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

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

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

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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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