CHAPTER 51
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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 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
Bacterial
Viral
Drug induced
Nutritional factors
Protozoa
Chronic Diarrhea
Tumors
Diabetes mellitus
Addison’s disease
Hyperthyroidism
Irritable bowel syndrome
AIDS
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Antidiarrheals:
Mechanism of Action
Adsorbents

Coat the walls of the 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 (atropine, hyoscyamine)
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Antidiarrheals:
Mechanism of Action (cont’d)
Antimotility drugs: opiates

Decrease bowel motility and relieve rectal spasms

Decrease transit time through the bowel, allowing more time for water and electrolytes to be absorbed

Reduce pain by relief of rectal spasms

Examples: paregoric, opium tincture, codeine, loperamide (over the counter), diphenoxylate
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Antidiarrheals:
Mechanism of Action (cont’d)
Intestinal flora modifiers

Probiotics or 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 (Lactinex)
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Antidiarrheals:
Adverse Effects
Adsorbents

Increased bleeding time

Constipation, dark stools

Confusion, twitching

Hearing loss, tinnitus, metallic taste, blue gums
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Antidiarrheals:
Adverse Effects (cont’d)
Anticholinergics


Urinary retention, hesitancy, 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, sedation, dizziness, lethargy

Nausea, vomiting, anorexia, constipation

Respiratory depression

Hypotension

Urinary retention

Flushing
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Antidiarrheals: Interactions

Adsorbents decrease the absorption of many drugs, including digoxin, clindamycin, quinidine, hypoglycemic drugs, others

Adsorbents cause increased bleeding time and bruising when given with anticoagulants

Antacids can decrease effects of anticholinergic antidiarrheal drugs

Many other interactions
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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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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 physician immediately if symptoms persist

Monitor for therapeutic effect
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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

Hyperosmotic

Saline

Stimulant

Peripherally acting opioid antagonists
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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
Use
Acute and chronic constipation, irritable bowel syndrome, diverticulosis
Emollient Acute and chronic constipation, fecal impaction facilitation of BMs in anorectal conditions
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Laxatives: Indications (cont’d)
Laxative Group
Hyperosmotic
Use
Chronic constipation
Diagnostic and surgical preps
Saline Constipation
Diagnostic and surgical preps
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Laxatives: Indications (cont’d)
Laxative Group
Stimulant
Use
Acute constipation
Diagnostic and surgical preps
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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 ounces of water

Patients should take bulk-forming laxatives as directed by the manufacturer with at least
240 mL (8 ounces) 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 physician 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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