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Digestive System. Chapter 56. Structures of Digestive System. Oral Cavity Esophagus Stomach Small intestine Large intestine Pancreas Gallbladder Liver. Teeth, Gums and Mouth. Is the client capable of chewing Do they have teeth? What condition are the teeth in?

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structures of digestive system
Structures of Digestive System
  • Oral Cavity
  • Esophagus
  • Stomach
  • Small intestine
  • Large intestine
  • Pancreas
  • Gallbladder
  • Liver
teeth gums and mouth
Teeth, Gums and Mouth
  • Is the client capable of chewing
  • Do they have teeth?
  • What condition are the teeth in?
  • Are there sores in the mouth that make it painful to chew?
oral cavity
Oral Cavity
  • Chewing mechanically breaks food into smaller particles, which can be swallowed more easily and provide a larger surface area for enzyme action.
  • Saliva lubricates the food for easier swallowing and initiates the digestion of starches.
esophagus
Esophagus
  • Can the client swallow?
  • Do they have a history of GERD, Hiatal hernia or esophageal stricture?
    • GERD: gastro esophageal reflux disease
    • Hiatal hernia
    • Esophageal stricture
esophagus9
Esophagus
  • Main function is to move food from the pharynx to the stomach.
  • Secretes some mucous and has some peristaltic movement.
  • Two sphincters:
    • Upper sphincter prevents air from entering the esophagus during inspiration
    • Lower esophageal sphincter prevents reflux of acidic gastric contents into the esophagus
secretions of digestive system
Secretions of Digestive System
  • Mucus
  • Saliva
  • Gastric juices
    • Mucous
    • Digestive enzymes
    • Hydrochloric acid
    • Electrolytes
stomach
Stomach
  • Serves as a reservoir
  • Churns and mixes the food with digestive juices:
    • Secretes mucous
    • Hydrochloric acid
    • Enzymes
    • Starts protein breakdown and secretes intrinsic factor for absorption of vitamin B12 from the ileum
    • Little absorption of any nutrients or drugs
    • Highly lipid-soluble substances - some drugs and alcohol – are absorbed
    • Gastric emptying time is about 4 hours
gastric juices
Gastric Juices
  • Major digestive enzyme of gastric juice is pepsin, a proteolytic enzyme that functions best at a pH of 2 or 3.
  • Hydrochloric acid provides the acid medium to promote pepsin activity.
  • Major function of gastric juice is to begin digestion of proteins.
mucous
Mucous
  • Mucous is secreted in the stomach to protect the stomach wall from the proteolytic action of pepsin.
  • When mucous is not secreted, gastric ulceration occurs.
pancreatic juices
Pancreatic Juices
  • Pancreatic juices are alkaline (pH of 8 or above).
  • Contains amylase for carbohydrate digestion, lipase for fat digestion, and trypsin and chymotrypsin for protein digestion.
  • Contains sodium bicarbonate a base that neutralizes the acid from the stomach.
small intestine
Small Intestine
  • Consists of duodenum, jejunum, ileum
  • Pancreatic and bile ducts empty into the duodenum
  • Secretes digestive enzymes, hormones and mucous
  • Digestion and absorption occurs – including most orally administered drugs
large intestine
Large Intestine
  • Consists of cecum, colon, rectum, and anus
  • Main function is elimination
nutritional support products vitamins and mineral electrolytes

Nutritional Support Products, Vitamins, and Mineral-Electrolytes

Chapter 57

nutrients
Nutrients
  • Water, carbohydrates, proteins, fats, vitamins and minerals are required to promote and maintain health and prevent illness.
  • Vitamins are required for normal body metabolism, growth, and development.
nutritional deficiency
Nutritional Deficiency
  • Clients are unable to ingest, digest, absorb or utilize sufficient nutrients to improve or maintain health.
nutritional products
Nutritional Products
  • Liquid enteral products
  • Intravenous fluids
  • Pancreatic enzymes
  • Vitamins
  • Minerals - electrolytes
liquid formulas
Liquid Formulas
  • OTC preparation for oral or tube feedings
  • Nutritionally complete except for water
  • Special formulas for clients with renal or hepatic failure
  • High protein for increased calories
nursing responsibilities
Nursing Responsibilities
  • Read can to make sure the supplement ordered is correct.
  • Calories per ounce and additives may differ.
  • Make sure client drinks water.
  • Especially important on clients dependant on care takers for fluid intake – gastrostomy tube feeds.
intravenous solutions
Intravenous Solutions
  • Used when oral fluids or tube feedings are contraindicated.
  • Used short term to provide fluids and electrolytes.
  • Dextrose and sodium chloride major solution used
    • Dextrose 5% in 0.2 % normal saline
    • Dextrose 5% in 0.45 % normal saline
potassium chloride
Potassium Chloride
  • Most common additive:
    • potassium chloride or KCL
    • Usual dose KCL 2 mEq / 100 mL of IV solution.
  • KCL is considered a medication and needs to be charted on MAR (medication administration record).
total parenteral nutrition
Total Parenteral Nutrition
  • Long-term use from weeks to months to provide all nutrients required for normal body functions – growth and tissue repair.
  • Usually administered through central line.
  • Fluids often have high concentration of dextrose 5 % or 10% along with extra minerals.
  • Proteins and lipids are given IV through special filters.
  • Must go in at prescribed rate – no catching up on fluids.
vitamin supplements
Vitamin Supplements
  • Most often self supplied
  • Billion dollar OTC industry
  • Preparations should not included more than recommended amounts of vitamin D, folic acid and vitamin A
  • Most are synthetic preparations
  • Most contain minerals – large doses of all minerals are toxic
minerals electrolytes
Minerals - Electrolytes
  • 22 minerals
  • Calcium and phosphorus have major role in bone metabolism
  • Electrolytes - Body must contain equal number of negative and positive charges
  • Adequate amounts contained in protein foods so extra intake is not needed if diet is adequate
  • Most common dietary deficiency: calcium and iron
calcium iron
Calcium - Iron

Calcium supplements - most adolescent and adult females would benefit from calcium supplements (1000 to 1300 mg daily).

Iron supplements – often used during periods of increase need – pregnancy.

Iron should not be taken otherwise due to high risk for accumulation and toxicity.

overweight obese adults
Overweight / Obese Adults
  • 60% of adults are overweight or obese
  • Etiology
    • Physiologic factors
    • Genetic factors
    • Environmental factors
    • Psychosocial factors - depression
slide32
BMI
  • BMI calculations: www.cdc.gov
  • Desired BMI is 18.5 to 24.9
  • Extremes may represent underweight or overweight / obese
  • Insurance companies are using BMI calculations to determine health insurance coverage.
diseased related to obesity
Diseased Related to Obesity
  • Cancer
  • Cardiovascular disease
  • Diabetes type II
  • Dyslipidemia (high cholesterol)
  • Gallstones
drug therapy
Drug Therapy
  • BMI greater than 30
  • Part of a weight management program – exercise – decrease in calorie intake
  • Once drugs stopped weight gain tends to re-occur
drugs used in weight loss
Drugs Used in Weight Loss
  • Appetite suppressants
    • phentermine
    • sibutramine
  • Fat blockers
    • Orlistat
phentermine
Phentermine
  • Brand names: Adipex-P, Obenix, Oby-Trim
  • Classification pharmacologic: anorectics
  • Classification therapeutic: appetite suppressant
  • Action: decrease appetite by possible changing brain levels of serotonin. Phentermine is a nervous system stimulator like the amphetamines causing stimulation, elevation in blood pressure, and increased heart rate.
sibutramine
Sibutramine
  • Brand name: Meridia
  • Classification pharmacologic: appetite suppressant
  • Classification therapeutic: weight control agent
  • Action: Acts as an inhibitor of the reuptake of serotonin, norepinephrine and dopamine; increases the anxiety-producing effects of serotonin.
contraindications to use
Contraindications to Use
  • Pregnancy and lactation
  • Patients with severe hepatic or renal disease.
  • Uncontrolled hypertension
  • CHF or cardiovascular disease
side effects
Side Effects
  • CNS stimulation: confusion, dizziness, euphoria, headache, insomnia, restlessness
  • Heart palpitations, hypertension, tachycardia
  • Changes in libido or impotence
orlistat
Orlistat
  • Brand name: Xenical
  • Classification pharmacologic: lipase inhibitor
  • Classification therapeutic: weight control agent
  • Action: Decreases the absorption of dietary fat by reversibly inhibiting enzyme (lipases), which are necessary for the breakdown and subsequent adsorption of fat.
  • Therapeutic effect: weight loss
orlistat41
Orlistat
  • Side effects: fecal urgency, flatus, increased defecation, oily evacuation, fecal incontinence
peptic ulcer disease
Peptic Ulcer Disease
  • Ulcer formation in the esophagus, stomach or duodenum
  • Mucous exposed to gastric acid and pepsin
  • Imbalance between cell-destructive and cell-protective effects
    • Gastric acid and pepsin
    • H. pylori – infectious process
gastric ulcers
Gastric Ulcers
  • Ulcer of stomach
  • Associated with stress
  • NSAID ingestion (non-steroidal anti-inflammatories)
  • H. pylori
  • Alcohol consumption
  • Smoking
  • More likely to occur in older adults
duodenal ulcer or peptic ulcer
Duodenal Ulcer or Peptic Ulcer
  • Ulcer found in the duodenum or upper portion of the small intestine
  • Associated with H. pylori and NSAIDs
  • Higher incidence in smokers
sign and symptoms
Sign and Symptoms
  • Burning pain in abdomen between breastbone and belly button.
  • Nausea / vomiting
  • Chest pain (dull and achy)
  • Loss of appetite
  • Frequent burping or hiccupping
  • Blood in vomit or bowel movement
diagnosis
Diagnosis
  • Upper endoscopy: patient is put under sedation and a small flexible tube with a tiny camera on the end is inserted through the mouth, down the esophagus into the stomach and duodenum.
  • pH probe to measure acid going to the area
  • Biopsy to test for H. pylori
treatment
Treatment
  • Antibiotics: H. pylori: amoxicillin and metronidazole (Flagyl)
  • Acid blockers: histamine H-2 blockers: Zantac, Pepcid, Tagamid and Axid (OTC)
  • Antacids
  • Proton pump inhibitors (prescription): Prilosec, Prevacid, Aciphex and Nexium.
  • Cytoprotective agents: Carafate, Cytotec or OTC Pepto-Bismol
slide51
GERD
  • Most common disorder of esophagus
  • Characterized by regurgitation of gastric contents into esophagus and exposure of esophageal mucous to gastric acid and pepsin.
  • Main symptom is heart burn - occurs after eating
  • Cause is thought to be incompetent lower esophageal sphincter
treatment of acid peptic disorders
Treatment of acid-peptic disorders
  • Promote healing of lesions and prevent recurrence of lesions by decreasing cell-destructive effects or increasing cell- protective effects.
acid suppressant drugs
Acid-Suppressant drugs
  • Alkaline substances work primarily in the stomach
  • Work to raise the pH to 3.5 and inhibits conversion of pepsingogen to pepsin
  • Common antacid products:
    • Maalox
    • Mylanta
    • Gelusil
    • Amphojel
potential problems
Potential Problems
  • May prevent absorption of most drugs taken at the same time.
  • In stress ulcers need to be taken hourly to neutralize gastric ulcers.
  • In the ICU may be given continuous NG drip.
  • Antacids with magnesium are contraindicated in clients with renal disease.
  • Antacids with high sugar content are contraindicated in clients with diabetes.
helicobacter pylori agents
Helicobacter pylori Agents
  • Multiple drug therapy to treat the H. pylori organism and heal related ulcers
  • Antimicrobial
    • Amoxacillin
    • Clarithromycin
    • Metronidazol
    • Tetrocycline)
  • Histamine2 Receptor Antagonists
histamine2 receptor antagonists
Histamine2 Receptor Antagonists
  • Histamine causes strong stimulation of gastric acid
  • Histamine 2 receptor blocks this action
    • Cimetidine or Tagamet – most widely used
    • Famotidine or Pepcid
    • Nizatidine or Axid
    • Ranitidine or Zantac – more potent than Tagamet
cimetadine
Cimetadine
  • Classification Pharmacologic: histamine H2 antagonist
  • Classification Therapeutic: anti-ulcer agent
  • Action: Inhibits the action of histamine at the H2-receptor site located primarily in gastric parietal cells, resulting in inhibition of gastric secretion. In addition has some antibacterial action against H.Pylori.
how provided
How provided
  • Adults 300 mg 4 times daily or 800 mg at bedtime for treatment of active ulcers.
  • Adults 300 mg daily or 400 mg at bedtime prophylaxis for duodenal ulcer.
  • GERD: 300 to 600 mg every 6 hours for maximum dose of 2400 mg daily.
  • PO children 20 to 40 mg/kg
  • IV: 300 mg IV every 6 hours
caution
Caution
  • Have been replaced with newer drugs. Cimetadine is less expensive but may cause confusion and antiandrogenic effects. Newer drugs can be taken in smaller doses and less frequently.
  • Cimetadine is now OTC
proton pump inhibitors
Proton Pump Inhibitors
  • Strong inhibitors of gastric acid secretion
    • Nexium
    • Prevacid
    • Prilosec
    • Aciphex
    • Cytotec
    • Carafate
slide63
PPIs
  • Are the first choice of drugs – they heal gastric and duodenal ulcers more rapidly and may be more effective in treating erosive esophagitis, and erosive gastritis. May also be effective in treating H. pylori.
nexium
Nexium
  • Classification Pharmacologic: proton-pump inhibitors
  • Classification Therapeutic: anti-ulcer agent
  • Action: binds to an enzyme on gastric parietal cells in the presence of acid gastric pH, preventing the final transport of hydrogen ions into the gastric lumen.
  • Therapeutic effect: diminished accumulation of acid in the gastric lumen with lessened gastro-esophogeal reflux GERD.
dosing
Dosing
  • PO: 20 to 40 mg once a day
  • IV 20 to 40 mg once daily
prilosec or omeprazole
Prilosec or omeprazole
  • Therapeutic classification: antiulcer agent
  • Pharmacologic classification: proton pump inhibitors
  • Indications: management of GERD, duodenal ulcer or H. pylori.
  • Action: binds to an enzyme on gastric parietal cells in the presence of acidic gastric pH, preventing the final transport of hydrogen ions into the gastric lumen.
use in special populations
Use in Special Populations
  • Pediatrics – will be given to prevent GI bleeding
    • Asthmatics on IV or po corticosteroids
    • Head trauma on IV dexamethasone for cerebral swelling
  • Older Adults – calcium carbonate antacids like “Tums” due to decreased side effects
  • Renal impairment – magnesium containing preparations (Mylanta, Maalox) contraindicated – need good kidney function to eliminate magnesium
  • Critical care units may use to prevent GI bleeding.
laxatives and cathartics69
Laxatives and Cathartics
  • Used to promote bowel elimination
    • Laxatives implies mild effects and elimination of soft, formed stool
    • Cathartics implies stronger effects and elimination of liquid or semi-liquid stool.
indications for use
Indications for Use
  • Relieve constipation in pregnant women and elderly clients.
  • To prevent straining of clients with coronary artery disease.
  • To empty the bowel in preparation for a surgery or diagnostic procedure.
  • To accelerate elimination of toxic substance.
  • To reduce serum cholesterol.
bulk forming laxatives
Bulk Forming Laxatives
  • Substances that are largely unabsorbed from the intestine.
  • When water is added the substances swell and become gel like.
  • Added bulk and size of the fecal mass stimulates peristalsis and defecation.
bulk forming laxatives72
Bulk-forming Laxatives
  • Methylcellulose or Citrucel
  • Polycarbophil or FiberCon
  • Psyllium or Metamucil
psyllium
Psyllium
  • Classification Pharmacologic: bulk-forming agent
  • Classification Therapeutic: laxatives
  • Action: combines with water in the intestinal contents to form an emollient gel or viscous solution that promotes peristalsis and reduces transit time.
  • Client teaching: increase bulk in diet, increase fluid intake and mobility. Do not use laxatives with abdominal pain or vomiting.
surfactant laxatives
Surfactant Laxatives
  • Stool Softeners – decrease the surface tension of the fecal mass to allow water to penetrate into the stool.
  • Mixes fat and water in stool to make it softer and easier to expel
    • Colace and Surfak
ducusate
Ducusate
  • Brand names: Colace, Dulcolax soft gels, Correctol stool softener …
  • Classification Pharmacologic: Stool softener
  • Classification Therapeutic: laxatives
  • Action: Promotes incorporation of water into stools, resulting in softer fecal mass. May also promote electrolyte and water secretion into the colon.
saline laxatives
Saline Laxatives
  • Not well absorbed from the intestine
  • increase osmotic pressure in the intestinal lumen and causes water to be retained
  • Distension of the bowel leads to increased peristalsis and decreased intestinal transit time.
  • Used when rapid bowel evacuation is needed
  • Two most common: magnesium citrate and milk of magnesia
uses of magnesium citrate
Uses of Magnesium Citrate
  • Bowel evacuation prior to procedure – colonoscopy or abdominal surgery.
  • Overdose to eliminate substance through GI tract quickly.
stimulant cathartics
Stimulant Cathartics
  • Strongest and most abused.
  • Act by irritating the GI mucosa and pulling water into the bowel lumen.
  • Feces move through GI system too rapidly to absorb water so the stools are watery.
  • Should not be used for longer than a week or electrolyte imbalance may occur.
stimulants cathartics
Stimulants Cathartics
  • Bisacodyl or Dulcolax
  • Castor Oil
  • Glycerine rectal suppository
bisocodyl
Bisocodyl
  • Brand names: Bisac-Evac, Carter’s Little Pills, Dulcolax…
  • Classification Pharmacologic: stimulant laxative
  • Classification Therapeutic: laxative
  • Action: Stimulates peristalsis. Alters fluid and electrolyte transport, producing fluid accumulation in the colon.
  • Therapeutic Effect: evacuation of the colon.
lubricant laxative
Lubricant Laxative
  • Mineral oil is the only lubricant laxative
  • It lubricates the fecal mass
  • Elimination occurs in 6 to 8 hours
  • Often used in fecal impaction
  • Used in the pediatric population for children with chronic constipation
laxative uses in special populations
Laxative Uses in Special Populations
  • Pediatrics: constipation accounts for 3% of all office visits
    • Glycerine suppositories for infants
    • Stool softeners for the older child
    • Mineral oil with constipation
geriatric population
Geriatric Population
  • Geriatric: 15 to 20% of community clients are constipated and 50% of nursing home residents.
  • Laxatives can be overused
  • Bulk forming laxatives best for long term use.
  • Metamucil – need to take with full glass of water.
  • Encourage fluids, fiber rich foods and movement.
cancer
Cancer
  • Clients on pain control for cancer often have constipation from use of pain control drugs and slow GI motility.
  • Management: stool softener such as Colace and increased bulk / fiber in diet.
spinal cord injury
Spinal Cord Injury
  • SCI impairs ability to sense that a bowel movement is imminent and the ability to control the timing and place of bowel evacuation.
  • Tend to go between incontinence and fecal impaction.
  • Need bowel program to facilitate regular bowel movements.
antidiarrheal drugs88
Antidiarrheal Drugs
  • Used to treat diarrhea
  • Diarrhea is rapid expulsion of liquid or semi-liquid stools due to infection or inflammation.
  • Absorption of fluid and electrolytes are limited.
causes of diarrhea
Causes of Diarrhea
  • Excessive use of laxatives
  • Intestinal infections due to virus or protozoa
  • E-Coli
  • Salmonella from contaminated poultry, meats eggs – touching animals and not washing hands
  • Undigested or highly spiced foods
  • Lack of digestive enzymes – cystic fibrosis, metabolic disorders
  • Inflammatory bowel disease
  • Drug therapy
  • Stress and anxiety
  • HIV
antidiarrheal drugs90
Antidiarrheal Drugs
  • Treatment will depend on underlying cause.
  • Often replacement of the loss fluids and electrolytes lost in the stool is all that is needed.
loperamide
loperamide
  • Trade names: Imodium, Imodium A-D, Kaopectate, Maaox antidiarrheal, Pepto diarrheal control.
  • Therapeutic classification: antidiarrheal
  • Action: inhibits peristalsis and prolongs transit time by direct effect on nerves in the intestinal muscle wall.
  • Therapeutic effect: relief of diarrhea
  • Side effects: drowsiness, constipation
antiemetics

Antiemetics

Chapter 62

antiemetics93
Antiemetics
  • Drugs used to prevent or treat nausea and vomiting
  • N & V accompany almost any illness or stress situation
  • GI disorders including infection or inflammation, liver, gallbladder, overeating, indigestion, foods that irritate GI mucosa
  • Cardiovascular
  • Drug therapy
  • Pain and noxious stimuli
  • Emotion or physical stress
  • Motion sickness
  • Radiation therapy and chemo therapy
phenothiazines
Phenothiazines
  • Central nervous system depressants used in the treatment of psychosis and psychotic symptoms
  • Have therapeutic effects in nausea and vomiting by their ability to block dopamine from receptor sites in the brain.
  • Act on vomiting center.
  • May cause serious side effects (hypotension, sedation)
  • Compazine and Phenergan
compazine
Compazine
  • Classification Pharmacologic: phenothiazines
  • Classification Therapeutic: antiemetics, anti-psychotics
  • Action: Alters the effects of dopamine in the CNS. Possesses significant anticholinergic and alpha-adrenergic blocking activity. Depresses the chemoreceptor trigger zone in the CNS.
  • Therapeutic effects: Diminished nausea and vomiting. Diminished signs and symptoms of psychoses or anxiety.
dosing96
Dosing
  • PO: 5 – 10 mg every 3-4 times a day.
  • IM: 5-10 mg every 3-4 times a day.
  • Rectally: 25 mg twice daily
antihistamines
Antihistamines
  • Primarily used to prevent histamine from exerting its widespread effects on body tissue.
  • H1 receptor blocking agent
  • Thought to relieve nausea and vomiting by blocking the action of acetylcholine in the brain (Anticholinergic effects)
  • Dramamine often used in motion sickness
dramamine
Dramamine
  • Classification: antiemetic, antihistamines
  • Action: inhibits vestibular stimulation. Has significant CNS depressant, anticholinergic, antiemetic properties.
  • Therapeutic effects: Decreased vestibular stimulation which may prevent motion sickness.
  • Side effects: drowsiness, dizziness, hyperactivity in children, hypotension
benzodiazephine anti anxiety drug
Benzodiazephine Anti-anxiety Drug
  • Lorazepam and Ativan often used in very agitated patients by producing mild relaxation.
lorazepam
lorazepam
  • Ativan
  • Therapeutic classification: anesthetic adjuncts, anti-anxiety, sedative / hypnotic.
  • Pharmacologic classification: benzodiazepines
  • Action: depresses the CNS, probably by potentiating GABA, an inhibitory neurotransmitter.
  • Adverse effects: dizziness, drowsiness, lethargy – if given to rapidly IV: apnea and cardiac arrest.
prokinetic agents
Prokinetic Agents
  • Increases GI motility and the rate of gastric emptying by increasing the release of acetylcholine from nerve ending in the GI tract.
  • Reglan or metoclopramide is the most commonly used drug.
  • Used when nausea and vomiting associated with non-obstructive gastric retention.
metroclopramide
metroclopramide
  • Brand names: Reglan
  • Classification: antiemetic
  • Action: Blocks dopamine receptors in chemoreceptor trigger zone in the CNS. Stimulates motility of the upper GI tract and accelerates gastric emptying.
  • Unlabeled use: hiccups and migraine headaches.
serotonin receptor antagonist
Serotonin Receptor Antagonist
  • Antagonize serotonin receptors, preventing their activation by the effects of emetogenic drugs and toxins.
  • Zofran has been called the wonder drug for clients undergoing chemotherapy.
  • Often used in combination with corticosteroids
ondansetron
ondansetron
  • Brand name: Zofran
  • Classification Pharmacologic: 5 HT, antagonists
  • Classification Therapeutic: antiemetics
  • Action: Blocks the effects of serotonin at F-HT-receptor sites located in the vagal nerve terminals and chemo-receptor trigger zone in CNS.
  • Therapeutic use: severe nausea and vomiting following surgery or chemotherapy.