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  1. 1. Drugs Acting on URT Drugs for COPD 1
  2. 2. 1. Antitussives2. Decongestants 1. Topical Nasal Decongestants 2. Oral Decongestants 3. Topical Nasal Steroid Decongestants3. Antihistamines/H1 Receptor Agonist 1. Expectorants 2. Mucolytics 2
  3. 3. 1. ANTITUSSIVES Benzonatate Codeine Dextromethorphan hydrobromide (Balminil) 3
  4. 4. 1. ANTITUSSIVESACTION: Suppress the cough reflex by acting on the medulla’s cough center Anesthetize cough receptors of vagal afferent fibers throughout the bronchi, alveoli and pleura (Benzonatate) 4
  5. 5. 1. ANTITUSSIVESINDICATION: Tx of NONPRODUCTIVE cough  Common colds  Sinusitis  Pharyngitis  Pneumonia 5
  6. 6. 1. ANTITUSSIVESCONTRAINDICATIONS: + hypersensitivity Pregnancy and lactation CNS depressionCAUTION: Asthma and emphysema –secretion can accumulate as a result of cough suppression Hx of narcotic addiction = makes sedation and drowsiness 6
  7. 7. 1. ANTITUSSIVESADVERSE EFFECTS: Dryness on mucus membranes Increase viscosity of secretion CNS effects: drowsiness, sedation and HA GI: constipation, GI upset, nasal congestion 7
  8. 8. 1. ANTITUSSIVESNURSING CONSIDERATIONS:1. Maintain airway patency and suction secretions if necessary2. Assess breath sounds and determine characteristics of cough (productive/ nonproductive; viscosity of secretions)3. Encourage to maintain fluid intake of 2-3 L a day4. Advise to report to physician id cough persist for > 1wk or if chest pain occurs. 8
  9. 9. 2. DECONGESTANTS Ephedrine sulfate (Ephedrine) Oxymetazoline hydrochloride phenylephrine 9
  10. 10. 2. DECONGESTANTS Adrenergic drugs produce LOCAL VASOCONSTRICTION decreasing blood flow to the irritated capillaries of the mucus membrane lining the nasal passages and sinus cavities 10
  11. 11. 2. DECONGESTANTSTOPICAL NASAL DECONGESTANTSACTION: Imitate the effects of SNS Cause VASOCONSTRICTION Results to decreased nasal membrane inflammationINDICATIONS: Relief from nasal congestion (common cold, sinusitis, allergic rhinitis) Dilation of nares for dx procedure Relief from pain and congestion in otitis media 11
  12. 12. 2. DECONGESTANTSTOPICAL NASAL DECONGESTANTSCAUTION Mucous membrane lesions-lead to systemic absorption Glaucoma, HPN, DM, thyroid dse, coronary dse and prostate problems = may exacerbate by decongestants 12
  13. 13. 2. DECONGESTANTSTOPICAL NASAL DECONGESTANTSADVERSE EFFECTS: Local reaction = stinging & burning Rebound congestion:  Nasal Congestion- when decongestants are used more than 3- 5 days Increased pulse, blood pressure and urinary retention 13
  14. 14. 2. DECONGESTANTSTOPICAL NASAL DECONGESTANTSNURSING CONSIDERATION:1. Assess for presence of glaucoma, HPN, coronary dse and prostate problems  Can exacerbate the condition2. Assess skin color, temp, orientation, reflexes, respirations, breath sounds and bladder  To determine sympathomimetic effects of the drug 14
  15. 15. 2. DECONGESTANTSTOPICAL NASAL DECONGESTANTSNURSING CONSIDERATION:3. Teach about proper administration to ensure therapeutic effect 3. Instruct clear nasal passages 4. Keep head tilted backward when applying drops/spray 5. Maintain position for few seconds after drug administration 15
  16. 16. 2. DECONGESTANTSORAL DECONGESTANTSACTION: Stimulate alpha-adrenergic receptors in nasal mucous membrane Resulting to decrease membrane size, drainage of sinuses and improvement of air flowINDICATION: Relief from pain and congestion with otitis media Tx of nasal congestion related to common colds, sinusitis and allergic rhinits 16
  17. 17. 2. DECONGESTANTSORAL DECONGESTANTSCONTRAINDICATION: Glaucoma HPN DM Thyroid disease Coronary disease Prostate problems 17
  18. 18. 2. DECONGESTANTSORAL DECONGESTANTSADVERSE EFFECTS: Rebound congestion Anxiety Restlessness Tremors HPN Arrhythmias Sweating and pallor 18
  19. 19. 2. DECONGESTANTSORAL DECONGESTANTSNURSING CONSIDERATIONS:1. Assess for presence of disorders present in CI2. Monitor PR, BP and cardiac response to detect adverse effects3. Instruct that drug should not be used more than a week4. Caution not to combine topical decongestants with other drugs with the same components = lead to overdose 19
  20. 20. 2. DECONGESTANTSTOPICAL STEROID NASAL DECONGESTANTSACTION: Exact mechanism of action is not known.INDICATION: Tx of allergic rhinitis who do not respond to any other form of decongestants Relief of inflammation following nasal polyp removal. 20
  21. 21. 2. DECONGESTANTSTOPICAL STEROID NASAL DECONGESTANTSPHARMACOKINETICS: Action is not immediate Require 1 week of admin to achieve therapeutic effectCONTRAINDICATION: Acute infection Can cause Candida albican infection Should not be exposed to airborne infection: chickenpox and measles 21
  22. 22. 2. DECONGESTANTSTOPICAL STEROID NASAL DECONGESTANTSADVERSE EFFECT: Stinging and burning sensation Mucosal dryness HA 22
  23. 23. 2. DECONGESTANTSTOPICAL STEROID NASAL DECONGESTANTSNURSING CONSIDERATION:1. Reinforce use of drug even if results are not seen immediately.  Therapeutic effect can take up to 2-3 wks after use2. Monitor for dev’t of infection.3. Encourage to avoid areas where airborne infection may be present.4. Allow to clear nasal passages prior to drug administration. 23
  24. 24. 3. ANTIHISTAMINES / H1 RECEPTOR AGONISTSACTION: Compete with histamine for H1 receptor sites in the client’s arterioles, capillaries and secretory glands in mucous membrane They do not inhibit histamine release Possess anticholinergic and antipruritic effect 24
  25. 25. 25
  26. 26. 3. ANTIHISTAMINES / H1 RECEPTOR AGONISTSINDICATIONS: Systemic tx of allergic rhinitis and conjunctivitis Reduce rhinorrhea, lacrimation, nasal and conjunctival pruritus and sneezing 26
  27. 27. 3. ANTIHISTAMINES / H1 RECEPTOR AGONISTSCAUTIONS: Renal/hepatic impairment Hx of arrhythmias / prolong QT intervalsADVERSE EFFECT: Sedation Anticholinergic effect  Dry mouth, urinary retention, stuffy nose, blurred vision 27
  28. 28. 3. ANTIHISTAMINES / H1 RECEPTOR AGONISTSNURSING CONSIDERATIONS:1. Administer on an EMPTY STOMACH, 1 hr before or 2 hrs after meal for best absorption2. Administer with food if + GI upset3. Monitor cough and viscosity of sputum; effects of drug can impair expectoration of secretions4. Encourage adeqaute fluid intake; 8-12 glasses/day 28
  29. 29. 3. ANTIHISTAMINES / H1 RECEPTOR AGONISTSNURSING CONSIDERATIONS:5. Instruct to eat ice chips/hard candy  if mouth becomes dry6. Caution from driving and ambulating without assistance = blurred vision is 1 SE7. Instruct to avoid alcohol intake while using the drug  to prevent extreme sedation8. Have client void before drug administration  to prevent urinary retention 29
  30. 30. 3.1 EXPECTORANTSACTION: Decrease viscosity of secretion increasing the fluid in the respiratory tract Reduce adhesiveness and surface tension of fluids to allow easier movement of thin secretions. 30
  31. 31. 3.1 EXPECTORANTSINDICATIONS: Cough associated with common cold Bronchial asthma Relief of dry and non-productive cough URTI  Bronchitis  Influenza  Sinusitis  Emphysema 31
  32. 32. 3.1 EXPECTORANTSCONTRAINDICATION: + hypersensitivity to expectorantsCAUTION: Ineffective cough reflex Respiratory insufficiency Pregnant and breastfeeding 32
  33. 33. 3.1 EXPECTORANTSADVERSE EFFECTS: Vomiting (large dose) Diarrhea Nausea Drowsiness Abdominal pain 33
  34. 34. 3.1 EXPECTORANTSNURSING CONSIDERATIONS:1. Caution client not to take drug longer than a week and to seek medical attention if cough persist2. Assess breath sounds and evaluate characteristics and frequency of cough3. Instruct to maintain oral fluid intake of 2-3liters a day to enhance effects of expectorants 34
  35. 35. 3.1 EXPECTORANTSNURSING CONSIDERATIONS:4. Instruct to check with physician before taking any OTC/herbal preparation5. Advise to avoid driving or engaging in dangerous tasks if drowsiness and dizziness occurs to prevent injury 35
  36. 36. 3.2 MUCOLYTICS Acetylcysteine (Mucomyst) Dornase alfa (Pulmozyme) 36
  37. 37. 3.2 MUCOLYTICSACTION: Decreased viscosity of mucus by breaking or altering the chemical bonds of glycoprotein complexes in mucus Acetylcysteine protect liver cells from damage during acetaminophen toxicity by normalizing hepatic glutathione level and binding with acetaminophen’s hepatotoxic metabolite Dornase alfa breaks down mucus through separation of extracellular DNA from protein 37
  38. 38. 3.2 MUCOLYTICSINDICATIONS: Abnormal, thick and viscous mucus Antidote of acetaminophen overdoseCONTRAINDICATIONS: + allergyCAUTION Acute bronchospasm, PUD & esophageal varices 38
  39. 39. 3.2 MUCOLYTICSADVERSE EFFECTS: Stomatitis N&V Drowsiness Rhinorrhea Bronchospasm 39
  40. 40. 3.2 MUCOLYTICSNURSING CONSIDERATIONS:1. Avoid combining with other drugs in nebulizer to prevent loss of effectiveness2. Client should wipe acetylcysteine residue from their face if they are receiving the drug by face mask3. Caution with cystic fibrosis who are taking dornase alfa to continue with all therapies  the drug serves as a palliative tx for respiratory symptoms associated with the disorder. 40
  41. 41. 1. Bronchodilators/Xanthines2. Sympathomimetic bronchodilators3. Anticholinergic bronchodilators4. Inhaled steroids5. Leukotriene Receptor Antagonist6. Lung Surfactant7. Mast cell Stabilizers 41
  42. 42. 1. Bronchodilators/Xanthines Aminophylline (Truphylline) Caffeine Theophylline  (*should not be taken with cimetidine and ciprofloxacin as they cause toxicity) 42
  43. 43. 1. Bronchodilators/XanthinesACTION: Affects smooth muscles of respiratory tract by releasing 2 prostaglandins, resulting in smooth muscle relaxation Inhibit the release of slow-reacting substance of anaphylaxis (SRSA) and histamine, results in decreased swelling of the bronchi 43
  44. 44. 1. Bronchodilators/XanthinesINDICATION: Acute bronchospasms Prevention and maintenance therapy for clients with COPD and asthma Mgt of bronchospasm during anesthesia 44
  45. 45. 1. Bronchodilators/XanthinesNURSING CONSIDERATIONS:1. Administer with FOOD/MILK if gastric upset occurs2. Assess if client is also taking beta-adrenergic blocker because they can decrease bronchodilating effect3. Assess if client smoke  Nicotine increases metabolism of xanthenes= higher dosage may be prescribed4. Monitor HR and rhythm at regular intervals during the duration of the therapy 45
  46. 46. 1. Bronchodilators/XanthinesNURSING CONSIDERATION:5. Instruct to maintain oral fluid intake of 2-3 L  to make secretion less viscous6. Advise to consult with physician before taking over-the- counter medications  to avoid possible AE7. Instruct client to avoid respiratory irritants such as smoke, dust and strong scents 46
  47. 47. 2. Sympathomimetic Bronchodilators Albuterol (Asmavent, Proventil, Ventolin) Bitolterol (Tornalate) Ephedrine Epinephrine (Adrenaline) Formoterol (Foradil) Isoetharine (Bronkometer) Isoproterenol (Isuprel) Levalbuterol (Xopenex) Terbutaline (Brethine, Bricanyl) Salmeterol (Serevent) Metaproterenol (Alupent, Orcipren) Pirbuterol (Maxair, Autohaler) 47
  48. 48. 2. Sympathomimetic BronchodilatorsACTION: Stimulate beta receptors in the smooth muscle of the tracheobronchial tree to open airway passagesINDICATION: Reversal of airway constriction in acute and chronic bronchial asthma 48
  49. 49. 2. Sympathomimetic BronchodilatorsNURSING CONSIDERATIONS: Inform the client that the drug of choice may vary for each individual Instruct to administer the minimal amount of the drug necessary  to produce therapeutic effect to avoid occurrence of adverse drug reaction Client with exercise-induced asthma should take these drugs 30min to 1 hr before exercise Encourage small, frequent meal if GI upset occurs 49
  50. 50. 3. ANTICHOLINERGIC BRONCHODILATORS Ipratropium bromide (Atrovent) Tiotropium (Spiriva) 50
  51. 51. 3. ANTICHOLINERGIC BRONCHODILATORSACTION: Bronchodilation by inhibiting cholinergic receptors in bronchial smooth muscleINDICATION: Long-term tx of reversible bronchospasm associated with COPD Initial bronchodilation occurs within 1st few minutes after inhalation Max therapeutic effects 1-2hrs 51
  52. 52. 3. ANTICHOLINERGIC BRONCHODILATORSNURSING CONSIDERATIONS: Provide small, frequent meals if GI upset occurs. Instruct not to excess 12 inhalations in 24h to prevent occurrence of AE Instruct to avoid driving or operating dangerous machinery to prevent injury Have client to void before each dose if urinary retention becomes a problem. 52
  53. 53. 4. INHALED STEROIDS Beclomethasone (Beclodisk, Beclovent) Budesonide (Entocort) Flunisolide (Aerobid, Bronalide) Fluticasone (Flonasone) 53
  54. 54. 4. INHALED STEROIDSACTION: Decrease swelling by inhibiting the effectiveness of anti-inflammatory cells Promote beta-adrenergic receptors activity resulting to relaxation of smooth muscles and bronchodilation 54
  55. 55. 4. INHALED STEROIDSINDICATION: Chronic bronchitis Bronchial asthma in clients with steroid-dependent asthma Tx of allergic rhinitis and prophylactic tx of exercise-induced asthma Systemic adverse reactions are reduced , though rapidly absorbed thru IV 55
  56. 56. 4. INHALED STEROIDSCONTRAINDICATION: Acute asthma attackCAUTION: TB , viral infection HPN, DM, PUDADVERSE EFFECTS: Mouth irritation Oral candidiasis URTI 56
  57. 57. 4. INHALED STEROIDSNURSING CONSIDERATION: Instruct to pt who’s receiving a corticosteroid and bronchodilator to administer the bronchodilator 1st before steroid  to ensure penetration of steroids in airway Instruct to perform oral care after using inhaled steroids. Instruct on the proper use of inhaler Provide food with oral doses to minimize GI upset Inform that the drug must not be stopped abruptly, doses must be tapered to avoid AE 57
  58. 58. 5. LEUKOTRIENE RECEPTOR ANTAGONISTS Montelukast (Singulair) Zafirlukast (Accolate) Zileuton (Zyflo) 58
  59. 59. 5. LEUKOTRIENE RECEPTOR ANTAGONISTS Compete with receptor sites, thus inhibiting inflammatory reaction associated with asthma and blocking its s/sxINDICATION: Prophylactic and long-term tx of bronchial asthma Montelukast = for children <1.2mos 59
  60. 60. 5. LEUKOTRIENE RECEPTOR ANTAGONISTSNURSING CONSIDERATION: Administer on an empty stomach to facilitate absorption Inform that the drug should be taken continuously according to prescribed regimen Instruct to avoid OTC containing aspirin while taking leukotriene receptor antagonist  Aspirin may cause decrease effectiveness of drug Use in caution in administering these drugs if client is taking propanolol, theophylline and warfarin  Lead to toxicity 60
  61. 61. 6. LUNG SURFACTANTS Beractant (Survanta) Calfactant (Infasurf) Colfosceril (Exosurf Neonata) Poractant (Curosurf) 61
  62. 62. 6. LUNG SURFACTANTS Naturally occurring lipid compounds that reduce alveoli surface tension Expanding the alveoli to allow gas exchangeINDICATION: Replacement of surfactant in neonates with RDS 62
  63. 63. 6. LUNG SURFACTANTS Onset of action begins immediately after instillation into the neonate’s tracheaADVERSE EFFECTS: PDA, hypotension, IVH, pneumothorax, hyperbilirubinemia, sepsis 63
  64. 64. 6. LUNG SURFACTANTSNURSING CONSIDERATION: Monitor neonate continuously during administration and prepare life support measures Ensure proper placement of the endotracheal tube to provide adequate delivery of the drug Suction the infant before administering the drug. 64
  65. 65. 7. MAST STABILIZERSACTION: Cromolyn  inhibit histamine release to prevent allergic response when respiratory tract is exposed to potential allergens Neodocromil  Inhibits mediators of inflammatory cells such as eosinophil, neutrophils, macrophage and mast cells thereby blocking the overall inflammatory response 65
  66. 66. 7. MAST STABILIZERS Cromolyn  Active in lungs, most of the inhaled dose is excreted during exhalation Neodocromil  Excreted unchanged in urine 66
  67. 67. 7. MAST STABILIZERSNURSING CONSIDERATION: Caution against discontinuing the drug abruptly  May cause rebound adverse effects Administer oral drugs 30 minutes before meals and at bedtime  to promote relief from symptoms of asthma Advise not to wear soft contact lenses if cromolyn eye drops are used  Cause stain 67
  68. 68. 68
  69. 69.  Instruct to blow nose gently Have client lie down with head tilted back ward over the edge of the bed.  Young children and infants, hold the head over the edge of the bed or pillow; “football” hold to immobilize the infant Draw medication from dropper and hold dropper above the nostril to instill the medication Have the client turn to the other side and repeat the process on the other nostril Instruct to remain in that position for 2-3min, to allow the drops to reach the nasal mucosa. 69
  70. 70.  Instruct to blow nose gently Have client sit upright Block the client’s right/left nostril Hold spray bottle and shake. Immediately after shaking, insert tip of the bottle into the open nostril Ask the client to inhale through the open nostril as you squeeze a puff of spray at the same time 70
  71. 71.  If the medication is a suspension, shake the canister to disperse and mix the active bronchodilator with the propellant Open client’s mouth and place the canister outlet 2- 4 inches in front of the mouth. This space will allow the propellant to evaporate and will prevent large particles from settling in the mouth Activate the metered dose inhaler and instruct the client to inhale deeply for 10 seconds to open the airways and disperse the drug 71
  72. 72.  Instruct to hold breath, and exhale slowly so that the drug will reach the p.tissue If prescribed, repeat the procedure after 2-3min. The use of small dose with 2-3 inhalations enhances deposition of the drug in the smaller airways. Rinse mouth taking inhalers Cleanse the apparatus according to manufacturer’s instructions. 72