Clinical reasoning is a way that nurses think and process our knowledge, including what we have read or learned in the past, and apply it to the current practice context of what we are seeing right now ^[1] Nurses make decisions all the time but making decisions requires a complex thinking process. There are many tools that are useful and found online that can support your thinking through to clinical judgments. This book uses the nursing process and clinical judgment language to help you understand the application of medication to your clinical practice.  It is important to understand a clinical judgement model such as NCSBN because they provide a framework to measure and understand how to make clinical judgments ^[2]

Now that we have reviewed the GI system, elimination, and common GI-related disorders,  let’s look at clinical reasoning and decision-making about related medications.

Assessment

Although there are numerous details to consider when administering medications, it is always important to first think about what you are giving and why.

First, let’s think of why? Recognizing Cues

Whenever a nurse administers medications related to the GI system and elimination, there are common assessments that should be documented, such as an abdominal assessment and documentation of bowel sounds and bowel patterns. Nausea, vomiting, diarrhea, and constipation are often symptoms of other conditions of the body. It is important to find the underlying cause for these symptoms related to the GI symptoms.

Some GI symptoms can mimic other conditions in the body that are more serious. For instance, if a client complains of “heartburn”, the nurse should perform a complete focused cardiac assessment and not assume it is GI-related because clients may erroneously attribute many cardiac conditions to “heartburn.”

Dehydration can also be a serious risk in clients that have severe nausea, vomiting, and/or diarrhea. Priority assessments and documentation related to monitoring for dehydration, especially in vulnerable populations of infants, children, and the elderly, assess for symptoms of dehydration, such as decreased blood pressure associated with tachycardia, decreased skin turgor, and decreased urine output or dark concentrated urine. If lab tests are ordered, monitor hemoglobin, hematocrit, and serum sodium levels for additional signs of dehydration. If signs of dehydration occur, the provider should be immediately notified, and treatment initiated for dehydration.

Interventions

Next, plan (refine your hypothesis), and take action.

Nurses should read the drug label information and follow the recommendations for administering GI medications with other medications or the intake of food. Cultural preferences should also be accommodated when safe and feasible because the client may believe in alternative methods for treating GI discomfort.

Some OTC medications can be recommended to clients experiencing GI symptoms. For instance, probiotics have been found to be likely safe in all populations, and the nurse can advocate for the use of probiotics in clients with diarrhea or those at risk for diarrhea because of other medications prescribed. It is important to teach clients not to exceed dosages of OTC medications because life-threatening adverse effects may occur.

In addition to teaching about medication therapy, nurses can also teach clients nonpharmacological interventions. For instance, for clients with nausea, vomiting, and diarrhea, replacing fluid and electrolytes by drinking water, sports drinks, or sodas without caffeine; and eating soft, bland food like bananas, rice, and toast. ^[3]

Children with severe diarrhea may also require oral rehydration solutions to replace lost fluids and electrolytes.

For clients with constipation, non-pharmacological measures include:

• Getting enough fiber in the diet
• Drinking plenty of water and other liquids
• Getting regular physical activity
• Trying to have a bowel movement at the same time every day^[4]

Another important consideration for implementation is the route of administration. This is especially the case if a client is nauseated or vomiting.

Evaluation

Finally, evaluate the outcomes of your action. 

It is important to always evaluate the client’s response to a medication.

Clients should experience improvement of symptoms within the defined time; if not, the provider should be notified. Increased pain or new symptoms may need to be reported immediately. For instance, if a client begins vomiting or defecating blood, this should be immediately reported.

Because antidiarrheals treat the symptoms of diarrhea but do not eliminate the cause of it, if symptoms do not resolve within 48 hours, the provider should be notified, and other potential causes of diarrhea investigated. Evaluation for dehydration should continuously occur until the condition resolves.

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

Now that we have reviewed basic concepts and clinical decision making, we will next take a closer look at specific administration considerations, therapeutic effects, adverse/side effects, and teaching needed for each class of medications related to GI system and elimination.