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GASTROINTESTINAL MEDICATIONS Presented by: CARMINA F. GURREA, RN 1
OBJECTIVESAt the end of the presentation, the students will beable to:1. Describe the general goals of therapy when administering gastrointestinal system medications2. Enumerate the different gastrointestinal medications3. Identify the uses of the different gastrointestinal medications4. Describe nursing considerations related to administration of gastrointestinal medications5. List significant client education points related to gastrointestinal system medications.
GASTROINTESTINAL MEDICATIONSA. Gastrointestinal F. Antiemetics Stimulants G. Histamine H2B. Medications to Antagonists Decrease GI Tone H. Proton Pump & Motility InhibitorsC. Antidiarrheals I. AntacidsD. Laxatives J. MucosalE. Emetics Protective Agents
Action and Use• Decrease reflux by increasing sphincter tone and enhancing acid clearance and decreasing gastric emptying.• Used for prevention and reduction of nausea and vomiting due to chemotherapy, and for facilitation of small bowel intubations• Used for gastric emptying caused by diabetic gastroparesis, gastroesophageal reflux, postoperative nausea and vomiting
Side Effects• Drowsiness, diarrhea, restlessness, fatigue• Parkinson – like symptomsAdverse Effects/ Toxicity• Seizures• Agranulocytosis• Depression with suicide ideations
Key Points in Drug Administration• Metoclopramide PO should be taken 30 minutes before meals and bedtime• Metoclopramide IV should be given 30 minutes prior to chemotherapy for antiemetic effect• Concurrent use of macrolides and antifungal agents may cause serious cardiac dysrhythmias (cisapride)
Nursing Considerations• Monitor for possible hypernatremia and hypokalemia, particularly if client has congestive heart failure (CHF) or cirrhosis of liver• Extrapyramidal symptoms may occur in young adults and the elderly and with high – dose treatment of metoclopramide
Client Education• Instruct client to report signs and symptoms of side effects.• Instruct client to report signs of acute dystonia immediately.• Advise client not to drive for a few hours after taking metoclopramide
MEDICATIONS TO DECREASE GI TONE AND MOTILITY (ANTICHOLINERGICS AND ANTISPASMODICS)• Dicyclomine hydrochloride (Bentyl)• Hyoscyamine sulphate (Levsin)• Chlordiazepoxide hydrochloride (Librax)• Glycopyrrolate (Robinul)
Action and Use• Anticholinergics: antagonize the action of acetylcholine at the cholinergic receptor sites• Antispasmodics: are similar and they are believed to relax smooth muscle• Used for treatment of spasms of the gastrointestinal (GI) tract such as pyrolospasms, ileitis, irritable bowel syndrome
Side Effects• Hypersensitivity• Urticaria, rash, dry mouth, nausea vomiting, constipation, urinary hesitance and retention• Impotence, blurred vision, worsening of glaucoma• Palpitations, headache, flushing, drowsiness, dizziness, confusion
Adverse Effects/ Toxicity• May cause dilated, non – reactive pupils, visual changes• Tachycardia• Dysphagia, decreased or absent bowel sounds• Hyperthermia, hypertension, increased respiratory rate
Key Points in Drug Administration• Give medications 30 to 60 minutes before meals and at bedtime for therapeutic effect.• Contraindicated in narrow – angle glaucoma, obstructive GI disease, paralytic ileus, obstructive uropathy
Nursing Considerations• An understanding of the factors contributing to the diarrhea is essential in effective treatment• Clients who lose significant potassium with diarrhea are at risk for the development of paralytic ileus and cardia dysrhythmias• They should also be monitored for metabolic acidosis because of loss of bicarbonate and impaired renal excretion of acids.• Document indications and present medications• Monitor vital signs, urine output, and visual changes.• Monitor intake and output (I & O)
Client Education• Instruct client to avoid exposure to high temperatures because of risk of hyperthermia.• Advise client to report side effects to health care provider.• Instruct client on dietary / fluid interventions to decrease constipation• Instruct client to report any additional medications prescribed.• Instruct client to monitor I & O.
Action and Use• Slow and/ or inhibit GI motility by acting on nerve endings of the intestinal wall, thereby reducing the volume of stools, increasing viscosity and decreasing fluid and electrolyte loss.• Used for symptomatic relief of acute non – specific diarrhea and diarrhea of inflammatory disease.
Side Effects• Nausea and vomiting• Dry mouth, dizziness, drowsiness, constipation• Temporary darkening of stools and tongue may occur with bismuth salicylate
Adverse Effects/ Toxicity• Clinical signs and symptoms of overdose include drowsiness, decreased blood pressure (BP), seizures, apnea, blurred vision, dry mouth, and psychosis.• Risk of aspirin toxicity with concurrent use of aspirin, bismuth salicylate• Other adverse effects include central nervous system (CNS) depression, respiratory depression, hypotonic reflexes, angioedema, anaphylaxis, and paralytic ileus.
Key Points in Drug Administration• Shake suspension well; chew tablets thoroughly• Stool may appear gray – black (may mask GI bleeding)• Do not give concurrently with other medications• Seek medical care if diarrhea persists for more than 2 days in the adult• Do not use to treat diarrhea in children; seek medical attention
Nursing Considerations• Note allergies• Document onset, duration, and frequency of symptoms• Document previous therapies used.• Note current medications• Identify causative factors; perform stool analysis if necessary and ordered• Assess for evidence of dehydration or electrolyte imbalance• Monitor vital signs and I & O• Note presence of co – morbid conditions• Check abdomen for tenderness, distention, bowel sounds, or masses• Administer bismuth and tetracycline one hour apart.
Client Education• Instruct client to drink fluids to avoid dehydration and alleviate dry mouth• Instruct client to follow the BRAT diet: Bananas, Rice, Applesauce, Tea/ Toast to avoid dehydration if recommended by healthcare provider• Advise client not to exceed prescribed dose• Instruct client to consult health care provider if diarrhea persists over 2 days• Advise client to use caution in activities requiring alertness if dizziness/ drowsiness is present (possible side effects)
Client Education• Instruct client to report occurrence of fever, nausea and vomiting, abdominal pain or distension• Advise client to avoid dairy products• Teach good personal hygiene to avoid skin irritation or breakdown because of diarrhea.• Instruct client to avoid alcohol ingestion while taking the medication• Instruct client to notify healthcare provider if pregnant or breastfeeding.
Actions & Uses• Laxatives swell in water, forming an emollient gel that increases bulk in the intestines.• Peristalsis is stimulated by the increased fecal mass, which decreases the transit time.• They generally produce a laxative effect within 12 to 14 hours but may require 2 to 3 days for full effect.
Side Effects• Abdominal discomfort and/or bloating, flatulence• Nausea and vomiting, diarrheaAdverse Effects/ Toxicity• Rare reports of allergic reactions to karaya such as urticaria, rhinitis, dermatitis, bronchospasm• Esophageal obstruction, swelling, or blockage may occur when insufficient fluid is used in mixing a bulk – forming laxative.
Key Points in Drug Administration• It is essential that adequate fluids be given for bowel absorption since these agents rely on water to increase their bulk.• Each dose should be given with a full glass of liquid (240mL)• Fiber increases stool bulk and water retention in the bowel.• Do not use if fecal impaction is present.
Nursing Considerations• Assess swallowing ability, adequately mix agents in liquid and encourage additional fluid intake.• Monitor for aspiration.• Add at least 8 oz (240mL) of water or juice to drug• Separate psyllium administration from digoxin, salicylates, and anticoagulants by 2 hours
Client Education• Instruct client that these agents require adequate hydration to be effective• Encourage additional fluids and exercise.• Instruct client to take them 2 hours after meals and any oral medications.• Instruct client that full effect of medication may not occur for 2 to 3 days.
Actions & Uses• Are called stimulants because they stimulate peristalsis via mucosal irritation which increased motility.• Defecation occurs between 6 to 12 hours after oral administration• Rectal administration of bisacodyl and senna produces catharsis within 15 minutes to 2 hours.
Side Effects• Nausea and vomiting, abdominal cramps, diarrhea, laxative dependence• Muscle weakness, fluid/electrolyte imbalance• Rectal burning or irritation with suppository use.Adverse Effects/ Toxicity• Hypokalemia, hypocalcemia• Metabolic acidosis or alkalosis
Key Points in Drug Administration• Bedtime administration of dose promotes a morning bowel movement• Swallow tablet whole; do not crush• Do not take within 1 hour of antacids or milk• Castor oil may induce premature labor• If taken with antacids may result in GI irritation or cramping
Nursing Considerations• Evaluate for nausea and vomiting, abdominal pain or diarrhea• Evaluate for medication effectiveness• Monitor for fluid/ electrolyte imbalances• Administer medication 1 hour before or after ingestion of milk or an antacid• Evaluate for laxative dependence and offer counselling.
Client Education• Discourage client from chronic use of laxatives; use beyond 1 week should be avoided.• Instruct client to increase fluid intake and diet high in fiber• Instruct to take medications 1 hour before or after ingestion of milk or an antacid.
Actions & Uses• They increase osmotic pressure within the intestinal lumen, which results in luminal retention of water, softening of stool.• Used for treatment of occasional constipation• Used to reduce ammonia levels (Lactulose)• May take 2 to 4 days to take effect.
Side Effects• Glycerin: rectal irritation and burning, hyperaemia of the rectal mucosa• Lactulose and Miralax: flatulence, abdominal cramps/ bloating, diarrheaAdverse Effects/ Toxicity• Fluid and electrolyte imbalances
Key Points in Drug Administration• Contraindicated in bowel obstruction• Antibiotics may decrease laxative effect by elimination of bacteria needed to digest in active form.
Nursing Considerations• Miralax should always be dissolved in 8 oz of water• Dilute lactulose in water or juice to decrease sweet taste• Monitor frequency and consistency of stools• Monitor for electrolyte imbalances especially in the elderly.
Client Education• Instruct client that Miralax should be dissolved in 8 oz of water• Instruct client that the medication may take 2 to 4 days for effect• Advise client to contact physician if unusual bloating, cramping or diarrhea occurs• Instruct client that prolonged use may result in electrolyte imbalance and laxative dependence.• Instruct client to take medication with juice to improve taste
Actions & Uses• Used on scheduled basis for clients who are likely to become constipated, such as with hospitalization, bed rest, post – surgical status, and for those receiving opioid analgesic medications.• Stool softeners are often referred to as emollient laxatives.• Softening of feces generally occurs after 1 to 3 days.• Used for constipation associated with dry, hard stools and to decrease strain of defecation.
Side Effects – Mild abdominal cramping, diarrhea – Dependence with long – term use or excessive use – Bitter tasteAdverse Effects/ Toxicity – Throat irritation has occurred with docusate sodium solution – Docusate has been associated with hepatotoxicity when used in combination with oxyphenisatin or dantrol
Key Points in Drug Administration• Offer fluids after each PO dose• Contraindicated with intestinal obstruction, undiagnosed abdominal pain, vomiting or other signs of appendicitis, fecal impaction, or acute abdomen
Nursing Considerations• Monitor frequency and consistency of stools• Monitor for electrolyte imbalances especially in the elderly
Client Education• Instruct client to take medication with milk or juice to decrease bitter taste.• Encourage client to increase fluid intake• Inform client that it may require 1 to 3 days to soften fecal matter.
Actions & Uses• Magnesium, sulphate, phosphate, and citrate salts are used when rapid bowel evacuation is required, as in bowel evacuation in preparation for procedures or surgery.• Orally administered magnesium and sodium phosphate salts are effective within 30 minutes to 6 hours.
Side Effects• Cramping and urgency to defecateAdverse Effects/ Toxicity• Safe when administered for short – term management• They may cause significant fluid and electrolyte imbalances when used for prolonged periods or in certain clients.
Key Points in Drug Administration• Saline agents are not recommended for children under 2 years of age because of potential for hypocalcemia• Contraindicated in the presence of abdominal pain, nausea and vomiting, or other signs and symptoms of appendicitis or acute abdomen• Concomitant use with antacids may inactivate both.
Nursing Considerations• Dehydration and electrolyte imbalances may occur from repeated administration without appropriate fluid replacement• Encouraged increased fluid intake• Monitor drug effectiveness
Client Education• Instruct client on drug dosing• Instruct client to avoid frequent or prolonged use due to laxative dependence• Instruct client to report side effects to health care provider• Advise client to report health care provider if ineffective• Encourage client to increase fluid intake.
EMETICS• Ipecac SyrupAction and Use• Directly irritate the GI mucosa and stimulate chemoreceptor trigger zone• Emetics are used to induce vomiting after oral poisoning or drug overdose
Side Effects – Drowsiness – Arrythmias – Diarrhea – Mild CNS depressionAdverse Effects/ Toxicity – May be cardiotoxic if not vomited and allowed to absorb, leading to heart conduction disturbances.
Key Points in Drug Administration• Ipecac syrup dose is 15 to 30 mL orally• Onset of action usually occurs in 20 minutes• Follow dose with 240cc water for adults and children older than 12, ½ to 1 glass of water for infants up to 1 year, and 1 to 2 glasses of water for children younger than 12 years of age.• Do not give to infants less than 6 months of age.• Do not use with corrosive or petrolatum distillates (gasoline, kerosene, volatile oils or caustic substances)• Do not give to semicomatose or unconscious clients during intoxication, seizures, shock or any loss of gag reflex.
Nursing Considerations• Evaluate origin of agent ingested• There is a risk of aspiration of vomitus in children less than 12 months, the elderly, and in anyone with altered level of consciousness or gag reflex• Drug may be abused by clients with eating disorders• Monitor medication effect• Administer with at least 200 to 300 cc of water• Assess respiratory status and level of consciousness• Review abuse potential
Client Education• Instruct client to contact poison control before administering ipecac syrup• Advise client to seek immediate medical attention when poisoning is suspected• Instruct client to keep all medications out of reach of children• Advise client to check the expiration date periodically as drug is available over the counter• Avoid drinking milk or carbonated beverages that may alter effectiveness• Instruct client that vomiting does not occur, go immediately to health care provider/emergency room to decrease toxic absorption of drug
Action and Use• Emesis is a complex reflex brought about by activation of the vomiting center (a nucleus of neurons located in the medulla oblongata)• Certain stimuli activate the vomiting center directly (e.g. gastrointestinal irritation) while other stimuli (e.g. drugs, toxins, radiation) act within the medulla to stimulate the chemoreceptor zone (CTZ); presumably by altering the function of these neuroreceptors that emetogenic compounds and antiemetic drugs produce their effects.
Side Effects• Phenothiazines can produce extrapyramidal reactions, anticholinergic effects, hypotension and sedation.• Butyrophenones can also produce extrapyramidal reactions, sedation and hypotension• Cannbinoids may cause temporal disintegration, dissociation, depersonalization and dysphoria
Adverse Effects/ Toxicity• Cannbinoids are contraindicated for clients with psychiatric disorders• Phenothiazines: agranulocytosis, thrombocytopenia
Key Points in Drug Administration• In cancer chemotherapy antiemetic combinations are more beneficial than single – drug treatment: this may suggest that there is more than one mechanism triggering the emesis.• Parenteral preparations should be given deep IM to avoid leakage of the drug into the subcutaneous tissues• Anticipatory nausea and vomiting should be treated 1 hour before meals or treatment.• Contraindicated with CNS depression and coma• Use cautiously in clients with glaucoma, seizures, intestinal obstruction, prostatic hyperplasia, asthma, cardiac, pulmonary or hepatic disease.
Nursing Considerations• Dronabinol and nabilone have a high potential for abuse• Check vital signs regularly for risk of hypotension or tachycardia• Observe for side effects and adverse reactions• Monitor I & O for urine retention• Observe for mood changes or involuntary movements• Monitor lab values: liver function test, electrolytes and renal function (blood urea nitrogen and creatinine)
Client Education• Avoid activities that require alertness• Teach signs and symptoms to report to health care provider• Instruct client to avoid alcohol and CNS depressant drugs• Instruct diabetic clients to monitor blood glucose• Teach client to take medications as prescribed• Instruct client to avoid excessive sunlight/ UV light because of potential photosensivity• Advise clients to increase fluids and dietary fiber to decrease risk of constipation• To be more effective instruct client to take medication 30 to 60 minutes
Action and Use• Reduce gastric acid secretion by blocking histamine 2 in the gastric parietal cells• Histamine H2 antagonists are used to treat duodenal ulcer, gastric ulcer, hypersecretory conditions such as Zollinger – Ellison syndrome, reflux esophagitis• Used for prevention of stress ulcers in critically ill clients, combination therapy to treat Helicobacter pylori (bacteria found in gastric mucosa)
Side Effects – Somnolence, diaphoresis, rash, headache – Taste disorder, diarrhea, constipation, dry mouthAdverse Effects/ Toxicity – Rare but may include agranulocytosis, neutropenia, thrombocytopenia, aplastic anemia, pancytopenia – Anaphylaxis
Key Points in Drug Administration• IV administered drugs should not be mixed with other medications• Avoid antacid use within 1 hour of administration• May be given as single dose, twice daily or with meals and at bedtime• Decreased ketaconazole absorption with Famotidine• Nizatidine may increase salicylate levels with high dose of aspirin• Cimetidine: decreased metabolism of beta adrenergic blockers
Nursing Considerations• Reduce dosages usually required for clients with hepatic or renal impairment• Assess medications for possible interactions• Evaluate nutritional status and dietary interventions• Evaluate need for smoking cessation and alcohol abuse programs
Client Education• Instruct client to avoid smoking, which causes gastric stimulation• Advise client to avoid antacid (agent reducing acidity) use within 1 hour of dose• Instruct clients to take medications only as directed.• Inform client that once – a – day dosage should be taken at bedtime; if prescribed more than daily, take before meals• Instruct client to avoid gastric irritants such as alcohol, aspirin or non-steroidal anti-inflammatory drugs (NSAIDS)
Action and Use• Block acid production by inhibiting the H+ - K+ ATPhase at the secretory surface of the gastric parietal cells, thereby blocking the formation of gastric acid• Used for treatment of erosive or ulcerative gastroesophageal reflux disease (GERD) or duodenal ulcers, active benign gastric ulcers, and nonsteroidal anti – inflammatory drug (NSAID) – associated gastric ulcers (short term)• Used for healing and reduction in relapse rates of heartburn symptoms in erosive or ulcerative GERD (maintenance)• Used for treatment of pathological hypersecretory conditions such as Zollinger Ellison syndrome (long – term)
Side Effects• Headache, diarrhea, constipation, abdominal pain, nausea, flatulence• Rash, hyperglycemia, dizziness, pruritus, dry mouth• Injection site reaction with pantoprazole
Key Points in Drug Administration• May give with antacids• If unable to swallow capsules, lansoprazole and esomeprazole capsules may be opened and sprinkled on applesauce before taking• To give per nasogastric (NG) tube, dilute capsule contents in 40-cc juice• Omeprazole, pantoprazole, and rabeprazole must be swallowed whole• Not recommended in children or nursing mothers.• May increase liver enzymes.
Nursing Considerations• Dosage should be reduced in severe liver disease• Document reason for therapy, duration of symptoms and drug efficacy• Monitor for side effects• Monitor laboratory test results including liver function test, CBC, and renal function (BUN, creatinine)• Review any diagnostic findings• Assess for pregnancy or lactation
Client Education• Review side effects with clients, instruct to report diarrhea• Instruct client to take medications as prescribed; do not increase dose• Advise client to follow prescribed diet and activities to decrease symptoms• Inform client that medication is generally for short – term therapy; instruct client to keep health care appointments for continued signs and symptoms• Instruct client that esomeprazole and omeprazole should be taken before meals• Advise client to notify health care provider of any difficulty swallowing since omeprazole, pantoprazole, and rabeprazole must be swallowed whole• Instruct client that lansoprazole and esomeprazole capsules may be opened and sprinkled.
Action and Use• Gastric acid neutralizing agent• Used for symptomatic relief of hyperacidity associated with GI disorders• Used as an antiflatulent to alleviate symptoms of gas and bloating
Side Effects• Belching, constipation, flatulence, diarrhea• Gastric distension
Adverse Effects/ Toxicity• Hypophosphatemia (anorexia, malaise, tremors, muscle weakness)• Aluminum toxicity (dementia) may occur with repeated dosing• Hypercalcemia and metabolic alkalosis may occur with antacids containing calcium carbonate• May worsen hypertension and heart failure from increased sodium intake with use of those antacids containing sodium carbonate
Key Points in Drug Administration• Antacids should be taken at least 2 hours apart from other drugs where a drug interaction may occur• Magnesium hydroxide is contraindicated in the presence of abdominal pain, nausea, vomiting, diarrhea, severe renal dysfunction, fecal impaction, rectal bleeding, colostomy, ileostomy• Aluminum carbonate antacids: prolonged use of high doses in presence of low serum phosphate
Key Points in Drug Administration• Calcium carbonate antacids: hypercalcemia and hypercalciuria, severe renal disease, renal calculi, GI hemorrhage or obstruction, dehydration• Dihydroxyaluminum sodium carbonate: aluminum sensitivity, severe renal disease, dehydration, clients on sodium – restricted diets.• Antacids may bind with other drugs, therefore decreasing the drug’s absorption and effectiveness, such as tetracycline.
Nursing Considerations• Shake suspension well• Flush NG tube with water after administration• Observe for signs and symptoms of altered phosphate levels: anorexia, muscle weakness, and malaise
Client Education• Instruct client on methods to avoid constipation• Instruct client to take as directed; do not exceed maximum dose• Instruct client to keep out of reach of children• Advise client to drink plenty of fluids• Explain antacids may interact with certain medications; notify health care provider of any prescribed medications• Warn client not to use if diagnosed with kidney disease
Action and Use• Misoprostol (Cytotec) inhibits gastric secretion, protects gastric mucosa by increasing bicarbonate and mucus production and decreases pepsin levels.• Sucralfate (Carafate) protects the site of ulcer from gastric acid by forming an adherent coating with albumin and fibrinogen; it absorbs pepsin decreasing its activity• Misoprostol (Cytotec) is used for the prevention of gastric ulcers, investigational use with duodenal ulcers.• Sucralfate (Carafate) is used for short – term treatment of duodenal ulcers with continued maintenance treatment at lower doses; investigational use for gastric ulcers.
Side Effects• Dizziness, headache, constipation, diarrhea, nausea, vomiting, flatulence, dry mouth and rash• Misoprostol may cause spotting, cramping, dysmenorrhea, menstrual disorders, and postmenopausal bleedingAdverse Effects/ Toxicity• Angioedema• Respiratory difficulty, laryngospasm• Seizures
Key Points in Drug Administration• Sucralfate should be taken 1 hour before meals and bedtime or 2 hours after meals• Sucralfate should be taken 2 hours after medications and not within 2 hours of antacids• Misoprostol should be taken with food• Misoprostol is contraindicated in clients who are allergic to prostaglandins or who are pregnant or lactating• Misoprostol may cause miscarriage with serious bleeding
Nursing Considerations• Assess GI symptoms• Assess for pregnancy• Monitor concomitant medications• Give medications according to prescription• Monitor for side effects• Assess respiratory status, swallowing or change in gag reflex
Client Education• Instruct client to avoid gastric irritants such as caffeine, alcohol, smoking, and spicy foods• Instruct client to take medication as prescribed and do not share with others.• Advise client to report side effects to healthcare provider for possible dosage change• Instruct client in contraceptive practices while on misoprostol• Instruct female clients to report any abnormal vaginal bleeding
Client Education• Instruct client not to take misoprostol if pregnant; if client becomes pregnant while taking misoprostol, she should stop taking it• Inform client to avoid pregnancy at least 1 month or 1 menstrual cycle after stopping medication• Instruct client to increase fluids and fiber to decrease constipation• Instruct on antacid use to decrease interaction• Advise client to report immediately any difficulty swallowing or breathing