte imbalances, hypotension, weakness

Side effects

Elsevier items and derived items © 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc.

23

Stimulant (Irritant) Laxatives
  

Phenolphthalein (Ex-Lax, Correctol) Bisacodyl (Dulcolax) Action

Increase peristalsis by irritating sensory nerve endings in intestinal mucosa

 

Results: orally 6-12 hrs, supp 15-60 min Side effects

Abdominal cramps, weakness, reddish brown urine, diarrhea

Elsevier items and derived items © 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc.

24

Bulk-Forming Laxatives

Psyllium hydrophilic mucilloid (Metamucil) Calcium polycarbophil (Fiber-Con)

Action • Absorb water into intestines, increase bulk and
peristalsis

Results
• 8-12 hrs

Elsevier items and derived items © 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc.

25

Bulk-Forming Laxatives

Administration

Mix in glass of water or juice, stir, drink immediately, follow with 1 glass water Abdominal cramps Excess laxative • Nausea,vomiting, gas, diarrhea

Side effects
 

Elsevier items and derived items © 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc.

26

Emollients (Stool Softeners)
 

Docusate (Colace) Action
  

Lowers surface tension Promotes water accumulation in intestine Emulsifies and lubricates feces for easier passage

Elsevier items and derived items © 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc.

27

Emollients (Stool Softeners) (cont’d)

Use
 

Prevents constipation Reduces straining post surgery or myocardial infarction Abdominal cramping, nausea, vomiting, diarrhea

Side effects

Elsevier items and derived items © 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc.

28

Laxatives

Contraindications
 

Undiagnosed abdominal pain Inflammatory disorders of the GI tract • Appendicitis, diverticulitis, ulcerative colitis  Spastic colon  Bowel obstruction

Pregnancy

Elsevier items and derived items © 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc.

29

Case Study
A client who is taking chemotherapy for cancer of the right kidney is extremely nauseated and vomiting.

Critical Thinking  Which types of antiemetic are appropriate for cancer chemotherapy?

Elsevier items and derived items © 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc.

30

Practice Question #1
Ondansetron (Zofran) has been ordered for the client who is taking cancer chemotherapy to control the severe nausea and vomiting. What side effects are possible?
Headache, dizziness, and fatigue Constipation, anxiety, and fever Abdominal cramping and irritability D. Psychosis and middle ear disturbances
A. B. C.

Elsevier items and derived items © 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc.

31

Practice Question #1 (cont’d)
Answer: A. Rationale: Side effects of ondansetron (Zofran) include headache, dizziness, and fatigue. Constipation, anxiety, fever, abdominal cramping, irritability, psychosis, and middle ear disturbances are not side effects/adverse effects of ondansetron.

Elsevier items and derived items © 2009, 2006, 2003 by Saunders, an imprint of Elsevier Inc.

32

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