NRSB 321 Module 3 Part 3 Elimination and

NRSB 321 Module 3 Part 3

Elimination and more…. • What individuals are at risk for elimination problems. • How to recognize when an individual has problems with elimination. • Appropriate nursing and collaborative interventions to optimize elimination. • Comparative and contrasting risk factors as well as signs and symptoms for diarrhea, constipation, fecal impaction, and a bowel obstruction. • The appropriate nursing and collaborative interventions for diarrhea, constipation, fecal impaction, and a bowel obstruction. • Beginning concepts of Type II Diabetes.

Crossword Puzzle: • Please work on crossword puzzle with the person beside you.

Diarrhea • Abnormal passage of stools with increased frequency, fluidity, and weight, or with

Diarrhea (cont’d) Acute diarrhea • Sudden onset in a previously healthy person • Lasts from 3 days to 2 weeks • Self-limiting • Resolves without sequelae Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 5

Diarrhea (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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 6

Causes of Diarrhea Acute Diarrhea Bacteria Viruses Drug-induced Nutritional factors Protozoa Chronic Diarrhea Tumors Diabetes mellitus Addison’s disease Hyperthyroidism Irritable bowel syndrome AIDS Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 7

Goals of Diarrhea Treatment • • Stopping the stool frequency Alleviating the abdominal cramps Replenishing fluids and electrolytes Preventing weight loss and nutritional deficits from malabsorption Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 8

Antidiarrheals • Adsorbents • Antimotility drugs (anticholinergics and opiates) • Probiotics (bacterial replacement drugs)

Antidiarrheals: Mechanism 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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 10

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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 11

Antidiarrheals: Mechanism of Action (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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 12

Antidiarrheals: Mechanism of Action (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) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 13

Antidiarrheals: Adverse Effects Adsorbents • Increased bleeding time • Constipation, dark stools • Confusion • Tinnitus • Metallic taste • Blue tongue Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 14

Antidiarrheals: Adverse Effects (cont’d) Anticholinergics • Urinary retention, impotence • Headache, dizziness, confusion, anxiety, drowsiness, confusion • Dry skin, flushing • Blurred vision • Hypotension, bradycardia Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 15

Antidiarrheals: Adverse Effects (cont’d) Opiates • Drowsiness, dizziness, lethargy • Nausea, vomiting, constipation • Respiratory depression • Hypotension • Urinary retention • Flushing Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 16

Antidiarrheals: 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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 17

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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 18

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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 19

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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 20

Antidiarrheals: Nursing Implications (cont’d) • Teach patients to notify their prescriber immediately if symptoms persist • Monitor for therapeutic effect Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 21

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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 22

Laxatives • • • Bulk-forming Emollient (stool softeners, lubricant laxatives) Hyperosmotic Saline Stimulant Peripherally

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) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 24

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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 25

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) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 26

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) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 27

Laxatives: Mechanism of Action (cont’d) Stimulant • Increases peristalsis via intestinal nerve stimulation • Examples – senna (Senekot) – bisacodyl (Dulcolax) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 28

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) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 29

Laxatives: Indications Laxative Group Bulk-forming Emollient Use Acute and chronic constipation, irritable bowel syndrome, diverticulosis Acute and chronic constipation, fecal impaction, facilitation of bowel movements in anorectal conditions Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 30

Laxatives: Indications (cont’d) Laxative Group Hyperosmotic Saline Stimulant Use Chronic constipation, diagnostic and surgical preps Constipation, diagnostic and surgical preps Acute constipation, diagnostic and surgical preps Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 31

Laxatives: Adverse Effects • Bulk-forming – – • Impaction Fluid overload Electrolyte imbalances Esophageal blockage Emollient – – Skin rashes Decreased absorption of vitamins Electrolyte imbalances Lipid pneumonia Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 32

Laxatives: Adverse Effects (cont’d) • Hyperosmotic – Abdominal bloating – Electrolyte imbalances – Rectal irritation • Saline – – – Magnesium toxicity (with renal insufficiency) Cramping Electrolyte imbalances Diarrhea Increased thirst Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 33

Laxatives: Adverse Effects (cont’d) • Stimulant – – – Nutrient malabsorption Skin rashes Gastric irritation Electrolyte imbalances Discolored urine Rectal irritation • All laxatives can cause electrolyte imbalances! Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 34

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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 35

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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 36

Laxatives: Nursing Implications (cont’d) • 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 m. L (8 oz) of water Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 37

Laxatives: Nursing Implications (cont’d) • 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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 38

Discuss: A. B. C. D. Population at risk for bowel elimination problems? Are there any individual risks factors? What can bowel incontinence cause? What can bowel retention cause?

In your learning group, discuss how the following risk factors are linked to elimination problems: • • • Age (older adults) Neurologic impairment Altered mobility Cognitive impairment Congenital defects Medical conditions, such as stroke, spinal cord injury, brain injury