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Chapter 51
Bowel Disorder Drugs
| Term | Definition |
|---|---|
| Diarrhea | 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 and resolves without sequelae. |
| Chronic Diarrhea | lasts for more than 3 to 4 weeks. associated with recurring passage of diarrheal stools, fever, loss of appetite, nausea, weight loss, & chronic weakness. |
| Causes of diarrhea: Acute | bacteria, viruses, drug induced, nutritional factors, protozoa |
| Causes of diarrhea: Chronic | tumors, diabetes mellitus, addison's disease, hyperthyroidism, irritable bowel syndrome, AIDS |
| Goals of diarrhea treatment | stopping the stool frequency, alleviating the abdominal cramps, replenishing fluids and electrolytes, preventing weight loss and nutritional deficits from malabsorption. |
| Antidiarrheals | Adsorbents Antimotility drugs (Anticholinergics and opiates) Probiotics (also known as intestinal flora modifiers and bacterial replacement drugs) |
| Adsorbents | coat the walls of the GI tract. Bind to the causative bacteria or toxin, which is then eliminated through the stool. EX: bismuth subsalicylate (peptic-bismol), activated charcoal, and antilipemic drugs colestipol and cholestyramine. |
| Antidiarrheals Mechanism of action: Adsorbents | coat walls of GI tract. bind to causative bacteria or toxin to their adsorbent surface for elimination from the body through the stool. |
| Antidiarrheals Mechanism of action: Activated charcoal | coats walls of Gi tract & adsorbs bacteria, used in drug overdose b/c of drug binding properties. |
| Antidiarrheals Mechanism of action: Anticholinergics | slow peristalsis by reducing rhythmic contractions & smooth muscle tone of GI tract; they also have drying effect & reduce gastric secretions. |
| Antidiarrheals Mechanism of action: Opiates | decrease bowel motility & reduce pain by relief of rectal spasms. decrease transit time through the bowel, allowing more time for water and electrolytes to be absorbed. |
| Antidiarrheals Mechanism of action: probiotics | also known as 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. |
| The antidiarrheal drug jomotil contains both diphenoxylate, a synthetic opiate agonist, & atropine, an anticholinergic. The purpose of the atropine in this combination is to: | B. discourage recreational use of the opiate diphenoxylate. Rationale: because person will experience unpleasant anticholinergic effects such as dry mouth, abd pain, blurred vision, & tachycardia. |
| Antidiarrheal drugs: Indications | Adsorbents: milder cases Anticholinergics & opiates: more severe cases Probiotics: Antibiotic-induced diarrhea |
| Antidiarrheal drugs contraindications | known drug allergy and any major acute GI condition, such as intestinal obstruction or colitis, unless the drug is ordered by the pt's prescriber after careful consideration of the specific case. |
| Antidiarrheal drugs: Adverse effects: Adsorbents | increased bleeding time, constipation, dark stools, confusion, tinnitus, metallic taste, and blue tongue. |
| Antidiarrheal drugs: Adverse effects: Anticholinergics | urinary retention, impotence, headache, dizziness, confusion, anxiety, drowsiness, confusion, dry skin, flushing, blurred vision, hypotension, hypotension, bradycardia. |
| Antidiarrheal drugs: Adverse effects: Opiates | drowsiness, dizziness, lethargy, nausea, vomiting, constipation, hypotension, urinary retention, flushing. |
| Antidiarrheals Interactions | Adsorbents decrease the absorption of many drugs + digoxin, quinine, & hypoglycemic drugs. adsorbents cause increased bleeding time & bruising when given w/ anticoagulants (Warfarin). toxic effects of methotrexate more likely when given w/ adsorbents. |
| A pt. who take coumadin has been prescribed an adsorbent for diarrhea. It is important for the nurse to assess the pt. for bruising b/c use of coumadin w/ adsorbents interferes with the absorption of vitamin: | D. Vitamin K |
| A patient is experiencing diarrhea while completing a course of antibiotic therapy. Which of the following agents does the nurse anticipate administering to the patient? | A. L. acidophilus (Acid) |
| Bismuth Subsalicylate (Adsorbent) (D) | avail OTC, used w/ caution in children & teens who have or are recovering from chickenpox or influenza b/c of risk for reye's syndrome. adverse effects: all adverse effects of aspirin-based product. two alarming but harmless adverse effects: temporary... |
| Bismuth Subsalicylate cont. | darkening of tongue and stool. available OTC for oral use. |
| Belldonna alkaloid combinations (C-X) (anticholinergic) | used to treat many GI disorders, including diarrhea; but use is limited. Donnatal most commonly used. use of these preps contraindicated in pt's who have known hypersensitivity to anticholinergics, narrow angle glaucoma, GI obstruction, .... |
| Belldonna alkaloid combinations cont. | myasthenia gravis, paralytic ileus, & toxic megacolon. Donnatal tabs contain combo of 4 diff. alkaloids= atropine, hyoscyamine, phenobarbital, & scopolamine. avail forms: elixir, tablets, extended release tabs. pregnancy cat C-X depending on ingredients. |
| Diphenoxylate (Lotomil, Lonox) with atropine (C) (opiate) | acts on smooth muscle of intestinal tract, inhibiting GI motility & excess GI propulsion. has little or no analgesic activity; abuse & physical dependence may occur. combined w/ atropine to discourage recreational use. large amounts= extreme .... |
| Diphenoxylate (Lotomil, Lonox) with atropine cont. | anticholinergic effects (dry mouth, abdominal pain, tachycardia, & blurred vision. contraindicated in pt's experiencing diarrhea associated w/ pseudomembranous colitis or toxigenic bacteria. PO only. |
| Loperamide (Imodium A-D) (B) (Opiate) | inhibits peristalsis in intestinal wall & internal secretion, thereby decreasing number of stools & their water content. physical dependence not reported. only opiate antidiarrheal drug avail OTC. contraindicated in severe ulcerative colitis.... |
| Loperamide cont. | , pseudomembranous colitis, & acute diarrhea associated w/ E. coli. |
| Lactobacillus Acidophilus (Acid) & Lactobacillus GG (Culturelle) (Probiotics) | acid producing bacteria prepared & concentrated, dried culture for PO administration. normal inhabitants of GI tract. they create unfavorable environment for overgrowth of fungi & bacteria. more than 70 yrs for treatment of uncomplicated diarrhea, .... |
| Lactobacillus Acidophilus (Acid) & Lactobacillus GG (Culturelle) cont. | Caused y antibiotic therapy that destroys normal intestinal flora. |
| Saccharomyces Boulardii (Florastor) | commonly used probiotic used for C. Diff infections |
| Nursing Implications: Antidiarrheals | obtain thorough history of bowel patterns, general state of health, & recent Hx of illness or dietary changes; assess for allergies. Do not give bismuth subsalicylate to children or teens w/ chickenpox or influenza b/c of risk for reyes syndrome. |
| Before administering Belladona alkaloids, it is most important for the nurse to assess the patient for a history of which condition? | C. Myasthenia gravis |
| Antidiarrheals Nursing Implications | Use adsorbents carefully in older pt's & those w/ decreased bleeding time, clotting disorders, recent bowel surgery, or confusion. do not administer anticholinergics to pt's w/ a history of narrow angle glaucoma, GI obstruction, myasthenia gravis... |
| Antidiarrheals Nursing Implications cont. | paralytic ileus, or toxic megacolon. |
| Antidiarrheals Nursing Implications | teach patients to take meds exactly as prescribed & to be aware of their fluid intake & dietary changes. assess fluid volume status, input, output, & mucous membranes before, during & after initiation of treatment. |
| Antidiarrheals Nursing Implications | teach pt's to notify their prescribers immediately if symptoms persist. monitor for therapeutic effect. |
| Which antidiarrheal does the nurse associate w/ development of adverse effects of urinary retention, headache, confusion, dry skin, rash, & blurred vision? | A. anticholinergics |
| Constipation | abnormally infrequent & difficult passage of feces through the lower GI tract. symptom not a disease. disorder of movement through the colon or rectum. can be caused by a variety of diseases or drugs. |
| Consipation treatment | surgical, nonsurgical treatments (dietary (fiber, supplementation), behavioral (increased physical activity), pharmacologic) |
| Laxatives | bulk forming Emollient (stool softeners, lubricant laxatives) Saline Stimulant |
| Digestive process | Ingestion-> Digestion->absorption-> storage & removal |
| Laxatives mechanism of action : Bulk forming | high fiber, absorb water to increase bulk, distend bowel to initiate reflex bowel activity. Examples: psyllium (Metamucil) & methyl cellulose (Citrucil) |
| Laxative mechanism of action: Emollient | stool softeners & lubricants. Promote more water & fat in the stools. lubricate the fecal material & intestinal walls. Examples: stool softeners(decussate salts (Colace, Surfak), Lubricants (mineral oil) |
| Laxatives mechanism of action: Hyperosmotic | increase fecal water content, results in bowel dissension, increased peristalsis, & evacuation. Examples: Polyethylene glycol (PEG), Sorbitol, Glycerin, Lactulose (also used to reduce elevated serum ammonia levels) |
| Laxatives mechanism of action: Saline | increase osmotic pressure w/in the intestinal tract, causing more water to enter the intestines. results in bowel distention, increased peristalsis & evacuation. Examples: magnesium hydroxide (milk of magnesia) & magnesium citrate (Citroma) |
| Laxatives mechanism of action: Stimulant | increases peristalsis via intestinal nerve stimulation. Examples: Senna (Senokot) & Bisacodyl (Dulcolax) |
| Peripherally acting opioid antagonists | treatment of constipation related to opioid use & bowel resection therapy. block entrance of opioid into bowel. strict regulations for use. Allow bowel to function normally with continued opioid use. (methylatrexone (Relistor) & Alvimopan (Entereg)) |
| Laxatives indications | facilitation of bowel movements in pt's w/ inactive colon or anorectal disorders, reduction of ammonia absorption in hepatic encephalopathy (lactulose only), treatment of drug induced constipation, treatment of constipation associated w/ pregnancy &/or |
| Laxatives indications | postobstetric period, treatment of constipation caused by reduced physical activity or poor dietary habits, removal of toxic substances from the body, facilitation of defamation in megacolon, prep for colonic diagnostic procedures or surgery. |
| Laxatives indications: bulk forming | acute & chronic constipation, irritable bowel syndrome, diverticulosis. |
| Laxatives indications: Emollient | acute & chronic constipation, fecal impaction, facilitation of bowel movements in anorectal conditions. |
| Laxatives indications: Hyperosmotic | chronic constipation, diagnostic & surgical preps. |
| Laxatives indications: Saline | Constipation, diagnostic & surgical preps |
| Laxatives indications: Stimulant | acute constipation, diagnostic & surgical preps |
| A patient is taking lactulose four times a day but does not have a history of constipation. In fact, he has had bowel movements every day. What is the probable reason for the lactulose? | C. Reduction of high ammonia levels associated w/ liver failure |
| Laxatives Contraindications | drug allergy, cautious use in presence of acute surgical abdomen, appendicitis symptoms such as abdominal pain, nausea, & vomiting, fecal impaction (mineral oil enamas exerted), intestinal obstruction; & undiagnosed abdominal pain. |
| Laxatives Adverse effects: Bulk forming | impaction, fluid overload, electrolyte imbalances, esophageal blockage. |
| Laxatives Adverse effects: Emollient | skin rashes, decreased absorption of vitamins, electrolyte imbalances, lipid pneumonia. |
| Laxatives Adverse effects: Hyperosmotic | abdominal bloating, electrolyte imbalances, and rectal irritation |
| Laxatives Adverse effects: Saline | Magnesium toxicity (with renal insufficiency), cramping, electrolyte imbalances, diarrhea, & increased thirst. |
| Laxatives Adverse effects: Stimulant | Nutrient malabsorption, skin rashes, gastric irritation, electrolyte imbalances, discolored urine, rectal irritation. |
| Laxatives Adverse effects | All laxatives cause electrolyte imbalances. |
| Laxatives Interactions | alter intestinal function, interact w/ other drugs, b/c many drugs are absorbed in the intestines. Bulk forming laxatives decrease absorption of antibiotics, digoxin, salicylates, tetracyclines, & warfarin. mineral oil can decrease the absorption... |
| Laxatives Interactions cont. | of fat soluble vitamins (A, D, E, K). Hyperosmotic laxatives can cause increased CNS depression if they are given w/ barbiturates, general anesthetics, opioids, or antipsychotics. oral antibiotics can decrease effects of lactulose. stimulant laxatives... |
| Laxatives Interactions cont. | decrease absorption of antibiotics, digoxin, nitrofurantoin, salicylates, tetracyclines, & oral anticoagulants. |
| Methylcellulose (Citrucel) (B) (Bulk forming laxative) | synthetic, attracts water into the intestine & absorbs excess water into the stool, stimulating the intestines & increasing peristalsis. contraindications include GI obstruction & hepatitis. PO drug avail in powdered form that provides approximately 2g of |
| Methylcellulose cont. | fiber per heaping tablespoon. |
| Psyllium (Metamucil, fiberall) (B) (Bulk-forming laxatives) | natural, obtained from dried seed of plantago psyllium plant. many characteristics of methyl cellulose. contraindicated in pt's w/ intestinal obstruction or fecal impaction + pt's experiencing abdominal pain &/or nausea & vomiting. PO in wafer or powder |
| Docussate salts (Calcium & Sodium) (Colace) (Emollient laxative) | stool softening emollient laxative that facilitate the passage of water & lipids (fats) into the fecal mass, which softens stool. used to treat constipation, soften fecal impactions, & prevent opioid induced constipation. combo products available |
| Docussate salts cont. | contraindicated in patients w/ intestinal obstruction, fecal impaction, or nausea & vomiting. |
| Mineral oil (Emollient laxative) (B) | eases passage of stool by lubricating intestines & preventing water from escaping the stool. only lubricant laxative in the emollient category. mixture of liquid hydrocarbons derived from petroleum & most commonly used to treat constipation associated... |
| Mineral oil cont. | w/ hard stools or fecal impaction. contraindicated in patients w. intestinal obstruction, abdominal pain, or nausea & vomiting. available in enemas & PO. combination of products that contain mineral oil like Haleys M-O which includes both mineral oil & |
| Mineral oil cont. | milk of magnesia. |
| Glycerin (Hyperosmotic laxative) (C) | promotes bowel movement by increasing osmotic pressure in the intestine, which draws fluid into the colon. mild laxative, can be used in children. contraindicated in pt's w/ known hypersensitivity. avail as rectal solution & both adult * ped suppositories |
| Lactulose (Enulose) (B) (Hyperosmotic laxative) | synthetic of natural sugar lactose. colonic bacteria digest it to produce lactic acid, formic acid, & acetic acid, which creates hyper osmotic environment that draws water into colon & produces laxative effect. drug-induced acidic environment reduces... |
| Lactulose cont. | blood ammonia levels by converting ammonia to ammonium. ammonium is water soluble cation trapped in intestines & cannot be reabsorbed into systemic circulation. reduces serum ammonia levels in pt's w/ hepatic encephalopathy... |
| Lactulose cont. | contraindicated in pt's on low lactose diet. avail as solution oral or rectal sue. |
| Polyethylene glycol 3350 (PEG) (Colyte, miralax) (C) (Hyperosmotic laxative) | most commonly given before diagnostic or surgical bowel procedures, b/c is very potent laxative that induces total cleansing of bowel. 335o designation refers to osmolality of drug. avail: powdered dosage form that contains mix of electrolytes that.... |
| Polyethylene glycol 3350 cont. | stimulate bowel evacuation. reconstituted in 1 gal & drank gradually by pt. before procedure. contraindicated in GI obstruction, gastric retention, bowel perforation, toxic colitis, toxic megacolon, or ileus. oral solution & electrolytes available for... |
| Polyethylene glycol 3350 cont. | GI lavage. diarrhea usually occurs w/in 4 hrs. Miralax is PEG 3350 product available OTC & can be used daily for constipation in much smaller amounts that those for total bowel cleansing. |
| Magnesium salts (Saline laxatives) Magnesium citrate (Citroma) & Magnesium hydroxide (Phillips milk of magnesia) | unpleasant tasting OTC laxative preparations. used w/ caution in patients with renal insufficiency because they can be absorbed enough to cause hypermagnesemia. most commonly used to evacuate bowel rapidly in prep for endoscopic exam to help remove.... |
| Magnesium salts (Saline laxatives) Magnesium citrate (Citroma) & Magnesium hydroxide (Phillips milk of magnesia) cont. | unabsorbed poisons from the GI tract. contraindicated in renal disease, abd pain, nausea & vomiting, obstruction, acute surgical abdomen, or rectal bleeding. magnesium hydroxide avail in oral liquid and tablet form. & found in variety of combo products. |
| Magnesium salts (Saline laxatives) Magnesium citrate (Citroma) & Magnesium hydroxide (Phillips milk of magnesia) cont. | magnesium oxide is used as supplement not a laxative. |
| Bisacodyl (Dulcolax) (Stimulant laxative) | most commonly used. avail as oral tab & rectal suppository. used for constipation or for whole bowel evacuation prior to endoscopic exam. avail OTC. |
| Senna (Senokot) (stimulant laxative) | obtained from dried leaves of cassia acutifolia plant. used for relief of acute constipation or bowel preparation for surgery or exam. may cause abdominal pain. can produce complete bowel evacuation in 6-12 hrs. available in a variety of dosages as ... |
| Senna cont. | tabs, syrup, & granules. Senokot-S, includes both senna & stool softener decussate sodium. |
| Irritable bowel syndrome (IBS) | condition og toxic intestinal discomfort characterized by cramps, diarrhea, &/or constipation. pt's cope w/ symptoms by avoiding irritating foods &/or taking OTC laxatives & antidiarrheal drugs. women affected more than men. |
| Lubiprostone (Amitiza) (IBS drug) (C) | chloride channel activator used for treatment of chronic idiopathic constipation & IBS w/ constipation in women 18 yrs & up. adverse effects: nausea, diarrhea, & abd pain. only used in emergencies. contraindicated in known or suspected bowel obstruction. |
| Alosetron (Lotronex) (IBS drug) | selective serotonin 5-HT3 receptor antagonist indicated for treatment of severe, chronic, diarrhea predominant IBS in women who have failed conventional therapy. if response inadequate after 4 weeks, drug discontinued. may be discont. immediately if... |
| Alosetron cont. | constipation/signs of ischemic colitis occur. only physicians who have enrolled in prometheus prescribing program (manufacturer sponsored) can prescribe alosetron. FDA issued black box b/c infrequent but serious GI adverse reactions + ischemic colitis. |
| Linaclotide (Linzess) (IBS drug) | minimally absorbed peptide guanylate cyclase-C agonist. indicated for treatment of IBS w/ constipation & chronic idiopathic constipation. contraindicated in GI obstruction, children younger than 17. most common side effects: diarrhea (can be serious),... |
| Linaclotide cont. | abd pain, & flatulence. avail in oral capsule which should be taken on empty stomach. |
| Laxatives Nursing Implications | obtain thorough Hx of presenting symptoms, elimination patterns, & allergies. Assess fluid & electrolytes before initiating therapy. inform patients not to take laxative or cathartic if they are experiencing nausea, vomiting, or abdominal pain. |
| A hospitalized patient is experiencing diarrhea. Which of the following does the nurse identify as adverse side effects of diphenoxylate with atropine therapy? (select all) | B. Abdominal pain D. Blurred Vision |
| Nursing Implications: Laxatives | a healthy, high fiber diet & increased fluid intake should be encouraged as an alternative to laxative use. long term use of laxatives often results in decreased bowel tone & may lead to dependency. all laxative tabs should be swallowed whole, not.... |
| Nursing Implications: Laxatives cont. | crushed or chewed, especially if enteric coated. |
| Nursing Implications Laxatives | pt's should take all laxative tabs w/ 6-8 oz of water. pt's should take bulk-forming laxatives as directed by the manufacturer w/ at least 240 mL (8 oz) of water. |
| Nursing Implications: Laxatives | give bisacodyl w/ water because of interactions w/ milk, antacids, & juices. inform pt's to contact their prescribers if they experience severe abd pain, muscle weakness, cramps, or dizziness, which may indicate possible fluid or electrolyte loss. |
| Nursing Implications: Laxatives cont. | monitor for therapeutic effect. |
| A 48 yo pt. has been admitted w/ abd pain, & states that she has not had a bowel movement for 4 days. Her abdomen is distended & slightly tender. Which laxative would be appropriate for this patient? | D. No laxative should be given at this time. (B/c abdominal pain is present & can indicate obstruction) |
| Nursing Implications: IBS drugs | perform general assessment & additional assessment of liver functioning as well assess for underlying cardiac disease. follow administration guidelines. assess for therapeutic response. |
| Patient education | counsel pt. on antidiarrheals to take w/ caution when performing tasks that req mental alertness or motor skills until it is clear how the med affects them. advise to immediately report to the prescriber any abd distention or firm/hard abd, abd pain, .. |
| Patient education cont. | worsening or no improvement, rectal bleeding, unrelieved constipation/diarrhea, fever, nausea, vomiting, or other GI-related s/s, dizziness, muscle weakness, & muscle cramping. |
| Patient education | Encourage frequent mouth care, fluid intake, or use of sugarless gum or candy to help w/ dry mouth. |
| Patient education | Educate pt. that normal bowel patterns for one person may not be normal for another. keep all antidiarrheals/laxatives out of reach of children. |
| Patient education | for pt's taking powder form of methyllcellulose, emphasize need to have powder thoroughly mixed w/ last 6 oz of liquid, which is stirred & drunk immediately to avoid esophageal or throat obstruction. |
| Patient education | inform pt. taking senna to avoid other meds w/in 1 hr of taking it & that it often takes 6-12 hrs for the laxative effect to occur. |
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