{"id":336,"date":"2019-11-04T23:42:21","date_gmt":"2019-11-04T23:42:21","guid":{"rendered":"https:\/\/pressbooks.publishdot.com\/nursingpharmacology\/chapter\/7-4-antidiarrheal-laxatives\/"},"modified":"2021-12-07T11:21:07","modified_gmt":"2021-12-07T11:21:07","slug":"7-4-antidiarrheal-laxatives","status":"publish","type":"chapter","link":"https:\/\/pressbooks.publishdot.com\/nursingpharmacology\/chapter\/7-4-antidiarrheal-laxatives\/","title":{"raw":"7.4 Antidiarrheal Medications and Laxatives","rendered":"7.4 Antidiarrheal Medications and Laxatives"},"content":{"raw":"
\n\nThe digestive system is continually at work, but unless something goes amiss, you don't notice your digestive system working. This section will focus on bowel disorders that occur in the lower intestine during the final step of digestion called [pb_glossary id=\"1269\"]defecation[\/pb_glossary]<\/strong>, when undigested materials are removed from the body as feces. During this final step, the large intestine absorbs water and changes the waste from liquid into stool; then peristalsis helps move the stool into the rectum. Diarrhea and constipation occur when conditions occur that affect this final step of defection.\n\nThe process of defecation begins when mass movements force feces from the colon into the rectum, stretching the rectal wall and provoking the defecation reflex, which eliminates feces from the rectum. This parasympathetic reflex is mediated by the spinal cord. It contracts the sigmoid colon and rectum, relaxes the internal anal sphincter, and initially contracts the external anal sphincter. Figure 7.9[footnote]\"Anorectum.gif<\/a>\" by U.S. Government National Institutes of Health is licensed under CC0<\/a>[\/footnote]<\/sup> reviews the anatomy of the rectum and its external and internal sphincters. The presence of feces in the anal canal sends a signal to the brain, which gives the person the choice of voluntarily opening the external anal sphincter (defecating) or keeping it temporarily closed. If defecation is delayed until a more convenient time, it takes a few seconds for the reflex contractions to stop and the rectal walls to relax. The next mass movement will trigger additional defecation reflexes until defecate occurs.[footnote]This work is a derivative of Anatomy and Physiology<\/a> by OpenStax<\/a> licensed under CC BY 4.0<\/a>. Access for free at https:\/\/openstax.org\/books\/anatomy-and-physiology\/pages\/1-introduction<\/a>[\/footnote]<\/sup>\n\n[caption id=\"\" align=\"aligncenter\" width=\"297\"]\"Illustration Figure 7.9 Anatomy of the Rectum[\/caption]\n\nIf defecation is delayed for an extended time, additional water is absorbed, making the feces firmer and potentially leading to constipation. Alternatively, if the waste matter moves too quickly through the intestines, not enough water is absorbed, and diarrhea can result. Figure 7.10[footnote]\"BristolStoolChart.png<\/a>\" by Cabot Health, Bristol Stool Chart is licensed under CC BY-SA 3.0<\/a>[\/footnote]<\/sup> demonstrates the Bristol Stool Chart that is used to assess stool characteristics ranging from very constipated to diarrhea.\n\n[caption id=\"\" align=\"aligncenter\" width=\"961\"]\"Image Figure 7.10 Bristol Stool Chart[\/caption]\n\nYou can further review how the digestive system works at the following links:\n\nDigestive System Processes and Regulation<\/a>\n\nYour Digestive System and How it Works<\/a> [footnote]National Institute of Diabetes and Digestive and Kidney Diseases, National Institute of Health. (2018). Treatment for constipation.<\/em>https:\/\/www.niddk.nih.gov\/health-information\/digestive-diseases\/constipation\/treatment<\/a>.[\/footnote] <\/sup>\n\nVideo on Digesting Food<\/a> [footnote]Digesting Food<\/a> by Stanford School of Medicine and Khan Academy is licensed under CC BY-NC-SA 3.0<\/a>.[\/footnote]<\/sup>\n

7.4a Antidiarrheals<\/h2>\n

Pathophysiology<\/h3>\n[pb_glossary id=\"1273\"]Diarrhea[\/pb_glossary]<\/strong> is defined as the passage of three or more loose or liquid stools per day (or more frequent passage than is normal for the individual). Frequent passing of formed stools is not considered diarrhea. Diarrhea has multiple causes such as bacteria from contaminated food or water; viruses such as influenza, norovirus, or rotavirus; parasites found in contaminated food or water; medicines such as antibiotics, cancer drugs, and antacids that contain magnesium; food intolerances and sensitivities; and diseases that affect the colon, such as Crohn's disease or irritable bowel syndrome.[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> The most severe threat posed by diarrhea is dehydration caused by the loss of water and electrolytes. Diarrheal disease is a leading cause of child mortality and morbidity throughout the world due to dehydration; frail elderly are also at risk. When severe diarrhea occurs, assessment for dehydration and electrolyte imbalances receive top priority and rehydration with oral rehydration solutions or IV fluids may be required.[footnote]World Health Organization. (2017, May 2). Diarrhoeal disease.<\/em>https:\/\/www.who.int\/en\/news-room\/fact-sheets\/detail\/diarrhoeal-disease<\/a>.[\/footnote]<\/sup>\u00a0Common medications used to manage the symptoms of diarrhea are discussed below.\n

<\/h3>\n

Nursing Considerations<\/h3>\n

Assessment<\/strong><\/h4>\nWhen administering antidiarrheals, the nurse should document an abdominal assessment, frequency of bowel movements and stool characteristics, and if there is skin breakdown in the anal area. Dehydration is a serious risk in patients with severe diarrhea, so priority assessments and documentation relate to monitoring for dehydration, especially in vulnerable populations of infants, children, and elderly. If signs of dehydration occur, the provider should be immediately notified and treatment initiated for dehydration.\n

Implementation<\/strong><\/h4>\nTeach the patient to not exceed dosages of OTC medications because life-threatening adverse effects may occur. Probiotics have been found to be likely safe in all populations, and the nurse can advocate for the use of probiotics in patients with diarrhea or those at risk for diarrhea because of other medications prescribed. In addition to teaching about medication therapy, nurses can also teach patients with diarrhea other nonpharmacological interventions, such as replacing fluid and electrolytes by drinking water, sports drinks, or sodas without caffeine; and eating soft, bland food like bananas, rice, and toast. Children with severe diarrhea may also require oral rehydration solutions to replace lost fluids and electrolytes. The nurse should also keep in mind that antidiarrheals should be used very cautiously with children because some categories are contraindicated.\n

Evaluation<\/strong><\/h4>\nBecause antidiarrheals treat the symptoms of diarrhea but do not eliminate the cause of it, if symptoms do not resolve within 48 hours, the provider should be notified and other potential causes of diarrhea investigated. Monitor for serious adverse effects such as increased bleeding in patients taking salicylates and for abnormal heart rhythms in patients taking loperamide and notify the provider immediately. Evaluation for dehydration should continuously occur until the condition resolves.\n

Antidiarrheal Medication Classes<\/h3>\nThere are three common mechanisms of action of [pb_glossary id=\"1274\"]antidiarrheal[\/pb_glossary] <\/strong>medications: adsorbents, which help eliminate the toxin or bacteria from the GI tract; [pb_glossary id=\"2275\"]antimotility[\/pb_glossary]<\/strong> agents, which slow peristalsis; and probiotics, which help to restore the normal bacteria found in the lower intestine. Oral rehydration agents may also be used in patients with diarrhea to replace fluid and electrolyte loss, but they do not treat the diarrhea. Antibacterial agents may also be used to treat diarrhea caused by specific infections, such as campylobacter or giardia, but they are not routinely needed.[footnote]World Health Organization. (2017, May 2). Diarrhoeal disease.<\/em>https:\/\/www.who.int\/en\/news-room\/fact-sheets\/detail\/diarrhoeal-disease<\/a>[\/footnote]<\/sup>\n

Adsorbents<\/h4>\n[pb_glossary id=\"1275\"]Adsorption[\/pb_glossary]<\/strong> is the adhesion of molecules to a surface. This process differs from absorption, where a substance is dissolved or penetrates into a surface. Bismuth subsalicylate (brand name Pepto Bismol) is an example of an adsorbent (see Figure 7.11[footnote]\"PeptoBismol Bottle.JPG<\/a>\" by ParentingPatch<\/a> is licensed under CC BY-SA 3.0<\/a>[\/footnote]<\/sup>).\n\n[caption id=\"\" align=\"aligncenter\" width=\"283\"]\"Photo Figure 7.11 Bismuth Subsalicylate[\/caption]\n\nMechanism of Action<\/strong> Adsorbent medications work by coating the walls of the GI tract and binding the causative bacteria or toxin for elimination from the GI tract through the stool.[footnote]Lilley, L., Collins, S., & Snyder, J. (2014). Pharmacology and the Nursing Process.<\/em> pp. 782-862. Elsevier.[\/footnote]<\/sup>Bismuth subsalicylate also decreases the flow of fluids and electrolytes into the bowel, reducing inflammation within the intestine.[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\nSpecific Administration Considerations <\/strong>Bismuth subsalicylate contains salicylate. It should be avoided if the patient has an allergy to salicylates (including aspirin) or if the patient is taking other salicylate products such as aspirin. It should not be used if the patient has an ulcer, a bleeding problem, or bloody or black stool. Children and teenagers who have or are recovering from chicken pox or flu-like symptoms should not use this product. When using this product, if changes in behavior with nausea and vomiting occur, consult a doctor because these symptoms could be an early sign of Reye's syndrome, a rare but serious illness. Liquid products should be shaken well before use. Tablets should be swallowed whole and not chewed unless they are a chewable tablet. Medication can cause a black or darkened tongue. If symptoms worsen, a fever, or ringing in the ears occurs, or if diarrhea lasts longer than 48 hours, contact the provider. [footnote]This work is a derivative of Daily Med<\/a> by U.S. National Library of Medicine<\/a> in the public domain. [\/footnote],[footnote]A.D.A.M. Medical Encyclopedia [Internet]. 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\nPatients should be advised to take medication as directed.\u00a0 They should be aware of potential color changes to stool that may occur and that the medication contains aspirin.\u00a0 They should discontinue the medication if tinnitus occurs.[footnote]uCentral from Unbound Medicine. https:\/\/www.unboundmedicine.com\/ucentral<\/a>[\/footnote]<\/sup>\n

Antimotility<\/h4>\nAntimotility medications help to treat diarrhea by slowing peristalsis. There are two categories of antimotility medication: anticholinergics and opiate-like medication.\n

Anticholinergics<\/h4>\nMechanism of Action<\/strong> Hyoscyamine is an anticholinergic that works on the smooth muscle of the GI tract to inhibit propulsive motility and decreases gastric acid secretion.\n\nSpecific Administration Considerations<\/strong> Read drug label information for all contraindications, including but not limited to, glaucoma, myasthenia gravis, and paralytic ileus. Diarrhea may be an early symptom of incomplete intestinal obstruction, and the use of this drug would be inappropriate and possibly harmful. CNS symptoms and other adverse effects may occur that are common with anticholinergic medications.[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\nPatient Teaching & Education<\/strong>\n\nPatients should receive instruction that these medications may cause dizziness and drowsiness.\u00a0 If patients experience dry mouth, frequent oral hygiene may alleviate discomfort.[footnote]uCentral from Unbound Medicine. https:\/\/www.unboundmedicine.com\/ucentral<\/a>[\/footnote]<\/sup>\n

Opioid-like medication<\/h4>\nMechanism of Action<\/strong> Loperamide has an opioid-like chemical structure but causes fewer CNS effects. It works by decreasing the flow of fluids and electrolytes into the bowel and by slowing down the movement of the bowel to decrease the number of bowel movements (see Figure 7.12[footnote]\"Loperamide2mg.JPG<\/a>\" by Kristoferb<\/a> is licensed under CC BY-SA 3.0<\/a>[\/footnote]<\/sup>).\n\n[caption id=\"\" align=\"aligncenter\" width=\"560\"]\"Photo Figure 7.12 Loperamide[\/caption]\n\nSpecific Administration Considerations<\/strong> Loperamide should not be given to a child younger than two years of age because of the risk of serious breathing and heart problems. Taking more than the prescribed dose can cause a serious abnormal heart rhythm that can lead to death. Read the drug label carefully for information about interaction with other medications, especially antidysrhythmics and antipsychotics.[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\nPatient Teaching & Education<\/strong>\n\nPatients should take medications as directed.\u00a0 They should also avoid alcohol and other CNS depressants.\u00a0 The medications may cause drowsiness.[footnote]uCentral from Unbound Medicine. https:\/\/www.unboundmedicine.com\/ucentral<\/a>[\/footnote]<\/sup>\n

Probiotics<\/h4>\nProbiotics are used for the prevention and treatment of diarrhea. They are often used concomitantly with antibiotics to prevent the common associated side effects of diarrhea (see Figure 7.13[footnote]\"WildWood Probiotic Soyogurt<\/a>\" by Veganbaking.net<\/a> is licensed under CC BY-SA 2.0<\/a>[\/footnote]<\/sup>). An example of a probiotic is lactobacillus.\n\n[caption id=\"attachment_330\" align=\"aligncenter\" width=\"480\"]\"Photo Figure 7.13 Probiotics come in several forms[\/caption]\n\nMechanism of Action<\/strong> Probiotics help replenish normal bacterial flora in the gastrointestinal tract.\n\nSpecific Administration Considerations\/ Patient Teaching<\/strong> & Education<\/strong> Side effects of probiotics are mild such as gas and bloating. Probiotics are safe for use in children.[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\nNow let's take a closer look at medication grids comparing medications used to treat diarrhea. (See Table 7.4a[footnote]This work is a derivative of\u00a0Daily Med<\/a>\u00a0by\u00a0U.S. National Library of Medicine<\/a>\u00a0in the\u00a0public 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>.)<\/span>\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.\u00a0Prototype\/generic medications listed in the grids below are also hyperlinked directly to a Daily Med page.\n\n \n
\n\nTable 7.4a Comparison of Medications Used to Treat Diarrhea\n\n<\/div>\n\n\n\n\n\n\n\n
\n
Class<\/strong><\/h5>\n<\/th>\n
\n
Prototype\/Generic<\/strong><\/h5>\n<\/th>\n
\n
Administration 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
Adsorbents<\/th>\nbismuth subsalicylate<\/a> (Pepto Bismol)<\/td>\nAvoid if taking other salicylates\n\nDo not use in children or teenagers recovering from chicken pox or flu-like symptoms as may cause Reye's syndrome\n\nDo not use if patient has an ulcer, bleeding problem, or bloody or black stool<\/td>\nDecreased diarrhea symptoms<\/td>\nMay cause black or darkened tongue\n\nContact provider if symptoms worsen, a fever, or ringing in the ears occurs, or if diarrhea lasts longer than 48 hours<\/td>\n<\/tr>\n
Anticholinergic<\/th>\nhyoscyamine<\/a><\/td>\nContraindicated in glaucoma, myasthenia gravis, or paralytic ileus<\/td>\nDecreased diarrhea symptoms<\/td>\nMay cause CNS and other adverse effects associated with anticholinergic medication<\/td>\n<\/tr>\n
Opiate-like medication<\/th>\nloperamide<\/a> (lmodium)<\/td>\nContraindicated in children younger than 2 and with several other medications; read drug label information before administering<\/td>\nDecreased diarrhea symptoms<\/td>\nBlack Box Warning: May cause abnormal heart rhythm<\/td>\n<\/tr>\n
Probiotics<\/th>\nlactobacillus<\/a><\/td>\nPediatric dosing is age based and varies by product<\/td>\nPrevention of diarrhea or decreased symptoms of diarrhea<\/td>\nMild such as gas and bloating<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n \n
\n
\n

Critical Thinking Activity 7.4a \"Image<\/h2>\n<\/header>\n
\n
    \n \t
  1. A patient has been prescribed loperamide for diarrhea associated with gastroenteritis. The patient begins to complain of \"heart palpitations.\" What is the nurse's next best response?<\/li>\n \t
  2. A child, aged 6, has diarrhea. The mother asks the nurse what OTC medications she can provide to her child to help resolve the diarrhea. What is the nurse's best response?<\/li>\n<\/ol>\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>\n

    7.4.b Constipation<\/h2>\n

    Pathophysiology<\/h3>\nConstipation is defined as \"three or fewer bowel movements in a week; stools that are hard, dry or lumpy; stools that are difficult or painful to pass; or the feeling that not all stool has passed.\"[footnote]National Institute of Diabetes and Digestive and Kidney Diseases, National Institute of Health. (2018). Symptoms and causes of constipation.<\/em>https:\/\/www.niddk.nih.gov\/health-information\/digestive-diseases\/constipation\/symptoms-causes<\/a>[\/footnote]<\/sup> If defecation is delayed for an extended time, additional water is absorbed, thus making the feces firmer and potentially leading to constipation. There are several causes of constipation, such as lack of proper fluids or fiber in the diet, lack of ambulation, various disease processes, recovery from surgical anesthesia and opiates, and side effects of many medications. A list of these potential causes can be found in Figure 7.6.[footnote]National Institute of Diabetes and Digestive and Kidney Diseases, National Institute of Health. (2018). Symptoms and causes of constipation.<\/em>https:\/\/www.niddk.nih.gov\/health-information\/digestive-diseases\/constipation\/symptoms-causes<\/a>[\/footnote] <\/sup>Because there are several potential causes of constipation, treatment should always be individualized to the patient. Many times, constipation can be treated with simple changes in diet, exercise, or routine. However, when medications are also needed to resolve constipation, there are several categories of laxative medications that work in different ways. Classes of laxative medications are described below.\n\nFigure 7.6 Common Causes of Constipation\n\n\n\n\n\n
    Medications<\/strong><\/th>\nAntacids that contain aluminum and calcium\n\nAnticholinergics and antispasmodics\n\nAnticonvulsants\u2014used to prevent seizures\n\nCalcium channel blockers\n\nDiuretics\n\nIron supplements\n\nMedicines used to treat Parkinson's disease\n\nNarcotic pain medicines\n\nSome medicines used to treat depression<\/td>\n<\/tr>\n
    Health and Nutrition Problems<\/strong><\/th>\nNot eating enough fiber\n\nNot drinking enough liquids or dehydration\n\nNot getting enough physical activity\n\nCeliac disease\n\nDisorders that affect the brain and spine, such as Parkinson's disease\n\nSpinal cord or brain injuries\n\nDiabetes\n\nHypothyroidism\n\nInflammation linked to diverticular disease or proctitis\n\nIntestinal obstructions, including anorectal blockage and tumors<\/td>\n<\/tr>\n
    Daily Routine Changes<\/strong><\/th>\nPregnancy\n\nAging\n\nTraveling\n\nIgnoring the urge to have a bowel movement\n\nMedication changes\n\nChange in diet<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n \n\n \n\n \n\n \n\n \n\n \n\n \n\n \n\n \n\n \n\n \n\n \n\n \n\n \n\n \n\n \n\n \n\n \n\n \n\n \n\n \n\n \n\n \n\n \n\nNursing Considerations<\/span>\n
    \n

    Assessment<\/strong><\/h4>\nThe nurse should assess for the potential cause of the patient's constipation and appropriately individualize the treatment and patient education. The nurse should document an abdominal assessment that includes discomfort, distention, and decreased bowel sounds. The date of the last bowel movement should also be documented. The patient may be asked additional history questions such as the appearance of the stool to determine if it is hard and dry, if passing the stool is difficult or painful, or if there is a feeling of incomplete emptying.\n

    Implementation<\/strong><\/h4>\nMany facilities have a bowel medication protocol with progressive treatment of constipation ranging from stool softeners to stimulants to enemas, depending on the length of time since the last bowel movement. Medications should be administered according to label instructions, and the patient should be instructed when to expect a bowel movement will occur. Measures to prevent constipation should also be discussed with the patient.\n\nPatient teaching for all classes of laxative medications should be individualized based on the cause of constipation. Measures to prevent constipation should be reviewed with the patient, such as:\n