1. Bowel Disorder Drugs DSN Kevin Dobi, MS, APRN
Chapter 51
Bowel Disorder Drugs
DSN Kevin Dobi, MS, APRN
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3. Diarrhea
Abnormal passage of stools with increased frequency, fluidity, and weight, or with increased stool water excretion
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4. Diarrhea (cont’d) Acute diarrhea
Sudden onset in a previously healthy person
Lasts from 3 days to 2 weeks
Self-limiting
Resolves without sequelae
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5. Diarrhea (cont’d) Chronic diarrhea Lasts for more than 3-4 weeks
Associated with recurring passage of diarrheal stools, fever, loss of appetite, nausea, vomiting, weight loss, and chronic weakness
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6. Causes of Diarrhea Acute Diarrhea Chronic Diarrhea Bacteria Tumors
Viruses Diabetes mellitus
Drug-induced Addison’s disease
Nutritional factors Hyperthyroidism
Protozoa Irritable bowel syndrome
AIDS
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7. Goals of Diarrhea Treatment
Stopping the stool frequency
Alleviating the abdominal cramps
Replenishing fluids and electrolytes
Preventing weight loss and nutritional deficits from malabsorption
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8. Antidiarrheals Adsorbents
Antimotility drugs (anticholinergics and opiates)
Probiotics (bacterial replacement drugs)
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9. Antidiarrheals: Mechanism of Action
Adsorbents
Coat the walls of the gastrointestinal (GI) tract
Bind to the causative bacteria or toxin, which is then eliminated through the stool
Examples: bismuth subsalicylate (Pepto-Bismol), activated charcoal, aluminum hydroxide, others
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10. Antidiarrheals: Mechanism of Action (cont’d)
Antimotility drugs: anticholinergics
Decrease intestinal muscle tone and peristalsis of GI tract
Result: slows the movement of fecal matter through the GI tract
Examples: belladonna alkaloids
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11. Antidiarrheals: Mechanism of Action (cont’d)
Antimotility drugs: opiates
Decrease bowel motility and reduce pain by relief of rectal spasms
Decrease transit time through the bowel, allowing more time for water and electrolytes to be absorbed
Examples: paregoric, opium tincture, codeine, loperamide (over the counter), diphenoxylate
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12. Antidiarrheals: Mechanism of Action (cont’d)
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
Example: L. acidophilus (Bacid)
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13. Classroom Response Question
The antidiarrheal drug Lomotil contains both diphenoxylate, a synthetic opiate agonist, and atropine, an anticholinergic. The purpose of the atropine in this combination is to
enhance the effects of the diphenoxylate.
discourage recreational use of the opiate diphenoxylate.
counteract the adverse effects of the diphenoxylate.
act as an adsorbent for bacteria in the bowel.
Correct answer: B
Rationale: A small dose of atropine, combined with diphenoxylate, discourages recreational use of this drug because if taken in large doses, a person will experience unpleasant anticholinergic effects such as dry mouth, abdominal pain, blurred vision, and tachycardia.
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14. Antidiarrheals: Adverse Effects
Adsorbents
Increased bleeding time
Constipation, dark stools
Confusion
Tinnitus
Metallic taste
Blue tongue
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15. Antidiarrheals: Adverse Effects (cont’d)
Anticholinergics
Urinary retention, impotence
Headache, dizziness, confusion, anxiety, drowsiness, confusion
Dry skin, flushing
Blurred vision
Hypotension, bradycardia
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16. Antidiarrheals: Adverse Effects (cont’d)
Opiates
Drowsiness, dizziness, lethargy
Nausea, vomiting, constipation
Respiratory depression
Hypotension
Urinary retention
Flushing
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17. Antidiarrheals: Interactions
Adsorbents decrease the absorption of many drugs, including digoxin, quinidine, and hypoglycemic drugs
Adsorbents cause increased bleeding time and bruising when given with anticoagulants (warfarin)
Toxic effects of methotrexate are more likely when given with adsorbents
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18. Antidiarrheals: Nursing Implications
Obtain thorough history of bowel patterns, general state of health, and recent history of illness or dietary changes; assess for allergies
Do NOT give bismuth subsalicylate to children or teenagers with chickenpox or influenza because of the risk of Reye’s syndrome
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19. Classroom Response Question
Before administering belladonna alkaloids, it is most important for the nurse to assess the patient for a history of which condition?
Anemia
Diabetes mellitus
Myasthenia gravis
Hypertension
Correct answer: C
Rationale: Use of the belladonna alkaloid preparations is contraindicated in patients who have shown a hypersensitivity to anticholinergics and in patients with narrow-angle glaucoma, GI obstruction, myasthenia gravis, paralytic ileus, and toxic megacolon.
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20. Antidiarrheals: Nursing Implications (cont’d)
Use adsorbents carefully in elderly patients or those with decreased bleeding time, clotting disorders, recent bowel surgery, confusion
Do not administer anticholinergics to patients with a history of narrow-angle glaucoma, GI obstruction, myasthenia gravis, paralytic ileus, and toxic megacolon
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21. Antidiarrheals: Nursing Implications (cont’d)
Teach patients to take medications exactly as prescribed and to be aware of their fluid intake and dietary changes
Assess fluid volume status, I&O, and mucous membranes before, during, and after initiation of treatment
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22. Antidiarrheals: Nursing Implications (cont’d)
Teach patients to notify their prescriber immediately if symptoms persist
Monitor for therapeutic effect
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23. Classroom Response Question
Which antidiarrheal does the nurse associate with the development of adverse effects of urinary retention, headache, confusion, dry skin, rash, and blurred vision?
Anticholinergics
Adsorbents
Probiotics
Opiates
Correct answer: A
Rationale: Anticholinergics work by decreasing GI peristalsis through their parasympathetic blocking effects. Adverse effects include urinary retention, headache, confusion, dry skin, rash, and blurred vision.
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24. 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
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25. Laxatives Bulk-forming
Emollient (stool softeners, lubricant laxatives)
Hyperosmotic
Saline
Stimulant
Peripherally acting opioid
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26. Laxatives: Mechanism of Action
Bulk-forming
High fiber
Absorb water to increase bulk
Distend bowel to initiate reflex bowel activity
Examples
psyllium (Metamucil)
methylcellulose (Citrucel)
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27. Laxatives: Mechanism of Action (cont’d)
Emollient
Stool softeners and lubricants
Promote more water and fat in the stools
Lubricate the fecal material and intestinal walls
Examples
Stool softeners: docusate salts (Colace, Surfak)
Lubricants: mineral oil
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28. Laxatives: Mechanism of Action (cont’d)
Hyperosmotic
Increase fecal water content
Results in bowel distention, increased peristalsis, and evacuation
Examples:
Polyethylene glycol (PEG)
Sorbitol, glycerin
Lactulose (also used to reduce elevated serum ammonia levels)
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29. Laxatives: Mechanism of Action (cont’d)
Saline
Increase osmotic pressure within the intestinal tract, causing more water to enter the intestines
Results in bowel distention, increased peristalsis, and evacuation
Examples
Magnesium hydroxide (Milk of Magnesia)
Magnesium citrate (Citroma)
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30. Laxatives: Mechanism of Action (cont’d)
Stimulant
Increases peristalsis via intestinal nerve stimulation
Examples
senna (Senekot)
bisacodyl (Dulcolax)
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31. Peripherally Acting Opioid Antagonists
Treatment of constipation related to opioid use and bowel resection therapy
Block entrance of opioid into bowel
Strict regulations for use
Allow bowel to function normally with continued opioid use
methylnaltrexone (Relistor)
alvimopan (Entereg)
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32. Laxatives: Indications
Laxative Group Use Bulk-forming Acute and chronic constipation, irritable bowel syndrome, diverticulosis Emollient Acute and chronic constipation, fecal impaction, facilitation of bowel movements in anorectal conditions
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33. Laxatives: Indications (cont’d)
Laxative Group Use
Hyperosmotic Chronic constipation,
diagnostic and surgical preps
Saline Constipation, diagnostic and surgical preps
Stimulant Acute constipation, diagnostic and surgical preps
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34. Classroom Response Question
A patient is receiving 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?
Cleansing the bowel before a procedure
Removal of helminths
Reduction of high ammonia levels associated with liver failure
Daily maintenance to prevent constipation
Correct answer: C
Rationale: Lactulose helps to reduce blood ammonia levels by converting ammonia to ammonium, which can then be eliminated by the body.
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35. Laxatives: Adverse Effects
Bulk-forming
Impaction
Fluid overload
Electrolyte imbalances
Esophageal blockage
Emollient
Skin rashes
Decreased absorption of vitamins
Lipid pneumonia
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36. Laxatives: Adverse Effects (cont’d)
Hyperosmotic
Abdominal bloating
Electrolyte imbalances
Rectal irritation
Saline
Magnesium toxicity (with renal insufficiency)
Cramping
Diarrhea
Increased thirst
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37. Laxatives: Adverse Effects (cont’d)
Stimulant
Nutrient malabsorption
Skin rashes
Gastric irritation
Electrolyte imbalances
Discolored urine
Rectal irritation
All laxatives can cause electrolyte imbalances!
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38. 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
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39. Laxatives: Nursing Implications (cont’d)
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
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40. Laxatives: Nursing Implications (cont’d)
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
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41. Laxatives: Nursing Implications (cont’d)
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
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42. Classroom Response Question
A 48-year-old patient has been admitted with abdominal pain, and states that she has not had a bowel movement for 4 days. Her abdomen is distended and slightly tender. Which laxative would be appropriate for this patient?
Milk of magnesia
A bulk-forming laxative
Mineral oil
No laxative should be given at this time
Correct answer: D
Rationale: These laxatives are contraindicated in the presence of undiagnosed abdominal pain, as taking a laxative in cases of intestinal obstruction could be very harmful to the patient. No laxatives should be given if the patient has undiagnosed abdominal pain.
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Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

43. Irritable Bowel Syndrome
Chronic intestinal discomfort characterized by cramps, diarrhea, and/or constipation
Patients usually cope with the symptoms by avoiding irritating foods and/or taking over-the-counter (OTC) laxatives and antidiarrheal drugs
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44. Drugs for Irritable Bowel Syndrome
tegaserod (Zelnorm)
lubiprostone (Amitiza)
alosetron (Lotronex)
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45. Drugs for Irritable Bowel Syndrome: Nursing Implications
Perform a general assessment and additional assessment of liver functioning as well as assessment for any underlying cardiac disease
Follow administration guidelines
Assess for therapeutic response
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