McKenna's Pharmacology for Nursing, 2e

902

P A R T 1 1  Drugs acting on the gastrointestinal system

CRITICAL THINKING SCENARIO Histamine-2 antagonists

THE SITUATION W.T., a 48-year-old travelling salesman, had experienced increasing epigastric discomfort during a 7-month period. When he finally sought medical care, the diagnosis was a peptic ulcer. He began taking Mylanta for relief of his immediate discomfort, as well as ranitidine ( Tagamet ), 150 mg b.i.d. W.T. was referred to the nurse for teaching and given an appointment for a follow-up visit in 3 weeks. CRITICAL THINKING Think about the physiology of duodenal ulcers and the various factors that can contribute to aggravating the problem. What teaching points should be covered with this person regarding diet, stress factors, and use of alcohol and tobacco? What adverse effects of the drugs should this person be aware of? What lifestyle changes may be necessary to ensure ulcer healing, and how can W.T. be assisted in making these changes fit into the demands of his job? DISCUSSION Further examination indicated that W.T. is a healthy man except for the ulcer. He admits to smoking cigarettes, drinking alcohol regularly at business lunches and dinners, and eating a great deal of fast food and drinking a lot of coffee when he is on the road. He states that his job has become increasingly stressful as the economy has worsened. Because he is basically healthy and does not seek medical care unless very uncomfortable (7 months of pain), he may find it difficult to comply with his drug therapy and any suggested lifestyle changes. W.T. needs education, which for purposes of building trust, should preferably be with the same nurse. The instruction should include information on duodenal ulcer disease; ways to decrease acid production (such as avoiding cigarettes, acid-stimulating foods, alcohol and caffeine); and ways to improve the protective mucus layer of the stomach by decreasing stress and anxiety-causing situations. In addition, spacing of the ranitidine and antacid doses should be stressed. Ranitidine should be taken 1 hour before or 2 hours after any antacids because they can interfere with the absorption of ranitidine and the person may not receive a therapeutic dose. W.T. should be encouraged to avoid OTC medications and self-medication because several of these products contain ingredients that could aggravate his ulcer or interfere with the effectiveness of the drugs that have been prescribed. W.T. should be encouraged to return

for regular medical evaluation of his drug therapy and his underlying condition. Finally, W.T. should feel that he has some control over his situation. Because he does not routinely seek medical care, he may be more comfortable with a medical regimen that he has participated in planning. Allow him to suggest ways to decrease stress, ways to cut down on smoking or the use of alcohol without interfering with the demands of his job, and the best times to take the drugs in his schedule. He will learn in time which foods and situations irritate his condition. However, research has not shown that bland or restrictive diets are particularly effective in decreasing ulcer pain or spread, and they may actually increase anxiety. W.T. should be encouraged to jot down the situations or times of day that seem to cause him the most problems. This information can help to provide a guide for adjusting lifestyle and/or dietary patterns to aid ulcer healing and prevent further development of ulcers. anticoagulants, phenytoin, beta-blockers, alcohol, quinidine, lignocaine, theophylline, benzodiazepines, nifedipine, tricyclic antidepressants (TCAs) and carbamazepine. Focus the physical examination on the following areas: Neurological: orientation, affect Skin: colour, lesions Cardiovascular: pulse, cardiac auscultation GI: liver evaluation Laboratory tests: full blood count, liver, renal function tests Implementation Administer with meals and at bedtime. Provide comfort and safety measures: analgesics, access to bathroom, safety precautions. Arrange for decreased dose in renal/hepatic disease. Provide support and reassurance to deal with drug effects and lifestyle changes. Provide teaching regarding drug name, dosage, adverse effects, precautions and warnings to report. Evaluation Evaluate drug effects: relief of GI symptoms, ulcer healing, prevention of ulcer progression. Monitor for adverse effects: headache, dizziness, insomnia, gynaecomastia, arrhythmias, GI alterations. CARE GUIDE FOR W.T.: HISTAMINE-2 ANTAGONISTS Assessment: History and examination Assess W.T.’s health history for allergies to any of these drugs, renal or hepatic failure, and other drugs being taken, such as antimetabolites, alkylating agents, oral