Outcome Evaluation

• Because symptoms vary in intensity and among patients, a specific drug therapy may not lead to equivalent symptom abatement in different patients.

• Monitor for adequate relief of symptoms. Patients whose pain does not respond to drug therapy may have a psychological comorbid condition and may require psychiatric intervention.

• Specifically, monitor for relief of pain if present initially. Monitor patients with symptoms of constipation or diarrhea for frequency, appearance, and size of stools in relationship to their normal characteristics. As stools normalize, associated symptoms such as bloating and abdominal distention should resolve.

• For IBS-C patients taking bulk producers, monitor for relief of constipation. Hard stools should become softer within 72 hours. IBS-M patients may gain relief with these agents as well.

Patient Encounter 3, Part 2

Upon further questioning, the patient states that she had similar symptoms (often following menses) near the end of graduate school 6 years ago. The symptoms gradually subsided after graduation, so she did not seek medical attention. She is an accountant and recently received a promotion at work. As a result, she has taken on considerably more responsibility.

PMH: Anxiety; muscle contractions; headaches

FH: Mother has migraine headaches

SH: Nonsmoker; drinks a glass of wine occasionally

Meds: Naproxen 220 mg every 12 hours as needed for headaches and menstrual pain; loperamide 2 mg as needed for diarrhea

Allergies: No known drug allergies

Gen: Alert and oriented; well-developed and well-nourished, anxious black woman

VS: BP 137/88 mm Hg, P 80 bpm, RR 21 per minute, T 37.1 °C (98.7°F), Ht 57" (170 cm), Wt 74 kg (173 lb)

Integ: Hair and nails unremarkable; scalp dry and flaky; skin otherwise unremarkable HEENT: PERRLA, EOMI Chest: Clear to A & P bilaterally

CV: RRR, normal S1, and S2; no S3 or S4 Abd: (+) BS, mildly tender LLQ

Rectal: No palpable masses; no hemorrhoids; stool negative for occult blood What information is consistent with a diagnosis of IBS? Outline an appropriate therapeutic plan for this patient.

• Monitor antidepressant therapy for relief of lower abdominal pain.

• Antispasmodics may provide limited relief of crampy abdominal pain.

• Assess 5-HT4 receptor agonists (tegaserod) for relief of crampy abdominal pain and bloating.

• Evaluate 5-HT3 receptor antagonists (alosetron) for relief of abdominal pain and fecal incontinence.

• Antimotility agents should be expected to reduce stool frequency and control diarrhea.

• Monitor complete blood cell count, serum electrolytes and chemistries, stool guai-ac, and erythrocyte sedimentation rate yearly for changes that might signal an overlapping organic problem.

• Refer any patient presenting with red flag signs for medical evaluation.

Patient Care and Monitoring for IBS

1. Assess symptoms to determine if patient-directed therapy is appropriate or whether physician evaluation is needed.

2. Determine the type, severity, and frequency of symptoms and possible exacerbating factors.

3. Listen attentively to the patient's complaints and reassure the patient to allay fears about invasive disease.

4. Obtain a thorough current history ofprescription, nonprescription, and dietary supplement use.

5. Determine if any IBS treatments have been attempted and how effective they have been.

6. Determine whether the patient has received educational intervention about IBS, health promotion, and symptom prevention measures.

7. Provide patient education about IBS symptoms, lifestyle modifications, and drug therapy for IBS:

• Explain how to use medications relative to symptom intensity.

• If taking alosetron, determine nonadherence with special use requirements.

• Describe potential adverse effects.

• List drugs that may interact with the therapy.

• Discuss what to do if red flag symptoms occur.

Abbreviations Introduced in This Chapter

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