Chapter 25 Drugs Used to Treat Gastro-Esophageal Reflux and Peptic Ulcer Diseases

gastro-esophageal reflux disease (GERD) is common stomach disorder peptic ulcer disease (PUD), there are ulcerations in the GI tract (box 25-1 pg. 318) (box 25-2 p. 318… full description of GERD/PUD) goals of drug therapy for GERD and PUD: relieve symptoms promote healing prevent recurrence

Box 25-1 Upper Digestive System: Structure and Function: digestive system breaks down food physically and chemically so it can be absorbed and used by cells aka: GI (gastro-intestinal) system removes solid wastes from body involves alimentary canal (GI tract) and the accessory organs of digestion (fig 25-1) alimentary canal is a long tube, extends from mouth to anus it’s major parts: mouth pharynx, esophagus, stomach, small intestine, large intestine accessory organs: teeth, tongue, salivary glands, liver, gallbladder, pancreas

esophagus is a 10” long muscular tube, extends from pharynx to stomach Upper Digestive System: Structure and Function cont… digestion begins in mouth with food being broken down by teeth chewing the food, tongue aids in chewing and swallowing saliva moistens food particles to ease swallowing and begin digestion, during swallowing the tongue pushes food into pharynx pharynx (throat) is muscular tube, swallowing continues as pharynx contracts, this contraction pushes food into esophagus. esophagus is a 10” long muscular tube, extends from pharynx to stomach peristalsis (involuntary muscle contractions) move food down the esophagus and alimentary canal

food mixed and churned with these juices for a semi-liquid call chyme Upper Digestive System: Structure and Function cont… stomach: muscular, pouch-like sac, in UL abdominal cavity. strong stomach muscles stir/churn food to break it up into smaller particles mucous membrane lines stomach, it contains glands that secrete gastric juices food mixed and churned with these juices for a semi-liquid call chyme through peristalsis, chyme is pushed from stomach into small intestine. duodenum is first part of small intestine

Delegation Guidelines Drugs Used to Treat Gastro-Esophageal Reflux and Peptic Ulcer Diseases: Some drugs used to GERD and PUD are given parenterally- by subcutaneous, intramuscular or intravenous injection. Because you do NOT give parenteral dose forms, they are NOT included in this chapter. Should a nurse delegate the administration of such to you, you must: - remember that parenteral dosages are often very different from dosages other routes -Refuse the delegation. Make sure to explain why. Do NOT just ignore the request. Make sure the nurse knows that you cannot give drug and why

Assisting With the Nursing Process Antacids: drugs that buffer, neutralize, or absorb hydrochloric acid in the stomach pH of hydrochloric acid is 1 or 2, antacids raise it to 3 or 4, gastric juice loses its corrosive effect Assisting With the Nursing Process antacids: ASSESSMENT: ask about constipation or diarrhea. Measure BP if person has hypertension, some antacids are high in sodium. Observe for edema and signs/symptoms of heart failure (ch.21). Observe for “coffee grounds” vomitus and bloody or tarry stools, ask person to describe onset, duration and location of pain or discomfort. PLANNING: see table 25-1 for “Dose Forms” IMPLEMENTATION: follow directions on MAR and product container, give other drugs 1 hour before or 2 hours after giving antacids EVALUATION: report and record: chalky taste: common problem, brand or flavor may need to be changed. diarrhea, constipation: some products cause one or the other, drug order may alternate products

Histamine (H2)-Receptor Antagonists: histamine: substance released in response to allergic reactions and tissue damage from trauma or infection antagonist: drug that has opposite action of another drug or competes for same receptor site histamine causes an increase in the secretion of gastric juices. Histamine (H2)- receptor antagonists (aka histamine blockers) block the action of histamine they bind to H2 receptor, this results in decreased amounts of gastric juices pH of stomach contents rises drugs are used to treat GERD, duodenal ulcers, stress ulcers in critically ill persons stress ulcer: gastric or duodenal ulcer that develops in persons under severe stress

Assisting With the Nursing Process histamine blocker: ASSESSMENT: observe for confusion and orientation to person, time and place PLANNING: see table 25-2 (pg. 320) for “Dose Forms” IMPLEMENTATION: see table 25-2 (pg. 320) for “Adult Dosage Range”, give with food or milk as directed by the nurse and MAR. give antacids (if ordered) 1 hour before or 2 hours after a histamine blocker EVALUATION: report and record: dizziness, headache, sleepiness: usually mild and resolve, provide for safety diarrhea, constipation: give drugs as ordered for diarrhea/constipation, follow care plan for fluid intake and diet confusion, slurred speech, disorientation, hallucinations: may occur in persons with liver or kidney diseases and in persons over age 50. Resolves 3-4 days after therapy stops. Provide for safety anorexia, nausea, vomiting, jaundice: may signal liver toxicity

Gastro-Intestinal Prostaglandins: prostaglandins are fatty acids, normally present in GI tract and inhibit gastric juice secretion this protects the stomach and duodenal lining from ulcers GI prostaglandins inhibit gastric acid secretion misoprostol (Cytotec) used to prevent/treat gastric ulcers caused by NSAIDS or aspirin Assisting With the Nursing Process misoprostol (Cytotec): ASSESSMENT: ask about diarrhea PLANNING: Oral Dose Forms 100 and 200mcg tablets IMPLEMENTATION: adult dose 100-200mcg tablets, 4x/day, give drug with food during NSAID therapy EVALUATION: report and record: diarrhea: dose related, usually develops after about 2 weeks of therapy, often resolves after about 8 days. Follow care plan for fluid intake and diet

Proton Pump Inhibitors (PPIs): parietal cells in stomach secrete gastric acid PPIs inhibit the gastric acid pump of the parietal cells, thus they block the gastric acid production used to treat severe esophagitis, GERD, and gastric and duodenal ulcers may be used with antibiotics if infection is cause of PUD Assisting With the Nursing Process Proton Pump Inhibitors(PPIs): ASSESSMENT: ask about diarrhea PLANNING: see table 25-3 (pg 321) for “Oral Dose Forms” IMPLEMENTATION: : see table 25-3 (pg 321) for “Adult Dosage Range”. Capsules/tablets should be swallowed whole, should not be opened, crushed or chewed EVALUATION: report and record: diarrhea, headache, muscle pain, fatigue: usually mild, follow care plan for fluid intake and diet rash: may signal allergic reaction, do NOT give next dose until approved by nurse

Assisting With the Nursing Process sucralfate (Carafate): Coating Agents: coating agents form a substance that adheres to the crater of an ulcer agent protects ulcer from gastric juices does NOT inhibit gastric secretions or change gastric pH sucralfate (Carafate) is used to treat duodenal ulcers Assisting With the Nursing Process sucralfate (Carafate): ASSESSMENT: ask about constipation PLANNING: Oral Dose Forms: 1g tablets or 1g/10mL suspension IMPLEMENTATION: : adult dose is 1 tablet one hour before each meal and at bedtime. Drug given on empty stomach. Antacids (if ordered) are given at least 30mins before sucralfate (Carafate) EVALUATION: report and record: constipation: usually mild, tends to resolve. Follow care plan for fluid intake and diet dry mouth: provide oral hygiene: usually mild and tends to resolve. Nurse may allow person to have hard candy or ice chips dizziness: usually mild and tends to resolve, provide for safety

Prokinetic Agents: drugs that stimulate movement/motility metoclopramide (Reglan): is a gastric stimulant used to: lower esophageal sphincter pressure (reduces acid reflux) increase stomach contractions (empties stomach faster) relax pyloric valve (allows stomach contents to empty into duodenum faster increase GI peristalsis (moves chyme/feces faster through intestinal tract) prevent vomiting during cancer therapy

Assisting With the Nursing Process metoclopramide (Reglan): ASSESSMENT: observe for GI bleeding, ask about abdominal pain, discomfort, observe for restlessness, involuntary movements, facial grimacing, abnormal tongue movements. Measure blood glucose if diabetic PLANNING: Oral Dose Forms: 5 and 10 mg tablets, 5mg/5mL syrup IMPLEMENTATION: : adult dose is 10mg thirty minutes before meals and at bedtime EVALUATION: report and record: drowsiness, fatigue, lethargy, dizziness, nausea: usually mild and tend to resolve, provide for safety restlessness, involuntary movements, facial grimacing, abnormal tongue movements: provide for safety

Anti-Spasmodic Agents: GI tract is controlled by cholinergic branch of ANS (ch 14) nerve endings that release acetylcholine (neurotransmitter) are called cholinergic fibers cholinergic fibers stimulate GI tract to : secrete saliva and gastric juices move stomach and intestinal contents through the GI tract (peristalsis) anti-spasmodic agents have an anti-cholinergic action, they prevent acetylcholine from attaching to cholinergic receptors in the GI tract results in decreased gastric juices and decreased GI motility because cholinergic fibers are throughout body effects of these drugs are also seen throughout: -reduced perspiration -reduced oral and bronchial secretions -dilated pupils -blurred vision -constipation -urinary hesitancy or retention -tachycardia and palpitations -orthostatic hypotension -mental confusion -delusions -nightmares -euphoria -paranoia -hallucinations

Assisting With the Nursing Process anti-spasmodics: ASSESSMENT: observe for confusion, depression, nightmares and hallucinations. Measure BP apical heart rate for 1 minute. Note if rhythm is regular or irregular. Measure intake/output PLANNING: see table 25-4 (p. 323) for “Oral Dose Forms” IMPLEMENTATION: : see table 25-4 (p. 323) for “Adult Dose Range” EVALUATION: report and record: blurred vision: provide for safety constipation, urinary retention: follow care plan for fluid intake/diet, give stool softeners as ordered (ch 26) dryness of mouth, throat, nose: provide oral hygiene, nurse may allow gum, hard candy or ice chips confusion, depression, nightmares, hallucinations: provide for safety orthostatic hypotension: usually mild, measure BP daily (standing/supine), provide for safety palpitations, dysrhythmias: measure apical heart rate for 1 minute, note if rhythm is regular or irregular