N241 chap 50, 51, 52 W22-2.pptx

CHAPTER 50 ACID-CONTROLLING DRUGS Copyright © 2020 Elsevier Inc. All Rights Reserved. ACID-RELATED PATHOPHYSIOLOGY THE STOMACH SECRETES HYDROCHLORIC ACID (HCL) BICARBONATE PEPSINOGEN INTRINSIC FACTOR MUCUS PROSTAGLANDINS Copyright © 2020 Elsevier Inc. All Rights Reserved. 2 GLANDS OF THE STOMACH CAR...

CHAPTER 50 ACID-CONTROLLING DRUGS Copyright © 2020 Elsevier Inc. All Rights Reserved. ACID-RELATED PATHOPHYSIOLOGY THE STOMACH SECRETES HYDROCHLORIC ACID (HCL) BICARBONATE PEPSINOGEN INTRINSIC FACTOR MUCUS PROSTAGLANDINS Copyright © 2020 Elsevier Inc. All Rights Reserved. 2 GLANDS OF THE STOMACH CARDIAC PYLORIC GASTRIC THE CELLS OF THE GASTRIC GLAND ARE THE LARGEST IN NUMBER AND OF PRIMARY IMPORTANCE WHEN DISCUSSING ACID CONTROL. Copyright © 2020 Elsevier Inc. All Rights Reserved. 3 Parietal cells Produce and secrete HCl Primary site of action for many of the drugs used to treat acidrelated disorders Mucous cells Mucussecreting cells (surface epithelial cells) protective mucus coat Protect against self-digestion by HCl and digestive Copyright © 2020 Elsevier Inc. All Rights Reserved. Chief cells Secrete pepsinogen, a proenzyme Pepsinogen becomes pepsin when activated by exposure to acid. Pepsin breaks down proteins (proteolytic). Cells of the Gastric Gland 4 HYDROCHLORIC ACID SECRETED BY PARIETAL CELLS WHEN STIMULATED BY FOOD, CAFFEINE, CHOCOLATE, AND ALCOHOL MAINTAINS STOMACH AT PH OF 1 TO 4 ACIDITY AIDS IN THE PROPER DIGESTION OF FOOD AND DEFENSES AGAINST MICROBIAL INFECTION VIA THE GASTROINTESTINAL (GI) TRACT. SECRETION ALSO STIMULATED BY: LARGE FATTY MEALS EMOTIONAL STRESS Copyright © 2020 Elsevier Inc. All Rights Reserved. 5 ACID-RELATED DISEASES Peptic ulcer disease (PUD) Gastric or duodenal ulcers that involve digestion of the GI mucosa by the enzyme pepsin Copyright © 2020 Elsevier Inc. All Rights Reserved. Helicobacter pylori (H. pylori) Bacterium found in GI tract of 90% of patients with duodenal ulcers and 70% of those with gastric ulcers First-line therapy includes a 10to 14-day course of a proton pump inhibitor (PPI) and the antibiotics clarithromycin and either amoxicillin or metronidazole or a combination of a PPI, bismuth subsalicylate, and the antibiotics tetracycline and metronidazole. 6 ACID-RELATED DISEASES (CONT.) STRESS-RELATED MUCOSAL DAMAGE GI LESIONS ARE A COMMON FINDING IN INTENSIVE CARE UNIT (ICU) PATIENTS, ESPECIALLY WITHIN THE FIRST 24 HOURS AFTER ADMISSION. DECREASED BLOOD FLOW, MUCOSAL ISCHEMIA, HYPOPERFUSION, AND REPERFUSION INJURY. NASOGASTRIC (NG) TUBES AND VENTILATORS A HISTAMINE RECEPTOR–BLOCKING DRUG OR A PPI ARE GIVEN FOR PREVENTION. Copyright © 2020 Elsevier Inc. All Rights Reserved. DATA DO NOT SUPPORT THE 7 TYPES OF ACID-CONTROLLING DRUGS Antacids H2 antagoni sts Copyright © 2020 Elsevier Inc. All Rights Reserved. PPIs 8 Basic compounds used to neutralize stomach acid Salts of aluminum, magnesium, calcium, and/or sodium ANTACIDS Many antacid preparations also contain the antiflatulent (antigas) drug simethicone. Many aluminum- and calciumbased formulations also include magnesium, which not only contributes to the acidneutralizing capacity but also counteracts Copyright © 2020 Elsevier Inc. the All Rightsconstipating Reserved. 9 effects of aluminum and calcium. DO NOT PREVENT THE OVERPRODUCTION OF ACID BUT INSTEAD HELP TO NEUTRALIZE ACID SECRETIONS ANTACIDS: MECHANISM OF ACTION PROMOTE GASTRIC MUCOSAL DEFENSE MECHANISMS STIMULATE SECRETION OF: MUCUS: PROTECTIVE BARRIER AGAINST HCL BICARBONATE: HELPS BUFFER ACIDIC PROPERTIES OF HCL PROSTAGLANDINS: PREVENT ACTIVATION OF PROTON PUMP Copyright © 2020 Elsevier Inc. All Rights Reserved. 10 ANTACIDS: DRUG EFFECTS REDUCTION OF PAIN ASSOCIATED WITH ACID-RELATED DISORDERS RAISING THE GASTRIC PH 1 POINT (1.3 TO 2.3) NEUTRALIZES 90% OF THE GASTRIC ACID. REDUCING ACIDITY REDUCES PAIN AS A RESULT OF: BASE-MEDIATED INHIBITION OF THE PROTEINDIGESTING ABILITY OF PEPSIN INCREASE IN THE RESISTANCE OF THE STOMACH LINING TO 11 IRRITATION INCREASE IN THE TONE OF Copyright © 2020 Elsevier Inc. All Rights Reserved. ANTACIDS: INDICATIO NS ACUTE RELIEF OF SYMPTOMS ASSOCIATED WITH PEPTIC ULCER, GASTRITIS, GASTRIC HYPERACIDITY, AND HEARTBURN Copyright © 2020 Elsevier Inc. All Rights Reserved. 12 Known allergy to a specific drug product ANTACIDS: CONTRAINDICATIO NS Severe renal failure or electrolyte disturbances: potential toxic accumulation of electrolytes in the antacids themselves GI obstruction: antacids may stimulate GI motility when they are undesirable because of the presence of an obstructive process requiring surgical intervention Copyright © 2020 Elsevier Inc. All Rights Reserved. 13 ANTACIDS OVER-THE-COUNTER (OTC) FORMULATIONS AVAILABLE AS: CAPSULES AND TABLETS POWDERS CHEWABLE TABLETS SUSPENSIONS EFFERVESCENT GRANULES AND TABLETS Copyright © 2020 Elsevier Inc. All Rights Reserved. 14 ANTACIDS: ALUMINUM SALTS HAVE CONSTIPATING EFFECTS OFTEN USED WITH MAGNESIUM TO COUNTERACT CONSTIPATION OFTEN RECOMMENDED FOR PATIENTS WITH RENAL DISEASE (MORE EASILY EXCRETED) EXAMPLES ALUMINUM CARBONATE: BASALJEL HYDROXIDE SALT: ALTERNAGEL COMBINATION PRODUCTS (ALUMINUM AND MAGNESIUM): GAVISCON, MAALOX, MYLANTA, DI-GEL Copyright © 2020 Elsevier Inc. All Rights Reserved. 15 ANTACIDS: MAGNESIUM SALTS COMMONLY CAUSE DIARRHEA; USUALLY USED WITH OTHER DRUGS TO COUNTERACT THIS EFFECT DANGEROUS WHEN USED WITH RENAL FAILURE; THE FAILING KIDNEY CANNOT EXCRETE EXTRA MAGNESIUM, RESULTING IN ACCUMULATION EXAMPLES HYDROXIDE SALT: MAGNESIUM HYDROXIDE (MILK OF MAGNESIA) COMBINATION PRODUCTS SUCH AS MAALOX, MYLANTA (ALUMINUM AND MAGNESIUM) Copyright © 2020 Elsevier Inc. All Rights Reserved. 16 ANTACIDS: CALCIUM SALTS MANY FORMS BUT CARBONATE IS MOST COMMON MAY CAUSE CONSTIPATION, KIDNEY STONES ALSO NOT RECOMMENDED FOR PATIENTS WITH RENAL DISEASE—MAY ACCUMULATE TO TOXIC LEVELS LONG DURATION OF ACID ACTION—MAY CAUSE INCREASED GASTRIC ACID SECRETION (HYPERACIDITY REBOUND) OFTEN ADVERTISED AS AN EXTRA SOURCE OF DIETARY CALCIUM EXAMPLE: TUMS (CALCIUM CARBONATE) Copyright © 2020 Elsevier Inc. All Rights Reserved. 17 ANTACIDS: SODIUM BICARBONATE HIGHLY SOLUBLE BUFFERS THE ACIDIC PROPERTIES OF HCL QUICK ONSET BUT SHORT DURATION MAY CAUSE METABOLIC ALKALOSIS (IRRITABILITY, MUSCLE TWITCHING, NUMBNESS, TINGLING, SHALLOW RESP, HA, THIRST) SODIUM CONTENT MAY CAUSE PROBLEMS IN PATIENTS WITH HEART FAILURE (HF), HYPERTENSION, OR RENAL INSUFFICIENCY. Copyright © 2020 Elsevier Inc. All Rights Reserved. 18 ANTACIDS AND ANTIFLATULENTS ANTIFLATULENTS: USED TO RELIEVE THE PAINFUL SYMPTOMS ASSOCIATED WITH GAS SEVERAL DRUGS ARE USED TO BIND OR ALTER INTESTINAL GAS AND ARE OFTEN ADDED TO ANTACID COMBINATION PRODUCTS. SIMETHICONE Copyright © 2020 Elsevier Inc. All Rights Reserved. 19 ANTACIDS: ADVERSE EFFECTS MINIMAL AND DEPEND ON THE COMPOUND USED OVERUSE: METABOLIC ALKALOSIS ALUMINUM AND CALCIUM: CONSTIPATION MAGNESIUM: DIARRHEA CALCIUM: KIDNEY STONES, REBOUND HYPERACIDITY CALCIUM CARBONATE: PRODUCES GAS AND BELCHING; OFTEN COMBINED WITH Copyright © 2020 Elsevier Inc. All Rights Reserved. SIMETHICONE 20 ANTACIDS: DRUG INTERACTIONS ADSORPTION OF OTHER DRUGS TO ANTACIDS REDUCES THE ABILITY OF THE OTHER DRUG TO BE ABSORBED INTO THE BODY (EX. QUINOLONES) CHELATION CHEMICAL BINDING, OR INACTIVATION, OF ANOTHER DRUG PRODUCES INSOLUBLE COMPLEXES RESULT: REDUCED DRUG ABSORPTION INCREASED STOMACH PH INCREASED ABSORPTION OF BASIC DRUGS DECREASED ABSORPTION OF ACIDIC DRUGS INCREASED URINARY PH INCREASED EXCRETION OF ACIDIC DRUGS Copyright © 2020 Elsevier Inc. All Rights Reserved. DECREASED EXCRETION OF BASIC DRUGS 21 Assess for allergies and preexisting conditions that may restrict the use of antacids, such as: NURSING IMPLICATION S: ANTACIDS Fluid imbalances Renal disease GI obstruction HF Pregnancy Patients with HF or hypertension should not use antacids with high sodium content. Copyright © 2020 Elsevier Inc. All Rights Reserved. 22 Use with caution with other medications because of the many drug interactions. NURSING IMPLICATION S: ANTACIDS (CONT.) Most medications should be administered 1 to 2 hours after an antacid. Antacids may cause premature dissolving of enteric-coated medications, resulting in stomach upset. Copyright © 2020 Elsevier Inc. All Rights Reserved. 23 NURSING IMPLICATION S: ANTACIDS (CONT.) Be sure that chewable tablets are chewed thoroughly and liquid forms are shaken well before giving. Administer with at least 8 oz of water to enhance absorption (except for “rapiddissolve” forms). Copyright © 2020 Elsevier Inc. All Rights Reserved. 24 Long-term selfmedication with antacids may mask symptoms of serious underlying diseases, such as malignancy or bleeding ulcers. If symptoms remain ongoing, the patient should seek medical evaluation. NURSING IMPLICATIONS: ANTACIDS (CONT.) Copyright © 2020 Elsevier Inc. All Rights Reserved. 25 NURSING IMPLICATIONS: ANTACIDS (CONT.) MONITOR FOR ADVERSE EFFECTS: NAUSEA, VOMITING, ABDOMINAL PAIN, DIARRHEA WITH CALCIUM-CONTAINING PRODUCTS: CONSTIPATION, ACID REBOUND MONITOR FOR THERAPEUTIC RESPONSE: NOTIFY THE HEALTH CARE PROVIDER IF SYMPTOMS ARE NOT RELIEVED. Copyright © 2020 Elsevier Inc. All Rights Reserved. 26 ANTACIDS Copyright © 2017, Elsevier Inc. All rights reserved. 27 HISTAMINE 2 (H2) RECEPTOR ANTAGONISTS Reduce acid secretion All available OTC in lower dosage forms Most popular drugs for treatment of acidrelated disorders Cimetidine (Tagamet) Famotidine (Pepcid) Ranitidine (Zantac) (N-Nitrosodimethylamine (NDMA) Copyright © 2020 Elsevier Inc. All Rights Reserved. 28 H2 ANTAGONISTS: MECHANISM OF ACTION Competitively block the H2 receptor of acidproducing parietal cells Increase in the pH of the stomach Copyright © 2020 Elsevier Inc. All Rights Reserved. Reduced hydrogen ion secretion from the parietal cells Relief of many of the symptoms associated with hyperacidityrelated conditions 29 Drug effect H2 ANTAGONIS TS: DRUG EFFECT AND INDICATION S Suppressed acid secretion in the stomach Indications Gastroesophageal reflux disease (GERD) PUD Erosive esophagitis Adjunct therapy to control upper GI bleeding Zollinger-Ellison syndrome Copyright © 2020 Elsevier Inc. All Rights Reserved. 30 H2 ANTAGONISTS: ADVERSE EFFECTS OVERALL, VERY FEW ADVERSE EFFECTS CENTRAL NERVOUS SYSTEM ADVERSE EFFECTS IN ELDERLY PATIENTS INCLUDE CONFUSION AND DISORIENTATION. CIMETIDINE MAY INDUCE IMPOTENCE AND GYNECOMASTIA. THROMBOCYTOPENIA HAS BEEN REPORTED WITH RANITIDINE AND FAMOTIDINE. Copyright © 2020 Elsevier Inc. All Rights Reserved. 31 H2 ANTAGONISTS: DRUG INTERACTIONS CIMETIDINE (TAGAMET) BINDS WITH P-450 MICROSOMAL OXIDASE SYSTEM IN THE LIVER, BY INHIBITING THE METABOLISM OF DRUGS METABOLIZED VIA THIS PATHWAY, CIMETIDINE MAY RAISE THE BLOOD CONCENTRATIONS OF CERTAIN DRUGS. ALL H2 ANTAGONISTS MAY INHIBIT THE ABSORPTION OF DRUGS THAT REQUIRE AN ACIDIC GI ENVIRONMENT FOR ABSORPTION. BECAUSE OF ITS POTENTIAL TO CAUSE DRUG INTERACTIONS, CIMETIDINE HAS BEEN LARGELY REPLACED BY RANITIDINE AND FAMOTIDINE (DOES NOT BIND TO THE P-450 ENZYME SYSTEM) CIMETIDINE IS STILL USED TO TREAT CERTAIN ALLERGIC REACTIONS. Copyright © 2020 Elsevier Inc. All Rights Reserved. 32 H2 ANTAGONIST S: DRUG INTERACTIO NS (CONT.) Smoking has been shown to decrease the effectiveness of H2 blockers. For optimal results, H2 receptor antagonists are taken 1 to 2 hours before antacids. Copyright © 2020 Elsevier Inc. All Rights Reserved. 33 NURSING IMPLICATIONS: H2 ANTAGONISTS ASSESS FOR ALLERGIES AND IMPAIRED RENAL OR LIVER FUNCTION. USE WITH CAUTION IN PATIENTS WHO ARE CONFUSED, DISORIENTED, OR OLDER. TAKE 1 TO 2 HOURS BEFORE ANTACIDS. Copyright © 2020 Elsevier Inc. All Rights Reserved. 34 H2 RECEPTOR ANTAGONISTS Copyright © 2017, Elsevier Inc. All rights reserved. 35 PROTON PUMP INHIBITORS THE PARIETAL CELLS RELEASE POSITIVE HYDROGEN IONS (PROTONS) DURING HCL PRODUCTION. THIS PROCESS IS CALLED THE PROTON PUMP. H2 BLOCKERS AND ANTIHISTAMINES DO NOT STOP THE ACTION OF THIS PUMP. Copyright © 2020 Elsevier Inc. All Rights Reserved. 36 PROTON PUMP INHIBITO RS (CONT.) Lansoprazole (Prevacid) Omeprazole (Prilosec) Pantoprazole (Protonix) Esomeprazole (Nexium) Copyright © 2020 Elsevier Inc. All Rights Reserved. 37 PROTON PUMP INHIBITORS: MECHANISM OF ACTION IRREVERSIBLY BIND TO H+/K+ ATPASE ENZYME THIS BOND PREVENTS THE MOVEMENT OF HYDROGEN IONS FROM THE PARIETAL CELL INTO THE STOMACH. RESULTS IN ACHLORHYDRIA—ALL GASTRIC ACID SECRETION IS TEMPORARILY BLOCKED. Copyright © 2020 Elsevier Inc. All Rights Reserved. 38 TO RETURN TO NORMAL ACID SECRETION, THE + + PROTON PUMP INHIBITOR S: INDICATIO NS GERD Erosive esophagitis Short-term treatment of active duodenal and benign gastric ulcers Zollinger-Ellison syndrome Nonsteroidal antiinflammatory drug (NSAID)– induced ulcers Stress ulcer prophylaxis Treatment of H. pylori–induced ulcers Given with an antibiotic (metronidazole/Amoxi Copyright © 2020 Elsevier Inc. All Rights Reserved. cillin) 39 PROTON PUMP INHIBITORS: ADVERSE EFFECTS PPIS ARE GENERALLY WELL TOLERATED. POSSIBLE PREDISPOSITION TO GI TRACT INFECTIONS: CLOSTRIDIUM DIFFICILE OSTEOPOROSIS AND RISK OF WRIST, HIP, AND SPINE FRACTURES IN LONG-TERM USERS PNEUMONIA DEPLETION OF MAGNESIUM LINK BETWEEN PPIS AND DEMENTIA AS WELL AS DEVELOPMENT OF LUPUS ERYTHEMATOUS Copyright © 2020 Elsevier Inc. All Rights Reserved. 40 Warfarin: increased chance of bleeding PROTON PUMP INHIBITORS: DRUG INTERACTIO NS Absorption of ketoconazole, ampicillin, iron salts, and digoxin Clopidogrel Food may decrease absorption of the PPIs. Copyright © 2020 Elsevier Inc. All Rights Reserved. 41 PROTON PUMP INHIBITORS Copyright © 2017, Elsevier Inc. All rights reserved. 42 ASSESS FOR ALLERGIES AND HISTORY OF LIVER DISEASE. NOT ALL ARE AVAILABLE FOR PARENTERAL ADMINISTRATION. NURSING IMPLICATIO NS: PROTON PUMP INHIBITORS MAY INCREASE SERUM LEVELS OF DIAZEPAM AND PHENYTOIN; MAY INCREASE CHANCE FOR BLEEDING WITH WARFARIN Copyright © 2020 Elsevier Inc. All Rights Reserved. 43 NURSING IMPLICATIONS: PROTON PUMP INHIBITORS (CONT.) THE GRANULES OF PANTOPRAZOLE CAPSULES MAY BE GIVEN VIA NG TUBES, BUT THE NG TUBE MUST BE AT LEAST 16 GAUGE OR THE TUBE MAY BECOME CLOGGED. CAPSULE CONTENTS MAY BE OPENED AND MIXED WITH APPLE JUICE BUT DO NOT CHEW OR CRUSH DELAYED-RELEASE GRANULES. Copyright © 2020 Elsevier Inc. All Rights Reserved. 44 CHAPTER 51 BOWEL DISORDER DRUGS Copyright © 2020 Elsevier Inc. All Rights Reserved. Copyright © 2020 Elsevier Inc. All Rights Reserved. 46 ABNORMAL PASSAGE OF STOOLS WITH INCREASED FREQUENCY, FLUIDITY, AND WEIGHT OR WITH INCREASED STOOL WATER EXCRETION ACUTE DIARRHEA SUDDEN ONSET IN A PREVIOUSLY HEALTHY PERSON LASTS FROM 3 DAYS TO 2 WEEKS SELF-LIMITING RESOLVES WITHOUT SEQUELAE DIARRH EA CHRONIC DIARRHEA LASTS FOR MORE THAN 3 TO 4 WEEKS ASSOCIATED WITH RECURRING PASSAGE OF DIARRHEAL STOOLS, FEVER, LOSS OF APPETITE, NAUSEA, VOMITING, WEIGHT 47 Copyright © 2020 Elsevier Inc. All Rights Reserved. LOSS, AND CHRONIC WEAKNESS DIARRHEA CAUSES ACUTE CHRONIC BACTERIA TUMORS VIRUSES DIABETES MELLITUS DRUG INDUCED ADDISON’S DISEASE NUTRITIONAL FACTORS HYPERTHYROIDISM PROTOZOA IRRITABLE BOWEL SYNDROME AIDS Copyright © 2020 Elsevier Inc. All Rights Reserved. 48 STOPPING THE STOOL FREQUENCY ALLEVIATING THE ABDOMINAL CRAMPS GOALS OF DIARRHE A TREATME NT REPLENISHING FLUIDS AND ELECTROLYTES PREVENTING WEIGHT LOSS AND NUTRITIONAL DEFICITS FROM MALABSORPTION Copyright © 2020 Elsevier Inc. All Rights Reserved. 49 Adsorbents ANTIDIARRHEA LS Antimotility drugs (anticholinergics and opiates) Probiotics (also known as intestinal flora modifiers and bacterial replacement drugs) Copyright © 2020 Elsevier Inc. All Rights Reserved. 50 ANTIDIARRHEALS: MECHANISM OF ACTION ADSORBENTS COAT THE WALLS OF THE GASTROINTESTINAL (GI) TRACT BIND TO THE CAUSATIVE BACTERIA OR TOXIN, WHICH IS THEN ELIMINATED THROUGH THE STOOL EXAMPLES: BISMUTH SUBSALICYLATE (PEPTOBISMOL), ACTIVATED Copyright © 2020 Elsevier Inc. All Rights Reserved. CHARCOAL, AND 51 ANTIDIARRHEALS: MECHANISM OF ACTION (CONT.) ANTIMOTILITY DRUGS: (ANTICHOLINERGICS & OPIATES) DECREASE INTESTINAL MUSCLE TONE AND PERISTALSIS OF GI TRACT SLOWS THE MOVEMENT OF FECAL MATTER THROUGH THE GI TRACT DRYING EFFECT REDUCE GASTRIC SECRETIONS EXAMPLE: USE IS LIMITED; BELLADONNA ALKALOIDS (DONNATAL ELIXIR) 52 CONTRAINDICATED: HYPERSENSITIVITY TO ANTICHOLINERGICS, GI Copyright © 2020 Elsevier Inc. OBSTRUCTION, PARALYTIC ILEUS All Rights Reserved. ANTIDIARRHEALS: MECHANISM OF ACTION (CONT.) ANTIMOTILITY DRUGS: OPIATES DECREASE BOWEL MOTILITY AND REDUCE PAIN BY RELIEF OF RECTAL SPASMS DECREASE TRANSIT TIME THROUGH THE BOWEL, ALLOWING MORE TIME FOR WATER AND ELECTROLYTES TO BE ABSORBED EXAMPLES: PAREGORIC, OPIUM TINCTURE, CODEINE, OTC - LOPERAMIDE, DIPHENOXYLATE PAREGORIC HAS JUST 0.4 MG/ML OF MORPHINE WHILE OPIUM TINCTURE CONTAINS 10 MG/ML Copyright © 2020 Elsevier Inc. All Rights Reserved. 53 ANTIDIARRHEALS: MECHANISM OF ACTION (CONT.) PROBIOTICS AKA INTESTINAL FLORA MODIFIERS AND BACTERIAL REPLACEMENT DRUGS BACTERIAL CULTURES OF LACTOBACILLUS ORGANISMS WORK BY: SUPPLYING MISSING BACTERIA TO THE GI TRACT SUPPRESSING THE GROWTH OF DIARRHEA-CAUSING BACTERIA EXAMPLE: LACTOBACILLUS ACIDOPHILUS (BACID) Copyright © 2020 Elsevier Inc. All Rights Reserved. 54 Adsorbents: milder cases ANTIDIARRHEA LS: INDICATIONS Anticholinergics and opiates: more severe cases Probiotics: antibioticinduced diarrhea Copyright © 2020 Elsevier Inc. All Rights Reserved. 55 ANTIDIARRHEALS: ADVERSE EFFECTS ADSORBENTS INCREASED BLEEDING TIME (BIND TO VIT K) CONSTIPATION, DARK STOOLS CONFUSION TINNITUS METALLIC TASTE BLUE TONGUE Copyright © 2020 Elsevier Inc. All Rights Reserved. 56 ANTIDIARRHEALS: ADVERSE EFFECTS (CONT.) ANTICHOLINERGICS URINARY RETENTION, IMPOTENCE HEADACHE, DIZZINESS, CONFUSION, ANXIETY, DROWSINESS, CONFUSION DRY SKIN, FLUSHING BLURRED VISION HYPOTENSION, BRADYCARDIA Copyright © 2020 Elsevier Inc. All Rights Reserved. 57 ANTIDIARRHEALS: ADVERSE EFFECTS (CONT.) OPIATES DROWSINESS, DIZZINESS, LETHARGY NAUSEA, VOMITING, CONSTIPATION RESPIRATORY DEPRESSION HYPOTENSION URINARY RETENTION FLUSHING Copyright © 2020 Elsevier Inc. All Rights Reserved. 58 ANTIDIARRHEALS: INTERACTIONS ADSORBENTS DECREASE THE ABSORPTION OF MANY DRUGS, INCLUDING DIGOXIN, QUINIDINE, AND HYPOGLYCEMIC DRUGS. ADSORBENTS CAUSE INCREASED BLEEDING TIME AND BRUISING WHEN GIVEN WITH ANTICOAGULANTS (WARFARIN). Copyright © 2020 Elsevier Inc. All Rights Reserved. 59 ANTIDIARRHE ALS: NURSING IMPLICATION S Use Use adsorbents carefully in older patients and those with decreased bleeding time, clotting disorders, recent bowel surgery, or confusion. Do not adminis ter Do not administer anticholinergics to patients with a history of narrowangle glaucoma, GI obstruction, paralytic ileus, or toxic megacolon. Obtain thorough history of bowel patterns, general state of health, and recent history of illness or dietary changes; assess for allergies. Obtain Copyright © 2020 Elsevier Inc. All Rights Reserved. 60 Teach Asses s ANTIDIARRHE ALS: NURSING IMPLICATIONS (CONT.) Teach patients to take medications exactly as prescribed and to be aware of their fluid intake and dietary changes. Assess fluid volume status, input and output, and mucous membranes before, during, and after initiation of treatment. Teach Teach patients to notify their prescribers immediately if symptoms persist. Monit or Monitor for therapeutic effect. Copyright © 2020 Elsevier Inc. All Rights Reserved. 61 ANTIDIARRHEALS Copyright © 2017, Elsevier Inc. All rights reserved. 62 Abnormally infrequent and difficult passage of feces through the lower GI tract CONSTIPATI ON Symptom, not a disease Disorder of movement through the colon or rectum Can be caused by a variety of diseases or drugs Copyright © 2020 Elsevier Inc. All Rights Reserved. 63 CONSTIPATIO N: TREATMENT Surgical Nonsurgical treatments Dietary (e.g., fiber supplementation) Behavioral (e.g., increased physical activity) Pharmacologic Copyright © 2020 Elsevier Inc. All Rights Reserved. 64 LAXATIVES Bulk forming Emollient (stool softeners, lubricant laxatives) Saline Copyright © 2020 Elsevier Inc. All Rights Reserved. Hyperosmotic Stimulant 65 LAXATIVES: MECHANISM OF ACTION BULK FORMING HIGH FIBER ABSORB WATER TO INCREASE BULK DISTEND BOWEL TO INITIATE REFLEX BOWEL ACTIVITY EXAMPLES Copyright © 2020 Elsevier Inc. All Rights Reserved. PSYLLIUM (METAMUCIL) 66 LAXATIVES: MECHANISM OF ACTION (CONT.) EMOLLIENT STOOL SOFTENERS AND LUBRICANTS PROMOTE MORE WATER AND FAT IN THE STOOLS LUBRICATE THE FECAL MATERIAL AND INTESTINAL WALLS EXAMPLES STOOL SOFTENERS: DOCUSATE SALTS (COLACE, SURFAK) LUBRICANTS: MINERAL OIL Copyright © 2020 Elsevier Inc. All Rights Reserved. 67 LAXATIVES: MECHANISM OF ACTION (CONT.) HYPEROSMOTIC INCREASE FECAL WATER CONTENT RESULTS IN BOWEL DISTENTION, INCREASED PERISTALSIS, AND EVACUATION EXAMPLES POLYETHYLENE GLYCOL (PEG) SORBITOL, GLYCERIN LACTULOSE (ALSO USED TO REDUCE ELEVATED SERUM AMMONIA LEVELS) Copyright © 2020 Elsevier Inc. All Rights Reserved. 68 LAXATIVES: MECHANISM OF ACTION (CONT.) SALINE INCREASE OSMOTIC PRESSURE WITHIN THE INTESTINAL TRACT, CAUSING MORE WATER TO ENTER THE INTESTINES RESULTS IN BOWEL DISTENTION, INCREASED PERISTALSIS, AND EVACUATION EXAMPLES MAGNESIUM HYDROXIDE (MILK OF MAGNESIA) Copyright © 2020 Elsevier Inc. All Rights Reserved. 69 LAXATIVES: MECHANISM OF ACTION (CONT.) STIMULANT INCREASES PERISTALSIS VIA INTESTINAL NERVE STIMULATION EXAMPLES SENNA (SENOKOT) BISACODYL (DULCOLAX) Copyright © 2020 Elsevier Inc. All Rights Reserved. 70 LAXATIVES: INDICATIONS Laxative group Use Bulk forming Acute and chronic constipation, irritable bowel syndrome, diverticulosis Emollient Acute and chronic constipation, fecal impaction, facilitation of bowel movements in anorectal conditions Copyright © 2020 Elsevier Inc. All Rights Reserved. 71 LAXATIVES: INDICATIONS (CONT.) Laxative group Use Hyperosmotic Chronic constipation, diagnostic and surgical preps Saline Constipation, diagnostic and surgical preps Stimulant Acute constipation, diagnostic and surgical preps Copyright © 2020 Elsevier Inc. All Rights Reserved. 72 Bulk forming LAXATIV ES: ADVERSE EFFECTS Impaction Fluid overload Electrolyte imbalances Esophageal blockage Emollient Skin rashes Decreased absorption of vitamins Electrolyte imbalances Lipid pneumonia Copyright © 2020 Elsevier Inc. All Rights Reserved. 73 Hyperosmotic LAXATIVE S: ADVERSE EFFECTS (CONT.) Abdominal bloating Electrolyte imbalances Rectal irritation Saline Magnesium toxicity (with renal insufficiency) Cramping Electrolyte imbalances Diarrhea Increased thirst Copyright © 2020 Elsevier Inc. All Rights Reserved. 74 LAXATIVES: ADVERSE EFFECTS (CONT.) STIMULANT NUTRIENT MALABSORPTION SKIN RASHES GASTRIC IRRITATION ELECTROLYTE IMBALANCES DISCOLORED URINE RECTAL IRRITATION ALL LAXATIVES CAN CAUSE ELECTROLYTE IMBALANCES! Copyright © 2020 Elsevier Inc. All Rights Reserved. 75 LAXATIVES: NURSING IMPLICATIONS OBTAIN A THOROUGH HISTORY OF PRESENTING SYMPTOMS, ELIMINATION PATTERNS, AND ALLERGIES. ASSESS FLUID AND ELECTROLYTES BEFORE INITIATING THERAPY. INFORM PATIENTS NOT TO TAKE A LAXATIVE OR CATHARTIC IF THEY ARE EXPERIENCING NAUSEA, VOMITING, OR ABDOMINAL PAIN. Copyright © 2020 Elsevier Inc. All Rights Reserved. 76 LAXATIVES: NURSING IMPLICATIONS A HEALTHY, HIGH-FIBER DIET AND INCREASED FLUID INTAKE SHOULD BE ENCOURAGED AS AN ALTERNATIVE TO LAXATIVE USE. LONG-TERM USE OF LAXATIVES OFTEN RESULTS IN DECREASED BOWEL TONE AND MAY LEAD TO DEPENDENCY. ALL LAXATIVE TABLETS SHOULD BE SWALLOWED WHOLE, NOT CRUSHED OR CHEWED, ESPECIALLY IF ENTERIC COATED. Copyright © 2020 Elsevier Inc. All Rights Reserved. 77 LAXATIVES: NURSING IMPLICATIONS (CONT.) PATIENTS SHOULD TAKE ALL LAXATIVE TABLETS WITH 6 TO 8 OZ OF WATER. PATIENTS SHOULD TAKE BULK-FORMING LAXATIVES AS DIRECTED BY THE MANUFACTURER WITH AT LEAST 240 ML (8 OZ) OF WATER. Copyright © 2020 Elsevier Inc. All Rights Reserved. 78 LAXATIVES: NURSING IMPLICATIONS (CONT.) GIVE BISACODYL WITH WATER BECAUSE OF INTERACTIONS WITH MILK, ANTACIDS, AND JUICES. INFORM PATIENTS TO CONTACT THEIR PRESCRIBERS IF THEY EXPERIENCE SEVERE ABDOMINAL PAIN, MUSCLE WEAKNESS, CRAMPS, OR DIZZINESS, WHICH MAY INDICATE POSSIBLE FLUID OR ELECTROLYTE LOSS. Copyright © 2020 Elsevier Inc. All Rights Reserved. 79 LAXATIVES Copyright © 2017, Elsevier Inc. All rights reserved. 80 CHAPTER 52 ANTIEMETIC AND ANTINAUSEA DRUGS Copyright © 2020 Elsevier Inc. All Rights Reserved. Nausea Unpleasant feeling that often precedes vomiting DEFINITIO NS Emesis (vomiting) Forcible emptying of gastric and, occasionally, intestinal contents Antiemetic drugs Used to relieve nausea and vomiting Copyright © 2020 Elsevier Inc. All Rights Reserved. 82 VOMITING CENTER AND CHEMORECEPTOR TRIGGER ZONE VOMITING CENTER (VC) CHEMORECEPTOR TRIGGER ZONE (CTZ) BOTH LOCATED IN THE BRAIN ONCE STIMULATED, CAUSE THE VOMITING REFLEX Copyright © 2020 Elsevier Inc. All Rights Reserved. 83 Copyright © 2020 Elsevier Inc. All Rights Reserved. 84 TYPES OF NAUSEA AND VOMITIN G Chemotherapy induced Postoperative General Copyright © 2020 Elsevier Inc. All Rights Reserved. 85 ANTIEMETICS AND ANTINAUSEA DRUGS ANTICHOLINERGIC DRUGS ANTIHISTAMINES (HISTAMINE 1 [H1] RECEPTOR BLOCKERS) PROKINETIC DRUGS SEROTONIN BLOCKERS TETRAHYDROCANNABINOIDS Copyright © 2020 Elsevier Inc. All Rights Reserved. 86 ANTIEMETI CS AND ANTINAUS EA DRUGS: MECHANIS M OF ACTION Many different mechanisms of action Most work by blocking one of the vomiting pathways, thus blocking the stimulus that induces vomiting. Copyright © 2020 Elsevier Inc. All Rights Reserved. 87 Specific indications vary per class of antiemetics. INDICATIO NS General use for each type: prevention and reduction of nausea and vomiting Copyright © 2020 Elsevier Inc. All Rights Reserved. 88 MECHANISM OF ACTION AND OTHER INDICATIONS ANTICHOLINERGIC DRUGS (ACETYLCHOLINE [ACH] BLOCKERS) BIND TO AND BLOCK ACH RECEPTORS IN THE INNER EAR LABYRINTH BLOCK TRANSMISSION OF NAUSEATING STIMULI TO CTZ ALSO BLOCK TRANSMISSION OF NAUSEATING STIMULI FROM THE RETICULAR FORMATION TO THE VC SCOPOLAMINE (TRANSDERM-SCŌP, SCOPACE) Copyright © 2020 Elsevier Inc. All Rights Reserved. 89 MECHANISM OF ACTION AND OTHER INDICATIONS ANTIHISTAMINE DRUGS (H1 RECEPTOR BLOCKERS) INHIBIT ACH BY BINDING TO H1 RECEPTORS PREVENT CHOLINERGIC STIMULATION IN VESTIBULAR AND RETICULAR AREAS, THUS PREVENTING NAUSEA AND VOMITING ALSO USED FOR MOTION SICKNESS, NONPRODUCTIVE COUGH, ALLERGY SYMPTOMS, SEDATION EXAMPLES DIMENHYDRINATE (DRAMAMINE) DIPHENHYDRAMINE (BENADRYL) MECLIZINE (ANTIVERT) Copyright © 2020 Elsevier Inc. All Rights Reserved. 90 MECHANISM OF ACTION AND OTHER INDICATIONS (CONT.) PROKINETIC DRUGS BLOCK DOPAMINE RECEPTORS IN THE CTZ CAUSE CTZ TO BE DESENSITIZED TO IMPULSES IT RECEIVES FROM THE GASTROINTESTINAL (GI) TRACT ALSO STIMULATE PERISTALSIS IN GI TRACT, ENHANCING EMPTYING OF STOMACH CONTENTS ALSO USED FOR GASTROESOPHAGEAL REFLUX DISEASE, DELAYED GASTRIC EMPTYING METOCLOPRAMIDE (REGLAN) LONG-TERM USE MAY CAUSE IRREVERSIBLE TARDIVE DYSKINESIA. Copyright © 2020 Elsevier Inc. All Rights Reserved. 91 MECHANISM OF ACTION AND OTHER INDICATIONS SEROTONIN BLOCKERS BLOCK SEROTONIN RECEPTORS IN THE GI TRACT, CTZ, AND VC USED FOR NAUSEA AND VOMITING IN PATIENTS RECEIVING CHEMOTHERAPY AND FOR POSTOPERATIVE NAUSEA AND VOMITING EXAMPLES ONDANSETRON (ZOFRAN) Copyright © 2020 Elsevier Inc. All Rights Reserved. 92 MECHANISM OF ACTION AND OTHER INDICATIONS (CONT.) TETRAHYDROCANNABINOIDS MAJOR PSYCHOACTIVE SUBSTANCE IN MARIJUANA INHIBITORY EFFECTS ON RETICULAR FORMATION, THALAMUS, CEREBRAL CORTEX ALTER MOOD AND BODY’S PERCEPTION OF ITS SURROUNDINGS, WHICH MAY HELP RELIEVE NAUSEA AND VOMITING DRONABINOL (MARINOL) USED FOR NAUSEA AND VOMITING ASSOCIATED WITH CHEMOTHERAPY AND FOR ANOREXIA ASSOCIATED Copyright © 2020 Elsevier Inc. All Rights Reserved. WITH WEIGHT LOSS IN AIDS PATIENTS 93 ADVER SE EFFECT S Vary according to drug used Stem from their nonselective blockade of various receptors Copyright © 2020 Elsevier Inc. All Rights Reserved. 94 NURSING IMPLICATIONS ASSESS COMPLETE NAUSEA AND VOMITING HISTORY, INCLUDING PRECIPITATING FACTORS. CURRENT MEDICATIONS. CONTRAINDICATIONS AND POTENTIAL DRUG INTERACTIONS. WARN PATIENTS ABOUT DRIVING OR PERFORMING ANY HAZARDOUS TASKS Copyright © 2020 Elsevier Inc. All Rights Reserved. 95 NURSING IMPLICATIONS (CONT.) TAKING ANTIEMETICS WITH ALCOHOL MAY CAUSE SEVERE CENTRAL NERVOUS SYSTEM DEPRESSION. CHANGE POSITIONS SLOWLY TO AVOID HYPOTENSIVE EFFECTS. FOR CHEMOTHERAPY, ANTIEMETICS ARE OFTEN GIVEN 30 TO 60 MINUTES BEFORE CHEMOTHERAPY BEGINS. MONITOR FOR THERAPEUTIC EFFECTS & ADVERSE EFFECTS. Copyright © 2020 Elsevier Inc. All Rights Reserved. 96 ANTINAUSEA/ ANTIEMETICS Copyright © 2017, Elsevier Inc. All rights reserved. 97