Pharmacology Unit 9: Chapters 48-50
A woman calls the health care provider's office, worried about her 82-year-old mother, Basanthi Singh. Mrs. Singh had a stroke 6 years ago and requires help with most ADLs. Since her husband's death 18 months ago, she rarely leaves home. She has lost 11 kg (25 lb) because she "just can't get interested" in her meals. She has never liked milk and now refuses to drink milk or eat dairy products. Mrs. Singh's daughter has been prescribed bisphosphonates, and wonders if her mother should also be on them. 1) What risk factors does Mrs. Singh have for osteoporosis and hypocalcemia? 2) What other factors should be considered before making a recommendation for an appointment to discuss a bisphosphonate prescription?
1) Mrs. Singh is a frail older patient who is postmenopausal and with, potentially, a significantly limited calcium intake. Her diet may lack sufficient quantities of vitamin D, and she has decreased physical activity and lack of exposure to sunshine. Her daughter reports that Mrs. Singh is uninterested in eating, has physical limitations, and is not able to get out of the house into the sunshine without assistance. 2) As the nurse, you would want to take a thorough dietary history including if any calcium and vitamin D supplements are used. You would also consider the physical limitations that Mrs. Singh has as a result of her stroke. Is she able to prepare her own meals or does she have to rely on her daughter and others? Does she have favorite foods that are rich in the nutrients necessary? You may also consult with the health care provider about the need for depression screening for Mrs. Singh. Her lack of interest in her meals and remaining at home since her husband's death may indicate depression that is interfering with ADLs and nutrition. Mrs. Singh should be evaluated by the provider. Bisphosphonates may be required, but if other risk factors such as depression are present, additional treatment may be needed.
Hazel Leonard is a 65-year-old African American woman who visits her ophthalmologist with reports of blurry vision and not being able to see well at night while driving. Her health history includes adult-onset diabetes for the past 10 years and osteoporosis since age 55. Her medical regimen includes diet control for the diabetes and Boniva monthly. She denies any injury to her eyes and last had an eye exam 1 year ago. Her provider diagnoses primary open-angle glaucoma. 1) What factors are present in Mrs. Leonard's health history that you identify as predisposing conditions for the development of primary open-angle glaucoma? 2) What would be possible effects from systemic absorption if the provider has prescribed beta-adrenergic drops (e.g., timolol, carteolol)? Prostaglandin drops (e.g., latanoprost, bimatoprost)? Cholinergic agonists (e.g., carbachol, pilocarpine)?
1) Predisposing factors that Mrs. Leonard has include the fact that she is an African American, and that she is an older adult with a history of diabetes. Other general predisposing factors that may not apply to Mrs. Leonard include Asian descent, genetic factors, congenital defects in infants and children, a history of eye trauma, infection, inflammation, hemorrhage, tumors, or cataracts. Long-term use of topical corticosteroids, some antihypertensives, antihistamines, and antidepressants may also contribute to the development or progression of glaucoma. Risk factors associated with glaucoma would include HTN, migraine headaches, refractive disorders with a high degree of nearsightedness or farsightedness, and the normal aging process. 2) If eyedrops for glaucoma are given frequently or if the tear duct is not held after administering the drop and the solution is swallowed, systemic effects may be observed. Adverse effects from beta-adrenergic blocker drops include angina, anxiety, bronchoconstriction, hypotension, and dysrhythmias. Systemic adverse effects from prostaglandin drops include respiratory infection, angina, muscle or joint pain. Cholinergic agonist drops may cause systemic adverse effects such as salivation, tachycardia, hypotension, bronchospasm, nausea, and vomiting.
Ryan Keogh is an 18-year-old high school student in his senior year and a catcher for the varsity baseball team. He has had acne for several years, but lately it has worsened. He has been using topical benzoyl peroxide but is becoming discouraged at the increase in breakouts. He feels it has started to affect his social life and his parents make an appointment for him with a dermatologist. The dermatologist diagnoses Ryan's skin condition as acne vulgaris and prescribes tretinoin (Retin-A). 1) What are some potential reasons why Ryan's acne outbreaks may have increased at this time? 2) As the nurse, what will you teach Ryan about the application of tretinoin and adverse effects that may occur?
1) Ryan's increase in acne at this time may be linked to rising androgen levels as he progresses through puberty. Because he is active in outdoor sports activities, the use of sunscreen, and sweat, dust, and dirt from athletic fields may be aggravating the condition. 2) Ryan should wash his face gently with a mild soap and water, especially after participating in sports practices or games. He should apply a thin layer of the tretinoin to the acne areas, avoiding the eye area. He should discontinue any benzoyl peroxide or other topical drugs while he is using the tretinoin to avoid excessive dryness. Tretinoin often causes local skin effects such as redness, peeling, or a temporary hyperpigmentation. Ryan should limit sun exposure to the treated areas and should consult with his health care provider about the use of sunscreens.
A young woman calls the triage nurse in her mother's health care provider's office with questions concerning her mother's medication. The mother, age 76, has been taking alendronate (Fosamax) after a bone density study revealed a decrease in bone mass. The daughter is worried that her mother may not be taking the drug correctly and asks for information to minimize the potential for drug adverse effects. What information should the triage nurse incorporate in a teaching plan regarding the oral administration of alendronate?
Alendronate (Fosamax) is poorly absorbed after oral administration and can produce significant GI irritation. It is important that the patient or patient's daughter be educated regarding several elements of drug administration. To promote absorption, the drug should be taken first thing in the morning with 8 oz of water 30 minutes before food or beverages are ingested or any other medications are taken. It has been shown that certain beverages, such as orange juice and coffee, interfere with drug absorption. By delaying eating for 30 minutes or more, the patient is promoting absorption of the drug. Additionally, the patient should be taught to sit upright after taking the drug to reduce the risk of esophageal irritation. Alendronate must be used carefully in patients with esophagitis or gastric ulcer. If the patient misses a dose, she should be told to skip it and not to double the next dose. Alendronate has a long half-life, and missing an occasional dose will do little to interfere with the therapeutic effect of the drug.
Which of the following teaching points will the nurse provide to a patient with a new prescription for alendronate (Fosamax)? A) Take the medication with a full glass of water 30 minutes before breakfast. B) Take the medication with a small snack or meal containing dairy. C) Take the medication immediately before bed. D) Take the medication with a calcium supplement.
Answer: A Rationale: Alendronate (Fosamax) should be taken on an empty stomach with a full glass of water, and the patient should remain upright for a minimum of 30 minutes to prevent esophageal irritation. Options B, C, and D are incorrect. The drug should not be taken with food and should be taken early in the day. Cognitive Level: Applying Nursing Process: Implementation Client Need: Physiological Integrity
The nurse evaluates the patient's understanding of the procedure for application of triamcinolone (Kenalog, Aristocort) cream for acute contact dermatitis of the neck, secondary to a reaction to perfume. The patient asks why she can't just use up some fluocinonide (Lidex) cream she has left over from a poison ivy dermatitis last month. The nurse's response will be based on which of the following? A) High-potency corticosteroid creams should be avoided on the neck or face because of the possibility of additional adverse effects. B) All creams should be discarded after the initial condition has resolved. C) Fluocinonide cream is too low potency to use for contact dermatitis. D) Contact dermatitis from perfume is harder to treat than poison ivy dermatitis.
Answer: A Rationale: High-potency corticosteroid creams such as fluocinonide (Lidex) should be avoided in the highly vascular neck and facial areas because of the possibility of adverse effects. Options B, C, and D are incorrect. Topical corticosteroid creams may be kept at room temperature until the expiration date unless there are signs of discoloration of the cream, unless otherwise stated on the label, or as instructed by the health care provider. Fluocinonide is one of the higher-potency creams available for topical use. Contact dermatitis is a skin reaction to touching antigenic material, and the body's reaction depends on the antigen-antibody response not necessarily to the antigen itself. Cognitive Level: Applying Nursing Process: Implementation Client Need: Physiological Integrity
The nurse is planning health teaching for a patient who has been prescribed latanoprost (Xalatan) drops for open-angle glaucoma. The nurse should include which of the following in the teaching plan? A) The drops may cause darkening and thickening of the eyelashes and upper lid and darkening of the iris color. B) The drops may cause a temporary loss of eyelashes that will regrow once the drug is stopped. C) The drops will cause dilation of pupils, and darkened glasses should be worn in bright light. D) The drops will cause a permanent bluish tint to the conjunctiva that is harmless.
Answer: A Rationale: Latanoprost (Xalatan) may cause darkening and thickening of the eyelashes and upper lid and darkening of the color of the iris. Options B, C, and D are incorrect. It will not cause mydriasis (dilation of the pupils), loss of eyelashes, or a bluish tint to the sclera. Cognitive Level: Applying Nursing Process: Planning Client Need: Physiological Integrity
After trying many other treatments, a 28-year-old female is started on isotretinoin for treatment of severe acne. While she is on this medication, what explicit instructions must be followed? (Select all that apply) A) She must use two forms of birth control and have pregnancy tests before beginning, during, and after she is on the therapy. B) She must have vision checks performed every 6 months. C) She must increase intake of vitamin A-rich foods. D) She must return every 2 to 3 months for laboratory tests. E) She must delay any future pregnancies for a period of 5 years.
Answer: A, B, D Rationale: Isotretinoin is teratogenic and pregnancy must be avoided while on this medication. To be eligible for treatment, female patients must agree to frequent pregnancy tests and commit to using two forms of birth control while on the drug. Because of adverse visual, hepatic, and lipid effects, periodic vision screening and laboratory work must be monitored. Options C and E are incorrect. Isotretinoin is a retinoid closely related to vitamin A. Vitamin A may be toxic when taken in large doses. Normal daily intake is usually sufficient to meet the body's needs without supplementation. Women must not become pregnant while taking isotretinoin but do not have to wait 5 years after taking the drug to become pregnant. Cognitive Level: Analyzing Nursing Process: Implementation Client Need: Physiological Integrity
The patient is prescribed timolol (Timoptic) for treatment of glaucoma. During the history and physical, the nurse assesses for which of the following medical disorders that may be a contraindication to the use of this drug? (Select all that apply) A) Heart block B) Heart failure C) Liver disease D) Chronic obstructive pulmonary disease E) Renal disease
Answer: A, B, D Rationale: The nurse needs to notify the health care provider if the patient has a history of heart block, bradycardia, cardiac failure, heart failure, or COPD because timolol may be contraindicated for clients with these conditions. If the drug is absorbed systemically, it will worsen these conditions. Proper administration lessens the danger that the drug will be absorbed systemically. Options C and E are incorrect. The renal and hepatic systems are not affected by timolol. Cognitive Level: Analyzing Nursing Process: Assessment Client Need: Physiological Integrity
The nurse is explaining to a student nurse the physiological principle for how colchicine (Colcrys) achieves its effect. What response will the nurse give to the student? A) It decreases the deposits of uric acid in the joint spaces. B) It reduces the pain associated with joint inflammation by uric acid crystals. C) It increases renal excretion of uric acid. D) It prevents the formation of uric acid in the liver.
Answer: B Rationale: Colchicine (Colcrys) decreases inflammation caused by uric acid crystals and thus reduces pain. Once a mainstay of gout therapy, it has been replaced by NSAIDs for treatment of inflammation and pain and is reserved for patients who have not responded well to or cannot tolerate NSAIDs. Options A, C, and D are incorrect. Colchicine does not decrease the deposits of uric acid crystals, increase renal excretion, or reduce production of uric acid. Cognitive Level: Applying Nursing Process: Implementation Client Need: Physiological Integrity
A 15-year-old patient started using topical benzoyl peroxide (Benzaclin, Fostex) 1 week ago for treatment of acne and is discouraged that her acne is still visible. What is the nurse's best response? A) "The cream should have started working by now. Check with your provider about switching to a different type." B) "Some improvement will be noticed quickly, but full effects may take several weeks to a month or longer." C) "Acne is very difficult to treat. It may be several months before you notice any effects." D) "If your acne is not gone by now, you may need an antibiotic too. Ask your provider."
Answer: B Rationale: Initial drying of the skin caused by benzoyl peroxide will help begin to clear acne lesions in the early stages of treatment, but it may take several weeks before full effects are visible. Options A, C, and D are incorrect. One week of keratolytic therapy for acne should demonstrate the beginning of therapeutic effects. Most acne is responsive to keratolytic therapy but may need an antibiotic included as part of the treatment plan after a full course of the keratolytic has been tried. Only in severe cases is oral drug therapy usually considered after other treatment options have not been successful. Cognitive Level: Applying Nursing Process: Implementation Client Need: Physiological Integrity
The patient is treated for head lice with permethrin (Nix). Following treatment, the nurse will reinforce which of the following instructions? A) Remain isolated for 48 hours. B) Inspect the hair shafts, checking for nits daily for 1 week following treatment. C) Shampoo with permethrin three times per day. D) Wash linens with cold water and bleach.
Answer: B Rationale: To ensure the effectiveness of drug therapy, patients should inspect hair shafts after treatment, checking for nits by combing with a fine-toothed comb after the hair is dry. This procedure must be conducted daily for at least 1 week after treatment. Options A, C, and D are incorrect. The patient does not require isolation, and permethrin solution is applied once and allowed to remain in the hair for approximately 10 minutes. Linens should be washed with hot water; bleach is not required. Cognitive Level: Analyzing Nursing Process: Implementation Client Need: Physiological Integrity
A 62-year-old female has received a prescription for alendronate (Fosamax) for treatment of osteoporosis. The nurse would be concerned about this order if the patient reported which condition? (Select all that apply) A) She enjoys milk, yogurt, and other dairy products and tries to consume some with each meal. B) She is unable to sit upright for prolonged periods because of severe back pain. C) She is lactose intolerant and rarely consumes dairy products. D) She has had trouble swallowing and has been told she has "problems with her esophagus." E) She has a cup of green tea every night before bed.
Answer: B, C, D Rationale: Bisphosphonates such as alendronate require the patient to take the drug on an empty stomach and remain upright for 30 minutes to 1 hour. Adequate serum calcium levels should be confirmed before starting bisphosphonates, and adequate calcium and vitamin D intake should be encouraged while on drug therapy. Any narrowing of the esophagus may place the patient at risk of increased adverse esophageal effects from the drug. Options A and E are incorrect. Adequate calcium intake is advised while on bisphosphonates to maintain normal serum calcium levels. The use of green tea is not a contraindication to the use of bisphosphonates. Cognitive Level: Analyzing Nursing Process: Assessment Client Need: Physiological Integrity
The teaching plan for a 24-year-old female who is receiving tretinoin (Avita, Retin-A, Trentin-X) for treatment of acne should include which of the following instructions? (Select all that apply) A) Obtain 20 to 30 minutes of sun exposure per day to help dry the skin and prevent breakouts. B) Wash the face with a mild soap, avoiding scrubbing, twice a day. C) Use oil-free sunscreens, sun hats, and protective clothing to avoid sun exposure. D) Expect some dryness, redness, and peeling while on the drug but report severe skin irritation. E) Cover the area with a light dressing covered in plastic wrap to prevent the cream from rubbing off.
Answer: B, C, D Rationale: Washing the face gently with a mild soap and using sunscreens and protection from sun exposure are part of the care required for patients who are taking tretinoin. Mild dryness, redness, and peeling skin are all possible adverse effects that are expected. Any severe skin irritation or pain should be reported. Options A and E are incorrect. Sun exposure should be avoided unless specifically instructed to do so by the health care provider. The heat trapped by the plastic wrap may exacerbate the acne. Cognitive Level: Applying Nursing Process: Planning Client Need: Physiological Integrity
Timolol (Timoptic) drops have been ordered to treat glaucoma. Because of the possibility of systemic adverse effects, what essential instruction should the patient receive? A) Monitor urine output and daily weight. Promptly report any edema. B) Monitor blood glucose and alert the health care provider to any significant changes. C) Hold slight pressure on the inner canthus of the eye for 1 minute after instilling the drop. D) Monitor respiratory rate and for signs and symptoms of upper respiratory infection.
Answer: C Rationale: Beta-adrenergic drugs such as timolol (Timoptic) may reduce resting heart rate and blood pressure. The patient should hold slight pressure on the inner canthus of the eye to prevent the drug from entering the lacrimal duct with possible systemic absorption. Options A, B, and D are incorrect. Timolol (Timoptic) should not affect urine output or respiratory rate, increase the risk of respiratory infections, or affect glucose levels. Cognitive Level: Analyzing Nursing Process: Implementation Client Need: Physiological Integrity
A patient with a history of glaucoma who has been taking latanoprost (Xalatan) eyedrops complains of severe pain in the eye, severe headache, and blurred vision. What should be the nurse's first response? A) Document the occurrence; this symptom is expected. B) Medicate the patient with a narcotic analgesic. C) Notify the health care provider immediately. D) Place the patient in a quiet darkened environment.
Answer: C Rationale: Closed-angle glaucoma is an acute type of glaucoma that is caused by stress, impact injury, or medications. Pressure inside the anterior chamber increases suddenly because the iris is pushed over the area where the aqueous fluid normally drains. Signs and symptoms include intense headaches, difficulty concentrating, bloodshot eyes, blurred vision, and a bulging iris. Closed-angle glaucoma constitutes an emergency. Options A, B, and D are incorrect. All other options are inappropriate in this emergency and only delay appropriate and prompt treatment. Cognitive Level: Applying Nursing Process: Implementation Client Need: Physiological Integrity
The patient who is receiving allopurinol (Lopurin) for treatment of gout asks why he should avoid the consumption of alcohol. The nurse's response is based on the knowledge that the use of alcohol along with allopurinol may result in which of the following? A) It significantly increases the drug levels of allopurinol. B) It interferes with the absorption of antigout medications. C) It raises uric acid levels. D) It causes the urine to become more alkaline.
Answer: C Rationale: Gout is a metabolic disorder characterized by the accumulation of uric acid in the bloodstream or joint cavities. Alcohol increases uric acid levels. Options A, B, and D are incorrect. Alcohol does not cause a significant increase in drug levels of allopurinol, does not affect the absorption of antigout medications, and increases urine acidity. Cognitive Level: Analyzing Nursing Process: Implementation Client Need: Physiological Integrity
A patient has been taking hydroxychloroquine (Plaquenil) for rheumatoid arthritis. Which of the following symptoms may alert the nurse to a possible toxic effect? A) Cardiac dysrhythmias B) Joint stiffness or effusions C) Blurred vision or diminished ability to read D) Decreased muscle strength
Answer: C Rationale: Hydroxychloroquinel (Plaquenil) may cause visual disturbances such as blurred vision, photophobia, and diminished ability to read. Irreversible retinal changes may occur and any change in vision or other symptoms should be immediately reported. Options A, B, and D are incorrect. Hydroxychloroquine is not associated with cardiac dysrhythmias or decreased muscle strength. Decreased muscle strength and joint stiffness or effusions may be associated with rheumatoid arthritis. Cognitive Level: Analyzing Nursing Process: Evaluation Client Need: Physiological Integrity
Which assessment findings in a patient who is receiving calcitriol (Calcijex, Rocaltrol) should the nurse immediately report to the health care provider? A) Muscle aches, fever, dry mouth B) Tremor, abdominal cramping, hyperactive bowel sounds C) Bone pain, lethargy, anorexia D) Muscle twitching, numbness, and tingling of the extremities
Answer: C Rationale: Toxicity from calcitriol (Calcijex, Rocaltrol) includes symptoms of hypercalcemia and bone pain, anorexia, nausea and vomiting, increased urination, hallucinations, and dysrhythmias. Options A, B, and D are incorrect. Muscle aches, fever, and dry mouth are not related to calcitriol toxicity, and other causes, including infection, should be investigated. Tremor, abdominal cramping, hyperactive bowel sounds, muscle twitching, numbness, and tingling of the extremities are signs of hypocalcemia. Calcitriol may cause symptoms of hypercalcemia. Cognitive Level: Analyzing Nursing Process: Evaluation Client Need: Physiological Integrity
Appropriate administration is key for patients who are taking eyedrops for the treatment of glaucoma to optimize therapeutic effects and reduce adverse effects. The nurse would be concerned if the patient reports administering the drops in which of the following manners? A) Into the conjunctival sac B) Holding slight pressure on the tear duct (lacrimal duct) for 1 minute after instilling the eyedrops C) Avoiding direct contact with the eye dropper tip and the eye D) Leaving contact lenses in to be sure the eyedrop is maintained in the eye
Answer: D Rationale: Contact lenses should be removed before instilling eyedrops and remain out for a minimum of 15 minutes after instilling eyedrops. Options A, B, and C are incorrect. Administering eyedrops into the conjunctival sac, applying slight pressure to the lacrimal duct for 1 full minute, and avoiding direct contact with the dropper tip and the eye are all appropriate techniques to use when administering eyedrops. Cognitive Level: Applying Nursing Process: Evaluation Client Need: Physiological Integrity
The nurse emphasizes to the patient with glaucoma the importance of notifying the health care provider performing an eye examination of a glaucoma diagnosis because of potential adverse reactions to which of the following drugs? A) Antibiotic drops B) Cycloplegic drops C) Anti-inflammatory drops D) Anticholinergic mydriatic drops
Answer: D Rationale: Patients with glaucoma must be especially careful with anticholinergic mydriatics, because these drugs can worsen glaucoma by impairing aqueous humor outflow and thereby increasing intraocular pressure. Options A, B, and C are incorrect. Antibiotic drops, cycloplegic, and anti-inflammatory drugs may be used with caution in the client with glaucoma. Cognitive Level: Analyzing Nursing Process: Implementation Client Need: Physiological Integrity
The nurse is planning teaching for a patient prescribed desoximetasone (Topicort) for atopic dermatitis. The nurse will teach the patient to anticipate which possible adverse effects? A) Localized pruritis and hives B) Hair loss in the application area C) Worsening of acne D) Burning and stinging of the skin in the affected area
Answer: D Rationale: Topical reactions such as burning or stinging in the area topical corticosteroids such as desoximetasone (Topicort) are applied are common. Options A, B, and C are incorrect. The drug should not cause hair loss or worsening of acne. If pruritus and hives occur, they should be evaluated as signs of possible allergy to the cream. Cognitive Level: Applying Nursing Process: Planning Client Need: Physiological Integrity
Why are antibiotics used in the treatment of some acne conditions?
Antibiotics are sometimes used in combination with acne medications to lessen the severe redness and inflammation associated with the disorder, especially when the acne is inflammatory and results in cysts and pustules, and to reduce bacterial colonization.
Is the amount of calcium available in a calcium supplement always the same? What is the difference?
Calcium supplements consist of complexed calcium in salts such as carbonate, lactate, or phosphate. The amount of calcium in a tablet will differ depending upon its salt. The dose of calcium that a supplement will deliver depends upon the anion it is complexed with and how much is available for the body to use. The body is able to use ionized and complexed calcium. Bound calcium is not available for use. The calcium dose contained in a supplement is known as elemental calcium and is listed on the product label.
Patients are taught to put gentle pressure on the lacrimal duct for one minute after instilling eye drops. What is the purpose of this technique?
Patients should be taught to hold gentle pressure on the inner canthus of the eye over the tear duct for one full minute after instilling eyedrops to prevent drug leakage into the nasopharynx with possible systemic effects. It also allows for sufficient time for better absorption of the drop.
A 36-year-old man comes to the emergency department complaining of severe pain in the first joint of his right big toe. The triage nurse inspects the toe and notes that the joint is red, swollen, and extremely tender. Recognizing this as a typical presentation for acute gouty arthritis, what historical data should the nurse obtain relevant to this disease process?
The triage nurse should obtain information about the onset of symptoms, degree of discomfort, and frequency of attacks. A familial history of gout can be predictive, because primary gout is inherited as an X-linked trait. A past medical history of renal calculi may also be predictive of acute gouty arthritis. The nurse should ask the patient questions about his diet and fluid intake. An attack of gout can be precipitated by alcohol intake (particularly beer and wine), starvation diets, and insufficient fluid intake. In addition, the nurse should obtain information about prescribed drugs and the use of OTC drugs containing salicylates. Thiazide diuretics and salicylates can precipitate an attack. The nurse should also ask about recent lifestyle events. Stress, illness, trauma, or strenuous exercise can precipitate an attack of gouty arthritis in the sensitive patient.
To determine a patient's ability to administer glaucoma medications, the nurse asks the 82-year-old woman to instill her own medications prior to discharge. The nurse notes that the patient is happy to cooperate and watches as the she quickly bends her head back, opens her eyes, and drops the medication directly onto her cornea. The patient blinks several times, smiles at the nurse, and says, "There, it is no problem at all!" What correction should the nurse make in the patient's technique?
All ophthalmic agents should be administered in the conjunctival sac. The cornea is highly sensitive, and direct application of medication to the cornea may result in excessive burning and stinging. The conjunctival sac normally holds one or two drops of solution. The patient should be reminded to place pressure on the inner canthus of the eye following administration of the medication to prevent the medication from flowing into the nasolacrimal duct. This maneuver helps prevent systemic absorption of medication and decreases the risk of side effects commonly associated with antiglaucoma agents.
A 36-year-old woman is seen by her health care provider for scaling patches on her forearms, elbows, and lower legs. She is diagnosed with psoriasis vulgaris and the provider prescribes betamethasone cream (Diprosone). After six months of therapy, her psoriasis has not been responsive to betamethasone and she is prescribed calcipotriene (Dovonex). What effect does betamethasone have in the treatment of psoriasis? What teaching should the patient receive about this new prescription for calcipotriene?
Betamethasone is used to reduce the inflammation that occurs with psoriasis. Calcipotriene is a derivative of vitamin D that is applied topically to the skin to decrease cell turnover. It is applied in thin layers and is not recommended for use over large surface areas because hypocalcemia may result. Excessive sun exposure to the areas should be avoided while using calcipotriene, and it may take 2 to 3 weeks to see improvement. Because this woman is within childbearing age, she should be taught to consult with the health care provider if she plans to be or is pregnant. The drug is pregnancy category C.
A 3-year-old girl is playing nurse with her dolls. She picks up her mother's flexible metal necklace and places the tips of the necklace in her ears for her "stethoscope." A few hours later, she cries to her mother that her "ears hurt." The child's mother takes her to see the health care provider at an after-hours clinic. An examination reveals abrasions in the outer ear canal and some dried blood. The health care provider prescribes corticosporin otic drops. What does the nurse need to teach the mother about instillation of this medication?
Cortisporin otic is a combination of neomycin, polymyxin B, and 1% hydrocortisone. The technique for instilling this drug applies to most eardrops. The nurse needs to instruct the mother to position her daughter in a side-lying position with the affected ear facing up. The mother needs to inspect the outer (visible) ear canal for the presence of drainage or cerumen and, if present, gently remove it with a cotton-tipped applicator. Any unusual odor or drainage could indicate a ruptured tympanic membrane and should be reported to the health care provider. Next, the mother should be taught to straighten the child's external ear canal by pulling down and back on the auricle to promote distribution of the medication to deeper external ear structures. After the drops are instilled, the mother can further promote medication distribution by gently pressing on the tragus of the ear. The mother should be taught to keep her daughter in a side-lying position for 3 to 5 minutes after the drops are instilled. If a cotton ball has been prescribed, it should be placed in the ear without applying pressure. The cotton ball can be removed in 15 minutes.
A senior nursing student is participating in well-baby screenings at a public health clinic. While examining a 4-month-old infant, the student notes an extensive, confluent diaper rash. The baby's mother is upset and asks the student nurse about the use of OTC corticosteroid ointment and wonders how she should apply the cream. How should the student nurse respond?
To establish a rapport with the baby's mother, the nurse should first respond to the mother's anxiety. She should validate that the baby's condition is cause for concern and commend the mother for seeking medical guidance. The nursing student should recognize that the availability of OTC preparations may be a temptation to a young mother who only wants to see her infant more comfortable and relieved of symptoms. The use of topical corticosteroid ointments can be potentially harmful, especially for young children. Corticosteroids, when absorbed by the skin in large enough quantities over a long period, can result in adrenal suppression and skin atrophy. Children have an increased risk of toxicity from topically applied drugs because of their greater ratio of skin surface area to weight compared with that of adults. The health care provider at the public health clinic should assess this patient, and once a drug treatment modality is prescribed, the student nurse should make sure that the baby's mother understands the correct method for drug administration.