Chapter 51

BOWEL DISORDER DRUGS

Diarrhea 2

 Abnormal passage of stools with increased

frequency, fluidity, and weight or with
increased stool water excretion
 Acute diarrhea
 Sudden onset in a previously healthy person
 Lasts from 3 days to 2 weeks
 Self-limiting

 Resolves without sequelae

Diarrhea (Cont.) 3

 Chronic diarrhea
 Lasts for more than 3 to 4 weeks
 Associated with recurring passage of diarrheal
stools, fever, loss of appetite, nausea, vomiting,
weight loss, and chronic weakness
Causes of Diarrhea 4

 Acute diarrhea
 Bacteria

 Viruses

 Drug induced
 Nutritional factors
 Protozoa
Causes of Diarrhea (Cont.) 5

 Chronic diarrhea
 Tumors

 Diabetes mellitus
 Addison’s disease
 Hyperthyroidism

 Irritable bowel syndrome

 AIDS
Goals of Diarrhea Treatment 6

 Stopping the stool frequency

 Alleviating the abdominal cramps
 Replenishing fluids and electrolytes
 Preventing weight loss and nutritional
deficits from malabsorption
Antidiarrheals 7

 Adsorbents
 Antimotility drugs (anticholinergics and
opiates)
 Probiotics(also known as intestinal flora
modifiers and bacterial replacement drugs)
Antidiarrheals:
Mechanism of Action
8

 Adsorbents
 Coat the walls of the gastrointestinal (GI) tract
 Bindto the causative bacteria or toxin, which is
then eliminated through the stool
 Examples: bismuth subsalicylate (Pepto-Bismol),
activated charcoal, and antilipemic drugs
colestipol and cholestyramine
Antidiarrheals:
Mechanism of Action (Cont.)
9

 Antimotility drugs: anticholinergics

 Decrease intestinal muscle tone and peristalsis
of GI tract
 Result:slows the movement of fecal matter
through the GI tract
 Example: belladonna alkaloids
Antidiarrheals:
Mechanism of Action (Cont.)
10

 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,
over-the-counter (OTC) loperamide,
diphenoxylate
Antidiarrheals:
Mechanism of Action (Cont.)
11

 Antimotility drugs: anticholinergics

 Slow peristalsis by reducing the rhythmic
contractions and smooth muscle tone of the GI
tract
 Drying effect
 Reduce gastric secretions
 Used in combination with adsorbents and
opiates
Antidiarrheals:
Mechanism of Action (Cont.)
12

 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: Lactobacillus acidophilus (Bacid)
Audience Response System
Question #1 13

The antidiarrheal drug Lomotil contains both

diphenoxylate, a synthetic opiate agonist, and atropine,
an anticholinergic. What is the purpose of the additive,
atropine?

A. Enhance the effects of the diphenoxylate.

B. Discourage recreational use of the opiate
diphenoxylate.
C. Counteract the adverse effects of the diphenoxylate.
D. Act as an adsorbent for bacteria in the bowel.
 14
Answer to System
Question #1
ANS: B

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.
Antidiarrheals: Indications 15

 Adsorbents: milder cases

 Anticholinergics and opiates: more severe
cases
 Probiotics: antibiotic-induced diarrhea
Audience Response System
Question #2
16

A patient is experiencing diarrhea while

completing a course of antibiotic therapy. Which
of the following agents does the nurse anticipate
administering to the patient?

A. L. acidophilus
B. Bismuth subsalicylate
C. Diphenoxylate with atropine
D. Loperamide
Answer to System Question #2
17

ANS: A

L. acidophilus is a probiotic often used in the

treatment of antibiotic-induced diarrhea. The other
agents are usually not used in the treatment of
antibiotic-induced diarrhea.
Antidiarrheals:
Adverse Effects
18

 Adsorbents
 Increased bleeding time
 Constipation, dark stools
 Confusion

 Tinnitus

 Metallic taste
 Blue tongue
Antidiarrheals:
Adverse Effects (Cont.)
19

 Anticholinergics
 Urinary retention, impotence
 Headache,dizziness, confusion, anxiety,
drowsiness, confusion
 Dry skin, flushing
 Blurred vision
 Hypotension, bradycardia
Antidiarrheals:
Adverse Effects (Cont.)
20

 Opiates
 Drowsiness, dizziness, lethargy
 Nausea, vomiting, constipation
 Respiratory depression
 Hypotension

 Urinary retention
 Flushing
Antidiarrheals: Interactions 21

 Adsorbentsdecrease 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.
Audience Response System
Question #3
22

A patient who takes warfarin has been prescribed an

adsorbent for diarrhea. It is important for the nurse to
assess the patient for bruising because use of warfarin
with adsorbents interferes with the absorption of which
vitamin?

A. A
B. D
C. E
D. K

NOTE: No input is required to proceed.

Answer to System Question #3
23

ANS: D

The oral anticoagulant warfarin is more likely to

cause increased bleeding times or bruising when
co-administered with adsorbents. This is thought to
be because the adsorbents bind to vitamin K, which
is needed to make certain clotting factors. Vitamin K
is synthesized by the normal bacterial flora in the
bowel.
Antidiarrheals:
Nursing Implications
24

 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.
 Audience Response System
25

Question #4
Before administering belladonna alkaloids, it is most important for
the nurse to assess the patient for a history of which condition?

A. Anemia
B. Diabetes mellitus
C. Myasthenia gravis
D. Hypertension

NOTE: No input is required to proceed.

 26
Answer to System
Question #4
ANS: C

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.
Antidiarrheals:
Nursing Implications
27

 Use adsorbents carefully in older patients

and those with decreased bleeding time,
clotting disorders, recent bowel surgery, or
confusion.
 Donot administer anticholinergics to
patients with a history of narrow-angle
glaucoma, GI obstruction, myasthenia
gravis, paralytic ileus, or toxic megacolon.
Antidiarrheals:
Nursing Implications (Cont.)
28

 Teachpatients to take medications exactly

as prescribed and to be aware of their fluid
intake and dietary changes.
 Assessfluid volume status, input and
output, and mucous membranes before,
during, and after initiation of treatment.
Antidiarrheals:
Nursing Implications (Cont.)
29

 Teach
patients to notify their prescribers
immediately if symptoms persist.
 Monitor for therapeutic effect.
Audience Response System
Question #5 30

Which antidiarrheal does the nurse associate with the development

of adverse effects of urinary retention, headache, confusion, dry skin,
rash, and blurred vision?

A. Anticholinergics
B. Adsorbents
C. Probiotics
D. Opiates

NOTE: No input is required to proceed.

 31
Answer to System
Question #5
ANS: A

Anticholinergics work by decreasing GI peristalsis through

their parasympathetic blocking effects. Adverse effects
include urinary retention, headache, confusion, dry skin,
rash, and blurred vision.
Constipation 32

 Abnormally infrequent and difficult passage

of feces through the lower GI tract
 Symptom, not a disease
 Disorder of movement through the colon or
rectum
 Can be caused by a variety of diseases
or drugs
Constipation: Treatment 33

 Surgical
 Nonsurgical treatments
 Dietary (e.g., fiber supplementation)
 Behavioral (e.g., increased physical activity)
 Pharmacologic
Laxatives 34

 Bulk forming
 Emollient (stool softeners, lubricant
laxatives)
 Hyperosmotic
 Saline
 Stimulant
Laxatives: Mechanism of Action 35

 Bulk forming
 High fiber
 Absorb water to increase bulk
 Distend bowel to initiate reflex bowel activity
 Examples
 Psyllium (Metamucil)
 Methylcellulose (Citrucel)
Laxatives: Mechanism of Action (Cont.) 36

 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
Laxatives: Mechanism of Action (Cont.) 37

 Hyperosmotic
 Increase fecal water content
 Results
in bowel distention, increased peristalsis,
and evacuation
 Examples
 Polyethylene glycol (PEG)
 Sorbitol, lacitol, glycerin
 Lactulose
(also used to reduce elevated serum
ammonia levels)
Laxatives: Mechanism of Action (Cont.) 38

 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
Laxatives: Mechanism of Action (Cont.) 39

 Stimulant
 Increasesperistalsis via intestinal nerve
stimulation
 Quicker acting but not long term
 Examples
 Senna (Senokot)
 Bisacodyl (Dulcolax)
Peripherally Acting Opioid Antagonists 40

 Only for patients taking opioids

 Block entrance of opioid into bowel
 Strict regulations for use
 Allow bowel to function normally with
continued opioid use
 Methylnaltrexone (Relistor)
 Alvimopan (Entereg)
 Naloxagol (Movantik)
Laxatives: Indications 41

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
Laxatives: Indications (Cont.)42
Laxative group Use
Hyperosmotic Chronic constipation, diagnostic
and surgical preps

Saline Constipation, diagnostic and

surgical preps

Stimulant Acute constipation, diagnostic and

surgical preps
Audience Response System
Question #6 43

A patient is taking 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
 44
Answer to System
Question #6
ANS: C

Lactulose helps to reduce blood ammonia levels by

converting ammonia to ammonium, which can then
be eliminated by the body.
Laxatives: Adverse Effects 45

 Bulk forming
 Impaction
 Fluid disturbances
 Electrolyte imbalances
 Esophageal blockage
 Emollient
 Skin rashes
 Decreased absorption of vitamins
 Electrolyte imbalances
 Lipid pneumonia
Laxatives: Adverse Effects 46

(Cont.)
 Hyperosmotic
 Abdominal bloating
 Electrolyte imbalances
 Rectal irritation
 Saline
 Magnesium toxicity (with renal insufficiency)
 Cramping
 Electrolyte imbalances
 Diarrhea
 Increased thirst
Laxatives: Adverse Effects 47

(Cont.)
 Stimulant
 Nutrient malabsorption
 Skin rashes
 Gastric irritation
 Electrolyte imbalances
 Discolored urine
 Rectal irritation
 All laxatives can cause ALL electrolyte
imbalances!
Laxatives: Nursing Implications 48

 Obtain a thorough history of presenting

symptoms, elimination patterns, and
allergies.
 Assess fluid and electrolytes before
initiating therapy.
 Informpatients not to take a laxative or
cathartic if they are experiencing nausea,
vomiting, or abdominal pain.
Audience Response System
Question #7
49

A hospitalized patient is experiencing diarrhea.

Which of the following does the nurse identify as
adverse side effects of diphenoxylate with
atropine therapy? (Select all that apply.)

A. Increased salivation
B. Abdominal pain
C. Bradycardia
D. Blurred vision

NOTE: No input is required to proceed.

Answer to System Question #7
50

ANS: B, D

When administering diphenoxylate with atropine,

the nurse should assess the patient for adverse
effects, including dry mouth, abdominal pain,
tachycardia, and blurred vision.
Laxatives: Nursing Implications 51

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.
 Alllaxative tablets should be swallowed
whole, not crushed or chewed, especially if
enteric coated.
Laxatives: Nursing Implications (Cont.) 52

 Patients should take all laxative tablets with

6 to 8 oz of water.
 Patientsshould take bulk-forming laxatives
as directed by the manufacturer with at
least
240 mL (8 oz) of water.
Laxatives: Nursing Implications (Cont.) 53

 Givebisacodyl with water because of

interactions with milk, antacids, and juices.
 Inform patients to contact their prescribers
if they experience severe abdominal pain,
muscle weakness, cramps, or dizziness,
which may indicate possible fluid or
electrolyte loss.
 Monitor for therapeutic effect.
Audience Response System
54

Question #8

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.

NOTE: No input is required to proceed.

 55
Answer to System
Question #8
ANS: D

These laxatives are contraindicated in the presence of

undiagnosed abdominal pain because 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.
Irritable Bowel Syndrome 56

 Chronic
intestinal discomfort characterized
by cramps, diarrhea, or constipation
 Patientsusually cope with the symptoms by
avoiding irritating foods or taking OTC
laxatives and antidiarrheal drugs.
Drugs for Irritable Bowel Syndrome 57

 Drugs for IBS-D

 Alosetron (Lotronex)
 Rifaximin (Xifaxan)
 Eluxadoline (Viberzi)
 Drugs for IBS-C
 Lubiprostone (Amitiza)
 Linacotide (Linzess)
Drugs for Irritable Bowel Syndrome:
Nursing Implications
58

 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.