Ch 33 Pharmacology (Drugs for Inflammation and Fever)

A 24-year old client reports taking acetaminophen (Tylenol) fairly regularly for headaches. The nurse knows that a client who consumes excess acetaminophen per day or regularly consumes alcoholic beverages should be observed for what adverse effect? 1. Hepatic toxicity 2. Renal damage 3. Thrombotic effects 4. Pulmonary damage

1. Hepatic Toxicity Rationale: excessive doses of acetaminophen or regular consumption of alcohol may increase the risk of hepatic toxicity when acetaminophen is used. Options 2,3, and 4 are incorrect. Renal or pulmonary toxicity and thrombotic events are not adverse effects associated specifically with acetaminophen.

Treatment of inflammation

1. Identify the cause 2. Apply ice and rest 3. Topical drugs should be used first if possible because they cause fewer side effects. 4. Use oral medications NSAIDS and corticosteroids.

A client with a history of hypertension is to start drug therapy for rheumatoid arthritis. Which of the following drugs would be contraindicated, or used cautiously, for this client? (Select all that apply.) 1. Aspirin 2. Ibuprofen 3. Acetaminophen (Tylenol) 4. Naproxen (Aleve) 5. Methylprednisolone (Medrol)

2. Ibuprofen 4. Methylprednisolone (Medrol) 5. Methylprednisolone (Medrol) Rationale: NSAIDS such as Ibuprofen and naproxen have been shown to increase the risk of serious thrombotic events, myocardial infarction, and stroke, which can be fatal. These drugs should be used cautiously or avoided in clients with hypertension. Corticosteroids such as methyprednisolone may cause fluid retention, which may increase the client's blood pressure. Cautious and frequent monitoring will be required if the client takes this drug. Options 1 and 3 are incorrect. Aspirin or acetaminophen would provide pain relief only without treating the underlying inflammation associated with rheumatoid arthritis.

Common diseases that benefit from anti inflammatory

Allergic rhinitis, anaphylaxis, ankylosing spondylitis, contact dermatitis, Crohn's disease, glomerulonephritis, Hashimoto's thyroiditis, peptic ulcer disease, RA, SLE, and ulcerative colitis.

Inflammation

Body's defense mechanism that responds to different stimuli. Ex. Heat, death of cells, chemicals, physical injury. Helps control the injury and trap microorganisms. Signs and symptoms: swelling, warmth, pain and redness.

Acetaminophen

Class: Antipyretic/Analgesic Use: fever and pain Adverse Effect: high doses cause liver failure Nursing Implications: monitor pain level and fever.

Ibuprofen (Advil, Motrin)

Classification: NSAID/Analgesic, anti-inflammatory/antipyretic Use: treats mild and moderate inflammation, fever and pain. Adverse Effects: heartburn, nausea, epicanthic pain, bleeding and dizziness. Nursing implication: monitor for peptic ulcer, gastrointestinal bleeding, give with food to decrease nausea.

Prednisone

Classification: anti-inflammatory/Corticosteroids Use: inflammation Adverse effects: -short term: few side effects -long term use: Cushing Syndrome (hyperglycemia, muscle weakness, fat distribution to the face (moon face) and shoulders, bruising and fragile bones (easily fractured)) Nursing implications: monitor blood sugar, electrolytes, corticosteroids can mask infections, must wean medication.

Cycloocygenase-2 (COX 2)

Formed only after tissue injury and serves to promote inflammation.

Chronic inflammation

Has a slower onset and may continue for prolonged periods

Acute inflammation

Has an immediate onset and 8 to 10 days are normally needed for the symptoms to resolve and for repair to begin. (If the body cannot contain or neutralize the damaging agent, inflammation may continue for long periods and become chronic)

Histamine

Key chemical mediators of inflammation. Stored and released by mast cells; causes vasodilation, smooth-muscle construction, tissue swelling, and itching.

Cyclooxygenase (COX)

Key enzyme in the biosynthesis of prostaglandins. (NSAIDs block inflammation by inhibiting COX)

Nursing Process: NSAIDS (Diagnosis)

Knowledge deficit

Nursing Process: NSAIDS (Assessment)

Monitor vital signs, health history, lab values and allergies.

Two primary drug classes used for inflammation

Nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids NSAIDs - mild to moderate pain, inflammation, and fever. Corticosteroids - severe or disabling inflammation.

Nursing Process: NSAIDS (Evaluation)

Patient verbalizes understanding of importance of drug use.

Cycloocygenase-1 (COX 1)

Present in all tissues and serves protective functions such as reducing gastric acid secretion, promoting renal blood flow, and regulating smooth muscle tone in blood vessels and the bronchial tree.

Bradykinin

Present in an inactive form in plasma be mast cells; vasodilator that causes pain; effects are similar to those of histamine; broken down by angiotensin converting enzyme (ACE)

Prostaglandins

Present in most tissues and stored and released by mast cells; increase capillary permeability, attract white blood cells to site of inflammation, cause pain and induce fever.

Chemical Mediators

Released by damage tissue that act as "alarms" to notify the surrounding area of injury. (Histamine, Leukotrienes, Bradykinin, Complement, and Prostaglandins)

Complement

Series of at least 20 proteins that combine in a cascade fashion to neutralize or destroy an antigen; stimulates histamine release by mast cells

Leukotrienes

Stored and release by mast cells; effects are similar to those of histamine; contributes to symptoms of asthma and allergies.

Mast cells

Stores histamines. Located in the skin, bronchial tree, along blood vessels, digestive tract. Detect foreign agents or injury and respond by releasing histamine, which initiates inflammatory response within seconds.

Nursing Process: NSAIDS (Planning)

The patient will explain the use and adverse effects of NSAIDS.

Goal of pharmacotherapy with anti inflammatory drugs

To prevent or decrease the intensity of the inflammatory response and reduce fever, if present.

The client has been taking aspirin for several days for headache. During the assessment, the nurse discovers that the client is experiencing ringing in the ears and dizziness. What is the most appropriate action by the nurse? 1. Question the client about history of sinus infections. 2. Determine whether the client has mixed the aspirin with other medications. 3. Tell the client not to take any more aspirin. 4. Tell the client to take the aspirin with food or milk.

3. Tell the client not to take any more aspirin. Rationale: high doses of aspirin can produce side effects of tinnitus, dizziness, headache, and sweating. These symptoms should be reported to the health care provider. Options 1,2, and 4 are incorrect. Sinus infections may cause dizziness if the Eustachian tubes are blocked but should not cause tinnitus. The nurse should assess whether any of the client's medications also contain aspirin, but most OTC combination remedies include acetaminophen and not aspirin. Taking aspirin with food or milk may decrease the incidence of GI upset but not prevent tinnitus.

The nurse is counseling a mother regarding antipyretic choices for her 8-year-old daughter. When asked why aspirin is not a good drug to use, what should the nurse tell the mother? 1. It is not as good an antipyretic as is acetaminophen 2. It may increase fever in children under age 10. 3. It may produce nausea and vomiting. 4. It increases the risk of Reye's syndrome in children under 18 with viral infections

4. It increases the risk of Reye's syndrome in children under 18 with viral infections Rationale: aspirin and salicylates are associated with an increased risk of Reye's syndrome in children under 18, especially in the presence of viral infections. Options 1, 2, and 3 are incorrect. Acetaminophen is not significantly different than aspirin or salicylates should not increase fever although it may cause nausea or vomiting related to GI irritation; however, it is not contraindicated in children specifically for this reason.

While educating the client about hydrocortisone (Cortef), the nurse would instruct the client to contract the health care provider immediately if which of the following occurs? 1. There is a decrease of two lb in weight. 2. There is an increase in appetite. 3. There is tearing of the eyes. 4. There is any difficulty breathing.

4. There is any difficulty breathing. Rationale: side effects that need to be reported immediately include difficulty breathing; heartburn; chest, abdomen, or joint or bone pain; nosebleed; blood in sputum when coughing, vomitus, urine, or stool; fever; chills or signs of infection; increased thirst or urination; fruity breath odor; falls; or mood swings. Options 1,2, and 3 are incorrect. An increase in weight due to fluid retention may occur but not a decrease in weight. An increase in appetite is a common effect from corticosteroids. An increase in tearing of the eyes is not associated with corticosteroids.

The nurse is admitting a client with rheumatoid arthritis. The client has been in asking prednisone (Aristospan) for an extended time. During the assessment, the nurse observes that the client has a very round moon-shaped face, bruising, and an abnormal contour of the shoulder. What does the nurse conclude based on these findings? 1. These are normal reactions with the illness. 2. These are probably birth defects. 3. These are symptoms of myasthenia gravis. 4. These are symptoms of adverse drug effects from the prednisone.

4. These are symptoms of adverse drug effects from the prednisone Rationale: signs and symptoms of bruising and a characteristic pattern of fat deposits in the cheeks (moon face), shoulders (buffalo hump), and abdomen are common adverse effects associated with long term prednisone use. Options 1,2, and 3 are incorrect. These symptom are not indicative of the disease process, birth defects, or myasthenia gravis.

Anaphylaxis

A life threatening allergic response that may result in shock and death. Large amount of chemical mediators are released rapidly.