n Assessment

Learn as much as possible about the health history of the patient, including the presence of drug allergy, other drug use, and the presence of asthma, glaucoma, peptic ulcer, prostatic hypertrophy, bladder neck obstruction, respiratory or cardiac disease, and the possibility of pregnancy. Assess the patients work and activities to see if drowsiness might be a problem. A patient with thyroid disease or migraine headaches may be unable to take antihistamines because of the tachycardia (rapid heartbeat) produced. These conditions are either contraindications (factors that rule out the use of a drug) or precautions (factors that indicate a drug should be used with great care) for the use of antihistamines.

As you listen to the patient describe respiratory symptoms, think about whether the problem might be SAR, PAR, or PNAR. The patient may have a history of allergic reactions with allergic nasal congestion (usually seasonal in onset), runny nose, or cough related to a cold or allergy. You may observe symptoms of rhinitis: sneezing, nasal discharge, and inflamed nasal mucosa. The patient may also have edema, dermatographism (wheals, or a raised surface of the skin where it has been scratched), conjunctivitis (inflammation of the inner eyelid and eye), eczema (a chronic condition producing irritation of the skin), insect bites, or contact dermatitis. The nasal mucosa may be swollen, boggy (soft), and pale, and there may be nasal plugging or a clear, watery discharge. Increased sinus pressure may be found when pushing on or palpating the frontal or maxillary sinuses.

These drugs are so common that it is important to learn the drug effects of antihistamine use. In young children, antihistamines may cause hallucinations, convulsions, and even death. Older adult patients are also extremely sensitive to these drugs. Some products may cause teratogenic effects (deformities) in a fetus, although most first and second generation drugs are Category B drugs with a few Category C drugs. Antihistamines should be used with caution in children with a family history of sleep apnea or sudden infant death syndrome (SIDS), or in children with symptoms of Reye syndrome.

n Diagnosis

Through reading the patient’s chart, you will learn why the patient is taking this drug: they may have SAR, PAR, or PNAR, or whether the medication is being given for some other type of allergic reaction. The severity of the symptoms will help in making the nursing diagnosis and deciding what additional nursing actions need to be taken (for example, hydration of the patient [giving additional fluid]).

n Planning

The sedative effect is common to most first generation antihistamines like diphenhydramine (Benadryl), less so with loratadine (Claritin) which is a second-generation antihistamine. The drowsiness caused by antihistamines makes it dangerous for the person taking them to operate heavy machinery or drive.

Some antihistamines may be given parenterally to treat hypersensitivity to blood products, as adjunctive therapy to analgesia, or in treating motion sickness. Most antihistamines are administered orally. Many are available in OTC preparations, although the forms with the highest dosage are available only by prescription. Most drug companies have at least one preparation available by prescription, so that people with Medicare or Medicaid benefits are able to get these drugs with their cards. Antihistamines may be administered rectally, or topically via nasal inhalation or ophthalmic solutions also.

Products that are used when a patient is hospitalized for severe respiratory difficulty are often administered by inhalation therapy by a respiratory therapist—an individual especially trained to use respiratory equipment and to assist the patient to get the most air into and out of their lungs. Watching and working with these respiratory therapists can help nurses increase their own skills to help patients breathe better.

n Implementation

Antihistamines should be taken only when needed. The type and dosage should be chosen for the desired effect and the person being treated. For example, one of the first-generation ethanolamine derivatives makes people very sleepy, and people who do tasks that require alertness probably should not use them. Sometimes a patient is having trouble sleeping and so the doctor may want to give them a drug that will make them drowsy so they might give them a drug from the ethanolamine category. Some drugs cause less drowsiness but may not be as effective in getting rid of the symptoms.

If tolerance (increased resistance to a drug caused by repeated use) to one type of antihistamine develops, the patient might be told to switch to another type to see if it is more helpful. Medications also might be changed or rotated to keep symptoms under control.

Giving oral doses with meals or milk can limit GI side effects however, the nurse should make sure that the medication can be given with foods or milk or if they need to be taken on an empty stomach. Antihistamines given orally are usually well absorbed; parenteral administration is rarely needed. When an intramuscular (IM) preparation such as diphenhydramine is used, it should be injected deep into the muscle to prevent tissue irritation. Intravenous (IV) injection of these agents should be done slowly, with the patient lying down because of the risk of the drug causing a low blood pressure. Long-term use of topical nasal antihistamines increases the risk of sensitization, often causing a rebound effect, or an increase in the symptoms you are trying to stop.

n Evaluation

n Assessment

Learn as much as possible about the health history of the patient, including allergy to antitussives, presence of COPD that may influence the patient’s response to an opioid, possibility of pregnancy, and the use of other drugs or alcohol that may cause drug interactions. These conditions may be contraindications or precautions to the use of antitussives.

Ask about a history of a nonproductive cough or a prolonged and productive cough, which may keep the patient awake at night or cause muscular pain.

n Diagnosis

Take care to learn why the patient has a productive cough. Signs of infection, allergy, or other problems might suggest the source of the cough.

n Planning

Patients with hypersensitivity (allergy) to these drugs or patients with COPD who have problems with breathing are not usually given opioid antitussives. Opioid antitussives may cause drug dependence. Some of the antitussives are Schedule II controlled substances.

These preparations may cause drowsiness, so the patient should be cautioned to avoid tasks requiring alertness after taking the medication.

n Implementation

Antitussives come only in oral forms. They should be used only for short periods. Short therapy decreases the risk of rebound symptoms from prolonged use or the possibility of addiction to opioid products.

n Evaluation

Watch for therapeutic effects: the cough stops or there is a decrease in frequency and duration of coughing spells, and the patient is able to sleep better at night. Also watch the patient for adverse reactions and drug tolerance.

n Patient and Family Teaching

n Assessment

Learn as much as possible about the health history of the patient, including specific respiratory signs and symptoms, other medications, allergy, possibility of pregnancy, and presence of infection.

The patient may have a history of allergies, asthma, bronchitis, emphysema, recurrent acute or chronic attacks of wheezing, cough with or without mucoid sputum, dyspnea, fatigue, intolerance to exercise, and in severe cases, cyanosis (bluish color to the skin). Acute upper or lower respiratory tract infections may precede the onset of acute symptoms.

n Diagnosis

Confirm that the patient’s condition is stable. These products are not effective in an acute asthma attack. The patient should have no signs or symptoms of illness.

n Planning

The patient should begin taking these drugs when an acute attack of asthma is over, the airways are clear, and the patient can breathe easily.

The amount of drug the lungs are able to use depends on proper use of the nebulizer or if using an inhaler with spacer, the degree of bronchospasm present, and the amount of secretions in the tracheobronchial tree. It has been estimated that approximately 5% to 10% of the inhaled drug reaches the lungs using a standard inhaler. A spacer will increase this percentage.

n Implementation

Cromolyn is taken by standard inhaler. Two inhalations four times daily at regular intervals is the standard regimen.

Occasionally, cough and bronchospasm may follow administration of cromolyn. Some patients may not be able to continue using this drug, even when taking bronchodilators at the same time.

Patients must be careful when decreasing the dosage or stopping the use of cromolyn or nedocromil; this decrease in dosage can cause asthmatic symptoms to recur.

Gastrocrom is an oral concentrate which should be emptied into a half glass of water. Do not mix the solution with fruit juice, milk, or food. Medicine should be taken at least 30 minutes before meals and at bedtime.

n Evaluation

Symptoms of asthma should improve within 4 weeks of using cromolyn or nedocromil. The therapeutic effect is shown when the frequency of asthma attacks decrease and the intensity of the episodes lessen. Because the drug should be given when a patient’s condition is stable, a visit is typically scheduled 2 weeks after the first dose and at least once more within the first 4 weeks to see how effective the medication has been.

Watch the patient carefully when the dose is being reduced or stopped. The drug regimen must be checked if there is no effect within 4 weeks.

n Patient and Family Teaching

n Assessment

Learn as much as you can about the health history of the patient, including whether the patient is pregnant or breastfeeding or has a history of hyperthyroidism, heart disease, hypertension, diabetes, glaucoma, seizures, or psychoneurotic disease. Ask whether the patient is taking other drugs that may interact with bronchodilators or has a history of allergy. Any of these conditions may present contraindications or precautions to the use of sympathomimetic bronchodilators.

The patient may have a history of allergies, asthma, bronchitis, emphysema, recurrent acute or chronic attacks of wheezing, and cough. The patient may have had an acute upper or lower respiratory tract infection before the onset of acute symptoms.

n Diagnosis

As you work with the patient, you will confirm that the patient is having an asthma attack or has respiratory difficulty from COPD. The asthma pattern shows the severity of asthma, and national treatment guidelines suggest that the severity of asthma determines the treatment. For example, the first-line therapy for any asthma attack is a short-acting beta₂ agonist. In addition, you may discover the patient needs hydration, strategies to reduce anxiety, or education about the condition.

n Planning

To relieve bronchial spasm, beta₂ receptors in bronchial smooth muscle cells must be stimulated. One of the drawbacks of beta₂ adrenergic bronchodilators is that their effects are not limited to beta₂ receptors. Some agents also stimulate beta₁ receptors, which increase the rate and force of cardiac contraction.. Thus these beta₂ bronchodilator drugs should be given with extreme caution to individuals who already have cardiovascular, endocrine, or convulsive disorders that may be affected by these drugs.

n Implementation

The routes of administration of bronchodilators vary, according to how sick the patient is (the diagnostic classification) and the preparation to be used. Drugs may be given parenterally, orally, or by oral inhalation (nebulizers, or metered-dose inhalers [MDIs]). The medications selected depend on established guidelines and whether short-term treatment or long-term management is required. A patient who is using an inhaler for the first time should be shown how to use the inhaler and given written instructions to refer to later. Research shows that many patients do not use inhalers correctly, so every time the patient comes in for health care, the nurse should ask for a demonstration of how the MDI is being used.

Use of more than one sympathomimetic agent at a time is contraindicated although a rapid-acting drug might be used when a long-acting drug taken on a regular basis is not effective

With many bronchodilators, if the drug is used too frequently, refractoriness, or lack of response to a drug that a patient has used before with good effectiveness, may develop. Patients also may get less relief from aerosols if they are used too often. Irritation of the bronchial tree and oropharynx may occur with use of powdered drug forms or other inhalted agents. Rinsing the mouth with water after each treatment helps reduce this problem.

n Evaluation

Check the patient’s pulse and blood pressure to see if the heart is affected by the drug. Response to therapy varies among patients. The patient should be watched carefully to see if breathing problems have improved.

Patients should be watched for the development of tolerance, which is shown by less response to the drug.

n Patient and Family Teaching

n Assessment

Learn as much as possible about the health history of the patient, including whether the patient is pregnant or has a history of smoking, allergy, renal or liver dysfunction, heart disease, cardiac dysrhythmias, peptic ulcer, severe hypertension, or glaucoma. These conditions are contraindications or precautions to the use of xanthines.

n Diagnosis

The severity of asthma or COPD is determined by history and is linked to the treatment. Look for any other problems that may require your help: need for increased hydration, insomnia, or feelings of anxiety.

n Planning

The half-life of xanthine bronchodilators is shorter in smokers than in nonsmokers, which may make it necessary to use a higher dosage for smokers.

Some xanthine bronchodilators come in a liquid formulation with alcohol. It is not necessary to use drug formulations that contain alcohol; the addition of alcohol may be harmful to some patients.

n Implementation

Xanthine products are available in a number of forms: capsules, sustained-release tablets and capsules, aqueous solutions and suspensions, hydroalcoholic elixirs, suppositories, rectal solutions, and IV and IM injections.

The amount of the theophylline base varies in xanthine products, and the preparations are not therapeutically equal. This inequality may cause difficulty when the patient is switched from one product to another. The health care provider will want to get blood theophylline levels to make sure that the patient is getting the right amount of medicine.

The rate of absorption of oral theophylline depends on the dosage form used. Oral liquids have the fastest absorption rate, followed by uncoated tablets. Sustained-release tablets and capsules produce inconsistent blood levels and should usually be used only at night. Food does not influence the absorption of theophylline. Absorption of rectal suppositories is slow and sometimes unpredictable. The rate of absorption for rectal solutions and IM injections is usually equivalent to that of an oral solution.

The rates of metabolism and excretion of theophylline are also variable. Xanthines are metabolized in the liver and excreted by the kidneys. The serum half-life of the drugs can range from 3 to 12 hours in adults and to 9 hours in children. Heart failure, liver dysfunction, and pulmonary edema can slow excretion, and smoking can increase excretion. Children younger than 9 years of age actually require larger doses of theophylline than adults to maintain the same therapeutic blood levels of the drug. Thus the dosage must be prescribed on an individualized basis and be carefully monitored. It is common for an initial loading dose to be indicated.

Because of the need to increase or decrease the amount of medication based on the symptoms as well as the serum drug levels, the use of fixed-combination bronchodilator products (that is, a sympathomimetic, a xanthine, and an expec-torant combined in one product) is not recom-mended. Fixed-combination products do not make it possible to change the doses of each individual drug, and a fixed-combination drug may lead to toxicity from some of the drugs. Use of selected sympathomimetic and xanthine bronchodilators administered at the same time, however, may have a synergistic effect. These combination products, once common, are rarely used today.

n Evaluation

The patient’s breathing status and symptoms should be watched for any change. Be alert for signs of toxicity, such as tachycardia or dysrhythmias, vomiting, dizziness, and irritability. Therapeutic blood levels of theophylline and the amount of theophylline base in each preparation will affect the patient’s clinical response.

Children and older adult patients are highly sensitive to these drugs and should be carefully watched for CNS stimulation. Notify the health care provider if you suspect the drug dosage may need to be changed.

To minimize GI symptoms, administer the drug with food and water. Rectal irritation may develop from use of suppository forms.

n Patient and Family Teaching

n Assessment

Learn as much as possible about the health history of the patient to determine the status of the patient’s asthma and what other medications the patient might be taking. Ask about the possibility of pregnancy, breastfeeding, or liver disease.

n Diagnosis

Carefully evaluate the patient to determine the possibility of infection, the presence of anxiety (which may cause more rapid breathing), a lack of knowledge, or anything else that may complicate the asthma treatment regimen.

n Planning

These drugs are not started if the patient is having an acute asthma attack. They are adjunctive drugs given as part of an asthma treatment regimen. Watch to see if there might be adverse drug interactions with other medications the patient is taking. Some of these medications involve special storage requirements.

n Implementation

Most of these medications are given once or twice daily. They are usually well tolerated, and no significant problems are associated with them.

n Evaluation

Therapeutic effect is seen with a reduction in number and severity of asthma attacks. Patients should report to their health care provider if they have an increase in asthma attacks.

n Patient and Family Teaching

n Assessment

Learn everything you can about the severity of the patient’s asthma. Look for symptoms of other respiratory infection, allergens, or stress that might have triggered an asthma attack. Collect information about whether the patient takes the asthma medication correctly and as prescribed. Does the patient have other conditions that could be made worse by systemic corticosteroids?

n Diagnosis

Classify symptoms of asthma by severity, and identify asthma triggers. Diagnose needs for patient teaching. Does the patient need to take in more fluids? Does the patient need more education?

n Planning

Develop a teaching plan to meet the educational needs that have been discovered. The health care provider will order oral products at the lowest effective dose for the shortest time possible, so plan to be watchful for adverse effects that may develop from the medication.

n Implementation

Sometimes patients can reverse an asthma attack by controlling their breathing. Patients who learn these techniques may be fearful and unable to breathe slowly when the attack begins. Stay with the patient and offer reassurance and help with breathing exercises during an acute asthmatic attack. Also begin giving the patient extra water to reduce the thickness of secretions and help the patient cough them up and spit them out. Show the patient the proper way to hold the medication canister, take a breath, and compress the canister so that the medication is released into the lungs and not into the mouth. To insure that the medicine is at the proper angle to go into the lungs and not the throat, if the patient can stand, they should be able to see their feet while using the inhaler. (If they cannot see their feet, they are holding the inhaler at the wrong angle). Begin teaching the patient about the disease process, the medication regimen, equipment, and procedures. Using a spacer or holder chamber device and washing out the mouth after inhalation will improve systemic absorption and decrease local side effects.

n Evaluation

Have the patient show you how the inhaler is used. Watch for improvement in the patient’s breathing. Wheezing should decrease.

n Patient and Family Teaching

Education should focus on the disease process, triggers to asthma attacks, and appropriate therapy.

The patient and family should learn about taking the medicine and knowing when it is not effective. Make sure the patient understands when to contact the health care provider.

Explain how corticosteroid medications are used together with other products. This information should be put in writing so the patient can refer to it later.

n Assessment

Learn as much as possible about the patient’s health history. The patient may have a history of nasal congestion, postnasal drip, nasal discharge, sneezing, sore throat, headache, itchy eyes, lacrimation (excess tear production), nasal polyps, earache, decreased hearing, URTI, or allergies.

Ask about allergy to adrenergic agents, narrow-angle glaucoma, concurrent MAO inhibitor or tricyclic antidepressant therapy, and loss of sensation in the fingers and toes. These are contraindications to the use of decongestants. Decongestants should be used cautiously by patients with hypertension, dysrhythmias, heart disease, angina, hyperthyroidism, diabetes, advanced arteriosclerotic conditions, glaucoma, prostatic hypertrophy, or chronic cough because of the possibility of systemic vasoconstriction and tachycardia. Patients with a long history of asthma and emphysema who also have degenerative heart disease should also be cautioned about the use of decongestants. Excessive use of topical decongestants may result in GI absorption that causes systemic effects. The safe use of decongestants in pregnancy has not been established.

Decongestants should be used with caution in patients with hypertension, hyperthyroidism, diabetes, cardiac disease, glaucoma, or prostatic hyperplasia. Drugs containing pseudoephedrine are used in the manufacture of methamphetamines. Many states have regulations regarding the purchase of decongestants where they track and limit the number of purchases by an individual. The drugs containing decongestants are placed behind the counter at the pharmacy and individuals have to sign for them.

n Diagnosis

To make certain the treatment is appropriate, the exact cause of the patient’s problem must be found. Determine if rhinitis is related to allergy or infection.

n Planning

Frequent and continual use of topical decongestants or use at dosages greater than recommended may result in a rebound effect. Topical decongestants should be used only in acute states, for no longer than 3 to 5 days, and should be used very carefully at low doses in older adults.

n Implementation

Oral decongestants are considered to be more effective and longer lasting than nasal preparations because they can reach all parts of the mucous membrane in the nasal passages. The disadvantage of systemic agents is that their effects may not be limited to the nasal mucosa; they may also affect other parts of the body. This is why caution is advised for patients with certain medical conditions.

Topical forms may be supplied as drops, sprays, jellies, and oral inhalation agents. The advantage of topical administration is the rapid onset of action and direct stimulation of the nasal mucosa. Drops have a tendency to pass into the hypopharynx and then be swallowed, thus passing into the GI tract. Sprays deliver a fine mist that is easily trapped in the upper respiratory tract, so they are less likely to reach the GI tract. Topical preparations should not be used for more than 3 to 5 days because of the risk of a rebound effect. Oral preparations are more appropriate for long-term use in the rare occasions where required.

To prevent swallowing of the drug, the patient’s head should be tipped back when giving nose drops. Use care not to touch the skin while administering solutions. Solutions can become contaminated with use and result in growth of bacteria and fungi.

n Evaluation

Expect to see symptoms disappear. However, symptoms may return if there is rebound congestion following overly long use. If headache and nervousness occur, stop the treatment and contact the health care provider.

n Patient and Family Teaching

There are many decongestants on the market that are available OTC. A lot of these OTC products contain combinations of medications to make them attractive to the patient with several symptoms. These products may contain a decongestant and one or more antihistamine, analgesic, antitussive, expectorant, or anticholinergic products. Each additional medication increases the precautions for use of the product and the adverse effects that may occur. For example, drugs that contain anticholinergics cause drying of mucus secretions. They should be avoided in patients with asthma or COPD. The patient should consider whether there is a need for all of the drugs listed on the label of these combination products. Also, the types of drugs that make up even well-known products change frequently. Pharmacists are excellent sources of information about OTC medications, and patients should be encouraged to seek their professional advice before self-treating with a decongestant product.

n Assessment

Learn as much as possible about the health history of the patient, including the history of cough, presence of other respiratory disease, allergy, and other medications that may cause drug interactions.

n Diagnosis

Are there needs for hydration? Is the patient able to take water by mouth, or is he or she receiving IV fluid? Diagnose any lack of knowledge the patient may have.

n Implementation

n Evaluation

Monitor to see that secretions become thinner and are decreased. If the patient uses more than the recommended dosage, adverse reactions may occur.

n Patient and Family Teaching

n Assessment

Learn as much as possible about the health history of the patient, including allergy, fungal infections, tuberculosis, ocular herpes simplex, local infections (especially of the nose, sinus, or throat), and the possibility of pregnancy. These conditions are contraindications or precautions to the use of topical nasal steroids. Ask about the patient’s past experience with and response to nasal sprays.

n Diagnosis

Learn why the patient requires intranasal medication. Identify any other problem secondary to medication use or misuse, such as presence of adverse effects or patient education deficits.

n Planning

The patient receiving topical intranasal steroids should not be given smallpox vaccination or immunizations, because the immunologic response may be decreased. In the patient with latent tuberculosis or reactivated tuberculosis, close observation and possible chemoprophylaxis may be indicated. The effects of these drugs are increased in patients with hypothyroidism and cirrhosis.

n Implementation

The recommended dosage must not be exceeded. The dosage should be decreased when the patient begins to improve.

n Evaluation

Watch for a reduction in nasal stuffiness, obstruction, and discharge, and for relief of sinus headaches. Also monitor how often the medication is used and what dosage is used. Watch for cracked or bleeding nasal mucosa. Be alert for adverse reactions such as signs of systemic absorption and fluid retention, increased blood pressure, weight gain, ankle edema, or evidence of local infection.

Nasal dryness and irritation are side effects and do not usually require stopping the drug. The dosage of these drugs should be gradually reduced to avoid adrenocortical insufficiency.

These drugs may decrease resistance to infection, as well as mask some common signs of infection. Elevation of blood pressure, retention of salt and fluid, and increased potassium and calcium loss may occur if the patient takes large doses. This may be treated with dietary salt restriction and potassium supplementation. Loss of the ability to smell, shortness of breath, unrelieved stuffy nose, chest tightness, or wheezing all indicate a need for intervention by a health care provider.

The patient should be watched for signs of sys-temic absorption, because fluid retention and temporary inhibition of pituitary-adrenal function may develop.

n Patient and Family Teaching