NSG 304 Pharm - Chapter 33

Status asthmaticus

acute, severe asthma

Work-exacerbated asthma

adverse respiratory outcome resulting from work-related conditions

Mast cells

cells releasing substances that produce bronchoconstriction and inflammation in response to causative stimuli

Triggers

factors that initiate asthma symptoms

Maintenance inhalant medications

long-term control beta2-agonists used to achieve and maintain prophylactic control of persistent asthma

Leukotrienes

strong chemical mediators of bronchoconstriction and inflammation, the major pathologic features of asthma

The nurse has finished teaching a 15-year-old client how to use an inhaler to treat asthma. What statement by the client suggests an understanding of the teaching?

"I need to shake the inhaler well before taking the medication." * Just before each use, the client should shake the inhaler well. After shaking, proper technique involves exhaling before placing the inhaler in the mouth; taking a slow, deep breath while delivering the medication into the mouth; and holding the breath for approximately ten seconds before exhaling slowly. A subsequent dose can be administered within a few minutes of the first.

The nurse is providing education to a client who has been prescribed theophylline. The nurse interprets what client statement as a sign of successful teaching?

"I should avoid beverages that contain caffeine." * Both theophylline and caffeine are xanthines. Theophylline increases cardiac output and heart rate. Since caffeine also stimulates heart rate, taking them concurrently can have an additive effect. The nurse would not recommend limiting fluid intake, and there is no need to increase potassium consumption. The drug can cause restlessness and difficulty sleeping, not sedation.

A patient tells you that her friend has recommended using caffeine to treat her asthma. How would you appropriately respond to this patient?

"Prescription drugs have been proven effective in treating asthma, and caffeine hasn't been. Since uncontrolled asthma can be deadly, I wouldn't recommend that you switch from your medications to caffeine." * Since, in general, herbal and dietary therapies in asthma have not been studied in controlled clinical trials, they are unproven and should be avoided. Because asthma can result in death in a matter of minutes, patients should be counseled not to use dietary or herbal supplements in place of prescribed bronchodilating and anti-inflammatory medications. Although caffeine is a mild bronchodilator, combining it with bronchodilating drugs can increase the adverse effects of those drugs.

When evaluating an asthmatic client's knowledge of self-care, the nurse recognizes that additional instructions are needed when the client makes which of the following statements?

"When I am short of breath, I will increase the use of my fluticasone." * Fluticasone is an inhaled steroid and should not be used during acute asthmatic attacks. Washing linens weekly will decrease the incidence of dust mites. When clients can participate in some, but not all of usual activities, they are in the yellow zone. Once medication is inhaled, the client should hold his or her breath for 10 seconds so that medication can reach deep into the lungs.

A client comes to the clinic because of an exacerbation of asthma. When obtaining the client's history, the nurse would anticipate hearing the client report an increase in which of the following? Select all that apply.

- Chest tightness - Dyspnea - Cough * Worsening of cough, tachypnea, dyspnea, and generalized wheezing and chest tightness usually precede an asthma exacerbation. Nasal congestion and bradypnea usually are not associated with an exacerbation.

The nurse teaches a client receiving an inhaled corticosteroid about the possibility of developing oral thrush. Which action(s) would the nurse include in the teaching plan as a way to reduce this risk? Select all that apply.

- Cleaning the inhaler per package instructions - Using proper technique when administering dose - Performing strict oral hygiene * To decrease the likelihood of developing oral thrush, a client should use strict oral hygiene, cleanse the inhaler as directed in the package instructions, and use proper technique when administering a dose. There is no need to avoid eating after administration, and using the drug only every other day would not be effective.

The pulmonologist sees many patients daily who suffer from a variety of respiratory disorders. What are some of the common signs and symptoms many of these patients present?

- Cough - Increased secretions - Mucosal congestion * Common signs and symptoms of respiratory disorders include cough, increased secretions, mucosal congestion, and bronchospasm. Increased temperature is not common among respiratory disorders unless infection is involved.

A client is prescribed an inhaled corticosteroid. The nurse would instruct the client about which as a possible adverse reaction(s)?

- Fungal infection - Pharyngeal irritation * Adverse reactions of inhaled corticosteroids include oral, laryngeal, and pharyngeal irritation and fungal infection. An unpleasant taste sensation and cough are potential adverse effects of mast cell stabilizers. A headache is a potential adverse reaction to leukotriene modifiers.

A nurse is preparing a teaching plan for a client and caregiver on the proper use of a dry powder inhaler. Which instruction(s) will the nurse include in this teaching? Select all that apply

- Hold breath for 10 seconds. - Inhale quickly. * To properly use a dry powder inhaler, the client should do the following: prepare the medication for inhalation, place the mouthpiece close to the lips, inhale quickly, hold breath for 10 seconds, not swallow capsules provided, and not place the inhaler in water.

After reviewing information about drugs used to treat lower respiratory system conditions, a group of nursing students demonstrate understanding of the information when they identify which as an example of a short-acting beta-2 agonist (SABA)?

Albuterol * Albuterol is a SABA. Formoterol, salmeterol, and arformoterol are all long-acting beta-2 agonists.

A nurse would expect to increase the dosage of theophylline if the client has a current history of which of the following?

Cigarette smoking * Nicotine increases the metabolism of xanthines; therefore, an increased dosage would be necessary. Hyperthyroidism, gastrointestinal, upset or alcohol intake requires cautious use of the drug because these conditions may be exacerbated by the systemic effects of the drug. The drug dosage may need to be decreased in these situations.

A nurse is providing discharge planning for a 45-year-old woman who has a prescription for oral albuterol. The nurse will question the patient about her intake of which of the following?

Coffee * The nurse should assess the patient's intake of caffeine, including coffee, tea, soda, cocoa, candy, and chocolate. Caffeine has sympathomimetic effects that may increase the risk for adverse effects. Alcohol, salt, and vitamin C intake is important to assess, but does not potentiate the effects of albuterol.

The nursing instructor is teaching a session explaining mast cell stabilizers. The instructor determines the session is successful when the students correctly choose which drug as an example?

Cromolyn * Cromolyn is an example of a mast cell stabilizer. Beclomethasone is an inhaled corticosteroid. Albuterol is a short-acting beta2 agonist. Montelukast is an example of a leukotriene modifier.

A client with asthma has been prescribed an anti-inflammatory medication. How does an anti-inflammatory drug reduce this client's bronchoconstriction?

Decreasing airway hyperreactivity to stimuli * Bronchodilators, or antiasthmatics, are medications used to facilitate respirations by dilating the airways. They are helpful in symptomatic relief or prevention of bronchial asthma and for bronchospasm associated with chronic obstructive pulmonary disease (COPD). Reducing inflammation prevents and reduces bronchoconstriction by decreasing airway hyperreactivity to various stimuli that decreases mucosal edema and formation of mucus secretions that narrow airways. Anti-inflammatory drugs do not increase the ability to metabolize medication or increase uptake of steroids.

The nurse is providing education to the parents of a child who has been newly diagnosed with asthma. During teaching, the nurse should explain that asthma attacks occur when mast cells release substances that cause what reaction?

Inflammation * When lung tissues are exposed to causative stimuli, mast cells release substances that cause bronchoconstriction and inflammation, increased capillary permeability and fluid leakage, and changes in the mucus-secreting properties of the airway epithelium.

The nurse is reviewing a client's morning blood work and notes a theophylline level of 22.2 mcg/mL (123.21 µmol/L). What action should the nurse take?

Inform the health care provider that the client has toxic theophylline levels. * To determine theophylline dosage, prescribers should measure serum theophylline levels. Therapeutic range is 5 to 15 mcg/mL (27.75 to 83.25 µmol/L); toxic levels are 20 mcg/mL (111 µmol/L) or above. The health care provider must be informed of this elevated serum level.

A newborn, experiencing ineffective alveolar expansion, is receiving treatment. What intervention should the nurse implement to assure the administration of the prescribed medication has been effective?

Monitoring respirations for bilateral chest movement * Ensure proper placement of the endotracheal tube with bilateral chest movement and lung sounds to provide adequate delivery of the drug. Suctioning should be avoided for at least 2 hours after the surfactant is instilled into the newborn's endotracheal tube. Neither the delivery of supplemental oxygen nor position changes are related to the delivery of the medication into the infant's lungs.

The mother of your patients, 7-year-old twin boys, is hungry for additional information on the management of asthma. She's particularly interested in preventing exacerbations with the newest information available. Where would you direct her for more information?

NAEPP Guidelines * Because of asthma's significance, NIH assembled experts who established "Guidelines for the Diagnosis and Management of Asthma." These were updated in 2007, including an expanded portion on childhood asthma.

The nurse is preparing to teach a child with asthma and caregivers about the prescribed corticosteroids. Which factor should the nurse point out will require monitoring?

Rate of growth * The nurse should monitor the rate of growth of the child. Children are at risk for a reduction in growth when oral corticosteroids or higher doses of the inhalant form are used. Blood pressure, skin turgor, and urine output are not altered with corticosteroid therapy.

A client, experiencing respiratory distress related bronchi constriction, will benefit from what therapeutic action provided by anticholinergic medication therapy?

Relaxation of smooth muscle * Anticholinergics can be used as bronchodilators because of their effect on the vagus nerve, resulting in relaxation of smooth muscle in the bronchi, which leads to bronchodilation. None of the other options describe the bronchial dilation affected of the anticholinergic classification of medications.

A client has been admitted to a health care facility with acute bronchospasm. The health care provider prescribes the drug epinephrine. Through which route should the nurse administer the drug?

Subcutaneous * The nurse should use the subcutaneous route to administer epinephrine for acute bronchospasm. Doses of epinephrine are measured in tenths of a milliliter. A tuberculin syringe is used for measuring and administering these drugs by the parenteral route. The other routes, such as intravenous, intramuscular, and intradermal, are not appropriate routes to administer the drug epinephrine.

The nurse is caring for a 38-year-old client who is beginning treatment with albuterol. Which should the nurse identify as a potential adverse effect of the drug?

Tachycardia * Adverse effects of adrenergic bronchodilators such as albuterol include tachycardia, arrhythmias, palpitations, restlessness, agitation, and insomnia. Bronchodilators do not cause polydipsia, nausea or diarrhea.

What action by the client would indicate that the client understands how to use an inhaler?

The client holds his or her breath for several seconds after compressing the canister. * Holding the breath prevents exhalation of medication still remaining in the mouth. The client should inhale when the canister is compressed, not as soon as the inhaler enters his or her mouth. The client should only administer one dose of medication at a time, and the client should wait to exhale until after the breath has been held as long as possible. Spacers are not used with powdered medications.

The nurse is caring for a 38-year-old client with asthma who has been started on albuterol. What assessment finding should the nurse most likely attribute to adverse medication effects?

The client's heart rate is 99 beats/min. * Adrenergic agents stimulate beta1-adrenergic receptors in the heart as well as beta2-adrenergic receptors in the lungs. Adrenergic agents do not cause polydipsia, fever, or diarrhea.

Why are inhaled steroids used to treat asthma and COPD?

They act locally to decrease release of inflammatory mediators * When administered into the lungs by inhalation, steroids decrease the effectiveness of the inflammatory cells. This has two effects, which are decreased swelling associated with inflammation and promotion of beta-adrenergic receptor activity, that may promote smooth muscle relaxation and inhibit bronchoconstriction.

A 70-year-old client is being treated for chronic obstructive pulmonary disease (COPD) with theophylline. What will be a priority assessment by the nurse?

Use of nicotine * Nutritional status, weight, and activity level would be important for a nurse to know about a COPD client. However, it would be most important for the nurse to know whether the client smokes or uses tobacco in other ways or smoking cessation methods that involve nicotine. Nicotine increases the metabolism of theophyllines; the dosage may need to be increased to produce a therapeutic effect.

Eosinophilic phenotype

allergic response of individuals with severe asthma who have blood eosinophil counts of 150/μL or greater

Bronchospasm (also called bronchoconstriction)

constriction of the air passages of the lung (as in asthma) by spasmodic contraction of the bronchial muscles

Airway hyperresponsiveness

exaggerated bronchoconstrictive response to stimuli

Atopic sensitization

predisposition toward developing certain allergic hypersensitivity reactions

Rescue inhalant medications

quick-relief, short-acting beta2-agonists used during periods of acute symptoms and exacerbations