gastrointestinal nursing case study

Gastrointestinal Nursing

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Gastrointestinal Case Studies

Gastrointestinal (GI) disorders refer to conditions affecting the digestive system, including the esophagus, stomach, small and large intestines, liver, pancreas, and gallbladder.

Source: https://www.cancer.gov/publications/dictionaries/cancer-terms/def/gastrointestinal-tract

Common GI disorders

• Gastroesophageal reflux disease (GERD)
• Peptic ulcer disease
• Inflammatory bowel disease (IBD)
• Irritable bowel syndrome (IBS)
• Celiac disease
• Colorectal cancer
• Gallbladder disease
• Pancreatitis
• Gastrointestinal infections (e.g., gastroenteritis)

Symptoms and signs

Symptoms and signs of GI disorders vary depending on the specific condition. Common symptoms may include abdominal pain, bloating, nausea, vomiting, diarrhea, constipation, difficulty swallowing, heartburn, and rectal bleeding.

Diagnostic Investigation

Diagnostic tests for GI disorders may include imaging studies such as endoscopy, colonoscopy, CT scan, MRI, and ultrasound, as well as blood tests, stool tests, and breath tests.

Options for GI disorders may include lifestyle modifications such as dietary changes and exercise, medications, and surgery. Examples of treatment modalities for specific conditions include:

• GERD: proton pump inhibitors (PPIs), H2 receptor blockers, antacids
• Peptic ulcer disease: antibiotics to eradicate H. pylori bacteria, PPIs, H2 receptor blockers, antacids
• IBD: immunomodulators, biologics, corticosteroids, aminosalicylates
• IBS: dietary changes, probiotics, antispasmodics, fiber supplements
• Celiac disease: gluten-free diet
• Colorectal cancer: surgery, radiation therapy, chemotherapy
• Gallbladder disease: surgery to remove the gallbladder (cholecystectomy)
• Pancreatitis: supportive care, pain management, enzyme supplements
• Hepatitis: antiviral medications, liver transplant
• Gastrointestinal infections: antibiotics, anti-diarrheal medications, fluid replacement therapy

Treatment plans are individualized based on the patient’s specific condition and medical history, and may involve a combination of different therapies.

HEALTH & MEDICAL CASE STUDIES (V1.01) Copyright © by Dr. Tranum Kaur is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License , except where otherwise noted.

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• Published: 12 August 2009

An elderly man presenting with an acute upper gastrointestinal bleed: a case report

• Riaz A Agha 1  

Cases Journal volume  2 , Article number:  7951 ( 2009 ) Cite this article

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An 80 year old man presented to the Accident and Emergency Department complaining of "black stools", increasing shortness of breath, chest tightness and epigastric pain. An upper gastro-intestinal bleed was diagnosed and the patient was managed conservatively with aggressive resuscitation and close monitoring. An oesophogastroduodenoscopy found no cause for the bleeding which ceased and the patient was discharged with a general practitioner follow-up.

Introduction

Acute upper gastrointestinal haemorrhage (AUGH) is a common medical emergency with a significant associated mortality [ 1 ] despite ongoing advances in its management [ 2 ].

Following decades of research, the introduction of risk stratification and prognostic scoring in the Rockall Score has allowed for the early division of this pool of patients into low or high risk of re-bleeding or death. This allows for the more effective management of resources and has brought greater awareness to the need for close monitoring of high risk patients who can decompensate suddenly on busy wards and admissions units.

Case presentation

A retired 80 year old Caucasian man presented to the Accident and Emergency Department complaining of "black stools", increasing shortness of breath, chest tightness and epigastric pain. Three days previously he had celebrated his birthday when he noted epigastric pain. This was similar in nature to the pain from his duodenal ulcers 20 years ago (managed conservatively at the time). The pain was relieved by eating and settled with simple analgesia and rest. From that point, the patient had black stools daily with decreasing exercise tolerance and shortness of breath on exertion. His past medical history included atrial fibrillation (AF), hypertension, and ischaemic heart disease with a bare metal stent inserted 6 weeks prior to admission in the left anterior descending branch. The patient was taking aspirin and warfarin for AF. The patient was a non-smoker, with minimal alcohol intake, a body mass index (BMI) of 25 and with no family history of note.

The patient was found to be normotensive at 130/80, but with a postural diastolic drop of 15 mmHg with a pulse of 80, decreased skin turgor, oxygen saturation of 98% on air and a respiratory rate of 16. Routine blood tests found that Haemoglobin (Hb) was 12.5 g/dL, with a urea/creatinine ratio >100 and an International Normalised Ratio (INR) of 2.3. On examination the patient was found to have mild tenderness in the epigastric region. The patient's initial Rockall score was thus four which carries a 24.6% risk of mortality [ 3 ].

The patient was treated with normal saline IV fluids and his anticoagulants were stopped. Reversal of warfarin with vitamin K was not deemed necessary. Fluid and stool charts together with regular observations were initiated. Oesophogastroduodenoscopy (OGD) was scheduled to take place within 72 hours of admission. During the period prior to OGD, the patient's blood pressure dropped to 110/70, pulse increased to 95 and Hb decreased to 10.3 g/dL. The patient did not become symptomatic and a blood transfusion was not performed although a group had already been taken. Fluid resuscitation and close observation continued during this period with good urine output and just one further episode of malaena. OGD was performed without complication and found no ulcers or bleeding points down to the fourth part of the duodenum. The patient's Hb recovered to 13.5 g/dL and he became normotensive and euvolaemic. Anticoagulants were restarted and the patient was discharged four days after admission without further event with a GP follow-up scheduled.

Conclusions

This case report illustrates the need for prognostic scoring, close observation and aggressive fluid resuscitation in the management of GI bleeds.

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Author contributions

Riaz Agha is the sole author, who saw the patient, assessed and treated him.

Abbreviations

atrial fibrillation

acute upper gastrointestinal haemorrhage

body mass index

haemoglobin

international normalised ratio

intravenous.

Rockall TA, Logan RF, Devlin HB, Northfield TC: Incidence of and mortality from acute upper gastrointestinal haemorrhage in the United Kingdom. Steering Committee and members of the National Audit of Acute Upper Gastrointestinal Haemorrhage. Br Med J. 1995, 311: 222-226.

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Agha R, Miller M, George ML, Sabharwal T: Arterial embolisation to control haemorrhage following colonoscopic polypectomy. International Journal of Surgery. 2008, 6: 420-421. 10.1016/j.ijsu.2007.01.005.

Article   CAS   PubMed   Google Scholar  

Rockall TA, Logan RF, Devlin HB, Northfield TC: Selection of patients for early discharge or outpatient care after acute upper gastrointestinal haemorrhage. Lancet. 1996, 347: 1138-1140. 10.1016/S0140-6736(96)90607-8.

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Department of Gastroenterology, Hinchingbrooke Health Care NHS Trust, Hinchingbrooke Hospital, Hinchingbrooke Park, Huntingdon, Cambridgeshire, PE29 6NT, UK

Riaz A Agha

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Agha, R.A. An elderly man presenting with an acute upper gastrointestinal bleed: a case report. Cases Journal 2 , 7951 (2009). https://doi.org/10.4076/1757-1626-2-7951

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Received : 25 May 2009

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Published : 12 August 2009

DOI : https://doi.org/10.4076/1757-1626-2-7951

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Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Pharmacology [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2023.

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Chapter 7 Gastrointestinal System

7.1. gastrointestinal introduction, learning objectives.

• Identify the classifications and actions of gastrointestinal system drugs

• Give examples of when, how, and to whom gastrointestinal system drugs may be administered

• Identify the side effects and special considerations associated with gastrointestinal system drug therapy

• Identify considerations and implications of using gastrointestinal system medications across the life span

• Apply evidence-based concepts when using the nursing process

• Identify indications and adverse/side effects associated with the use of herbal supplements

• Identify and interpret related laboratory tests

• Identify nursing responsibilities related to health teaching and health promotion

Gastrointestinal disorders are common. How many times have you heard someone complaining of an upset stomach, heartburn, nausea, constipation, or diarrhea? Occasionally, these ailments will go away on their own…but if they do not, there are a variety of medications that can be used to treat them. Treatment can include prescription and over-the-counter drug therapy, in addition to nonpharmacological interventions. In this chapter, you will learn about medications used to treat common disorders within the gastrointestinal system.

7.2. BASICS CONCEPTS OF THE GASTROINTESTINAL SYSTEM

Prior to discussing specific GI disorders and associated medication classes, it is important to have a clear understanding of the anatomy the gastrointestinal system.

Review of Anatomy of the Gastrointestinal System

It is important to know the basic anatomy and physiology of the gastrointestinal system to understand how gastrointestinal (GI) medications work. See Figure 7.1 [ 1 ] for an illustration of the anatomical components of the GI system. There are a variety of medications used to treat common GI disorders, so this chapter’s content is divided into three subsections discussing medications classes treating common disorders: antiulcer, antidiarrheals/laxatives, and antiemetics. Each subsection will further review the GI anatomy and physiology related to these conditions and medications.

Components of GI System

For additional details related to the content in this chapter, review information in OpenStax Anatomy and Physiology using the areas noted below[ 2 ]:

Overview of the Digestive System

Digestive System Processes and Regulation

The Stomach

The Small and Large Intestines

Chemical Digestion and Absorption: A Closer Look

See the following supplementary YouTube videos to review the gastrointestinal system and digestive processes.

Gastrointestinal System Review[ 3 ]

Ted Ed Review of Digestive System [ 4 ]

Khan Academy Review of GI System [ 5 ]

7.3. ANTIULCER MEDICATIONS

This section will review the anatomy and pathophysiology of the digestive process and common hyperacidity disorders and then apply the nursing process to administering several hyperacidity medications.

Review of Anatomy and Pathophysiology of the Digestive Process

This section will discuss antiulcer medications. We will begin by reviewing the anatomy and physiology of the digestive process. 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 ]

An Image of the Stomach With Surface Epithelium Cells in the Mucosa, and an Enlarged Image of the Gastric Gland Showing Chief and Parietal Cells

Surface epithelium cells  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  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 , 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 , 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) , often referred to by clients 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 ]

Illustration of GERD

Hyperacidity Disorders

Peptic ulcer disease (PUD)  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.

Stress-related mucosal damage  is another common condition that can occur in hospitalized clients leading to PUD. Thus, many postoperative or critically ill clients receive medication to prevent the formation of stress ulcers.[ 3 ] See an image of a duodenal ulcer in Figure 7.4 .[ 4 ]

Image of a Duodenal Ulcer

View supplementary videos on heartburn and gastric ulcers:

Heartburn [ 5 ]

Gastric Ulcer [ 6 ]

Applying the Nursing Process to Hyperacidity Medications

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 client complains of chest pain, the nurse should perform a complete focused cardiac assessment and not assume it is GI-related because clients may erroneously attribute many cardiac conditions to “heartburn.”

Implementation

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 client 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.

Clients 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.

Hyperacidity Medication Classes

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.

Antacids (see Figure 7.5 [ 7 ]) 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.

Mechanism of Action:  Antacids neutralize gastric acidity and elevate the pH of the stomach. Elevated pH also inactivates pepsin, a digestive enzyme.

Indications:  Antacids are used to relieve heartburn, acid indigestion, and upset stomach.

Nursing Considerations:  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 client 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 medicines. Calcium carbonate may be contraindicated in clients with preexisting kidney disease because it may cause  hypercalcemia .

Side Effects/Adverse Effects:  Common side effects of calcium carbonate include constipation and  rebound hyperacidity  when it is discontinued.[ 8 ]

Health Teaching & Health Promotion:  In addition to the information under “Nursing Considerations,” clients 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 ],[ 10 ],[ 11 ],[ 12 ]

H2-Receptor Antagonist

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 clients because of its binding to  cytochrome P-450 enzymes  in the liver, which affects the metabolism of other drugs.

Mechanism of Action:  H2-receptor antagonists block histamine’s action at the H2 receptor of the parietal cell, thus reducing the production of hydrochloric acid.

Indications:  Famotidine (see Figure 7.6 [ 13 ]) 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.

OTC Famotidine

Nursing Considerations:  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 clients younger than 1 year old, as well as in elderly clients.

Side Effects/Adverse Effects:  Common side effects include headache, dizziness, constipation, and diarrhea. Individuals must immediately report increased pain or other signs of bleeding ulcers such as coughing/vomiting of blood.

Health Teaching & Health Promotion:  Clients taking the oral suspension should be instructed to shake it vigorously for 5 to 10 seconds prior to each use.[ 14 ],[ 15 ] The medication may cause constipation so fluids and high-fiber diet should be encouraged. Additionally, smoking interferes with histamine antagonists and should be discouraged.[ 16 ],[ 17 ]

Proton Pump Inhibitors

A common proton pump inhibitor (PPI) is pantoprazole (see Figure 7.7 [ 18 ]). 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.

OTC Omeprazole

Mechanism of Action:  PPIs bind to the hydrogen-potassium ATPase enzyme system of the parietal cell, also referred to as the “proton pump” because it pumps hydrogen ions into the stomach. PPIs inhibit the secretion of hydrochloric acid, and the antisecretory effect lasts longer than 24 hours.

Indications:  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  infections, a common cause of duodenal ulcers.

Nursing Considerations:  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. IV pantoprazole can potentially exacerbate zinc deficiency, and long-term therapy can cause hypomagnesemia, so the nurse should monitor for these deficiencies.

Side Effects/Adverse Effects:  Concerning side effects of proton pump inhibitors include hypersensitivity, anaphylaxis, and serious skin reactions. Individuals taking proton pump inhibits may also be susceptible to zinc, magnesium, and B12 deficiencies. Clients may also experience headache, abdominal pain, diarrhea, or constipation. Individuals taking proton pump inhibitors may also be at risk for acute renal dysfunction, osteoporosis, and acute lupus erythematosus. If individuals experience increased pain or signs of a bleeding ulcer, such as coughing/vomiting blood, this should be immediately reported to their health care provider. Long-term use of PPIs may also increase the risk of pneumonia[ 19 ].

Health Teaching & Health Promotion:  In addition to the considerations above, instruct clients to call their provider if their condition does not improve or gets worse, especially if bleeding occurs.[ 20 ],[ 21 ] Use of alcohol, NSAIDS, or foods that cause GI irritation should be discouraged.[ 22 ],[ 23 ]

Mucosal Protectants

Sucralfate is a mucosal protectant used to cover and protect gastrointestinal ulcers.

Mechanism of Action:  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.

Indications:  Sucralfate is used in the treatment of ulcers.

Nursing Considerations:  Administer sucralfate on an empty stomach, two hours after or one hour before meals. Sucralfate should be cautiously used with clients with chronic renal failure or those receiving dialysis due to impaired excretion of small amounts of absorbed aluminum that can occur with sucralfate.

Side Effects/Adverse Effects:  A common side effect related to mucosal protectant medications includes constipation.

Health Teaching & Health Promotion:  In addition to the considerations above, instruct clients to call their provider if their condition does not improve or gets worse.[ 24 ],[ 25 ],[ 26 ],[ 27 ]

Antiflatulent

Simethicone is an antiflatulent that is commonly found in other OTC antacids (see Figure 7.8 [ 28 ]). 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.

Combination OTC Product With Simethicone

Mechanism of Action:  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.

Indications:  Simethicone is used to treat the symptoms of gas such as uncomfortable or painful pressure, fullness, and bloating.

Nursing Considerations:  Simethicone is usually taken four times a day, after meals and at bedtime. For liquid form, shake drops before administering.

Side Effects/Adverse Effects:  Common side effects include nausea, constipation, diarrhea, or headache.

Health Teaching & Health Promotion:  Clients can be instructed about other measures to assist with gas expulsion such as changing position, ambulating, avoiding the use of straws, and tapering intake of beans and cruciferous vegetables.[ 29 ],[ 30 ],[ 31 ],[ 32 ]

“GI Meds Hyperacidity Quiz” by E. Christman for   Open RN   is licensed under   CC BY 4.0

Now let’s take a closer look at the medication grids comparing medications used to treat hyperacidity in Table 7.3 .[ 33 ],[ 34 ],[ 35 ],[ 36 ]

Medication grids are intended to assist students to learn key points about each medication. 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. Detailed information on a specific medication can be found for free at  DailyMed . On the home page, enter the drug name in the search bar to read more about the medication. Prototype/generic medications listed in the grids below are also linked to a DailyMed page.

Hyperacidity Medication Grids

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Critical Thinking Activity 7.3

A client who recently underwent surgery has a medication order for daily pantoprazole. The nurse reviews the client’s medical history and finds no history of GERD or peptic ulcer disease. The client does not report any symptoms of heartburn, stomach pain, or sour stomach. The nurse reviews the provider orders for an indication for this medication before calling the provider to clarify.

What is the likely indication for this drug therapy for this client?

Note: Answers to the Critical Thinking activities can be found in the “ Answer Key ” section at the end of the book.

7.4. ANTIDIARRHEAL MEDICATIONS AND LAXATIVES

This section will review the anatomy and pathophysiology of defecation and the condition of diarrhea and then apply the nursing process to administering antidiarrheals. From there, we will discuss the condition of constipation, apply the nursing process to treating constipation, and discuss classes of laxatives.

Review of Anatomy and Physiology of Defecation

The 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  defecation , 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.

The 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 [ 1 ] 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 defecation occurs.[ 2 ]

Anatomy of the Rectum

If 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 [ 3 ] demonstrates the Bristol Stool Chart that is used to assess stool characteristics, ranging from very constipated to diarrhea.

Figure 7.10

Bristol Stool Chart

Additional information about how the digestive system works can be reviewed using the information below:

“Digestive System Processes and Regulation” in Open Stax Anatomy and Physiology.

Your Digestive System and How it Works [ 4 ]

Video on Digesting Food [ 5 ]

Diarrhea  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.[ 6 ] 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.[ 7 ] Common medications used to manage the symptoms of diarrhea are discussed below.

Applying the Nursing Process to Administering Antidiarrheals

When 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 clients 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.

Teach the client 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 clients with diarrhea or those at risk for diarrhea because of other medications prescribed. In addition to teaching about medication therapy, nurses can also teach clients 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.

Because 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 clients taking salicylates and for abnormal heart rhythms in clients taking loperamide and notify the provider immediately. Evaluation for dehydration should continuously occur until the condition resolves.

Antidiarrheal Medication Classes

There are three common mechanisms of action of  antidiarrheal  medications: adsorbents, which help eliminate the toxin or bacteria from the GI tract;  antimotility  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 clients 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.[ 8 ]

Adsorption  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 [ 9 ]).

Figure 7.11

Bismuth Subsalicylate

Mechanism of Action:  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.[ 10 ] Bismuth subsalicylate also decreases the flow of fluids and electrolytes into the bowel, reducing inflammation within the intestine.[ 11 ]

Indications:  Adsorbent medications are used to treat conditions that involve excess gas or toxins in the digestive system.

Nursing Considerations:  Bismuth subsalicylate contains salicylate. It should be avoided if the client has an allergy to salicylates (including aspirin) or if the client is taking other salicylate products such as aspirin. It should not be used if the client 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 provider 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.[ 12 ],[ 13 ]

Side Effects/Adverse Effects:  Side effects of adsorbent medications include black or darkened tongue. Individuals should contract their provider if symptoms worsen or if they experience a fever or ringing in the ears.

Health Teaching & Health Promotion:  Clients should be advised to take medication as directed. They should be aware of potential color changes to stool that may occur and that the medication contains aspirin. They should discontinue the medication if tinnitus occurs.[ 14 ]

Antimotility

Antimotility medications help to treat diarrhea by slowing peristalsis. There are two categories of antimotility medication: anticholinergics and opiate-like medications.

Anticholinergics

Mechanism of Action:  Hyoscyamine is an anticholinergic that works on the smooth muscle of the GI tract to inhibit propulsive motility and decreases gastric acid secretion.

Indications:  Anticholinergic medications are a class of drugs that block the action of the neurotransmitter acetylcholine in the nervous system.

Nursing Considerations:  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.[ 15 ],[ 16 ]

Side Effects/Adverse Effects:  Common side effects of anticholinergic medications include dry mouth, constipation, blurred vision, and confusion, especially in older adults.

Health Teaching & Health Promotion:  Clients should receive instruction that these medications may cause dizziness and drowsiness. If clients experience dry mouth, frequent oral hygiene may alleviate discomfort.[ 17 ]

Opioid-like Medication

Mechanism of Action:  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 [ 18 ]).

Figure 7.12

Indications:  Opioid-like medications such as loperamide work by slowing down the movement of the intestines, which reduces the frequency and volume of bowel movements.

Nursing Considerations:  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.[ 19 ],[ 20 ]

Side Effects/Adverse Effects:  Common side effects of loperamide may include constipation, abdominal discomfort, nausea, vomiting, dizziness, drowsiness, or allergic skin reactions such as hives.

Health Teaching & Health Promotion:  Clients should take medications as directed. They should also avoid alcohol and other CNS depressants. The medications may cause drowsiness.[ 21 ]

Probiotics 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 [ 22 ]). An example of a probiotic is lactobacillus.

Figure 7.13

Probiotics Come in Several Forms

Mechanism of Action:  Probiotics help replenish normal bacterial flora in the gastrointestinal tract.

Indications:  Probiotics are live microorganisms that are beneficial for digestive health.

Nursing Considerations:  Probiotic usage should be tailored to the individual’s specific health needs because not all strains of probiotics have the same health benefits.

Side Effects/Adverse Effects:  Probiotics may have some side effects such as gas, bloating, and diarrhea.

Health Teaching & Health Promotion:  Side effects of probiotics are mild such as gas and bloating. Probiotics are safe for use in children.[ 23 ],[ 24 ]

Now let’s take a closer look at medication grids comparing medications used to treat diarrhea. (See Table 7.4a .[ 25 ],[ 26 ])

Medication grids are intended to assist students to learn key points about each medication. 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. Detailed information on a specific medication can be found for free at  DailyMed . On the home page, enter the drug name in the search bar to read more about the medication. Prototype/generic medications listed in the grids below are also linked directly to a DailyMed page.

Diarrhea Medication Grids

Critical Thinking Activity 7.4

1. A client has been prescribed loperamide for diarrhea associated with gastroenteritis. The client begins to complain of “heart palpitations.” What is the nurse’s next best response?

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?

Constipation

Constipation 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.”[ 27 ] 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 Table 7.4b .[ 28 ]

Because there are several potential causes of constipation, treatment should always be individualized to the client. 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.

Common Causes of Constipation

Applying the Nursing Process to Administering Laxatives

The nurse should assess for the potential cause of the client’s constipation and appropriately individualize the treatment and health teaching. 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 client 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.

Many 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 client should be instructed when to expect a bowel movement will occur. Measures to prevent constipation should also be discussed with the client.

Patient teaching for all classes of laxative medications should be individualized based on the cause of constipation. These measures to prevent constipation should be reviewed with the client:

• Getting enough fiber in the diet

• Drinking plenty of water and other liquids

• Getting regular physical activity

• Trying to have a bowel movement at the same time every day[ 29 ]

If a bowel movement does not occur within the expected time frame, the provider should be notified, and other causes investigated for individualized treatment. It is imperative that good documentation of bowel movements and communication among staff occur when constipation is being treated with various medications. If there is a complete absence of bowel sounds, worsening distension or abdominal pain, a smearing of stool, or other findings indicating that a paralytic ileus or blockage may be occurring, the provider should be immediately notified.

Laxative Medication Classes

There are five categories of laxative medications commonly used to treat constipation: fiber supplements,  stool softeners ,  osmotic agents , lubricants, and  stimulants.  Fiber supplements and stool softeners are often used daily to prevent constipation, whereas the other laxative categories are used to treat constipation. Table 7.4c compares the mechanism of action for each laxative category and includes common prototype and OTC brand names.[ 30 ],[ 31 ],[ 32 ]

Categories of Laxatives Used to Treat Constipation

Fiber Supplements

Psyllium (brand name Metamucil) is an example of a common OTC fiber supplement (see Figure 7.14 [ 33 ]).

Figure 7.14

Psyllium in Powder Form

Mechanism of Action:  Psyllium adds bulk to the stool to facilitate passage through the rectum.

Indications:  A type of soluble fiber that is commonly used as a dietary supplement and as an ingredient in some medications to help treat constipation.

Nursing Considerations:  When administering, put one dose into an empty glass and mix with at least 8 ounces of water or other fluid. Taking this product without enough liquid may cause choking. Stir briskly and drink promptly. If mixture thickens, add more liquid and stir. Administer at least 2 hours before or 2 hours after other medications as it can affect absorption. Psyllium usually produces a bowel movement within 12 to 72 hours. It may cause bloating and cramping.

Side Effects/Adverse Effects:  Psyllium is generally well-tolerated; however, some individuals may experience abdominal discomfort, ongoing constipation, diarrhea, or obstruction. It may also interfere with medication absorption.

Health Teaching & Health Promotion:  When teaching clients how to take psyllium at home, in addition to the above considerations, advise them to start with one dose per day but may gradually increase to three doses per day as necessary to maintain soft stools.

Stool Softeners

Docusate is a common OTC stool softener that is also used frequently in health care settings.

Mechanism of Action:  Docusate facilitates movement of water and fats into stool to make it soft and improve regularity of bowel movements.

Indications:  Stool softeners are medications that help to moisten and soften the stool, making it easier to pass.

Nursing Considerations:  Docusate usually produces a bowel movement in 12 to 72 hours. It may cause stomach cramping.

Side Effects/Adverse Effects:  Stool softeners can cause diarrhea, nausea, vomiting, abdominal cramping, and electrolyte imbalances in some clients.

Health Teaching & Health Promotion:  Stool softeners may interact with other medications, such as blood thinners or antibiotics. They should not be used in individuals with intestinal blockages.

Osmotic Agents

Milk of Magnesia and polyethylene glycol 3350 (brand name Miralax) are examples of common osmotic agents used to promote a bowel movement (see Figure 7.15 ).[ 34 ]

Figure 7.15

Miralax & Milk of Magnesia

Mechanism of Action:  Osmotic agents cause water to be retained with the stool, increasing the number of bowel movements and softening the stool so it is easier to pass.

Indications:  They are often used to treat constipation or to prepare for certain medical procedures, such as colonoscopies.

Nursing Considerations:  Polyethylene glycol 3350 has a bottle top that can be used as a measuring cap to contain 17 grams of powder when filled to the indicated line. Fill to the top of clear section in cap, which is marked to indicate the correct dose (17 g); stir and dissolve in any 4 to 8 ounces of beverage (cold, hot, or room temperature) and then administer.

Side Effects/Adverse Effects:  Side effects of osmotic agents include diarrhea, abdominal cramping, electrolyte imbalance, dehydration, or allergic reactions.

Health Teaching & Health Promotion:  In addition to the administration considerations above, teach clients that polyethylene glycol usually produces a bowel movement in 1-3 days. It may cause loose, watery stools.

A mineral oil enema (brand name Fleet enema) is an example of a lubricant laxative (see Figure 7.16 [ 35 ]).

Figure 7.16

Mineral Oil Enema

Mechanism of Action:  Mineral oil coats the stool to help seal in water.

Indications:  Mineral oil may be used to relieve constipation by lubricating and softening the stool.

Nursing Considerations:  Read drug label for children as some brands can be used in children aged 2 or older, whereas others are not intended for children.

Side Effects/Adverse Effects:  Side effects of mineral oil enemas may include irritations and inflammation of anal area, electrolyte imbalances, dehydration, or interference with medication absorption.

Health Teaching & Health Promotion:  A mineral oil enema generally produces a bowel movement in 2 to 15 minutes. It may cause stomach cramps, bloating, upset stomach, or diarrhea.

Bisacodyl is an example of a stimulant laxative.

Mechanism of Action:  Bisacodyl causes the intestines to contract, inducing the stool to move through the colon.

Indications:  Stimulant laxatives such as bisacodyl are used to treat constipation and prepare the bowel for medical procedures.

Nursing Considerations:  Oral dosage or rectal suppositories are available. See instructions for how to insert a rectal suppository. Instruct the client to retain suppository for about 15 to 20 minutes (see Figure 7.17 [ 36 ]).

Figure 7.17

Administering a Rectal Suppository

Side Effects/Adverse Effects:  Common side effects of bisacodyl include abdominal cramps, nausea, and vomiting, diarrhea, rectal irritation, dehydration, or electrolyte imbalances. Adverse effects may include severe abdominal pain, rectal bleeding, severe dehydration, fainting, and hypokalemia.

Health Teaching & Health Promotion:  A bowel movement is generally produced in 15 minutes. Bisacodyl may cause stomach cramps, dizziness, or rectal burning.

Many herbal substances may be useful in facilitating natural bowel function. Substances such as senna can have a significant benefit in relieving constipation due to its laxative properties. Senna is a plant that belongs to the legume family.

Mechanism of Action:  Senna leaves contain compounds known as anthraquinones, which act as stimulant laxatives by increasing motility of the intestines.

Indications:  Senna is given to increase motility of the intestines and promote bowel movements.

Nursing Considerations:  Overuse of senna can result in diarrhea and dehydration. Clients should take adequate fluids to prevent dehydration. Short-term use is recommended to diminish risk of dependence.

Side Effects/Adverse Effects:  Senna can cause cramps, bloating, and abdominal discomfort. Overuse can lead to diarrhea and dehydration, as well an electrolyte imbalance.

Health Teaching & Health Promotion:  Senna can cause discoloration of the urine, turning it into a reddish-brown color. It is important that clients take senna at the lowest possible dose for the shortest duration of time .

Now let’s take a closer look at the medication grids comparing medications used to treat constipation. (See Table 7.4d ).[ 37 ],[ 38 ]

Medication Grid Comparing Laxatives Used to Treat Constipation

“GI Bowel Disorder Mediations Quiz” by E. Christman for   Open RN   is licensed under   CC BY 4.0

Critical Thinking Activity 7.4b

A client who underwent hip surgery two days ago has not had a bowel movement since before admission. The client is receiving oxycontin ER 10 mg every 12 hours and oxycodone 5 mg every 4 hours for pain. The client describes abdominal discomfort, and the nurse finds decreased bowel sounds in all quadrants. The nurse notifies the provider, follows the bowel protocol, and administers docusate sodium to the client.

1. What are the potential causes of constipation that should be addressed for this client?

2. What is the mechanism of action for docusate?

3. The client asks how quickly the medication will work. What is the nurse’s best response?

4. What other preventative measures for constipation should the nurse teach the client?

5. If docusate is not effective within 24 hours, what other medications can the nurse anticipate being ordered?

7.5. ANTIEMETICS

This section will review the pathophysiology of nausea and vomiting and then apply the nursing process to administering antiemetic medications.

Review of the Pathophysiology of Nausea and Vomiting

Nausea and vomiting are common conditions. Nausea is the unpleasant sensation of having the urge to vomit, and vomiting (emesis) is the forceful oral expulsion of gastric contents.[ 1 ] There are many potential causes of nausea and vomiting, such as the following:

• Morning sickness during pregnancy
• Gastroenteritis  and other infections
• Motion sickness
• Food poisoning
• Side effects of medicines, including those for cancer chemotherapy
• GERD and ulcers
• Intestinal obstruction
• Poisoning or exposure to a toxic substance
• Diseases of other organs (cardiac, renal, or liver)

Nausea and vomiting are common and are usually not serious. However, the health care provider should be contacted immediately if the following conditions occur:

• Vomiting for longer than 24 hours
• Blood in the vomit (also called  hematemesis )
• Severe abdominal pain
• Severe headache and stiff neck
• Signs of dehydration, such as dry mouth, infrequent urination, or dark urine

Treatment of nausea and vomiting should be tailored to the cause. There are several medications that work on different neuroreceptors that when used can treat nausea and vomiting. For severe cases of vomiting, intravenous fluids may also be needed to treat the accompanying dehydration.[ 2 ],[ 3 ]

The Vomiting Center and Associated Neurotransmitters

The vomiting center can be activated directly by irritants or indirectly following input from four principal areas: gastrointestinal tract, cerebral cortex and thalamus, vestibular region, and chemoreceptor trigger zone (CRTZ). See Figure 7.18 for an illustration of the pathophysiology of nausea and vomiting.[ 4 ]

Figure 7.18

Pathophysiology of Nausea and Vomiting

An important part of the emesis circuit is the  chemoreceptor trigger zone (CTZ) , located in the  area postrema  in the brain. The CTZ is not restricted by the blood–brain barrier, which allows it to respond directly to toxins in the bloodstream such as anesthesia and opioids. The CTZ also receives stimuli from several other locations in the body, including the vestibular center; visceral organs such as the GI tract, kidneys, and liver; the thalamus; and the cerebral cortex.

The vestibular center and cerebral cortex can stimulate the vomiting center directly or indirectly through the CTZ. The  vestibular system  is located within the inner ear and gives a sense of balance and spatial orientation for the purpose of coordinating movement with balance. The feeling of nausea associated with motion sickness often arises from stimuli from the vestibular center. The gastrointestinal tract sends stimuli to the CTZ via cranial nerves IX and X related to obstruction, distension, inflammation, and infection. The cerebral cortex and other parts of the brain can also stimulate a sense of nausea related to odors, tastes, and images and send these stimuli to the CTZ. The CTZ forwards these signals to the vomiting center in the brain. Pain can also directly stimulate the vomiting center.

The  vomiting center  (VC) is located in the medulla in the brain. In response to these stimuli, the vomiting center initiates vomiting by inhibiting peristalsis and producing retro-peristaltic contractions beginning in the small bowel and ascending into the stomach. It also produces simultaneous contractions in the abdominal muscles and diaphragm that generate high pressures to propel the stomach contents upwards. Additionally, autonomic stimulation of the heart, airways, salivary glands, and skin cause other symptoms associated with vomiting such as salivation, pallor, sweating, and tachycardia. Several neurotransmitters are involved in the nausea and vomiting process, and antiemetic medications are targeted to specific neuroreceptors.[ 5 ]

Table 7.5a compares the neurotransmitters involved in the nausea and vomiting process, classes of antiemetic medication targeting these neurotransmitters, prototype antiemetic medications, and associated mechanisms of action.[ 6 ] Each medication class is also discussed in more detail later in this section.

Neurotransmitters and Associated Medications Used to Treat Nausea and Vomiting

Applying the Nursing Process to Administering Antiemetics

When administering antiemetics, identify factors contributing to the symptoms of nausea and vomiting so that treatment can correctly target the cause. Document the frequency and amount of emesis and effects on the client’s appetite and fluid intake. Assess for symptoms of dehydration, such as decreased blood pressure associated with tachycardia, decreased skin turgor, and decreased urine output or dark concentrated urine. If lab tests are ordered, monitor hemoglobin, hematocrit, and serum sodium levels for additional signs of dehydration.

Advocate for the most effective route of administration if the client is vomiting. Consider timing of administration of antiemetics in advance of meals when appetite is affected. Follow drug label administration information and monitor the client closely for potential side effects associated with that category of medication. For example, when administering anticholinergics and antihistamines, monitor for anticholinergic side effects, especially in elderly clients.

Monitor for improvement of nausea and vomiting and notify the provider if expected improvement does not occur so that other treatment can be initiated. Continue to monitor for dehydration. Teach the client these nonpharmacological interventions for nausea:

• Drink enough fluids to avoid dehydration. If you are having trouble keeping liquids down, drink sips of clear liquids every few minutes.
• Eat bland foods; stay away from spicy, fatty, or salty foods.
• Eat smaller meals more often.
• Avoid strong smells because they can sometimes trigger nausea and vomiting.
• If you are pregnant and have morning sickness, eat crackers before you get out of bed in the morning.[ 7 ]

Antiemetic Medication Classes

Scopolamine is an example of an anticholinergic medication that is often used to treat motion sickness or nausea and vomiting associated with surgical recovery from anesthesia and/or opiate analgesia.

Mechanism of Action:  Anticholinergics block ACh receptors in the vestibular center and within the brain to prevent nausea-inducing stimuli to the chemoreceptor trigger zone (CTZ) and the vomiting center (VC). They also dry GI secretions and reduce smooth muscle spasms.

Indications:  Anticholinergics, like scopolamine, are commonly used to prevent motion sickness and treat nausea and vomiting

Nursing Considerations:  The scopolamine transdermal patch (see Figure 7.19 )[ 8 ] is designed for continuous release of scopolamine following application to an area of intact skin on the head, behind the ear. The system is formulated to deliver approximately 1 mg of scopolamine to the systemic circulation over three days. It is contraindicated in clients with glaucoma. It has been reported to exacerbate psychosis, induce seizures, and cause drowsiness, confusion, and sedation. Due to its anticholinergic properties, scopolamine can decrease gastrointestinal motility and cause urinary retention. Scopolamine should be discontinued in clients who develop difficulty in urination. Scopolamine transdermal patches contain an aluminized membrane; skin burns have been reported at the application site in clients wearing an aluminized transdermal system during an MRI scan. Remove scopolamine transdermal patches before undergoing an MRI.

Figure 7.19

Scopolamine Transdermal Patch

Application instructions:

• Only wear one transdermal system at any time.
• Do not cut the transdermal system.
• Apply the transdermal system to the skin in the postauricular area (hairless area behind one ear).
• After the transdermal system is applied on the dry skin behind the ear, wash hands thoroughly with soap and water and dry hands.
• If the transdermal system becomes displaced, discard the transdermal system, and apply a new transdermal system on the hairless area behind the other ear.
• For surgeries other than cesarean section, apply one scopolamine transdermal system the evening before scheduled surgery. Remove the transdermal system 24 hours following surgery.

Side Effects/Adverse Effects:  Anticholinergics have potential side effects such as dry mouth, constipation, blurred vision, confusion, and memory impairment, especially in elderly clients.

Health Teaching & Health Promotion:  Scopolamine transdermal patches may impair the mental and/or physical abilities required for the performance of hazardous tasks such as driving a motor vehicle, operating machinery, or participating in underwater sports. Concomitant use of other drugs (e.g., alcohol, sedatives, hypnotics, opiates, and anxiolytics) that cause central nervous system (CNS) adverse reactions, or that have anticholinergic properties, may increase this impairment. Inform clients not to operate motor vehicles or other dangerous machinery or participate in underwater sports until they are reasonably certain that scopolamine does not affect them adversely. Scopolamine can cause temporary dilation of the pupils, resulting in blurred vision if it comes in contact with the eyes. Advise clients to wash their hands thoroughly with soap and water and dry their hands immediately after handling the transdermal system. Upon removal, fold the used transdermal system in half with the sticky side together, and discard in household trash in a manner that prevents accidental contact or ingestion by children, pets, or others.[ 9 ]

Antihistamines

Meclizine is an example of an antihistamine that is often used to treat motion sickness.

Mechanism of Action:  Antihistamines block H1 receptors in the vestibular center and may also block acetylcholine (ACh).

Indications:  Antihistamines such as meclizine block the action of histamine in the body. When H1 receptors are blocked in the vestibular center, this prevents motion sickness and nausea.

Nursing Considerations:  Antihistamines are contraindicated in clients with glaucoma or an enlarged prostate gland. Dosage should be started one hour before travel begins.

Side Effects/Adverse Effects:  Antihistamines have potential side effects such as drowsiness, dry mouth, blurred vision, and constipation. Some antihistamines can also interact with other medications or medical conditions.

Health Teaching & Health Promotion:  Advise clients of the following:

• Do not exceed recommended dosage.
• Be advised that drowsiness may occur.
• Avoid alcohol, sedatives, and tranquilizers, which may increase drowsiness.
• Avoid alcoholic drinks.
• Be careful when driving a motor vehicle or operating machinery.[ 10 ]

Dopamine Antagonists

Prochlorperazine is an example of a dopamine antagonist used to treat nausea and vomiting. It can also be used as an antipsychotic medication.

Mechanism of Action:  Prochlorperazine blocks dopamine in the chemoreceptor trigger zone (CTZ). It also calms the central nervous system and may also block acetylcholine.

Indications:  Dopamine antagonists block the action of dopamine in the brain and can help treat nausea and vomiting .

Nursing Considerations:  Prochlorperazine can be administered orally, intramuscularly, rectally or intravenously. It is contraindicated in children under age 2 or under 20 pounds. Severe side effects have occurred when used to treat psychosis.

Side Effects/Adverse Effects:  Potential side effects are drowsiness, restlessness, dry mouth, constipation, and movement disorders, especially with long-term use.

Health Teaching & Health Promotion:  Clients should be instructed to take medications as prescribed. They should avoid alcohol and other CNS depressants. Clients may experience increased photosensitivity, and extreme temperatures should be avoided. Clients should be advised that urine may turn pinkish to reddish-brown.[ 11 ]

Prokinetics

Metoclopramide is an example of a prokinetic medication (see Figure 7.20 ).[ 12 ]

Figure 7.20

Mechanism of Action:  Metoclopramide blocks dopamine and may also sensitize tissues to acetylcholine. It is used to promote peristalsis to empty the gastrointestinal tract and thus reduce nausea.

Indications:  Metoclopramide is a dopamine antagonist that can be used to treat gastrointestinal disorders by improving motility.

Nursing Considerations:  Metoclopramide can be administered orally, intramuscularly, and intravenously. The onset of pharmacological action of metoclopramide is 1 to 3 minutes following an intravenous dose, 10 to 15 minutes following intramuscular administration, and 30 to 60 minutes following an oral dose. Pharmacological effects persist for 1 to 2 hours.

Metoclopramide should not be used whenever stimulation of gastrointestinal motility might be dangerous (e.g., in the presence of gastrointestinal hemorrhage, mechanical obstruction, or perforation). Metoclopramide is contraindicated in clients with pheochromocytoma because the drug may cause a hypertensive crisis. Metoclopramide should not be used in epileptics or clients receiving other drugs that are likely to cause extrapyramidal reactions because the frequency and severity of seizures or extrapyramidal reactions may be increased. Rare reports of neuromalignant syndrome have occurred.

Side Effects/Adverse Effects:  Metoclopramide has potential side effects, such as drowsiness, restlessness, movement disorders, and an increased risk of depression and suicidal thoughts, especially with long-term use.

Health Teaching & Health Promotion:  Teach clients to immediately inform the health care provider if they experience new feelings of depression or abnormal muscle movements they cannot control such as the following:

• Lip smacking, chewing, or puckering of the mouth
• Frowning or scowling
• Sticking out the tongue
• Blinking and moving the eyes
• Shaking of the arms and legs[ 13 ]

Serotonin Antagonists

Ondansetron is an example of a serotonin (5HT) antagonist often used to treat severe nausea and vomiting associated with chemotherapy, postoperative nausea and vomiting, and hyperemesis during pregnancy. (See Figure 7.21 [ 14 ] for an image of ondansetron blocking the 5-HT 3  receptor.)

Figure 7.21

Ondansetron Blocking the 5-HT 3  Receptor

Mechanism of Action:  Ondansetron blocks serotonin receptors in the GI tract, the chemoreceptor trigger zone (CTZ), and the vomiting center (VC). See Figure 7.22 [ 15 ] and Figure 7.23 [ 16 ] for images of the injectable and oral formulations of ondansetron.

Figure 7.22

Ondansetron in Injectable Form

Figure 7.23

Ondansetron in Tablet Form

Indications:  Serotonin antagonists, also known as serotonin blockers, are a class of drugs that block the action of serotonin, a neurotransmitter in the brain.

Nursing Considerations:  Ondansetron is available as an orally disintegrating tablet and as an injectable for those clients too nauseated to tolerate oral medication. It is contraindicated with apomorphine.  Serotonin syndrome  can occur if administered concurrently with other serotonin antagonists or selective serotonin reuptake inhibitors. Ondansetron can cause headaches, drowsiness, constipation, fever, and diarrhea. A rare but serious adverse effect of ondansetron is QT prolongation that can cause an abnormal cardiac rhythm.

Side Effects/Adverse Effects:  It is important to note that serotonin antagonists have potential side effects such as dizziness, headache, constipation, and nausea. Some serotonin antagonists can also interact with other medications or medical conditions.

Health Teaching & Health Promotion:  Teach clients to immediately inform their health care provider if they experience a change in heart rate, light-headedness, or feel faint or have any signs and symptoms of hypersensitivity reactions such as fever, chills, rash, or breathing problems.[ 17 ]

Neurokinin Receptor Antagonists

Aprepitant is an example of a neurokinin antagonist used to prevent nausea and vomiting associated with chemotherapy and surgery.

Mechanism of Action:  Aprepitant inhibits substance-P neurokinin receptors in the brain stem.

Indications:  Neurokinin receptor antagonists are a class of drugs that block the action of substance P, a neuropeptide that plays a role in pain, inflammation, and other physiological processes.

Nursing Considerations:  Aprepitant is usually administered concurrently with dexamethasone (a corticosteroid) and ondansetron. It can be administered orally or intravenously. It has clinically significant CYP3A4 drug interactions with medications, such as pimozide, diltiazem, and rifampin, and can decrease INR levels when taken concurrently with warfarin. It can also reduce the effectiveness of oral contraceptives.

Side Effects/Adverse Effects:  Neurokinin receptor antagonists have potential side effects such as fatigue, dizziness, constipation, and decreased appetite.

Health Teaching & Health Promotion:  Teach clients taking warfarin that they will need to monitor their INR levels more closely, which may require adjustment of the warfarin dosage, while taking aprepitant. Teach clients using an oral contraceptive to use backup birth control.[ 18 ]

Tetrahydrocannabinols (THC)

Dronabinol or medical marijuana is an example of a  THC  medication used to treat nausea in clients with cancer or AIDS (see Figure 7.24 [ 19 ] and Figure 7.25 [ 20 ]).

Figure 7.24

Dronabinol, a THC Medication

Figure 7.25

Medical Marijuana

Mechanism of Action:  THC has inhibitory effects in the cerebral cortex causing an alteration in mood and the body’s perception of its surroundings, which may relieve nausea and vomiting, as well as stimulate the appetite.

Indications:  THC has antiemetic properties and can be used to treat nausea and vomiting associated with chemotherapy or other medical conditions.

Nursing Considerations:  THC will cause a dose-related responses such as elation, heightened awareness, and laughing. THC should be used cautiously in elderly clients because they may be more sensitive to the neurological, psychoactive, and postural hypotensive effects of the drug. In general, dose selection for an elderly client should be cautious, usually starting at the low end of the dosing range.

Side Effects/Adverse Effects:  THC has potential side effects, including impaired memory and concentration, impaired motor coordination, anxiety, and paranoia. Additionally, THC can be habit-forming and may have psychoactive effects that can impair daily activities.

Health Teaching & Health Promotion:  Teach clients to not drive, operate machinery, or engage in any hazardous activity when using THC. Keep out of reach of children and pets.[ 21 ]

Herbal and Vitamin Supplements

Ginger has been used in traditional Indian and Chinese medicine as an antiemetic. Although its mechanism of action is not completely understood, ginger is thought to antagonize the 5HT and cholinergic receptors and may have direct activity on the gastrointestinal tract. Although ginger can cause reflux and heartburn and may potentially cause bleeding because of its anticoagulant effects, dosages of up to 2 grams per day in divided doses of 250 mg are considered safe even in pregnant women. Pyridoxine (vitamin B6) has also been recommended for treating nausea and vomiting in pregnancy. Typical dosages of pyridoxine 10 to 25 mg every eight hours cause minimal adverse effects.[ 22 ]

Now let’s take a closer look at the medication grid comparing medications used to treat nausea. See Table 7.5b .[ 23 ]

Antiemetics Medication Grids

Critical Thinking Activity 7.5

A nurse is caring for a client who underwent surgery earlier today and is experiencing nausea and vomiting. The original post-op orders included prochlorperazine, but the client continues to experience vomiting despite receiving this medication. The nurse calls the provider and receives a new order for ondansetron orally dissolving tablets 8 mg three times daily as needed.

1. How will the nurse assess for symptoms of dehydration?

2. When administering the medication, the client states, “This tastes terrible! Why can’t I have a normal pill to swallow?” What is the nurse’s best response?

3. What other measures should the nurse teach the client to reduce feelings of nausea and avoid dehydration?

7.6. LEARNING ACTIVITIES

Case Study 1

Mrs. Jones is a 68-year-old female who has been admitted to the hospital for the management of gastroesophageal reflux disease (GERD). She has a history of hypertension and dyslipidemia and is currently taking lisinopril and atorvastatin. Her symptoms include heartburn, chest pain, and difficulty swallowing. Her physician has prescribed omeprazole, a proton pump inhibitor (PPI), to manage her GERD symptoms.

1. What are proton pump inhibitors?

2. What is the mechanism of action of PPIs?

3. What are the potential side effects of PPIs?

4. What should the nurse monitor for in Mrs. Jones while she is taking omeprazole?

5. How should the nurse instruct Mrs. Jones to take omeprazole?

6. What are some important drug interactions with omeprazole?

7. When should the nurse instruct Mrs. Jones to follow up with her health care provider?

Case Study 2

Mr. Lopez is a 45-year-old male who presents to the emergency department with complaints of severe diarrhea for the past 24 hours. He has been experiencing cramping, nausea, and frequent watery stools. He reports no recent travel or dietary changes. Upon further assessment, the health care provider diagnoses him with acute infectious diarrhea and prescribes loperamide to manage his symptoms.

1. What is loperamide?

2. What is the mechanism of action of loperamide?

3. What are the potential side effects of loperamide?

4. What should the nurse monitor for in Mr. Lopez while he is taking loperamide?

5. How should the nurse instruct Mr. Lopez to take loperamide?

6. What are some important drug interactions with loperamide?

7. When should the nurse instruct Mr. Lopez to follow up with his health care provider?

Note: Answers to the Case Studies can be found in the “ Answer Key ” sections at the end of the book.

“GI Flashcards” by E. Christman for   Open RN   is licensed under   CC BY 4.0

Test your clinical judgment with this NCLEX Next Generation-style bowtie question:  GI Assignment 1 .[ 1 ]

Test your clinical judgment with this NCLEX Next Generation-style bowtie question:  GI Assessment 2 .[ 2 ]

VII. GLOSSARY

The adhesion of molecules to a surface. For example, bismuth salicylate coats the walls of the GI tract and binds the causative bacteria or toxin for elimination from the GI tract through the stool.

Used to neutralize stomach acid and reduce the symptoms of heartburn.

Relieve the symptoms of diarrhea, such as an increased frequency and urgency when passing stools, but do not eliminate the cause of it.

Medications that help to treat diarrhea by slowing peristalsis.

A structure in the medulla oblongata in the brain stem that controls vomiting. Its location in the brain also allows it to play a vital role in the control of autonomic functions by the central nervous system.

Area in the brain that responds directly to toxins in the bloodstream and also receives stimuli from several other locations in the body that stimulate the vomiting center.

Enzymes produced from the cytochrome P450 genes involved in the formation (synthesis) and breakdown (metabolism) of various molecules, chemicals, and medications within cells.

The digestive process where undigested materials are removed from the body as feces.

The passage of three or more loose or liquid stools per day (or more frequent passage than is normal for the individual).

The forceful oral expulsion of gastric contents.

Infection of the intestines.

Caused by excessive hydrochloric acid that tends to back up, or reflux, into the lower esophagus.

Blood in the vomit.

Elevated levels of calcium in the bloodstream.

Necessary for the absorption of vitamin B12 in the small intestine.

Cause water to be retained with the stool, increasing the number of bowel movements and softening the stool so it is easier to pass.

Cells in the gastric glands that produce and secrete hydrochloric acid (HCl) and intrinsic factor.

A digestive enzyme.

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.

Used for the prevention and treatment of diarrhea by restoring normal bacteria flora in the gastrointestinal tract.

Medications used to promote peristalsis to empty the gastrointestinal tract and reduce nausea.

Bind to the hydrogen-potassium ATPase enzyme system of the parietal cell and inhibit the release of hydrogen ions into the stomach.

A side effect of medication causing elevated levels of hydrochloric acid in the stomach after the medication is discontinued.

Symptoms associated with serotonin syndrome may include the following: mental status changes (e.g., agitation, hallucinations, delirium, and coma), autonomic instability (e.g., tachycardia, labile blood pressure, dizziness, diaphoresis, flushing, hyperthermia), neuromuscular symptoms (e.g., tremor, rigidity, myoclonus, hyperreflexia, incoordination), and seizures, with or without gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea).

Laxatives that cause the intestines to contract, inducing stool to move through the colon.

Laxatives that facilitate movement of water and fats into stool to make it soft and improve regularity of bowel movements.

A common condition in hospitalized clients that can lead to peptic ulcer disease (PUD).

Medication to prevent the formation of stress ulcers.

Cells found within the lining of the stomach that secrete mucus as a protective coating.

Tetrahydrocannabinols found in marijuana.

An area located within the inner ear that gives a sense of balance and spatial orientation for the purpose of coordinating movement with balance.

An area in the brain that initiates vomiting by inhibiting peristalsis and producing retro-peristaltic contractions beginning in the small bowel and ascending into the stomach. It also produces simultaneous contractions in the abdominal muscles and diaphragm that generate high pressures to propel the stomach contents upwards.

Licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/ .

• Cite this Page Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Pharmacology [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2023. Chapter 7 Gastrointestinal System.
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• GASTROINTESTINAL INTRODUCTION
• BASICS CONCEPTS OF THE GASTROINTESTINAL SYSTEM
• ANTIULCER MEDICATIONS
• ANTIDIARRHEAL MEDICATIONS AND LAXATIVES
• ANTIEMETICS
• LEARNING ACTIVITIES

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Acute upper gastrointestinal bleed: a case study

Affiliation.

• 1 Molloy College, Rockville Centre, New York, USA. [email protected]
• PMID: 10646396

Upper gastrointestinal (UGI) bleeding on a presenting symptom is of major significance for nurse practitioners in any clinical setting. Bleeding in the upper gastric tract is a symptom of a disease process rather than a disease in itself. UGI bleeding accounts for 300,000 hospitalizations annually. An astute knowledge of the pathophysiology and clinical presentations of UGI bleeding enables swift intervention and a reduction in morbidity and mortality rates. This article presents a case report of a white male in his fifties diagnosed with metastatic colon cancer and acute UGI bleeding and emphasizes the need for early screening and detection, disease education, and prompt interventions to minimize associated complications.

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• [Acute ulcerative gastrointestinal hemorrhages in the middle-aged and elderly]. Pinskiĭ SB, Ageenko VA. Pinskiĭ SB, et al. Khirurgiia (Mosk). 1980 Sep;(9):16-20. Khirurgiia (Mosk). 1980. PMID: 6999219 Russian. No abstract available.
• [Standards for bleeding ulcer in the upper gastrointestinal tract]. Mössner J, Caca K. Mössner J, et al. Dtsch Med Wochenschr. 2003 Jun 13;128 Suppl 2:S64-8. doi: 10.1055/s-2003-40164. Dtsch Med Wochenschr. 2003. PMID: 12817325 Review. German. No abstract available.
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Inflammatory Bowel Disease Case Study (45 min)

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What further history questions would you ask Ms. Hale?

• Normal” bowel habits – how many times a day, color, consistency
• Previous experiences with bleeding?
• Diet and lifestyle habits
• Other medical conditions and medication history

Ms. Hale reports she has 5-10 bowel movements daily, she has had 3 already this morning. She reports she’s used to that, especially if she eats greasy foods. She says “I had just accepted that I would never poop normally, but I’ve never seen that amount of blood before. It was crazy!”. She reports a weight loss of 10 lbs in the last 4 months.

What additional nursing assessments need to be performed?

• Full set of vital signs
• Full abdominal assessment
• Assess any bowel movements
• Assess skin and pulses for signs of anemia or poor perfusion due to bleeding

What diagnostic tests would you expect the provider to order? Why?

• CBC – to assess for severity of bleeding (keep in mind that the H/H may take some time to ‘catch up’ to the blood loss)
• Colonoscopy – to evaluate for a source of bleeding
• Digital Rectal Exam and fecal occult blood test

Ms. Hale’s vital signs are stable. The provider found frank blood on a digital rectal exam. Ms. Hale received a colonoscopy, which showed a bleeding ulcer in her transverse colon, which was cauterized, but no other signs of bleeding.  The provider believes this may have been an isolated incident due to irritation caused by the patients greasy food diet and IBS. He orders for her to be discharged home.

What discharge instructions should be included for Ms. Hale?

• Avoid foods that are irritating to the bowels
• Report increased bleeding/bloody stools or severe abdominal pain
• Drink plenty of water
• Eat bland foods for 2-3 days to avoid irritation to the ulcer that was cauterized

Ms. Hale returns to the ED 2 days later complaining of bright red blood in her stools – two yesterday and five already today. She reports severe lower abdominal pain, nausea and vomiting. 

What further diagnostic testing should be done at this time?

• Repeat colonoscopy, possible endoscopy, CT scan
• Labs – check CRP and ESR for inflammatory markers
• Re-check CBC due to further bleeding

The nurse notes open sores in Ms. Hale’s mouth and Ms. Hale also begins reporting epigastric pain.

An endoscopy, repeat colonoscopy, and CT scan show severe thickening of the mucosa in the small and large intestine, with some ulcerations in the duodenum and ileocecal junction, in addition to the previous one seen in the transverse colon.

What do you believe might be the issue for Ms. Hale?

• She may actually have an inflammatory bowel disease, NOT irritable bowel syndrome.
• If that’s the case, she’s obviously having a significant exacerbation at this time.

Is Ms. Hale presenting with signs of Ulcerative Colitis or Crohn’s Disease? Explain.

• Ms. Hale is presenting with signs of Crohn’s Disease – the telltale sign is that there are ulcerations and thickening of the mucosa in places OTHER than the large intestine. Ulcerative Colitis ONLY affects the colon.
• Ms. Hale has ulcerations in her mouth and small intestine.
• Although Ulcerative colitis tends to have bloody stools more often than Crohn’s, bloody stools are also possible during Crohn’s exacerbations

A Gastroenterology specialist officially diagnoses Ms. Hale with Inflammatory Bowel Disease, and explains that these symptoms can sometimes be misdiagnosed until they become severe.  Specifically, he diagnoses her with Crohn’s Disease and explains how it affects the entire GI tract. He will write for new medications and discharge her home tomorrow, as long as she is stable.

What medications would you expect Ms. Hale to be discharged with? Why?

• Corticosteroids – to decrease the inflammation
• Immunomodulators – to decrease the autoimmune inflammatory response
• Antidiarrheals – to prevent large loss of fluids in stool

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Nursing Case Studies

This nursing case study course is designed to help nursing students build critical thinking.  Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process.  To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy  to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs.  If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding.  In the end, that is what nursing case studies are all about – growing in your clinical judgement.

Nursing Case Studies Introduction

Cardiac nursing case studies.

• 6 Questions
• 7 Questions
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Obstetrics Nursing Case Studies

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• 9 Questions

Metabolic/Endocrine Nursing Case Studies

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Open Access

Peer-reviewed

Research Article

Clinical judgment model-based nursing simulation scenario for patients with upper gastrointestinal bleeding: A mixed methods study

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Writing – original draft

Affiliation Department of Nursing, Nambu University, Gwangju, Republic of Korea

Roles Formal analysis, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation College of Nursing, Chonnam National University, Gwangju, Republic of Korea

• AeRi Jang, 
• Hyunyoung Park

• Published: May 3, 2021
• https://doi.org/10.1371/journal.pone.0251029
• Peer Review
• Reader Comments

Assisting patients with upper gastrointestinal bleeding is a crucial role for nurses, and as future nurses, students should demonstrate sound clinical judgment. Well-structured, high-quality simulations are useful alternatives to prepare students for clinical practice. However, nursing simulation scenarios focused on enhancing clinical judgment in managing upper gastrointestinal bleeding are limited. This study aims to develop, apply, and evaluate an effective nursing simulation scenario for patients with upper gastrointestinal bleeding based on Tanner’s clinical judgment model using a mixed methods study design. A high-fidelity patient simulation was conducted among 80 undergraduate nursing students divided into a simulated control group ( n = 39) and an experimental group ( n = 41). Subsequent student performance evaluations used questionnaires and video recordings. After scenario simulations, the students showed a statistically significant increase in theoretical knowledge ( p = 0.001) and clinical performance skills ( p < 0.001), but there was no significant increase in self-confidence ( p = 0.291). According to the video analysis, the “noticing” clinical judgment phase was the most frequently observed phase, while “reflection” was the least frequently observed phase. Additionally, “education” was the most frequently observed nursing domain, and “anxiety” was the least frequently observed domain. Although further simulation repetitions are required to reinforce students’ self-confidence when caring for patients with upper gastrointestinal bleeding, the scenario was deemed effective. Moreover, emphasis should be placed on developing various scenarios to strengthen students’ clinical judgment skills, especially “reflecting” and “emotional care.”

Citation: Jang A, Park H (2021) Clinical judgment model-based nursing simulation scenario for patients with upper gastrointestinal bleeding: A mixed methods study. PLoS ONE 16(5): e0251029. https://doi.org/10.1371/journal.pone.0251029

Editor: César Leal-Costa, Murcia University, SPAIN

Received: December 29, 2020; Accepted: April 17, 2021; Published: May 3, 2021

Copyright: © 2021 Jang, Park. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the paper and its Supporting Information files.

Funding: This work was supported by the National Research Foundation of Korea (NRF 2017R1C1B5017463).

Competing interests: The authors have declared that no competing interests exist.

Introduction

Nursing academic institutions have difficulty securing practice facilities for their students’ clinical placements because of the COVID-19 pandemic. As such, simulations have been actively used worldwide as an alternative format for clinical practice [ 1 ]. Understanding the clinical judgment process and how nurses think in actual clinical situations are essential considerations for simulations to be appropriately used as an alternative to clinical practice. Therefore, simulations should reinforce practicing clinical judgment by allowing students to think like a nurse. Tanner [ 2 ] presented the clinical judgment process as a model that incorporates various tasks, such as noticing, interpreting, responding, and reflecting. Instructors are challenged to provide effective simulations that improve competencies, such as clinical judgment, and prepare students to become future nurses, but these skills only develop over time through experience [ 3 ]. Simulations have already been identified as a potent approach for developing nursing students’ clinical judgment [ 4 , 5 ].

Furthermore, well-structured, high-quality simulations have been suggested as effective teaching modalities comparable to hospital-based clinical experiences [ 6 ]. However, to effectively improve nursing student competencies using simulations, medical school faculties need to select diverse scenarios reflecting real-world situations through multiple simulation experiences [ 4 , 7 ]. Despite the COVID-19 pandemic, it is a critical time for educators to share ideas about using simulations to prepare students for clinical environments [ 1 ]. Developing simulation scenarios based on the clinical judgment model and evaluating students’ clinical judgment experience during the simulations will help construct meaningful simulation experiences that could replace clinical practice during and after the pandemic.

Simulation scenario development for nursing education

Although upper gastrointestinal bleeding (UGIB) is curable with medications or endoscopic hemostasis treatments, its hospital mortality rate can go as high as 8.7% [ 8 , 9 ]. As such, patients with UGIB require rapid and timely diagnosis and treatment. To date, published guidelines have emphasized the nurses’ role in interpreting signs, symptoms, and risk factors related to UGIB [ 10 ]. Adding specific materials to nursing students’ curricula to help them rapidly develop their capabilities and display their effectiveness in caring for patients with UGIB is essential to reinforce their knowledge.

Nursing educators encourage their students to develop clinical judgment and apply their knowledge and experience in decision-making or patient care [ 2 , 11 ]. Specifically, Tanner [ 2 ] proposed the clinical judgment model (CJM), which explains how nurses should think in practical situations where clinical judgment is required, and includes four phases: noticing, interpreting, responding, and reflecting. The most effective proposed teaching method for enhancing nursing students’ clinical judgment is simulation-based learning [ 12 ], as it allows students to acquire the required knowledge, skills, and attitudes in a practical manner [ 13 ].

Although several simulation-related studies have used Tanner’s model, such research focused on post-simulation debriefing or assessment rubric development [ 14 – 16 ]. However, improving the nurses’ clinical judgment requires a simulation scenario based on clinical judgment [ 17 ]. In this area, studies based on Tanner’s model are lacking.

Notably, in previous literature related to simulations for patients with UGIB, clinical judgment focused on scenario development and the student self-evaluation processes [ 18 ]. As such, these scenarios’ effects have only been evaluated based on self-confidence and satisfaction levels [ 19 ]. Other scenarios were also developed to improve the endoscopic techniques of resident physicians [ 20 ].

The study has two major purposes. First, this study aims to develop a simulation-based learning scenario integrated with the phases of Tanner’s model to create simulations that effectively improve nursing students’ capability to advance in the clinical field. Second, this study applies and evaluates a scenario’s effectiveness when caring for patients with UGIB.

Materials and methods

The study utilized a mixed methods design ( Fig 1 ). Specifically, a self-report survey and video analysis were used to evaluate the developed scenario’s effectiveness and review the experimental group’s simulations, respectively [ 21 ].

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• TIFF original image

https://doi.org/10.1371/journal.pone.0251029.g001

Participants

Recruitment was announced on a notice board at Songwon University, and the study’s participants mainly included 3rd-year nursing students who took a course on the digestive system. The students recruited for the study understood its purpose and provided their written consent. Among the recruited students, those who had difficulties participating in discussions or team activities arising from physical or mental issues, disagreed with the confidentiality agreement related to the scenario’s operation, or took pictures and video recordings during the study were excluded. The study’s results were obtained from 80 participants (4 dropped out for personal reasons) divided into two groups: 41 students in the experimental group and 39 students in the simulated control group. To calculate the number of the study participants, G-power 3.19.2 and “ANOVA: repeated measures, within-between interaction” were chosen (effect size = 0.25, α = 0.05, power = 0.95, correlation coefficient = 0.5). The experimental and control groups included 36 students each, which was considered representative of the larger student population.

Scenario development

The high-fidelity human patient simulation scenario was developed by two adult nursing professors and one simulation professor for 3rd-year medical school students in South Korea. This scenario mainly focused on applying the clinical judgment steps (assessing, diagnosing, planning, implementing, and evaluating) in the nursing process to provide urgent care for patients with UGIB. The title, learning objectives, simulation operating methods, and teaching materials were determined to develop the scenario, and available facilities and equipment were identified. In line with the learning objectives, five domains required sound clinical judgment for caring for patients with UGIB, including bleeding, pain, nutrition, anxiety, and education. The scenario was subsequently developed to allow students to practice the four phases of Tanner’s CJM in each of the five domains. Content related to medical treatment was based on guidelines provided by Bai and Li [ 10 ]. In the developed scenario, a 48-year-old female with intermittent epigastric pain visited the hospital for further evaluation because of hematemesis, and her primary diagnosis was gastric ulcer bleeding. The scenario presented a situation where the patient showed vomited blood in a paper cup to the nurse during a regular ward round. Students were assigned roles in each simulation team, including one charge nurse, two or three acting nurses, and one documenting nurse.

Two nurses with over five years of experience in a gastroenterology ward confirmed the clinical practice’s reproducibility to verify the developed scenario’s validity. One gastroenterologist confirmed the medical aspect of the scenario, and two nursing professors in charge of the simulations confirmed the feasibility of the simulated operation. The initial scenario was revised based on feedback from the expert panel and finalized after the pilot test.

Study assistants’ training.

The simulation operator and instructor have over two years of clinical experience and simulation operation experience. Both underwent two rounds of 2 h training sessions on study-related information conducted by a researcher. The instructor also participated in an 8 h simulation-related education session. During the training period, the data collector was taught the questionnaire completion method and common cautions, such as confidentiality and data management.

Measurement tools.

For homogeneity tests between the experimental and simulated control groups, the study investigated metacognition [ 22 ], self-deterministic learning motivation [ 23 ], and critical thinking ability [ 24 ], each of which can affect the clinical judgment process using questionnaires ( S1 and S2 Files ).

This study adopted a strategy proposed by Yang [ 25 ] as a self-regulated academic measuring tool modified to fit nursing students using a Cronbach’s alpha coefficient of 0.910 to measure nursing students’ metacognition. For self-deterministic learning motivation, the academic self-regulation questionnaire (SRQ-A) was adapted and validated, following the method of Bak et al. [ 26 ], using a Cronbach’s alpha coefficient of 0.900. The study also used the thinking tendency measuring tool for Yoon’s [ 27 ] critical thinking using a Cronbach’s alpha coefficient of 0.901.

This study gauged the self-confidence, theoretical knowledge, and clinical performance skills to verify the scenario’s effectiveness based on Tanner’s CJM. Jeffries et al. [ 28 ] suggested the participants’ responses and learned behavior to measure learning achievement in simulation education. The corresponding tool developed here was verified by two adult nursing professors and two clinical nurses, and the content validity indexes of all comprised items were over 1.0. For self-confidence measurements, the instrument consisted of seven items, based on a Cronbach’s alpha coefficient of 0.933. Meanwhile, the theoretical knowledge instrument consisted of 10 items, with higher scores showing a higher level of knowledge. As for clinical performance skills, the instrument consisted of 27 items with a Cronbach’s alpha coefficient of 0.931. Higher scores on the scale represented a higher level of the item being measured.

Data collection.

Data collection was conducted from November 23 to December 1, 2018, at the Songwon University simulation lab through a survey using structured self-report questionnaires and an observation method using video analysis. One week before the simulation operation, the experimental group performed self-learning activities as prelearning using online materials such as video clips. The materials developed covered numerous aspects, including theoretical knowledge (30 min) and performance skill (30 min), related to nursing care for patients with UGIB. Each student team consisted of four to five members, and a total of nine teams were involved in the simulation.

The simulation class lasted for 100 min, which was comprised of a presimulation team activity (60 min), simulation operation (20 min), and postsimulation (20 min). The simulation operator played the doctor and monitored the simulation process, while the simulator moderator played the patient and adjusted the simulation. For the simulated control group, general characteristics and homogeneity-related variables were previously measured. A pretest to determine confidence, theoretical knowledge, and clinical performance skill levels was immediately provided after prelearning using online materials. The pretest for the simulated control group and the posttest for the experimental group were conducted at one-week intervals to prevent treatment diffusion. A separate surveyor conducted the data survey.

The entire simulation operation process for the nine teams in the experimental group was recorded using a high-definition camcorder for video analysis. The analysis was conducted by an expert with over four years of nursing experience in a gastroenterology ward and an expert with over three years of simulation operating experience. The video analysis team first classified the nursing actions expected for each clinical judgment process in the scenario developed before proceeding to the video analysis. Both experts independently examined the frequency of students’ clinical judgment behaviors by reviewing and analyzing the recorded videos.

In this study, the students’ clinical judgment behavior is defined as the actual performance of actions for noticing, interpreting, responding, and reflecting in the nursing care domains of bleeding, pain, nutrition, anxiety, and education involving patients with UGIB. The examiners’ rating reliability was substantial, with a Cohen’s kappa coefficient (κ) of 0.7. Any disagreement between the examiners was resolved by consensus.

Data analysis

Collected data were analyzed using Statistical Package for the Social Sciences (SPSS Version 20.0; IBM, 2012). The participants’ general characteristics and the value of each variable were calculated using descriptive statistics, including frequency, percentage, mean, and standard deviation. The homogeneity test of participants was performed using a Chi-square test and a t-test. Verification of the effectiveness of the scenario application was analyzed using a t-test. The video analysis results on the frequency of students’ clinical judgment were examined based on the mean, minimum, and maximum.

Ethical considerations

Ethical approval was obtained from the Ministry of Health and Welfare–designated Korean Public Institutional Review Board (IRB No. PO1-201811-13-004). A research assistant obtained written informed consent from each participant after explaining this study’s purpose, the lack of disadvantages in refusal, and the possibility of withdrawal at any time. For the control group, the same simulation education was provided after the experimental group’s posttest.

Developed scenario

The scenario’s final version allowed nursing students to experience Tanner‘s clinical judgment process in the five areas (bleeding, pain, nutrition, anxiety, and education) required in the nursing and care of patients with UGIB. For instance, in the “noticing” stage under the “bleeding” domain, 10 cues (including blood pressure decrease and heart rate increase) were provided in which the participants could make clinical judgments. In the “interpreting and responding” stage, 17 items, including vital sign check or oxygen saturation level check, were established as appropriate actions. In the “reflecting” stage, three items, including checking hemoglobin test results after blood transfusions, were established. This detailed scenario is further described in Table 1 .

https://doi.org/10.1371/journal.pone.0251029.t001

General characteristics and homogeneity test

There were 31 female students (75.6%) and 10 male students (24.4%) in the experimental group, and 35 female students (89.7%) and 4 male students (10.3%) in the control group. The average ages of the experimental and control groups were 23.10 and 23.05, respectively. According to the homogeneity test, neither group displayed statistically significant differences in gender, age, satisfaction levels in their nursing majors, adult nursing scores in the previous semester, metacognition, self-deterministic learning motivation, or critical thinking ( Table 2 ).

https://doi.org/10.1371/journal.pone.0251029.t002

Verification of effectiveness on scenario application

Although there was no significant increase in self-confidence ( p = 0.291), the simulated control group’s pretest score was 22.41, and the posttest score of the experimental group was 23.49. Theoretical knowledge showed a statistically significant increase ( p = 0.001), presenting a pretest score of 3.36 in the control group and a posttest score of 4.71 in the experimental group. Clinical performance skills also showed a statistically significant increase ( p < 0.001), presenting a pretest score of 27.44 in the control group and a posttest score of 34.98 in the experimental group ( Table 3 ).

https://doi.org/10.1371/journal.pone.0251029.t003

According to the video analysis, students performed the “noticing” stage 12.7 times; the “interpreting and responding” stage was performed 9.4 times, and the “reflecting” stage was performed 9.0 times. Based on the nursing domain results, the domain with the highest observed frequency compared to the expected frequency was “education” (expected = 8, observed = 5.4), and the lowest was “anxiety” (expected = 8, observed = 0.4). As observed in Tanner’s CJM phases, the phase with the highest observed frequency compared to the expected frequency was “noticing” (expected = 30. observed = 12.7), and the lowest was “reflecting” (expected = 9, observed = 2.1; Table 4 ).

https://doi.org/10.1371/journal.pone.0251029.t004

This study’s UGIB patient scenario was developed based on Tanner‘s clinical judgment process for five nursing domains. Existing research on simulation-based education for nursing students involving patients with UGIB generally focused on training and evaluating nursing skills required for gastrointestinal emergencies rather than clinical judgment—the focus of this study [ 18 , 19 ]. In previous studies, rather than developing a scenario, Tanner’s model was used to analyze students’ clinical judgment skills after applying the simulation [ 15 ] or verifying the effectiveness of a scenario based on objectified figures of clinical judgment skill improvements [ 14 , 16 ]. However, the scenario developed in this study went beyond the evaluation of clinical skills when caring for patients with UGIB. It was a systemically designed scenario appropriate for nursing care to promote clinical judgment in the “bleeding,” “pain,” “nutrition,” “anxiety,” and “education” nursing domains, as required in clinical settings for patients with UGIB. This scenario is significant because it is the first trial that requires nursing students to think like real nurses in the field through a simulation that is faithful to the clinical judgment process.

The results showed a statistically significant increase in theoretical knowledge and clinical performance skills; self-confidence also increased, although it was not statistically significant. A previous meta-analysis study on simulation effects, knowledge, and performance showed a statistically significant increase, and self-confidence showed a statistically significant increase due to simulation learning effects [ 18 , 19 , 29 ]. Similarly, Pereia-Salgado et al. [ 30 ] operated simulations for “advance care planning” for nurses, where self-confidence results displayed a statistically significant increase in “initiating” and “revisiting.” Here, the nursing simulation significantly increased the participants’ self-confidence compared to the presimulation.

The findings of previous studies differ from those of the present study for the following reasons. First, because of this study’s short-term application of the simulation scenario, it was difficult to attain a statistically significant increase in self-confidence. Moreover, the simulation was likely a burden to the students because it allowed them to learn about the clinical judgment process. Further research should investigate the development and repetitive application of various simulation scenarios that promote students’ self-confidence in using clinical judgment in nursing practice. During the simulation-based experience, simulation educators and facilitators should also use effective cues to help participants build self-confidence and achieve expected learning outcomes.

The video analysis results indicate that nursing educators who apply the simulation should be more attentive in enhancing nursing students’ performance in the “reflecting” phase of Tanner’s model and in “emotional care.” Among the clinical judgment process phases, “reflecting” was not observed as frequently as “noticing” or “interpreting and responding.” This result indicates that the simulation educator should provide more cues and sufficient time for the nursing students to reach and finish the “reflecting” clinical judgment process in a scenario operation. The “anxiety” domain displayed the lowest observed frequency. Meanwhile, the observed frequency of the “noticing” domain was 0 instead of the expected value of 4, representing how nursing students actively carried out clinical judgment behaviors for physical care involving bleeding, pain, and nutrition.

Conversely, clinical judgment in emotional care, which helps reduce patients’ anxiety during the simulation operation, was insufficient. Empathy, which positively affects patients as it plays an essential factor in the therapeutic relationship between nurses and their patients, is an ability that can be developed through simulations [ 31 ]. Therefore, further development and operation of simulation scenarios are needed for students to practice varied and holistic nursing-oriented clinical judgment.

This study’s results are somewhat difficult to generalize due to several limitations. The participants were recruited from the nursing department of one university. Thus, the study results can be misinterpreted because of extraneous variables from the simulated control group study design. Moreover, the maturation effect cannot be controlled, and the evaluator’s subjectivity could affect the video analysis.

Conclusions

This study successfully developed and applied a simulation scenario for patients with UGIB based on Tanner’s CJM. It also identified the effectiveness of simulations and the current level of clinical judgment among undergraduate nursing students. The scenario was developed to allow students to practice the four phases of clinical judgment in five domains while effectively improving their theoretical knowledge and clinical performance when caring for patients with UGIB. Future studies can follow several suggestions. First, a randomized design study using the developed scenario for patients with UGIB should be conducted with students from different educational institutes. Second, diverse simulation-based education using different scenarios should be developed to strengthen “reflecting” in clinical judgment and “emotional care” in nursing situations. Third, a longitudinal study should evaluate clinical judgment ability improvements after repeatedly applying scenarios based on Tanner’s CJM. Fourth, future studies should examine non-face-to-face teaching methods and the effects of using Tanner’s model-based simulation in a virtual environment. Fifth and last, this study proposed a well-exposed and evaluated clinical simulation scenario for urgent clinical situations. However, future studies can use a randomized study design to evaluate multiple scenarios of the same clinical situation.

Supporting information

S1 file. original research participant presurvey questionnaire in korean..

https://doi.org/10.1371/journal.pone.0251029.s001

S2 File. Translated research participant presurvey questionnaire.

https://doi.org/10.1371/journal.pone.0251029.s002

Acknowledgments

The study’s authors would like to express their heartfelt thanks to the gastroenterologist, nurses, professors, consultants who assisted in scenario development, the instructors and operators who assisted during scenario operation, and the participants in this study. This study could not be accomplished without their valuable time and support.

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• 11. Regulation terminology: Version 1. International Council of Nurses. 2005 November [Cited 2020 December 10]. Available from: https://www.area-c54.it/public/regulation%20terminology.pdf
• 18. Park, SJ. Development and evaluation of a virtual simulation program on nursing care for patients with acute upper gastrointestinal bleeding. MSc thesis, Kyung Hee University, Seoul. 2018.
• 21. Park IH, Jou IS, Ru HS, Seo EH, Lee JM, Kim YG. Nursing research: Principles and practice. 2nd ed. Seoul: Komoonsa; 2016.
• 25. Yang MH. The study on development and validation of self-regulated learning model. PhD dissertation, Seoul National University, Seoul. 2000.
• 27. Yoon J. Development of an instrument for the measurement of critical thinking disposition: In nursing, PhD dissertation. Catholic University of Korea, Seoul. 2004.

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Case study: gastroenterology, severe gastrointestinal (gi) bleed secondary to xarelto with a hemoglobin-based oxygen carrier (sanguinate) available as precautionary measure.

A 78-year old man who is one of Jehovah’s Witnesses presented with fatigue and weakness along with a 4-week history of maroon colored stools.  He was recently admitted to another hospital for a pulmonary infection, where he was found to be in atrial fibrillation (AF) and diagnosed with a non-ischemic cardiomyopathy.  He was placed on Xarelto, one of the newer anticoagulants, as a preventative measure, due to his AF.  His past medical history included hypertension, type-2 diabetes mellitus, mild aortic stenosis, hematuria, and arterio-venous malformations in the gastrointestinal tract. 

His hemoglobin upon admission was 4.1 g/dL, which decreased to 3.1 on the 3rd day after admission.  Xarelto was discontinued upon admission and he was placed on aspirin 325 mg/day.  An upper GI endoscopy, was normal.  A colonoscopy revealed a transverse colon polyp but no active bleeding.  He also had a video capsule endoscopic exam where a small “pill camera” is swallowed and video pictures of the entire GI tract are recorded.  This exam was significant for an arterial-venous malformation (AVM) in the proximal small bowel, which was not actively bleeding at that time.  An echocardiogram showed a left-ventricular ejection fraction of 40%, which was much improved over a prior exam at an outside hospital showing a 10% ejection fraction. 

His treatment plan included the following regimen given daily:  folate 1 mg IV, vitamin B12 1,000mcg SQ, iron sucrose 200 mg IV, and erythropoietin 40,000 units IV.  Phlebotomy blood loss was minimized using neonatal tubes, which require about 10% of the blood volume compared to the full adult sized tubes. 

Given his very low hemoglobin, and his risk factors for coronary artery disease, our team decided to obtain a hemoglobin-based oxygen carrier (Sanguinate), in case he developed congestive heart failure or symptomatic myocardial ischemia.  This was procured within 24 hours after the necessary FDA phone calls and paperwork, along with the Johns Hopkins IRB emergency applications.  These measures were required given that Sanguinate (and all other hemoglobin based oxygen carriers) are not yet FDA approved, and are only available for “compassionate use”.  Since the half-life of these compounds is relatively short, the concept is to use them as a temporary measure while the erythropoietic regimen is given to promote red blood cell production.  Although the Sanguinate was obtained, its use was not necessary since the patient did not exhibit symptoms, despite severe anemia, and responded well to the erythropoietic therapy.

The hemoglobin level upon discharge on day #7 was 5.1 g/dL.  He was not symptomatic from this anemia (his heart rate was 50 bpm).  He was sent home on all his prior medications except for Xarelto.  Aspirin 325 mg/day, and iron sulfate 325 mg/day were recommended upon discharge.  He visited the infusion clinic three times in three weeks, where iron dextran 1 gram IV, and erythropoietin 40,000 units IV, were given during each visit.  His last hemoglobin was 11.1 g/dL after these three treatments.   He is being followed up by Cardiology, Gastroenterology and Hematology.