CH 36: ANTIHISTAMINES, DECONGESTANTS, ANTITUSSIVES, & EXPECTORANTS

Expectorants: MOA

(Depends on drug) 1. Reflex stimulation. Loosening & thinning of respiratory tract secretions occurs in response to irritation of GI tract produced by drug. *Guaifenesin is the only such drug currently available.* 2. Direct stimulation of the secretory glands in the respiratory tract.

Which anticholinergic effect is seen in a patient who takes brompheniramine? 1. Frequent urination 2. Dry mouth 3. Blue-green vision 4. Excessive watering of eyes

2. Dry mouth Antihistamines such as brompheniramine cause reduced salivary flow, leading to dry mouth. Anticholinergic effects of antihistamines, such as blurred vision, are common, not colored vision. They may also cause urinary retention, not frequent urination. Antihistamines help relieve excessive watering of eyes.

Echinacea: INTERACTIONS

Amiodarone, cyclosporine, phenytoin, methotrexate, ketoconazole, barbiturates; tolerance likely to develop if used for more than 8 weeks. Because some preparations have a high alcohol content, they may cause acetaldehyde syndrome with disulfiram (Antabuse).

Nonopioid Antitussives: DRUGS

Benzonatate (Tessalon Perles) Dextromethorphan (Robitussin) Diphenhydramine (Benadryl)

NAPHAZOLINE

Cause dilated arterioles to constrict, which reduces nasal blood flow and congestion. *Pregnancy category C drug*

Echinacea: ADVERSE EFFECTS

Dermatitis, upset stomach or vomiting, dizziness, headache, unpleasant taste

Antihistamines: HERBS

Echinacea Goldenseal

Goldenseal: ADVERSE EFFECTS

Gastrointestinal (GI) distress, emotional instability, mucosal ulceration (e.g., when used as a vaginal douche)

fexofenadine + Phenytoin

Increased metabolism Decreased fexofenadine levels

Expectorants: ADVERSE EFFECTS

N/V, gastric irritation

Echinacea: CONTRAINDICATIONS

Patients with acquired immunodeficiency syndrome, tuberculosis, connective tissue diseases, multiple sclerosis

DIPHENHYDRAMINE

Traditional antihistamine *Pregnancy category B* Anticholinergic, sedative effects, hypnotic Not advised in older adults because of the "hangover" effect & increased potential for falls. Used for relief/ prevention of histamine-mediated allergies, motion sickness, tX of Parkinson's disease (due to its anticholinergic effects), & promotion of sleep. Also used in conjunction with epinephrine in management of anaphylaxis and Tx of acute dystonic reactions.

Goldenseal: INDICATIONS

Treatment of upper respiratory tract infections, allergies, nasal congestion, and numerous genitourinary, skin, ophthalmic, and otic conditions

8. The nurse notes in a patient's medication history that the patient is taking benzonatate (Tessalon Perles) as needed. Based on this finding, the nurse interprets that the patient has which problem? a. Cough b. Seasonal allergies c. Chronic rhinitis d. Motion sickness

a. Cough

1. When assessing a patient who is to receive a decongestant, the nurse will recognize that a potential contraindication to this drug would be which condition? a. Glaucoma b. Fever c. Peptic ulcer disease d. Allergic rhinitis

a. Glaucoma

2. When giving decongestants, the nurse must remember that these drugs have alpha-adrenergic-stimulating effects that may result in which effect? a. Fever b. Bradycardia c. Hypertension d. CNS depression

c. Hypertension

Decongestants + Systemic sympathomimetic drugs

drug toxicity

Nonsedating Antihistamines: DRUGS

loratadine (Claritin) chlorpheniramine (generic) fexofenadine (Allegra) desloratadine (Clarinex)

Expectorants: PT TEACHING

• Avoid ETOH & ETOH-containing products and don't use meds for longer > 1 wk. If cough or Sx continue, contact the prescriber for further instructions or assessment. •Encourage intake of fluids, unless contraindicated, to help thin secretions for easier expectoration. • Must report a fever of >100.4° F (38° C), cough, or o/ Sx lasting >3-4 days.

Decongestants: PT TEACHING

• Only taking as ordered & adhere to instructions regarding dose & frequency. • Frequent, long-term, or excessive use of decongestants (whether oral forms or nasal inhaled forms) may lead to rebound congestion in which the nasal passages become more congested as the effects of the drug wear off. • Report to prescriber any excessive dizziness, heart palpitations, weakness, sedation, or excessive irritability. • Must report a fever of >100.4° F (38° C), cough, or o/ Sx lasting >3-4 days.

CODEINE

*Opioid antitussive- Schedule V, alone- Schedule II Pregnancy category C* Potentially addictive and can depress respirations as part of its CNS depressant effects. Contraindicated: hypersensitivity to opiates, respiratory depression, increased intracranial pressure, seizure disorders, severe respiratory disorders, ETOH use. Caution: CNS depression, anoxia, hypercapnia, impaired renal function, liver disease, BPH, COPD

A patient is prescribed guaifenesin for treatment of productive cough. What instruction should the nurse give to the patient for maximum therapeutic effect? 1. "Increase your fluid intake." 2. "Increase your fiber intake." 3. "Increase your protein intake." 4. "Increase your carbohydrate intake."

1. "Increase your fluid intake." The nurse should instruct the patient to increase fluid intake, because it helps to liquefy secretions, assists in breaking up thick secretions, and makes it easier to cough up secretions. The nurse may advise an increase in dietary fiber to prevent constipation. The nurse may advise an increase in proteins and carbohydrates in the patient's diet if there is a deficiency of these nutrients.

A patient is prescribed disulfiram for alcohol abuse. During the assessment, the nurse finds that the patient is also taking echinacea for wound healing. What should the nurse instruct the patient to do? 1. "Stop using echinacea." 2. "Increase carbohydrate intake." 3. "Increase the dose of disulfiram." 4. "Take both drugs simultaneously."

1. "Stop using echinacea." Echinacea should not be administered if the patient is on the disulfiram treatment, because it may result in acetaldehyde syndrome. Therefore, the nurse should instruct the patient to stop further use of echinacea. Increase in carbohydrate intake may not be helpful for preventing this interaction. Disulfiram should not be administered in a higher dose to the patient, because it causes severe hazardous effects. The patient should not take echinacea and disulfiram simultaneously, because it causes drug-drug interaction and results in acetaldehyde syndrome.

The nurse observes a mild cough in a patient after hernia repair. Which medication should the nurse expect the provider to prescribe for this patient? 1. Antitussive 2. Expectorant 3. Decongestant 4. Antihistamine

1. Antitussive Antitussives are used to suppress cough. A patient who has undergone hernia repair needs to keep the abdominal muscles relaxed, and coughing can strain the abdominal muscles and worsen the hernia. Expectorants are used to thin secretions and promote coughing out secretions. Decongestants are used to relieve congestion of the upper and lower respiratory tract. Antihistamines are used to treat allergic symptoms.

An older adult with pneumonia is experiencing a cough that is disrupting rest and sleep. Which types of medication should the nurse expect to administer to this patient to promote sleep and rest? Select all that apply. 1. Codeine 2. Fluticasone 3. Guaifenesin 4. Fexofenadine 5. Pseudoephedrine

1. Codeine 3. Guaifenesin The nurse administers codeine to stop the cough and guaifenesin to help mobilize and expectorate secretions. This should result in fewer cough-related interruptions to the patient's sleep and rest. Fluticasone is an intranasal steroid, which is not indicated for this patient. Fexofenadine is not indicated for pneumonia and is likely to dry the mucous membranes, making expectoration of secretions more difficult. Pseudoephedrine, an adrenergic decongestant, can cause sympathetic stimulation, which is likely to be detrimental to an older adult.

The health care provider indicates that a patient will be prescribed an opioid antitussive. Which medication should the nurse anticipate the provider will order? 1. Codeine 2. Benzonatate 3. Levocetirizine 4. Promethazine with dextromethorphan

1. Codeine Codeine is classified as an opioid antitussive. Benzonatate and promethazine with dextromethorphan are both nonopioid antitussives. Levocetirizine is an antihistamine.

Which is the best antitussive to administer to a patient with peripheral arterial disease (PAD)? 1. Codeine 2. Benzonatate 3. Diphenhydramine 4. Dextromethorphan

1. Codeine Codeine is the best choice of antitussive for a patient with PAD, because it does not have the side effect profile of the nonopioid antitussive agents. It is less sedating and, therefore, less likely to result in a fall or patient injury from sedation. Benzonatate is a nonopioid antitussive and is less effective than opioid drugs. Diphenhydramine is a first-generation histamine1 (H1) blocker that can help relieve a cough caused by postnasal drip or upper respiratory congestion but has no antitussive effect. Dextromethorphan is a nonopioid antitussive.

What are the adverse effects of echinacea? Select all that apply. 1. Dizziness 2. Headache 3. Dermatitis 4. Mucosal ulceration 5. Emotional instability

1. Dizziness 2. Headache 3. Dermatitis Echinacea is an herbal medicine commonly used for stimulation of the immune system and antisepsis and to treat viral infections, influenza-like respiratory tract infections, and chronic ulcerations. Dizziness, headache, and dermatitis are adverse effects of echinacea. Mucosal ulceration and emotional instability are adverse effects of goldenseal.

Which patient conditions indicate the need for a nasal decongestant? Select all that apply. 1. Hay fever 2. Dust allergy 3. Nasal surgery 4. Chronic rhinitis 5. Productive cough

1. Hay fever 2. Dust allergy 3. Nasal surgery 4. Chronic rhinitis Nasal decongestants are used to relieve nasal congestion that is caused by hay fever, dust allergy, or chronic rhinitis. Nasal decongestants are also used to reduce swelling of the nasal passages and to facilitate visualization of the nasal and pharyngeal membranes before surgery. Expectorants are used for the relief of productive cough.

The use of goldenseal is contraindicated in patients with which conditions? Select all that apply. 1. Pregnancy 2. Nasal congestion 3. Genitourinary disease 4. Respiratory tract infection 5. Chronic gastrointestinal disorder

1. Pregnancy 5. Chronic gastrointestinal disorder Goldenseal is an herbal medicine. Use of goldenseal is contraindicated in patients with a positive report of pregnancy or chronic gastrointestinal disorder. Goldenseal has uterine stimulant properties. It is contraindicated in pregnant patients because it may cause preterm labor. Use of goldenseal is contraindicated for patients with chronic gastrointestinal disorder because it causes gastrointestinal distress. Goldenseal is recommended for the treatment of nasal congestion, genitourinary disease, and upper respiratory tract infection. It helps relieve these symptoms.

During discharge, which instruction should the nurse provide to a patient who is prescribed naphazoline after reconstructive surgery on the nose? 1. "Increase fluids to 3 L/day." 2. "Avoid caffeinated products." 3. "Rest with your head elevated." 4. "Use a humidifier while sleeping."

2. "Avoid caffeinated products." Naphazoline may be indicated in the postoperative treatment of nasal surgery for short-term hemostasis. The nurse should instruct the patient to avoid caffeinated products to prevent overstimulation of the sympathetic nervous system. Maintaining hydration, elevating the head, and using humidification are prerequisites for nasal surgery to hydrate mucous membranes.

The nurse is instructing a patient on the use of beclomethasone dipropionate. Which statement by the patient indicates an understanding of the teaching? 1. "I need to take this medication only when my symptoms get bad." 2. "I will need to taper off the medication to prevent acute adrenal crisis." 3. "I will need to monitor my blood sugar more closely, because it may increase." 4. "This medication will help prevent the inflammatory response of my allergies."

2. "I will need to taper off the medication to prevent acute adrenal crisis." Beclomethasone dipropionate is a steroid spray administered nasally. It is used to prevent allergy symptoms. Its effect is localized, and therefore the patient does not have systemic side effects with normal use and does not have to worry about weaning off the medication as with oral corticosteroids. Because the medication has a localized effect, it will not produce the changes in blood sugar that would be generated by systemic steroids.

A patient complains of worsening nasal congestion despite the use of oxymetazoline nasal spray every 2 hours. What is the nurse's most appropriate response? 1. "Oxymetazoline is not an effective nasal decongestant." 2. "Overuse of nasal decongestants results in rebound congestion." 3. "You are probably displaying an unexpected reaction to oxymetazoline." 4. "Oxymetazoline should be administered every hour for severe congestion."

2. "Overuse of nasal decongestants results in rebound congestion." Frequent, long-term, or excessive use of decongestants (whether oral forms or nasal inhaled forms) may lead to rebound congestion in which the nasal passages become more congested as the effects of the drug wear off. When this occurs, the patient generally uses more of the drug, precipitating a vicious cycle with more congestion.

The nurse makes a home visit to a middle-aged patient who has a history of asthma. The patient's spouse purchased an over-the-counter antihistamine. However, the nurse instructs the spouse not to administer the drug to the patient. Which complication is the nurse trying to prevent? 1. Paradoxical reactions 2. Collapse of lung alveoli 3. Decrease in respiratory rate 4. Allergic reactions to the drug

2. Collapse of lung alveoli Antihistamines tend to dry up secretions. These dried-up secretions may be difficult for an asthma patient to expectorate. As a result, the secretions can pool in the lungs, causing atelectasis or collapse of pulmonary alveoli. Therefore, antihistamines should be avoided in patients with asthma. Paradoxical reactions occur in older adults and are characterized by dizziness, confusion, sedation, and hypotension. Decrease in respiratory rate happens only in the case of overdose, or if the antihistamine is taken along with other central nervous system depressants such as alcohol. There is no evidence of drug allergy in the patient; therefore, allergic reaction to antihistamines is unlikely.

What are the side effects associated with naphazoline? Select all that apply. 1. Pruritus 2. Headache 3. Dizziness 4. Drowsiness 5. Nervousness

2. Headache 3. Dizziness 5. Nervousness Naphazoline is an intranasal decongestant. Topically applied adrenergic nasal decongestants may be absorbed into the circulation; however, the dosage amount absorbed is usually too small to cause systemic effects. If there are excessive dosages (e.g., excessive use or amounts), these may precipitate cardiovascular effects such as increase in blood pressure and CNS stimulation with headache, nervousness, or dizziness. Pruritus and lightheadedness are not side effects of naphazoline. Pruritus is side effect of benzonatate. Drowsiness may occur with the use of antitussives.

The primary health care provider prescribes oxymetazoline to a patient with sinusitis who complains of nasal congestion and difficulty in breathing. About which possible adverse effect should the nurse teach to the patient? 1. Dry mouth 2. Palpitations 3. Constipation 4. Gastrointestinal irritation

2. Palpitations Oxymetazoline impairs blood flow and can cause cardiovascular disorders such as palpitations and hypertension. Oxymetazoline does not have anticholinergic action and does not cause dry mouth or constipation. Oxymetazoline does not increase acidic levels of gastric fluid and does not cause gastrointestinal irritation.

The use of fexofenadine is contraindicated in patients with which conditions? 1. Skin rashes 2. Renal impairment 3. Vitamin C deficiency 4. Vitamin A deficiency

2. Renal impairment Fexofenadine is contraindicated in patients with renal impairment, because it may be accumulated in the patient's body and cause complications from overdose. Fexofenadine is not contraindicated in patients with skin rashes or vitamin C or A deficiency, because it does not cause any interaction in those cases.

A patient with motion sickness is prescribed diphenhydramine. For which side effect will the nurse watch in the patient? 1. Pruritus 2. Headache 3. Dry mouth 4. Lightheadedness

3. Dry mouth Diphenhydramine is an H1 antagonist. It has anticholinergic action and reduces secretions. Therefore, the nurse should watch for dry mouth in the patient. Pruritus and headache are side effects of benzonatate. Lightheadedness is a side effect of codeine and hydrocodone.

The nurse is assessing a patient with respiratory congestion and finds that the patient is pregnant. Which medicine should the nurse expect the health care provider to prescribe for this patient? 1. Loratadine 2. Fexofenadine 3. Guaifenesin 4. Diphenhydramine

3. Guaifenesin Guaifenesin should be prescribed to the patient, because it is an expectorant and pregnancy category C drug. It is safe to use during pregnancy. Loratadine, fexofenadine, and diphenhydramine are antihistamines and are pregnancy category B drugs that are unsafe to use during pregnancy. These drugs are not helpful for treatment of respiratory congestion. These drugs are used for perennial allergic rhinitis allergic reactions, motion sickness, and nighttime insomnia.

Which patients are the best candidates to receive antitussive cough medication? 1. Patients with pharyngitis and rhinitis 2. Patients with chronic paranasal sinusitis 3. Patients who have undergone hernia surgery 4. Patients with bronchitis with productive cough

3. Patients who have undergone hernia surgery Antitussives are administered to patients who have recently undergone hernia surgery to enhance their comfort and reduce respiratory distress. Expectorants are used to relieve productive cough in patients with pharyngitis and bronchitis. Nasal decongestants are used to relieve nasal congestion in patients with rhinitis. In patients with chronic paranasal sinusitis, expectorants are used for cough suppression. Topics

What is the rationale for administering a medication in the same class as chlorpheniramine and clemastine to a patient with an upper respiratory infection? 1. Inhibition of the cough reflex 2. Promotion of patient sleepiness 3. Suppression of mucus secretion 4. Shrinkage of mucous membranes

3. Suppression of mucus secretion Chlorpheniramine and clemastine are alkylamine and ethanolamine antihistamines, respectively, and are used in upper respiratory infections for their anticholinergic properties. The drugs help dry mucous membranes and diminish histamine-mediated inflammation, resulting in less mucus secretion. Opioid antitussives inhibit cough reflex. The antihistamines belonging to the same class as chlorpheniramine and clemastine have low sedative effects; hence, they do not cause sleepiness. Nasal decongestants shrink mucous membranes.

A patient who has allergic rhinitis comes to the clinic for a scheduled allergy test. After performing a health history, the nurse informs the patient that the allergy test will have to be rescheduled. What may be the reason for this? 1. The patient is afraid of injections. 2. The patient has severe symptoms of rhinitis. 3. The patient is being treated with antihistamine drugs. 4. The patient is being treated with oral antibiotic drugs.

3. The patient is being treated with antihistamine drugs. Allergic rhinitis is usually treated with antihistamines. The drug may give false results in an allergy test, because allergic reactions are also mediated by histamines. All antihistamines should be stopped 4 days before the scheduled allergy test. A fear of injections cannot be resolved by postponing the allergy test. Severe symptoms of rhinitis are unrelated to the allergy test, and hence cannot be a reason for rescheduling the test. Oral antibiotics do not interfere with the allergy test and are not a reason for postponing the test.

7. The order for a 4-year-old patient reads: "Give guaifenesin, 80 mg PO, every 4 hours as needed for cough. Maximum of 600 mg/24 hours." The medication comes in a bottle that has 100 mg/5 mL. How many milliliters will the nurse give per dose?

4 mL

A patient reports to the nurse that after taking guaifenesin for 1 week, the productive cough still persists. What advice should the nurse give to the patient? 1. "Decrease your fluid intake." 2. "Take loratadine twice a day." 3. "Increase the dose of guaifenesin." 4. "Consult your primary health care provider."

4. "Consult your primary health care provider." The nurse should advise the patient to consult with the primary health care provider so that the patient can be evaluated and the prescription can be changed accordingly. The patient should not take expectorants for more than 1 week, because it may cause drug dependency and drug tolerance. Increasing, not decreasing, fluid intake helps in thinning secretions for easier expectoration. Loratadine is not helpful in treating productive cough. Loratadine is used for the treatment of allergic rhinitis and chronic urticaria. The nurse should not advise the patient to take an increased dose of guaifenesin, because it produces hazardous effects in the patient.

The nurse is teaching a patient about the use of an expectorant. What is the most important instruction for the nurse to include in the patient teaching? 1. "Take the medication once a day only, at bedtime." 2. "Restrict your fluids to decrease mucus production." 3. "Increase your fiber and fluid intake to prevent constipation." 4. "Increase your fluid intake to decrease viscosity of secretions."

4. "Increase your fluid intake to decrease viscosity of secretions." Expectorant drugs are used to decrease viscosity of secretions and allow them to be more easily expectorated. Increasing fluid intake helps this action. The medications should be taken twice daily with extra fluids. It is not necessary to increase fiber.

A patient is prescribed dextromethorphan for treatment of cough. What instruction should the nurse give to the patient for safe administration of the drug? 1. "Use a humidifier while sleeping." 2. "Elevate your bed while sleeping." 3. "Increase your fluid intake to 3000 mL per day." 4. "Restrict activities that require mental alertness."

4. "Restrict activities that require mental alertness." Dextromethorphan is a nonopioid antitussive drug that may also cause sedation, drowsiness, or dizziness. The nurse should advise the patient to avoid activities that require mental alertness. It helps prevent injury to the patient. Use of a humidifier helps maintain hydration levels, but does not reduce the risk of injury to the patient. Elevating one's head while sleeping helps with lung expansion and promotes breathing. Fluid intake should be increased when decongestants are administered, because fluids help liquefy secretions and make it easier to cough up secretions.

The nurse is caring for a patient in the clinic who states being afraid of taking antihistamines because of being a truck driver. What is the best information for the nurse to give this patient? 1. "Take the medication only when you are not driving." 2. "You are correct; you should not take antihistamines." 3. "Take a lower dose than normal when you have to drive." 4. "You may be able to safely take a nonsedating antihistamine."

4. "You may be able to safely take a nonsedating antihistamine." Nonsedating antihistamines may be safer for the patient to take, but the patient should still monitor for signs of sedation. If sedation occurs, the patient should be instructed to avoid taking these drugs while driving. Taking a lower dose will decrease the drug's effectiveness.

Which medication can cause paradoxical reactions in children? 1. Antacid 2. Antitussive 3. Decongestant 4. Antihistamine

4. Antihistamine An antihistamine can cause paradoxical reaction in children. Dizziness, confusion, sedation, and hypotension are symptoms associated with paradoxical reaction. An antacid may cause constipation or other reactions with an overdose. An antitussive can cause drowsiness or dizziness in the patient. A decongestant can cause rebound congestion with frequent use or overdose.

A patient presenting with cough is prescribed diphenhydramine. The nurse instructs the patient to avoid consuming alcohol. Which consequence of drug interaction with alcohol would be prevented if the patient follows the nurse's instructions? 1. Allergic rhinitis 2. Motion sickness 3. Nighttime insomnia 4. Central nervous system (CNS) depression

4. Central nervous system (CNS) depression Diphenhydramine interacts with alcohol, causing CNS depression and leading to a decrease in respiratory rate and heart rate and loss of consciousness. Therefore, the nurse should instruct the patient to avoid alcohol consumption. Allergic rhinitis, motion sickness, and nighttime insomnia are indications for the use of diphenhydramine. These conditions are not the result of an interaction between diphenhydramine and alcohol.

Which drug will the primary health care provider prescribe for a patient who has nighttime insomnia and motion sickness? 1. Cetirizine 2. Loratadine 3. Fexofenadine 4. Diphenhydramine

4. Diphenhydramine Diphenhydramine should be prescribed for the patient, because this drug is useful for treating nighttime insomnia as well as motion sickness. Diphenhydramine s a traditional antihistamine and works both peripherally and centrally. It has anticholinergic and sedative effects. Cetirizine, loratadine, and fexofenadine are nonsedating antihistamines. These drugs work peripherally and do not have a sedating effect. Therefore, these drugs are not helpful in treating nighttime insomnia.

Which antihistamine causes sedation an adverse drug effect? 1. Loratadine 2. Fexofenadine 3. Desloratadine 4. Diphenhydramine

4. Diphenhydramine The most common adverse effects with diphenhydramine include sedation and antimuscarinic effects, including dry mouth, urinary retention, and constipation. The newer antihistamines such as loratadine, fexofenadine, and desloratadine are usually less sedating because of reduced distribution to the central nervous system.

An older adult who presents with a cough is instructed not to use diphenhydramine. What is the possible reason for this? 1. Diphenhydramine causes seizures. 2. Diphenhydramine causes constipation. 3. Diphenhydramine causes lightheadedness. 4. Diphenhydramine causes a "hangover" effect.

4. Diphenhydramine causes a "hangover" effect. Diphenhydramine is not administered to older adults because it produces a "hangover" effect and increases the risk for falls, which may cause severe injury. Diphenhydramine does not produce seizure, constipation, or lightheadedness. Seizure is a side effect of over-the-counter cough and cold products. Constipation and lightheadedness are side effects of codeine and hydrocodone.

The nurse observes that a patient who is taking phenylephrine and vitamin C tablets has developed rebound congestion. What is the probable reason for rebound congestion? 1. Drug-drug interaction 2. Phenylephrine tolerance 3. Allergic reaction to vitamin C 4. Frequent use of phenylephrine

4. Frequent use of phenylephrine Rebound congestion results from frequent, long-term use or overdose of decongestants. Phenylephrine and vitamin C do not cause any drug-drug interaction. Rebound congestion does not indicate that the patient has phenylephrine tolerance. Rebound congestion is not associated with allergy to vitamin C.

Which drug is contraindicated in a patient who has Addison's disease? 1. Naphazoline 2. Benzonatate 3. Fexofenadine 4. Hydrocodone

4. Hydrocodone Hydrocodone is contraindicated in a patient who has Addison's disease, because administration of hydrocodone may worsen the disease condition. Naphazoline, fexofenadine, and benzonatate can be administered to the patient, because they do not worsen the symptoms of Addison's disease.

A patient complains that symptoms of allergic rhinitis are persistent even after taking fexofenadine. After checking the patient's history, the nurse finds that the patient is taking phenytoin for the treatment of seizures. What should the nurse interpret from this information? 1. It indicates drug tolerance. 2. It indicates dystonic reaction. 3. It indicates paradoxical reaction. 4. It indicates drug-drug interaction.

4. It indicates drug-drug interaction. Phenytoin decreases the fexofenadine level in the body. Therefore, the drug does not have the desired therapeutic effect. The persistent allergic rhinitis is caused by drug interaction, not drug tolerance. Dystonic reaction is related to muscle contractions. Twisting and repetitive movements or abnormal postures can be observed in this condition. Paradoxical reaction is observed in older adults and children from the use of antihistaminic drugs.

During the assessment of a patient, the nurse finds symptoms of dizziness, confusion, sedation, and hypotension. After reviewing the patient's medical history, the nurse finds that the patient is taking diphenhydramine for treatment of nighttime insomnia. What should the nurse interpret from the assessment? 1. It is an allergic reaction. 2. It is a dystonic reaction. 3. It is rebound congestion. 4. It is a paradoxical reaction.

4. It is a paradoxical reaction. Diphenhydramine is an antihistaminic drug. Antihistaminic drugs may produce paradoxical reactions such as dizziness, confusion, sedation, and hypotension in older adults. These are not allergic reactions to the drug. In cases of dystonic reaction, sustained muscle contractions cause twisting and repetitive movements or abnormal postures. Rebound congestion results from long-term use, or overdose, of nasal decongestants.

For which adverse drug effect is the nurse alert in an older adult patient taking diphenhydramine? 1. Hay fever 2. Insomnia 3. Hypertension 4. Urinary retention

4. Urinary retention The most common adverse effects with diphenhydramine include sedation and antimuscarinic effects, including dry mouth, urinary retention, and constipation. Insomnia is an adverse effect of adrenergic drugs. Hay fever is a symptom of allergic rhinitis and not a side effect of diphenhydramine. Hypertension is a side effect of excessive dosages of topically applied adrenergic nasal decongestants.

Goldenseal: CONTRAINDICATIONS

Acute or chronic GI disorders; pregnancy (has uterine stimulant properties); should be used with caution by those with cardiovascular disease

Decongestants: INDICATIONS

Acute or chronic rhinitis, common cold, sinusitis, hay fever, o/ allergies. Reduce swelling of the nasal passages and to facilitate visualization of the nasal and pharyngeal membranes before surgery or diagnostic procedures.

diphenhydramine, cetirizine + ETOH, MAOIs, CNS depressants

Additive effects Increased CNS depression

Decongestants + Monoamine Oxidase Inhibitors (MAOIs)

Additive pressor effects (e.g., raising BP)

Antihistamines: ADVERSE EFFECTS

CV: Hypotension, palpitations, syncope CNS: Sedation, dizziness, muscular weakness, paradoxical excitement, restlessness, nervousness, seizures GI: N/V/D, constipation O/: Dryness of mouth, nose, and throat; urinary retention; vertigo; visual disturbances; tinnitus; HA

Opioid Antitussives: DRUGS

Codeine Hydrocodone (Norco)

Antihistamines: MOA

Compete with histamine for the H1 receptors in the smooth muscle surrounding blood vessels and bronchioles. Affect secretions of lacrimal, salivary, & respiratory mucosal glands, (primary anticholinergic actions of antihistamines).

Goldenseal: INTERACTIONS

Gastric acid suppressors (including antacids, histamine H2 blockers [e.g., ranitidine], proton pump inhibitors [e.g., omeprazole]): reduced effectiveness due to acid-promoting effect of herb Antihypertensives: reduced effectiveness due to vasoconstrictive activity of herb

Expectorants: DRUGS

Guaifenesin (Mucinex) *Pregnancy category C*

Antihistamines: fexofenadine + Erythromycin & o/ CYP450 inhibitors

Inhibit metabolism Increased fexofenadine levels

loratadine + Ketoconazole, cimetidine, erythromycin

Inhibit metabolism Increased loratadine levels

Antihistamines: INDICATIONS

Management of nasal allergies, seasonal or perennial allergic rhinitis (e.g., hay fever), urticaria, common cold Sx. Tx of allergic reactions, motion sickness, Parkinson's disease (due to their anticholinergic effects), vertigo. Additionally- sleep aid.

Decongestants: DRUGS

Naphazoline (Privine) Triamcinolone acetonide (Nasacort AQ) Fluticasone proprionate (Flonase)

Decongestants: CONTRAINDICATIONS

Narrow-angle glaucoma, uncontrolled cardiovascular disease, hypertension, diabetes, and hyperthyroidism. Patient is unable to close his or her eyes (such as after a cerebrovascular accident), Hx CVA/ TIA, long-standing asthma, benign prostatic hyperplasia, or diabetes.

Decongestants: ADVERSE EFFECTS

Nervousness, insomnia, palpitations, tremor, mucosal irritation and dryness. Excessive dosages- CV effects (i.e. HTN, palpitations); CNS effects (HA, nervousness, dizziness).

BENZONATATE

Nonopioid antitussive *Pregnancy category C* Thought to work by anesthetizing or numbing cough receptors. Cautious use in those with productive cough.

DEXTROMETHORPHAN

Nonopioid antitussive *Pregnancy category C* When used in recommended dosages, it is safe, nonaddicting, & doesn't cause respiratory or CNS depression. *Popular drug of abuse.* Contraindicated: hyperthyroidism, advanced cardiac & vessel disease, HTN, glaucoma, use of MAOIs within past 2 wks, asthma or emphysema, persistent HA.

LORATADINE

Nonsedating antihistamine *Pregnancy category B* Used to relieve the symptoms of seasonal allergic rhinitis (e.g., hay fever) & urticaria. Should not be given w/: aclidinium, azelastine, ipratropium, orphenadrine, KCl, tiotropium, umeclidinium. Not recommended for children younger <2 y/o.

FEXOFENADINE

Not recommended for those with renal impairment.

Antihistamines: CONTRAINDICATIONS

Not to be used as the sole drug therapy during acute asthmatic attacks. O/: narrow-angle glaucoma, cardiac disease, kidney disease, hypertension, bronchial asthma, chronic obstructive pulmonary disease, peptic ulcer disease, seizure disorders, benign prostatic hyperplasia, and pregnancy. Caution: impaired liver function or renal insufficiency, lactating mothers.

Decongestants: INTERACTIONS

O/: methyldopa, urinary acidifiers, alkalinizers.

Antitussives: MOA

Opioid & nonopiod- Suppress cough reflex through direct action on the cough center in CNS (medulla). Drying effect on mucosa of the respiratory tract, which increases the viscosity of respiratory secretions. Helps reduce Sx (i.e. runny nose, postnasal drip). Opioid (only)- provide analgesia

Antitussives: INTERACTIONS

Opioid antitussives (codeine and hydrocodone) may potentiate effects of o/ opioids, general anesthetics, tranquilizers, sedatives & hypnotics, tricyclic antidepressants, ETHOH, & o/ CNS depressants.

Expectorants: INDICATIONS

Relief of productive cough associated with: common cold, bronchitis, laryngitis, pharyngitis, pertussis, influenza, & measles. Suppression of coughs caused by chronic paranasal sinusitis.

Antihistamines: PT TEACHING

Sedating effects of traditional antihistamines. Pt needs to avoid activities that require mental alertness until tolerance to sedation occurs or until he or she accurately judges that the drug has no impact on motor skills or responses to motor activities. Include a list of drugs the patient must avoid, such as alcohol and CNS depressants. With traditional and nonsedating antihistamines, a humidifier may be needed to help liquefy secretions, making expectoration of sputum easier. Encourage intake of fluids, unless contraindicated.

Decongestants: MOA

Stimulation of SNS. Shrink engorged nasal mucous membranes and relieve nasal stuffiness. Adrenergic- constricts small arterioles that supply structures of the upper respiratory tract, primarily the blood vessels surrounding the nasal sinuses. Nasal secretions in the swollen mucous membranes are better able to drain, either externally through the nostrils or internally through reabsorption into the bloodstream or lymphatic circulation.

Echinacea: INDICATIONS

Stimulation of the immune system, antisepsis, treatment of viral infections and influenza-like respiratory tract infections, promotion of wound healing, and chronic ulcerations

Antitussives: INDICATIONS

Stop cough reflex when the cough is nonproductive &/or harmful.

Antitussives: PT TEACHING

Take w/ caution & report to prescriber any fever, chest tightness, change in sputum from clear to colored, difficult or noisy breathing, activity intolerance, or weakness.

3. The nurse is reviewing a patient's medication orders for prn (as necessary) medications that can be given to a patient who has bronchitis with a productive cough. Which drug will the nurse choose? a. An antitussive b. An expectorant c. An antihistamine d. A decongestant

b. An expectorant

6. The nurse is giving an antihistamine and will observe the patient for which side effects? (Select all that apply.) a. Hypertension b. Dizziness c. "Hangover" effect d. Drowsiness e. Tachycardia f. Dry mouth

b. Dizziness c. "Hangover" effect d. Drowsiness f. Dry mouth

4. The nurse knows that an antitussive cough medication would be the best choice for which patient? a. A patient with a productive cough b. A patient with chronic paranasal sinusitis c. A patient who has had recent abdominal surgery d. A patient who has influenza

c. A patient who has had recent abdominal surgery

5. A patient is taking a decongestant to help reduce symptoms of a cold. The nurse will instruct the patient to observe for which possible symptom, which may indicate an adverse effect of this drug? a. Increased cough b. Dry mouth c. Slower heart rate d. Heart palpitations

d. Heart palpitations

Traditional Antihistamines: DRUGS

diphenhydramine (Benadryl) cetirizine (Zyrtec) brompheniramine (Bromfed, Dimetapp) chlorpheniramine (ChlorTrimeton) dimenhydrinate (Dramamine) meclizine (Antivert, Dramamine II) promethazine (Phenergan)

Antitussives: ADVERSE EFFECTS

• Benzonatate: dizziness, HA, sedation, nausea, constipation, pruritus, nasal congestion • Codeine & hydrocodone: sedation, N/V, lightheadedness, constipation • Dextromethorphan: dizziness, drowsiness, nausea • Diphenhydramine: sedation, dry mouth, & o/ anticholinergic effects

General PT TEACHING

• Those w/ upper or lower respiratory Sx or disease processes of the impact of the environment on their Sx or condition- avoid dry air, smoke-filled environments, & allergens. • Always check for possible drug interactions because many OTC & Rx drugs could lead to adverse effects if taken concurrently with any of the antihistamines, decongestants, antitussives, or expectorants. • Take med w/ snack or meals to minimize GI upset. • Immediately report to prescriber any difficulty breathing, palpitations, or unusual adverse effects.