NURS 6521 Week 7: Gastrointestinal and Hepatobiliary System

NURS 6521 Week 7: Gastrointestinal and Hepatobiliary System

Sample Answer for NURS 6521 Week 7: Gastrointestinal and Hepatobiliary System Included After Question

Gastrointestinal (GI) and hepatobiliary disorders affect the structure and function of the GI tract. Many of these disorders often have similar symptoms such as abdominal pain, cramping, constipation, nausea, bloating, and fatigue. Since multiple disorders can be tied to the same symptoms, it is important for advanced practice nurses to carefully evaluate patients and prescribe treatment that targets the cause rather than the symptom. Once the underlying cause is identified, an appropriate drug therapy plan can be recommended based on medical history and individual patient factors. In this Discussion, you examine a case study of a patient who presents with symptoms of a possible GI/hepatobiliary disorder, and you design an appropriate drug therapy plan. 

Consider the following case study: 

Patient HL comes into the clinic with the following symptoms: nausea, vomiting, and diarrhea. The patient has a history of drug abuse and possible Hepatitis C. HL is currently taking the following prescription drugs:  

• Synthroid 100 mcg daily 

• Nifedipine 30 mg daily 
• Prednisone 10 mg daily 

To prepare: 

• Review this week’s media presentation on pharmacology for the gastrointestinal system. 
• Review the provided case study. Reflect on the patient’s symptoms, medical history, and drugs currently prescribed. 
• Think about a possible diagnosis for the patient. Consider whether the patient has a disorder related to the gastrointestinal and hepatobiliary system or whether the symptoms are the result of a disorder from another system or other factors such as pregnancy, drugs, or a psychological disorder. 
• Consider an appropriate drug therapy plan based on the patient’s history, diagnosis, and drugs currently prescribed. 

With these thoughts in mind: 

By Day 3 

Post an explanation of your diagnosis for the patient including your rationale for the diagnosis. Then, describe an appropriate drug therapy plan based on the patient’s history, diagnosis, and drugs currently prescribed. 

By Day 6 

Read a selection of your colleagues’ responses and respond to at least two of your colleagues on two different days who diagnosed the patient differently than you did, in one or more of the following ways: 

• Provide alternative recommendations for drug treatments. 
• Offer and support an alternative perspective using readings from the classroom or from your own research in the Walden Library. 
• Validate an idea with your own experience and additional research. 

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit! 

Submission and Grading Information 

Grading Criteria  

Symptoms of various gastrointestinal (GI) and hepatobiliary disorders often overlap making diagnosis and treatment challenging. Consider the case of a 21-year-old female who is rushed to the hospital by her roommate. The patient is not conscious enough to describe her symptoms or medical history to the health care provider. However, the roommate is able to share that the patient has experienced abdominal pain for the past three days, as well as vomiting, constipation, and bloating. After unsuccessful attempts at contacting the patient’s family, the roommate decided to bring her in for care. At this point, medical history and currently prescribed drugs are unknown. However, this patient requires treatment for symptoms that could be the result of various underlying disorders. As an advanced practice nurse, you could potentially be responsible for this patient’s care. How would you proceed to care for this patient? What type of drug therapy would you recommend not knowing if she is currently taking other prescribed drugs? Are there certain drugs you should avoid in order to prevent a drug-drug interaction? 

This week you examine diagnoses for patients with potential GI and hepatobiliary disorders. You also develop a drug therapy plan based on patient history and diagnosis. 

Learning Objectives 

By the end of this week, students will: 

• Assess patients with gastrointestinal and hepatobiliary disorders 
• Develop drug therapy plans based on patient history and diagnosis 
• Understand and apply key terms, concepts, and principles related to prescribing drugs to treat gastrointestinal and hepatobiliary disorders 

Photo Credit: PIXOLOGICSTUDIO/Science Photo Library/Getty Images 

Learning Resources 

This page contains the Learning Resources for this week. Be sure to scroll down the page to see all of this week’s assigned Learning Resources. To access select media resources, please use the media player below. 

Required Readings 

Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (Eds.). (2017). Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins. 

• Chapter 28, “Nausea and Vomiting” (pp. 429-446)
  This chapter focuses on the etiology of nausea and vomiting, as well as body systems that impact or trigger nausea and vomiting. It also covers various drugs used to treat nausea and vomiting including the process of selecting, administering, and managing drug therapy for patients.  

  

• Chapter 29, “Gastroesophageal Reflux Disease and Peptic Ulcer Disease” (pp. 447-462)
  his chapter begins with an overview of risk factors, symptoms, and clinical stages of gastroesophageal reflux disease (GERD). It then examines drugs used to treat GERD and peptic ulcer disease (PUD), including proper dosages, possible adverse reactions, contraindications, and special considerations.  

  

• Chapter 30, “Constipation, Diarrhea, and Irritable Bowel Syndrome” (pp.465-494)
  This chapter begins by exploring disorders associated with constipation and diarrhea, as well as drugs used in treatment. It also covers the pathophysiology of irritable bowel syndrome and related drug therapies.  

  

• Chapter 31, “Inflammatory Bowel Disease” (pp. 497-515)
  This chapter examines the causes, pathophysiology, and diagnostic criteria of inflammatory bowel disease (IBD), Crohn’s disease, and ulcerative colitis. It also identifies drugs used to treat IBD, including proper dosage, adverse reactions, and special considerations.  

 

Chalasani, N., Younossi , Z., Lavine, J. E., Charlton, M., Cusi, K., Rinella, M., Harrison, S. A., Brunt, E. M., & Sanya, A. J. (2018). The diagnosis and management of nonalcoholic fatty liver disease: Practice guidance from the American Association for the Study of Liver Diseases. Hepatology, 67(1), 328-357. Retrieved from https://aasldpubs.onlinelibrary.wiley.com/doi/pdf/10.1002/hep.29367 

 

Required Media 

 

Laureate Education, Inc. (Executive Producer). (2012). Pharmacology for the gastrointestinal system. Baltimore, MD: Author. 

  

This media presentation outlines drug treatment options for disorders of the gastrointestinal system. 

  

Note: The approximate length of this media piece is 2 minutes. 

 

Optional Resources 

Refer to the Optional Resources listed in Week 1. 

 

 

To access your rubric: 

Discussion Rubric 

 

Submission 

Post by Day 3 and Respond by Day 6 

 

To participate in this Discussion: 

Week 7 Discussion 

 

 

Week 7 Quiz 

This week’s Quiz covers the content you have explored this week. The Quiz may include the following topics: 

• Drug classifications by indication—gastrointestinal tract 
• Drugs—management of gastroesophageal reflux disease (GERD), inflammatory bowel disease, and irritable bowel syndrome; NSAIDS; treatment options for cirrhosis, liver disease, pancreatitis, peptic ulcers, and viral hepatitis 
• Drug dosage calculations 
• Drug interactions 

By Day 7 

You have 90 minutes to complete this 36-question Quiz. 

This quiz is a test of your knowledge in preparation for your certification exam. No outside resources including books, notes, websites, or any other type of resource are to be used to complete this quiz. You are expected to comply with Walden University’s Code of Conduct. 

Submission and Grading Information 

Submit Your Quiz by Day 7 

 

To submit your Quiz: 

Week 7 Quiz 

 

 

Week In Review 

This week you assessed gastrointestinal and hepatobiliary disorders that included your rationale for the diagnosis, and developed an appropriate drug therapy plan based on patient history, diagnosis and current prescribed drugs. 

Next week you will begin to explore infections by considering issues surrounding the prevalence, management, and education about HIV/AIDS and viral and bacterial infections, as well as the appropriate use of antimicrobial agents. 

Next Week 

A Sample Answer For the Assignment: NURS 6521 Week 7: Gastrointestinal and Hepatobiliary System

Title: NURS 6521 Week 7: Gastrointestinal and Hepatobiliary System

               Nausea, vomiting, and diarrhea can be caused by a number of disease processes. The patient indicated for the purposes of the discussion presents with these symptoms, has a history of drug abuse and possible hepatitis C, and takes Synthroid (Levothyroxine Sodium), Prednisone, and Nifedipine. In this discussion a possible diagnosis will be identified, the appropriate drug therapy plan will be discussed, the current drug regime will be explored, and drugs to suppress vomiting and nausea will be determined. 

Diagnosis 

               Nausea, vomiting, and diarrhea can all be caused by a Hepatitis C infection. Hepatitis C is a systemic viral infection which primarily affects the liver (Huether & McCance, 2017). The infections cause hepatocyte injury as a result of the immune response, inflammation, and fibrosis which can eventually lead to cirrhosis (Huether & McCance, 2017). It takes about 30-60 days to incubate, it can be transmitted parenterally, sexually, across the placenta (Huether & McCance, 2017), and has a high transmission rate in patients who are considered to be drug abusers (Illinois Department of Public Health). Clinically, patients can present with a mild fever, headache, muscle aches, fatigue, loss of appetite, nausea, vomiting and diarrhea (Illinois Department of Public Health). As the disease progresses patients can present with dark-coffee colored urine, clay-colored stools, abdominal pain, and jaundice (Illinois Department of Public Health). The presence of Hepatitis C would warrant an adjustment to the current medication regime. 

Appropriate Drug Therapy Plan 

               The patient is currently on nifedipine, prednisone, and levothyroxine sodium. The medication warranting adjustment due to the presence of Hepatitis C would be the prednisone. Prednisone is converted into the active form, prednisolone, by the liver (Connective RX, 2018). When patients have liver impairment, it is recommended to utilize prednisolone instead of prednisone to avoid the need for the liver to convert the prednisone into prednisolone (Connective RX, 2018). 

Current Drug Regime 

               Prednisone is a systemic corticosteroid that can be utilized for adrenocortical insufficiency, dermatitis, asthma exacerbation, irritable bowel syndrome, exacerbation of COPD and more (Connective RX, 2018). It suppresses of prevents the inflammation or immune response, is 70-90 % protein bound, metabolized by the liver, excreted by in the urine, and peaks in 1-2 hours (Connective RX, 2018). As indicated above, prednisolone is recommended instead of prednisone in patients with hepatic impairment (Connective RX, 2018). Adverse responses can include weakness, insomnia, irritability (Connective RX, 2018), and aggression (Arcangelo, Peterson, & Reinhold, 2017). 

               Nifedepine is a calcium channel blocker that can be used for hypertension, angina, migraine prophylaxis, and altitude sickness (Connective Rx, 2018). It blocks the influx of extracellular calcium through the vascular and myocardial membrane pores (Connective Rx, 2018). It is protein bound, metabolized by the liver rapidly and completely, excreted in the urine, and has a 50-70 % bioavailability (Connective Rx, 2018). Side effects can include dizziness, headache, and weakness (Connective Rx, 2018). 

               Levothyroxine Sodium, also known as synthroid, “exhibits all of the actions of the thyroid hormone” (Connective Rx, 2018). It is 99 % protein-bound, has a slow metabolic clearance, and has a bioavailability of 48%-74% (Connective Rx, 2018). It can be used for hypothyroidism, myxedema coma, and hormonal replacement for organ preservation during the organ transplant process (Connective Rx, 2018). Caution should be utilized with individuals with renal impairment (Connective Rx, 2018). Side effects include diarrhea, nausea, vomiting, and abdominal pain. 

Drugs to Suppress Vomiting and Nausea 

               Promethazine is a phenothiazine that blocks dopamine receptors in the chemoreceptor trigger zone (Arcangelo, Peterson, & Reinhold, 2017). It should not be prescribed with medications that cause central nervous system depression such as hypnotics, opiates, and sedatives (Arcangelo, Peterson, & Reinhold, 2017). Adverse responses can include drowsiness, sedation, and extrapyramidal symptoms (Arcangelo, Peterson, & Reinhold, 2017). Alcohol increases the central nervous system depression (Arcangelo, Peterson, & Reinhold, 2017). 

Summary 

               Nausea, vomiting, and diarrhea can be symptoms of multiple disease processes. Hepatitis C can be the cause of these symptoms in the scenario presented. Due to the hepatic impairment in Hepatitis C, it is recommended to utilize prednisolone instead of Prednisone, due to the liver’s responsibility to convert prednisone into the active form, prednisolone. The current drug regime was discussed, and the suggested medication to suppress the nausea and vomiting is Promethazine. 

  

References 

Arcangelo, V. P., Peterson, A. M., & Reinhold, J. A. (2017). Pharmacotherapeutics for Advanced Practice: A Practical Approach. Ambler, PA: Lippincott Williams & Wilkins. 

Connective Rx. (2018). Nifedipine. Retrieved from PDR: https://www.pdr.net/drug-information/nifedipine?druglabelid=1481 

Connective RX. (2018). Prednisone. Retrieved from PDR: https://www.pdr.net/drug-information/prednisone-tablets?druglabelid=3516 

Connective Rx. (2018). Synthroid. Retrieved from PDR: https://www.pdr.net/drug-information/synthroid?druglabelid=26 

Huether, S. E., & McCance, K. L. (2017). Understanding Pathophysiology. S. Louis, Missouri: Elsivier. 

Illinois Department of Public Health. (n.d.). Hepatitis C. Retrieved from Health Beat: www.idph.state.il.us/public/hb/hbhepc.htm 

A Sample Answer 2 For the Assignment: NURS 6521 Week 7: Gastrointestinal and Hepatobiliary System

Title: NURS 6521 Week 7: Gastrointestinal and Hepatobiliary System

HL is the patient in the case study who is experiencing nausea, vomiting, and diarrhea.  He has a history of drug abuse with suspected hepatitis C.  He is presently prescribed Synthroid 100 mcg daily, nifedipine 30 mg daily, and prednisone 10 mg daily.  More information is needed to make a positive diagnosis for HL.  Since hepatitis C is a concern, the patient’s liver status needs to be evaluated.  According to Arcangelo et al. 2017, sudden onset of nausea, vomiting, and diarrhea suggests that the patient may have gastroenteritis, pancreatitis, cholecystitis, or a drug related-side effect (p.432).  All of the mentioned factors could cause HL to experience NVD. 

Taking a look at the medications that HL is Levothyroxine (Synthroid) mechanism of action turns to T3 and then binds to thyroid receptor proteins exerting metabolic effects through DNA and protein synthesis (Kizior, 2018, p.667).  HL has to be diagnosed with a thyroid disorder to be taking levothyroxine which is a thyroid hormone replacement.  The pharmacokinetics of levothyroxine is that it is variable, incomplete absorption from the GI tract, the protein binding is greater than 99%, widely distributed, it is metabolized in the liver and eliminated by biliary excretion (Kizior, 2018, p.667).  The half-life of this medication is 6-7 days meaning that it can accumulate in the patient’s body easily.  A common side of effect of Synthroid is GI intolerance which is one of the symptoms that HL is experiencing.   

HL is also taking nifedipine which inhibits calcium ion movement across the cell membranes, depressing contractions of cardiac, vascular smooth muscles (Kizior, 2017, p.808.  Nifedpine is a medication that is absorbed from the GI tract, it is primarily eliminated through the urine (Kizior, 2017, p. 808).  Like many other medications, one of the adverse effects is that this medication can cause GI intolerance as well.  The only other medication that HL is taking at this time is prednisone which is also broken down in the liver, converted to prednisolone and excreted through the urine.  Prednisone has a half-life of 2.5-3.5 hours (Kizior, 2017, p.954). 

There is a lot of information that was left out of the case study to help with diagnosing the patient.  It would be important to know if anyone else that he has come into contact with has the same symptoms.  This important because NVD are symptoms associated with food poisoning and other illnesses that are easily spread and contagious.  How long has he had these symptoms could help to determine if they are chronic or acute.  However, with the information presented in this case study HL, I would be diagnosed with gastroenteritis. 

Gastroenteritis is an infectious disease that consists of having three or more loose stools per day that may be accompanied by fever and vomiting (Canziani, Uestuener, Fossali, Lava, Bianchetti, Agostoni, Milani, 2018, p.2). The symptoms associated with this disorder is nausea, vomiting, diarrhea, muscle aches, and low-grade fever (Mayo Clinic, 2018).  To diagnose this disease, the provider would do a physical exam and obtain a stool sample. Stool samples are helpful; rapid stool test can determine if the patient has rotavirus or norovirus. However, there are no fast test for other viruses that can cause gastroenteritis (Mayo Clinic, 2018).   

The course of treatment would be to treat the symptoms and prevent dehydration.  Antiemetic such as ondansetron is used to prevent or treat nausea and vomiting. According to Kizior 2017, it blocks serotonin peripherally on the vagal nerve and terminals and centrally in chemoreceptor trigger zone (p.857).  To treat the patient’s diarrhea, it would be recommended that he use loperamide or bismuth subsalicylate, both are available over the counter without a prescription. Loperamide affects the intestinal wall muscles through opioid receptors; it is poorly absorbed in the GI tract but metabolized by the liver (Kizior, 2018, p. 689).  If the patient is suspected that the gastroenteritis is bacterial or parasitic, it would not be recommended to use an anti-diarrheal.  I would advise the patient to eat a bland diet avoiding caffeinated and fatty foods until and to get adequate rest.   

  

  

Reference: 

  

Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (Eds.). (2017).  

Pharmacotherapeutics for advanced practice: A practical approach(4th ed.). Ambler, PA: Lippincott Williams & Wilkins. 

Canziani, B. C., Uestuener, P., Fossali, E. F., Lava, S. A. G., Bianchetti, M. G., Agostoni, C., &  

Milani, G. P. (2018). Clinical Practice: Nausea and vomiting in acute gastroenteritis: physiopathology and management. European Journal Of Pediatrics, 177(1), 1–5. https://doi-org.ezp.waldenulibrary.org/10.1007/s00431-017-3006-9 

Kizior, R. (2018). Saunders Nursing Drug Handbook 2019. Elsevier – Health Sciences Division. 

Viral gastroenteritis (stomach flu). (2018, October 16). Retrieved January 9, 2019, from  

https://www.mayoclinic.org/diseases-conditions/viral-gastroenteritis/symptoms-causes/syc-20378847 

A Sample Answer 3 For the Assignment: NURS 6521 Week 7: Gastrointestinal and Hepatobiliary System

Title: NURS 6521 Week 7: Gastrointestinal and Hepatobiliary System

Scenario: 

Patient HL comes into the clinic with the following symptoms: nausea, vomiting, and diarrhea. The patient has a history of drug abuse and possible Hepatitis C. HL is currently taking the following prescription drugs: 

• Synthroid 100 mcg daily  
• Nifedipine 30 mg daily  
• Prednisone 10 mg daily  

  

H.L.’s Current Drug Therapy 

Synthroid is a brand name for generic levothyroxine. Levothyroxine is indicated in those with hypothyroidism and some types of thyroid cancer. Levothyroxine is a synthetically prepared levorotatory isomer of thyroxine. Levothyroxine is protein bound and has a bioavailability of 48%-80%. It is excreted by the renal system (DrugBank, 2019). Common side effects include insomnia, tremors, palpitations, angina, tachycardia, and anxiety (Skidmore-Roth, 2018).       

Nifedipine is a calcium channel blocker. Its mechanism of action is to inhibit calcium ion influx across the cell membrane during cardiac depolarization, thus, producing coronary vascular smooth muscle relaxation or dilation. Nifedipine is metabolized by the liver, and 60-80% is excreted as metabolites in urine. Adverse effects of the drug included nausea, vomiting, and diarrhea as well as headaches, dizziness, increased liver function tests (LFTs), flushing, and polyuria (Skidmore-Roth, 2018).  

Prednisone is a corticosteroid that is used as an anti-inflammatory or immunosuppressant drug. It can be used for various disorders of several systems such as endocrine disorders, skin conditions, allergic states, respiratory diseases, hematologic disorders and neoplastic or gastrointestinal diseases (Drugs.com, 2017). Prednisone decreases inflammation by increasing capillary permeability and lysosomal stabilization. It is administered orally and well absorbed. Prednisone is metabolized by the liver, has a half-life of 3-4 hours and is excreted in urine. Adverse effects include tachycardia, diarrhea, nausea, poor wound healing, hyperglycemia, fluid retention, and mood changes (Skidmore-Roth, 2018). 

A Drug Therapy Problem: Specific Association Between the Drug Therapy and the Patient’s Condition 

            A possible cause of H.L.’s symptoms of nausea, vomiting, and diarrhea may be caused by the antihypertensive agent nifedipine due to their history of possible hepatitis C. According to the National Institute of Health (2018), nifedipine therapy has been linked to several cases of clinically apparent acute liver injury. Complete recovery is generally expected after discontinuing the drug and with recovery in three to eight weeks. Moreover, nifedipine should be prescribed with caution in those with cirrhosis of the liver or hepatic impairment due to the reduced clearance of the drug and increased systemic exposure (Nifedipine Rx, n.d.).  

Hepatitis C Treatment Options 

            H.L.’s history indicates a history of drug abuse and the possibility of having hepatitis C. Hepatitis C is a liver infection caused by the hepatitis C virus (HCV). It is estimated that 71 million people have chronic hepatitis C, according to the World Health Organization. Those at highest risk for HCV infection are individuals who inject illicit drugs with nonsterile needles. In developed countries, such as the U. S., most of the new HCV infections are reported in injection drug users. Fortunately, HCV infection is curable with antiviral agents. The Infectious Diseases Society of America, the American Associations for the Study of Liver Diseases, and the International Antiviral Society-USA have guidelines in the treatment of HCV infection (Dhawan, 2018). 

            For acute HCV infection, it is recommended to monitor the patient for spontaneous clearance for a minimum of 6 months before initiating treatment. However, interferon (IFN) sparing regimens are safe for acute HCV infections. For chronic HCV infection, a combination therapy of ribavirin to propylene glycol interferon (PEG-IFN) is used. Interferons have an antiviral, antiproliferative, and immune-regulating activity. PEG-IFN is administered weekly by subcutaneous injection. It is metabolized by the liver and excreted by the kidneys. Most common adverse reactions are headaches, fatigue, myalgia, weakness, and inflammation at the injection site (Drugs.com, 2018b). 

            Ribavirin is an anti-viral drug that is administered as a tablet and should be taken with food. It has direct antiviral activity in tissue culture against many RNA viruses including HCV. Serious adverse side effects include depression, suicide, bacterial infections, and relapse of drug abuse/overdose (Drugs.com, 2018c). 

Proposed Drug Therapy Plan 

            A possible drug therapy plan would be to stop the nifedipine the allow for the liver to recover and instead, start atenolol for blood pressure control. Atenolol is a cardio-selective beta-adrenergic receptor blocking agent used to treat hypertension or angina pectoris.  About 50% of an oral dose of atenolol is absorbed from the gastrointestinal tract as atenolol undergoes little or no metabolism by the liver. Atenolol is excreted by the renal system. Adverse side effects are mild and transient (Drugs.com, 2018a). However, there is a moderate interaction between H.L.’s current drug therapy of prednisone and atenolol. The patient should be taught to notify their provider if they experience sudden, unexplained weight gain or swelling of the hands, ankles, or feet. Prednisone may also reduce the effects of atenolol in lowering blood pressure (Drugs.com, n.d.). 

 

References 

Dhawan, V. K. (2018). Hepatitis C. Retrieved January 9, 2019, from Medscape. 

DrugBank. (2019). Levothyroxine. Retrieved from https://www.drugbank.ca/drugs/DB00451 

Drugs.com. (2018a). Atenolol tablets. Retrieved from https://www.drugs.com/pro/atenolol-tablets.html#s-34067-9 

Drugs.com. (2018b). Peginterferon Alfa-2b. Retrieved from https://www.drugs.com/ppa/peginterferon-alfa-2b.html 

Drugs.com. (2018c). Ribavirin. Retrieved from https://www.drugs.com/pro/ribavirin.html#s-34090-1 

Drugs.com. (2017). Prednisone. Retrieved from https://www.drugs.com/pro/prednisone.html#s-34090-1 

Drugs.com. (n.d.) Drug interaction report. Retrieved from https://www.drugs.com/interactions-check.php?drug_list=1936-0,1463-869,273-0 

National Institute of Health. (2018). Nifedipine. Retrieved from https://livertox.nih.gov/Nifedipine.htm 

(Nifedipine Rx). (n.d.). Nifedipine (Rx). Retrieved January 8, 2019, from Medscape. 

Skidmore-Roth, L. (2018). Mosby’s 2018 nursing drug reference (31st ed.). St. Louis, MO: Elsevier. 

A Sample Answer 4 For the Assignment: NURS 6521 Week 7: Gastrointestinal and Hepatobiliary System

Title: NURS 6521 Week 7: Gastrointestinal and Hepatobiliary System

HL’s clinical presentation includes the symptoms of nausea, vomiting, and diarrhea.  These symptoms can be related to a number of gastrointestinal disorders. Aside from a known history of drug abuse, and the possibility that HL has Hepatitis C, HL is taking medication for a thyroid disorder, a blood pressure medication, and a corticosteroid which is often used to treat some sort of inflammatory response.   

In order to come to a diagnosis, a complete history, physical exam, and potential diagnostic workup is necessary.  Reviewing the patient’s medication history can give me insight as to whether this patient’s symptoms are a result of a drug effect or possible interaction.  I would consider potential intolerance to prescribed medications and drug interactions. 

HL is taking the thyroid hormone Synthroid 100 mcg daily.  This medication is used to treat hypothyroidism and replaces or supplements low or missing thyroxine in patients who do not produce enough thyroxine naturally (Synthroid, 2018).  Adverse reactions associated with Synthroid therapy are primarily those of hyperthyroidism due to therapeutic overdosage, which can include diarrhea, vomiting, abdominal cramps, and elevations in liver function tests (Synthroid, 2018).  HL appears to be on a normal adult dose of Synthroid, so I would not suspect that this is the cause of nausea, vomiting, or diarrhea.  That being said, it is important that HL is having his or her thyroid levels checked periodically to verify that an appropriate dose of Synthroid is being prescribed.  

HL is also taking the medication nifedipine which is a calcium channel blocker that is typically used to treat hypertension and angina.  Since hepatic biotransformation is the predominant route for the disposition of nifedipine, the pharmacokinetics may be altered in patients with chronic liver disease and have a longer half-life and bioavailability (Nifedipine, 2018). Nausea, vomiting, and diarrhea are not common side effects of nifedipine, so I would also not assume that HL’s symptoms are related to this medication.   

This patient is taking prednisone 10 mg daily which is an anti-inflammatory or immunosuppressant medication that can treat many different disorders.  Steroid medication can weaken the immune system, making it easier for a person to get an infection or worsening an infection that a patient already has (Prednisone, 2018). Nausea and vomiting could be a side effect of prednisone, although diarrhea is not a common side effect, and HL is on a low dose of this medication.  Contradictory to potential side effects just listed, corticosteroids do have antiemetic properties, typically when used for chemotherapy-induced nausea and vomiting (Arcangelo, Peterson, Wilbur, Reinhold, 2017, p. 432).   

I have not found that Synthroid, nifedipine, and prednisone taken together would interact in a way that would result in nausea, vomiting, and diarrhea.  

Potential Diagnosis 

Hepatitis C is often referred to as the “silent epidemic” as infected patients are often asymptomatic with only 10% reporting symptoms associated with jaundice (Poll, 2012, p. 397).  This leads me to believe that HL’s symptoms are not directly a cause of hepatitis C.  This scenario does not indicate that HL has a confirmed diagnosis of hepatitis C or that medications are being prescribed for this specific disease process.  I would proceed with laboratory testing to evaluate current liver function tests for HL as well as diagnostic testing for hepatitis C. I would consider other potential causes of HL’s symptoms. 

Some of the potential diagnoses that I would consider include gastroenteritis, drug withdrawal from opiates, appendicitis, cholecystitis, and ulcerative colitis.  “Acute onset of nausea and vomiting suggests gastroenteritis, pancreatitis, cholecystitis, or a drug-related side effect.  When nausea and vomiting are associated with diarrhea, headache, and myalgias, the cause is viral gastroenteritis” (Arcangelo, Peterson, Wilbur, Reinhold, 2017, p. 432).   

Gastroenteritis would be my first thought as this patient presents with all three symptoms of nausea, vomiting, and diarrhea.  Typically, ulcerative colitis, pancreatitis, and cholecystitis do not present with all three symptoms of nausea, vomiting, and diarrhea.  Appendicitis can cause nausea and vomiting and a change in bowel pattern, although diarrhea is not a classic sign.  I would determine if a CT scan is necessary based on lab results as well as an abdominal exam to assess for abdominal tenderness and suspicion of appendicitis.  

Since HL has a known history of drug abuse, I would consider the possibility that this clinical presentation could be the result of opiate withdrawal.  Opioid withdrawal produces side effects that may mimic the flu with muscle aches, tearing, runny nose, insomnia, agitation, and sweating (Drug Withdrawal Symptoms, Timelines, and Treatment, 2019).  As symptoms progress, nausea, vomiting, diarrhea, abdominal cramps, and chills occur (Drug Withdrawal Symptoms, Timelines, and Treatment, 2019).  I would assess for drug abuse by asking HL if he or she has been using opiates, how frequently, and when the last time opiates were used.  

I believe the most likely cause for HL’s symptoms is gastroenteritis.  I would proceed to treat gastroenteritis and drug withdrawal in a similar manner with providing symptomatic control with antiemetics and rehydration.   

Drug therapy plan 

The goals of drug therapy for the treatment of nausea and vomiting are to “alleviate the subjective feeling of nausea and the objective act of vomiting and their associated complications” (Arcangelo, Peterson, Wilbur, Reinhold, 2017, p. 432).  If improvement or control of nausea and vomiting does not occur within 5 to 60 minutes, it is reasonable to try a different medication or method to control the symptoms (Arcangelo, Peterson, Wilbur, Reinhold, 2017, p. 432).   

Nausea, vomiting, and diarrhea are common symptoms seen in emergency departments, urgent care, and clinical settings.  In addition to attempting to identify the underlying cause, antiemetics and antidiarrheal agents can be considered for the relief of symptoms.  Selecting the appropriate antiemetic should be based on patient-specific factors, history, and presentation.   A class of drugs called phenothiazines such as prochlorperazine can be used as first-line therapy for mild to moderate nausea and vomiting.   

Prochlorperazine is an antiemetic and phenothiazine derivative that is useful in the symptomatic treatment of nausea and vomiting in adults. The mechanism of action of this medication blocks postsynaptic mesolimbic dopaminergic receptors in the brain and exhibits a strong alpha-adrenergic and anticholinergic blocking effect depressing the release of hypothalamic and hypophyseal hormones (Prochlorperazine, 2019).  This is believed to depress the reticular activating system affecting the basal metabolism, body temperature, wakefulness, vasomotor tone, and vomiting (Prochlorperazine, 2019).  The usual dosing of the oral form of this medication for an adult is 5 to 10 mg every 4 to 6 hours as needed oral, intravenous, or intramuscular.  The onset of action for oral prochlorperazine is 30 to 40 minutes and peak antiemetic effect for IV effect is 30 to 60 minutes. The oral medication is metabolized primarily in the liver, has a half-life of 6 to 10 hours both oral and IV route, and is excreted mainly in the feces.  

There are no hepatic adjustments for dosing prochlorperazine, but caution should be used with caution in patients with hepatic impairment as should be considered with HL as this patient may have hepatitis C.  There are no identified drug interactions with Synthroid, nifedipine, or prednisone that I could identify with the use of prochlorperazine.  Prochlorperazine can display extrapyramidal side effects that fall into the categories of acute akathisia, dystonia, parkinsonism, and tardive dyskinesia (Collins et al., 2001, p. 492).  One article states that there is a 44% incidence of akathisia in patients after a single dose of prochlorperazine and the symptoms can be very distressing to patients (Collins et al., 2001).  Administering medications such as Benadryl or lorazepam may be given as prophylaxis (Collins et al., 2001).   

After assessing the effectiveness of the antiemetic, I would want to ensure the patient is able to tolerate oral rehydration.  I don’t know if this clinic would have the ability to obtain IV access to give medications and intravenous rehydration, but I would consider this if I were able as part of my treatment plan.   

I would consider the use of an anti-diarrheal medication, although this would depend on the patient’s story and severity. Most cases of diarrhea are self-limiting, and I might actually hesitate to recommend an anti-diarrheal agent to HL as “antimotility from these agents may exacerbate infectious diarrhea by preventing the excretion of the infectious organism, allowing the organism more contact time in the intestines” (Arcangelo, Peterson, Wilbur, Reinhold, 2017, p. 476). If HL was to continue to have diarrhea once nausea and vomiting were controlled, I would suggest the use of an over the counter medication such as loperamide to take at home with a dose of 4 mg orally, followed by 2 mg oral after each loose stool with a maximum of 16 mg per day (Loperamide, 2019).  This medication should be used in caution in patients with hepatic impairment due to reduced first-pass metabolism, so signs of central nervous system toxicity should be monitored (Loperamide, 2019).  As with prochlorperazine, this medication can cause drowsiness or dizziness.  Loperamide acts directly on circular and longitudinal intestinal muscles, through the opioid receptor, to inhibit peristalsis and prolong transit time; reduces fecal volume, increases viscosity, and diminishes fluid and electrolyte loss; demonstrates antisecretory activity (Loperamide, 2019).  

  

References 

Arcangelo, V.P., Peterson, A.M., Wilbur, V., & Reinhold, J.A. (Eds.). (2017). Pharmacotherapeutics for advanced practice: A practical approach(4thed.). Ambler, PA: Lippincott Williams & Wilkins. 

Collins, R. W., Jones, J. B., Walthall, J. D., Chisholm, C. D., Giles, B. K., Brizendine, E. J., & Cordell, W. H. (2001). Intravenous administration of prochlorperazine by 15-minute infusion versus 2-minute bolus does not affect the incidence of akathisia: A prospective, randomized, controlled trial. Annals of Emergency Medicine,38(5), 491-496. doi:10.1067/mem.2001.119249 

Drug Withdrawal Symptoms, Timelines, and Treatment. (2019).  Retrieved January 9, 2019, from https://americanaddictioncenters.org/withdrawal-timelines-treatments 

Loperamide. (2019). Retrieved January 9, 2019, from https://www.merckmanuals.com/professional/gastrointestinal-disorders/gastroenteritis/overview-of-gastroenteritis#section_47 

Poll, R. (2012). Hepatitis C part I: Detection and assessment. Practice Nursing, 23(8): 396-400. Retrieved from https://web-b-ebscohost-com.ezp.waldenulibrary.org/ehost/pdfviewer/pdfviewer?vid=6&sid=9f9950bf-ef3f-4e5e-ba56-e39cb9f3aea0%40pdc-v-sessmgr05 

Prochlorperazine. (2019). Retrieved January 9, 2019, from https://www.merckmanuals.com/professional/gastrointestinal-disorders/gastroenteritis/overview-of-gastroenteritis#section_47 

Synthroid. (2018). Retrieved January 8, 2019, from https://www.drugs.com/pro/synthroid.html 

A Sample Answer 5 For the Assignment: NURS 6521 Week 7: Gastrointestinal and Hepatobiliary System

Title: NURS 6521 Week 7: Gastrointestinal and Hepatobiliary System

Hep C is a viral condition that introduces a non-cytopathic virus to the liver cell and replicates causing necrosis of the cell using either immune-mediated cytolysis, hepatic steatosis, insulin resistance or oxidative stress (Irshad et al, 2013). It is a blood borne virus that is often transmitted through the sharing of needles with injectable drugs (CDC, 2015). It can be transmitted in anyway that there may be exposure to blood and blood products.  

Nifedipine is a medication that is used with hypertension and angina. This medication is a calcium channel blocker and functions by inhibiting calcium ions from moving across the cell membrane. The result of this is the relaxation of cardiac muscle as well as vasodilation (Arcangelo et al, 2017). It is used more commonly with severe hypertension. Amlodipine has become the more commonly used CCB due to being more cost effective to patients with the patent expiration in 2007 (Bryan, 2018). Nifedipine should not be used in patients that have essential hypertension or are in hypertensive crisis in relation to the inconsistencies in reflex tachycardia and blood pressure fluctuations that it has been known to cause. Common side feects of the medication are mood alterations, gastrointestinal upset, headache, dizziness, palpitations, peripheral edema, flushing, and gingival hyperplasia (Arcangelo et al, 2017). The patient having a history of hep C could cause portal vein hypertension as the reason for this medication being prescribed (Copestead and Banasik, 2014). They could also be having GI upset in relation to the use of this medication or to the disease process. Determining how long the patient has been taking this medication and when the symptoms started will help to identify if it is the medication being responsible for the current symptoms. 

Prednisone is a steroid that functions by binding reversibly to albumin and to transcortin (Bashar et al, 2018). The medication may cause anxiety, tremors, increased hunger, fluid retention which can case hypertension and imbalances of electrolytes, elevated blood glucose levels, and insomnia. When taken for prolonged periods patients can develop duodenal and gastric ulcers, hirsutism, cataracts, hypokalemia, fat redistribution, osteoporosis, and elevated triglycerides. This medication may have been prescribed as an anti-rejection medication if the patient were to have had a liver transplant related to the hep C infection and the damage caused to the liver (Henry et al, 2007). Another reason this medication may have been prescribed is if the patient had recently suffered from a viral respiratory infection. This seems unlikely since the patient does not have a prescription for an albuterol inhaler. Another indication for this medication is with the treatment of IBS. In this manner they work to suppress the immune system and inhibit prostaglandin (Arcangelo et al, 2017). More information as to patient condition would be needed in order to understand the prescribing of this particular medication. If it has been taken for a prolonged period, the patient may need to have a complete GI workup to determine if an ulceration has occurred.  

Levothyroxine is a treatment for hypothyroidism. This condition is a result of the decreased levels of T4 or other thyroid hormones but can also be caused by the failure of either the hypothalamus or pituitary gland. The medication functions by replacing the omitted T4 into the patient’s system. No medications that the patient is currently taking have any interactions with this medication. A common symptom of hypothyroidism that may have impact on the patient current condition is constipation. If the medication were not functioning as desired, the patient could become constipated and develop a bowel obstruction resulting in nausea, vomiting and in some cases diarrhea around the obstruction. More information such as when the patient’s last substantial bowel movement occurred, if they have recently used any form of opioid or narcotic that could cause decreased bowel motility, and if they have had any other symptoms of hypothyroidism. If this is the case, an abdominal x-ray could determine if there is an ileus or obstruction.  

More data from the patient is necessary in order to determine the cause of the nausea and vomiting. Once more subjective data is obtained, physical assessment can be completed. From there, the ordering of diagnostics may be necessary.  

  

Arcangelo, V., Peterson, A., Wilbur, V., and Reinhold, J. (2017) Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lipincott Williams and Wilkins 

Bashar, T., Hasan Apu, M., and Mostaid, M. (2018). Pharmacokinetics and bioavailability study of a prednisolone tablet as a single oral dose in Bangladeshi healthy volunteers. Sage Journals. Retrieved from: https://journals.sagepub.com/doi/full/10.1177/1559325818783932 

Bryan, J. (2018). Nifedipine: From the treatment of angina to the treatment of hypertension. The Pharmaceutical Journal. Retrieved from: https://www.pharmaceutical-journal.com/opinion/comment/nifedipine-from-the-treatment-of-angina-to-the-treatment-of-hypertension/11011713.article?firstPass=false 

Copestead, L. and Banasik, J. (2014). Pathophysiology (5th ed.). St. Louis, MO: Elsevier Inc. 

CDC (2015). Viral hepatitis. Centers for Disease Control and Prevention. Retrieved from: https://www.cdc.gov/hepatitis/hcv/index.htm 

Henry, S., Metsellar, H., Van Dijck, J., and Tilanus, H. (2007). The Impact of steroids on hepatitis C virus replication in vivo and in vitro. Annals of the New Yourk Academy of Sciences. 1110(1): 439-447 

Irshad, M., Mankotia, D., and Irshad, K. (2013). An insight into the diagnosis and pathogenesis of hepatitis C virus infection. World Journal of Gastroenterology. 19(44): 7896-7909 

A Sample Answer 6 For the Assignment: NURS 6521 Week 7: Gastrointestinal and Hepatobiliary System

Title: NURS 6521 Week 7: Gastrointestinal and Hepatobiliary System

HL currently is taking these medications and is complaining of nausea, vomiting, and diarrhea. He has a history of hepatitis C and substance abuse and is taking the flowing medication: 

Synthroid 100 mcg daily- this medication is absorbed by gastrointestinal tract system, highly protein bound, which is responsible for its distribution, mostly metabolized by the liver, and eliminated from the body through the renal system and feces (Food and Drug Administration, 2019). Some potential side effects from Synthroid are, headaches, irritable, nausea, vomiting, increase liver function, palpitations, trouble with breathing among others (Food and Drug Administration, 2019).  

Nifedipine 30 mg daily- Is used to treat hypertension and stable angina, by dilating arteries, which impact the afterload and workload of the peripheral system, therefore decreasing blood pressure. In stable angina is decrease the amount of oxygen that is consumed by decreasing afterload, thus making more oxygen available for delivery to the myocardial system (Glowm.com, 2019). Nifedipine is quickly absorbed by the gastrointestinal system after it is taken by mouth, not all the medication reaches the circulatory system due to first past, serum therapeutic level is 25 to 100 ng/ml, is disturbed by plasma protein, metabolized in the liver and excreted through urine and feces, half-life is 2 to 5 hours (Glowm.com, 2019). Some possible side effects are; nausea, diarrhea, constipation, dizziness, headaches, rash and muscle cramps, among others (Glowm.com, 2019).  

Prednisone to 110 mg daily- Is used to treat a wide variety of autoimmune disorders. It is absorbed in the gastrointestinal system, distribution method is unknown, high protein binding capabilities, metabolized in the liver, and excreted in urine, and a half-life 2- 3 hour (Drugbank.com, 2019).   

            According to the American Cancer Society (2017), there are various antiemetics that are used to treat and prevent nausea and vomiting. Antiemetics are used to inhibit the various pathways in the body that are responsible for the trigger of the feeling of nausea and vomiting (American Cancer Society, 2018).  Some antiemetics will work on the portion of the brain that is responsible for vomiting and others are used as rescue, if the first nausea medication is proven to be ineffective (American Cancer Society, 2017). The American Cancer Society further stated that antiemetics and medication for vomiting are placed into categories based on the effect upon the body. These are the list of anti-emetics and medication for vomiting, according to the (American Cancer Society, 2017) 

Serotonin (5-HT3) antagonists:  These medications work by inhibiting the mechanism serotonin, which is believed to be involved with causing nausea and vomiting (Examples: ondansetron, granisetron, dolasetron), (American Cancer Society, 2017). 

NK-1 antagonists-  According to the American Cancer Society (2017) these medication work by impending nausea and vomiting, they are used together with another anti-emetic medication (Examples: aprepitant, rolapitant). 

Steroids- Are administered with another antiemetic, their exact mechanics are not completely understood in the prevention and treatment of nausea and vomiting (Example: dexamethasone), (American Cancer Society, 2017).  

Dopamine antagonists- Act on the neurotransmitter dopamine by preventing it from binding to the area of the brain the is responsible for nausea and vomiting. They are often administered when nausea and vomiting are unable to be managed by other medication. (Examples: prochlorperazine, metoclopramide), (American Cancer Society, 2017). 

Anti-anxiety drugs- Help with the reduction of anxiety and keeping the person calm which in turn reduce vomiting and nausea (Examples: lorazepam, alprazolam), (American Cancer Society, 2017). 

Cannabinoids – “Contain the active ingredient in marijuana. These drugs may be used to treat nausea and vomiting from chemo when the usual anti-emetic drugs don’t work. They also may be used to stimulate appetite”.  (Example: dronabinol) (American Cancer Society, 2017). 

Antacids – According to the (American Cancer Society, 2017), these medications are “used to reduce indigestion and heartburn, which can feel like and sometimes lead to nausea and vomiting”. (Examples: ranitidine, famotidine) (American Cancer Society, 2017). 

While there several medical conditions that can cause nausea and vomiting but based on HL history of hepatitis C he could be experiencing liver damage, cirrhosis and liver cancer. According to the Center for Disease Control (2018) “left untreated, chronic hepatitis C can cause serious health problems, including liver damage, cirrhosis (scarring of the liver), liver cancer, and even death”. The treatment plan for HL would be to refer him to a physician with advanced training dealing with a patient who might be experiencing liver failure. This is because liver disease is the life-threatening disorder.” Management consists of intensive care support, treatment of specific etiology if present and early detection of candidates for liver transplantation” (Panackel, Thomas, Sebastian, and Mathia (2015). Special attention should be given to coma care, fluid management, hemodynamics, metabolic parameters, and infection control. Coagulation parameters complete blood count, metabolic panel, and arterial blood gases should be checked frequently (Panacket et al., 2015). Acute liver failure despite all advances remains a condition “with high mortality’, (Panacket, et al, 2015). Early identification of acute liver failure and “prompt intensive care management is critical improve outcome. Liver transplant remains the only intervention with a survival benefit. Liver assist devices and hepatocyte transplant remain experimental and further advances are required” (Panacket, et al., 2015).  

            There are serval categories of medications that are currently being utilized to treat nausea and vomiting. HL nausea and vomiting can be attributed from hepatitis C, which can cause damage to the liver, liver cancer. Careful assessment must be done based on the medical history of the patient to ensure that correct treatment is chosen.  

References 

American Cancer Society (2017). Medicines to prevent and treat nausea and vomiting. Retrieved  

from https://www.cancer.org/treatment/treatments-and-side-effects/physical-side- 

effects/nausea-and-vomiting/nausea-and-vomiting-drugs.html 

Center for Disease Control (2017). Hepatitis c questions and answers for the public. Retrieved  

from https://www.cdc.gov/hepatitis/hcv/cfaq.htm 

Drugbank.com (2019). Prednisone. Retrieved from  

https://www.drugbank.ca/drugs/DB00635 

Food and Drug Administration (2019). Synthroid. Retrieved from  

https://www.accessdata.fda.gov/drugsatfda_docs/label/2008/021402s011lbl.pdf 

Glowm.com (2019). Nifedipine. Retrieved from  

https://www.glowm.com/resources/glowm/cd/pages/drugs/n022.html 

Panackel, C., Thomas, R., Sebastian, B., & Mathai, S. K. (2015). Recent advances in  

management of acute liver failure. Indian Journal of Critical Care Medicine, 19(1), 27- 

33. doi: 10.4103/0972-5229.148636

A Sample Answer 7 For the Assignment: NURS 6521 Week 7: Gastrointestinal and Hepatobiliary System

Title: NURS 6521 Week 7: Gastrointestinal and Hepatobiliary System

     HL comes into the clinic with nausea, vomiting, and diarrhea (N/V/D), history of drug abuse and possible Hepatitis C. Medications include Synthroid 100 mcg daily, nifedipine 30 mg daily and prednisone 10 mg daily. The following briefly discusses this patients’ current symptoms and possible causes, current medications, options to treat his N/V/D, and pharmacological treatments for Hepatitis C. 

     While viral gastroenteritis is the most common cause of acute diarrhea, especially when accompanied by nausea and vomiting (Barr & Smith, 2014), a patient history will help to delineate symptoms.  Why is HL having N/V/D and for how long? Does he have a fever and what is his skin turgor like? Has the patient travelled out of country lately, is he currently using drugs, is anyone else in his family or social circle sick, when did he last eat, does he have pain and where, what is the nature of his diarrhea,  and is there blood in it are all questions to ask HL (Arcangelo, Peterson, Wilbur, & Reinhold, 2017)?  HL does not have a fever, a fecal occult blood test is negative, skin turgor is good, has had diarrhea and vomiting for one-and-a-half days, HL is an active participant in a residential rehabilitation program, and he does not have constricted or dilated pupils. He does not know of anyone else who is sick and has been trying to sip water and Gatorade in small amounts over the last two days. This is likely a case of viral gastroenteritis, which is self-limiting, and treatment should consist of oral rehydration and relief of symptoms (Barr & Smith, 2014). 

     HL takes levothyroxine, nifedipine, and prednisone. Levothyroxine is synthetically produced and replaces thyroxine (T4) usually made by the thyroid in response to a negative feedback loop governed by the hypothalamus-pituitary-thyroid axis (Hammer & McPhee, 2014). It should be taken on an empty stomach, since absorption is affected by the presence of food, and seventy percent will be metabolized into triiodothyronine (T3) and reverse triiodothyronine. It is metabolized in the liver, and while standard doses are unlikely to cause liver damage, hypersensitivity reactions have occurred with high doses (National Institutes of Health, n.d.). Levothyroxine 100 mcg daily should be continued and managed with annual thyroid stimulating hormone (TSH) levels if TSH has already been normalized (Grove, 2018). 

     Nifedipine is a dihydropyridine calcium channel blocker (CCB) indicated to treat hypertension and chronic stable angina and is a first-line treatment option for hypertension in black patients (Arcangelo et al., 2017). CCBs stop calcium ions from crossing across cell membranes and the dihydropyridine class has higher affinity to cells in the vascular system than they do in the heart (Whalen, Finkel, & Panavelil, 2015). Nifedipine is readily absorbed from the gastrointestinal (GI) tract, has decreased bioavailability secondary to first pass metabolism in the liver, and metabolites are excreted by the kidneys (The Global Library of Women’s Medicine [GLOWN], n.d.). The dose of 30 mg nifedipine should be continued; it is appropriate if blood pressure has been well controlled and this should not be adjusted per vital signs from an isolated visit. 

     Prednisone, a glucocorticoid, can be indicated for many reasons including multiple sclerosis, rheumatoid arthritis, asthma, Hodgkin and non-Hodgkin lymphomas, and after organ transplantation (Whalen et al., 2015). Prednisone is absorbed well after oral administration and must be changed into prednisolone, its active form by the liver and is excreted by the kidneys (Whalen et al., 2015). More patient information is needed to determine if this medication should be continued, even low dose daily doses increase the risk of adverse effects over time (Whalen et al., 2015). Long term steroid use also puts this patient at risk for diarrhea caused by pathogens (Barr & Smith, 2014). 

     Treatment should be aimed at restoring or maintaining hydration, and relief of symptoms. Because HLs vital signs are within normal ranges and skin turgor is good, oral hydration an essential first step to treatment which is often forgone for intravenous fluid resuscitation (Barr & Smith, 2014). 

     Pharmacological treatment of HL’s nausea and vomiting can include drugs from the phenothiazine, antihistamine, benzodiazepine, serotonin antagonist, NK1 antagonists, and others (Arcangelo et al., 2017). For HL, concurrent diarrhea makes metoclopramide a poor choice as increased gastric motility is not desirable, and the “go-to” choice of ondansetron, a serotonin antagonist, may be a poor choice because it is better suited to prevent nausea than treat it, it may increase severity of diarrhea, and can cause an increase in serum hepatic enzymes (Arcangelo et al., 2017). An initial 25 mg oral or suppository dose of promethazine would be appropriate for this patient with lower 12.5 mg doses given as needed every four to six hours, or the smallest effective dose (Wyeth, n.d.). Promethazine works by blocking dopamine receptors in the chemoreceptor trigger zone (Arcangelo et al., 2017) but also blocks H1 histamine at its receptors (Wyeth, n.d.).  Promethazine is well absorbed with relief occurring in as little as 20 minutes, it is metabolized by the liver and excreted in the urine (Wyeth, n.d.). 

     Pharmacological treatment of diarrhea would include over-the-counter loperamide. Though loperamide acts on the mu opioid receptors, it does not cross the blood-brain barrier, nor cause euphoric effects (Arcangelo et al., 2017) and does not pose a risk for the patient with a history of drug use (RxList, n.d.). Loperamide’s action on the opioid receptors in the gut inhibit acetylcholine release decreasing motility (Whalen et al., 2015). It is poorly absorbed, metabolized in the liver and excreted in the stool (RxList, n.d.). 

     Does HL have hepatitis C? If so, there are several newer combination treatments, such as ledipasvir and sofosbuvir, that have demonstrated effectiveness in removing all evidence of the hepatitis C virus (HCV) from the blood (Mullins, Gibson, & Klibanov, 2015). For brevity, ledipasvir/sofosbuvir will be discussed, though other combinations have surfaced including glecaprevir-pibrentasvir and sofosbuvir-velpatasvir. Ledipasvir disrupts the replication of viral DNA by inhibiting the HCV non-structural protein 5A (PubChem, n.d.).  It is highly protein bound and is mostly excreted in the stool unchanged (Mullins et al., 2015). Sofosbuvir inhibits HCV non-structural protein 5B preventing viral replication (DrugBank, n.d.). It is metabolized in the liver and is excreted renally (Mullins et al., 2015). Treatment with the ledipasvir-sofosbuvir combination lasts twelve to twenty-four weeks and is highly effective for those infected with the hepatitis C genotype 1 virus (Mullins et al., 2015). 

  

  

References 

Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (Eds.). (2017). Pharmacotherapeutics for advanced practice a practical  

     approach (4th ed.). Philadelphia, PA: Wolters Kluwer. 

Barr, W., & Smith, A. (2014). Acute diarrhea in adults. American Family Physician, 3(89), 180-189. Retrieved from 

     https://www.aafp.org/afp/2014/0201/p180.html 

DrugBank. (n.d.). Sofosbuvir. Retrieved January 9, 2019, from https://www.drugbank.ca/drugs/DB08934 

Grove, E. (2018). Thyroid problems. InnovAiT, 11(4), 206-211. https://doi.org/10.1177/1755738017752743 

Hammer, G. D., & McPhee, S. J. (2014). Pathophysiology of disease: An introduction to clinical medicine (7th ed.). New York, NY: McGraw 

     Hill Education. 

Mullins, C., Gibson, W., & Klibanov, O. M. (2015). Harvoni (ledipasvir and sofosbuvir) for hepatitis C. The Nurse Practitioner, 40(11), 22- 

     26. https://doi.org/10.1097/01.NPR.0000472253.59198.1c 

National Institutes of Health. (n.d.). Drug record. Thyroid hormone. Retrieved January 9, 2019, from 

     https://livertox.nih.gov/ThyroidHormone.htm 

PubChem. (n.d.). Ledipasvir. Retrieved January 9, 2019, from https://pubchem.ncbi.nlm.nih.gov/compound/Ledipasvir#section=Top 

RxList. (n.d.). Imodium. Retrieved January 9, 2019, from https://www.r(PubChem, n.d.)xlist.com/imodium-drug.htm#description 

The Global Library of Women’s Medicine. (n.d.). Nifedipine. Retrieved January 9, 2019, from 

     https://www.glowm.com/resources/glowm/cd/pages/drugs/n022.html 

Whalen, K., Finkel, R., & Panavelil, T. A. (2015). Lippincott illustrated reviews: Pharmacology (6th ed.). Philadelphia, PA: Wolters Kluwer. 

Wyeth. (n.d.). Phenergan. Retrieved January 9, 2019, from 

     https://www.accessdata.fda.gov/drugsatfda_docs/label/2004/07935s030lbl.pdf 

A Sample Answer 8 For the Assignment: NURS 6521 Week 7: Gastrointestinal and Hepatobiliary System

Title: NURS 6521 Week 7: Gastrointestinal and Hepatobiliary System

            HL is a 20-year-old male patient with a recent blood test and diagnosis for  Hepatitis C because of symptoms that he presented with two months ago, and his history of intravenous drug use along with a history of hypothyroidism and hypertension had presented to the clinic last week with new onset of nausea, vomiting, and blood-streaked diarrhea and was diagnosed with acute exacerbation of one type of inflammatory bowel disease called ulcerative colitis.  Ulcerative colitis is  a chronic inflammatory disease process that affects the mucosa of the rectum and anus that has a prevalence of 619,000 patients in the United States (Archangelo, Peterson, Wilbur & Reinhold, 2017).  HL was prescribed prednisone 10 mg orally for the acute exacerbation of his irritable bowel disease which is added to his current pharmacological regimen of levothyroxine 100 mcg and nifedipine 30 mg orally daily.  HL returned to the clinic today to discuss the pharmacological management treatment that he has started for hepatitis C but notified the practitioner that he has been having some nausea and vomiting episodes with the use of antiviral treatment. 

Analysis of Current Pharmacological Regiman 

            HL takes levothyroxine 100 mg orally daily for hypothyroidism and is prescribed to restore hormonal balances to promote gluconeogenesis, protein synthesis stimulation, and cell growth and differentiation promotion (Vallerand, Sanoski, & Quiring, 2019).  According to Vallerand, Sanoski, and Quiring (2019),  absorption occurs within the gastrointestinal tract at a rate between 40 to 80%, binds to proteins at a rate of 99%, and is metabolized by the liver and also has enterohepatic recirculation but is excreted through feces in bile.  Onset is unknown for oral administration with a peak and duration at 1-3 weeks and should be administered with a full glass of water but 30-60 minutes before breakfast (Vallerand, Sanoski, & Quiring, 2019).   

            Nifedipine is a calcium channel blocker prescribed for hypertension that inhibits the transportation of calcium into myocardial and vascular smooth muscle cells resulting in systemic vasodilation that aids in the reduction of blood pressure (Vallerand, Sanoski, & Quiring, 2019).   Nifedipine is well absorbed and metabolized by the liver, but rapid metabolization can occur because of combination with medications that utilize the CYP3A4 system that decreases the bioavailability of the drug by 45-70% (Vallerand, Sanoski, & Quiring, 2019).  According to Vallerand, Sanoski, & Quiring (2019),  this medication binds to proteins 92-99% of the time and has an onset of 20 minutes and a duration of 6-8 hours and is essential to avoid grapefruit or grapefruit juice when taking this medication because it will increase serum levels and effect. 

            Prednisone is anti-inflammatories steroidal immune modifiers that overpowers the systemic inflammatory response and modifies the immune response (Vallerand, Sanoski & Quiring, 2019).    The drug is administered orally and is well absorbed throughout the body after being converted to prednisolone and then metabolized by the liver with onset within hours with a duration that lasts over 1.2 to 1.5 days (Vallerand, Sanoski & Quiring, 2019).  The medication should be taken in the morning to correlate with the bodies natural cortisol secretion schedule and encourage a diet high in protein, calcium, and potassium but low in sodium and carbohydrates if chronic administration of prednisone is prescribed (Vallerand, Sanoski, & Quiring, 2019).   

Medical Plan of Care 

            HL has come to the clinic today to discuss the medical management of his recent Hepatitis C diagnosis and the patient notified the practitioner that he is suffering from nausea and vomiting after beginning the medications. Hepatitis C is a viral blood infection that is spread through the use of contaminated needles or other tools used for invasive procedures that have not been adequately sterilized but most often found in patients that use or abuse intravenous drugs (Thomas, 2014).    Hepatitis C virus replicates primarily in the liver and is the primary cause of liver disease followed by cirrhosis, and the primary goal of pharmacological therapy is to eradicate the virus and reverse or prevent the complications that occur with chronic hepatitis C (Thomas, 2014).    Treatment with antiviral medications was started for this patient using sofosbuvir, ribavirin, and peginterferon alfa for 12 weeks because these medications inhibit RNA-dependent RNA polymerase stopping viral replication through inhibition (Thomas, 2014).   Sofosbuvir has a peak between 0.5 to 2 hours after metabolization and rapid absorption and has a duration of 24 hours;  extensive metabolization occurs with conversion into an active antiviral and than followed by transformation into GS-331007 that does not have antiviral components than finally excreted by urine or feces (Vallerand, Sanoski, & Quiring, 2019).  

            Ribavirin is an antiviral agent that stops the synthesis of viral DNA and RNA concurrently inhibiting replication of the virus (Vallerand, Sanoski, & Quiring, 2019).    Ribavirin is metabolized by the liver with metabolites being excreted by the kidneys with rapid absorption after metabolization after first pass hepatic metabolism with 64% bioavailability with a peak of 1.7 to 3 hours and a duration of 12 hours (Vallerand, Sanoski & Quiring, 2019).   Peginterferon alfa-2a is an immune modifier used to prevent decreased progression of liver damage and is administered through subcutaneous injection, but through this administration, the medication is well absorbed with a peak between 72-96 hours and a duration of 1 week (Vallerand, Sanoski, & Quiring, 2019).  It is essential for the advanced practitioner to educate the patient on the importance of taking the medications through the prescribed period of 12 weeks and taking  missed doses immediately also it is essential to inform the patient on requiring blood testing during treatment to monitor for anemia and platelet levels. 

            It is determined by the practitioner that the current symptoms of nausea and vomiting are a result of adverse reaction to antiviral therapy.  It is essential for the patient to continue with the treatment, so the practitioner decides to prescribe anti-emetic to help the patient with the adverse symptoms.  Phenothiazines are first-line therapy choices for mild to moderate nausea with prochlorperazine and promethazine the effective medications that are prescribed in this class of anti-emetic (Archangelo, Peterson, Wilbur, & Reinhold, 2017).   Promethazine inhibits the effect of the chemoreceptor trigger zone in the medulla that helps promote the antiemetic properties of the medication and is well absorbed after oral or intramuscular administration (Vallerand, Sanoski, & Quiring, 2019).   Promethazine binds to proteins between 65-90% and is metabolized by the liver with an onset within 20 minutes and a duration between 4-12 hours for oral and intramuscular administration (Vallerand, Sanoski, & Quiring, 2019).    This option is not a good option for HL because of his concurrent IV drug use because of the sedative effects of the medications can cause additive CNS depression  that could result in acute sedation (Vallerand, Sanoski, & Quiring, 2019).   A serotonin antagonist is a better pharmacological option for HL because of the lack of adverse sedative effects found with promethazine.  Ondansetron has been prescribed for HL as an antiemetic that works by antagonizing serotonin receptors in the central nervous system and peripherally in the vagal and splanchnic afferent fibers of the upper GI tract(Archangeo, Peterson, Wilbur & Reinhold, 2017). 

  Ondansetron is completely absorbed after oral administration with metabolization in the liver with rapid onset and a peak between 15-30 minutes and a duration of four to eight hours (Vallerand, Sanoski & Quiring, 2019).    This medication does come in many different preparations, but the best option for HL would be the orally disintegrating tablets because it does not require the patient to swallow the pill creating a possibility of the medication not working after losing it through emesis.    The patient also takes drugs that are metabolized by the liver and with the diagnosis of hepatitis requires continual monitoring to ensure that the patient is receiving the full benefits of the drugs that he is taking for the disease processes that he has been diagnosed with and it is also essential to educate the patient on cessation of IV drug use and provide resources for rehabilitation after the cessation. 

Reference 

Archangelo, V.P., Peterson, A.M., Wilbur, V & Reinhold, J.A. (Eds.).  

(2017). Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins 

Nightingale, A. (2006). Treatment and manage of inflammatory bowel disease. (Cover story). 

Primary Health Care, 16(4), 27–32. https://doi org.ezp.waldenulibrary.org/10.7748/phc2006.05.16.4.27.c604 

Thomas, H. C. (2014). Viral hepatitis. [electronic resource]. Chichester, West Sussex : John Wiley 

& Sons, c2014. Retrieved from https://ezp.waldenulibrary.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=cat06423a&AN=wal.EBC1319495&site=eds-live&scope=site 

Vallerand, A. H., Sanoski, C. A., & Quiring, C. (2019). Daviss drug guide for 

            nurses (16th ed.). Philadelphia, PA: F.A. Davis Company. 

A Sample Answer 9 For the Assignment: NURS 6521 Week 7: Gastrointestinal and Hepatobiliary System

Title: NURS 6521 Week 7: Gastrointestinal and Hepatobiliary System

Patient HL comes into clinic with the following symptoms: nausea, vomiting and diarrhea. The patient has a history of drug abuse and possible hepatitis C. HL is currently taking the following prescription medications: Synthriod 100 mcg daily, Nifedipine 30 mg daily and Prednisone 10 mg daily. 

Diagnosis 

Patient HL would require a further work up due to the diarrhea to include a stool specimen to rule out any bacterial infection in the stool, possibly a drug screen to rule out the use of illegal drugs due to the history and further blood work to rule out hepaitits C. With the presenting complaints I would diagnose the patient with gastroenteritis pending further results. Gastroenteritis is an inflammation of the lining of the intestines caused by a virus, bacteria or parasites ( Medline Plus, 2018). Symptoms of gastroenteritis include diarrhea, nausea and vomiting ( Medline Plus, 2018). Dehydration is most common in gastroenteritis so making sure the patient is hydrated is of upmost importance, in sever cases a patient may be treated with antiemetics, antidiarrheals and antibiotics to control symptoms and prevent further complications.  

Drug Therapy 

Azithromycin is a macrolide antibacterial drug used to treat mild to moderate infections caused by susceptible strains of designated microorganisms ( Drugs.com, 2019). Azithromycin is contraindicated in patients with a history of hepatic dysfunction ( Drugs.com, 2019). If the patient is in fact positive for hepatitis C azithromycin would not be recommended and supportive measures would be more appropriate ( Antiemetics, antidiarrheals and increase in fluid intake). The principal pharmacokinetic/ pharmacodynamic parameter best associated with clinical and microbiological cure has not been elucidated in clinical trials with azithromycin ( Drugs.com, 2019). 

Loperamide is the first line treatment for individuals with diarrhea ( Arcangelo, Peterson, Wilbur & Reinhold, 2017). “Loperamide is an opioid receptor agonist that acts on the u-opioid receptors of the myenteric plexus of the large intestine, similar to the action of morphine without action on the CNS” ( Arcangelo, Peterson, Wilbur & Reinhold, 2017).  it is not well absorbed and does not provide analgesic or euphoric effects ( Arcangelo, Peterson, Wilbur & Reinhold, 2017). Caution should be used in patients with bloody diarrhea, fever or fecal leukocytes( Arcangelo, Peterson, Wilbur & Reinhold, 2017). “Adverse effects include constipation and dry mouth. Patients should be cautioned regarding the potential for drowsiness, as it does not cross the blood- brain barrier, however, may induce drowsiness on some individuals” ( Arcangelo, Peterson, Wilbur & Reinhold, 2017). 

Antiemetics 

Phenothiazines are a commonly used class of drugs to treat nausea and vomiting ( Arcangelo, Peterson, Wilbur & Reinhold, 2017). Prochloperazine and promethazine are the most frequent medications used in this class ( Arcangelo, Peterson, Wilbur & Reinhold, 2017). The mechanism of action presumably involves dopamine receptor blockade in the CTZ ( Arcangelo, Peterson, Wilbur & Reinhold, 2017). “Anticholenergic activity in the vomiting and vestibukar centers of the brain may also contribute to the mechanism of action. Caution must be used in patients with a history of drug abuse as the combinations of medications may increase CNS depression” ( Arcangelo, Peterson, Wilbur & Reinhold, 2017). 

Current Medications 

Synthroid is indicated as a replacement therapy in primary, secondary and tertiary congenital or acquired hypothyroidism ( Drugs.com, 2018). Oral levothyroxine is a synthetic T4 hormone that exerts the same psychological effect as endogenous T4, thereby maintaining normal T4 levels when a deficiency is present ( Drugs.com, 2018). Absorption of orally administered T4 from the gastrointestinal tract ranges from 40% to 80% (Drugs.com, 2018). The majority of synthriod is absorbed from the jejunum and upper ilieum ( Drugs.com, 2018). ” Circulating thyroid hormones are greater than 99% bound to plasma proteins, including thyroxine-binding globulin, thyroxine- binding prealbumin and albumin, whose capacities and affinites vary from each hormone” ( Drugs.com, 2018). The liver is the major site of deiodination also occuring at a number of additional sites, including kidneys and other tissues ( Drugs.com, 2018). 

Nifedipine is a calcium channel blocker that works by relaxing the muscles of the heart and blood vessels and is used to treat hypertension ( Drugs.com, 2017). Nifedipine is rapidly and fully absorbed after oral administration ( Drugs.com, 2017). The drug is detectable in serum ten minutes after oral administration and peak blood levels occur at approximately thirty minutes ( Drugs.com, 2017). Nifedipine is extensively converted to inactive metabolites and approximately 80% of nifedipine and its metabolites are eliminated per the kidneys ( Drugs.com, 2017). 

Prednisone is used as an anti-inflammatory or an immunosupressant used to treat allergic disorders, skin conditions, ulcerative colitis, lupus or breathing disorders ( Drugs.com, 2018). Prednisone tablets contain prednisone which is a glucocorticoid . Glucocorticoid are adrenalcortical steriods, both naturally occuring and synthetic, which are readily absorbed by the gastrointestinal tract ( Drugs.com, 2018). 

Hepatitis C Medications 

Currently available therapies can achieve sustained virologic response defined as the absense of detectable virus twelve weeks after completion of treatment ( Centers for Disease Control and Prevention, 2018). Over ninety percent of HCV infected individuals can be cured of HCV infection regardless of HCV genotype, with eight to twelve weeks of therapy ( Centers for Disease Control and Prevention, 2018). There are approximately thirty seven different medications used to treat hepatitis C by genotype, some of the popular medications are as follows, daclatasvir is indicated for use with sofosbuvir with or without ribavirin for treatment of hepatitis c ( Spach & kim, 2018). Sofosbuvir is a direct acting antiviral agent against hepatitis C ( Spach & Kim, 2018). The direct mechanism of ribavirin contributes to its antiviral efficacy is not fully understood ( Spach & Kim, 2018). Ribavirin has direct antiviral activity in tissue culture against many RNA viruses ( Spach & Kim, 2018). 

References 

Arcangelo, V.P., Peterson, A.M., Wilbur, V. & Reinhold, J.A. (2017). Pharmacotherapeutics for advanced practice: A practical approach. (4th ed). Ambler, PA: Lippincott, Williams & Wilkins 

Centers for Disease Control and Prevention. (2018). Hepatitis C Questions and Answers for Health Professionals. Retrieved from: https://www.cdc.gov/hepatitis/hcv/hcvfaq.htm#section4 

Drugs.com. (2019). Azithromycin. Retrieved from: https://www.drugs.com/pro/azithromycin-dihydrate.html 

Drugs.com. (2017). Nifedipine. Retrieved from: https://www.drugs.com/pro/nifedipine-capsules.html 

Drugs.com. (2018). Prednisone. Retrieved from: https://www.drugs.com/pro/prednisone.html 

Drugs.com. ( 2018). Synthriod. Retrieved from: https://www.drugs.com/pro/synthriod.html 

Medline Plus. (2018). Gastroenteritis. Retrieved from: https://www.medlineplus.gov/gastroenteritis.html 

Spach, D.H. & Kim, N. ( 2018). Antiretroviral Medications. Retrieved from: https://www.hepatitisc.uw.edu/page/treatments/drugs 

A Sample Answer 10 For the Assignment: NURS 6521 Week 7: Gastrointestinal and Hepatobiliary System

Title: NURS 6521 Week 7: Gastrointestinal and Hepatobiliary System

HL presents to the clinic with symptoms of nausea, vomiting, and diarrhea.  History of drug abuse and possible Hepatitis C.  Currently prescribed levothyroxine 100mcg daily, nifedipine 30mg daily, and prednisone 10mg daily. 

Review of Current Medications 

     Levothyroxine is a synthetic T4 hormone that increases the basal metabolic rate and the utilization and mobilizations of glycogen stores (levothyroxine, n.d.).  It is absorbed 40-80% in the GI tract with a bioavailability of 64% (nonfasting) and 79-81% (fasting) individuals (levothyroxine, n.d.).  Levothyroxine is 99% protein bound with volume of distribution of 9-10L (levothyroxine, n.d.).  It is mainly eliminated through the urine (levothyroxine, n.d.).  Adverse effects frequency not defined may include flushing, diarrhea, headache, and anxiety (levothyroxine, n.d.). 

     Nifedipine is a calcium channel blocker that inhibits the influx of calcium ions across myocardial and vascular smooth muscle cell membranes without affecting serum calcium concentrations (nifedipine, n.d.).  Nifedipine has a bioavailability between 40-77% and peaks in 30-120 minutes (nifedipine, n.d.).  Nifedipine is 92-98% protein bound with a volume of distribution of 1.42-2.2 L/kg (nifedipine, n.d.).  It is metabolized in the liver and excreted through the urine and feces (nifedipine, n.d.).  Adverse effects may include peripheral edema, dizziness, headache and nausea (nifedipine, n.d.).  

     Prednisone is a glucocorticosteroid that has mild to moderate anti-inflammatory effects by controlling the rate of protein synthesis, slowing the rate of migration of polymorphonuclear leukocytes and fibroblasts, reversing capillary permeability, and stabilizing lysosomes at a cellular level (prednisone, n.d.).   Prednisone has a bioavailability of 92% and is 65-91% protein bound (prednisone, n.d.).  It is extensively metabolized in the liver and is excreted through the urine (prednisone, n.d.).  Glucocorticosteroids are known to have many adverse effects including mood swings, depression, anxiety, insomnia, restlessness, aggression, psychosis and personality changes (Arcangelo, 2017). 

Phenothiazines 

     Phenothiazines is one of the most commonly prescribed medication classifications in the treatment of nausea and vomiting (Arcangelo, 2017).  Prochlorperazine is a commonly prescribed phenothiazine acts through its antidopaminergic effects, blocking dopamine receptors in the brain and blocking the vagus nerve in the GI tract (prochlorperazine, n.d.).  Prochlorperazine is 12.5% bioavailable with a volume of distribution of 1400-1548 L (prochlorperazine, n.d.).   It is metabolized in the liver and excreted primarily in the feces (prochlorperazine, n.d.).  The most commonly experienced side effects are drowsiness or sedation (Arcangelo, 2017).  

Antihistamines-Anticholinergics 

     This classification of medications is used in the treatment of mild nausea and motion sickness (Arcangelo, 2017).  Hydroxyzine, a commonly used antihistamine-anticholinergic act by inhibiting respiratory, vascular and GI smooth muscle constriction (hydroxyzine, n.d.).  Hydroxyzine reaches onset in 15-30 minutes and peak in 1-2 hours.  Hydroxyzine has a volume of distribution of 16 L/kg in adults and 23L/kg in the elderly (hydroxyzine, n.d.).  It is metabolized in the liver and is excreted through the urine (hydroxyzine, n.d.).  Adverse effects include dry mouth and drowsiness (hydroxyzine, n.d.).  

Benzodiazepines 

     Lorazepam, a common benzodiazepine prescribed in the treatment of nausea and vomiting is believed to centrally affect the vomiting center (Arcangelo, 2017).  Lorazepam is 90% bioavailable and in oral doses reaches a peak in 2 hours (lorazepam, n.d.).  Lorazepam is 85-93% protein bound with a volume of distribution of 1.3 L/kg in adults (lorazepam, n.d.). Lorazepam undergoes glucuronic acid conjugation and is excreted in the urine mainly as inactive metabolites (lorazepam, n.d.).  The most common side effects include drowsiness, fatigue, confusion, and impaired coordination (Arcangelo, 2017). 

Serotonin Antagonists 

     This classification is utilized to prevent nausea and vomiting, often being used in patients who are receiving chemotherapy and radiation (Arcangelo, 2017).  The addition of ondansetron has made this classification of medications more affordable.  Ondansetron’s exact mechanism of action is not fully understood, but what is known is that it selectively binds to 5-HT3 receptor in the periphery and in the CNS causing effects in the GI tract (ondansetron, n.d.).  It is between 56-71% bioavailable and is 70-76% protein bound with a volume of distribution of 2.2-2.5 L/kg in adults (ondansetron, n.d.).  It is hepatically metabolized and excreted primarily through the urine but some through feces (ondansetron, n.d.).  Common side effects include a headache, malaise, and constipation (ondansetron, n.d.).  

Metoclopramide 

     Metoclopramide acts by blocking the dopamine receptors and serotonin receptors in chemoreceptor trigger zone of the central nervous system, it sensitizes tissues to acetylcholine, enhances gastric motility excluding secretions, and increases lower esophageal sphincter tone (metoclopramide, n.d.).  When administered orally it is 65-95% bioavailable and peaks in 60-120 minutes (metoclopramide, n.d.).  Metoclopramide is 30-40% protein bound with a volume of distribution of 3.5 L/kg (metoclopramide, n.d.).  It is metabolized in the liver and is excreted through the urine (metoclopramide, n.d.).  Commonly experienced side effects are extrapyramidal symptoms such as dystonia (Arcangelo, 2017).  

Direct Acting Antivirals 

     Direct acting antivirals (DAAs) have proven to be effective in the treatment of chronic hepatitis C (Foster et al., 2016).  Sofosbuvir, a DAA, acts by suppressing viral replication through inhibiting HCV Ns5B RNA-dependent polymerase (sofosbuvir, n.d.).  Sofosbuvir reaches peak plasma in 0.5-2 hours and is 61-65% protein bound (sofosbuvir, n.d.).  It is metabolized in the liver and is excreted in the urine (sofosbuvir, n.d.).  Side effects may include fatigue, headache, nausea, insomnia, and pruritis (sofosbuvir, n.d.).  

     A major setback with the use of direct-acting antivirals in the treatment of hepatitis C virus is the costs associated with treatment.  The high price of these medications has limited access to care and rationing of these medications in the United States, focusing treatment on those who have advanced liver disease, access to specialty care, and who are not current substance users (Rosenthal & Graham, 2016).  In a study conducted by Aggarwal et al. (2017), they looked at the effectiveness of generic DAAs and the cost-saving potentials that could potentially be effective.  In their study, they found that in India treatment with generic DAAs improved patient outcomes and provided a similar value for money within 2 years’ time as the individual’s life expectancy and quality of life improved. 

Diagnosis 

     While there is certainly a multitude of diagnosis that could be probable for this patient, the one that I find the most plausible is related to the history of his drug abuse.  I would be concerned that HL’s current symptoms are a result of drug usage or drug withdrawal.  If this was the case, I would be more cautious in prescribing benzodiazepines for concern of abuse or addiction.  I would also be concerned about prescribing any medications that could suppress the CNS system if the patient is still actively abusing substances.  Alcohol and marijuana are two of the most commonly abused substances in the United States.  I have encountered patients who abuse marijuana and have suffered from hyperemesis syndrome from its usage.  While hyperemesis syndrome related to cannabinoid use would not account for diarrhea associated in this case, without out having greater detail I support substance abuse related illnesses as a potential diagnosis. 

References 

Aggarwal, R., Chen, Q., Goel, A., Seguy, N., Pendse, R., Ayer, T., & Chhatwal, J. (2017, May 17). Cost-effectiveness of hepatitis C treatment using generic direct-acting antivirals available in India. PLOS ONE. http://dx.doi.org/10.1371/journal.pone.0176503 

Arcangelo, V.P., Peterson, A.M., Wilbur, V., & Reinhold, J.A. (Eds.).  (2017).  Pharmacotherapeutics for advance practice: A practical approach (4th ed.).  Ambler, PA: Lippincott Williams & Wilkins. 

Foster, G. R., Irving, W. L., Cheung, M. C., Walker, A. J., Hudson, B. E., Verma, S., … Agarwal, K. (2016, June). Impact of direct-acting antiviral therapy in patients with chronic hepatitis C and decompensated cirrhosis. Journal of Hepatology, 64, 1224-1231. http://dx.doi.org/10.1016/j/jhep.2016.01.029 

hydroxyzine. (n.d.). Retrieved from https://reference.medscape.com/drug/atarax-vistaril-hydroxyzine-343395#10 

levothyroxine. (n.d.). Retrieved from https://reference.medscape.com/drug/synthroid-levoxyl-levothyroxine-342732#10 

lorazepam. (n.d.). Retrieved from https://reference.medscape.com/drug/ativan-loraz-lorazepam-342906#10 

metoclopramide. (n.d.). Retrieved from https://reference.medscape.com/drug/reglan-metozolv-odt-metoclopramide-342051#10 

nifedipine. (n.d.). Retrieved from https://reference.medscape.com/drug/procardia-xl-nifedipine-342378#10 

ondansetron. (n.d.). Retrieved from https://reference.medscape.com/drug/zofran-zuplenz-ondansetron-342052#4  

prednisone. (n.d.). Retrieved from https://reference.medscape.com/drug/prednisone-intensol-342747#10 

prochlorperazine. (n.d.). Retrieved from https://reference.medscape.com/drug/compazine-spansules-prochlorperazine-342055#10 

Rosenthal, E. S., & Graham, C. S. (2016). Price and affordability of direct-acting antiviral regimens for hepatitis C virus in the United States. Infectious Agents and Cancer, 11. http://dx.doi.org/10.1186/s13027-016-0071-z 

sofosbuvir. (n.d.). Retrieved from https://reference.medscape.com/drug/sovaldi-sofosbuvir-999890#10 

A Sample Answer For the Assignment: NURS 6521 Week 7: Gastrointestinal and Hepatobiliary System

Title: NURS 6521 Week 7: Gastrointestinal and Hepatobiliary System

Introduction 

Gastrointestinal (GI) and hepatobiliary disorders impact the functioning and structure of the GI tract. A majority of these disorders are often associated with similar symptoms that include abdominal pain, cramping, nausea, constipation, bloating, and fatigue. However, multiple diseases can be tied to the same symptom hence becoming important for advanced practice nurses to carefully review and evaluate the patients and prescribe treatments that mainly target at killing the causative agent rather than the symptom (Arcangelo, Peterson, Wilbur & Reinhold, 2017). After identifying the underlying cause of the disease, appropriate drug therapy is recommended from medical history and individual patient factors. This discussion will examine the symptoms of the patient in the case study and identify if they result from a possible GI or hepatobiliary disorder, then will design an appropriate drug therapy plan.   

‘Media presentation on pharmacology for the gastrointestinal system’ 

According to this presentation, infections in the gastrointestinal tract are caused by bacteria. The most common bacteria that cause this disorder include Helicobacter pylori, Staphylococcus aureus, and Bacillus cereus. As in most cases in the healthcare sector, proper media channels are applied to checking the status of the infections. The media presentation provides more details and describes the measures of drug treatments for the infected gastrointestinal tract.  

  

  Case Study Review 

In the case study provided, patient HL visits the clinic with symptoms that included nausea, vomiting, and diarrhea. After examination, the patient is found to have a history of drug abuse and the possibility of Hepatitis C. the patient has a current prescription of various drugs that include daily intake of Synthroid 100mcg, Nifedipine 30mg, and Prednisone 10mg.  

The entire case study describes how gastrointestinal and hepatobiliary disorders affect the functioning of the GI tract through similar symptoms like nausea, bloating, diarrhea and cramping. This case study has explained how these infections or symptoms can be treated through proper selection and administration of medicine to the patients infected with the GI disorder, primarily resulting from serious consideration of medical history.   

Patient current Medications 

Concerning the above symptoms of the patient, the patient is subjected to a combination of three drugs. The drugs include Synthroid where the patient takes 100g daily. The drug has a low level of thyroid hormone, and it is used to treat constipation. Nifedipine XL drug is administered in 30g every day. It is a calcium ion influx inhibitor which prevents the influx of calcium ions into the cardiac muscle and smooth muscle. The medicine is used to treat hypertension and angina. Another drug prednisone is taken 10mg daily (McQuaid, n.d). The medication is a, and it is used to treat severe ulcerative colitis and regional enteritis. Therefore, these drugs as administered in the medical facility are good enough to manage the gastrointestinal tract infection (McQuaid, n.d). 

Diagnosis and Drug Therapy 

Based on the patient present illness and past medical history, following possible diagnosis can be made: 

• Hypothyroidism  
• Acute Gastroenteritis  
• Bowel obstruction  
• Cirrhosis      

             As indicated in the case, the patient’s symptoms included vomiting, nausea, and diarrhea. Therefore, regarding these symptoms, it was evident and clear that the patient had an infection on the gastrointestinal tract (Arcangelo, Peterson, Wilbur & Reinhold, 2017). These symptoms are related to the gastrointestinal and hepatobiliary disorders. However, in some cases, the infection of the gastrointestinal tract is self-limiting, making the symptoms to disappear in four-to-five days without medication. In most severe cases, where the symptoms are prominent, the prescription is accompanied by an examination of stools, blood as well as endoscopy (McQuaid, n.d) 

         As an advanced nurse practitioner, it is imperative to rule out all the causes and conceivable diagnosis with required lab test to confirm the diagnosis. Deprived of having much information about patient past medical history, it is a problematic to diagnose actual disease and treat the patient.  Patient has a history of drug abuse which can cause bowel obstruction and due to the history of Hepatitis C, patient might have liver problem causing the symptoms. Based on the medication that patient is currently taking, hypothyroidism could be a diagnosis and the patient’s present illness should be an adverse effect from the inappropriate medication. Overdose  of the medication Synthroid can cause the patient’s current symptoms also. That is why, TSH level should be checked first including other blood test such as Liver function test, CBC to find out patient’s condition. Systematically, the history and physical examination including lab test is required to better treat patient. Based on the blood test results, specially the TSH result, the current medication dose can be adjusted or decrease.  

Conclusion 

Gastrointestinal tract infection has various symptoms, and healthcare professionals should examine the symptoms before providing a specific prescription for the disorder. Prescription depends on symptoms, medical history. Therefore, drug therapy is vital in treating such infections. 

References 

Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (Eds.). (2017). Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins. 

McQuaid, K. R. (n.d). ‘Drugs Used in the Treatment of Gastrointestinal Diseases’. Retrieved January 8, 2018, from access pharmacy: https://accesspharmacy.mhmedical.com/content.aspx?sectionid=69113919&bookid=1193 

A Sample Answer For the Assignment: NURS 6521 Week 7: Gastrointestinal and Hepatobiliary System

Title: NURS 6521 Week 7: Gastrointestinal and Hepatobiliary System

            The typical characteristic of gastrointestinal and hepatobiliary disorders can have signs such as nausea, vomiting, diarrhea, and abdominal distention. The most frequent complaint of the patient is nausea which vomiting can linger in the large number associated with medical diagnosis including medication use, pregnancy, and motion sickness (Huether, & McCance, 2017). Other symptoms may occur because each patient is different, it can minizine symptoms or can be a poor historian.   

Case Study 

A35 years old Caucasian male brought in to the hospital by rescue 246 after a bystander observed patient vomiting profusely and having diarrhea on the side of the road called 911. It appears the patient is experiencing an episode of acute gastroenteritis. The patient has a history of alcoholism and drug abuse, possible Hepatitis C as the patient reports in the assessment. The patient is currently taking the following prescription drugs: Synthroid (Levothyroxine)100 mcg daily; Nifedipine (Procardia)30 mg daily; and Prednisone (Deltasone)10 mg daily (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). 

Drug Therapy 

Synthroid and prednisone have the potential to decrease the seizure threshold and must be considered prescribed in a patient with seizure disorders. Synthroid can have adverse effects if misused or not taken correctly. Diarrhea is a usual side effect of Synthroid; however, nausea and vomiting along with appetite changes are a severe side effect of Synthroid and should be reported to the health practitioner immediately. Prednisone may affect nifedipine effect in lowering blood pressure in a hypertensive patient. Nifedipine in a potential Hep C patient should be reconsidered because the liver extensively metabolizes calcium channel blockers (CCBs).  The half-lives of CCBs may be prolonged substantially in patients with severe hepatic impairment, with the potential for significant drug accumulation. Although vomiting, nausea, and diarrhea are not common side effects of nifedipine, this drug has been related to several instances of clinically apparent acute liver injury (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). 

Additionally, prednisone should be taken with precaution if you have a thyroid condition.  A side effect of prednisone is pancreatitis which presents with severe pain in your upper stomach, nausea, and vomiting. Though this case study did not give much information on why the patient is on prednisone, the possible use will be for the controlling of Hepatitis C-related arthropathic, which is one of the most common extrahepatic manifestations of hepatitis C virus (HCV) infection. Prednisone is prescribed as an alternative option for HCV patients who are unresponsive to NSAIDs or have advanced liver disease, such as cirrhosis, and in those who have contraindications to their use (nephrotoxicity); short-term, low-dose prednisone (5 to 10 mg) is usually prescribed. Nifedipine will increase the level or effect of prednisone by affecting hepatic/intestinal enzyme CYP3A4 metabolism and should be used with caution (Suo et al., 2015).   

Treatment Plan 

The primary goal of therapy is to lessening symptoms and the prevention of complications.  Because the patient is having nausea and vomiting, administering promethazine (Phenergan) can stop the signs and help prevent dehydration (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Phenergan can cause drowsiness or dizziness, and drinking alcohol can increase these side effects; therefore teach patient about the risk of alcohol intake, driving, or engaging in activities that impair thinking or actions. Loperamide (Imodium) is a first line drug to treat diarrhea, and it can be purchased over-the-counter (Huether, & McCance, 2017). Encouraging the patient to drink clear liquids and broth to help replace fluids and electrolytes.  Gradually reinstate bland foods such as toast, crackers, rice, bananas, or oatmeal that will be easy to digest (Sevilla-Sanchez et al.,). 

The patient has a history of drug abuse and possible hepatitis C. Therefore, a comprehensive history and physical examination are required to create a full picture of any underlining issues that is causing the patient’s symptoms for hepatitis C (Tang et al., 2017). Medication reconciliation is needed to be conducted for potential drug interactions. Besides, the diagnostic workup is necessary for further evaluation. Drug Screen test, urinalysis, abdominal ultrasound, blood tests such as liver panel, CBC, CMP, TSH, Hepatitis C RNA test, genotype test, and antibody test for HCV will be ordered to determine the cause of the symptoms (Calès et al.,).   

Conclusion  

            Eventually, assessing patient symptoms, medication reconciliation, appropriate tests, and laboratory blood work can help to collect a more effective medical history in identifying the accurate diagnosis and develop the proper treatment plan for gastrointestinal and hepatobiliary disorders. The provider should be attentive of side effect of a certain medication that could aggravate the patient condition and prolong the length of stay in the hospital. The treatment of gastrointestinal and hepatobiliary disorders require knowledge and understanding of the disease process for better quality of care. 

  

 References 

Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (Eds.). (2017). Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins. 

Calès, P., Boursier, J., Lebigot, J., de Ledinghen, V., Aubé, C., Hubert, I., & Oberti, F. (2017). Liver fibrosis diagnosis by blood test and elastography in chronic hepatitis C: agreement or combination? Alimentary Pharmacology & Therapeutics, 45(7), 991–1003. https://doi-org.ezp.waldenulibrary.org/10.1111/apt.13954 

Huether, S. E., & McCance, K. L. (2017). Understanding pathophysiology (6th ed.). St. Louis, MO: Mosby 

 Sevilla-Sanchez, D., Molist-Brunet, N., Amblàs-Novellas, J., Roura-Poch, P., Espaulella-Panicot, J., & Codina-Jané, C. (2017). Adverse drug events in patients with advanced chronic conditions who have a prognosis of limited life expectancy at hospital admission. European Journal of Clinical Pharmacology, 73(1), 79–89. https://doi-org.ezp.waldenulibrary.org/10.1007/s00228-016-2136-8 

Suo, S., Wang, X., Zarlenga, D., Bu, R.-E., Ren, Y., & Ren, X. (2015). Phage display for identifying peptides that bind the spike protein of transmissible gastroenteritis virus and possess diagnostic potential. Virus Genes, 51(1), 51–56. https://doi-org.ezp.waldenulibrary.org/10.1007/s11262-015-1208-7 

Tang, W., Chen, W., Amini, A., Boeras, D., Falconer, J., Kelly, H., … Easterbrook, P. (2017). Diagnostic accuracy of tests to detect Hepatitis C antibody: a meta-analysis and review of the literature. BMC Infectious Diseases, 17(Suppl 1), 695. https://doi-org.ezp.waldenulibrary.org/10.1186/s12879-017-2773-2 

A Sample Answer For the Assignment: NURS 6521 Week 7: Gastrointestinal and Hepatobiliary System

Title: NURS 6521 Week 7: Gastrointestinal and Hepatobiliary System

Diagnosis 

The diagnosis that I have come up with based off of the scenario provided is acute viral gastroenteritis. I chose acute viral gastroenteritis because the patient is immunocompromised from Hepatitis C and a history of drug abuse. Patients are at an increased risk for developing viral gastroenteritis when immunocompromised. “Acute gastroenteritis is defined as diarrheal disease (three or more times per day or at least 200 g of stool per day) of rapid onset that lasts two weeks and may be accompanied by nausea, vomiting, fever, or abdominal pain” (Alexandraki & Smetana, 2018). Laboratory tests and stool studies are not required for the diagnosis of acute viral gastroenteritis and it is not necessary to determine the specific viral diagnosis. 

Drug therapy 

The antimotility agent Loperamide (Imodium) can be used in patients with diarrhea and who do not have a fever and stools are not bloody (LaRocque & Harris, 2018). The initial dose for Loperamide is 4 mg and then 2 mg after each loose stool for a maximum of 16 mg/day. The use of Loperamide is to control and relieve symptoms of chronic diarrhea that is associated with inflammatory bowel disease and also in acute nonspecific diarrhea in patients (Lexicomp, Inc., 2018). Adverse reactions of Loperamide are dizziness, constipation, abdominal cramps, nausea, abdominal distention, anaphylactic shock, angioedema, drowsiness, flatulence, skin rash, Stevens-Johnson syndrome (rare), toxic megacolon, and urinary retention (Lexicomp, Inc., 2018). 

The mechanism of action for Loperamide is that it acts by slowing the intestinal motility and by affecting water and electrolyte movement through the bowel. Loperamide binds to the opiate receptor in the cut wall and therefore releases acetylcholine and prostaglandins. This reduces propulsive peristalsis and increases intestinal transit time. Loperamide increases the anal sphincter tone and reduces incontinence and urgency (Johnson & Johnson Consumer Inc., 2016). 

Pharmacokinetics for Loperamide: 

• Absorption: “Plasma concentrations of unchanged drug remain below 2ng/mL after the intake of a 2 mg capsule of IMODIUM. Plasma loperamide concentrations are highest approximately 5 hours after administration of the capsule and 2.5 hours after the liquid. The peak plasma concentrations of loperamide were similar for both formulations” (Johnson & Johnson Consumer Inc., 2016).  
• Distribution: “The plasma protein binding of loperamide is about 95%. Loperamide is a P-glycoprotein substrate” (Johnson & Johnson Consumer Inc., 2016).  
• Elimination: The half-life for elimination is about 10.8 hours with a range of 9.1 to 14.4 hours. Elimination occurs mainly by oxidative N-demethylation (Johnson & Johnson Consumer Inc., 2016).  
• Metabolism: Loperamide is metabolized mainly by the cytochrome P450 (CYP450) isozymes, CYP2C8 and CYP3A4 forms N-demethyl loperamide (Johnson & Johnson Consumer Inc., 2016).  
• Excretion: “Excretion of the unchanged loperamide and its metabolites mainly occurs through the feces” (Johnson & Johnson Consumer Inc., 2016).  

Antiemetics can be used for patients who are unable to tolerate oral hydration due to excessive vomiting. One antiemetic that can be used in acute viral gastroenteritis in adults is ondansetron (Zofran) (Alexandraki & Smetana, 2018). Adverse reactions of ondansetron include headache, malaise, constipation, drowsiness, sedation, agitation, anxiety, paresthesia, sensation of cold, pruritus, diarrhea, gynecologic disease, urinary retention, injection site reaction, hypoxia, and fever (Lexicomp, Inc., 2018). 

Pharmacodynamics: 

• Absorption: “Oral: 100%, nonlinear absorption occurs with increasing oral doses; Zofran ODT tablets are bioequivalent to Zofran tablets; absorption does not occur via oral mucosa” (Lexicomp, Inc., 2018).  
• Distribution: Vd: Adults: 1.9 L/kg. Protein binding, plasma: 70% to 76% (Lexicomp, Inc., 2018).  
• Metabolism: “Extensively hepatic via hydroxylation, followed by glucuronide or sulfate conjugation; CYP1A2, CYP2D6, and CYP3A4 substrate; some demethylation occurs” (Lexicomp, Inc., 2018).  
• Time to peak: Oral: Approximately 2 hours; Oral soluble film: Approximately 1 hour (Lexicomp, Inc., 2018).  
• Excretion: “Urine (44% to 60% as metabolites, ~5% as unchanged drug); feces (~25%)” (Lexicomp, Inc., 2018).  
• Clearance: “Adult (normal): 19 to 40 years: 0.381 L/kg/hour; 61 to 74 years: 0.319 L/kg/hour; >75 years: 0.262 L/kg/hour” (Lexicomp, Inc., 2018).  

Mechanism of action: Ondansetron is a selective 5-HT3-receptor antagonist which blocks serotonin, both peripherally on vagal nerve terminals and centrally in the chemoreceptor trigger zone” (Lexicomp, Inc., 2018). 

“In adults who clearly have acute viral gastroenteritis (eg, outbreak with known etiology), we do not recommend the empiric use of antibiotics. In general, empiric therapy for community-acquired acute diarrhea (of unclear etiology) may be beneficial but does not appear to dramatically alter the course of illness in unselected populations” (Alexandraki & Smetana, 2018). 

Reference: 

Alexandraki, I., & Smetana, G. (2018). Acute viral gastroenteritis in adults. Retrieved from https://www.uptodate.com/contents/acute-viral-gastroenteritis-in-adults?search=gastroenteritis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H752813368 

Johnson & Johnson Consumer Inc. (2016). Imodium Capsules Rx. Retrieved from https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/017694s052lbl.pdf 

LaRocque, R., & Harris, J. (2018). Approach to the adult with acute diarrhea in resource-rich settings. Retrieved from https://www.uptodate.com/contents/approach-to-the-adult-with-acute-diarrhea-in-resource-rich-settings?sectionName=Symptomatic%20therapy&topicRef=16294&anchor=H2368017643&source=see_link#H2368017643 

Lexicomp, Inc. (2018). Loperamide: Drug information. Retrieved from https://www.uptodate.com/contents/loperamide-drug-information?source=see_link#F189668 

Lexicomp, Inc. (2018). Ondansetron: Drug information. Retrieved from https://www.uptodate.com/contents/ondansetron-drug-information?search=zofran&source=search_result&selectedTitle=1~141&usage_type=panel&kp_tab=drug_general&display_rank=1#F203706 

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