1. Nancy Pares, RN, MSN Metropolitan Community College

2.  One of the most important organ systems  Upper respiratory tract ◦ Nose, nasal cavity, pharynx, and paranasal sinuses (see pg 579 in Adams) ◦ ‘air conditioning’ of the respiratory tract  Warm, humidify and clean the air

3.  Sympathetic nervous system ◦ Constricts arterioles of the nose-widens the airway (relief of stuffiness)  Parasympathetic nervous system ◦ Dilates the aterioles of the nose-shrinks the airway (causes stuffiness)

4.  Primary action: block the actions/attachment of histamine at the H1 receptors ◦ OTC remedies for allergic rhinitis, motion sickness and insomnia ◦ Reduces inflammation and symptoms

5.  Diphenhydramine (Benedryl)  Action: blocks histamine from reaching its receptors  Uses: often combined with analgesics, decogestants, and expectorants; treatment of rashes, allergic reactions, Parkinson’s disease, motion sickness and insomnia

6.  Fexafenadine (Allegra)  Action: reduces nasal congestion, sneezing, tearing of the eyes.  Use:same as 1 st generation  Contraindication: hypersensitivity to drug; may have synergistic sedative effects.

8.  First generation drugs have more significant side effects than 2 nd generation  Side/effects ◦ Sedation or rarely excitability ◦ Anticholinergic effects (everything dries up) ◦ Nursing Moms may have decreased lactation (Category C) ◦ Respiratory secretions thicken ◦ Young children may exhibit hypersensitivity or overdose

9.  Promenthazine (Phenergan): motion sickness and n/v  Antihistamines may also be used for vertigo and insomnia  Contraindications: ◦ Hx of heart disease, narrow angle glaucoma, seizure disorder, CNS stimulation, renal impairment,or prostate disease.

10.  See page 581  Know prototypes: ◦ Diphenhydramine (Benedryl) ◦ Fexofenadine (Allegra)

11.  Action: ◦ stimulate alpha 1 adrenergic receptors in vascular smooth muscle which produces vasoconstriction. Vasoconstriction reduces the blood flow which slows the production of mucus and relieves symptoms.

12.  Routes of administration/side effects: ◦ intranasal-few side effects  Rebound congestion  Use no longer than 3-5 days  If dependence is developed, change to intranasal glucocorticoid ◦ oral  No rebound congestion  Onset of action is much slower

13.  Sympathomimetics: ◦ Oxymetazoline (Afrin)  Anticholinergic ◦ Ipratopium bromide (Atrovent)

14.  Antihistamines: ◦ Auscultate breath sounds ◦ Monitor VS (including ECG w HD) ◦ Monitor thyroid labs (antihistamines may cause thyroid storm ◦ Monitor vision changes and neuro status, especially LOC ◦ Measure I&O ◦ Monitor glucose levels ◦ Observe for anticholinergic crisis

15.  Decongestants: ◦ Assess VS, especially pulse and BP ◦ Monitor urinary output/flow ◦ Do not use with other OTC cold preps ◦ Immediately report palpitations, CP, dizziness, visual changes, excessive dry mouth ◦ Use proper technique on use and care of nasal spray dispensers.

16.  Antitussives (opioid and non opioid) ◦ Dampen the cough reflex  Expectorants ◦ Reduce the thickness-increases flow  Mucolytics ◦ Break down the chemical structure

17.  Codeine/hydrocodone ◦ Action:  raise the cough threshold in CNS; usually classified as Schedule III, IV or V ◦ S/E  Respiratory depression  Minimal potential for dependence ◦ Nursing Implications;  Caution use in asthma  Used in combination with antihistamines, decong (pg 590)  Monitor for drowsiness; know what s/e to report

18.  Dextromethorphan(Benylin) ◦ Action/S/E:  raises the cough threshold  s/e are rare ◦ Nursing implications:  No risk of dependence  Contraindicated in treatment of chronic cough (asthma, smoking, emphysema)

19.  Benzonatate (Tessalon) ◦ Action:  Suppresses cough by anesthetizing stretch receptors of lungs ◦ S/E  uncommon, may include sedation, nausea, HA ◦ Nursing implications:  Teach not to chew the pill-numbing effects

20.  Guaifenesin(Robitussin) ◦ Most common ◦ Tolerated by most ◦ Available OTC ◦ Few adverse effects

21.  Acetylcysteine (Mucomyst) ◦ Action/Use:  Breaks down mucous molecule  Cystic fibrosis, chronic bronchitis  Overdose of acetaminophen ◦ Route:  Inhalation-disease processes  IV/oral-overdose

22.  Critical thinking: ◦ When would an expectorant be used? ◦ When would an antitussive be used?

23.  Monitoring cough characteristics  Assess history of the cough  Use antitussives when cough interferes with ADL’s, rest or sleep  Teach goals of therapy  Caution food and water immediately following taking med  Teach about environmental modifications  Do not suppress productive cough  Maintain adequate fluid intake  Teach to read label-do not take more than recommended dose  Teach not to use prescription with OTC  Keep all meds out of reach of children-call Poison Control if ingested---no use of Ipecac (gag reflex diminished)

24.  Basic Physiology of lower resp. tract ◦ Trachea, bronchus, lung ◦ See page 594 in Adams ◦ Bronchioles are elastic smooth muscle which dilate and constrict based on metabolic needs.  Controlled by autonomic nervous system  Fight or flight response  Beta 2 adrenergic receptors stimulated=bronchodilation  Parasympathetic nervous system action  bronchoconstriction

25.  Aerosol ◦ Delivers to immediate site of action=fewer systemic effects ◦ Used for bronchospasm or decrease viscosity of mucous in bronchi  Nebulizer ◦ Machine that vaporizes liquid via face mask or handheld  Dry Powder Inhaler (DPI) ◦ Takes fine powder directly to bronchi  Metered Dose Inhalers (MDI) ◦ Uses a propellant to deliver measured dose to the lungs with each breath  MUST USE DEVICES CORRECTLY: ONLY 10-50% OF DRUG ACTUALLY REACHES LUNGS.

26. General info: -relax bronchial smooth muscle=widening the airway -beta agonists alone have no anti-inflammatory properties -some agents activate beta 1 and beta 2 receptors -newer agents only activate beta 2 receptors -inhaled beta adrenergic agents have little systemic toxicity

27.  Beta agonists/sympathomimetics  Methylxanthines  anticholinergics

28.  Action/Use: bronchodilatation via beta 2 receptor activation ◦ Classification by duration of action  Ultra short (effects last 2-3 hrs)  Short (effects last 5-6 hrs)  Intermediate ( 8 hrs)  Long (12 hrs) Formoterol (Foradil)  Prototype: salmertol (Seravent) ◦ S/E  Cardiac (tachycardia, dysrhythmias), hyperglycemia, tolerance of med, insomnia, nervousness, tremor ◦ Nursing Interventions/contraindications:  Monitor VS- especially BP; no MAOI’s, TAD, or antihistamines; teach about meds (timing, use of, s/s to report)

29.  Action/use: ◦ Bronchodilatation; chronic persistent asthma ◦ Related to caffeine; stimulate CNS  Route: IV or po (not inhaled)  Nursing Interventions: ◦ Assess VS-esp RR and lung sounds;monitor K+ levels, monitor for insomnia, hyperstimulation; limit use of caffeine and smoking; teach about meds (timing, use, as prescribed) ◦ Prototype: theophylline (Theo-dur)

30.  Action/use: ◦ Blocks cholinergic receptors in bronchial smooth muscle; chronic bronchitis, nasal congestion  S/E/route: ◦ Irritation of upper respiratory tract, dry mouth, GI distress, HA and anxiety; bitter taste ◦ MDI ◦ Prototype: ipratropium bromide (Atrovent)  Nursing interventions: ◦ Wait 5 min between this med and any other, proper technique, rinse mouth, report changes in urinary pattern

31.  Action/Use: ◦ Anti inflammatory; prophylactic treatment of bronchial asthma  S/E/routes: ◦ Local: hoarseness; systemic: adrenal gland atrophy, peptic ulcers, osteoporosis; growth a concern in children ◦ Oral = prednisone; IV= Solu-Medrol  Nursing interventions: ◦ Monitor VS, Assess for s/s of infection, assess lung sounds, oxygen sats, weight gain/loss, teach about meds.

32.  Assessment: ◦ Gas exchange  Cyanosis, activity tolerance, labs, pulm tests ◦ Monitor effectiveness of therapy  Change in cough, resp. effort, lung sounds, nature and quality of secretions ◦ Monitor for adverse effects of drugs

33.  Ineffective airway clearance RT bronchoconstricion  Impaired gas exchange RT disease process  Risk for injury RT adverse effects of drugs  Deficient knowledge RT disease process and medication regime

34.  The client will: ◦ Experience effective cough and clear breath sounds… ◦ Have 02 sats >90% …. ◦ Verbalize improvement in respiratory secretions ….

35.  Disease specific (amounts of 02)  Drug specific monitoring  Monitor for S/E

36.  Were the goals met?