Pharmacology Module 6 Diuretics PDF

PHARMOCOLOGY MODULE 6 CHAPTER 32 Diuretics: Increases urine elimination Loop Diuretics:. Inhibit the reabsorption of sodium & Chloride in the distal & proximal tubules. Of the kidney & the loop of Henle.. Loop diuretics have 3 acting sites which make the effectiveness of the diureti...

PHARMOCOLOGY MODULE 6 CHAPTER 32 Diuretics: Increases urine elimination Loop Diuretics:. Inhibit the reabsorption of sodium & Chloride in the distal & proximal tubules. Of the kidney & the loop of Henle.. Loop diuretics have 3 acting sites which make the effectiveness of the diuretic increase. Thiazide Diuretics: Inhibit the reabsorption of sodium and chloride ions in the ascending portion of the loop of Henle and early distal tubule of the nephron. The action results in the excretion of sodium, chloride, and water Thiazides are usually the first type to treat HYPERTENSION. *Both these types of diuretics will also cause the electrolyte potassium to be excreted in the urine, can result in the patient to become hypokalemic. Potassium-Sparing Diuretics: (Potassium Saving). Reduces the excretion of the potassium from the kidneys. Work by blocking reabsorption of sodium in the collecting tubules, thereby increasing sodium and water in the urine; This reduces the excretion of potassium. spironolactone (Aldactone) works to antagonize the action of Aldosterone. A hormone produced by the adrenal cortex; this enhances the reabsorption of sodium into the distal convoluted tubules of the kidneys. When this is blocked by the drug sodium, (but not potassium) Water is excreted. Osmotic diuretics increase the density of the filtrate in the glomerulus this prevents selective reabsorption of water, and it passes out his urine sodium and chloride excretion are also increased. Carbonic anhydrase inhibitors are sulfonamides with bacteriostatic action that inhibit the enzyme carbonic anhydrase. carbonic anhydrase inhibition results in the excretion of sodium potassium bicarbonate and water.  Diuretic drugs are used in treatment of the following. hypertension edema associated with heart failure cortical steroid and estrogen therapy and cirrhosis of the liver. renal disease (Acute failure, renal insufficiency, and nephrotic disease) cerebral edema seizures and altitude sickness spironolactone is used for male or female hormonal therapy for gender dysphoria. Infrequently for acute glaucoma topically and increased intraocular pressure (before and after eye surgery) Ethacrynic acid (loop diuretic) used for short term management of ascites caused by malignancy idiopathic edema or lymphedema. when clients are at risk for potassium loss the potassium sparing diuretics may be used with or in place of other categories of diuretics combination drugs have been developed to help reduce fluid when one agent is not sufficient for fluid reduction and may be ordered for specific situations these drugs are useful in treating clients who may be more likely to become hypokalemic or have severe edema from heart failure cirrhosis or nephrotic syndrome typically these drugs are not used initially to treat hypertension ALERT!! nonprescription diuretics example AQUABAN may be taken to relieve premenstrual bloating these products typically are composed of caffeine and ammonium chloride be aware people may use these drugs for weight loss causing electrolyte imbalance. Adverse reactions neuromuscular system: reactions dizziness Lightheadedness headache weakness fatigue cardiovascular system reactions orthostatic hypotension electrolyte imbalances glycosuria gastrointestinal system reactions anorexia nausea vomiting. dermatologic reactions rash photosensitivity extremity paresthesia’s or flaccid muscles may indicate hypokalemia low blood potassium hyperkalemia and increase in potassium level in the blood (potassium sparing diuretics) hypokalemia is most likely to occur with those with inadequate fluid intake and urine output those with diabetes or renal disease older adults and those are so really ill. Men taking Spironolactone may have Gynecomastia breast enlargement. Lifespan considerations for transgender spironolactone inhibits the secretion of testosterone and is used in feminizing hormonal therapy during male to female gender reassignment. Contraindications clients with known hypersensitivity to drugs electrolyte imbalances severe kidney or liver dysfunction and Anuria (cessation of urine) mannitol (an osmotic diuretic) is contradicting and clients with active intracranial bleeding except for doing a cranial craniotomy the potassium sparing diuretics are contraindicated in clients with hyperkalemia. not recommended for pediatric clients. Diuretics are used cautiously in clients with renal dysfunctions Thiazide and loop diuretics are used cautiously in clients with gout liver disease diabetes systemic lupus erythematosus, or diarrhea. cross sensitivity reaction may occur with the thiazides and sulfonamides some of the thiazide diuretics contain tartrazine (a yellow food dye) which may cause allergic type reactions or bronchial asthma. clients with sensitivities to sulfonamides may have allergic reactions to loop diuretics (furosemide to torsemide and bumetanide) potassium sparing diuretics should be used cautiously in clients with liver disease or diabetes All the diuretics may cause an increased risk of hypertension when taking with antihypertensive drugs. Interactions Carbonic Anhydrase Inhibitors Interacting Drug- Primidone (Treatment of seizure activity) Decreased effectiveness. Loop Diuretics Interacting drug- Cisplatin and aminoglycosides (Cancer treatment and anti-infective) Increased risk for ototoxicity Interacting drug- Anticoagulants or thrombolytics (Blood thinner) Increased risk for bleeding Interacting drug- Digitalis (Cardiac problems) Increased risk for cardiac arrhythmias Interacting drug- Lithium (Psychotic symptoms) Increased risk of lithium toxicity Interacting drug- Hydantoins (Treatment of seizure activity) Decreased diuretic effectiveness. Interacting Drug- NSAIDS and Salicylates (Pain relief) Decreased Diuretic Effectiveness Potassium Sparing Diuretics Interacting Drug- ACE inhibitors or potassium supplements (Cardiovascular Problems) Increased risk for Hyperkalemia Interacting Drug- NSAIDS, Salicylates and anticoagulants (Pain relief and blood thinner) Decreased diuretic effectiveness. Thiazide and Related diuretics Interacting drug- Allopurinol (Gout treatment) Increased risk of hypersensitivity to allopurinol Interacting Drug- Anesthetics (Surgical Anesthesia) Increases anesthetic effectiveness. Interacting drug- Antineoplastic drugs (Cancer treatment) Extended Leukopenia Interacting drug- Antidiabetic drugs (control of diabetes) Hyperglycemia Herbal Consideration- Herbal diuretics available OTC include celery, chicory, sassafras, juniper berries, St. John’s wort, ephedra, hibiscus, parsley and elderberry. No herbal diuretic should be taken without consulting PCP. Juniper berries are associated with renal damage, horsetail contains toxic compounds. Ephedrine should be avoided by clients who have hypertension.  Nursing Process: (Diuretics) - Pre-administration:. Before administration of a diuretic:. Take Vital Signs. Measure a weight to get a baseline to compare to fluid loss. Collect labs (Serum electrolytes are carefully reviewed). Patients with renal dysfunction should have BUN (blood uria nitrogen) and creatinine clearance levels monitored as well.. If the patient has peripheral edema inspect and measure the involved areas and document in the patients chart the degree and severity of the edema.. If the patient is receiving an Osmotic diuretic, the focus of the assessment is on the patient's disease or disorder and the symptoms being treated. ♥ If the patient has low urinary output and the osmotic diuretic is given to increase urinary output, review the ratio between intake and output and symptoms that the patient is experiencing. - Ongoing assessment: (Diuretics). As always with a diuretic you want to continue to measure and record the patient's Input and Output.. Any decrease in urinary output report to HCP. Report fluid loss as measured by weighing the patient at the SAME time DAILY (Ensure the patient is wearing the same amount of clothing each time). Frequent lab draws will be drawn such as serum electrolytes, uric acid and liver and kidney function test.. When patients take diuretics on an OUTPATIENT basis it is a nurses responsibility to teach them to weigh themselves and keep up with how much weight is being lost. - Planning (Diuretics):. Support the patients' needs related to adverse drug reactions and confidence in an understanding of the medication regimen. - Implementation: (Diuretics) - Patients with Edema:. Patients with edema caused by HF (♥ failure) are weighed daily.. Parenteral (IV) loop diuretics are typically used in the hospital for RAPID fluid loss when it interferes with CARDIAC function.. Weight loss of 2lbs daily is desirable to manage fluid loss and prevent dehydration and electrolyte imbalance.. Every 8 hours carefully measure and document the fluid intake and Output.. Patients with renal disease may require more frequent measurements of Output.. Patient's vitals are taken Q4. Assess areas of edema daily and evaluate how well the diuretic is working. - Patient with Hypertension:. Teach hypertensive patient how to monitor their own BP and ♥ rate.. If a patient is taking a Diuretic & Antihypertensive drug you really want to emphasize to your patients about monitoring vitals and be sure they understand.. Respiratory rate is also monitored more frequently with critically ill patients or if their BP is excessively high. - Patient with Increased Inter cranial Pressure:. MANNITOL is ONLY administered by IV ROUTE.. Mannitol may crystallize when exposed to low temperatures, check solution before administration.. IF mannitol Is crystalized return the solution back to the pharmacy and request a new dose.. The rate of administration and concentration of the drug is individualized to maintain a urine flow of at least 30-50 ml/hr.. When a patient is receiving the osmotic diuretic mannitol or urea for treatment of increased inter cranial pressure caused by cerebral edam, perform NEUROLOGICAL assessments (Pupils reactive to lights, level of consciousness, response to pain stimulus). Also retain vital signs at timed intervals - Patients with Renal Compromise:. When Thiazide Diuretics are administered, Renal Function should be monitored.. Thiazide Diuretics may cause AZOTEMIA which is accumulation of nitrogenous waste in the blood.. If Nonprotein nitrogen or BUN increases, the primary healthcare provider may consider withholding the drug or discontinuing it.. Serum uric acid concentrations are monitored periodically during treatment with thiazide diuretics, because these drugs may cause an acute attack of gout.. Insulin or oral anti diabetic drug dosages may require alterations because of hyperglycemia. Therefore, serum glucose concentrations are monitored periodically. - Patient at risk for Electrolyte Imbalance:. One of the primary imbalances to monitor is potassium.. Patients who experience cardiac arrhythmias or who are receiving Digoxin are more susceptible to significant potassium loss when taking diuretics.. Potassium Sparing Diuretics are recommended for these patients.. Monitor patients sparing diuretics because they are at risk for hyperkalemia. If this Serum Potassium levels exceed 5.3 the diuretic is stopped, and the primary health care provider is notified.. Treatment to reduce the Potassium can include administration of IV bicarbonate (if the patient is acidotic) or oral or parenteral glucose with rapid acting insulin.. Persistent hyperkalemia may require dialysis. Signs & Symptoms of common fluid and electrolyte imbalance with diuretic therapy: - Dehydration. Poor skin turgor. dry mucus. membranes. weakness. Dizziness. fever. low urine output - Hyponatremia (Excessive loss of sodium):. Cold Clammy skin. Decrease skin turgor.. Confusion. Hypotension. Irritability. Tachycardia - Hypomagnesemia (Low levels of Magnesium):. Leg & foot cramps. Hypertension. Tachycardia. Neuromuscular irritability. Trimmer. Hyperactive. Deep tendon. Reflexes. Confusion. Visual or auditory hallucinations. Paresthesias - Hypokalemia (Low blood Potassium):. Anorexia. Nausea and vomiting. Muscle twitching. Depression. Confusion. Bradycardia. Impaired thought process. Drowsiness - Hyperkalemia (High Blood Potassium):. Irritability. Anxiety. Confusion. Muscle cramps. Numbness or tingling sensation. Nausea. Diarrhea. Cardiac arrhythmias. Flaccid paralysis Impaired Urinary Elimination:. Teach the patient's using a diuretic at home to take it early in the day so nighttime sleep will not be interrupted.. Reassure your patients that are on bed rest with prompt responses to a call light When necessary and have a bedpan or a urinal within easy reach.. Onset of these drugs= Less than 60 min. Peak for diuretics= 1-4 hours. Duration of time= 8 hours or less (For most diuretics not all) TABLE 33.1 Examples of Onset and Duration of Activity of Diuretics DRUG ONSET DURATION OF ACTIVITY Acetazolamide tablets 1-1.5 8-12 hrs 2 hrs. Sustained release 18-24 hrs capsules 2 min. IV Route 4-5 hrs Amiloride 2 hrs. 24 hrs. Bumetanide oral 30-60min 4-6 hrs. IV route Within a few min. Less than 1 hr Ethacrynic Acid Oral Within 30 min 6-8 hrs IV route Within 5 min 2 hrs Furosemide oral Within 1 hr 6-8 hrs IV route Within 5 min 2 hrs. Mannitol (IV Route) 30-60 min 6-8 hrs. Spironolactone 24-48 hrs 48-72 hrs Thiazides & related 1-2 hrs. varies diuretics Triamterene 2-4 hrs 12-16 hrs Urea (IV route) 30-45 min 5-6 hrs Risk for Deficient Fluid: The most common adverse reaction associated with the administration of a diuretic is loss of fluid and electrolytes.  The most common imbalances are loss of potassium and water. Other electrolytes particularly potassium, water, magnesium, sodium & chloride are lost. When too much potassium is lost HYPOKALEMIA occurs. In certain patients receiving a digital glycoside or those who already have an existing cardiac arrhythmia hypokalemia has the potential to create a more serious arrhythmia. Hypokalemia is treated with POTASSIUM supplements or foods with high potassium content or by changing the diuretic to potassium sparing diuretic. Patients taking a loop diuretic are prone to magnesium deficiency *Gerontology lifespan considerations: older adults are particularly prone to fluid volume deficit and electrolyte imbalances while taking diuretics. Dehydration can occur if the patient reduces fluid intake because of fear of incontinence. Education for patients: Preventing Potassium Imbalances. Diuretics increase the excretion of water and sodium. Some of these drugs also increase the excretion of potassium, which places the patient at risk for hypokalemia, a possibly life- threatening condition. Patients can reduce their risk of hypokalemia by eating foods rich in potassium, which will replace the loss caused by the diuretic.. When you teach, make sure your patient understands the following:. Potassium can be replenished by diet; take supplements only when instructed to do so by your primary health care provider. The following foods have higher levels of potassium than other foods:. Top 10 foods with the highest amount of potassium per serving: white beans, dark leafy greens, baked potatoes with skin on, dried apricots, acorn squash, plain low-fat yogurt, salmon, avocado, mushrooms, bananas. Fruits (10 highest) : apricots, prunes, dried currants / raisins, dates, figs, dried coconut, avocado, bananas, oranges, nectarines and peaches. Vegetables (10 highest): sun-dried tomatoes, spin- ach, Swiss chard, mushrooms, sweet potato, kale, brussels sprouts, zucchini, green beans, asparagus. Other sources: chocolate, molasses, nuts. NURSING ALERT ❗️ Warning signs of a fluid and electrolyte Imbalance include dry mouth, thirst, weakness, lethargy, drowsiness, restlessness, muscle pain or cramps, confusion, GI disturbances, hypotension, oliguria, tachycardia & seizures Risk for Injury: Patients receiving a diuretic (particularly a loop or thiazide diuretic) and a digitalis glycoside concurrently require frequent monitoring of the pulse rate and rhythm because of the possibility of cardiac arrhythmias. Any significant changes in the pulse rate and rhythm are immediately reported to the primary health care provider. patients may experience dizziness or lightheadedness during the first couple weeks of diuretic therapy or when a rapid diuretic has occurred Education for patients and family: Do not stop taking the drug or omit doses, except on the advice of a primary health care provider. If a GI upset occurs, take the drug with food or milk. Take the drug early in the morning (once a day dosage) unless directed otherwise to minimize the effects on nighttime sleep. Twice a day dosing should be administered early in the morning (7am) and early afternoon (2pm) or as directed by the primary healthcare provider. Do not reduce fluid intake to reduce the need to urinate. Be sure to continue the fluid intake recommended by the primary health care provider. Avoid alcohol and nonprescription drugs unless approved by the primary health care provider. Hyper- tensive patients should be careful to avoid medications that increase blood pressure, such as OTC drugs for appetite suppression and cold symptoms. Notify the primary health care provider if any of the following occur muscle cramps or weakness, dizziness, nausea, vomiting, diarrhea, restlessness, excessive thirst, general weakness, rapid pulse, increased heart rate or pulse, or GI distress. If dizziness or weakness occurs, observe caution while driving or performing hazardous tasks, rise slowly from a sitting or lying position, and avoid standing in one place for an extended time. Weigh yourself weekly or as recommended by the primary healthcare provider. Contact the healthcare provider if weight loss or weight gain exceeds 3 to 5 pounds a week.  If foods or fluids high in potassium are recommended by the primary health care provider, eat the amount recommended. Do not exceed this amount or eliminate these foods from the diet for more than 1 day, except when told to do so by the primary health care provider (see Patient Teaching for Improved Patient Outcomes: Preventing Potassium Imbalances). After a time, the diuretic effect of the drug may be mini- mal because most of the body's excess fluid has been removed. Continue therapy to prevent further accumulation of fluid. If taking thiazide or related diuretics, loop diuretics, potassium-sparing diuretics, carbonic anhydrase inhibitors, or triamterene, avoid exposure to sunlight or ultra- violet light (sunlamps, tanning beds), because exposure may cause severe sunburn. For patients who have diabetes mellitus and who take loop or thiazide diuretics: Know that blood glucometer test results for glucose may be elevated. Contact the primary health care provider if home-tested blood glucose levels increase. For patients who take potassium-sparing diuretics: Avoid eating foods high in potassium and avoid the use of salt substitutes containing potassium. Read food labels carefully. Do not use a salt substitute unless a particular brand has been approved by the primary health care provider. Also avoid the use of potassium supplements. Male patients who take spironolactone may experience gynecomastia. This is usually reversible when therapy is discontinued. For patients who take thiazide diuretics: These agents may cause gout attacks. Contact the primary health care provider if significant, sudden joint pain occurs. For patients who take carbonic anhydrase inhibitors: During treatment for glaucoma, contact the primary health care provider immediately if eye pain is not relieved or if it increases. When a patient with epilepsy is being treated for seizures, a family member of the patient should keep a record of all seizures witnessed and bring this to the HCP. Key Points: Excessive fluid is involved in many conditions such as HF endocrine disturbances, and kidney and liver diseases. Pressure of fluid in the blood vessels contributes to hyper- tension. Diuretics are drugs that reduce body fluid by increasing production of urine by altering the excretion or reabsorption of electrolytes in the kidney.  Loop, thiazide, and potassium- sparing diuretics are used to treat HF, endocrine disturbances, and kidney and liver diseases. Osmotic and carbonic anhydrase inhibitors are used in the treatment of cerebral edema and seizures, intraocular pressure, and altitude sickness. Fluid loss is monitored by vital signs and weight reduction as well as measured fluid intake and output. Some people may be reluctant to take diuretics for fear of incontinence Others may reduce fluid intake for the same reason. Dehydration and electrolyte imbalances are more likely to occur when patients engage in these behaviors. Common adverse reactions to the medications include dizziness, headache, weakness, anorexia, nausea, and vomiting Rashes and photosensitivity may occur with sun exposure. Again, patients should be monitored for electrolyte imbalances to reduce these adverse reactions. Loop diuretics: Furosemide Potassium Sparing Diuretics: Spironolactone Thiazide Diuretics: Chlorothiazide Hydrochlorothiazide Osmotic Diuretics: Mannitol (only given IV route) Antacids used in the treatment of hyperacidity caused by heartburn, acid indigestion, or sour stomach. gastroesophageal reflux disease (GERD) peptic ulcers Adverse reactions antacids can cause diarrhea or Constipation the magnesium and sodium containing antacids may have a laxative effect and produce diarrhea aluminum and calcium containing products tend to produce Constipation. Aluminum containing antacid- Constipation, intestinal impaction, anorexia, weakness, tremors and bone Pain. Magnesium containing antacids- cause severe diarrhea dehydration hypermagnesemia (Nausea, vomiting, hypotension, decreased respirations) Calcium containing antacids-cause rebound hyperacidity, metabolic alkalosis, hypercalcemia vomiting, confusion, headache renal calculi, neurologic impairment. Sodium bicarbonate- systemic alkalosis and rebound hyperacidity. Antacids Contraindications clients with known severe abdominal pain or unknown cause during lactation. sodium containing antacids are contraindicated in clients with cardiovascular problems such as hypertension or heart failure and those on sodium restricted diets. calcium containing antacids are contraindicated in clients with renal calculi or hypercalcemia. aluminum containing antacids are used cautiously in clients with gastric outlet obstruction or those with upper GI bleeding. magnesium and aluminum containing antacids are used cautiously and in clients with Decreased kidney function. The calcium containing antacids are used cautiously in clients with respiratory insufficiency renal impairment or cardiac disease antacid classified as pregnancy category C drugs and should be used with caution during pregnancy (Category C) INTERACTING DRUG COMMON USE EFFECT OF INTERACTION Digoxin, Isoniazid, Phenytoin, Treatment of cardiac Decreased absorption of the and chlorpromazine. problems, infection, seizures, interacting drug results in a nausea and vomiting. decreased effect of those drugs. Tetracycline Anti-Infective Decreased effectiveness of anti-infective. Corticosteroids Treatment of inflammatory Decreased Anti-inflammatory and respiratory problems properties. Salicylates Pain Relief Pain relievers are excreted more rapidly in the urine. CHAPTER 38: Antacids used in the treatment of hyperacidity caused by heartburn, acid indigestion, or sour stomach. gastroesophageal reflux disease (GERD) peptic ulcers Adverse reactions antacids can cause diarrhea or Constipation the magnesium and sodium containing antacids may have a laxative effect and produce diarrhea aluminum and calcium containing products tend to produce Constipation. Aluminum containing antacid- Constipation, intestinal impaction, anorexia, weakness, tremors and bone Pain. Magnesium containing antacids- cause severe diarrhea dehydration hypermagnesemia (Nausea, vomiting, hypotension, decreased respirations) Calcium containing antacids-cause rebound hyperacidity, metabolic alkalosis, hypercalcemia vomiting, confusion, headache renal calculi, neurologic impairment. Sodium bicarbonate- systemic alkalosis and rebound hyperacidity. Antacids Contraindications clients with known severe abdominal pain or unknown cause during lactation. sodium containing antacids are contraindicated in clients with cardiovascular problems such as hypertension or heart failure and those on sodium restricted diets. calcium containing antacids are contraindicated in clients with renal calculi or hypercalcemia. aluminum containing antacids are used cautiously in clients with gastric outlet obstruction or those with upper GI bleeding. magnesium and aluminum containing antacids are used cautiously and in clients with Decreased kidney function.  The calcium containing antacids are used cautiously in clients with respiratory insufficiency renal impairment or cardiac disease antacid classified as pregnancy category C drugs and should be used with caution during pregnancy (Category C) INTERACTING DRUG COMMON USE EFFECT OF INTERACTION Digoxin, Isoniazid, Phenytoin, Treatment of cardiac Decreased absorption of the and chlorpromazine. problems, infection, seizures, interacting drug results in a nausea and vomiting. decreased effect of those drugs. Tetracycline Anti-Infective Decreased effectiveness of anti-infective. Corticosteroids Treatment of inflammatory Decreased Anti-inflammatory and respiratory problems properties. Salicylates Pain Relief Pain reliver is excreted more rapidly in the urine. Acid reducing agents- drugs that reduce the production of HCI these include histamine H2 antagonists proton pump inhibitors and miscellaneous drugs such as Pepsin inhibitors, prostaglandins, and cholinergic blockers. Histamine H2 Antagonist These drugs inhibit the action of histamine at the H2 receptor cells of the stomach, which then reduces the secretion of gastric acid. Histamine H2 antagonists do not cause the generalized body. Effects of the cholinergic blockers because they are selective to only the H2 receptors. When ulcers are present, the decrease in acid allows the ulcerated areas to heal. Examples of histamine H2 antagonists include cimetidine, Famotidine, Pepcid. Uses Prophylactically to treat stress related ulcers and acute upper GI bleeding in critically ill clients. heartburn, acid indigestion, sour stomach, GERD Gastric or duodenal ulcers gastric hypersecretory conditions (excessive gastric secretion of HCI) Adverse Reactions Histamine H2 antagonist adverse reactions are usually mild (Rare affecting less than 2% of users) Dizziness, somnolence, headache. Confusions, hallucinations, diarrhea  Males that take these medication causes them to be unable to get an erection (Impotence) Contraindications Histamine H2 antagonists are contraindicated severe renal or hepatic impairment. Severely ill older debilitated clients. Cimetidine is used cautiously in clients with diabetic diabetes, Histamine H2 agonist are pregnancy category B, (Cimetidine and famotidine) (Nizatidine) drugs should be used cautiously during pregnancy and lactation. Histamine H2 Antagonist Drug Interactions INTERACTING DRUG COMMON USE EFFECT OF INTERACTION Antacids and GI Distress Decreased Absorption of the metoclopramide H2 antagonist Carmustine Anticancer therapy Decreased White blood cell count Opioid Analgesics Pain Relief Increased risk of respiratory depression Oral anticoagulants Blood thinners Increased risk for bleeding Digoxin Cardiac Problems May decrease serum digoxin Levels Proton pump inhibitors- drugs with antisecretory properties. These drugs suppress gastric acid secretion by inhibition of the hydrogen potassium adenosine triphosphates. ATPase enzyme system of the gastric parietal cell. The enzyme system is also called the acid proton pump system. the proton pump inhibitors suppress gastric acid secretion by blocking the final step in the production of gastric acid by gastric mucosa example of proton pump inhibitors include Esomeprazole Nexium and Omeprazole (Prilosec) Uses Duodenal ulcers are specifically associated with H pylori infections. GERD or erosive esophagitis, pathologic hypersecretory conditions, prevention of bleeding and high-risk clients using anti platelet drugs.  An important use of these drugs is combination therapy for treatment of H pylori infection and clients would do adrenal ulcers. The drugs are combined with and Anti-infective ex. (Omeprazole or Lansoprazole) and Two Anti-infectives (Amoxicillin and Clarithromycin) or triple treatment (Bismuth, metronidazole, clarithromycin. Adverse Reactions Headache, nausea, diarrhea, and abdominal Pain. When elderly clients are diagnosed with C diff, the MAR should be checked for a proton pump inhibitor. Research shows a connection between long term PPI administration and C.difficile infection in those aged 65 years and older. Contraindications PPI’s are used cautiously in older adults and clients with hepatic impairment. Prolonged treatment may decrease ability to absorb Vitamin B12, resulting in anemia. PPI’s cause an increase of fractures in menopausal women taking high doses of PPI’s and undergoing treatment of osteoporosis with bisphosphonates. Drug Interactions INTERACTING DRUG COMMON USE EFFECT OF INTERACTION Sucralfate Management of GI Distress Decreased Absorption of the proton pump inhibitor Ketoconazole and ampicillin Anti-infective drug Decreased absorption of the anti-infective Oral Anti-coagulants Blood Thinners Increased Risk for bleeding Digoxin Cardiac problems Increased absorption of digoxin Benzodiazepines, phenytoin Management of anxiety and Risk for Toxic levels of seizure disorders antiseizure drugs Clarithromycin (With Anti-infective Risk for increase plasma omeprazole specifically) levels in both drugs Bisphosphonates Bone strengthening Increased risk for fractures. Gastrointestinal stimulants Metoclopramide (Reglan) is used to treat delayed gastric emptying and emesis that is it increased the motility of the upper GI tract without increasing secretions. By sensitizing acetylcholine, results in inhibiting vomiting and stimulation of the vomiting center in the brain. Uses GERD gastric stasis (failure to move food normally out of the stomach) in diabetic clients and clients with nausea and vomiting associated with cancer, chemotherapy and in clients in the immediate postop. Adverse Reactions With metoclopramide are usually mild. Higher doses or prolonged use may produce CNS symptoms, such as restlessness, drowsiness, dizziness, extrapyramidal effects (tremor, involuntary movements of the limbs, muscle rigidity) facial grimacing and depression. Contraindications GI obstruction, gastric perforation, hemorrhage, or pheochromocytoma. Parkinson’s Disease or seizure disorders Used cautiously in clients with diabetes and cardiovascular disease. Interacting drug Common use Effect of interaction Cholinergic blocking drugs Management of GI distress Decreased effectiveness of or opioid analgesics or pain relief metoclopramide Cimetidine Management of GI distress Decreased absorption of cimetidine Digoxin Cardiac Problems Decreased absorption of digoxin Monoamine Management of Depression Increased risk of hypertensive episode Levodopa Management of Disease Decreased metoclopramide and levodopa Antiemetics- Prevention of vomiting. Uses Before surgery to prevent nausea and vomiting during surgery. Immediately after surgery. Before, during and after administration of an antineoplastic drug that induces a high degree of nausea and vomiting.  during radiation therapy when the GI tract is in the treatment field during pregnancy for hyperemesis. Motion sickness Vertigo. Adverse reactions- The most common adverse reaction are degrees of drowsiness. Contraindications. Clients with severe CNS depression, the 5HT 3 receptor antagonist, should not be used in clients with heart block, block or prolonged QT intervals. In general, these drugs are not recommended during pregnancy and lactation. Prochlorperazine is contradicted. And clients with bone marrow depression, blood dyscrasia. Parkinson's disease or severe liver, and cardiovascular disease. Precautions Severe nausea and vomiting should not be treated with anti memetics alone. The cause of vomiting must be investigated. Antiemetic drugs may hamper the diagnosis of disorders such as brain tumor or injury appendicitis, or intestinal obstruction and drug toxicity. E.g (digitalis toxicity) delay, diagnosis. Many of these disorders could have consequences. cholinergic blocking Antiemetics are used cautiously in clients with glaucoma or obstructive disease of the GI or genitourinary system, those with renal hepatic dysfunction, and in older men with possible prostatic Hypertrophy. Promethazine is used cautiously in clients with hypertension, sleep apnea or epilepsy. The 5H3 receptor antagonist should be used cautiously in clients with cardiac conditions, problems or electrolyte imbalances. Interacting Drug Common Use Effect of Interaction CNS depressants Analgesia, sedation or pain Increased risk for sedation relief Antihistamines Allergy relief Increased adverse cholinergic blocking effects Antacids Management of gastric decreased absorption of distress antiemetic Rifampin with 5-HT3 TB/ HIV Decreased effectiveness of receptor antagonist 5-HT3 Receptor Lithium and Management of bipolar Increased risk for prochlorperazine disorder extrapyramidal effects. Emetics- Induces Vomiting  Ginger, a pungent root, has been used medicinally for GI problems such as motion sickness, nausea, vomiting, indigestion. As with any substance, a primary care provider should be consulted before any ginger remedy is taken. Nursing Process Upper GI: 🔅 Assessment 🔅 Pre-admission: As part of the pre-administration assessment for a patient receiving a drug for nausea and vomiting, document the number of times the patient has vomited, and the approximate amount of fluid lost. Before starting therapy, take vital signs and assess for signs of fluid and electrolyte imbalances. In the case of preventative administration of an anti- emetic, explain the rationale for preventing an episode of nausea rather than waiting for symptoms to occur when the primary health care provider knows the drugs or treatments being given will cause this problem. Ongoing Assessment: Monitor the patient frequently for continued complaints of pain, SOUR taste, or coffee ground or bloody vomit. If the patient is showing severe symptoms of electrolyte imbalance monitor vitals every 2-4 hours. Measure patients I’d & O’s carefully, after patient has ceased vomiting for a while the patient may resume to take oral fluids in sufficient quantity. Implementation: Antacids: Antacid may be administered hourly for the when used to treat acute peptic ulcer. After the first 2 weeks the drug is administered 1 to 2 hours after meals and at bed- time. ❗️ NURSING ALERT ❗️ Because of the possibility of an antacid interfering with the activity of other oral drugs, no oral drug should be administered within 1 to 2 hours of an antacid.  Nonoral Methods of Drug Administration: Patients taking acid reducing drugs may not be able to take oral medications because of preparation for an operative procedure, postoperative nausea, or physical condition. Many of these drugs, other than antacids, come in forms for both intramuscular (IM) and intravenous (IV) administration. The IV route is typically preferred if the patient has an existing IV line, because these drugs are irritating, and IM injections need to be given deep into the muscular tissue to minimize harm. ❗️Nursing Alert ❗️ When one of these drugs are given IV, monitoring the rate of infusion at frequent intervals. Too rapid of an infusion may induce cardiac arrhythmias. Patients who are debilitated and require feeding from an NG tube are at risk for gastric ulcer development and may be prescribed acid - reducing drugs. Always check the medication label to see if the pill can be crushed or the capsule opened before doing so. These can be mixed with 40 mL of water or apple juice and administered through the NG tube. The tube is flushed with fluid afterward. Many of these drugs come in a liquid form as well as tablet or capsule. Request the liquid form when administration is in a tube to decrease the chance of a clogged NG tube due to improper flushing. ❗️Nursing Alert ❗️ Always use oral syringes to draw up solutions for enteral tube administration. This helps to avoid accidental parenteral administration of oral preparation. Cancer Therapy: Different protocols for prechemotherapy nausea depend on the type of cancer treatment. Some cancer ( antineo- plastic) drugs rarely cause nausea, and others are highly emetogenic. Granisetron (Kytril), ondansetron (Zofran), and dolasetron ( Anzemet) are examples of antiemetics used when cancer chemotherapy drugs are very likely to cause nausea and vomiting. These drugs are administered regardless of vomiting history before the chemotherapy is given. The first dose is typically given IV during therapy, and the patient is asked to take it early at home for a specified period of time. It is important to explain to the patient that the drug prevents nausea and vomiting, and to be sure to take the entire does prescribe even when the patient feels fine at home. Risk for deficient fluid volume: When antacids are given, keep a record of the patient's bowel movements, because these drugs may cause constipation or diarrhea. If the patient experiences diarrhea, accurately record fluid intake and output along with a description of the diarrhea stool. Uncontrolled diarrhea can lead to fluid loss and dehydration. Changing to a different antacid usually alleviates the problem. Diarrhea may be controlled by combining a magnesium antacid with an antacid containing aluminum or calcium. Ineffective Health Management: When antacids are given, instruct the patient to chew the tablets thoroughly before swallowing and then drink a full glass of water or milk. If the patient expresses a dislike for the taste of the antacid or has difficulty chewing the tablet form, contact the primary health care provider. A flavored antacid may be ordered if the patient finds the taste unpleasant. A liquid form may be ordered if the patient has difficulty chewing a tablet. Liquid antacid preparations must be shaken thoroughly immediately before administration. If the patient cannot retain the oral form of the drug (other than the antacids), it may be given parenterally or as a rectal suppository (if the prescribed drug is available). When administering scopolamine for motion sickness, one transdermal system is applied behind the ear approximately 4 hours before the antiemetic effect is needed. Approximately 1 g of scopolamine is administered every 24 hours for 3 days. Advise the individual to discard any disk that becomes detached and to replace it with a fresh disk applied behind the opposite ear. ❗️Nursing Alert ❗️ Tardive dyskinesia (nonreversible, involuntary muscle spasms), which is typically associated with conventional antipsychotics, is known to occur with long -term use (12 weeks or more) of metoclopramide. Immediately report extrapyramidal symptoms to prevent tardive dyskinesia from occurring. Educating the Patient and Family:  When a drug to treat the upper Gl system is prescribed for outpatient use, and as you develop a teaching plan, include the following information: o If drowsy, avoid driving or performing other hazardous tasks when taking these drugs. o Do not use antacids indiscriminately. Check with a primary health care provider before using an antacid if other medical problems, such as a cardiac condition, exist (some antacids contain sodium). o Do not increase the frequency of use or the dose if your symptoms become worse; instead, see the primary health care provider as soon as possible. o Because antacids impair the absorption of some drugs, do not take other drugs within 2 hours before or after taking the antacid unless use of an antacid with a drug is recommended by the primary health care provider. o If pain or discomfort remains the same or becomes worse, if the stools turn black, or if vomitus resembles coffee grounds, contact the primary health care provider as soon as possible. o Magnesium-containing products may produce a laxative effect and may cause diarrhea; aluminum- or calcium-containing antacids may cause constipation. o Taking too much antacid may cause the stomach to secrete excess stomach acid. Consult the primary health care provider or pharmacist about appropriate dose. Do not use the maximum dose for more than 2 weeks, except under the supervision of a primary health care provider. o When taking proton pump inhibitors, swallow the whole tablet for at least 1 hour before eating. Do not chew, open, or crush. o When taking metoclopramide, immediately report any of the following signs: o difficulty speaking or swallowing; mask-like face; shuffling gait; rigidity; tremors; uncontrolled movements of the mouth, face, or extremities; and uncontrolled chewing or unusual movements of the tongue. o Avoid the use of alcohol and other sedative-type drugs unless use has been approved by the Primary healthcare provider. o Take antiemetics for cancer chemotherapy as prescribed. Do not omit a dose. Consult the primary health care provider if you have forgotten a dose of the medication. o When using rectal suppositories, remove foil wrapper and immediately insert the pointed end into the rectum without using force. o Motion sickness drugs should be taken about 1 hour before travel. o Misoprostol: Because this drug may cause spontaneous abortion, women of childbearing age need to use a reliable contraceptive. If pregnancy is suspected, discontinue use of the drug and notify the primary health care provider. Report severe menstrual pain, bleeding, or