exam 6 - ch 17, 4, 8, 22, 23

allergy

when a person comes into contact with a substance or allergen to which he or she is sensitive and an excessive reaction and inflammatory response occur

hypersensitivity

occur when immune system overreacts and develops a response to substances in the environment

immune system

protects the body from antigens (living things and nonliving things)

-produces antibody directed against offending antigen

antibodies

-are produced by lymphocytes

-neutralize offending antigen

lymphocytes

-make 5 different antibodies: IgA, D, E, G, and M

-IgE is body’s defense against allergens

how body responds to allergen

-antibodies release

-immune system cells and mast cells produce mediators (histamine and leukotriene) which start and continue inflammation

-cause contraction of smooth muscle and dilation and leakage of capillaries which leads to swelling, redness, tissue irritation and mucus production

all reactions are meant to keep invaders out of the body

Unfortunately this means it also prevents oxygen from entering the body

first generation antihistamines

prevent histamine from attaching to the tissue receptor sites, decreasing allergic symptoms

-can cause CNS depression

second generation antihistamines

prevent histamine from attaching to the tissue receptor sites, decreasing allergic symptoms

-the incidence of CNS depression is much less with these

leukotriene inhibitors (modifiers)

blocks production of leukotriene in WBCs, and montelukast and zafirlukast block the leukotriene receptors on tissues

-both actions stop allergy symptoms and prevent bronchoconstriction in asthma

mast cell stabilizers

prevent mast cell membranes from opening and releasing histamine and leukotriene

first gen antihistamines -warnings

-do not drive or operate hazardous equipment because the drugs cause drowsiness

-taking with other anticholinergics (TCAs) as it will show additive symptoms

-check urine output of pt who have an enlarged prostate because a side effect is urinary retention

-avoid for pts who have glaucoma because the action can increase intraocular pressure

-many OTC sleep aids contain first-gen antihistamines

-watch for hyper excitability and restlessness in children or older adults

-avoid bromphenaramine

-do not take with sedatives, opioids, anticholinergic drugs, or drugs that cause CNS depression

-take drugs for 2 weeks or less

first generation antihistamines (drugs)

-diphenhydramine (Benadryl)

-diphenhydramine cream (topical agent)

-brompheniramine (dimetapp)

second generation antihistamines (drugs)

-fexofenadine (allegra)

-loratadine (claritin)

-levocetirizine (xyzal)

second generation antihistamines -warnings

-teach pts to take zafirlukast 1 before or 2 hours after a meal because the drug is best absorbed on an empty stomach

-instruct pt taking the quick dissolving tablets to place them under the tongue and not to eat or drink until they have dissolved

-ask whether the pt has any kidney problems, because this allows the drug to remain in the system longer

-check urine output of patients who have an enlarged prostate because a side effect is urinary retention

-use caution with other drugs that cause sedation or CNS depression

-give levocetirizine in the evening because it has more sedating effects

leukotriene inhibitors (modifiers) (drugs)

-montelukast (Singulair)

-zafirlukast (accolate)

-zileuton (zyflo)

leukotriene inhibitors -warnings

-teach pts to report any yellowing of the skin or eyes, darkening of the urine, or white/gray stools because these drugs can impair the liver

-observe for changes in behavior or mood

-do not give during an asthma attack- they are prevention drugs

mast cell stabilizers (cromones) (drugs)

-cromolyn sodium (NasalCrom)

-nedocromil sodium (Tilade)

mast cell stabilizers -warnings

-remind pt that there may be mild stinging or burning of the nasal lining with use, but this is an expected side effect

-rinse mouth and gargle after using nebulizer to minimize dry mouth or throat

-these drugs must be used as prescribed daily to reduce symptoms

antihistamines actions

-block H1 and H2 receptors

-limit release of acetylcholine

-first gen cause sleepiness - given to reduce sneezing, itching, running nose

-second gen have more rapid onset- less effective against nasal congestion

blocking H1 vs H2 receptors

-H1 limits blood vessel vasodilation, capillary leak, swelling and bronchoconstriction

-H2 decreases stomach acid production

antihistamine side effects and adverse effects

-S/E: drowsiness, dry mouth, increased heart rate, increased blood pressure, dilated pupils, urinary retention

-adverse effects: increased intraocular pressure in patients with glaucoma, cardiac dysrhythmias, dangerously high blood pressure

-pt with thyroid disease should not take due to tachycardia

-if not contraindicated, take with food or milk and drink extra fluids

leukotriene actions

-zyflo blocks production of leukotriene within WBC

-singulair and accolate block the leukotriene receptors on tissues

-inflammatory response is reduced

-therapeutic effect seen in 3-7 days; not used for acute asthma attack

leukotriene inhibitors side effects

headache, nausea, diarrhea

-liver dysfunction possible with long term use

mast stabilizers actions

drug that reduces the amount of histamine and leukotriene released

-work on surface on mast cells and prevent them from opening to release the inflammatory mediators

-nasal allergies and asthma- drugs are inhaled

decongestants

drugs that reduce the swelling of the nasal passages

-sympathomimetics: drugs that mimic stimulation of the nervous system

-corticosteroids: drug build on the structure of cholesterol that can prevent or limit inflammation and allergy by slowing production of histamine and leukotriene

nasal corticosteroids (drugs)

-fluticasone (flonase sensimist)

-triamcinolone (Nasacort)

nasal corticosteroids -warnings

-relief is not immediate

-caution patients not to swallow the spray- can cause more side effects

-remind patients to clean and dry the applicator and never share

-watch for white patches in the nose or throat that may indicate a fungal infection -drugs reduce the local immune response

sympathomimetic drugs

-oxymetazoline nasal spray (Afrin)

-phenylephrine spray or drops (neo-synephrine)

-phenylephrine oral tabs or liquid (Nasop, Sudafed)

-pseudoephedrine (dimetapp, sudafed)

sympathomimetic drugs -warnings

-relief of nasal congestion is immediate

-remind pts to use the nasal spray only for a few days d/t rebound stuffiness

-caution pt to not swallow the spray

-warn patients with high blood pressure, heart disease, glaucoma, or prostate enlargement to use these drugs with caution

-suggest that patients who are using oral forms should take the drugs at least 4 hours before bed d/t insomnia

decongestants side effects and adverse reactions

-S/E: irritation and dryness of mucous membranes, overuse can cause nervousness, insomnia, tremors and heart palpitations, headaches, dizziness; slight nosebleed is common

-adverse: increased HR, increase force of contraction of heart muscle→ increases speed of electrical conduction in the heart and constricts blood vessels, cardiac dysrhythmias, HTN, palpitations→ heart attack

asthma

-long-term condition of airways that cause smooth muscle constriction and inflammation of airways and lungs

-internal airway obstruction: inflammation cause mucous membrane lining to swell and secrete extra mucous

COPD

a progressive disease that causes difficulty breathing

-obstructs airflow passages to upper and lower airways

-large amounts of sticky mucous produced, obstructs upper airways

-emphysema causes damage to lower airways; alveoli collapse and die

drug therapy for asthma and COPD

-bronchodilators and anti-inflammatory agents

-mucolytics

-goals: prevent acute asthma attacks, stop asthma attack as quickly as possible

bronchodilators

-drug that relaxes the airway smooth muscles, allowing the lumen of the airways to widen

-bind and stimulate the beta2-adrenergic receptors within the bronchial tube smooth muscle and allows them to relax

short-acting beta2-agonists (SABAs) action

cause bronchodilation by rapidly binding to beta2-adrenergic receptors in the bronchial smooth muscle and stimulating muscle relaxation

long-acting beta2-agonists (LABAs) action

cause bronchodilation by binding to beta2-adrenergic receptors in bronchial smooth muscle over time and eventually stimulating continued smooth muscle relaxation

cholinergic antagonists action

inhaled controller drugs that cause bronchodilation by preventing the nervous system from releasing some acetylcholine, which then allows more of the body’s own adrenaline to activate beta2-receptors in bronchial smooth muscle

short-acting beta2-agonists (SABAs) drugs

-albuterol

-levoalbuterol

-pirbuterol

short-acting beta2-agonists (SABAs) -warnings

-teach pts to carry drugs with them at all time

-monitor hr and other responses because excessive use causes rapid hr, nervousness, tremors

-if taking other inhaled drug, use this one first and then wait 5 mins

-instruct pt to use a spacer with the MDIs

long-acting beta2-agonists (LABAs) drugs

-arformoterol (Brovana)

-formoterol (foradil, Oxeze)

-salmeterol (Serevent)

long-acting beta2-agonists (LABAs) -warnings

-use daily as prescribed, even when symptoms are not present

-do not use as reliever/rescue drugs

cholinergic antagonists drugs

-ipratropium (Atrovent)

-tiotropium (Spiriva HandiHaler)

-tiotropium (Spiriva Respimat)

cholinergic antagonist -warnings

-shake MDI well before using

-drink plenty of fluids d/t mouth dryness

-expected side effects are stuffy nose, sore throat, and constipation

-report urinary retention or consistently increased HR (adverse effects)

inhaled corticosteroids drugs

-decreased inflamed airways; do NOT cause bronchodilation- not rescue drugs

-beclomethasone (Qvar)

-budesonide (Pulmicort)

-flunisolide (Aerospan HFA)

-fluticasone (Flovent HFA)

-mometasone (Asmanex)

inhaled corticosteroids -warnings

-do not use in pts who have candida or systemic fungal infections

-suggest pts rinse their mouths after use

-not used to treat an acute asthma attack

-use these drugs daily as prescribed

-notify HCP if white patches in mouth or throat or soreness in the mouth or throat appear

mucolytic action

expectorant- drug that decreases the thickness of respiratory secretion and aids in their remove

-increase amount of fluid in respiratory tract to help break down and dissolve mucous

-enhance action of respiratory cilia

antitussive action and side effect

drug that suppresses cough by depressing the cough centers in the CNS

-S/E: GI upset, dizziness, headache, rash, postural hypertension, nausea

-teach pt to drink plenty of fluid and use humidifier

-containing codeine can cause constipation

mucolytics drug and warning

-guaifenesin (mucinex)

-ask pt with any side effects how much and how often they are taking it because when taken as recommended, side effects are rare

-ask pt about back pain and difficulty passing urine d/t formation of kidney stones

-notify HCP if symptoms have not improved or worsened

antitussives - benzonatate

-avoid driving d/t sedation and dizziness

-swallow capsules whole, do not chew

-avoid drinking water after swallowing syrup

-notify HCP if symptoms have not improved or worsened

antitussives- dextromethophan (warnings)

-avoid driving d/t sedation and dizziness

-warn parents to not give their child a higher dose or more than prescribed d/t CNS responses, respiratory depression and seizures

-avoid drinking water after if using syrup

antitussives- codeine-containing

-warn parents that taking additional opioid drugs can result in additional drowsiness

-check respiratory rate frequently because respiratory depression is possible

-watch for nausea and vomiting- common side effect

-avoid driving

-physical addiction is rate but possible

-increase fluid because codeine can cause constipation

most common OTC categories

-laxatives

-antacids and H2 receptor antagonists

-analgesics

-cough and cold products

-vaginal antifungals

-smoking cessation products

-topical steroids

cannabis

-interacts with the endocannabinoid system and have an array of effects on the human

-THC- psychoactive compound that produce euphoria

-CBD- not as psychoactive; still affects receptor sites in the brain

-schedule I drug

cannabis side effects and drug interactions

-S/E: dry mouth, sedation, cough, anxiety, altered sense of time

-drug interactions: clozapine, duloxetine, olanzapine, haloperidol (cause decreased serum concentration); macrolide antibiotics, calcium channel blockers, antihistamines (cause increased serum concentrations)

-can increase warfarin in the blood

-added CNS depression when used with alcohol, barbiturates, or benzodiazepines

*serious adverse affects are rare

vitamins

chemical compounds that are found naturally in plant and animal tissues

-fat soluble (stored in body) and water soluble (readily excreted in the urine)

vitamin A

important for vision, gene expression, reproduction, embryo growth and development, healthy immune function

-used to treat disorders associated with fat malabsorption (celiac disease)

-foods: dairy products, fish, liver, spinach, broccoli

*can cause birth defects- excessive use during pregnancy can cause CNS defects

-overdose s/s: anorexia, abdominal pain, malaise, yellowing on nose and ears

vitamin B1 (thiamine)

a coenzyme needed for carbohydrate metabolism and energy production; assists in nervous system function

-alcoholism, gastric lesions, and hyperemesis of pregnancy can lead to deficiency

-s/s of deficiency: anorexia, vomiting, fatigue, aching muscles, ataxia fo fait, emotional disturbances, excessive alcohol use

-reactions: mild itching, sweating, nausea

-anaphylactic shock can occur when given IV

vitamin B2 (riboflavin)

important in metabolism of proteins, fats, and carbs; growth and development

-s/s of deficiency: cracks in the corners of the mouth, soreness and burning of the tongue and lips, and sore throat

-risk of deficiency for women taking oral contraceptives for 3 years or longer

-common food sources: dairy products, eggs, green leafy vegetables, organ meats, peanuts

-supplements can turn urine deeper yellow color

vitamin B3 (niacin)

-important in generating cellular energy

-s/s of deficiency: glossitis, stomatitis, diarrhea, dermatitis or lesions of body parts exposed to sun, fire or heat, mental changes that can progress to disorientation, loss of memory, confusion, hysteria, and manic outbursts

-side effects of supplements: skin warmth, flushing, itching - can be relieved by taking ASA

-food sources: peanuts, yeast, cereals, eggs, liver, red meats, whole grains, enriched bread

vitamin B6 (pyridoxine)

functions as a coenzyme in metabolism of protein, carbs and fats; immune and nervous system function

-risk for deficiency: older adult, women who are pregnant or breastfeeding, women taking oral contraceptives, alcoholics, diets poor in protein or high in refined foods

-s/s of deficiency: malaise, nervousness, irritability, difficulty walking, personality changes

*never give pyridoxine with levodopa (parkinsons disease med)

vitamin B9 (folic acid)

required for normal erythropoiesis and DNA synthesis- metabolized in liver

-used in alcoholism, infants receiving artificial formulas, lactation, oral contraceptive use, pregnancy

-women of childbearing age should have increased intake

-dietary measures are preferable to drug therapy

vitamin B12 (cyanocobalamin)

protein, fat and carb metabolism, RBC maturation, needed to make dna in new cells

-only found in animal products

-intrinsic factor must be present to absorb

-deficiency makes folate useless in the body

-s/s of deficiency: constipation, upset stomach, palpitations, shortness of breath, pale skin, numbness, muscle weakness

-food sources: organ meats, fish, seafood, eggs, nonfat dry milk, fortified nondairy milks, fermented cheeses

vitamin C (ascorbic acid)

necessary for formation of collagen in connective tissue, cartilage, skin, bone matrix; helps integrity of blood vessels and may promote resistance to infection

-may affect anticoagulants

-smoking increases need

-intermittent use of ethinyl estradiol can increase contraceptive failure

-food sources: oranges, grapefruit, strawberries, cauliflower, cantaloupe, beef liver, asparagus, green leafy vegetables

vitamin D

-D2: artificially manufactured by UV irradiation of ergot and yeasts

-D3: occurs naturally in fish oils; can be formed in animals and humans by UV irradiation of the skin

-main action: movement of calcium and phosphorus ions into the small intestine, kidneys and bone

-s/s of toxicity: anorexia, weight loss, vague aches and stiffness, constipation, diarrhea, convulsions, anemia, mold acidosis, impairment of kidney function

-foods: milk, infant formula, breast milk, oily fish, cod liver oil

vitamin E

antioxidant with neuroprotective and anti-inflammatory properties

-least toxic of fat solubles

-food sources: vegetable oils, nuts, wheat germ, rice germ, green leafy vegetables

-can increase clotting time in pt taking anticoagulants

-reduce HDL levels

vitamin K

helps liver formation of factors II, VII, IX, X- essential for blood clotting

-routine vitamin K1 injection at birth

-can reverse effects of warfarin overdose

-mineral oil and cholestyramine can inhibit GI absorption

-not IV admin due to risk for anaphylaxis

-food sources: liver and green leafy vegetables

calcium

essential for muscular and neurologic activity (especially cardiac)

-calcium requirements increased during adolescence, pregnant, post menopause

-hypocalcemia: muscle spasms, numbness of lips and fingers, weak brittle nails, fractures

-hypercalcemia: polyuria, constipation, abdominal pain, mouth dryness, anorexia, nausea, vomiting

-vitamin D is essential for absorption

iron

essential for production of myoglobin and hemoglobin

-supplements cause constipation and cramping

-s/s of overdose: lethargy, nausea, vomiting, abdominal pain, diarrhea, melena (blood in stool), dyspnea

-more absorbed on empty stomach

-liquid can discolor teeth- use straw

-food sources: fish, red meat, spinach, dried fruits

magnesium

important in maintaining osmotic pressure, ion balance, bone structure, muscular contraction, nerve conduction, cardiac function

-slight deficiency can prolong QT interval and cause torsades de pointes (ventricular tachycardia)

-stores are depleted with chronic alcohol use

-deficiency s/s: convulsions, slowed growth, digestive disturbances, spasticity of muscles and nerves, nervous conditions, vasodilation

-food sources: meat, milk, fruits, vegetables, spinach, chard, pumpkin seeds

potassium

maintains normal kidney function, contraction of muscle, transmission of nerve impulses

-s/s of hyperkalemia: flaccid paralysis, paresthesias of hands and feet, mental confusion, restlessness, malaise, heaviness of legs, hypotension, cardiac dysrhythmias

-dose is titrated slowly

-food sources: bananas, tomatoes, citrus fruits, dried fruits, cantaloupe, watermelon, nuts, dried beans, beef

zinc

essential for normal growth and repair- wound healing

-moves vitamin A from liver stores

-s/s of intoxication: drowsiness, lethargy, staggering gait, light-headedness, vomiting

-calcium competes with zinc for absorption

-food sources: seafood, meats, cereals, legumes

adult vs childrens ear

-adults: ear canal tilts downward, slightly s-shaped

-children: ear canal is shorter and straighter

excessive buildup of cerumen

can block sound waves and cause pain

drugs to manage ear problems

-middle ear: antimicrobial and anti-inflammatory drugs given orally

-pinna: topical application

-otic drugs: drugs that are prepared for delivery into the external ear canal

-cerumenolytics: soften ear wax (not for use if ear has drainage or discharge)

techniques to instilling drugs into the ear canal

-children: pull down and back

-adult: up and back

cerumenolytics

carbamide peroxide (debrox, murine ear wax removal)

-do not use longer than 4 days

-do not use on a patient who is dizzy- can increase dizziness

prostaglandin agonists

help control glaucoma by binding to prostaglandin receptor sites in the eye and relaxing smooth muscles in blood vessels- allows vessels to dilate and absorb aqueous humor

-used once a day; fewer systemic side effects

-bimatoprost, latanoprost, travoprost

prostaglandin agonists side effects and adverse reactions

-S/E: eye itching and redness at first, foreign body sensation, thickening and lengthening of eyelashes, darkening of skin on eye lids

-increase melanin→ may change eye color

-adverse: systemic effects including infection, asthma and corneal erosion

-never use if eye has been scratched or has an infection

-lifetime drug therapy

beta-adrenergic antagonists

reduce the amount of aqueous humor by binding to receptors in ciliary body of eye

-betaxolol hydrochlorine (betoptic 0.5%), cartelol (1%), levobunolol (0.25%), metipranolol (0.3%), timolol (0.25% or 0.5%)