1. Lower Gastrointestinal Disorders Nursing Management NUR 171

2. Diarrhea Treatment Goals: Stopping the stool frequency Alleviating the abdominal cramps Replenishing fluids and electrolytes Preventing weight loss and nutritional deficits from malabsorption 2Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

3. Antidiarrheals Adsorbents: MOA: coats the GI tract & binds to causative bacteria EX: bismuth subsalicyte, activated charcoal, Adverse effects: ↑ bleeding time, confusion, constipation, dark stools, metallis taste, blue tongue Drug interactions: ↓ absorption of digoxin, quinidine, and hypoglycemic drugs ↑ increased bleeding time and bruising when given with anticoagulants (warfarin) Toxic effects of methotrexate are more likely when given with adsorbents 3Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Urinary retention, impotence, Headache, dizziness, confusion, anxiety, drowsiness, confusion, dry skin, flushing, blurred vision, hypotension

4. Antidiarrheals: Antimotility drugs (anticholinergics and opiates) MOA: ↓ intestinal muscle tone and peristalsis of GI tract Rest & digest Ex: diclamine (Bentyl) Adverse effects: tachycardia, Bradycardia ↑ intraocular pressure Urinary retention 4Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

5. Antidiarrheals: Opiates MOA: acts on smooth muscle of the intestinal tract, inhibiting GI motility and excessive GI propulsion. Ex: Diphenoxylate (Lomotil, Lonox) Adverse effects: large dosages result in extreme anticholinergic effects (e.g., dry mouth, abdominal pain, tachycardia, blurred vision). Physical dependence may occur (opiates).

6. Antidiarrheals: Nursing Implications 1.Assess: history of bowel patterns, general state of health, and recent history of illness or dietary changes; assess for allergies 2.Assess for therapeutic effect 3. Assess fluid volume status, I&O, and mucous membranes before, during, and after initiation of treatment 4. Teach patients to notify their prescriber immediately if symptoms persist 5.Teach patients to take medications exactly as prescribed and to be aware of their fluid intake and dietary changes 6Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

7. Constipation Abnormally infrequent and difficult passage of feces through the lower GI tract Symptom, not a disease Disorder of movement through the colon and/or rectum Can be caused by a variety of diseases or drugs 7Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

8. Laxatives & Indications Laxative Group Use HyperosmoticChronic constipation, diagnostic and surgical preps SalineConstipation, diagnostic and surgical preps StimulantAcute constipation, diagnostic and surgical preps 8Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

9. Laxatives & Indications Laxative GroupUse Bulk-formingAcute and chronic constipation, IBS diverticulosis EmollientAcute and chronic constipation, fecal impaction, facilitation of bowel movements in anorectal conditions 9Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

10. Hyperosmotic Laxatives: MOA Increase fecal water content Results in bowel distention, increased peristalsis, and evacuation Adv. Effects: Abdominal bloating Electrolyte imbalances Rectal irritation Examples: Polyethylene glycol (PEG) Sorbitol, glycerin Lactulose (also used to reduce elevated serum ammonia levels) 10

11. Saline Laxatives: MOA Increase osmotic pressure within the intestinal tract, causing more water to enter the intestines EE: bowel distention, increased peristalsis, and evacuation AE: Magnesium toxicity (with renal insufficiency), Cramping, Electrolyte imbalances, Diarrhea Increased thirst Examples Magnesium hydroxide (Milk of Magnesia) Magnesium citrate (Citroma) 11

12. Stimulant Laxatives: MOA Increases peristalsis via intestinal nerve stimulation AE: Nutrient malabsorption, Skin rashes, Gastric irritation Electrolyte imbalances Discolored urine Rectal irritation Examples senna (Senekot) bisacodyl (Dulcolax) 12Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

13. Bulk-forming Laxatives: MOA High fiber Absorb water to increase bulk Distend bowel to initiate reflex bowel activity Ex: psyllium (Metamucil), methylcellulose (Citrucel) Adv. Effects Skin rashes Decreased absorption of vitamins Electrolyte imbalances Lipid pneumonia 13Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

14. Emollient Laxatives: MOA Stool softeners and lubricants Promote more water and fat in the stools Lubricate the fecal material and intestinal walls Ex: Stool softeners: docusate salts (Colace, Surfak) Lubricants: mineral oil 14Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

15. Laxatives: Nursing Implications Obtain a thorough history of presenting symptoms, elimination patterns, and allergies Assess fluid and electrolytes before initiating therapy Inform patients not to take a laxative or cathartic if they are experiencing nausea, vomiting, and/or abdominal pain 15Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

16. Laxatives: Nursing Implications A healthy, high-fiber diet and increased fluid intake should be encouraged as an alternative to laxative use Long-term use of laxatives often results in decreased bowel tone and may lead to dependency All laxative tablets should be swallowed whole, not crushed or chewed, especially if enteric coated 16Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

17. Laxatives: Nursing Implications Patients should take all laxative tablets with 6 to 8 oz of water Patients should take bulk-forming laxatives as directed by the manufacturer with at least 240 mL (8 oz) of water 17Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

18. Laxatives: Nursing Implications Give bisacodyl with water because of interactions with milk, antacids, and juices Inform patients to contact their prescriber if they experience severe abdominal pain, muscle weakness, cramps, and/or dizziness, which may indicate possible fluid or electrolyte loss Monitor for therapeutic effect 18Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

19. Focus on Inflammatory Bowel Disease

20. Collaborative Care Drug therapy Aminosalicylates Antimicrobials Corticosteroids Immunosuppressants Biologic and targeted therapies Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

21. Collaborative Care Drug therapy: Antirheumatic Sulfasalazine (Azulfidine) Decreases GI inflammation Effective in achieving and maintaining remission Mild to moderately severe attacks SE: Common; headache, nausea, fever, rash, and reversible infertility in men. Uncommon: Pancreatitis Rare: Steven-Johnsons syndrome, hepatitis, pneumonitis, agranulocytosis Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

22. Collaborative Care Antimicrobials Corticosteroids Decrease inflammation Used to achieve remission Helpful for acute flareups Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

23. Collaborative Care Immunosuppressants Suppress immune response Maintain remission after corticosteroid induction therapy Require regular CBC monitoring Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

24. Collaborative Care Nutritional therapy High-calorie High-protein Low-residue diet Vitamin and iron supplements Elemental diet Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

25. Nursing Management Nursing assessment Autoimmune disorders, infection Use of prescribed and OTC medicines Family history Diarrhea (presence of blood) Weight loss Anxiety, depression Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.