{"id":324,"date":"2019-11-04T23:42:17","date_gmt":"2019-11-04T23:42:17","guid":{"rendered":"https:\/\/pressbooks.publishdot.com\/nursingpharmacology\/chapter\/7-3-anti-ulcer\/"},"modified":"2021-12-07T11:21:07","modified_gmt":"2021-12-07T11:21:07","slug":"7-3-anti-ulcer","status":"publish","type":"chapter","link":"https:\/\/pressbooks.publishdot.com\/nursingpharmacology\/chapter\/7-3-anti-ulcer\/","title":{"raw":"7.3 Anti-Ulcer Medications","rendered":"7.3 Anti-Ulcer Medications"},"content":{"raw":"
\n

Pathophysiology<\/h2>\nThe stomach contains cells that secrete different substances as part of the digestive process: parietal cells, chief cells, and surface epithelium cells. See an image of the stomach and these cells in Figure 7.2.[footnote]\"2415 Histology of StomachN.jpg<\/a>\" by CNX OpenStax<\/a> is licensed under CC BY 3.0<\/a> Access for free at https:\/\/cnx.org\/contents\/FPtK1zmh@16.7:O9dvCxUQ@8\/23-4-The-Stomach<\/a>[\/footnote]<\/sup>\n\n[caption id=\"\" align=\"alignnone\" width=\"1214\"]\"Illustration Figure 7.2 An image of the stomach with surface epithelium cells in the mucosa, and an enlarged image of the gastric gland showing chief cells and parietal cells[\/caption]\n\n[pb_glossary id=\"1254\"]Surface epithelium cells[\/pb_glossary]<\/strong> are found within the lining of the stomach and secrete mucus as a protective coating. Parietal cells and chief cells are found within the gastric glands. [pb_glossary id=\"1255\"]Parietal cells[\/pb_glossary]<\/strong> produce and secrete hydrochloric acid (HCl) to maintain the acidity of the environment of a pH of 1 to 4. Parietal cells also secrete a substance called [pb_glossary id=\"2280\"]intrinsic factor[\/pb_glossary]<\/strong>, which is necessary for the absorption of vitamin B12 in the small intestine. Parietal cells are the primary site of action for many drugs that treat acid-related disorders. Chief cells secrete pepsinogen that becomes [pb_glossary id=\"1257\"]pepsin[\/pb_glossary]<\/strong>, a digestive enzyme, when exposed to acid. The stomach also contains enteroendocrine cells (ECL or enterochromaffin-like cells) located in the gastric glands that secrete substances including serotonin, histamine, and somatostatin. G cells in the stomach secrete gastrin that promotes secretions of digestive substances. Although these cells play an important role in the digestive system, acid-related diseases can occur when there is an imbalance of secretions. The most common mild to moderate hyperacidic condition is [pb_glossary id=\"1258\"]gastroesophageal reflux disease (GERD)[\/pb_glossary]<\/strong>, often referred to by patients as heartburn, indigestion, or sour stomach. GERD is caused by excessive hydrochloric acid that tends to back up, or reflux, into the lower esophagus. See Figure 7.3 for an illustration of GERD.[footnote]\"GERD.png<\/a>\" by BruceBlaus<\/a> is licensed under CC BY-SA 4.0<\/a>[\/footnote]<\/sup>\n\n[caption id=\"\" align=\"aligncenter\" width=\"504\"]\"Illustration Figure 7.3 Illustration of GERD[\/caption]\n\n[pb_glossary id=\"1259\"]Peptic ulcer disease (PUD)[\/pb_glossary]<\/strong> occurs when gastric or duodenal ulcers are caused by the breakdown of GI mucosa by pepsin, in combination with the caustic effects of hydrochloric acid. PUD is the most harmful disease related to hyperacidity because it can result in bleeding ulcers, a life-threatening condition.\n\n[pb_glossary id=\"1260\"]Stress-related mucosal damage [\/pb_glossary]<\/strong> is another common condition that can occur in hospitalized patients leading to PUD. Thus, many post-operative or critically ill patients receive medication to prevent the formation of a stress ulcer, which is also called [pb_glossary id=\"2302\"]prophylaxis[\/pb_glossary]<\/strong>.[footnote]Lilley, L., Collins, S., & Snyder, J. (2014). Pharmacology and the Nursing Process<\/em>. pp. 782-862. Elsevier.[\/footnote]<\/sup> See an image of a duodenal ulcer in Figure 7.4.[footnote]\"\"Duodenal ulcer01.jpg<\/a>\" by melvil<\/a> is licensed under CC BY-SA 4.0<\/a>[\/footnote]<\/sup>\n\n[caption id=\"\" align=\"aligncenter\" width=\"360\"]\"Photo Figure 7.4 Image of a duodenal ulcer[\/caption]\n\nLinks to supplementary videos illustrating heartburn and gastric ulcers: <\/span>\n\nHeartburn<\/a>[footnote]MedlinePlus. Bethesda (MD): National Library of Medicine (US); [updated 2019 October 23]. Heartburn; [updated 2019 October 2; cited 2019 October 27] https:\/\/medlineplus.gov\/ency\/anatomyvideos\/000068.htm<\/a>[\/footnote]<\/sup>\n\nGastric ulcer<\/a>[footnote]Blausen Medical. (2015, November 17). Gastric Ulcers<\/em> [Video].https:\/\/blausen.com\/en\/video\/gastric-ulcers\/#<\/a>[\/footnote]<\/sup>\n

Overall Nursing Considerations for Hyperacidity Medications<\/h2>\nAssessments:<\/strong> Whenever a nurse administers hyperacidity medications, there are common assessments that should be documented, such as an abdominal assessment and documentation of bowel patterns. During therapy, the nurse should continue to assess for potential medication interactions and side effects and be aware that vitamin B12 malabsorption may occur whenever stomach acidity levels are altered. Based on the category of medication, renal and liver function may require monitoring. Additionally, if a patient complains of chest pain, the nurse should perform a complete focused cardiac assessment and not assume it is GI-related because patients may erroneously attribute many cardiac conditions to \u201cheartburn.\u201d\n\nImplementation:<\/strong> The nurse should read the drug label information and follow the recommendations for administering hyperacidity medications with other medications or the intake of food. Cultural preferences should also be accommodated when safe and feasible because the patient may believe in alternative methods for treating GI discomfort. A written plan of care with modifications for safe use of medications with these alternative methods may be required.\n\nEvaluation:<\/strong> Patients should experience improvement of symptoms within the defined time period; if not, the provider should be notified. Increased pain or new symptoms of coughing\/vomiting of blood should be immediately reported because these symptoms can be signs of a life-threatening bleeding ulcer.\n

Hyperacidity Medication Classes<\/h2>\nThere are four major classes of medications used to treat hyperacidity conditions: antacids, H2-receptor antagonists, proton pump inhibitors, and mucosal protectants. Each class of medication is further described below.\n

Antacids<\/h3>\nAntacids (see Figure 7.5[footnote]\"Antacid-L478.jpg<\/a>\" by Midnightcomm is licensed under CC BY-SA 3.0<\/a>[\/footnote]<\/sup>) are used to neutralize stomach acid and reduce the symptoms of heartburn. There are many OTC medications available for this purpose, such as calcium carbonate, aluminum hydroxide, and magnesium hydroxide. Calcium carbonate is the prototype discussed as an example. Be sure to read drug label information regarding antacids as you administer them because each type has its own specific side effects. Many antacids also contain simethicone, an antiflatulent used for gas relief. Simethicone is further described in the medication grid below.\n\n\"Photo\n

Figure 7.5 Antacids<\/em><\/p>\n

Indications<\/strong><\/p>\nAntacids are used to relieve heartburn, acid indigestion, and upset stomach.\n\nMechanism of Action<\/strong>\n\nAntacids neutralize gastric acidity and elevate the pH of the stomach. Elevated pH also inactivates pepsin, a digestive enzyme.\n\nSpecific Administration Considerations<\/strong>\n\nCalcium carbonate comes in various formations such as a tablet, a chewable tablet, a capsule, or liquid to take by mouth. It is usually taken three or four times a day. Chewable tablets should be chewed thoroughly before being swallowed; do not swallow them whole. The patient should drink a full glass of water after taking either the regular or chewable tablets or capsules. Some liquid forms of calcium carbonate must be shaken well before use. Do not administer calcium carbonate within 1-2 hours of other medicines because calcium may decrease the effectiveness of the other medicine. Calcium carbonate may be contraindicated in patients with preexisting kidney disease because it may cause [pb_glossary id=\"1262\"]hypercalcemia[\/pb_glossary]<\/strong>. Common side effects of calcium carbonate include constipation and [pb_glossary id=\"1263\"]rebound hyperacidity [\/pb_glossary]<\/strong> when it is discontinued.[footnote]A.D.A.M. Medical Encyclopedia [Internet]. Atlanta (GA): A.D.A.M., Inc.; \u00a92019. Heartburn; [reviewed 2019 May 10; cited 2019 October 27]. https:\/\/medlineplus.gov\/ency\/anatomyvideos\/000068.htm<\/a>[\/footnote]<\/sup>\n\nPatient Teaching & Education<\/strong>\n\nIn addition to the information under \"Specific Administration Considerations,\" patients should be reminded to take OTC meds appropriately as prescribed and to not exceed the maximum dose. Other interventions to prevent hyperacidity can also be recommended, such as smoking cessation and avoiding food and beverages that can cause increased acidity (alcohol, high-fat or spicy foods, and caffeine). [footnote]Lilley, L., Collins, S., & Snyder, J. (2014). Pharmacology and the Nursing Process. pp. 782-862. Elsevier<\/em>.[\/footnote],[footnote]McCuistion, L., Vuljoin-DiMaggio, K., Winton, M, & Yeager, J. (2018). Pharmacology: A patient-centered nursing process approach<\/em>. pp. 443-454. Elsevier.[\/footnote],<\/sup>[footnote]This work is a derivative of Daily Med<\/a> by U.S. National Library of Medicine<\/a> in the public domain<\/a>. [\/footnote],[footnote]A.D.A.M. Medical Encyclopedia [Internet]. Atlanta (GA): A.D.A.M., Inc.; \u00a92019. Heartburn; [reviewed 2019 May 10; cited 2019 October 27]. https:\/\/medlineplus.gov\/ency\/anatomyvideos\/000068.htm<\/a>[\/footnote]<\/sup>\n

H2-Receptor Antagonist<\/h3>\nA common H2-receptor antagonist is famotidine. It is available OTC and is also often prescribed orally or as an IV injection in the hospital setting. Other H2-receptor antagonists include cimetidine and ranitidine. Cimetidine has a high risk of drug interactions, especially in elderly patients because of its binding to [pb_glossary id=\"1266\"]cytochrome P-450 enzymes[\/pb_glossary]<\/strong> in the liver, which affects the metabolism of other drugs.\n\n[caption id=\"\" align=\"aligncenter\" width=\"377\"]\"Photo Figure 7.6 OTC Famotidine[\/caption]\n\nIndications<\/strong>\n\nFamotidine (see Figure 7.6[footnote]\"My Still LIfe<\/a>\" by Bast Productions<\/a> is licensed under CC BY-NC-ND 2.0<\/a>[\/footnote]<\/sup>) is used to treat GERD, peptic ulcer disease, erosive esophagitis, and hypersecretory conditions, or as adjunct treatment for the control of upper GI bleeding. OTC famotidine is also used to treat heartburn or sour stomach.\n\nMechanism of Action<\/strong>\n\nH2-receptor antagonists block histamine\u2019s action at the H2 receptor of the parietal cell, thus reducing the production of hydrochloric acid.\n\nSpecific Administration Considerations<\/strong>\n\nTo prevent symptoms, oral famotidine is taken 15 to 60 minutes before eating foods or drinking drinks that may cause heartburn. Preexisting liver and kidney disease may require dosage adjustment. Famotidine is supported by evidence as safe for use in pediatric patients younger than 1 year old, as well as in geriatric patients.\n\nPatient Teaching & Education<\/strong>\n\nPatients taking the oral suspension should be instructed to shake it vigorously for 5 to 10 seconds prior to each use. [footnote]Lilley, L., Collins, S., Snyder, J. (2014). Pharmacology and the Nursing Process<\/em>. pp. 782-862. Elsevier.[\/footnote],[footnote]McCuistion, L., Vuljoin-DiMaggio, K., Winton, M, & Yeager, J. (2018). Pharmacology: A patient-centered nursing process approach<\/em>. pp. 443-454. Elsevier.[\/footnote] <\/sup>The medication may cause constipation so fluids and high-fiber diet should be encouraged.\u00a0 Additionally, smoking interferes with histamine antagonists and should be discouraged.[footnote]This work is a derivative of Daily Med<\/a> by U.S. National Library of Medicine<\/a> in the public domain<\/a>. [\/footnote],<\/sup>[footnote]A.D.A.M. Medical Encyclopedia [Internet]. Atlanta (GA): A.D.A.M., Inc.; \u00a92019. Heartburn; [reviewed 2019 May 10; cited 2019 October 27]. https:\/\/medlineplus.gov\/ency\/anatomyvideos\/000068.htm<\/a>[\/footnote]<\/sup>\n

Proton Pump Inhibitors<\/h3>\nA common proton pump inhibitor (PPI) is pantoprazole (see Figure 7.7[footnote]\"Prilosec Box 001<\/a>\" by cygnus921<\/a> is licensed under CC BY 2.0<\/a>[\/footnote]<\/sup>). It may be prescribed in various routes including orally, with an NG tube, or as an IV injection in the hospital setting. Other PPIs include esomeprazole, lansoprazole, and omeprazole. PPIs are more powerful than antacids and H2-receptor antagonists.\n\n\"Photo\n

Figure 7.7 OTC Omeprazole<\/em><\/p>\nIndications<\/strong>\n\nPantoprazole is used to treat damage from gastroesophageal reflux disease (GERD) in adults and children five years of age and older by allowing the esophagus to heal and prevent further damage. It is also used to treat conditions where the stomach produces too much acid, such as Zollinger-Ellison syndrome in adults. PPIs may also be given in combination with antibiotics to treat H.Pylori<\/em> infections, a common cause of duodenal ulcers.\n\nMechanism of Action<\/strong>\n\nPPIs bind to the hydrogen-potassium ATPase enzyme system of the parietal cell, also referred to as the \u201cproton pump\u201d because it pumps hydrogen ions into the stomach. PPIs inhibit the secretion of hydrochloric acid, and the antisecretory effect lasts longer than 24 hours.\n\nSpecific Administration Considerations<\/strong>\n\nPackets of delayed-release granules must be mixed with applesauce or apple juice and taken by mouth or given through a feeding tube. Consult the labeling of concomitantly used drugs to obtain further information about interactions because PPIs can interfere with the liver metabolism of other drugs.\u00a0 IV pantoprazole can potentially exacerbate zinc deficiency, and long-term therapy can cause hypomagnesemia, so the nurse should monitor for these deficiencies.\n\nPatient Teaching & Education<\/strong>\n\nIn addition to the considerations above, instruct patients to call their provider if their condition does not improve or gets worse, especially if bleeding occurs.[footnote]Lilley, L., Collins, S., Snyder, J. (2014). Pharmacology and the Nursing Process.<\/em> pp. 782-862. Elsevier.[\/footnote],[footnote]McCuistion, L., Vuljoin-DiMaggio, K., Winton, M, Yeager, J. (2018). Pharmacology: A patient-centered nursing process approach.<\/em> pp. 443-454. Elsevier.[\/footnote]<\/sup>\u00a0 Use of alcohol, NSAIDS, or foods that cause GI irritation should be discouraged.[footnote]This work is a derivative of Daily Med<\/a> by U.S. National Library of Medicine<\/a> in the public domain<\/a>. [\/footnote],[footnote]A.D.A.M. Medical Encyclopedia [Internet]. Atlanta (GA): A.D.A.M., Inc.; \u00a92019. Heartburn; [reviewed 2019 May 10; cited 2019 October 27; https:\/\/medlineplus.gov\/ency\/anatomyvideos\/000068.htm<\/a>[\/footnote]<\/sup>\n

Mucosal Protectants<\/h3>\nSucralfate is a mucosal protectant used to cover and protect gastrointestinal ulcers.\n\nIndications<\/strong>\n\nSucralfate is used in the treatment of ulcers.\n\nMechanism of Action<\/strong>\n\nSucralfate locally covers the ulcer site in the GI tract and protects it against further attack by acid, pepsin, and bile salts. It is minimally absorbed by the gastrointestinal tract.\n\nSpecific Administration Considerations<\/strong>\n\nAdminister sucralfate on an empty stomach, 2 hours after or 1 hour before meals. Constipation may occur. Sucralfate should be cautiously used with patients with chronic renal failure or those receiving dialysis due to impaired excretion of small amounts of absorbed aluminum that can occur with sucralfate.\n\nPatient Teaching & Education<\/strong>\n\nIn addition to the considerations above, instruct patients to call their provider if their condition does not improve or gets worse. [footnote]Lilley, L., Collins, S., Snyder, J. (2014). Pharmacology and the Nursing Process.<\/em> pp. 782-862. Elsevier.[\/footnote],[footnote]McCuistion, L., Vuljoin-DiMaggio, K., Winton, M, & Yeager, J. (2018). Pharmacology: A Patient-Centered Nursing Process Approach.<\/em> p.188-194 and 604-633. Elsevier.[\/footnote],[footnote]This work is a derivative of Daily Med<\/a> by U.S. National Library of Medicine<\/a> in the public domain<\/a>. [\/footnote],[footnote]A.D.A.M. Medical Encyclopedia [Internet]. Atlanta (GA): A.D.A.M., Inc.; \u00a92019. Heartburn; [reviewed 2019 May 10; cited 2019 October 27]. https:\/\/medlineplus.gov\/ency\/anatomyvideos\/000068.htm<\/a>[\/footnote]<\/sup>\n

Antiflatulent<\/h3>\nSimethicone is an antiflatulent that is commonly found in other OTC antacids (see Figure 7.8[footnote]\"Gelusil Antacid and Anti-Gas<\/a>\" by Wellspring Pharmaceutical<\/a> is licensed under CC BY 2.0<\/a>[\/footnote]<\/sup>).\u00a0 It is also safe for use in infants. Gas commonly occurs in the GI tract due to digestive processes and the swallowing of air. Gaseous distension can also occur postoperatively.\n\n[caption id=\"\" align=\"aligncenter\" width=\"382\"]\"Photo Figure 7.8 OTC Simethicone[\/caption]\n\nIndications<\/strong>\n\nSimethicone is used to treat the symptoms of gas such as uncomfortable or painful pressure, fullness, and bloating.\n\nMechanism of Action<\/strong>\n\nSimethicone works by altering the elasticity of the mucous-coated gas bubbles, which cause them to break into smaller bubbles, thus reducing pain and facilitating expulsion.\n\nSpecific Administration Considerations<\/strong>\n\nSimethicone is usually taken four times a day, after meals and at bedtime. For liquid form, shake drops before administering.\n\nPatient Teaching & Education<\/strong>\n\nPatients can be instructed about other measures to assist with gas expulsion such as changing position, ambulation, avoiding the use of straws, and tapering intake of beans and cruciferous vegetables. [footnote]Lilley, L., Collins, S., Snyder, J. (2014). Pharmacology and the Nursing Process.<\/em> pp. 782-862. Elsevier.[\/footnote],[footnote]McCuistion, L., Vuljoin-DiMaggio, K., Winton, M, & Yeager, J. (2018). Pharmacology: A patient-centered nursing process approach.<\/em> pp. 443-454. Elsevier.[\/footnote],[footnote]This work is a derivative of Daily Med<\/a> by U.S. National Library of Medicine<\/a> in the public domain<\/a>. [\/footnote],[footnote]A.D.A.M. Medical Encyclopedia [Internet]. Atlanta (GA): A.D.A.M., Inc.; \u00a92019. Heartburn; [reviewed 2019 May 10; cited 2019 October 27]. https:\/\/medlineplus.gov\/ency\/anatomyvideos\/000068.htm<\/a>[\/footnote]<\/sup>\n
\n

\u00a0Interactive Activity<\/h3>\n[h5p id=\"22\"]\n\n<\/div>\n<\/div>\nNow let\u2019s take a closer look at the medication grids comparing medications used to treat hyperacidity in Table 7.3.[footnote]Lilley, L., Collins, S., & Snyder, J. (2014).\u00a0Pharmacology and the Nursing Process.<\/em>\u00a0pp. 782-862. Elsevier.[\/footnote],[footnote]McCuistion, L., Vuljoin-DiMaggio, K., Winton, M, & Yeager, J. (2018).\u00a0Pharmacology: A patient-centered nursing process approach.<\/em>\u00a0pp. 443-454. Elsevier.[\/footnote]<\/span>,[footnote]This work is a derivative of Daily Med<\/a> by U.S. National Library of Medicine<\/a> in the public domain<\/a>. [\/footnote], [footnote]A.D.A.M. Medical Encyclopedia [Internet]. Atlanta (GA): A.D.A.M., Inc.; \u00a92019. Heartburn; [reviewed 2019 May 10; cited 2019 October 27].\u00a0https:\/\/medlineplus.gov\/ency\/anatomyvideos\/000068.htm<\/a>[\/footnote]<\/sup>\n\nMedication grids are intended to assist students to learn key points about each medication.\u00a0 Because information about medication is constantly changing, nurses should always consult evidence-based resources to review current recommendations before administering specific medication. Basic information related to each class of medication is outlined below.\u00a0 Detailed information on a specific medication can be found for free at Daily Med<\/a>. On the home page, enter the drug name in the search bar to read more about the medication.\u00a0 Prototype\/generic medications listed in the grids below are also hyperlinked directly to a Daily Med page.\n\n \n
\n\nTable 7.3 Medication Grid Comparing Hyperacidity Medications\n\n\n\n\n\n\n\n\n
\n
Class<\/strong><\/h5>\n<\/th>\n
\n
Prototype<\/strong><\/h5>\n<\/th>\n
\n
Administration <\/strong>Considerations<\/strong><\/h5>\n<\/th>\n
\n
Therapeutic Effects<\/strong><\/h5>\n<\/th>\n
\n
Adverse\/Side Effects<\/strong><\/h5>\n<\/th>\n<\/tr>\n
Antacid<\/th>\ncalcium carbonate<\/a><\/td>\nDo not administer within 1-2 hours of other medications\n\nDrink a full glass of water after administration\n\nUse cautiously with renal disease<\/td>\nDecreased symptoms of heartburn or sour stomach<\/td>\nConstipation\n\nHypercalcemia\n\nRebound hyperacidity when discontinued<\/td>\n<\/tr>\n
H2 blocker<\/th>\nfamotidine<\/a><\/td>\nAdminister 15 to 60 minutes before eating foods or drinking drinks that may cause heartburn\n\nPreexisting liver and kidney disease may require dosage adjustment<\/td>\nDecreased symptoms of heartburn or sour stomach\n\nDecreased pain if ulcers are present<\/td>\nSide effects: headache, dizziness, constipation, and diarrhea\n\nImmediately report increased pain or other signs of bleeding ulcers such as coughing\/vomiting of blood<\/td>\n<\/tr>\n
Proton Pump Inhibitor<\/th>\npantoprazole<\/a><\/td>\nDelayed release can be taken with or without food\n\nAdminister granules with apple juice or applesauce<\/td>\nDecreased symptoms of heartburn and pain<\/td>\nHypersensitivity; anaphylaxis and serious skin reactions\n\nPotential zinc, magnesium, or B12 deficiency\n\nHeadache, abdominal pain, diarrhea, constipation\n\nAcute renal dysfunction\n\nOsteoporosis-related bone fracture\n\nAcute lupus erythematosus\n\nImmediately report increased pain or other signs of bleeding ulcers such as coughing\/vomiting of blood<\/td>\n<\/tr>\n
Mucosal protectants<\/th>\nsucralfate<\/a><\/td>\nAdminister sucralfate on an empty stomach, 2 hours after or 1 hour before meals\n\nUse cautiously used patients with chronic renal failure<\/td>\nHealing of ulcer<\/td>\nConstipation<\/td>\n<\/tr>\n
Antiflatulant<\/th>\nsimethicone<\/a><\/td>\nShake drops before administering<\/td>\nRelief of gas discomfort<\/td>\nNone<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n \n\n<\/div>\n
\n
\n

Critical Thinking Activity 7.3\n\"Image<\/h2>\n<\/header>\n
\n\nA patient who recently underwent surgery has a medication order for daily pantoprazole. The nurse reviews the patient\u2019s medical history and finds no history of GERD or peptic ulcer disease. The patient does not report any symptoms of heartburn, stomach pain, or sour stomach. The nurse reviews the physician orders for an indication for this medication before calling the provider to clarify.\n\nWhat is the likely indication for this drug therapy for this patient?\n\nNote: Answers to the Critical Thinking activities can be found in the \"Answer Key\" sections at the end of the book.\n\n<\/div>\n<\/div>\n<\/div>","rendered":"
\n

Pathophysiology<\/h2>\n

The stomach contains cells that secrete different substances as part of the digestive process: parietal cells, chief cells, and surface epithelium cells. See an image of the stomach and these cells in Figure 7.2.[1]<\/sup><\/a><\/sup><\/p>\n

\"Illustration
Figure 7.2 An image of the stomach with surface epithelium cells in the mucosa, and an enlarged image of the gastric gland showing chief cells and parietal cells<\/figcaption><\/figure>\n

Surface epithelium cells<\/strong> are found within the lining of the stomach and secrete mucus as a protective coating. Parietal cells and chief cells are found within the gastric glands. Parietal cells<\/strong> produce and secrete hydrochloric acid (HCl) to maintain the acidity of the environment of a pH of 1 to 4. Parietal cells also secrete a substance called intrinsic factor<\/strong>, which is necessary for the absorption of vitamin B12 in the small intestine. Parietal cells are the primary site of action for many drugs that treat acid-related disorders. Chief cells secrete pepsinogen that becomes pepsin<\/strong>, a digestive enzyme, when exposed to acid. The stomach also contains enteroendocrine cells (ECL or enterochromaffin-like cells) located in the gastric glands that secrete substances including serotonin, histamine, and somatostatin. G cells in the stomach secrete gastrin that promotes secretions of digestive substances. Although these cells play an important role in the digestive system, acid-related diseases can occur when there is an imbalance of secretions. The most common mild to moderate hyperacidic condition is gastroesophageal reflux disease (GERD)<\/strong>, often referred to by patients as heartburn, indigestion, or sour stomach. GERD is caused by excessive hydrochloric acid that tends to back up, or reflux, into the lower esophagus. See Figure 7.3 for an illustration of GERD.[2]<\/sup><\/a><\/sup><\/p>\n

\"Illustration
Figure 7.3 Illustration of GERD<\/figcaption><\/figure>\n

Peptic ulcer disease (PUD)<\/strong> occurs when gastric or duodenal ulcers are caused by the breakdown of GI mucosa by pepsin, in combination with the caustic effects of hydrochloric acid. PUD is the most harmful disease related to hyperacidity because it can result in bleeding ulcers, a life-threatening condition.<\/p>\n

Stress-related mucosal damage <\/strong> is another common condition that can occur in hospitalized patients leading to PUD. Thus, many post-operative or critically ill patients receive medication to prevent the formation of a stress ulcer, which is also called prophylaxis<\/strong>.[3]<\/sup><\/a><\/sup> See an image of a duodenal ulcer in Figure 7.4.[4]<\/sup><\/a><\/sup><\/p>\n

\"Photo
Figure 7.4 Image of a duodenal ulcer<\/figcaption><\/figure>\n

Links to supplementary videos illustrating heartburn and gastric ulcers: <\/span><\/p>\n

Heartburn<\/a>[5]<\/sup><\/a><\/sup><\/p>\n

Gastric ulcer<\/a>[6]<\/sup><\/a><\/sup><\/p>\n

Overall Nursing Considerations for Hyperacidity Medications<\/h2>\n

Assessments:<\/strong> Whenever a nurse administers hyperacidity medications, there are common assessments that should be documented, such as an abdominal assessment and documentation of bowel patterns. During therapy, the nurse should continue to assess for potential medication interactions and side effects and be aware that vitamin B12 malabsorption may occur whenever stomach acidity levels are altered. Based on the category of medication, renal and liver function may require monitoring. Additionally, if a patient complains of chest pain, the nurse should perform a complete focused cardiac assessment and not assume it is GI-related because patients may erroneously attribute many cardiac conditions to \u201cheartburn.\u201d<\/p>\n

Implementation:<\/strong> The nurse should read the drug label information and follow the recommendations for administering hyperacidity medications with other medications or the intake of food. Cultural preferences should also be accommodated when safe and feasible because the patient may believe in alternative methods for treating GI discomfort. A written plan of care with modifications for safe use of medications with these alternative methods may be required.<\/p>\n

Evaluation:<\/strong> Patients should experience improvement of symptoms within the defined time period; if not, the provider should be notified. Increased pain or new symptoms of coughing\/vomiting of blood should be immediately reported because these symptoms can be signs of a life-threatening bleeding ulcer.<\/p>\n

Hyperacidity Medication Classes<\/h2>\n

There are four major classes of medications used to treat hyperacidity conditions: antacids, H2-receptor antagonists, proton pump inhibitors, and mucosal protectants. Each class of medication is further described below.<\/p>\n

Antacids<\/h3>\n

Antacids (see Figure 7.5[7]<\/sup><\/a><\/sup>) are used to neutralize stomach acid and reduce the symptoms of heartburn. There are many OTC medications available for this purpose, such as calcium carbonate, aluminum hydroxide, and magnesium hydroxide. Calcium carbonate is the prototype discussed as an example. Be sure to read drug label information regarding antacids as you administer them because each type has its own specific side effects. Many antacids also contain simethicone, an antiflatulent used for gas relief. Simethicone is further described in the medication grid below.<\/p>\n

\"Photo<\/p>\n

Figure 7.5 Antacids<\/em><\/p>\n

Indications<\/strong><\/p>\n

Antacids are used to relieve heartburn, acid indigestion, and upset stomach.<\/p>\n

Mechanism of Action<\/strong><\/p>\n

Antacids neutralize gastric acidity and elevate the pH of the stomach. Elevated pH also inactivates pepsin, a digestive enzyme.<\/p>\n

Specific Administration Considerations<\/strong><\/p>\n

Calcium carbonate comes in various formations such as a tablet, a chewable tablet, a capsule, or liquid to take by mouth. It is usually taken three or four times a day. Chewable tablets should be chewed thoroughly before being swallowed; do not swallow them whole. The patient should drink a full glass of water after taking either the regular or chewable tablets or capsules. Some liquid forms of calcium carbonate must be shaken well before use. Do not administer calcium carbonate within 1-2 hours of other medicines because calcium may decrease the effectiveness of the other medicine. Calcium carbonate may be contraindicated in patients with preexisting kidney disease because it may cause hypercalcemia<\/strong>. Common side effects of calcium carbonate include constipation and rebound hyperacidity <\/strong> when it is discontinued.[8]<\/sup><\/a><\/sup><\/p>\n

Patient Teaching & Education<\/strong><\/p>\n

In addition to the information under “Specific Administration Considerations,” patients should be reminded to take OTC meds appropriately as prescribed and to not exceed the maximum dose. Other interventions to prevent hyperacidity can also be recommended, such as smoking cessation and avoiding food and beverages that can cause increased acidity (alcohol, high-fat or spicy foods, and caffeine). [9]<\/sup><\/a>,[10]<\/sup><\/a>,<\/sup>[11]<\/sup><\/a>,[12]<\/sup><\/a><\/sup><\/p>\n

H2-Receptor Antagonist<\/h3>\n

A common H2-receptor antagonist is famotidine. It is available OTC and is also often prescribed orally or as an IV injection in the hospital setting. Other H2-receptor antagonists include cimetidine and ranitidine. Cimetidine has a high risk of drug interactions, especially in elderly patients because of its binding to cytochrome P-450 enzymes<\/strong> in the liver, which affects the metabolism of other drugs.<\/p>\n

\"Photo
Figure 7.6 OTC Famotidine<\/figcaption><\/figure>\n

Indications<\/strong><\/p>\n

Famotidine (see Figure 7.6[13]<\/sup><\/a><\/sup>) is used to treat GERD, peptic ulcer disease, erosive esophagitis, and hypersecretory conditions, or as adjunct treatment for the control of upper GI bleeding. OTC famotidine is also used to treat heartburn or sour stomach.<\/p>\n

Mechanism of Action<\/strong><\/p>\n

H2-receptor antagonists block histamine\u2019s action at the H2 receptor of the parietal cell, thus reducing the production of hydrochloric acid.<\/p>\n

Specific Administration Considerations<\/strong><\/p>\n

To prevent symptoms, oral famotidine is taken 15 to 60 minutes before eating foods or drinking drinks that may cause heartburn. Preexisting liver and kidney disease may require dosage adjustment. Famotidine is supported by evidence as safe for use in pediatric patients younger than 1 year old, as well as in geriatric patients.<\/p>\n

Patient Teaching & Education<\/strong><\/p>\n

Patients taking the oral suspension should be instructed to shake it vigorously for 5 to 10 seconds prior to each use. [14]<\/sup><\/a>,[15]<\/sup><\/a> <\/sup>The medication may cause constipation so fluids and high-fiber diet should be encouraged.\u00a0 Additionally, smoking interferes with histamine antagonists and should be discouraged.[16]<\/sup><\/a>,<\/sup>[17]<\/sup><\/a><\/sup><\/p>\n

Proton Pump Inhibitors<\/h3>\n

A common proton pump inhibitor (PPI) is pantoprazole (see Figure 7.7[18]<\/sup><\/a><\/sup>). It may be prescribed in various routes including orally, with an NG tube, or as an IV injection in the hospital setting. Other PPIs include esomeprazole, lansoprazole, and omeprazole. PPIs are more powerful than antacids and H2-receptor antagonists.<\/p>\n

\"Photo<\/p>\n

Figure 7.7 OTC Omeprazole<\/em><\/p>\n

Indications<\/strong><\/p>\n

Pantoprazole is used to treat damage from gastroesophageal reflux disease (GERD) in adults and children five years of age and older by allowing the esophagus to heal and prevent further damage. It is also used to treat conditions where the stomach produces too much acid, such as Zollinger-Ellison syndrome in adults. PPIs may also be given in combination with antibiotics to treat H.Pylori<\/em> infections, a common cause of duodenal ulcers.<\/p>\n

Mechanism of Action<\/strong><\/p>\n

PPIs bind to the hydrogen-potassium ATPase enzyme system of the parietal cell, also referred to as the \u201cproton pump\u201d because it pumps hydrogen ions into the stomach. PPIs inhibit the secretion of hydrochloric acid, and the antisecretory effect lasts longer than 24 hours.<\/p>\n

Specific Administration Considerations<\/strong><\/p>\n

Packets of delayed-release granules must be mixed with applesauce or apple juice and taken by mouth or given through a feeding tube. Consult the labeling of concomitantly used drugs to obtain further information about interactions because PPIs can interfere with the liver metabolism of other drugs.\u00a0 IV pantoprazole can potentially exacerbate zinc deficiency, and long-term therapy can cause hypomagnesemia, so the nurse should monitor for these deficiencies.<\/p>\n

Patient Teaching & Education<\/strong><\/p>\n

In addition to the considerations above, instruct patients to call their provider if their condition does not improve or gets worse, especially if bleeding occurs.[19]<\/sup><\/a>,[20]<\/sup><\/a><\/sup>\u00a0 Use of alcohol, NSAIDS, or foods that cause GI irritation should be discouraged.[21]<\/sup><\/a>,[22]<\/sup><\/a><\/sup><\/p>\n

Mucosal Protectants<\/h3>\n

Sucralfate is a mucosal protectant used to cover and protect gastrointestinal ulcers.<\/p>\n

Indications<\/strong><\/p>\n

Sucralfate is used in the treatment of ulcers.<\/p>\n

Mechanism of Action<\/strong><\/p>\n

Sucralfate locally covers the ulcer site in the GI tract and protects it against further attack by acid, pepsin, and bile salts. It is minimally absorbed by the gastrointestinal tract.<\/p>\n

Specific Administration Considerations<\/strong><\/p>\n

Administer sucralfate on an empty stomach, 2 hours after or 1 hour before meals. Constipation may occur. Sucralfate should be cautiously used with patients with chronic renal failure or those receiving dialysis due to impaired excretion of small amounts of absorbed aluminum that can occur with sucralfate.<\/p>\n

Patient Teaching & Education<\/strong><\/p>\n

In addition to the considerations above, instruct patients to call their provider if their condition does not improve or gets worse. [23]<\/sup><\/a>,[24]<\/sup><\/a>,[25]<\/sup><\/a>,[26]<\/sup><\/a><\/sup><\/p>\n

Antiflatulent<\/h3>\n

Simethicone is an antiflatulent that is commonly found in other OTC antacids (see Figure 7.8[27]<\/sup><\/a><\/sup>).\u00a0 It is also safe for use in infants. Gas commonly occurs in the GI tract due to digestive processes and the swallowing of air. Gaseous distension can also occur postoperatively.<\/p>\n

\"Photo
Figure 7.8 OTC Simethicone<\/figcaption><\/figure>\n

Indications<\/strong><\/p>\n

Simethicone is used to treat the symptoms of gas such as uncomfortable or painful pressure, fullness, and bloating.<\/p>\n

Mechanism of Action<\/strong><\/p>\n

Simethicone works by altering the elasticity of the mucous-coated gas bubbles, which cause them to break into smaller bubbles, thus reducing pain and facilitating expulsion.<\/p>\n

Specific Administration Considerations<\/strong><\/p>\n

Simethicone is usually taken four times a day, after meals and at bedtime. For liquid form, shake drops before administering.<\/p>\n

Patient Teaching & Education<\/strong><\/p>\n

Patients can be instructed about other measures to assist with gas expulsion such as changing position, ambulation, avoiding the use of straws, and tapering intake of beans and cruciferous vegetables. [28]<\/sup><\/a>,[29]<\/sup><\/a>,[30]<\/sup><\/a>,[31]<\/sup><\/a><\/sup><\/p>\n

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\u00a0Interactive Activity<\/h3>\n
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