Peak Development for ...

Medication Administration

Vol. 15 Issue 1 January 2014

GI Agents: Osmotic Laxatives

Peak Development Resources P.O. Box 13267 Richmond, VA 23225 Phone: (804) 233-3707 Fax: (804) 233-3705 Email: editor@peakdev.com

Peak Development for Medication Administration and Competency Assessment Tool for Medication Administration are components of a site license for the Peak Development Resources Competency Assessment System for Medication Administration and may be reproduced for this individual facility only. Sharing of these components with any other freestanding facility within or outside the licensees corporate entity is expressly prohibited.

After completion the learner should be able to: 1. Identify appropriate indications for use of osmotic laxatives. 2. Relate general characteristics of osmotic laxatives to specific patient situations. 3. Apply nursing process considerations for osmotic laxatives to patient situations. 4. Correctly calculate dosage for osmotic laxatives. Effective bowel function and elimination are important to good overall health and comfort. In some cases, medications are required to promote or restore effective bowel elimination, either for normal function or in preparation for medical procedures. Laxatives are substances that promote effective bowel elimination, and are in common use in the US and worldwide. In the US, approximately $725 million is spent on laxatives each year. There are a number of indications for laxative use, with the most common being treatment of constipation. The Centers for Disease Control and Prevention (CDC) define constipation as the passage of hard, dry, stool, accompanied by symptoms such as difficult expulsion, straining, and bloating. Also, bowel movements usually occur less than 3 times per week. Constipation is one of the most common GI disorders, and is experienced, at least occasionally, by the vast majority of people. Frequent or chronic constipation affects more than 400 million Americans each year. There are a number of different laxative types, such as osmotic, stimulant, lubricant, bulk -forming, and surfactant laxatives. Osmotic laxatives are commonly used, and include: polyethylene glycol (Miralax, GoLytely) lactulose magnesium hydroxide (Milk of Magnesia) magnesium citrate (Citroma) sodium phosphate (Osmoprep) Indications The most common indication for use of osmotic laxatives is the treatment of occasional

The information contained in Peak Development for Medication Administration is intended only as a guide for the practice of licensed nursing personnel who administer medications. Every effort has been made to verify the accuracy of the information herein. Because of rapid changes in the field of drug therapy, the reader is advised to consult the package insert, facility pharmacist or patients physician for relevant information. This is particularly important for new or seldom used drugs. Use of professional judgment is required in all patient care situations. It is the readers responsibility to understand and adhere to policies and procedures set forth by the employing institution. The editor and publisher of this newsletter disclaim any liability resulting from use or misuse of information contained herein. Copyright 2014

or chronic constipation. They are also used for bowel cleansing (bowel prep) prior to medical procedures, such as colonoscopy or surgery. Pharmacodynamics Osmotic laxatives draw water from the body into the lumen of the bowel, and also reduce absorption of water from the bowel. This effect softens the stool by adding water and adds bulk, which stimulates peristalsis. They also stimulate the release of cholecystokinin from the intestinal mucosa, a hormone that promotes bowel motility. Lactulose interacts with gut bacteria to produce acids that bring water into the bowel and stimulate peristalsis. Therefore, if the gut bacteria is reduced, such as by antibiotic use, the effects of lactulose may be decreased. Pharmacokinetics Absorption: Absorption of osmotic laxatives from the bowel is low; they generally remain within the lumen of the bowel, where their mechanism of action occurs, but may be absorbed into the circulation in small amounts Distribution/Metabolism: Not distributed or metabolized systemically Elimination: Via the fecal route Major Interactions Neomycin and other non-absorbed oral antibiotics: May reduce the effectiveness of lactulose by decreasing gut bacteria Adverse Effects/Toxicity Osmotic laxatives may cause cramping, bloating, abdominal distention, nausea, vomiting, diarrhea and gas. Dehydration, fluid volume overload, and electrolyte imbalance may also occur, especially with laxative abuse, renal or cardiac impairment, and in the elderly. The sodium phosphate products, when used for bowel prep, carry a black box warning that nephrotoxicity may occur. This has resulted in some cases of permanent renal impairment requiring dialysis. Use of magnesium products

may result in magnesium toxicity, particularly in the elderly and patients with renal impairment. Precautions/Contraindications Osmotic laxatives should not be used in patients with undiagnosed abdominal pain or vomiting, intestinal obstruction, or hypersensitivity to laxative ingredients. Cautious use is advised in patients with dehydration, fluid volume overload, or electrolyte imbalance. Magnesium and phosphate preparations for relief of constipation should be used cautiously in elderly patients and those with significant renal impairment or cardiac disease. When used for bowel prep, phosphate products should be used cautiously in the elderly and in those with dehydration, renal impairment, or those taking medications that affect renal function, such as diuretics, ACE inhibitors, and ARBs (angiotensin receptor blockers). These groups are most likely to be affected by acute renal injury from these products. Nursing Process Assessment Determine baseline status: Prior to laxative use for treatment of constipation, a thorough assessment of the patients GI status, current pattern of elimination, and typical dietary intake should be conducted. Any abnormalities, such as abdominal pain, distention, nausea, or hypo or hyperactive bowel sounds should be noted, as well as frequency, amount, color and consistency of bowel movements. Dietary intake should be assessed to identify patterns that either promote or prevent constipation, including intake of water and other fluids and high-fiber foods, such as fruits, vegetables and whole grains. In addition, a current medication history is important to identify factors promoting constipation, such as use of opioids or laxative abuse. Laxative abuse is common, particularly among the elderly and those with anorexia, bulimia and chronic constipation. The patients current activity level should also be assessed, as lack of physical activity is a significant risk factor for constipation. Identify risk factors: The patient should be assessed for risk factors, such as renal impairment, cardiac disease, and fluid/ electrolyte imbalance. In patients taking phosphate products for bowel prep, the medication history should also include assessment for drugs that may affect renal function, such as diuretics and ACE inhibitors. Age-specific considerations: Laxatives should not be taken in large amounts or for prolonged periods during pregnancy, to avoid fluid/electrolyte imbalance. Occasional use of polyethylene glycol (PEG) or lactulose for treatment of constipation is generally considered safe under a physicians guidance for pregnant and nursing mothers. Constipation in children is commonly treated with PEG, lactulose, or

magnesium hydroxide, again under the direction of a physician. The elderly have the highest prevalence of constipation among the various age groups, and use the most laxatives. They are also more likely to have associated risk factors requiring cautious use of laxatives, such as renal or cardiac impairment, dehydration and fluid volume overload. Planning and Analysis The goal of therapy with laxatives is to relieve constipation or to clear the bowel prior to medical procedures. Intervention Medication administration: For relief of constipation, the patient should be instructed in how to take the medication and when to expect relief. Lactulose and PEG usually produce a bowel movement in 1-3 days, while the magnesium products act in 30 min6 hours. For bowel prep, the patient should be provided verbal and written instructions at least one week prior to the procedure, if possible. This typically includes a clear liquid diet for 1-2 days prior to the procedure and use of prescribed laxatives until the bowel is clear. Observe for therapeutic effects: Relief of constipation is assessed by the patients report of improved comfort, and more frequent, softer bowel movements. For bowel prep, the stool should be clear, yellowish fluid with no solid pieces, other than tiny flecks. Observe for adverse effects: Monitor the patient, particularly those at increased risk, for dehydration, fluid volume overload and urinary changes. Lab work should be assessed for any changes in electrolyte balance or renal function. Also, observe for more common adverse effects, such as bloating, cramping, nausea and loose stools. Patient/Family teaching: For relief of constipation, education should include dietary and lifestyle factors, including regular daily exercise, 20-25 gm of fiber per day, increased fruits, vegetables, and whole grains, and at least 6-8 glasses of fluid daily (unless contraindicated). Laxatives should not be used for more than 1-2 weeks, without consulting a doctor. Laxatives should be taken as orderedthe dose or frequency should not be increased without consulting a doctor. It is not necessary to have a bowel movement every day patients should develop a pattern that is normal and comfortable for them. Some laxatives may take 23 days to provide relief this does not mean the laxative is not working. Evaluation The nurses role in assessment, monitoring and effective patient education promotes the successful use of osmotic laxatives for relief of constipation or bowel prep prior to medical procedures.

Peak Development for Medication Administration GI Agents: Osmotic Laxatives Page 2

Peak Development for ... Medication Administration Competency Assessment Tool

Vol. 15 Issue 1 January 2014

GI Agents: Osmotic Laxatives

NAME: DATE: UNIT:

Directions: Place the letter of the one best answer in the space provided.
_____1. The CDC defines constipation as: A. bowel movements occurring less than once daily B. passage of hard, dry stool C. whatever the patient says it is D. lack of any urge to have a bowel movement _____2. Osmotic laxatives act primarily by: A. lubricating the GI tract B. adding fiber into the bowel C. drawing water into the bowel D. irritating the mucosa of the GI tract _____3. Osmotic laxatives promote bowel movements by: A. softening stool B. increasing the bulk of stool C. stimulating the release of cholecystokinin D. all of the above _____4. Which of the following osmotic laxatives is most likely to be affected by changes in the patients gut bacteria, such as may occur with antibiotic use: A. lactulose B. polyethylene glycol C. magnesium hydroxide D. sodium phosphate

_____5. Which of the following osmotic laxatives carries a black box warning regarding the risk of renal damage when used for bowel prep: A. polyethylene glycol B. magnesium citrate C. lactulose D. sodium phosphate _____6. Which of the following patients should most clearly NOT take an osmotic laxative: A. Joey, who is 12 years old B. Carla, who is in her second trimester of pregnancy C. Dan, who has undiagnosed abdominal pain D. Nora, who is 78 years old with mild heart failure _____7. The elderly have the highest prevalence of constipation and use more laxatives than any other age group. A. True B. False _____8. A patient who has been advised by his doctor to take magnesium hydroxide for relief of constipation asks the nurse how long it will take to work. The nurse appropriately responds: A. It works fairly quickly, most people have a bowel movement within 6 hours. B. It will probably take about 24 hours for you to notice any effects. C. You should have a bowel movement in 23 days. D. Theres no way to know, all of these laxatives act differently on people. _____9. A bowel prep is most likely to be complete and successful when the patient reports which of the following types of bowel movement: A. soft, non-formed stool B. clear, yellowish fluid C. thin, brown liquid stool D. none - there is no bowel activity _____10. Drug Order: Lactulose solution 30 gm PO bid Drug Label: Lactulose solution 10 gm per 15 ml Give: A. 15 ml B. 30 ml C. 45 ml D. 60 ml
Competency Assessment Tool GI Agents: Osmotic Laxatives Page 2

Peak Development for ... Medication Administration

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