Student Handbook: Nutritional Products for Acute Pancreatitis PDF

2/14/24, 10:35 AM Realizeit for Student Introduction Management of acute pancreatitis is directed toward relieving symptoms and preventing or treating complications. Oral intake is often withheld and patients receive enteral feedings. Histamine 2 antagonists or proton pump inhibitors are used for ac...

2/14/24, 10:35 AM Realizeit for Student Introduction Management of acute pancreatitis is directed toward relieving symptoms and preventing or treating complications. Oral intake is often withheld and patients receive enteral feedings. Histamine 2 antagonists or proton pump inhibitors are used for acid suppression. Nausea and pain management is a priority for nursing care. Blood glucose management is required due to pancreatic inflammation. Key Terms Parenteral nutrition: intravenous provision of fluid and nutrients to a patient who is unable to ingest enough fluid and food due to a nonfunctional gastrointestinal tract. Nutritional Products Various products are available to supplement or substitute for dietary intake. These may consist of vitamins, minerals, liquid enteral formulas, IV fluids and nutrition, and pancreatic enzymes. Numerous liquid enteral formulas are available for oral or tube feedings, and many are nutritionally complete, except for water, when given in sufficient amounts (e.g., Ensure, Isocal, Sustacal, Resource). To meet fluid needs, it is necessary to give additional water. Most oral products come in a variety of flavors and contain 1 kcal/mL of formula. Additional products are available formulated for patients with special conditions (e.g., hepatic or renal failure, malabsorption syndromes) or needs (e.g., high protein, increased calories). When the GI tract is functional but the patient cannot ingest sufficient food and fluid, the nurse can give high-protein, high-calorie foods (e.g., milkshakes) or nutritionally complete supplements (e.g., Ensure) with meals, between meals, and at bedtime. In patients with a feeding tube, enteral nutrition provides fluid and nutrients. When the GI tract is nonfunctional, the nurse often gives IV fluids, or parenteral nutrition. Most of these solutions are nutritionally incomplete and are used short-term to supply fluids, electrolytes, and a few calories; additional nutrition may be necessary. Use For short-term use (e.g., 3–5 days), the goal is to provide adequate amounts of fluids and electrolytes and enough carbohydrates to minimize oxidation of body protein and fat for energy. The choice of a specific solution depends on individual needs, but it should contain at least 5% dextrose. A frequently used solution is 5% dextrose in 0.45% sodium chloride, 2000 to 3000 mL per 24 hours (provides ~170 kcal/L, water, sodium, and chloride). Vitamins may be added. These solutions are nutritionally inadequate. For long-term use (weeks to months), the goal is to provide all nutrients required for normal body functioning, including tissue repair. Basic solutions provide water, carbohydrate, protein, vitamins, and minerals. Patients usually receive fat emulsions (e.g., Intralipid) that are usually given separately to provide additional calories and essential fatty acids (500 mL of 10% emulsion provides 550 kcal). Use in Children For children with special needs in relation to nutrients, various enteral formulations are available. Some examples include Lofenalac for children with phenylketonuria; Nursoy and Soyalac, which contain soy protein, for children who are allergic to cow’s milk; and Nutramigen and Pregestimil, which contain easily digested nutrients for children with malabsorption or other GI problems. However, parenteral nutrition may be necessary. Use in Patients With Renal Impairment With enteral nutrition, Amin-Aid provides amino acids, carbohydrates, and a few electrolytes for patients with renal failure. With parenteral nutrition, several amino acid solutions are available for patients with renal failure (e.g., Aminosyn-RF). Nepro is a formulation for patients receiving dialysis. Suplena, which is lower in protein and some electrolytes than Nepro, is formulated for patients who are not receiving dialysis. Use in Patients With Hepatic Impairment For enteral feedings (usually by GI tube) in patients with liver failure, Hepatic-Aid II is available. For parenteral feeding in patients with hepatic failure and hepatic encephalopathy, HepatAmine, a special formula of amino acids, may be useful. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zVrT2hbWFsCuacrrvtQ3c5e2aqBPaKXEaVcMiuwkAz59F1Dmo… 1/13 2/14/24, 10:35 AM Realizeit for Student Caution is warranted with the use of enteral and parenteral fat preparations in patients with hepatic impairment. Medium-chain triglycerides (e.g., MCT oil), which are used to provide calories in other malnourished patients, may lead to coma in patients with advanced cirrhosis. Patients who require parenteral nutrition may develop high serum triglyceride levels and pancreatitis if given usually amounts of IV fat emulsions. Adverse Effects Adverse reactions, which are usually attributed to the hypertonicity of the preparations, include tachycardia, hypotension, dehydration, nausea, vomiting, diarrhea, and increased urine output. The risk of aspiration of formula is a consideration with tube feeding. Administering the Medication For oral supplemental feedings, it is necessary to chill liquids or pour them over ice and give them through a straw (unless contraindicated), from a closed container, between meals. This practice may improve formula taste and decrease formula odor. A straw directs the formula toward the back of the throat and decreases contact with taste buds. A closed container also decreases odor. For tube feedings, the nurse adheres to guidelines for safe administration (positioning, placement of tube, residual and aseptic management of formula and equipment). When medications are ordered, liquid preparations are preferable. Tablets or powders may stick in the tube lumen, which may mean the full dose of medication does not reach the stomach. Also, the obstruction of the tube is likely. It is important not to mix medications with tube feeding formula; this could interfere with drug absorption. Assessing for Therapeutic Effects For patients receiving nutritional formulas, the nurse observes for weight gain and increased serum albumin. For infants and children receiving milk substitutes, the nurse observes for decreased diarrhea and weight gain. Therapeutic effects depend on the reason for use (i.e., prevention or treatment of undernutrition). Assessing for Adverse Effects With commercial nutritional formulas (except Osmolite and Isocal), the nurse observes for tachycardia, hypotension, dehydration, nausea, vomiting, diarrhea, and increased urine output. These adverse reactions are usually attributed to the hypertonicity of the preparations. Beginning administration with small amounts of formula, given slowly, may prevent or minimize adverse effects. Histamine2 Receptor Antagonists Action Cimetidine inhibits the action of histamine at the H2 receptors of the stomach, decreasing the amount, acidity, and pepsin content of gastric juices. A single dose can inhibit acid secretion for 6 to 12 hours, and a continuous IV infusion can inhibit secretion for prolonged periods. Use in Older Adults With cimetidine, older adults are more likely to experience adverse effects, especially confusion, agitation, and disorientation. Use in Patients With Renal Impairment Use of cimetidine in patients with impaired renal function requires caution. It is necessary to reduce the dosage of cimetidine and other H2RAs in the presence of impaired renal function because the drugs are eliminated through the kidneys. Cimetidine may cause mental confusion in patients with renal impairment. It also blocks secretion of creatinine in renal tubules, thereby decreasing creatinine clearance and increasing serum creatinine level. Any dosage increase, if necessary, should be cautious, with close monitoring of renal function. QSEN Alert: Safety For patients on hemodialysis, cimetidine administration should occur at the end of dialysis. Use in Patients With Hepatic Impairment The partial metabolism of cimetidine and other H2RAs occurs in the liver, which means that drug levels are higher than anticipated in patients with impaired liver function. Cimetidine inhibits the hepatic metabolism of many other drugs; this is a major concern. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zVrT2hbWFsCuacrrvtQ3c5e2aqBPaKXEaVcMiuwkAz59F1Dmo… 2/13 2/14/24, 10:35 AM Realizeit for Student Use in Patients With Critical Illness H2RAs are commonly used in critically ill patients to prevent stress-induced gastric ulceration. These are usually administered by intermittent IV infusion. Generally, information about the pharmacokinetics of these drugs in critically ill patients is limited. It appears that in patients who are critically ill, H2RAs have a longer half-life and lower clearance rate than in people who are healthy. Use in Patients Receiving Home Care People take cimetidine in the home care setting. The home care nurse can assist patients by providing information about taking the drug correctly and monitoring responses. It is necessary to assess for potential drug–drug interactions with cimetidine. Adverse Effects Common adverse effects of cimetidine include diarrhea, dizziness, drowsiness, headache, confusion, and gynecomastia. They occur infrequently following the usual doses and standard duration of treatment. Adverse effects are more likely with prolonged use of high doses, with increasing age, and with impaired renal or hepatic function. Contraindications Contraindications include known hypersensitivity to cimetidine. Caution is warranted in people with renal and hepatic impairment and in women who are lactating or pregnant. Nursing Implications Preventing Interactions Antacids decrease absorption of cimetidine, so the drugs should not be given at the same time. No drugs are known to increase or decrease the effects of cimetidine. Additionally, no herbs increase or decrease the effects of cimetidine. QSEN Alert: Safety However, cimetidine contributes to multiple-drug interactions. A known inhibitor of many isozymes of the cytochrome P450 (CYP450) drug-metabo interferes with the hepatic metabolism of other drugs. Consequently, the clearance of affected drugs from the body is slower; the increased serum to cause adverse effects and toxicity unless dosage is reduced. Drugs that are affected by cimetidine include antidysrhythmics (lidocaine, propafenone, quinidine), the anticoagulant warfarin, anticonvulsants (carbamazepine, phenytoin), benzodiazepine antianxiety or hypnotic agents (alprazolam, diazepam, flurazepam, triazolam), beta-adrenergic blockers (labetalol, metoprolol, propranolol), the bronchodilator theophylline, calcium channel blocking agents (e.g., verapamil), tricyclic antidepressants (e.g., amitriptyline), and sulfonylurea antidiabetic drugs. In addition, cimetidine may increase serum levels (e.g., fluorouracil, procainamide and its active metabolite) and pharmacologic effects of other drugs (e.g., respiratory depression with opioid analgesics) by unidentified mechanisms. Cimetidine also may decrease effects of several drugs, including drugs that require an acidic environment for absorption (e.g., iron salts, indomethacin, fluconazole, tetracyclines) and miscellaneous drugs (e.g., digoxin, tocainide) by unknown mechanisms. The accumulation of the antihistamines, terfenadine and astemizole, may result in a prolongation of the QT interval and could lead to the development of ventricular dysrhythmias such as torsades de pointes. Cimetidine also may decrease the effects of drugs that require an acidic environment for absorption (e.g., iron salts, indomethacin, fluconazole, tetracyclines) and miscellaneous drugs (e.g., digoxin, tocainide) by unknown mechanisms. Administering the Medication H2RAs are available in a wide array of products, and it is essential to take precautions to ensure that the formulation, dosage strength, and method of administration are appropriate for the intended use. Oral administration of a single oral dose occurs at bedtime, and administration of multiple oral doses of cimetidine occurs with meals and at bedtime. QSEN Alert: Safety With the oral solution, it is important to measure the liquid with a marked measuring spoon or medicine cup, not with a tablespoon. IV administration requires dilution and administration over at least 2 minutes. For intermittent infusion, it is necessary to dilute and infuse over 15 to 20 minutes. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zVrT2hbWFsCuacrrvtQ3c5e2aqBPaKXEaVcMiuwkAz59F1Dmo… 3/13 2/14/24, 10:35 AM Realizeit for Student IM administration does not require dilution. Injection is given deep into a large muscle group. Assessing for Therapeutic Effects The nurse assesses for decreased epigastric pain with gastric and duodenal ulcers or decreased heartburn with GERD. Assessing for Adverse Effects With H2RAs, the nurse assesses for diarrhea or constipation, headache, dizziness, muscle aches, fatigue, skin rashes, mental confusion, delirium, coma, depression, and fever. Adverse effects are uncommon and usually mild with recommended doses. The nurse assesses for central nervous system effects, which have been associated with high doses in patients who are elderly or in those with impaired renal function. With long-term administration of cimetidine, other observed adverse effects include decreased sperm count and gynecomastia in men and galactorrhea in women. Other Drugs in the Class Unlike cimetidine, ranitidine (Zantac), famotidine (Pepcid, Pepcid AC), and nizatidine (Axid AR) do not affect the cytochrome P450 drugmetabolizing system in the liver and therefore do not interfere with the metabolism of other drugs. Use of these other drugs may be preferable in patients who are critically ill because they often require numerous other drugs with which cimetidine may interact. Ranitidine is more potent than cimetidine on a weight basis, and smaller doses can be given less frequently. Oral ranitidine reaches peak blood levels 1 to 3 hours after administration and is metabolized in the liver; approximately 30% is excreted unchanged in the urine. Parenteral ranitidine reaches peak blood levels in about 15 minutes; 65% to 80% is excreted unchanged in the urine. Famotidine and nizatidine pharmacokinetics are similar to cimetidine and ranitidine. Nizatidine is not available in a parenteral formulation. Compared with cimetidine, the other drugs cause similar effects except they are less likely to cause mental confusion and gynecomastia (antiandrogenic effects). Ranitidine decreases absorption of diazepam if given at the same time and increases hypoglycemic effects of glipizide. Antacids probably decrease absorption of ranitidine. Nizatidine increases serum salicylate levels in people taking high doses of aspirin. Proton Pump Inhibitors Action Omeprazole binds irreversibly to the gastric proton pump (e.g., the enzyme H+, K+-ATPase) to prevent the “pumping” or release of gastric acid from parietal cells into the stomach lumen, thereby blocking the final step of acid production. Inhibition of the proton pump suppresses gastric acid secretion in response to all primary stimuli, histamine, gastrin, and acetylcholine. Thus, omeprazole and other drugs in the class inhibit both daytime (including meal-stimulated) and nocturnal (unstimulated) acid secretion. Use in Older Adults Older adults tolerate PPIs well. PPIs are probably the drug of choice for treating symptomatic GERD because evidence suggests that patients 60 years of age and older require stronger antisecretory effects than younger adults. However, long-term use (greater than one year) is associated with increased risk of hip fractures in people older than 50 years of age; the risk of fractures increases the longer the medications are taken and is greater in people who take higher dosages of PPIs. The increased risk of fractures may be due to decreased calcium absorption due to achlorhydria (low or absent production of gastric acid in the stomach) from PPI therapy. It is important to consider appropriate dose and duration of therapy when treating GERD in older adults. Use in Patients With Hepatic Impairment With omeprazole, bioavailability is increased because of decreased first-pass metabolism and plasma half-life is increased. Metabolism of PPIs occurs in the liver, and use of these drugs may cause transient elevations in liver function tests. However, dosage adjustments are not recommended. Use in Patients With Critical Illness The PPIs are the strongest gastric acid suppressants used in patients who are critically ill. They usually tolerate the drugs well. IV administration, if necessary, is an option. Adverse Effects https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zVrT2hbWFsCuacrrvtQ3c5e2aqBPaKXEaVcMiuwkAz59F1Dmo… 4/13 2/14/24, 10:35 AM Realizeit for Student Adverse effects are minimal with both short- and long-term use. Nausea, diarrhea, and headache are the most frequently reported adverse effects. Use of high-dose PPIs or long-term use of the drugs carries a possible increased risk of bone fractures. (As previously stated, this may increase in older patients.) Contraindications Contraindications include known hypersensitivity to omeprazole. Nursing Implications Preventing Interactions Drug interactions with the PPIs are relatively few. Omeprazole increases blood levels of some benzodiazepines (diazepam, flurazepam, triazolam), phenytoin, and warfarin, probably by inhibiting hepatic metabolism. Coadministration of clopidogrel with PPIs may reduce the cardioprotective effects of clopidogrel. Clarithromycin increases effects of omeprazole and may increase blood levels. No herbs have been reported to increase or decrease the effects of omeprazole. Administering the Medication It is important that omeprazole be administered before food intake. Two 20-mg oral capsules or suspension packets are not equivalent to one 40-mg dose. The 20- and 40-mg dosages contain the same amount of sodium bicarbonate; substituting two 20-mg doses for one 40mg dose results in the administration of too much sodium bicarbonate. The patient should swallow the tablets or capsules whole, without crushing or chewing, because the drug formulations are delayed-release and long-acting. Crushing or chewing destroys these effects. Assessing for Therapeutic Effects The nurse assesses for decreased epigastric pain with gastric and duodenal ulcers and also assesses for decreased heartburn with GERDs. Assessing for Adverse Effects The nurse observes for the presence of headache, diarrhea, abdominal pain, nausea, and vomiting. Other Drugs in the Class The actions and pharmacokinetics of the other PPIs, including dexlansoprazole (Dexilant), esomeprazole (Nexium), lansoprazole (Prevacid), pantoprazole (Protonix), and rabeprazole (AcipHex) are similar to those of omeprazole. However, differences in their metabolism may lead to specific drug interactions. The PPIs are metabolized by the CYP450 system, with CPY2C19 having the predominant role in all PPIs but rabeprazole, which is metabolized primarily by CYP3A4. Dexlansoprazole capsules should be swallowed whole and not chewed. However, the capsules may be opened and sprinkled on a tablespoon of applesauce if a person is not able to swallow the capsule. Capsules may also be opened and administered via a nasal gastric tube. Doses greater than 30 mg do not provide additional benefit during the maintenance phase. Note that two 30-mg orally disintegrating tablets are not interchangeable with one 60 mg delayed-release capsule. Esomeprazole capsules can be opened, mixed with 50 mL of water, and swallowed or administered via nasogastric tube. Flush tube with water after administration. IV esomeprazole can be injected over no less than 3 minutes or infused over 10 to 30 minutes into a dedicated IV line. Flush the IV line with 5% dextrose or lactated Ringer's solution before and after esomeprazole administration. Lansoprazole and rabeprazole should be used cautiously and dosage should be reduced in patients with severe liver impairment. Those people with phenylketonuria should be advised that orally disintegrating tablets of lansoprazole may contain aspartame. Lansoprazole may cause drowsiness or dizziness. For patients who are unable to swallow capsules, they can have the lansoprazole (and esomeprazole) capsule opened and the granules mixed with applesauce or other acidic substances; this preserves the coating of the granules, allowing them to remain intact until they reach the small intestine. Chewing or crushing destroys the coating. For a liquid suspension, it is possible to mix the lansoprazole granules with 30 mL of water (use no other liquids), stir well, and swallow it immediately, without chewing the granules. The nurse ensures that oral pantoprazole is taken with or without food as per the manufacturer's recommendations. The nurse may administer IV pantoprazole over 15 minutes, injecting the drug into a dedicated line or the Y-site of an IV infusion. Here are some specific directions regarding pantoprazole administration: Use the in-line filter provided; if injecting in a Y-site, place the filter below the Y-site closest to the patient. Flush the IV line with 5% dextrose, 0.9% NaCl, or lactated Ringer's solution before and after administration. With regard to drug interactions, omeprazole and esomeprazole have the greatest potential. Esomeprazole appears to interfere with the metabolism of other drugs to a lesser degree than omeprazole. The metabolism of pantoprazole undergoes the same metabolism but is followed rapidly by sulfate conjugation. Because of this, pantoprazole has the lowest potential for drug interactions with other agents metabolized by the CYP450 system. Rabeprazole is metabolized by CYP2C19 but shows a strong affinity for CYP3A4 and is associated https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zVrT2hbWFsCuacrrvtQ3c5e2aqBPaKXEaVcMiuwkAz59F1Dmo… 5/13 2/14/24, 10:35 AM Realizeit for Student with very few known drug interactions. Although dexlansoprazole and lansoprazole are potent inhibitors of CYP2C19 and other CYP450 isoforms, these drugs are metabolized primarily by CYP3A4. Interactions with theophylline have been reported. Pain Management Adequate administration of analgesia is essential during the course of acute pancreatitis to provide sufficient pain relief and to minimize restlessness, which may stimulate pancreatic secretion further. Pain relief may require parenteral opioids such as morphine, fentanyl, or hydromorphone (Cameron & Cameron, 2020; Goodchild et al., 2019; Olson et al., 2019). The recommendation for pain management is the use of opioids, with assessment for their effectiveness, and altering therapy if pain is not controlled or is increased (Faghih et al., 2019; Goodchild et al., 2019; Olson et al., 2019). There is some evidence that implementing the World Health Organization (WHO) analgesia ladder provides a pragmatic approach to pain management in patients with pancreatitis (Z.orniak et al., 2019). This stepwise escalation from low potency to higher potency of nonsteroidal anti-inflammatory drugs (NSAIDs) alone or in combination with opioids may provide an effective method of pain management and lower the potential for opioid dependency (Z.orniak et al., 2019). NSAIDs must be avoided or used in caution in patients at risk for bleeding. GI paralysis and ileus are common problems in early acute pancreatitis that can be potentiated and aggravated with the use of high-dose opioids (Z.orniak et al., 2019). More research is needed to identify the best option for pain management in the patient with acute pancreatitis (Faghih et al., 2019). Until evidence-based recommendations are developed, guidelines for acute pain management in the perioperative setting should be followed (Rothrock, 2019). Antiemetic agents may be prescribed to prevent vomiting. Because the pathologic process responsible for pain is autodigestion of the pancreas, the objectives of therapy are to relieve pain and decrease secretion of pancreatic enzymes. The pain of acute pancreatitis is often very severe, necessitating the liberal use of analgesic agents. The current recommendation for pain management in this population is parenteral opioids, including morphine, hydromorphone, or fentanyl via patient-controlled analgesia or bolus (Goodchild et al., 2019; Olson et al., 2019). In patients who are critically ill, a continuous infusion may be needed. Because most opioids stimulate spasm of the sphincter of Oddi to some degree, consensus has not been reached on the most effective agent. Ensuring patient comfort, regardless of the opioid prescribed, is the most essential aspect of care. The nurse frequently assesses the pain level and the effectiveness of the pharmacologic (and nonpharmacologic) interventions. Opioids Hydromorphone (Dilaudid) is a Schedule II, semisynthetic derivative of morphine that has the same actions, uses, contraindications, and adverse effects as morphine. It is more potent on a milligram-to-milligram basis and more effective orally than morphine. Effects occur in 15 to 30 minutes, peak in 30 to 90 minutes, and last 4 to 5 hours. Hydromorphone is metabolized in the liver to inactive metabolites that are excreted through the kidneys. Meperidine (Demerol) is a synthetic drug similar to morphine in action and adverse effects. After injection, analgesia occurs in 10 to 20 minutes, peaks in 1 hour, and lasts 2 to 4 hours. After an oral dose, about half is metabolized in the liver and never reaches the systemic circulation. Prescribers order meperidine infrequently for therapeutic purposes, mainly because it produces a neurotoxic metabolite (normeperidine). Normeperidine accumulates with chronic use, large doses, or renal failure and produces CNS stimulation characterized by agitation, hallucinations, and seizures. The half-life of normeperidine is 15 to 30 hours, depending on renal function, and the effects of normeperidine are not reversible with opioid antagonist drugs. Meperidine is not recommended for cancer pain management or for use in older adults. Opioid Antagonists Naloxone (Evzio, Narcan): It is essential that this drug be readily available in all health care settings in which opioids are given. Action https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zVrT2hbWFsCuacrrvtQ3c5e2aqBPaKXEaVcMiuwkAz59F1Dmo… 6/13 2/14/24, 10:35 AM Realizeit for Student Naloxone (antidote) reverses analgesia and the CNS and respiratory depression caused by agonists. It competes with opioids for receptor sites in the brain and thereby prevents binding with receptors or displaces opioids already occupying receptor sites. When opioids cannot bind to receptor sites, they are “neutralized” and cannot exert their effects on body cells. Use Naloxone has long been the drug of choice to treat respiratory depression caused by an overdose of opioids. Given intravenously, naloxone begins to reverse CNS and respiratory depression induced by opioids in minutes. However, the American Heart Association’s recommendations for initial treatment of life-threatening opioid-related respiratory depression do not include the inhaled route. Use in Children Cautious use of naloxone is necessary in neonates and children. As usual, the dose is smaller and given according to kilogram weight. The child's renal and hepatic function also affects the response to the medication. The recommended route is IV only, to control absorption. Use in Patients With Renal Impairment Use of naloxone in renal impairment requires caution. If it is advised, it is necessary to give small dose. Impaired renal function leads to slower drug excretion and increased risk of accumulation. Use in Patients With Hepatic Impairment Similarly, use of naloxone in hepatic impairment requires caution. It is necessary to monitor the patient's liver function closely to prevent toxicity. Use in Patients With Critical Illness Critically ill patients who have increased intracranial pressure, seizure disorders, head trauma, or respiratory depression should not receive naloxone. However, people with coma of unknown origin may receive the drug to determine if the cause of the mental status change could result from opioids. Adverse Effects Adverse effects of naloxone include tremors, drowsiness, sweating, decreased respirations, hypertension, and nausea and vomiting. Naloxone itself has minimal toxicity. Contraindications Contraindications to naloxone include known hypersensitivity to the drug, presence of narcotic abuse, and pregnancy. The drug may precipitate withdrawal, producing tachycardia, hypertension, and violent behavior. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zVrT2hbWFsCuacrrvtQ3c5e2aqBPaKXEaVcMiuwkAz59F1Dmo… 7/13 2/14/24, 10:35 AM Realizeit for Student Nursing Implications Assessing for Therapeutic Effects The nurse assesses for reversal of opioid effects, including improved respiratory function and decreased sedation. Assessing for Adverse Effects The nurse assesses for decreased reparations and elevated blood pressure. With the use of naloxone, the nurse is prepared to repeat the dose. The return of pain is a factor to be considered. Other Drugs in the Class Naltrexone (Vivitrol) is an opiate antagonist that acts in the brain to prevent opiate effects (e.g., pain relief, feelings of well-being), making it effective in decreasing the desire to take opiates and in treating alcohol dependence. Professionals commonly use naltrexone as part of a complete treatment program for substance abuse (e.g., compliance monitoring, counseling, support, behavioral contract, lifestyle modification); health care providers administer the medication. The drug decreases the desire to drink alcohol, and the dose is based on the patient’s medical condition and response to treatment. Contraindications to naltrexone include concurrent use of opiates, including methadone. Such use can cause sudden withdrawal symptoms (see Box 49.5). After discontinuing opiates, at least 7 days should pass before a person starts taking naltrexone. To confirm absence of opioids, health care providers should verify self-reporting of opioid abstinence in addicted patients using urine analysis. If results for opioids are positive or there are signs of opiate withdrawal, a naloxone challenge test (administering small doses of naltrexone and observing for signs of withdrawal) is typically necessary. It is important to assess liver function in patients taking naltrexone, because liver problems may occur. Phenothiazines In this discussion, Promethazine, with its antiemetic action, serves as the prototype. Pharmacokinetics Promethazine is rapidly absorbed following oral administration and undergoes extensive first-pass metabolism in the liver. Clinical effects are apparent within 20 minutes after oral, intramuscular, or rectal administration; the effects last 4 to 6 hours. Metabolism occurs in the liver, with excretion in the urine. Action Promethazine and other phenothiazines have widespread effects on the body. The therapeutic effects of nausea and vomiting are attributed to their ability to block dopamine from receptor sites in the brain and CTZ. Use Promethazine is used for the prevention and treatment of nausea and vomiting associated with surgery, anesthesia, migraines, chemotherapy, and motion sickness. Use in Children The U.S. Food and Drug Administration (FDA) has issued a BLACK BOX WARNING ♦ alerting nurses that promethazine is contraindicated in children younger than two years of age because of the risk of potentially fatal respiratory depression. In addition, promethazine should not be used in children with hepatic disease, Reye's syndrome, a history of sleep apnea, or a family history of sudden infant death syndrome. Newer agents, such as ondansetron and aprepitant, are recommended for management of postoperative nausea and vomiting in pediatric patients. Use in Older Adults Older adults may have increased concerns with the adverse anticholinergic effects (e.g., dizziness, acute confusion, delirium, dry mouth, tachycardia, blurred vision, urinary retention, constipation). Use in Patients With Renal Impairment https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zVrT2hbWFsCuacrrvtQ3c5e2aqBPaKXEaVcMiuwkAz59F1Dmo… 8/13 2/14/24, 10:35 AM Realizeit for Student A dose reduction may be necessary in patients with renal impairment to avoid the possibility of adverse effects, toxicity, or increased sensitivity to phenothiazines. Use in Patients With Hepatic Impairment Phenothiazines are metabolized in the liver. Therefore, the presence of liver disease (e.g., cirrhosis, hepatitis) may slow metabolism and prolong drug elimination half-life, with resultant accumulation and increased risk of adverse effects. Thus, the drugs should be used cautiously in patients with hepatic impairment. Cholestatic jaundice may occur with promethazine. Adverse Effects With promethazine, common side effects include blurred vision, urinary retention, dry mouth, photosensitivity, drowsiness, and confusion. Contraindications Contraindications to use of promethazine include known hypersensitivity to the drug. Cautious use is necessary in people with glaucoma because the drug possesses antimuscarinic activity. Nursing Implications Preventing Interactions Several medications interact with promethazine, increasing its effects. Herbal interactions with promethazine have been reported with kava kava, St. John's wort, and valerian; an increased risk of CNS depression is a possibility. No herbs or foods that decrease the effects of promethazine have been identified. Administering the Medication The FDA has issued a BLACK BOX WARNING ♦ alerting nurses that promethazine is contraindicated for subcutaneous administration. The preferred parenteral route of administration is intramuscular, which reduces risk of surrounding muscle and tissue damage. However, the drug can cause pain at the injection site. The nurse avoids intravenous (IV) administration, if possible, because the drug can cause severe tissue injury. Assessing for Therapeutic Effects The nurse observes for prevention or resolution of nausea and vomiting. Assessing for Adverse Effects The nurse assesses for associated adverse anticholinergic effects (dry mouth, blurred vision, urinary retention, constipation, acute confusion, dizziness, tachycardia). It is necessary to be aware that hallucinations, convulsions, and sudden death may occur with excessive doses. The nurse also assesses tissue integrity with injection of the drug because the drug may cause severe tissue injury; burning and pain at the IV site justify immediate discontinuation of the drug. Patient Teaching The nurse teaches patients taking promethazine to use the lowest effective dosage and not to take other drugs with respiratory depressant effects concurrently. Patient Teaching Guidelines: Antiemetic Drugs General Considerations Try to identify the circumstances that cause or aggravate nausea and vomiting and avoid them when possible. Drugs are more effective in preventing nausea and vomiting than in stopping them. Thus, they should be taken before the causative event when Do not eat, drink, or take oral medications during acute vomiting episodes, to avoid aggravating the stomach upset. Lying down may help nausea and vomiting to subside; activity tends to increase stomach upset. After your stomach has settled down, try to take enough fluids to prevent dehydration and potentially serious problems. Tea, broth, and gelatins Do not drive an automobile or operate dangerous machinery if drowsy from antiemetic drugs, to avoid injury. If you take antiemetic drugs regularly, do not drink alcohol or take other drugs without consulting a health care provider. Several drugs interact w effects. Dronabinol, which is derived from marijuana and recommended only for nausea and vomiting associated with cancer chemotherapy, can cause d other mind-altering effects. You should avoid alcohol and other drugs that cause drowsiness. Also, do not drive or perform hazardous tasks requ dexterity, to decrease risks of injury. Self or Caregiver Administration Take the drugs as prescribed. Do not increase dosage, take more often, or take when drowsy, dizzy, or unsteady on your feet. Several of the drug effects, which are more severe if too much is taken. To prevent motion sickness, take medication 30 minutes before travel and then every 4 to 6 hours, if necessary, to avoid or minimize adverse effe Take or give antiemetic drugs 30 to 60 minutes before a nausea-producing event, when possible. This includes cancer chemotherapy, radiation t other treatments. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zVrT2hbWFsCuacrrvtQ3c5e2aqBPaKXEaVcMiuwkAz59F1Dmo… 9/13 2/14/24, 10:35 AM Realizeit for Student Take dronabinol only when you can be supervised by a responsible adult because of its sedative and mind-altering effects. Aprepitant (Emend) reduces the effectiveness of oral contraceptives; therefore, use an alternative form of birth control during therapy and for 1 m Other Drugs in the Class Phenothiazines are effective antiemetic agents. However, because of their adverse effects (e.g., sedation, cognitive impairment, extrapyramidal reactions), they are mainly indicated if vomiting is severe and cannot be controlled by other measures or only when a few doses are needed. Prochlorperazine (Compazine), which has a side-effect profile similar to that of promethazine, is the most commonly used antiemetic in this class for the treatment of severe nausea and vomiting associated with anesthesia. Chlorpromazine (Thorazine) is used less often than prochlorperazine for nausea and vomiting but is more commonly used in the treatment of psychosis and psychotic symptoms in other disorders. It is also used with intractable hiccups and treatment of nausea and vomiting associated with anesthesia. Perphenazine is used to manage severe nausea and vomiting. However, the FDA has issued a BLACK BOX WARNING ♦ for perphenazine because elderly patients with dementia-related psychosis treated with perphenazine and other antipsychotic drugs have an increased risk of death. It is important to reduce the dose as soon as possible to minimize significant adverse effects, including bradycardia, cardiac arrest, hypotension, catatonic-like states, extrapyramidal symptoms, and a blue-gray discoloration of the skin. 5-Hydroxytryptamine3 (5-HT3) or Serotonin Receptor Antagonists Ondansetron (Zofran) is the prototype of the 5-HT3 receptor antagonists. Pharmacokinetics Oral ondansetron is well absorbed from the GI tract and undergoes some first-pass metabolism. The drug’s half-life is 3 to 5.5 hours in most patients and 9 to 20 hours in patients with moderate or severe liver impairment. With the oral forms (disintegrating tablet or soluble film), action begins in 30 to 60 minutes and peaks in about 2 hours. With the IV form, onset and peak of drug action are immediate. The bioavailability is slightly increased by the presence of food but is unaffected by antacids. Action Ondansetron and the other 5-HT3 receptor antagonists antagonize serotonin receptors, preventing their activation by the effects of emetogenic drugs and toxins. Use Ondansetron is used to prevent or treat moderate to severe nausea and vomiting associated with cancer chemotherapy, radiation therapy, and postoperative status. Use in Children The drug is indicated for use in children, although little information is available about its use in children younger than six months of age. The American Society of Clinical Oncology recommends the use of a 5-HT3 receptor antagonist plus a corticosteroid before administering highdose chemotherapy or chemotherapy with high to moderate emetic risk to pediatric oncology patients. Use in Older Adults Dosage adjustment is not required in patients older than 65 years of age. Researchers have observed no overall differences in safety or effectiveness in older adults compared with younger patients. Use in Patients With Hepatic Impairment The drug's half-life is significantly increased in patients with moderate to severe hepatic impairment. This increases the risk of adverse effects. Use in Patients Receiving Home Care Oral administration of the drug may be given in the home setting. The home care nurse assesses for resolution of nausea and vomiting. Diarrhea is a common adverse effect; therefore, the nurse also needs to assist patients and caregivers with appropriate use of the drugs and other interventions to prevent fluid and electrolyte depletion. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zVrT2hbWFsCuacrrvtQ3c5e2aqBPaKXEaVcMiuwkAz59F1Dmo… 10/13 2/14/24, 10:35 AM Realizeit for Student Adverse Effects Adverse effects of ondansetron are usually mild to moderate. Common ones include diarrhea, headache, dizziness, constipation, fatigue, transient elevation of liver enzymes, and pain at the injection site. Contraindications Contraindications to ondansetron include known hypersensitivity to the drug. Nursing Implications Preventing Interactions Phenytoin, carbamazepine, rifampin, and other inducers of the cytochrome 450 (CYP) 3A4 enzymes increase the clearance of ondansetron and decrease serum concentrations. No dosage adjustment of ondansetron appears necessary for people taking these drugs based on available data. The use of ondansetron with apomorphine is contraindicated due to the potential of a significant drop of blood pressure or loss of consciousness with concurrent use. St. John’s wort may decrease ondansetron levels. Administering the Medication It is important to leave the disintegrating tablet in the blister pack until administration. Gentle removal is essential; it is necessary to peel back the blister backing and not push the tablet through the foil. The oral film dissolves rapidly on the tongue, without the need for water. Assessing for Therapeutic Effects The nurse assesses for verbal reports of decreased nausea and the absence of vomiting. Assessing for Adverse Effects Because headache and diarrhea are the most common adverse effects, the nurse gives special attention when assessing for these effects. It is also necessary to evaluate for stamina and balance. The nurse should note that use of ondansetron may mask a progressive ileus and gastric distension following abdominal surgery or in patients with chemotherapy-induced nausea and vomiting. Patient Teaching The drug may impair thinking or reactions, which means that it is necessary to advise patients to use caution with driving or other tasks requiring mental alertness. The nurse teaches patients with phenylketonuria that the orally disintegrating tablets contain phenylalanine. Other Drugs in the Class The other 5-HT3 receptor antagonist drugs may be less beneficial as rescue drugs in the treatment of chemotherapy-induced nausea and vomiting and more effective in the prevention of this condition. Granisetron (Sancuso, Sustol) and dolasetron (Anzemet) may be given intravenously or orally. The oral route of dolasetron is approved for chemotherapy-related nausea and vomiting; the IV route is only used for prevention of postoperative nausea and vomiting. Palonosetron (Aloxi) is given only intravenously. As with ondansetron, other 5-HT3 receptor antagonists are associated with dose-dependent increases in electrocardiographic intervals, including PR, QRS duration, and QT interval. These drugs should be avoided in patients taking class I and class III antidysrhythmic agents because of concerns about the development of torsades de pointes, with prolongation of the QT interval. Example Video: YouTube: Acute Pancreatitis - Causes, Symptoms, Diagnosis, Treatment, Pathology https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zVrT2hbWFsCuacrrvtQ3c5e2aqBPaKXEaVcMiuwkAz59F1Dmo… 11/13 2/14/24, 10:35 AM Realizeit for Student Summary Management of acute pancreatitis is directed toward symptomatic relief and complication prevention. Pain management and control of nausea and vomiting is a priority. Patients are often NPO and may receive enteral or parenteral feedings. Histamine 2 antagonists or proton pump inhibitors are used for gastric acid suppression. Patients require blood glucose monitoring and insulin coverage as needed in acute care settings and may be ongoing with chronic pancreatitis. References American Gastroenterological Association (AGA), www.gastro.org Dudek, S. G. (2013). Nutrition essentials for nursing practice (7th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Endocrine Society, www.endo-society.org Eliopoulos, C. (2018). Gerontological nursing (9th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Feldman, M., Friedman, L. S., & Brandt, L. J. (2015). Sleisenger & Fordtran’s gastrointestinal & liver disease (10th ed.). Philadelphia, PA: Saunders Elsevier. Ferri, F. F. (Ed.). (2014). Practical guide to the care of the medical patient (9th ed.). Philadelphia, PA: Mosby Elsevier. Goldman, L., & Schafer, A. I. (2015). Goldman’s cecil medicine (25th ed.). Philadelphia, PA: Saunders Elsevier. Greenberger, N. J., Blumberg, R. S., & Burakoff, R. (Eds.). (2015). Current diagnosis and treatment: Gastroenterology, hepatology & endoscopy. New York: McGraw-Hill. Karch, A. M. (2014). 2014 Lippincott’s nursing drug guide. Philadelphia, PA: Lippincott Williams & Wilkins. Lippincott. (2017). Nursing 2017 Drug handbook. Philadelphia, PA: Wolters Kluwer. Porth, C. M., & Grossman, C. (2014). Pathophysiology: Concepts of altered health status (8th ed.). Philadelphia, PA: Lippincott Williams & Wilkins National Digestive Diseases Information Clearinghouse (NDDIC), www.digestive.niddk.nih.gov National Pancreas Foundation (NPF), www.pancreasfoundation.org Fagenholz, P. J., & de Moya, M. A. (2014). Acute inflammatory surgical disease. Surgical Clinics of North America, 24(2014), 1–30. Gupte, A. R., & Forsmark, C. E. (2014). Chronic pancreatitis. Current Opinion in Gastroenterology, 30(5), 500–505. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zVrT2hbWFsCuacrrvtQ3c5e2aqBPaKXEaVcMiuwkAz59F1Dmo… 12/13 2/14/24, 10:35 AM Realizeit for Student Hong, M. T., Monye, L. C., & Seifert, C. F. (2015). Acid suppressive therapy for stress ulcer prophylaxis in noncritically ill patients. Annals of Pharmacotherapy, 49(9), 1004–1008. Lankisch, P. G., Apte, M. & Banks, P. A. (2015). Acute pancreatitis. The Lancet, 386(9988), 85–96. Marx, J., Hockberger, R. & Walls, R. (Eds.). (2013). Rosen’s emergency medicine: Concepts and clinical practice. Philadelphia, PA: Mosby Elsevier. McClave, S. A. (2013). Nutrition in pancreatitis. World Review of Nutrition & Dietetics, 105, 160–168. Rakel, R. E., & Rakel, D. P. (Eds.). (2015). Textbook of family medicine (9th ed.). Philadelphia, PA: Saunders Elsevier. Townsend, C. M., Beauchamp, R. D., Evers, B. M., et al. (2016). Sabiston’s textbook of surgery: The biological basis of modern surgical practice. Philadelphia, PA: Elsevier. Schepers, N. J., Besselink, M. G., van Santvoort, H. C., et al; Dutch Pancreatitis Study Group. (2013). Early management of acute pancreatitis. Best practice & research Clinical gastroenterology, 27(5), 727–743. Woo, T., & Robinson, M. (2016). Pharmacotherapeutics for advanced practice nurse prescribers (4th ed.). Philadelphia, PA: F.A. Davis. World Health Organization. https://www.who.int/ Zerem, E. (2014). Treatment of severe acute pancreatitis and its complications. World Journal of Gastroenterology, 20(38), 13879–13892. Review The H2RAs (e.g., cimetidine, famotidine, nizatidine, and ranitidine) inhibit secretion of gastric acid, decreasing the acidity of gastric juices. They are indicated for prevention and treatment of heartburn, peptic ulcer disease, GERD, esophagitis, GI bleeding due to stress ulcers, and hypersecretory syndromes such as Zollinger-Ellison syndrome. The PPIs (e.g., omeprazole, esomeprazole, lansoprazole, pantoprazole, rabeprazole) bind irreversibility to the gastric proton pump to prevent the release of gastric acid from parietal cells into the stomach lumen. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zVrT2hbWFsCuacrrvtQ3c5e2aqBPaKXEaVcMiuwkAz59F1Dmo… 13/13