Laxative Group Use

Report
Chapter 51
BOWEL DISORDER DRUGS
DSN
Copyright © 2014 by Mosby, an imprint of Elsevier
Inc.
KEVIN DOBI, MS, APRN
2
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Inc.
Diarrhea
3
 Abnormal passage of stools with increased
frequency, fluidity, and weight, or with increased
stool water excretion
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Inc.
Diarrhea4 (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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Diarrhea5 (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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Causes of6 Diarrhea
Acute Diarrhea
Diarrhea
Bacteria
Viruses
Drug-induced
Nutritional factors
Protozoa
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Chronic
Tumors
Diabetes mellitus
Addison’s disease
Hyperthyroidism
Irritable bowel
syndrome
AIDS
Goals of Diarrhea
Treatment
7
 Stopping the stool frequency
 Alleviating the abdominal cramps
 Replenishing fluids and electrolytes
 Preventing weight loss and nutritional deficits
from malabsorption
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Antidiarrheals
8
 Adsorbents
 Antimotility drugs (anticholinergics and opiates)
 Probiotics (bacterial replacement drugs)
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Antidiarrheals:
Mechanism
9 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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Inc.
Antidiarrheals:
Mechanism of 10Action (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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Inc.
Antidiarrheals:
Mechanism of 11Action (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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Antidiarrheals:
Mechanism of 12Action (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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Classroom Response Question
13
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
A.
B.
C.
D.
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.
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Antidiarrheals:
Adverse14 Effects
Adsorbents
 Increased bleeding time
 Constipation, dark stools
 Confusion
 Tinnitus
 Metallic taste
 Blue tongue
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Antidiarrheals:
Adverse Effects
(cont’d)
15
Anticholinergics
 Urinary retention, impotence
 Headache, dizziness, confusion, anxiety,
drowsiness, confusion
 Dry skin, flushing
 Blurred vision
 Hypotension, bradycardia
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Antidiarrheals:
Adverse Effects
(cont’d)
16
Opiates
 Drowsiness, dizziness, lethargy
 Nausea, vomiting, constipation
 Respiratory depression
 Hypotension
 Urinary retention
 Flushing
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Antidiarrheals:
17 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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Antidiarrheals:
Nursing Implications
18
 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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Classroom Response Question
19
Before administering belladonna alkaloids, it is most
important for the nurse to assess the patient for a
history of which condition?
A.
B.
C.
D.
Anemia
Diabetes mellitus
Myasthenia gravis
Hypertension
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Inc.
Antidiarrheals:
Nursing Implications
(cont’d)
20
 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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Antidiarrheals:
Nursing Implications
(cont’d)
21
 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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Antidiarrheals:
Nursing Implications
(cont’d)
22
 Teach patients to notify their prescriber
immediately if symptoms persist
 Monitor for therapeutic effect
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Classroom Response Question
23
Which antidiarrheal does the nurse associate with the
development of adverse effects of urinary retention,
headache, confusion, dry skin, rash, and blurred
vision?
A.
B.
C.
D.
Anticholinergics
Adsorbents
Probiotics
Opiates
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Constipation
24
 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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Laxatives
25
 Bulk-forming
 Emollient (stool softeners, lubricant laxatives)
 Hyperosmotic
 Saline
 Stimulant
 Peripherally acting opioid
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Laxatives: Mechanism
of Action
26
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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Laxatives: Mechanism
of Action (cont’d)
27
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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Laxatives: Mechanism
of Action (cont’d)
28
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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Laxatives: Mechanism
of Action (cont’d)
29
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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Laxatives: Mechanism
of Action (cont’d)
30
Stimulant
 Increases peristalsis via intestinal nerve
stimulation
 Examples
senna (Senekot)
 bisacodyl (Dulcolax)

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Peripherally Acting31Opioid 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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Laxatives: 32Indications
Laxative Group
Bulk-forming
Emollient
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Inc.
Use
Acute and chronic
constipation, irritable
bowel syndrome,
diverticulosis
Acute and chronic
constipation, fecal
impaction, facilitation
of bowel movements
in anorectal conditions
Laxatives: Indications
(cont’d)
33
Laxative Group
Hyperosmotic
Saline
Stimulant
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Use
Chronic constipation,
diagnostic and surgical
preps
Constipation,
diagnostic and surgical
preps
Acute constipation,
diagnostic and
surgical preps
Classroom Response Question
34
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?
A. Cleansing the bowel before a procedure
B. Removal of helminths
C. Reduction of high ammonia levels associated with
liver failure
D. Daily maintenance to prevent constipation
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Laxatives: Adverse
Effects
35
 Bulk-forming
 Impaction
 Fluid overload
 Electrolyte imbalances
 Esophageal blockage
 Emollient
 Skin rashes
 Decreased absorption of vitamins
 Electrolyte imbalances
 Lipid pneumonia
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Laxatives: Adverse
36 Effects (cont’d)
 Hyperosmotic
 Abdominal bloating
 Electrolyte imbalances
 Rectal irritation
 Saline
 Magnesium toxicity (with renal insufficiency)
 Cramping
 Electrolyte imbalances
 Diarrhea
 Increased thirst
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Laxatives: Adverse
37 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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Laxatives: Nursing
Implications
38
 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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Laxatives: Nursing Implications
(cont’d)
39
 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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Laxatives: Nursing Implications
(cont’d)
40
 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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Laxatives: Nursing Implications
(cont’d)
41
 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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Classroom Response Question
42
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?
A. Milk of magnesia
B. A bulk-forming laxative
C. Mineral oil
D. No laxative should be given at this time
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Irritable Bowel
Syndrome
43
 Chronic intestinal discomfort characterized by
cramps, diarrhea, and/or constipation
 Patients usually cope with the symptoms by
avoiding irritating foods and/or taking over-thecounter (OTC) laxatives and antidiarrheal drugs
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Drugs for Irritable44 Bowel Syndrome
 tegaserod (Zelnorm)
 lubiprostone (Amitiza)
 alosetron (Lotronex)
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Drugs for Irritable Bowel Syndrome:
Nursing Implications
45
 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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