Proton pump inhibitors

Proton pump inhibitors PPIs Nursing Pharmacology Study Guide

Proton pump inhibitors PPIs NCLEX Nursing Pharmacology Review

Nursing Pharmacology Study Guide: Proton Pump Inhibitors

Proton pump inhibitors (PPIs) are a group of medications mainly used to treat gastric acid-related disorders. 

PPIs work by inhibiting the gastric proton pumps from releasing gastric acid, providing long-lasting reduction in stomach acid production and allowing time for gastric ulcerations to heal.

Proton pump inhibitors are among the most prescribed medications worldwide.

They are the first line treatments when it comes to gastric acid-related disorders such as reflux, dyspepsia, and peptic-ulcer disease.

PPIs have been proven to be safe for both short and long-term use and can have very few side effects.

Some PPIs can be purchased over-the-counter for the short-term management of frequent heartburn, whereas prescription PPIs are indicated for patients who suffer from gastroesophageal reflux disease (GERD).

Indications for Proton Pump Inhibitors

PPIs can be prescribed for the following clinical conditions:

  1. Peptic and duodenal ulcer diseases. High levels of gastric acid in the stomach and intestines can cause corrosion in the stomach and intestinal lining. PPIs are the first-line treatment as they are more potent in reducing gastric acid production than H2 Receptor Agonists (H2RA) drugs, thus preventing further ulceration. Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly known to cause ulcers as their side effects due to long-term use. PPIs are usually prescribed in the prevention or treatment of such ulcers in patients who take NSAIDs.
  2. Gastroesophageal reflux disease. Gastric acid can harm the digestive tract lining. In the case of reflux, gastric acid can move up and down the esophagus causing erosion of the esophageal lining. PPIs are used in these conditions to reduce acid production and prevent further damage. PPIs are also indicated in cases of erosive esophagitis and Barrett’s esophagus.
  3. Eradication of H. Pylori infection. Most bacteria do not survive the acidity of stomach juices. However, H. pylori can thrive despite the acidity of the stomach and intestines. PPIs are commonly indicated for the patient, together with antibiotics.  
  4. Zollinger-Ellison Syndrome (Gastrinoma). This condition involves the presence of a tumor in the pancreas that causes large production of gastrin. Gastrin is a hormone that signals stomach acid secretion which may lead to ulcers. PPIs are used to counteract the effect by reducing stomach acid production.
  5. Other Uses. PPIs are sometimes used as an add-on therapy to individuals receiving antiplatelet therapy before and after they undergo endoscopic procedures which known to have high risk of bleeding, functional dyspepsia, and eosinophilic esophagitis.

Actions of Proton Pump Inhibitors

Proton pump inhibitors function to reduce gastric acid production. Once ingested, PPIs are absorbed in the proximal small bowel.

Upon entering the bloodstream, they work on the parietal cells of the stomach where the H, K-ATPase enzyme, or proton pump, is located. The gastric proton pumps are responsible for the acidification of the stomach juices and activation if the enzyme pepsin.

Proton pumps inhibitors are prodrug. That means that they will need to be activated by the acid in the parietal cells.

Therefore, proton pump inhibitors must be taken 30 minutes before ingestion of food to allow time for the activation to occur.

Also, they will need to be protected from stomach acid as it may affect its absorption.

Side Effects and Adverse Reactions of Proton Pump Inhibitors

Proton pump inhibitors are generally safe to be taken. Side effects are known to be minimal and may include the following:

  • Headache
  • Diarrhea
  • Constipation
  • Abdominal pain
  • Flatulence
  • Fever
  • Vomiting
  • Nausea
  • Rash

The side effects of proton pump inhibitors are generally well-tolerated. In some cases, more severe side effects may happen, and they are as follows:

  • Increased risk of Clostridium difficile infection
  • Increased risk of osteoporosis-related fractures
  • Reduction in the absorption of vitamin B12 or cyanocobalamin
  • Hypomagnesemia
  • Increased risk of heart attack
  • Steven-Johnson syndrome
  • Toxic epidermal necrolysis
  • Reduced kidney function
  • Pancreatitis
  • Reduced liver function
  • Erythema multiforme

Contraindications and Cautions for Proton Pump Inhibitors

Proton pump inhibitors are widely used; however, there are some instances that prohibit its use, such as:

  • Hypersensitivity or allergy to proton pump inhibitors or any of its components
  • Hepatic diseases. PPIs are metabolized by the liver. Therefore, it is important to take caution when using PPIs in the presence of any liver disease.
  • Caution in the use of anticonvulsants, anticoagulants, and benzodiazepines. PPIs can cause an alteration in the function of some enzymes that may delay the clearance of the said drugs.
  • Caution in the use of ketoconazole. Ketoconazole is absorbed more effectively in an acidic environment. Since PPIs work by reducing acid production, it is recommended that other antifungals be used.
  • Caution in the use of digoxin. PPIs can potentiate the absorption of digoxin. Extreme caution is necessary to prevent possible cardiac side effects.
  • Caution for pregnant and lactating mothers

Drug Interactions with Proton Pump Inhibitors

There are several considerations when taking proton pump inhibitors. Because of their potent ability to reduce gastric acid production, it is important to bear in mind that there are other medications that may not be absorbed well while this medication is taken.

On the other hand, toxicity of other medication can also occur. Other than certain medications, proton pump inhibitors also interact with high alcohol intake.

Alcohol can increase the side effects of PPIs and can worsen the gastrointestinal problem.  

Nursing Care Plan for Patients on Proton Pump Inhibitors

Possible Nursing Diagnoses

Risk for Diarrhea related to GI action of PPIs

Risk for Constipation related to GI action of PPIs

Imbalanced nutrition: less than body requirements related to GI symptoms

Disturbed Sensory Perception (Auditory, Kinesthetic) related to adverse effects of PPIs

Deficient knowledge related to PPI

Alteration in Comfort

Acute Pain

Nursing Assessment

Nursing InterventionRationale
Assess the patient for signs and symptoms of stomach pain, heartburn or reflux, stomach upset, nausea or vomiting, and GI bleeding.To confirm the indication for administering PPIs.  
Check the patient’s allergy status.Previous allergic reaction to PPIs will render the patient unable to take them. Alternatives to PPIs should therefore be considered in case of allergy.
Assess if the patient is pregnant or is a lactating mother.PPIs should be prescribed in caution to a pregnant woman or lactating mother as these drugs can potentially harm the fetus or newborn.
Check the patient’s list of current medications.Caution in the use of anticonvulsants, anticoagulants, and benzodiazepines. PPIs can cause an alteration in the function of some enzymes that may delay the clearance of the said drugs. Caution in the use of ketoconazole. Ketoconazole is absorbed more effectively in an acidic environment. Since PPIs work by reducing acid production, it is recommended that other antifungals be used. Caution in the use of digoxin. PPIs can potentiate the absorption of digoxin. Extreme caution is necessary to prevent possible cardiac side effects.  
Perform a focused physical assessment on the patient’s abdomen through inspection, palpation, and auscultation of bowel sounds.To confirm the indication for administering PPIs, and to assess the patient’s GI motility.  
Assess the patient’s mucous membranes and his/her ability to swallow.To check for any potential problems with administration, hydration, and absorption.
To ensure that the right form of PPIs is given.
Collect bloods for liver function tests.PPIs should be used cautiously in patients with hepatic disorders as they are metabolized in the liver.  

Nursing Planning and Intervention

Nursing InterventionRationale
Administer PPIs at least 30 minutes before mealTo ensure enough time for activation, optimal absorption and therapeutic action by PPIs.
Administer PPIs about 1 hour before or 2 hours after administering other oral medications, as prescribed.Ideal spacing of PPIs and other oral medications will ensure adequate absorption of the drugs administered.  
Educate the patient about the action, indication, common side effects, and adverse reactions to note when taking PPIs. Instruct the patient on how to self-administer PPIs.To inform the patient on the basics of PPIs, as well as to empower him/her to safely self-administer the medication.
Monitor the patient’s bowel movement and commence stool chart.PPIs may cause diarrhea or constipation. Early detection of either side effect can help institute a bowel program and relieve them effectively.

4.  Nursing Evaluation

Nursing InterventionRationale
Ask the patient to repeat the information about PPIs.To evaluate the effectiveness of health teaching on PPIs.
Monitor the patient for signs and symptoms of stomach pain, heartburn or reflux, stomach upset, nausea or vomiting, and GI bleeding.If the patient starts to have a coffee ground vomiting and/or persistent abdominal pain, the use of PPIs needs to be reviewed by the physician. Having blood in the stool or difficulty of swallowing may also warrant a review of the need to continue PPIs or to switch to an alternative treatment.
Monitor the patient’s weight daily.PPIs may cause unintentional weight loss due to diarrhea as their side effect.
Monitor the patient’s liver function.To ensure that the PPIs did not cause any liver dysfunction.  
Monitor the patient’s response to PPIs.To check for the relief of GI symptoms, as well as to see if the PPIs are effective or should be shifted to other GI medications due to an allergic reaction, severe side effects or adverse reactions.

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines and policies and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is not intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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