5.

Bulk Stimulants ,Lubricants, Other Laxatives ,GI Stimulants

1. Bulk Stimulants

 Bulk stimulants (also called mechanical stimulants) are rapid-acting, aggressive

 laxatives that cause the fecal matter to increase in bulk.
 They increase the motility of the GI tract by increasing the fluid in the intestinal
contents, which enlarges bulk, stimulates local stretch receptors, and activates
local activity
 Available agents are Magnesium Sulfate (Epsom salts), Magnesium Citrate
(Citrate of Magnesia), Magnesium hydroxide (Milk of Magnesia), Lactulose
(Chronulac), Polycarbophil (FiberCon), Psyllium (Metamucil), and Polyethylene
Glycol-Electrolyte Solution (GoLYTELY, MiraLAX).

 Therapeutic Actions and indicators

 Lactulose is a saltless osmotic laxative that pulls fluid out of the venous system
and into the lumen of the small intestine.
 Magnesium citrate and magnesium hydroxideis a milder and slower-acting lax
active. It works by a saline pull, bringing fluids into the lumen of the GI tract.
 Magnesium sulfate acts by exerting a hypertonic pull
against the mucosal wall, drawing fluid into the intestinal contents.
 Polycarbophil is a natural substance that forms a
gelatin-like bulk out of the intestinal contents.
 Polyethylene glycol-electrolyte solution is a hypertonic fluid containing many
electrolytes that pulls fluid out of the intestinal wall to increase the bulk of the
intestinal contents.
 Psyllium, another gelatin-like bulk stimulant, is similar to polycarbophil in action
and effect.

 Pharmacokinetics

 Drugs are not taken orally.

 Directly effective within the GI tract and not generally absorbed systemically.

 Contraindications
 Bulk laxatives are contraindicated with allergy to any component of the drug to
prevent hypersensitivity reactions and in acute abdominal disorders, including
appendicitis, diverticulitis, and ulcerative colitis, when increased motility could
lead to rupture or further exacerbation of the inflammation.

 Cautions
 Laxatives should be used with caution in heart block. CAD and debilitation,
which could be affected by the decrease in absorption and changes in electrolyte
levels that can occur, and with great caution during pregnancy and lactation
because, in some cases, stimulation of the GI tract can precipitate labor and many
of these agents cross the placenta and are excreted in breast milk.
 Polyethylene glycolelectrolyte solution should be used with caution in any patient
with a history of seizures because of the risk of electrolyte absorption causing
neuronal instability and precipitating seizures.

 Adverse Effect

 It is most commonly associated with bulk laxatives are GI effects such as

diarrhea, abdominal cramping, and nausea.
 CNS effects, including dizziness, headache, and weakness, are not uncommon
and may relate to loss of fluid and electrolyte imbalances that may accompany
laxative use.
 After laxative use you will experience sweating, palpitations, flushing, and even
fainting
 Patients must use caution and take bulk laxatives with plenty of water.
 If only a little water is used, the laxative may absorb enough fluid in the
esophagus to swell into a gelatin-like mass that can obstruct the esophagus and
cause severe problems.

 Clinically Important Drug-Drug interactions

 Bulk laxatives increase the motility of the GI tract, and some interfere with the
timing or process of absorption. It is advisable not to take laxatives with other
prescribed medications.
 The patient administered of laxatives and other medications should be separated
by at least 30 minutes.
 There is an increased risk of neuromuscular blockade when using
nondepolarizing neuromuscular junction blockers with magnesium salts; if this
combination is used, the patient must be closely monitored and appropriate life
support provided.

2. Lubricants

 Patients with hemorrhoids and those who have recently had rectal surgery may
need lubrication of the stool.
 Some patients who could be harmed by straining might also benefit from this type
of laxative.
 The recommended type of laxative is depend on the condition of the patient, the
speed of relief needed, and the possible implication of various adverse effects.
 Lubricating laxatives include Docusate (Colace), Glycerin (Sani-Supp), and
Mineral oil (Agoral Plain).

 Therapeutic Actions and Indications

 Glycerin is a hyperosmolar laxative that is used in suppository form to gently

evacuate the rectum without systemic effects higher in the GI tract.
 Mineral oil is the oldest of these laxatives. It is not absorbed and forms a slippery
coat on the contents of the intestinal tract.

 Pharmacokinetics
 Docusate and mineral oil are given orally.
 Glycerin is available as a rectal suppository or as a liquid for rectal retention.

 Contraindications

 These drugs are contraindicated with allergy to any component of the drug to
prevent hypersensitivity reactions and in acute abdominal disorders, including
appendicitis, diverticulitis, and ulcerative colitis, when increased motility could
lead to rupture or further exacerbation of the inflammation.

 Cautions

 Laxatives should be used with caution in heart block. CAD and debilitation,
which could be affected by the decrease in absorption and changes in electrolyte
levels that can occur, and with great caution during pregnancy and lactation
because, in some cases, stimulation of the GI tract can precipitate labor and many
of these agents cross the placenta and are excreted in breast milk.

 Adverse Effects

 It is most commonly associated with lubricant laxatives are GI effects such as

diarrhea, abdominal cramping, and nausea.
 Leakage and staining may be a problem when mineral oil is used and the stool
cannot be retained by the external sphincter.
 Less likely to happen with the lubricant laxatives than with the chemical or
mechanical stimulants.

 Clinically Important Drug-Drug interactions

 Frequent use of mineral oil can interfere with absorption of the fat-soluble
vitamins A, D, E, and K.

 Nursing Considerations for Patients Receiving Laxatives

Assessment: History and Examination

 Assess for possible contraindications or cautions: history of allergy to laxative to

prevent hypersensitivity reaction; fecal impaction or intestinal obstruction, which
could be exacerbated by increased gastrointestinal (GI) activity; acute abdominal
pain, nausea, or vomiting, which could represent an underlying medical
condition; and current status of pregnancy or lactation, which could be
contraindications or require cautious use.
 Perform a physical examination to establish baseline data before beginning
therapy and during therapy to determine the effectiveness of the drug and to
evaluate for any adverse effects associated with drug therapy.
 Inspect the skin for rash to monitor for adverse reactions.
 Assess the patient’s neurological status, including level of orientation and affect,
to evaluate any central nervous system (CNS) effects of the drug.
 Obtain a baseline pulse rate to assess for any cardiovascular effects of the drug.
 Assess bowel elimination patterns, including the patient’s perception of normal
frequency, actual frequency, and stool characteristics, to determine the need for
therapy.
 Investigate the patient’s nutritional intake, including fluid intake and ingestion of
fiber-containing foods, to evaluate for possible contributing factors related to the
need for the drug.
 Assess the patient’s level of activity to determine possible contributing factors for
decreased bowel motility.
 Perform an abdominal examination, including inspecting abdomen for distention,
palpating for masses, and auscultating for bowel sounds, to establish adequate
bowel function, rule out underlying medical conditions, and assess the
effectiveness of the drug.
 Monitor results of laboratory tests, including serum electrolyte levels, to detect
any changes related to altered absorption.

3. Gastrointestinal Stimulants

 Some drugs are available for more generalized GI stimulation that results in an
overall increase in GI activity and secretions
 These drugs stimulate parasympathetic activity or make the GI tissues more
sensitive to parasympathetic activity.
 Stimulants include Dexpanthenol (Ilopan) and Metoclopramide (Reglan).

 Therapeutic Actions and Indications

 Dexpanthenol works by increasing acetylcholine levels and stimulating the

parasympathetic system.
 Metoclopramide works by blocking dopamine receptors and making the GI cells
more sensitive to acetyl choline, which leads to increased GI activity and rapid
movement of food through the upper GI tract. It also studied for improvement of
lactation in doses of 30 to 45 mg/d.

 Pharmacokinetics

 Dexpanthenol is given by intramuscular (IM) injection and reaches peak levels

within 4 hours.

 Metoclopramide is given orally or by IM injection or intravenous (IV) infusion

and has a peak effect by all routes in 60 to 90 minutes.

 They are metabolized in the liver and excreted in feces and urine.
Metoclopramide crosses the placenta and enters breast milk; dexpanthenol may
cross the placenta and enter breast milk.

 Contractions

 These drugs helps to prevent hypersensitivity reactions or with any GI obstruction

or perforation, which could be exacerbated by the GI stimulation.
 Adverse Effects

 The most common adverse effects seen with GI stimulants include nausea,
vomiting, diarrhea, intestinal spasm, and cramping.
 Other adverse effects, such as declining blood pressure and heart rate, weakness,
and fatigue, may be related to parasympathetic stimulation, extrapyramidal
effects, and Parkinson-like syndrome.

 Clinically Important Drug-Drug Interactions

 Metoclopramide has been associated with decreased absorption of digoxin from

the GI tract; patients taking this combination should be monitored carefully.
 Decreased immunosuppressive effects and increased toxicity of cyclosporine
have occurred when combined with metoclopramide.
 Increased sedation can occur if either of these drugs is combined with alcohol or
other CNS sedative drugs.

 Nursing Considerations for Patients Receiving Gastrointestinal Stimulants

Assessment: History and Examination

 Assess for possible contraindications or cautions: any history of allergy to these

drugs to prevent hypersensitivity reactions; intestinal obstruction, bleeding, or
perforation, which could be exacerbated by stimulating the gastrointestinal (GI)
tract; and current status of pregnancy or lactation, which require cautious use.
 Perform a physical examination to establish baseline data before beginning
therapy and during therapy to determine the effectiveness of the drug and to
evaluate for the occurrence of any adverse effects associated with drug therapy.
 Perform an abdominal examination, including inspecting for distention, palpating
for masses, and checking bowel sounds, to ensure adequate GI function and
motility.
 Assess cardiopulmonary status, including pulse and blood pressure, to monitor
for possible cardiovascular adverse effects.
 Inspect skin for color and evidence of lesions or rash to assess for
hypersensitivity reactions.