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acute constipation defn
<3 BM per week
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chronic constipation defn
sx lasting >6wks
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recommeded daily fiber intake
20-30g
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step 1 in chronic constipation
dietary intervention
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step 2 in chronic constip
bulk-forming laxative + adequate fluid intake
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step 3 in chronic constip
sorbitol, lactulose, PEG
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step 4 in chronic constip
short term stimulant laxative
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step 5 in chronic constip
lubiprostone
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constip tx for paralyzed pts
ROUTINE USE of bowel stimulants (suppositories)
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constip tx for pregnant pts
nondrug (diet, fiber) then docusate, then senna in severe cases
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constip tx for children
glycerin suppositories oor Karo syrups
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constip tx for diabetics
metoclopramide and a stimulant
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constip tx for pts on chronic opioids
stimulant; add lactulose, sorbitol or PEG if needed. Methylnaltrexone.
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what to avoid in pts on opioids
bulk laxatives
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constip tx for post op pts
MOM, PEG then stimulants if needed; PUSH FLUIDS
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constip tx for for pts undergoing GI procedures
day before: clear liquid diet/ afternoon before: prep. FLUIDS FLUIDS FLUIDS
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osmoprep
oral prep agent; rx only
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suprep
oral prep agent; rx only
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avoid oral prep agents in pts with:
heart failure, renal disease, electrolyte abnormalities
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psyllium (metamucil)
bulk
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methylcullulose (citrucel)
bulk; mix with cold water; produces less gas
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bulk laxative moa
form emollient gel which retains water and stimulates BM
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bulk laxative advantages
SOFTEN stools better than docusate, well tolerated with few SE
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bulk laxative disadvan
MUST HAVE ADEQUATE FLUID INTAKE; taste, gas, impact on drug absorp, not ideal for bedridden
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docusate (DOSS)
QD or BID surfactant/emollient
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docusate MOA
STOOL SOFTENER; dec fecal surface tension
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docusate advantages
SAFE; prevemts hemorrhoids and hard poop(ew)
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docusate disadvan
not effective for active constipation
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mineral oil
lubricant; lubricates lumen of colon
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mineral oil advantages;
lubricates and SOFTENS
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mineral oil disadvantages
OILY AND GROSS. no one likes it. may dec absorp of fat sol vitamins
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what are the fat sol vitamins
ADEK
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Mg citrate
saline laxative
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phospha-soda
saline laxative
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saline laxative moa
draws fluid into colon which stimulates motility
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saline lax advantages
for ACUTE constip; QUICK ONSET; cheap
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saline lax disadvan
avoid in renal pts
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fleet's saline enema
saline lax with RAPID ONSET
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sorbitol
hyperosmotic agent
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lactulose
hyperosmotic agent
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PEG (miralax)
hyperosmotic agent; USE THIS ONE FOR DIABETICs
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hyperosmotic agents moa
draw fluid into colon via high conc of sugar, PEG, or glycerin
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hyperosmotic agents advan
well tolerated; SOFTENS and STIMULATES BM (2for1); EXCELLENT FOR CHRONIC
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hyperosmotic agents disadvan
1-4day onset; tastes sweet, nausea, cramps
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glycerin suppository
QUICK ONSET hyperosmotic agent; can be used for the kiddos too
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nulytely, golytely, halflyely
PEG (hyperosmotic); bowel prep that tastes bad and must be refrigerated
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karo corn syrup
hyperosmotic; can be used for kids
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bisacodyl
stimulant lax; EC = dont take with antacids
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stimlant lax moa
locally irritates nerves which stimulate motility
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stimulant lax advan
6-12hr onset; works in pts with motility disorders; can use for pts on opioids
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DOC for constipated people on opioids
stimulant laxative
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stimulant lax disadvan
cramps; avoid long term use in pts with GI motility issues
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bisacodyl suppositories
stimulant lax with quick onset
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lubiprostone (Amitiza)
sm intestine Cl channel activator that inc intestinal fluid; take with noms (food)
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what will work for chronic idiopathic constipation in ALL Adults
lubiprostone
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lubiprostone SE
diarrhea, nausea, HA
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lubiprostone disadvan
$$$$$$$, avoid in pregnant pts
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when to follow up for acute constip
1-2days
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when to follow up for chronic constip
1-2wks
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what to ask during follow up
stool freq, diarrhea?, dietary changes
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causes of urge incontinence
stroke, Alzheimers, Parkinsons, BPH w/overactive bladder
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urge incont features
OVERACTIVE BLADDER; overactivity of detrusor; large vol + urgency + freq
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how to treat urge incont
anticholinergics, antimuscarinics to dec detrusor contractions
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stress incont features
OUTLET INCOMPETANCE (leaky); small vol, women, triggers like sneezing
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causes of stress incont
urologic procedures, multiple childbirths, estrogen deficiency
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stress incont tx
KEGELS, alpha agonists, estrogen replacements, duloxetine
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overflow incont features
MALES, outlet obstruction, BPH w/o overactive bladder
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overflow incont tx
treat OBSTRUCTION; alpha blockers (BPH), Kegel
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atonic bladder feature
complete loss of bladder control
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atonic bladder causes
severe diabetes, neuropathy, stroke, spinal cord injury
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for which type of incontinence is drug therapy ineffective
atonic bladder
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atonic bladder tx
intermittent catherization
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functional incont features
inability to get to the bathroom in time. uhoh
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causes of fctional incont
physical impairment, dementia, UTIs, meds
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tx of fctional incont
eliminate the causes, scheduled voidings, no drugs usually
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oxybutynin (ditropan,XL)
GENERIC AVAILABLE; XL has less SE
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gelnique (oxybutynin)
lower rate of SE; rotate sites
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tolterodine (Detrol, LA)
fewer SE with LA formulation?
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trospium cl (sanctura, XR)
absorp dec by food
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solifenacin (vesicare)
more m3 selective; may have worse CNS SE
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darifenacin (Enablex)
HAS DRUG INTERACTIONS (others dont)
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fesoterodine (toviaz)
dose-related SE; prodrug
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anticholinergic SE
DRY MOUTH/EYES, CONSTIPATION, mydriasis, delirium, urinary retention, tachy, confusion, somnolence, blurry vision
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in which pts should anticholinergics be avoided
men with BPH w/o overactive bladder; Alzheimers pts
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when to follow up incont tx
review efficacy over 1-2mo
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