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Chapter 51
Bowel Disorder Drugs
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
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Diarrhea

Abnormal passage of stools with increased
frequency, fluidity, and weight, or with increased
stool water excretion
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Diarrhea (cont’d)
Acute diarrhea
 Sudden onset in a previously healthy person
 Lasts from 3 days to 2 weeks
 Self-limiting
 Resolves without sequelae
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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
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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
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Goals of Diarrhea Treatment




Stopping the stool frequency
Alleviating the abdominal cramps
Replenishing fluids and electrolytes
Preventing weight loss and nutritional deficits
from malabsorption
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Antidiarrheals



Adsorbents
Antimotility drugs (anticholinergics and opiates)
Probiotics (bacterial replacement drugs)
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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
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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
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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
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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)
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Classroom Response Question
The antidiarrheal drug Lomotil contains both
diphenoxylate, a synthetic opiate agonist, and
atropine, an anticholinergic. The purpose of the
atropine in this combination is to
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.
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Antidiarrheals:
Adverse Effects
Adsorbents
 Increased bleeding time
 Constipation, dark stools
 Confusion
 Tinnitus
 Metallic taste
 Blue tongue
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Antidiarrheals:
Adverse Effects (cont’d)
Anticholinergics
 Urinary retention, impotence
 Headache, dizziness, confusion, anxiety,
drowsiness, confusion
 Dry skin, flushing
 Blurred vision
 Hypotension, bradycardia
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Antidiarrheals:
Adverse Effects (cont’d)
Opiates
 Drowsiness, dizziness, lethargy
 Nausea, vomiting, constipation
 Respiratory depression
 Hypotension
 Urinary retention
 Flushing
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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
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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
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Classroom Response Question
Before administering belladonna alkaloids, it is
most important for the nurse to assess the patient
for a history of which condition?
A.
B.
C.
D.
Anemia
Diabetes mellitus
Myasthenia gravis
Hypertension
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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
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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
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Antidiarrheals:
Nursing Implications (cont’d)


Teach patients to notify their prescriber
immediately if symptoms persist
Monitor for therapeutic effect
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Classroom Response Question
Which antidiarrheal does the nurse associate with
the development of adverse effects of urinary
retention, headache, confusion, dry skin, rash, and
blurred vision?
A.
B.
C.
D.
Anticholinergics
Adsorbents
Probiotics
Opiates
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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
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Laxatives






Bulk-forming
Emollient (stool softeners, lubricant laxatives)
Hyperosmotic
Saline
Stimulant
Peripherally acting opioid
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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)
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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
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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)
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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)
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Laxatives: Mechanism of Action
(cont’d)
Stimulant
 Increases peristalsis via intestinal nerve
stimulation
 Examples


senna (Senekot)
bisacodyl (Dulcolax)
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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)
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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
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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
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Classroom Response Question
A patient is receiving 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
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Laxatives: Adverse Effects

Bulk-forming

Impaction
 Fluid overload
 Electrolyte imbalances
 Esophageal blockage

Emollient




Skin rashes
Decreased absorption of vitamins
Electrolyte imbalances
Lipid pneumonia
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Laxatives: Adverse Effects (cont’d)

Hyperosmotic




Abdominal bloating
Electrolyte imbalances
Rectal irritation
Saline





Magnesium toxicity (with renal insufficiency)
Cramping
Electrolyte imbalances
Diarrhea
Increased thirst
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Laxatives: Adverse Effects (cont’d)

Stimulant

Nutrient malabsorption
 Skin rashes
 Gastric irritation
 Electrolyte imbalances
 Discolored urine
 Rectal irritation

All laxatives can cause electrolyte imbalances!
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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
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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
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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 mL (8 oz) of water
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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
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Classroom Response Question
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
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Irritable Bowel Syndrome


Chronic intestinal discomfort characterized by
cramps, diarrhea, and/or constipation
Patients usually cope with the symptoms by
avoiding irritating foods and/or taking over-thecounter (OTC) laxatives and antidiarrheal drugs
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Drugs for Irritable Bowel Syndrome



tegaserod (Zelnorm)
lubiprostone (Amitiza)
alosetron (Lotronex)
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Drugs for Irritable Bowel
Syndrome: Nursing Implications



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
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