1. Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. CHAPTER 51 Bowel Disorder Drugs

2. 2 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

3. 3 Diarrhea  Abnormal passage of stools with increased frequency, fluidity, and weight, or with increased stool water excretion

4. 4 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Diarrhea (cont’d) Acute diarrhea  Sudden onset in a previously healthy person  Lasts from 3 days to 2 weeks  Self-limiting  Resolves without sequelae

5. 5 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Diarrhea (cont’d) Chronic diarrhea  Lasts for more than 3 weeks  Associated with recurring passage of diarrheal stools, fever, loss of appetite, nausea, vomiting, weight loss, and chronic weakness

6. 6 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Causes of Diarrhea Acute DiarrheaChronic Diarrhea BacterialTumors ViralDiabetes mellitus Drug inducedAddison’s disease Nutritional factors Hyperthyroidism ProtozoaIrritable bowel syndrome AIDS

7. 7 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Antidiarrheals: Mechanism of Action Adsorbents  Coat the walls of the 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

8. 8 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 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 (atropine, hyoscyamine)

9. 9 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Antidiarrheals: Mechanism of Action (cont’d) Antimotility drugs: opiates  Decrease bowel motility and relieve rectal spasms  Decrease transit time through the bowel, allowing more time for water and electrolytes to be absorbed  Reduce pain by relief of rectal spasms  Examples: paregoric, opium tincture, codeine, loperamide (over the counter), diphenoxylate

10. 10 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Antidiarrheals: Mechanism of Action (cont’d) Intestinal flora modifiers  Probiotics or 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 (Lactinex)

11. 11 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Antidiarrheals: Adverse Effects Adsorbents  Increased bleeding time  Constipation, dark stools  Confusion, twitching  Hearing loss, tinnitus, metallic taste, blue gums

12. 12 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Antidiarrheals: Adverse Effects (cont’d) Anticholinergics  Urinary retention, hesitancy, impotence  Headache, dizziness, confusion, anxiety, drowsiness, confusion  Dry skin, flushing  Blurred vision  Hypotension, bradycardia

13. 13 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Antidiarrheals: Adverse Effects (cont’d) Opiates  Drowsiness, sedation, dizziness, lethargy  Nausea, vomiting, anorexia, constipation  Respiratory depression  Hypotension  Urinary retention  Flushing

14. 14 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Antidiarrheals: Interactions  Adsorbents decrease the absorption of many drugs, including digoxin, clindamycin, quinidine, hypoglycemic drugs, others  Adsorbents cause increased bleeding time and bruising when given with anticoagulants  Antacids can decrease effects of anticholinergic antidiarrheal drugs  Many other interactions

15. 15 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 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

16. 16 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 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

17. 17 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 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

18. 18 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Antidiarrheals: Nursing Implications (cont’d)  Teach patients to notify their physician immediately if symptoms persist  Monitor for therapeutic effect

19. 19 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 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

20. 20 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Laxatives  Bulk forming  Emollient  Hyperosmotic  Saline  Stimulant  Peripherally acting opioid antagonists

21. 21 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 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)

22. 22 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 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

23. 23 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 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)

24. 24 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 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)

25. 25 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Laxatives: Mechanism of Action (cont’d) Stimulant  Increases peristalsis via intestinal nerve stimulation  Examples:  senna (Senekot)  bisacodyl (Dulcolax)

26. 26 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 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)

27. 27 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Laxatives: Indications Laxative GroupUse Bulk formingAcute and chronic constipation, irritable bowel syndrome, diverticulosis EmollientAcute and chronic constipation, fecal impaction facilitation of BMs in anorectal conditions

28. 28 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Laxatives: Indications (cont’d) Laxative GroupUse HyperosmoticChronic constipation Diagnostic and surgical preps SalineConstipation Diagnostic and surgical preps

29. 29 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Laxatives: Indications (cont’d) Laxative GroupUse StimulantAcute constipation Diagnostic and surgical preps

30. 30 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Laxatives: Adverse Effects  Bulk forming  Impaction  Fluid overload  Electrolyte imbalances  Esophageal blockage  Emollient  Skin rashes  Decreased absorption of vitamins  Electrolyte imbalances  Lipid pneumonia

31. 31 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Laxatives: Adverse Effects (cont’d)  Hyperosmotic  Abdominal bloating  Electrolyte imbalances  Rectal irritation  Saline  Magnesium toxicity (with renal insufficiency)  Cramping  Electrolyte imbalances  Diarrhea  Increased thirst

32. 32 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Laxatives: Adverse Effects (cont’d)  Stimulant  Nutrient malabsorption  Skin rashes  Gastric irritation  Electrolyte imbalances  Discolored urine  Rectal irritation  All laxatives can cause electrolyte imbalances!

33. 33 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 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

34. 34 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. 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

35. 35 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Laxatives: Nursing Implications (cont’d)  Patients should take all laxative tablets with 6 to 8 ounces of water  Patients should take bulk-forming laxatives as directed by the manufacturer with at least 240 mL (8 ounces) of water

36. 36 Mosby items and derived items © 2011, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Laxatives: Nursing Implications (cont’d)  Give bisacodyl with water because of interactions with milk, antacids, and juices  Inform patients to contact their physician if they experience severe abdominal pain, muscle weakness, cramps, and/or dizziness, which may indicate possible fluid or electrolyte loss  Monitor for therapeutic effect