Chapter 40 Drugs/Review

Ipratropium (Atrovent)

*Actions and Uses* - Blocks cholinergic receptors to produce bronchodialation * adverse effects* -cough, dryness of nasal mucosa, hoarseness, bitter taste (rinse), epistaxis *Contraindications* - hypersensitivity to soya lecthin (soybean, peanut) - propellant

Beclomethasone (QVAR)

*Actions and Uses* - reduces inflammation - used to decrease frequency of asthma attacks *Adverse Effects* - hoarseness, dry mouth, changes in taste, cataracts, growth inhibition in children with long term use, oropharanygeal candidiasis *Contraindications* - hypersensitivity, active infection, *caution* Pediatric patients

Montelukast (singulair)

*Actions and Uses* - used for prophylaxis of chronic asthma - prevents edema and inflammation by blocking leukotrienes *Adverse Effects* - headache, nausea, diarrhea - suicidal ideation, hallucinations, aggressiveness, depression *Contraindications* - hypersensitivity *caution* - hepatic impariment

Albuterol

*Actions and uses* - beta2-agonist - produces bronchodialation by working on smooth muscles *adverse effects* - palpations, headaches, throat irritation, tremor, nervousnness, restlessness, tachycardia, insomnia, dry mouth, chest pain, paradoxical bronchospasm, allergic reactions *contraindications* - hypersensitivity, caution - history of cardiac disease, hypertension

Ch 39: Pathophysiology of Asthma

- Chronic pulmonary disease with inflammation and bronchospams affecting 20M Americans. - Rx: (1) to decrease frequency, or (2) terminate attack - Highest rate of increase since 1980 among African-Americans - Highest incidence <18yo - 7-10% of children have it. 2x boys than girls. - 35% more common in adult women than men - Bronchospasm: intense breathlessness, coughing, gasping - Inflammation: histamine secretion, ↑mucous and edema, hyperresponsive to allergens - Bronchospasm + Inflammation = Airway obstruction - Tx: β2-adrenergic agonists for acute bronchoconstriction

Ch 39: Administration of Pulmonary Drugs via Inhalation

- High vasculature of respiratory system results in almost instantaneous onset of action of inhalants. ~ Aerosols: Rx for resp system + delivers directly to site of action - systemic effects. Tx INH min. systemic toxicity - precise dose difficult to measure due to pt breathing pattern and correct use of devise - swallowing rx > GI absorption > adverse systemic effects Devises for Aerosolization - Nebulizer: vaporize liquid rx into fine mist for INH by mask or handheld device - Dry powder inhaler (DPI): activated by inhalation to deliver fine powder directly to bronchial tree - Metered-dose inhalar (MDI): propellant delivery of puffs of drug

Ch 39: Leukotrienes

- mediators in allergic and asthmatic reactions synthsized by mast cells, neutrophils, basophils and eosinophils - promote edema, inflammation and bronchoconstriction in airways. - Similar effects to histamines.

Ch 39: Chronic obstructive pulmonary disease (COPD)

- several pulmonary conditions characterized by cough, mucus production, and impaired gas exchange. - MAIN:chronic bronchitis and emphysema. - progressive, with the terminal stage being emphysema.

Ch 39: Chronic bronchitis

-Recurrent disease of the lungs - excess mucus production, inflammation, and coughing. - airway becomes partially obstructed resulting in classic signs of dyspnea and coughing with impaired gas exchange.

Ch 39: Physiology of the Lower Respiratory Tract.

-Ventiation - move air in and out. -purely mechanical 12-18x/min. - Rate modifies by emotions, fever, stress, serum pH, medications. Diaphragm contracts (lowers) creating negative pressure and inspiration. - Diaphragm relates, passive ehalaxion.

Ch 39: The nurse should teach the client that salmeterol (Serevent) is not indicated for the termination of acute bronchospasm for which of the following reasons? a. It is not absorbed orally. b. It takes too long to act. c. It affects only beta-1 receptors d. It causes too much CNS stimulation.

...

KT

...Asthma is a chronic disease that has both inflammatory and bronchospasm components. Drugs are used to prevent asthmatic attacks and to terminate an attack in progress.

KT

...Beta-adrenergic agonists are the most effective drugs for relieving acute bronchospasm. These agents act by activating beta2 receptors in bronchial smooth muscle to cause bronchodilation.

KT

...Chronic obstructive pulmonary disease (COPD) is a progressive disorder treated with multiple pulmonary drugs. Bronchodilators, expectorants, mucolytics, antibiotics, and oxygen may offer symptomatic relief.

KT

...Inhalation is a common route of administration for pulmonary drugs because it delivers drugs directly to the sites of action. Nebulizers, MDIs, and DPIs are devices used for aerosol therapies.

KT

...Inhaled corticosteroids are often drugs of choice for the long-term prophylaxis of asthma. Oral corticosteroids are used for the short-term therapy of severe, acute asthma.

KT

...Mast cell stabilizers are safe drugs for the prophylaxis of asthma. They are less effective than the inhaled corticosteroids and are ineffective at relieving acute bronchospasm.

KT

...Methylxanthines such as theophylline were once the mainstay of chronic asthma pharmacotherapy. They are less effective and produce more side effects than the beta agonists.

KT

...The anticholinergic ipratropium is a bronchodilator occasionally used as an alternative to the beta agonists in asthma therapy.

KT

...The leukotriene modifiers, primarily used for asthma prophylaxis, act by reducing the inflammatory component of asthma.

Ch 39: A client has aminophylline ordered at 0.25 mg/kg/hr. The client weighs 50 kg. How many mg should be administered over a 6-hr period?

0.25mg x 50mg x 6hr = 75 mg

Ch 39: A client has albuterol 4 mg ordered tid. Concentrate of 2 mg in 5 mL is available. How many mL would be given per dose?

5mL/2mg x 4mg = 10 mL

Ch 39: The client is prescribed cromolyn (Intal) for treatment of asthma. The nurse teaches the action of this drug is: A) Anti-inflammatory. B) Anti-infective. C) Mucolytic. D) Bronchodilation.

A) Anti-inflammatory. Cromolyn (Intal) is classified as a mast cell stabilizer, since its action serves to inhibit mast cells from releasing histamine and other chemical mediators of inflammation. This drug should be taken on a daily basis, and is not effective at terminating acute asthma attacks.

Ch 39: An elderly male client is prescribed ipratropium (Atrovent) for the treatment of asthma. Appropriate nursing intervention includes: A) Teaching the client to report inability to urinate. B) Assessing for enlarged liver. C) Monitoring for development of diarrhea. D) Teaching the client to avoid caffeine in the diet.

A) Teaching the client to report inability to urinate. Anticholinergic bronchodilators should be used cautiously in elderly men with benign prostatic hypertrophy, and in all clients with glaucoma.

Ch 39: Common triggers of asthma

Air pollutants - tobacco, ozone, N2O / SOx Allergens - pollens, animal dander, household dust, mold Chemicals and food - ASA, IBP, β-blockers, sufite preservatives, nuts, MSG, shellfish, dairy Respiratory infections - bacterial, fungal, viral Stress - Emotional stress/anxiety, exercise in dry, cold climates

Ch 39: Nursing intervention for a client on long-term oral glucocorticoids includes: A) Monitoring blood glucose for hypoglycemia. B) Assessing for signs of GI bleeding. C) Assessing cardiac dysrhythmias. D) Assessing liver function tests.

B) Assessing for signs of GI bleeding. If taken for longer than 10 days, oral glucocorticoids can produce significant adverse effects, including adrenal gland atrophy, peptic ulcers, and hyperglycemia.

Ch 39: Client teaching for clients on long-term therapy with beta-adrenergic agonists for treatment of asthma should include: A) Discontinuing the drug if the heart rate increases. B) Notifying the physician if the drug no longer seems effective. C) Reducing the dosage of the drug if insomnia occurs. D) Monitoring intake and output

B) Notifying the physician if the drug no longer seems effective. Tolerance can develop to the therapeutic effects of the beta-agonists; therefore, the client must be instructed to seek medical attention should the drugs become less effective with continued use.

Ch 39: The client is using a beta-adrenergic agonist for treatment of asthma. The nurse teaches that the action of this drug is: A) Reducing mucus production. B) Relaxing smooth muscle, causing bronchodilation. C) Liquefying mucus. D) Reducing cough.

B) Relaxing smooth muscle, causing bronchodilation. Beta-adrenergic agonists (sympathomimetics) act by relaxing bronchial smooth muscle, resulting in a bronchodilation that lowers airway resistance and makes breathing easier for the client.

Ch 39: The nurse teaches the client that the major disadvantage of aerosol therapy is that: A) The medication is very expensive. B) The precise dose of the medication the client receives cannot be measured. C) The client cannot use the equipment unless supervised by medical personnel. D) The medication is irritating to the bronchial tree.

B) The precise dose of the medication the client receives cannot be measured. The major disadvantage to administering aerosol therapy is that the precise dose received by the client is difficult to measure, because it depends upon the client's breathing pattern and correct use of the aerosol device.

Ch 39: Perfusion

Blood flow through a tissue or organ.

Ch 39: Bronchiolar Smooth Muscle

Bronchioles - muscular, elastic structures whose diameter, or lumen, varies with contraction/relaxation of smooth musce. Bronchodilation - opens lumen, more airflow, ↑O2 --sympathetic branch activates β2-adrenergic receptors --β2-adrenergic agonists are called bronchodilators Bronchoconstriction - closes lumen, less airflow, ↓O2 --parasympathetic branch

Key Terms

Bronchioles are lined with smooth muscle that controls the amount of air entering the lungs. Dilation and constriction of the airways are controlled by the autonomic nervous system.

Ch 39: The client is receiving theophylline (Theo-Dur) for treatment of asthma. Nursing intervention is required if the client makes which of the following statements? A) "I will check my heart rate each day." B) "I will use my inhaler if I am wheezing." C) "I will take my medicine with my coffee each morning." D) "I will notify my doctor if my vision changes."

C) "I will take my medicine with my coffee each morning." The methylxanthines comprise a group of bronchodilators chemically related to caffeine. Because of the drugs' chemical similarities, clients should avoid foods and beverages containing caffeine when taking these drugs.

Ch 39: The client receives treatment for a respiratory condition through aerosol therapy. The nurse explains that the major advantage of this type if therapy is that: A) The client requires no skill to use it. B) It is safe for all clients. C) It delivers the medication to the site of action. D) It has no systemic side effects.

C) It delivers the medication to the site of action. An aerosol is a suspension of minute liquid droplets or fine solid particles in a gas. Aerosol therapy can give immediate relief for bronchospasm, or can loosen thick mucous. The major advantage of aerosol therapy is that it delivers medications to their immediate site of action, reducing systemic side effects.

Ch 39: Methylxanthine

Chemical derivative of caffeine. Theophyllin therapeutic level 10-20. narrow range. more side effects

Ch 39: Asthma

Chronic inflammatory disease of the lungs characterized by airway obstruction.

Ch 39: The client is using beclomethasone (Beclovent) for treatment of chronic asthma. Which of the following statements indicates that the client understands drug therapy? A) "I will not need a flu shot now that I'm taking this medicine." B) "I will use this drug only when I feel an attack coming on." C) "This is the only drug I will need to treat my asthma attacks." D) "I will use my bronchodilator if my wheezing increases."

D) "I will use my bronchodilator if my wheezing increases." Clients should be informed that inhaled glucocorticoids must be taken daily to produce their therapeutic effect, and that these medications are not effective at terminating episodes in progress.

Ch 39: The nurse teaches the client that the primary purpose of inhaled glucocorticoids is to: A) Relax bronchial smooth muscles. B) Achieve bronchodilation. C) Aid in the ability to cough up mucus. D) Prevent respiratory distress.

D) Prevent respiratory distress. The primary purpose of inhaled glucocorticoids is to prevent respiratory distress. The client should be advised that this medication should not be used during an acute asthma attack.

Ch 39: Dry powder inhaler (DPI)

Device used to convert a solid drug to a fine powder for the purpose of inhalation.

Ch 39: Nebulizer

Device used to convert liquid drugs into a fine mist for the purpose of inhalation.

Ch 39: Metered dose inhaler (MDI)

Device used to deliver a precise amount of drug to the respiratory system.

Ch 39: __________ use a propellant to deliver a measured dose of drug to the lung during each breath.

Metered dose inhalers (MDIs)

Ch 39: Ventilation

Process by which air is moved into and out of the lungs.

Ch 39: Bronchospasm

Rapid constriction of the airways.

Ch 39: Status asthmaticus

Severe, prolonged form of asthma unresponsive to drug treatment that may lead to respiratory failure.

Ch 39: Aerosol

Suspension of minute liquid droplets or fine solid particles in a gas.

Ch 39: Emphysema

Terminal lung disease characterized by permanent dilation of the alveoli.

Key terms

The physiology of the respiratory system involves two main processes. Ventilation moves air into and out of the lungs, and perfusion allows for gas exchange across capillaries.

Ch 39: Mr. H has been admitted to a respiratory floor after being treated in the ER for an exacerbation of asthma. The client states he has been on beclomethasone (Beconase) inhaler and an oral theophylline preparation for about 2 months. His last exacerbation of asthma was about 2 months ago, and he claims to be compliant with his medications. About a week ago, Mr. H started having a persistent cough, productive of green thick sputum. He has been short of breath and has been wheezing in the ER. The physician prescribed lorazepam (Ativan) and metaproterenol (Alupent) while Mr. H is in the ER. The nurse has chose a nursing diagnosis of Ineffecitve Airway Clearance due to infective process causing increased mucus production. a. Which assessment would indicate a possible infection and ineffective airway clearance? b. Which nursing interventions would need to be completed for the diagnosis of ineffective airway clearance?

a. Assessment: Green thick mucus. Increased incident of wheezing and shortness of breath and wheezing worsening over 2 weeks. b. Assess respiratory status, respiratory rate, vital signs, auscultation of breath sounds, pulmonary function studies; peak flow, ABGs and O2 sat. - Fluids: IV PRN, PO if possible 2-3 L QD - Head of bed elevated - O2 PRN to maintain O2 at satisfactory levels - Administer beta-2 agonist and monitor for improvement and side effects Client teaching to include: - Preventive inhaled (beclomethasone) - Fluids 2-3 L per day - Notify physician for any increased dyspnea, wheezing, fever, change in sputum color or consistency - Encourage compliance with meds and discuss side effects and ways to decrease side effects - Avoid environmental antigens that trigger asthma responses such as pollen, animal dander, dust, smoke, cold air - Eat regularly using smaller meals more frequently - Receive yearly vaccines to prevent respiratory infections. - Decrease or eliminate intake of caffeine. - Avoid smoking

Ch 39: What is the most common reason for school absenteeism? a. Asthma b. Ear infections c. Colds d. Heart disease

a. Asthma

Ch 39: Which of the following drug classes is most effective for relieving acute bronchospasm? a. Beta-2 agonists b. Mast cell stabilizers c. Methylxantines d. Anticholinergics

a. Beta-2 agonists

Ch 39: The nurse should know that candidiasis of the troat is a common complication during therapy with which class of medications? a. Inhaled glucocorticoids b. Mast cell stabilizers c. Beta-2 agonists d. Mucolytics

a. Inhaled glucocorticoids

Ch 39: Albuterol (Proventil, Salbutamol, others) a. Selective beta-2 agonists b. Nonselective beta-1 and beta-2 agonist c. Methylxanthine d. Anticholinergic e. Glucocorticoid

a. Selective beta-2 agonists

Ch 39: Why are selective beta-1 agonists ineffective for treating asthma? a. There are no beta-1 receptors in bronchial smooth muscle b. They cannot be delivered by the inhalation route c. They cause bronchoconstriction d. Their duration of action is too short.

a. There are no beta-1 receptors in bronchial smooth muscle

Ch 39: Goals of drug therapy for asthma are twofold: to __________ acute bronchospam and to reduce the __________ of asthma attacks.

arrest, frequency

Ch 39: When assessing a client, the nurse must know that which of the following is not characteristic of asthma? a. Inflammation b. Infection c. Bronchoconstriction d. Dyspnea

b. Infection

Ch 39: Epinephrine (Adrenalin, Bronkaid, Primatene) a. Selective beta-2 agonists b. Nonselective beta-1 and beta-2 agonist c. Methylxanthine d. Anticholinergic e. Glucocorticoid

b. Nonselective beta-1 and beta-2 agonist

Ch 39: Isoproterenol (Isoprel, Medihaler-Iso) a. Selective beta-2 agonists b. Nonselective beta-1 and beta-2 agonist c. Methylxanthine d. Anticholinergic e. Glucocorticoid

b. Nonselective beta-1 and beta-2 agonist

Ch 39: Glucocorticoids improve asthma symptoms by which of the following mechanisms? a. Causing bronchoconstriction b. Supressing inflammation c. blocking histamine release d. Drying bronchial secretions

b. Supressing inflammation

Ch 39: The nurse should teach clients that the primary use of mast cell inhibitors in the treatment of asthma is which of the following? a. To terminate acute asthma attacks b. To prevent asthmatic attacks c. To reduce secretions d. To reduce infections.

b. To prevent asthmatic attacks

Ch 39: Client taking zafirlukast (Accolate) or montelukast (Singulair) should be taught that they will see improvement within what time frame? a. 2 hours b. 2 days c. 1 week d. 1 month

c. 1 week

Ch 39: Exchange of gases occurs in which pulmonary structure? a. Pharynx b. Bronchioles c. Alveoli d. Bronchi

c. Alveoli

Ch 39: Mr. H has been admitted to a respiratory floor after being treated in the ER for an exacerbation of asthma. The client states he has been on beclomethasone (Beconase) inhaler and an oral theophylline preparation for about 2 months. His last exacerbation of asthma was about 2 months ago, and he claims to be compliant with his medications. About a week ago, Mr. H started having a persistent cough, productive of green thick sputum. He has been short of breath and has been wheezing in the ER. The physician prescribed lorazepam (Ativan) and metaproterenol (Alupent) while Mr. H is in the ER. The nurse has chose a nursing diagnosis of Ineffecitve Airway Clearance due to infective process causing increased mucus production. c. Give the therapeutic rationales for the two drugs taken by Mr. H prior to the ER visit. d. Give the therapeutic rationales for the two drugs taken by Mr. H during his ER visit.

c. Beclomethasone is a glucocorticoid used to decrease inflammation and prevent asthma attacks. Theophylline is a methylxanthine bronchodilator used to provide bronchodilation. d. Ativan is a CNS depressant that is used as an antianxiety agent to decrease the dyspnea due to stress and anxiety. Metaproterenol is a beta-2 agonist that will bronchodilate and relieve the dyspnea.

Ch 39: When administering glucocorticoids for the prophylaxis of nonpersistent asthma, the nurse should know that these drugs are most commonly administered by which route? a. Oral b. Topical c. Inhaled d. Intradermal

c. Inhaled

Ch 39: Aminophylline (Truphylline) a. Selective beta-2 agonists b. Nonselective beta-1 and beta-2 agonist c. Methylxanthine d. Anticholinergic e. Glucocorticoid

c. Methylxanthine

Ch 39: The two primary disorders classfied as COPD are __________ and __________.

chronic bronchitis, emphysema.

Ch 39: Stimulation of the parasympathetic nervous system results in bronchiole __________.

constriction

Ch 39: The nurse should teach the client that long-term treatment with oral corticosteroids may cause which serious adverse effect? a. Rebound congestion b. Hypertension c. Cancer d. Adrenal atrophy

d. Adrenal atrophy

Ch 39: Ipratropium (Atrovent, Combivent) a. Selective beta-2 agonists b. Nonselective beta-1 and beta-2 agonist c. Methylxanthine d. Anticholinergic e. Glucocorticoid

d. Anticholinergic

Ch 39: Which of the following classes would least likely be prescribed for asthma? a. Beta-2 agonists b. Methylxanthines c. Glucocorticoids d. Beta-blockers

d. Beta-blockers

Ch 39: During inspiration, air leaving the trachea next enters what area of the body? a. Pharynx b. Bronchioles c. Alveoli d. Bronchi

d. Bronchi

Ch 38: Triamcinolone (Azmacort) a. Selective beta-2 agonists b. Nonselective beta-1 and beta-2 agonist c. Methylxanthine d. Anticholinergic e. Glucocorticoid

e. Glucocorticoid

Ch 39: Budesonide (Pulmicort Turbuhaler) a. Selective beta-2 agonists b. Nonselective beta-1 and beta-2 agonist c. Methylxanthine d. Anticholinergic e. Glucocorticoid

e. Glucocorticoid

Ch 39: Fluticasone (Flovent) a. Selective beta-2 agonists b. Nonselective beta-1 and beta-2 agonist c. Methylxanthine d. Anticholinergic e. Glucocorticoid

e. Glucocorticoid

Ch 39: Salmeterol (Serevent) a. Selective beta-2 agonists b. Nonselective beta-1 and beta-2 agonist c. Methylxanthine d. Anticholinergic e. Glucocorticoid

e. Glucocorticoid

Ch 39: The respiratory rate, which is normally __________ per minute, can be modified by factors such as __________, __________, __________, and __________.

emotions, fear, stress, pain.

Ch 39: A machine that vaporizes a liquid durg into a fine mist that can be inhaled is called a __________.

nebulizer

Ch 39: The two main physiologic processes of the respiratory system are __________ and __________.

perfusion, ventilation

Ch 39: The process of gas exchange is called __________.

respiration

Ch 39: __________ is a sever, prolonged form of asthma that is unresponsive to drug therapy and may lead to respiratory failure.

status asthmaticus