Exam #3 212A

LAST ONE!

Pain Management

Adjuvant drugs of pain management

Adjuvant analgesics are medications from other drug classes that assist primary pain medications (like opioids) in relieving pain.

Purpose & Benefits

✅ Allows smaller opioid doses - reduces adverse effects like:

• Respiratory depression

• Constipation

• Urinary retention

✅ Synergistic effects - drugs with different mechanisms work together more effectively

✅ Multimodal approach - proven very effective for pain management

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Common Adjuvant Drug ClassesFor General Pain Management:

• NSAIDs

• Antidepressants

• Antiepileptic drugs (anticonvulsants)

• Corticosteroids

Supportive Medications:

• Antiemetics - prevent/relieve nausea and vomiting

• Laxatives - prevent/relieve constipation

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Neuropathic Pain Treatment

Opioids are NOT completely effective for neuropathic pain, making adjuvants essential.

What is Neuropathic Pain?

Pain from nerve damage caused by:

• Disease (diabetic neuropathy, postherpetic neuralgia from shingles, AIDS)

• Injury (including surgical nerve damage)

Symptoms Include:

• Allodynia - hypersensitivity to normally mild stimuli (light touch, bed sheets on feet)

• Hyperalgesia - excessive pain from uncomfortable stimuli (BP cuff pressure)

• Sensations described as: heat, cold, numbness, tingling, burning, or electrical

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Common Adjuvants for Neuropathic PainAntidepressants:

• Amitriptyline (TCA - most commonly used)

• Duloxetine (SNRI)

• Desipramine, nortriptyline

Mechanism: Block reuptake of norepinephrine and serotonin on descending pain pathway

Anticonvulsants (Gabapentinoids):

• Gabapentin

• Pregabalin (controlled substance - can cause euphoria)

Mechanism: Block sodium and calcium channels in CNS, diminishing pain transmission

Side Effects:

• Sedation and dizziness (often diminish with continued use)

• Weight gain (pregabalin)

• ⚠ FDA Warning: Breathing problems when combined with CNS depressants

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WHO Three-Step Analgesic Ladder

Step 1: Nonopioids ± adjuvants
Step 2: Opioids ± nonopioids ± adjuvants
Step 3: Opioids for moderate-severe pain ± nonopioids ± adjuvants

-Assist primary drugs in relieving pain

• NSAIDs

• Antidepressants

• Anticonvulsants

• Corticosteroids

-Example: Adjuvant drug for neuropathic pain

• Amitriptyline (Antidepressant)

• Gabapentin or pregabalin (anticonvulsant)

• Local anesthesia

Antidepressants:

• Tricyclic antidepressants (e.g., nortriptyline)

• Amitriptyline

• Particularly effective for chronic and neuropathic pain

Anticonvulsants/Antiepileptic Drugs:

• Examples: gabapentin or pregabalin (both anticonvulsants)

• Successfully treat chronic pain, especially neuropathic pain

Corticosteroids:

• Relieve pain from inflammation and bone metastasis

NSAIDs:

• Used as part of multimodal pain management

Local Anesthetics:

• Infusional lidocaine for neuropathic pain

Bone Pain Medications:

• Bisphosphonates

• Calcitonin

NSAID patient teaching

NSAID stands for Nonsteroidal Antiinflammatory Drug - a large and chemically diverse group of medications.

Three Main Properties

NSAIDs provide:

1. Analgesic (pain relief)

2. Antiinflammatory (reduces inflammation)

3. Antipyretic (reduces fever)

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Common Uses

✅ Mild to moderate pain (headaches, muscle pain, nerve pain, joint pain)
✅ Postoperative pain
✅ Arthritis (rheumatoid arthritis, osteoarthritis, ankylosing spondylitis)
✅ Gout
✅ Fever reduction
✅ Aspirin specifically: prevents blood clots, reduces risk of heart attack and stroke

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Common Examples

• Aspirin (acetylsalicylic acid) - the first NSAID, marketed in 1899

• Ibuprofen (Advil, Motrin)

• Naproxen (Aleve)

• Celecoxib (Celebrex) - COX-2 inhibitor

• Many others

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Key Points

📌 Many NSAIDs are available over-the-counter (OTC)

📌 NSAIDs have a ceiling effect - increasing the dose beyond a certain point doesn't increase pain relief but does increase side effects

📌 Often combined with opioids for better pain control with less opioid needed

📌 Generally have a more favorable side effect profile than corticosteroid antiinflammatory drugs (like prednisone)

📌 All NSAIDs can cause stomach ulcers and GI bleeding because they affect COX-1

Serious Risks to Discuss

⚠ Cardiovascular Risks:

• Increased risk of heart attack or stroke - can occur as early as the first weeks of use

• Risk increases with longer use and higher doses

• All NSAIDs carry this risk (FDA black box warning)

⚠ Gastrointestinal Risks:

• Most common serious adverse effect

• Symptoms range from mild heartburn to life-threatening GI bleeding

• Over 100,000 hospitalizations and 16,500 deaths annually related to NSAID use

• Most NSAID-related fatalities are from GI bleeding

⚠ Kidney Problems:

• Acute renal failure is common, especially if dehydrated

• Stay well-hydrated while taking NSAIDs

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What to Report Immediately

🚨 Contact your healthcare provider if you experience:

• Black, tarry stools or blood in stool

• Vomiting blood or "coffee ground" material

• Severe stomach pain

• Chest pain, shortness of breath

• Weakness on one side of body, slurred speech

• Decreased urination or swelling

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Safe Use Guidelines

✅ Take with food or milk to reduce stomach upset

✅ Use the lowest effective dose for the shortest time needed

✅ Drink plenty of water to protect kidneys

✅ Don't combine NSAIDs - avoid taking multiple NSAIDs together (including OTC products like ibuprofen, naproxen, aspirin)

✅ Tell all healthcare providers you're taking NSAIDs, especially before surgery

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Important Reminders

📌 NSAIDs are widely used and available without prescription, but they are not risk-free

📌 Read labels carefully - many OTC products contain NSAIDs

📌 Older adults and those with heart disease, GI problems, or kidney disease are at higher risk

📌 Follow your healthcare provider's instructions exactly

Tylenol vs. NSAIDs

Key Differences

Feature	Acetaminophen (Tylenol)	NSAIDs
Pain relief	✅ Yes	✅ Yes
Fever reduction	✅ Yes	✅ Yes
Anti-inflammatory	❌ No	✅ Yes
Mechanism	Works in CNS (central nervous system)	Blocks COX enzyme and prostaglandins in peripheral nervous system

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Safety ProfileAcetaminophen:

✅ Does NOT increase bleeding time
✅ Low incidence of GI side effects
✅ Analgesic of choice for many people, especially older adults
⚠ Main concern: Liver toxicity - always assess hepatic risk factors before use

NSAIDs:

⚠ More adverse effects than acetaminophen
⚠ GI toxicity and ulceration - most common serious effect
⚠ Cardiovascular risks - all NSAIDs carry risk for heart attack/stroke
⚠ Kidney problems - especially if dehydrated
⚠ Increased bleeding time

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When to Use EachBest for Acetaminophen:

• Mild to moderate pain without inflammation

• Patients at risk for GI bleeding

• Patients on blood thinners

• Older adults

• Patients with kidney concerns

Best for NSAIDs:

• Pain with inflammation (arthritis, injury, surgery)

• Conditions where anti-inflammatory effect is needed

• Can be more effective for certain types of pain

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Can They Be Combined?

✅ YES! Acetaminophen and an NSAID can be given together
✅ No need to stagger doses
✅ Often used together as foundation of postoperative pain management
✅ Provides better pain control than either alone

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Clinical Use

Both are appropriate alone for mild to moderate nociceptive pain, or added to opioids as part of multimodal pain management for more severe pain.

Important: Both have limited benefit for neuropathic pain - adjuvants like gabapentin or antidepressants are more effective for nerve pain.

NSAIDs complications

Gastrointestinal Complications

🔴 Most common and potentially serious adverse effect

• Symptoms range from mild heartburn to life-threatening GI bleeding

• Most NSAID-related deaths are from GI bleeding

• Over 100,000 hospitalizations and 16,500 deaths annually

• All NSAIDs can cause ulcers and bleeding due to COX-1 inhibition affecting stomach lining protection

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Cardiovascular Complications

🔴 FDA Black Box Warning (strengthened in 2015)

• Increased risk of heart attack or stroke

• Risk can occur as early as the first weeks of use

• Risk increases with longer use and higher doses

• Patients with previous heart attack are more likely to die in the first year if treated with NSAIDs

• Increased risk of heart failure

• Even patients without heart disease are at increased risk

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Kidney Complications

🔴 Acute renal failure is quite common with NSAID use

• Especially dangerous if patient is dehydrated

• Adequate hydration is essential

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Overdose Toxicity

CNS Effects:

• Drowsiness, lethargy, mental confusion

• Paresthesias (abnormal sensations), numbness

• Aggressive behavior, disorientation

• Seizures

• Intense headache, dizziness, cerebral edema

GI Effects:

• Nausea, vomiting

• GI bleeding

Severe Cases:

• Cardiac arrest

• Death

Treatment: Activated charcoal with supportive care
⚠ Hemodialysis is NOT effective due to high protein binding

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Who Should Avoid NSAIDs?

❌ Known drug allergy
❌ Aspirin allergy (must not receive any NSAIDs)
❌ Bleeding risk conditions (vitamin K deficiency, peptic ulcer disease)
❌ Third trimester pregnancy (category D - associated with maternal bleeding, decreased amniotic fluid, neonatal toxicity)
❌ Nursing mothers (excreted in breast milk)
❌ Stop 1 week before elective surgery due to bleeding risk

Fluid and Electrolytes

Dehydration diagnosis and cues

Assessment Cues

Cardiovascular Signs

• Increased heart rate - compensates for decreased blood volume

• Weak, thready peripheral pulses - difficult to find and easily blocked

• Decreased blood pressure with greater drop in systolic BP

• Orthostatic hypotension - BP drops when moving from lying → sitting → standing

• Flat neck and hand veins - even when lying down (normally distended in supine position)

• Increased risk for falls due to dizziness from decreased brain perfusion

Skin and Mucous Membranes

• Poor skin turgor - skin "tent" remains for minutes after pinching

• Dry, scaly skin

• Dry oral mucous membranes with thick, sticky coating

• Cracks and fissures in mouth

• Deep furrows on tongue

Kidney/Urinary Changes

• Urine output <500 mL/day (concerning in patients without kidney disease)

• Concentrated urine - specific gravity >1.030

• Dark amber color with strong odor

Neurologic Changes

• Altered mental status - often the first sign in older adults

• Changes in cognition

• Low-grade fever (fever also causes further dehydration - each 1°C increase = additional 500 mL fluid loss)

Respiratory Changes

• Increased respiratory rate - compensatory mechanism to maintain oxygen delivery with decreased perfusion

-There is no tell tale sign, but the most reliable indications of dehydration are loss of weight and cardiovascular changes

-Dehydration in adults would present as altered mental status

Bacterial, viral, and fungal infections and drug therapy antibiotics

Penicillin drug interactions HELP information I got is NOT FROM TEXTBOOK

• Probenecid: Used for gout, this blocks the excretion of penicillin, leading to higher, sustained, and potentially toxic plasma concentrations.

• Oral Contraceptives: Penicillin may reduce the effectiveness of birth control pills, potentially leading to breakthrough bleeding or unintended pregnancy.

• Blood Thinners (Warfarin):

  Penicillin can increase the effects of anticoagulants, increasing the risk of bleeding.

• Methotrexate: Penicillin reduces the excretion of methotrexate, causing dangerous increases in its concentration.

• Allopurinol: Simultaneous use increases the risk of developing a skin rash.

• Tetracyclines: These can decrease the effectiveness of penicillin.

Other Antibiotics: Combination with chloramphenicol, erythromycin, or sulphonamides should be avoided.

Nursing responsibility when starting antibiotic therapy

Pre-Administration Assessment

Critical Allergy Assessment

🔴 Most important first step

• Assess for hypersensitivity or allergic reactions - symptoms range from mild (rash, pruritus, hives) to severe (laryngeal edema, bronchospasm, hypotension, cardiac arrest)

• Use open-ended questions about previous reactions

• Distinguish true allergy from common adverse effects (nausea, upset stomach)

• Document severe reactions thoroughly

Physical Assessment

• Age and weight - document baseline

• Vital signs - establish baseline values

• Neurologic status - assess sensorium and level of consciousness (potential CNS adverse effects)

• GI assessment - bowel patterns and sounds (potential adverse effects)

• Immune status - patients with compromised immunity (cancer, lupus, AIDS, chronic illness) have diminished ability to resist infection

Laboratory Studies

1. Culture and sensitivity - assess bacterial sensitivity to antibiotic

2. Liver function - AST and ALT levels

3. Renal function - urinalysis, BUN, serum creatinine

4. Cardiac function - ECG, echocardiography as needed

5. Blood counts - WBC, hemoglobin, hematocrit, RBC, platelets, clotting values

Medication Review

✅ Complete list of all medications including OTC drugs, herbals, and dietary supplements ✅ Assess for contraindications, cautions, and drug interactions

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Special Considerations

Superinfection Risk:

• Assess for secondary infection from destruction of normal flora

• Monitor for fungal superinfections: fever, lethargy, perineal itching

Antibiotic Resistance:

• Continual concern, especially in pediatric patients and healthcare facilities

• Assess for symptoms of resistant infections

Cultural Assessment:

• Various racial/ethnic groups respond differently to specific drugs

• Consider alternative healing practices

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Administration Guidelines

Antibiotics in this category are often:

• Reserved for more potent infections

• Administered parenterally - requiring skillful assessment

• Requiring critical monitoring throughout therapy

Want specifics? Ask about:

• Patient education for antibiotic therapy

• Monitoring during treatment

• Evaluation of therapeutic effectiveness

-Usually get cultures and start on broad-spectrum antibiotics if it is emergent, and then when cultures come back, use narrow-spectrum antibiotics

Tetracycline patient teaching

Medication Administration

Timing and Food Interactions

🥛 Avoid milk products, antacids - or separate by 2 hours

• Dairy products decrease GI absorption significantly

• Take with a full glass of water and take on empty stomach

• Take 1 hour before bedtime to prevent esophageal ulceration

Tube Feeding Considerations

• Tetracyclines have decreased antibiotic effects when given with nutritional supplements (chemical inactivation)

• Must be given at least 2 hours before or after tube feedings

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Important Safety Information

Sun Exposure

☀ Avoid sun exposure - sunscreen does NOT seem to decrease photosensitivity

• Risk of severe photosensitivity reactions

☀Wear protective clothing

Medication Completion

✅ Take all prescribed medication to prevent superinfection

• Do not stop early even if feeling better

Pregnancy and Breastfeeding

⚠ Do not use in pregnancy - toxic to fetus
⚠ Do not breastfeed - excreted in breast milk

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Pediatric Considerations

🦷 Tooth discoloration may occur, especially in children
🚫 Not for use in children <8 years old

• May cause bone formation abnormalities

• Affects developing teeth and bones

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When to Notify Prescriber

Call immediately if:

• Diarrhea with pus, mucus, fever, or abdominal pain (possible C. difficile infection)

• Rash, itching, or signs of allergic reaction

• Pregnancy is planned or suspected

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Special Warnings

⚠ Never use outdated tetracycline products

• Can cause Fanconi's syndrome (nephrotoxicity)

• Check expiration dates carefully

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Monitoring During Therapy

Watch for signs of:

• Superinfection: fever, malaise, perineal itching, changes in cough/sputum

• GI symptoms: nausea, vomiting, diarrhea

• Anemia: fatigue, weakness

Cephalosporin contraindications

Primary Contraindication

🚫 Hypersensitivity to cephalosporins

• Absolute contraindication

• Assess thoroughly before administration

Cross-Sensitivity Concerns

⚠ Penicillin allergy - major consideration

• Patients sensitive to penicillin, cephalosporins, or carbapenems may have sensitivity to cephalosporins

• If allergic to systemic antibacterials, patient will also be allergic to topical dosage forms

• Always assess for previous allergic reactions

Critical Assessment Before Administration

Allergy History

• Allergic reactions and anaphylaxis: rash, urticaria, pruritus, wheezing, laryngeal edema

• May occur a few days after therapy begins

• Have EPINEPHrine, antihistamine, and emergency equipment available

Renal Disease

• Monitor creatinine/BUN

• Lower dose may be needed in renal impairment

• Cephalosporins are renally excreted

Pregnancy/Breastfeeding

• Use only if benefit outweighs fetal risk

• Use caution in breastfeeding (excretion unknown for some agents)

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Special Populations

Patients requiring careful evaluation:

• History of penicillin/beta-lactam allergy

• Compromised renal function

• Pregnant or breastfeeding patients

• Patients with history of GI disease (especially colitis)

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Monitoring Requirements

Watch for:

• CDAD (C. difficile-associated diarrhea): bowel pattern daily; discontinue if severe diarrhea occurs

• Infection signs: increased temperature, WBC, wound/sputum/urine characteristics

• Overgrowth of infection: perineal itching, fever, malaise, redness, drainage, rash

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Treatment of Anaphylaxis

If severe allergic reaction occurs:

• EPINEPHrine (first-line)

• Antihistamines

• Resuscitate if needed

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Key Nursing Actions

✅ Assess allergy history with open-ended questions
✅ Distinguish true allergy from adverse effects
✅ Document severe reactions thoroughly
✅ Ensure emergency equipment is available
✅ Monitor renal function throughout therapy

Antiseptic vs. disinfectant

-Antiseptics are bacteriSTATIC

• Inhibits the growth of microogranisms, does not kill

• Only applied exclusively to living tissue

-Disinfectants are bacteriCIDAL

• Can kill organisms

• Used only on nonliving objects to destroy organisms that may be present

• Called “cidal” agents

Healthcare associated infection facts

-Preventable

• 70% of health care-associated infections are preventable

-Most common mode of transmission: Direct contact

• Handwashing is the single most important thing health care professionals can do to prevent the spread of these potentially deadly infections

-Methods of reducing health care-associated infections include using disinfectants or using antiseptics

Definition

An infection acquired during treatment in a healthcare facility that was not present or incubating at admission and occurs more than 48 hours after admission.

Prevalence & Impact

• 1 in 25 hospitalized patients develops an HAI on any given day

• One of the top 10 leading causes of death in the United States

• Increase healthcare costs and prolong hospital stays

• Over 70% are preventable

Most Common Types

1. Urinary tract infections (UTIs) - most common HAI

2. Surgical site infections (SSIs)

3. Bloodstream infections

4. Pneumonia (including hospital-acquired pneumonia and ventilator-associated pneumonia)

Common Causative Organisms

• MRSA (methicillin-resistant Staphylococcus aureus) - now one of the most common

• Enterococcus

• Klebsiella

• Acinetobacter

• Pseudomonas aeruginosa

These organisms are typically multidrug-resistant and highly virulent due to exposure to strong antibiotics.

Sources of Infection

Endogenous - from patient's own flora
Exogenous - from outside sources:

• Hands of healthcare workers

• Medical devices (ventilators, IV lines, catheters, dialysis equipment)

• Tubes and implants

High-Risk Areas

• Critical care units

• Dialysis units

• Oncology units

• Transplant units

• Burn units

Patients in these areas have compromised host defenses, making them more vulnerable.

Primary Prevention Method

🧼 Handwashing - the single most important action healthcare professionals can take to prevent HAI transmission

Most common transmission mode: Direct contact

Why HAIs Occur

Tend to occur most often because healthcare workers do not follow basic infection control principles

Monitoring

Closely monitored by:

• Healthcare facilities

• The Joint Commission's National Patient Safety Goals (NPSGs)

• National Healthcare Safety Network (NHSN) of the CDC

Aminoglycoside adverse effects

Mnemonic"MEAN TOX"

M - Muscle weakness (neuromuscular paralysis - rare but reversible)

E - Ear damage (ototoxicity - 3-14% of patients)

• Cochlear damage → hearing loss

• Vestibular damage → balance problems

• Often NOT reversible

A - Auditory nerve injury (CN VIII damage)

• Tinnitus

• Sense of fullness in ears

• Dizziness

N - Nephrotoxicity (5-25% of patients)

• Urinary casts

• Proteinuria

• Increased BUN and serum creatinine

• Usually reversible

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T - Tinnitus (ringing in ears)

O - Overgrowth of nonsusceptible organisms (superinfection)

X - eXtra effects:

• Headache

• Paresthesia

• Vertigo

• Skin rash

• Fever

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Key Points to Remember

🔴 Most serious toxicities: Nephrotoxicity and ototoxicity

Nephrotoxicity:

• More common (5-25%)

• Usually reversible

• Monitor: BUN, creatinine, urinalysis

Ototoxicity:

• Less common (3-14%)

• Often NOT reversible → permanent hearing loss

• Results from CN VIII injury

• Symptoms: dizziness, tinnitus, fullness in ears, hearing loss, balance problems

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High-Risk Populations

⚠ Neonates - immature nervous and renal systems
⚠ Older adults - decreased neurologic and renal function
⚠ Patients with myasthenia gravis or Parkinson's - worsening muscle weakness

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Nursing Implications

✅ Keep therapy as short as possible
✅ Therapeutic drug monitoring essential
✅ Report immediately: hearing changes, tinnitus, ear fullness, dizziness, nausea with motion
✅ Monitor renal function throughout therapy

Neomycin patient teaching

Route-Specific Information

Oral Administration

• Used for bowel preparation before surgery or to reduce ammonia-producing bacteria in hepatic encephalopathy

• Poorly absorbed from GI tract (intentional for these uses)

Topical Administration

• Used for skin infections

• Apply thin layer to affected area

• Wash hands before and after application

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Key Safety Points

⚠ Serious Adverse Effects to Report Immediately

Ototoxicity (Ear Damage):

• Ringing in ears (tinnitus)

• Sense of fullness in ears

• Dizziness or balance problems

• Hearing loss

• Often NOT reversible - report early signs immediately

Nephrotoxicity (Kidney Damage):

• Decreased urination

• Swelling in feet/ankles

• Unusual fatigue

Neuromuscular Effects:

• Muscle weakness

• Difficulty breathing

• Numbness or tingling

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Medication Completion

✅ Take all prescribed medication even if feeling better

• Prevents antibiotic resistance

• Prevents superinfection

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Signs of Superinfection

Report these symptoms:

• Fever, malaise

• Perineal itching

• Changes in cough or sputum

• Severe diarrhea (may indicate C. difficile infection)

• White patches in mouth (oral thrush)

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Hydration

💧 Maintain adequate fluid intake (2 L/day unless contraindicated)

• Helps prevent nephrotoxicity

• Supports kidney function during therapy

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Allergic Reactions

🚨 Seek immediate help if you experience:

• Rash, hives, itching

• Wheezing or difficulty breathing

• Swelling of face, lips, tongue, or throat

• Tightness in chest

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Special Considerations

Pregnancy/Breastfeeding:

• Notify prescriber if pregnant, planning pregnancy, or breastfeeding

• Use only if benefit outweighs risk

Other Medications:

• Inform prescriber of ALL medications (prescription, OTC, supplements)

• Aminoglycosides have many drug interactions

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Follow-Up Care

• Keep all appointments for lab work (kidney function, drug levels)

• Hearing tests may be ordered during therapy

• Report any new or worsening symptoms promptly

Treatment of MRSA

Primary Antibiotics

IV vancomycin - antibiotic of choice

• Bactericidal glycopeptide

• Destroys bacteria by binding to cell wall

• Monitor for nephrotoxicity and ototoxicity

• Requires therapeutic drug monitoring

Oral linezolid (IV or oral)

• Allows patients to remain at home or assisted-living facilities

• Avoids skilled nursing facility admission

• Useful for older adults

IV daptomycin

• Alternative option for MRSA infections

IV ceftaroline

• First cephalosporin approved to treat MRSA

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Community-Associated MRSA (CA-MRSA)

Minocycline or doxycycline - usually effective

• Used for skin and soft tissue infections

• Treats abscesses, boils, and blisters

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Infection Prevention & ControlContact Precautions

All patients with HA-MRSA infection or colonization require Contact Precautions

Surveillance Programs

• Nasal swab cultures for patients and staff

• Identifies colonization early

Nursing Interventions to Decrease Transmission

• Chlorhexidine wipes for bathing

• Nasal mupirocin ointment administration

• Strict hand hygiene (most important!)

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Transmission Prevention

🚫 MRSA spreads by direct contact

Common entry points in hospitalized patients:

• Indwelling urinary catheters

• Vascular access devices

• Open wounds

• Endotracheal tubes

High-risk population: Older adults

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Treatment Duration

For chronic osteomyelitis with MRSA:

• Prolonged therapy >3 months typically needed

• Long-term vascular access (PICC line)

• May transition to oral therapy after IV completion

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Resistance Concerns

⚠ Vancomycin resistance has been rarely reported with MRSA (more common with Enterococcus)

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Key Points

✅ Susceptible to only a few antibiotics
✅ Treatment depends on location (healthcare vs. community)
✅ Prevention through Contact Precautions and hygiene is critical
✅ Increased hospital stays and costs with HA-MRSA

Vancomycin infusion precautions

Infusion Rate - CRITICAL

Red Man Syndrome Prevention

⚠ Infuse over AT LEAST 1 hour (minimum)

• Too rapid infusion → Red man syndrome

• Characterized by flushing/itching of head, face, neck, and upper trunk

• Bothersome but usually NOT harmful

• Reversible by slowing infusion rate

Hypotension Risk

• Rapid infusions may cause severe hypotension

• Possible cardiac arrest with IV push

• NEVER give by IV push

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Before Administration

✅ Assess skin color - important for detecting red man syndrome
✅ Baseline vital signs - especially blood pressure
✅ Check renal function - use with caution in renal dysfunction
✅ Assess hearing - use with caution in preexisting hearing loss
✅ Review drug/fluid compatibility - multiple incompatibilities exist

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Therapeutic Drug Monitoring

Trough Levels:

• Obtain before 4th dose of new regimen

• Draw within 30 minutes before next scheduled dose

• Target: 10-20 mcg/mL

• Peak levels are no longer used

Toxic levels (>50 mcg/mL):

• Ototoxicity (hearing loss) - often NOT reversible

• Nephrotoxicity (kidney damage) - usually reversible

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During Infusion

✅ Monitor vital signs and blood pressure
✅ Watch for signs of red man syndrome
✅ Ensure adequate hydration (≥2 L/day unless contraindicated)
✅ Dilute doses per manufacturer guidelines
✅ Protect from drug/diluent incompatibilities

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High-Risk Populations

⚠ Older adults
⚠ Neonates
⚠ Patients with preexisting renal dysfunction
⚠ Patients with hearing loss
⚠ Patients receiving other nephrotoxic drugs (aminoglycosides, cyclosporine, contrast media)

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Key Takeaway

Slow infusion = Safe infusion

The most preventable adverse effect is red man syndrome, which occurs with rapid administration. Always infuse over at least 1 hour and monitor blood pressure closely.

-Adverse effects: Ototoxicity, nephrotoxicity; can also be additive neuromuscular blocking effects in patients receiving neuromuscular blockers, Steven-Johnson syndrome, and red man syndrome

Antiviral

Acyclovir indications/patient teaching

• Treatments for HSV-1

  • Acyclovir (Zovirax): Used mainly to suppress the replication of HSV-1, HSV-2, and VZV.

  • Adverse effects: Nausea, diarrhea, headache, burning when topically applied

  • Available both topical, oral, and injectable

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Key Patient Teaching PointsContraindications & Precautions

✅ Only contraindication: Known severe drug allergy to acyclovir

Dosing & Administration

• Oral acyclovir: Typically dosed 5 times daily

• Take exactly as prescribed, even if symptoms improve

• Complete the full course of therapy

• Can be taken with or without food

Comparison to Similar Drugs

If prescribed valacyclovir or famciclovir instead:

• These are oral-only formulations for less serious infections

• Valacyclovir is dosed 3 times daily (more convenient than acyclovir's 5 times daily)

• Valacyclovir may provide more effective pain relief from zoster lesions

• Valacyclovir is a prodrug that converts to acyclovir in the body with better oral bioavailability

General Antiviral Teaching

• Well tolerated: Most antivirals for non-HIV infections have minimal side effects

• Safe for pregnant women

• Report any signs of allergic reaction immediately

• Stay hydrated (especially with IV formulations)

• Maintain good hygiene to prevent transmission

Infection-Specific Guidance

• For shingles/zoster: Early treatment is most effective; seek care at first sign of rash

• For herpes infections: Avoid contact with lesions; practice safe sex; inform partners

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Important Note

Acyclovir is surprisingly well tolerated compared to many antivirals. Severe drug allergy is the primary concern for contraindication.

Oseltamivir indications/patient teaching

Indications

Oseltamivir (Tamiflu) treats influenza A and B viruses:

• Treatment of active flu infection

• Prophylaxis (prevention) during flu season or after exposure

• Most effective when started within 48 hours of symptom onset

Available as: Oral capsules or suspension

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Key Patient Teaching Points

Timing is Critical

⏰ Start within 48 hours of flu symptoms for maximum effectiveness

• Early treatment reduces symptom duration and severity

• May still provide some benefit if started later, but less effective

Dosing & Administration

• Take exactly as prescribed for the full course (typically 5 days for treatment)

• Can be taken with or without food

• Taking with food may reduce nausea (a common side effect)

• Complete the entire course even if feeling better

What to Expect

✅ Benefits:

• May shorten flu duration by 1-2 days

• Reduces severity of symptoms

• Decreases risk of complications

⚠ Common side effects:

• Nausea and vomiting (most common)

• Headache

• Taking with food helps minimize GI upset

Important Reminders

• Not a substitute for flu vaccine - annual vaccination is still recommended

• Does not treat the common cold or other viral infections

• Report severe or worsening symptoms

• Stay hydrated and get adequate rest

• Practice infection control: hand hygiene, cover coughs, avoid close contact with others

When to Seek Care

Contact your healthcare provider if you experience:

• Difficulty breathing or shortness of breath

• Persistent high fever

• Confusion or altered mental status

• Severe or persistent vomiting

• Symptoms that improve then suddenly worsen

Prophylaxis Use

If prescribed for prevention:

• Take daily as directed during exposure period

• Continue for recommended duration (typically 10 days post-exposure or throughout flu season)

• Still practice good hygiene and infection prevention

Antifungal

Oral thrush treatment

What is Oral Thrush?

Oral candidiasis (thrush) is a fungal infection caused by Candida albicans, appearing as white patches in the mouth. It commonly affects immunocompromised patients, infants, and those on antibiotics or immunosuppressants.

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Drug Therapy

Systemic Antifungal

Fluconazole is the primary treatment:

• Available as oral or IV formulation

• IV form used if oral poorly tolerated

• IV administration notes:

  • Only use if solution is clear

  • Protect from light

  • Diluted solutions stable for only 24 hours

  • Stop infusion immediately if itching or rash occurs; take vital signs and contact prescriber

Topical Antifungal

Nystatin (Mycostatin) (oral suspension or lozenges):

• Lozenges/troches: Must be slowly and completely dissolved in mouth for optimal effect

  • Do NOT chew or swallow whole

• Oral suspension: Swish thoroughly in mouth for as long as possible before swallowing

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Supportive Care & Oral HygieneBrushing

• Use a soft toothbrush several times daily

• Gentle but thorough cleaning

Denture Care (if applicable)

• Brush dentures vigorously

• Soak in chlorhexidine gluconate before returning to patient

• Stomatitis related to dentures requires this disinfection step

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Patient Teaching

✅ Medication compliance:

• Complete full course even if symptoms improve

• Follow specific administration instructions for best results

✅ Oral care:

• Maintain meticulous oral hygiene

• Avoid irritating foods (spicy, acidic, hot)

• Stay hydrated

✅ Monitor for:

• Difficulty swallowing (may indicate esophageal candidiasis)

• Worsening symptoms despite treatment

• Signs of systemic infection in immunocompromised patients

✅ Address underlying causes:

• Review current medications with provider

• Manage immunosuppression when possible

• Control diabetes if present

Miconazole schedule

Topical Skin Infections

(Athlete's foot, jock itch, ringworm, other fungal infections)

Application: Apply sparingly to cleansed, dry, infected area twice daily

• Morning

• Evening

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Vaginal Yeast InfectionsOption 1: 3-Day Treatment

• 200 mg suppository inserted intravaginally

• Once daily at bedtime

• For 3 consecutive days

Option 2: 7-Day Treatment

• 100 mg suppository OR 5 g of 2% cream inserted intravaginally

• Once daily at bedtime

• For 7 days

Option 3: Single-Dose Treatment

• 1200 mg suppository inserted intravaginally

• One-time dosing

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Available Formulations

Topical:

• 2% aerosol spray and powder

• 2% powder

• 2% cream

Vaginal:

• 2% vaginal cream

• 100 mg suppository

• 200 mg suppository

• 1200 mg suppository (single dose)

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Patient Teaching

✅ Application tips:

• Cleanse and dry area thoroughly before applying

• Use sparingly - a little goes a long way

• Continue full course even if symptoms improve

✅ Common side effects:

• Vulvovaginal burning and itching

• Pelvic cramps

• Rash, urticaria, stinging

• Contact dermatitis

✅ When to contact provider:

• Symptoms worsen or don't improve after treatment course

• Signs of allergic reaction (hypersensitivity is a contraindication)

✅ Pregnancy: Category C - discuss with provider if pregnant or breastfeeding

Vitamins

Fat and water soluble vitamins

Water-Soluble Vitamins

Types: B-complex group and Vitamin C

Key Characteristics:

• Dissolve in water

• Easily excreted in urine

• Cannot be stored in large amounts in the body

• Daily intake required to prevent deficiencies

• Excess amounts are eliminated rather than stored

Clinical Significance:

• Deficiencies develop more quickly without regular intake

• Lower risk of toxicity due to urinary excretion

• Some B vitamins (B-complex and K) are synthesized by normal GI bacterial flora

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Fat-Soluble Vitamins

Types: Vitamins A, D, E, and K

Key Characteristics:

• Dissolve in fat

• Stored in liver and fatty tissues

• Do NOT need daily intake unless deficient

• Substantial amounts stored for long periods

• Deficiencies occur only after prolonged deprivation or absorption disorders

Clinical Significance:

• Higher risk of toxicity with excessive supplementation (hypervitaminosis)

• Vitamin D can be synthesized by skin with sunlight exposure

• Absorption may be decreased by laxatives and cholestyramine

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Comparison Table

Feature	Water-Soluble (B, C)	Fat-Soluble (A, D, E, K)
Storage	Minimal	Liver & fatty tissue
Daily intake needed?	Yes	No (unless deficient)
Excretion	Urine (easily)	Slower elimination
Toxicity risk	Lower	Higher
Deficiency onset	Rapid	Prolonged deprivation needed

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Nursing Implications

⚠ Assessment priorities:

• Dietary intake patterns and habits

• Laboratory values (vitamin levels, albumin, protein)

• Signs of deficiency or toxicity

• Medication interactions (especially laxatives, cholestyramine)

⚠ Patient teaching:

• Water-soluble: Emphasize consistent daily intake through diet

• Fat-soluble: Caution against megadosing (≥10x recommended amount)

• Both: Assess for contraindications and hypersensitivity

Skin, hair, and nails

Benzoyl peroxide

Mechanism of Action

Benzoyl peroxide combats Propionibacterium acnes (P. acnes), an anaerobic bacterium that causes acne. It works by:

• Slowly liberating active oxygen in the skin

• Creating an oxygen-rich environment unfavorable for P. acnes growth

• Providing antibacterial, antiseptic, drying, and keratolytic actions

Keratolytic = softens scales and loosens the outer horny layer of skin

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Effectiveness & Timeline

✅ Generally shows improvement within 4 to 6 weeks

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Adverse Effects

Dose-related (including overuse):

• Peeling skin

• Red skin (erythema)

• Sensation of warmth

Allergic reaction (STOP treatment):

• Blistering

• Swelling of skin

⚠ Common problem: Teenage patients often overuse benzoyl peroxide (and tretinoin) trying to cure acne quickly, resulting in painful, reddened skin. This usually resolves when medication is used as prescribed.

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Available Formulations

Multiple topical dosage forms:

• Cleansing bar

• Liquid

• Lotion

• Mask

• Cream

• Gel

• Cleanser

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Combination Therapy

Benzoyl peroxide is often used with:

• Topical antibiotics (preferred over systemic due to resistance concerns)

• Retinoids (anticomedogenic, comedolytic, anti-inflammatory)

For severe or unresponsive acne, systemic therapies may include oral contraceptives, antibiotics, spironolactone, or isotretinoin.

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Nursing Considerations

Before application:

• Cleanse affected area of debris, drainage, and residual medication

• Perform hand hygiene

• Wear gloves to prevent absorption through your skin

Patient teaching:

• Use as prescribed - avoid overuse

• Continue treatment even if improvement is slow

• Report blistering or swelling (allergic reaction)

• Be patient - results take 4-6 weeks

• Special consideration for darker skin tones (higher risk for hyperpigmentation)

Psychological support is important - acne negatively affects quality of life, self-esteem, and mood in adolescents.

Inflammatory bowel disease

Diverticulitis S/S to report STAT (Most likely SATA)

F - Fever >101°F (38.3°C)

Persistent or increasing temperature suggests worsening infection or complications

E - Extreme/Escalating abdominal pain

Severe pain lasting >3 days or generalized pain (suggests peritonitis)

V - Vital sign changes

• Tachycardia

• Hypotension

• Orthostatic changes (suggests hypovolemia/shock)

E - Evidence of bleeding

• Bloody stools

• Mahogany-colored stools

• Tarry/black stools

• Massive lower GI bleeding

R - Rebound tenderness (widespread)

Profound guarding and widespread rebound tenderness = generalized peritonitis

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Additional RED FLAGS

⚠ Signs of perforation/peritonitis:

• Generalized abdominal pain

• Profound guarding

• Abdominal distention

• Sepsis signs

⚠ Signs of shock:

• Hypotension

• Hypovolemia

• Decreased hematocrit/hemoglobin (with bleeding)

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When to Seek Emergency Care

Immediate hospitalization needed for:

• Temperature >101°F (38.3°C)

• Severe abdominal pain >3 days

• Lower GI bleeding

• Signs of peritonitis, abscess, or obstruction

Emergency surgery indicated for:

• Peritonitis

• Bowel obstruction

• Pelvic abscess

• Uncontrolled bleeding

Pathophysiology of paralytic ileus

Underlying Mechanism

The exact cause remains unknown, but paralytic ileus results from a multifactorial and complex interaction between the autonomic and central nervous systems that:

• Disorganizes electrical activity in the GI tract

• Causes paralysis of intestinal motility

• Suppresses activity of the entire GI tract (especially with endogenous and exogenous opioids)

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Cascade of Pathophysiologic Changes1. Impaired Absorption & Increased Secretion

• Accumulation of fluid and gas in the intestinal lumen

• Leads to distention proximal to the affected area

2. Worsening Distention

• Decreases the intestine's ability to absorb water and electrolytes

• Increases net secretion into the lumen

• Creates a vicious cycle

3. Fluid Sequestration

• Copious vomiting OR

• Sequestration of fluids in intestinal lumen

• Prevents reabsorption of fluids and electrolytes

4. Severe Fluid & Electrolyte Disturbances

Hypovolemia develops:

• ↓ Extracellular fluid volume

• ↓ Plasma volume

• Dehydration

• ↑ Hematocrit

• Hypotension

• Tachycardia

• → Hypovolemic shock (if severe)

Acid-base imbalances:

• Early: Metabolic alkalosis (excessive loss of hydrogen ions from gastric juice/vomiting)

• Prolonged: Metabolic acidosis (bicarbonate from pancreatic secretions and bile cannot be reabsorbed)

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Key Clinical Point

⚠ Bowel sounds may still be heard even when true paralytic ileus is present

✅ Only reliable indicator of resolution: Passage of flatus or stool

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Risk Factors

• Postoperative (most common)

• Opioid use (endogenous/exogenous)

• Electrolyte imbalances

• Neurologic disorders

Antiemetics

Different drug classes of antiemetics

1. Serotonin Blockers (5-HT₃ Antagonists)

Prototype: Ondansetron (Zofran)

Uses:

• Chemotherapy-induced nausea/vomiting

• Postoperative nausea/vomiting

• Hyperemesis gravidarum

Key points:

• Major breakthrough in antiemetic therapy (approved 1992)

• Available oral, IV, and orally disintegrating tablets

• IV doses up to 8 mg over 2-5 minutes

• Granisetron available as transdermal patch

• Pregnancy category B (concern for cleft palate in first trimester)

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2. Antidopaminergics

Common drugs: Prochlorperazine (Compazine), Promethazine (Phenergan), Amisulpride (Barhemsys)

Properties:

• Antidopaminergic

• Antihistaminic

• Anticholinergic

Note: Droperidol has FDA black box warning for QT prolongation and requires continuous ECG monitoring

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3. Neurokinin Receptor Antagonists (NK₁ Antagonists)

Prototype: Aprepitant (Emend)

Mechanism: Antagonizes substance P–neurokinin 1 receptors (NOT serotonin or dopamine receptors)

Uses:

• Highly emetogenic chemotherapy (including high-dose cisplatin)

• Postoperative nausea/vomiting

Important interactions:

• Augments ondansetron and dexamethasone effects

• Major CYP450 3A4 inhibitor

• Induces warfarin metabolism (monitor INR)

• Reduces oral contraceptive effectiveness

• Increases corticosteroid bioavailability

Fosaprepitant = IV form

Akynzeo = combination drug (palonosetron + netupitant)

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4-7. Additional Classes

The textbook mentions seven major classes total. The three detailed above are the most commonly used. Other antiemetics include:

Adjunct therapies:

• Corticosteroids (dexamethasone)

• Anxiolytics (lorazepam) - blunts memory of nausea/vomiting experience

These are especially beneficial for chemotherapy-induced nausea/vomiting when combined with serotonin blockers.

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Mechanism of Action

Most antiemetics work by blocking receptors in the CNS (chemoreceptor trigger zone and vomiting center), though some act directly in the GI tract.

Antiemetics and chemotherapy

Chemotherapy-Induced Nausea and Vomiting (CINV)

Types of CINV:

• Anticipatory - before receiving chemotherapy (triggered by thoughts, sights, sounds)

• Acute - within first 24 hours (most common type)

• Delayed - after first 24 hours (can last 5-7 days with drugs like cisplatin)

• Breakthrough - occurring intermittently

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Key Antiemetic Drug Classes for CINVFirst-Line: Serotonin Blockers (5-HT₃ Antagonists)

• Ondansetron (Zofran), Granisetron (Kytril)

• Greatly improved CINV control

• Standard for moderately and highly emetogenic regimens

Enhanced Control: NK₁ Receptor Antagonists

• Aprepitant (Emend)

• Added to regimens for moderately and highly emetogenic chemotherapy

• Significantly improves CINV control

Adjunct Therapies

• Dexamethasone (corticosteroid)

• Lorazepam (anxiolytic) - also blunts memory of nausea/vomiting

• Dronabinol

• Most effective when combined with serotonin blockers

Other Options

• Metoclopramide (Reglan)

• Prochlorperazine

• Scopolamine

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Evidence-Based Administration Principles

✅ Timing is critical:

• Give antiemetics BEFORE chemotherapy (30-60 minutes prior)

• Most effective when preventing nausea rather than treating it

• Usually given IV initially, then oral prescriptions for home use

✅ Scheduled dosing:

• Use on a scheduled basis for prevention

• Continue therapy even when CINV appears controlled

• Repeat based on response and duration

✅ Combination therapy:

• More effective than single-drug therapy

• Standardized protocols widely used

✅ Dose-dense chemotherapy:

• Increases CINV intensity

• Requires more aggressive antiemetic therapy

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Nursing Priorities

🎯 Coordinate with healthcare provider to ensure adequate CINV control

📚 Patient teaching:

• Take antiemetic at first sign of nausea to prevent it from becoming uncontrollable

• Continue scheduled doses even if feeling better

• Goals: prevent dehydration, malnutrition, and maintain comfort

PUD, GERD, and Diarrhea

Peptic ulcer disease interaction warning

ASPIRIN Mnemonic for PUD Drug InteractionsA - Aspirin (salicylates)

⚠ CANNOT take aspirin with bismuth subsalicylate - both are salicylic acids and could cause salicylate overdose

S - Step-down PPIs slowly

Do NOT stop PPIs abruptly - causes rebound activation of proton pump; taper over several days

P - Penicillin allergy? Use bismuth

Bismuth-based quadruple therapy preferred for patients allergic to penicillin-based medications (amoxicillin)

I - IV forms available

Esomeprazole and pantoprazole available IV for NPO patients

R - Rabeprazole/pantoprazole: do NOT crush

Enteric-coated tablets dissolve after leaving stomach - crushing destroys protective coating

I - Irritants to avoid

• Alcohol - stimulates gastric acid secretion

• Tobacco - stimulates gastric acid secretion

N - No bedtime snacks

Avoid bedtime snacks - may stimulate gastric acid secretion

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Key PUD Drug Therapy Points

Triple therapy (10-14 days):

• PPI (lansoprazole) + 2 antibiotics (metronidazole + tetracycline OR clarithromycin + amoxicillin)

Quadruple therapy:

• PPI + 2 antibiotics + bismuth (for penicillin allergy)

Bismuth teaching:

• ✅ Temporary black discoloration of stools/tongue (harmless)

• ❌ NO aspirin (salicylate overdose risk)

PPI administration tips:

• Some can be dissolved in sodium bicarbonate for feeding tubes

• Enteric-coated capsules can go in apple/orange juice through large-bore tubes

• Oral suspensions available for tube feeding

Long-term PPI risks:

• Increased osteoporotic fracture risk

• Assess periodically for continued necessity

GERD treatment (most likely SATA)

LIFESTYLE Mnemonic for GERD Treatment

L - Limit trigger foods

❌ Decrease LES pressure: peppermint, chocolate, fatty/fried foods, caffeine, carbonated beverages
❌ Irritate tissue: spicy foods, acidic foods (orange juice, tomatoes)

I - Increase meal frequency

✅ Eat 4-6 small meals daily instead of 3 large ones
✅ Large meals increase gastric volume/pressure and delay emptying

F - Food apps for tracking

📱 MyFitnessPal or MyPlate to follow healthier diet patterns

E - Eat slowly & chew thoroughly

Facilitates digestion and prevents eructation (belching)

S - Stop medications causing reflux

Discuss with provider eliminating drugs that lower LES pressure:

• Oral contraceptives

• Anticholinergics

• Sedatives

• NSAIDs (ibuprofen)

• Nitrates

• Calcium channel blockers

T - Three drug classes

1. Antacids

2. H2-receptor antagonists (histamine blockers)

3. Proton pump inhibitors (PPIs) - promote rapid tissue healing

Y - Years of management needed

⚠ GERD is a CHRONIC disorder requiring ongoing management
⚠ Treat more aggressively in older adults

L - Lifestyle modifications

• Weight reduction

• Smoking cessation

• Elevate head of bed 6 inches

• Avoid tight clothing/belts/binders

• Avoid bending over after meals

E - Education is key nursing role

Teach about:

• Chronic nature of disease

• Dietary modifications

• Proper medication adherence

• Signs of complications (stricture, Barrett's esophagus)

• Work with registered dietitian nutritionist (RDN)

• Support groups and credible online communities

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PPI Considerations

✅ Short-term IV options: esomeprazole, pantoprazole (for surgery/stress ulcer prevention)

⚠ Long-term PPI risks:

• Kidney, liver, cardiovascular disease

• Dementia

• GI tumors

• Nutrient absorption issues

• Increased infection susceptibility

• Requires monitoring during extended use

⚠ Recurrence common when PPIs stopped - may mask symptoms

Use of Bismuth subsalicylate

Primary IndicationsPeptic Ulcer Disease (PUD)

• Component of quadruple therapy for H. pylori eradication

• Regimen: PPI + bismuth + 2 antibiotics (tetracycline + metronidazole)

• Preferred for penicillin-allergic patients (alternative to amoxicillin-containing regimens)

Mechanism in PUD:

• Inhibits H. pylori from binding to mucosal lining

• Stimulates mucosal protection

• Promotes prostaglandin production

Diarrhea

• Antidiarrheal agent for acute, non-specific diarrhea

• Available OTC for symptomatic relief

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⚠ Critical Safety WarningsNO Aspirin or Salicylates

❌ Bismuth subsalicylate IS a salicylate
❌ Taking with aspirin or other salicylates → salicylate overdose/toxicity

Reye's Syndrome Risk

⚠ Do NOT give to children/teenagers with viral infections (chickenpox, influenza)
⚠ Parents must check with provider before administering

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Patient Teaching Points

✅ Expected side effect:

• Black discoloration of stools and/or tongue

• Temporary and harmless

• Reassure patients this is normal

✅ Administration:

• Take with adequate fluids

• Follow specific dosing directions

• Do not exceed maximum daily amounts

✅ When to contact provider:

• Diarrhea continues despite treatment

• Fever develops

• Abdominal pain occurs

• Bloody stools appear

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Clinical Context

H. pylori treatment duration: 10-14 days

Why bismuth matters: H. pylori is found in:

• ~90% of patients with duodenal ulcers

• ~70% of patients with gastric ulcers

• Prevalence increases with age (40-60% in those >60 years)

Upper airway obstructive disease

Status asthmaticus s/s and treatment (Most likely SATA)

CRITICAL Mnemonic for Status AsthmaticusSigns & SymptomsC - Complete airway obstruction warning

⚠ Sudden ABSENCE of wheezing + low O₂ saturation = complete airway obstruction → requires tracheotomy

R - Respiratory distress (extreme)

• Extremely labored breathing

• Increased respiratory rate

• Prolonged exhalation requiring more effort

• Unable to speak more than a few words between breaths

I - Intensifies despite usual therapy

Life-threatening acute episode that worsens once it begins and does NOT respond to usual asthma treatments

T - Tension in accessory muscles

• Use of accessory muscles for breathing

• Muscle retraction at sternum, suprasternal notch, and between ribs

I - IV neck veins distended

Distention of neck veins observed

C - Complications if not reversed

• Pneumothorax

• Cardiac arrest

• Respiratory arrest

A - Audible wheezing

Wheezing present (but remember: absence = complete obstruction)

L - Labored breathing on arrival

Patient arrives in emergency department with severe respiratory compromise

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IVSEOIT Treatment (Immediate)

I - IV fluids

Start immediately

V - Vigorous bronchodilators (systemic)

Potent systemic bronchodilators given stat

S - Steroids (systemic)

Administered immediately

E - Epinephrine

Given immediately

O - Oxygen therapy

Administer immediately

I - Intubation preparation

Prepare for emergency intubation

T - Tracheotomy readiness

If complete airway obstruction occurs (absent wheezing + low O₂ sat)

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Post-Crisis Management

Once breathing improves → manage similar to any asthma patient with:

• Controller medications

• Reliever medications (short-acting beta₂-agonists)

• Inhaled corticosteroids

• Monitoring and follow-up

Genetic mutation for emphysema

Alpha-1 Antitrypsin (α₁-Antitrypsin) Deficiency

The Genetic Mutation

Inherited deficiency of α₁-antitrypsin enzyme causes primary emphysema. This is an autosomal recessive disorder affecting the production or function of this protective enzyme.

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Normal Function

α₁-antitrypsin inhibits proteases (enzymes that break down lung tissue). This protective mechanism prevents damage from normal inflammatory processes in the lungs.

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What Goes Wrong

Without adequate α₁-antitrypsin:

• Neutrophils are recruited into the lungs

• Protease activity is unopposed (no inhibition)

• Proteases break down elastin in alveolar walls

• Inflammatory and structural damage develops

• Alveoli lose elasticity and become destroyed

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Clinical Clues

Suspect α₁-antitrypsin deficiency when:

• Emphysema develops before age 40

• Patient never smoked but still develops emphysema

• Family history of early-onset lung disease

⚠ Smoking accelerates lung damage even with this genetic condition

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Additional Complication

Hepatic fibrosis may also occur with α₁-antitrypsin deficiency

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TreatmentSupportive Care

Same as standard COPD treatment:

• Bronchodilators

• Inhaled corticosteroids

• Oxygen therapy

• Pulmonary rehabilitation

Specific Treatment

Intravenous augmentation therapy:

• Uses plasma-purified α₁-antitrypsin

• Slows disease progression

• Replaces the missing enzyme

Emerging Therapies

Gene therapy is being explored as a potential cure

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Key Distinction

• Primary emphysema = α₁-antitrypsin deficiency (genetic)

• Secondary emphysema = cigarette smoking (most common cause)

Both result in alveolar destruction and loss of elastic recoil, but the underlying mechanism differs.

What are characteristic features of emphysema? (Most likely SATA)

BARREL CHEST Mnemonic for Emphysema Features

B - Barrel chest appearance

1:1 ratio of anteroposterior (AP) to lateral chest diameter (normal = 1:1.5)
Result of lung hyperinflation and diaphragm flattening

A - Air trapping

• Loss of elastic recoil in alveolar walls

• Overstretching and enlargement of alveoli into bullae (air-filled spaces)

• Collapse of small bronchioles

• Hyperresonant sound on percussion

R - Reduced breath sounds

Commonly heard on auscultation, especially with emphysema

R - Respiratory pattern changes

• Prolonged expiration with pursed-lip breathing

• Inhalation starts before exhalation completes = uncoordinated breathing

• Rapid, shallow respirations with muscle fatigue

• Respiratory rate 40-50 breaths/min during acute exacerbation

E - Extremity muscle wasting

Thin appearance with loss of muscle mass in extremities
Neck muscles may be enlarged from accessory muscle use

L - Limited diaphragmatic excursion

Hyperinflated lung flattens the diaphragm, weakening its effectiveness

C - Cough (usually not productive)

Productive only during acute exacerbations (unlike chronic bronchitis with persistent productive cough)

H - Hyperinflation of lungs

Increased work of breathing and interference with airflow

E - Emphysema positioning

Tripod/orthopneic position: forward-bending posture with arms extended and braced on knees when sitting

S - Stooped, slow-moving appearance

Patient tends to be slightly stooped with decreased mobility

T - Thin body habitus

Weight loss, loss of appetite, muscle weakness common

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Additional Features

✅ Accessory muscle use (neck, chest wall, abdomen)
✅ Decreased chest vibration (fremitus)
✅ Wheezes on inspiration/expiration
✅ "Air hunger" sensation from increased oxygen need
✅ Late-stage: CO₂ retention, chronic respiratory acidosis, low PaO₂

⚠ Silent chest = serious airflow obstruction or pneumothorax

What is the cause of chronic bronchitis?

Cause of Chronic Bronchitis

Primary Cause

Inspired irritants, especially cigarette smoke

Cigarette smoking is the most common bronchial irritant responsible for chronic bronchitis.

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Pathophysiology

The irritant triggers a cascade of inflammatory responses:

1. Inflammation of bronchi and bronchioles

2. Vasodilation and mucosal edema

3. Congestion and bronchospasm

4. Increased number and size of mucus-secreting glands and goblet cells

5. Excessive thick mucus production (MUC5B mucin)

6. Bronchial wall thickening and fibrosis

7. Impaired ciliary function (especially from smoking)

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Other Contributing Factors

• Air pollution (tobacco smoke and environmental pollutants)

• Viral or bacterial pulmonary infections during childhood

• Impaired ability to inactivate proteolytic enzymes that damage airway tissues

• Unknown genetic characteristics

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Result

• Thick mucus is difficult to clear from airways

• Mucus provides a breeding ground for organisms → chronic infection

• Frequent infectious exacerbations from bacterial colonization

• Airways become narrowed and obstructed, especially during expiration

• Air trapping in distal lungs (hyperinflation)

• Impaired gas exchange: decreased PaO₂ (hypoxemia) and increased PaCO₂ (respiratory acidosis)

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Clinical Definition

Chronic bronchitis = productive cough for at least 3 months of the year for at least 2 consecutive years (in absence of other conditions that explain symptoms)

Arterial blood gases (Resolve and interpret)

Normal Values

Parameter	Normal Range	Meaning
pH	7.35-7.45	Acid-base balance
PaCO₂	35-45 mm Hg	Partial pressure of CO₂ (respiratory component)
HCO₃⁻	22-26 mEq/L	Bicarbonate (metabolic component)
PaO₂	80-100 mm Hg	Partial pressure of oxygen

Step-by-Step Interpretation

Step 1: Check the pH

• pH < 7.35 = Acidosis

• pH > 7.45 = Alkalosis

• pH 7.35–7.45 = Normal (or fully compensated)

Step 2: Determine Respiratory vs. Metabolic

Check PaCO₂:

• PaCO₂ > 45 = Respiratory acidosis

• PaCO₂ < 35 = Respiratory alkalosis

Check HCO₃⁻:

• HCO₃⁻ < 21 = Metabolic acidosis

• HCO₃⁻ > 28 = Metabolic alkalosis

Step 3: Match the Abnormal Value to pH

The parameter that moves in the same direction as pH identifies the PRIMARY problem:

• If pH is low (acidic) and PaCO₂ is high → Respiratory acidosis

• If pH is low and HCO₃⁻ is low → Metabolic acidosis

• If pH is high (alkalotic) and PaCO₂ is low → Respiratory alkalosis

• If pH is high and HCO₃⁻ is high → Metabolic alkalosis

Step 4: Check for Compensation

Partial compensation: pH abnormal, but opposite system is trying to correct

• Example: Respiratory acidosis with elevated HCO₃⁻ (kidneys retaining bicarbonate)

Full compensation: pH returns to normal range (7.35–7.45), but PaCO₂ and HCO₃⁻ remain abnormal

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Quick Examples

pH	PaCO₂	HCO₃⁻	Interpretation
7.28	58	26	Respiratory acidosis (uncompensated)
7.50	28	24	Respiratory alkalosis (uncompensated)
7.32	40	18	Metabolic acidosis (uncompensated)
7.38	50	30	Respiratory acidosis (fully compensated)

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Clinical Context

• Respiratory acidosis: COPD, respiratory depression, hypoventilation

• Respiratory alkalosis: Hyperventilation (pain, hypoxia, anxiety, PE)

• Metabolic acidosis: DKA, lactic acidosis, renal failure

• Metabolic alkalosis: Excessive vomiting, diuretic use

Infectious respiratory problems and drug therapy

What is the Cause of TB and transmission?

Causative Organism

Mycobacterium tuberculosis (MTB) - an aerobic bacillus (rod-shaped bacterium requiring high oxygen)

Less common: Mycobacterium bovis (from cattle)

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Why TB Affects the Lungs

MTB requires highly oxygenated body sites to grow and flourish, which explains why it most commonly affects the lungs.

Other sites of infection:

• Growing ends of bones

• Brain (cerebral cortex)

• Kidney, liver, genitourinary tract (less common)

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Transmission Route

Airborne droplets - highly contagious

TB spreads when a person with active TB:

• Coughs

• Laughs

• Sneezes

• Whistles

• Sings

Infected respiratory droplets become airborne and are inhaled by others. The infection then spreads to susceptible organs via the blood and lymphatic system.

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What Happens After InfectionIn Immunocompetent Individuals:

1. Bacilli reach bronchi or alveoli

2. Inflammation and exudative response occurs (pneumonitis)

3. Macrophages phagocytose the bacteria (but can't fully destroy them)

4. Granuloma (tubercle) forms to isolate the infection

5. Caseation necrosis develops (cheesy material inside granuloma)

6. Collagenous scar tissue walls off the bacilli

7. Result: Latent TB infection (LTBI) - no clinical disease

If Immune System Is Impaired:

Reactivation can occur with progressive disease spreading throughout:

• Lungs

• Lymph nodes

• Skin, eyes

• Nervous system

• Joints and bones

• Genitourinary system

• Abdomen

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Key Point

Not all TB infections develop into active TB. Normal immunity prevents full development in healthy individuals. MTB is a very slow-growing organism, making it more difficult to treat than most bacterial infections.

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Risk Factors for Spread

• HIV infection

• Emigration from high-prevalence countries

• Crowded institutional settings

• Homelessness

• Substance use

• Lack of access to medical care

What is the duration of treatment for TB?

Traditional Regimen

6 to 9 months (sometimes up to 12 months)

This is the standard duration for drug-susceptible TB using first-line therapy:

• Isoniazid

• Rifampin

• Pyrazinamide

• Ethambutol

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Shortened Regimen (FDA Approved 2022)

4 months

Uses a different combination:

• Isoniazid

• Rifapentine

• Moxifloxacin

• Pyrazinamide

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Why Treatment Takes So Long

• Mycobacterium tuberculosis is a very slow-growing organism

• Multiple drugs are needed to prevent drug resistance

• Treatment continues until the disease is under control

• Combination therapy kills or suppresses organisms as quickly as possible while reducing emergence of resistant strains

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Critical Patient Education Points

✅ Take medications exactly as ordered, at the same time every day

✅ Complete the ENTIRE prescription - even if feeling better

✅ Consistent dosing around the clock maintains steady blood levels and minimizes resistance

✅ Never skip doses or stop early - this is the most common cause of multidrug-resistant TB (MDR-TB)

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Consequences of Non-Adherence

⚠ Multidrug-resistant TB (MDR-TB): Resistant to isoniazid AND rifampin

⚠ Extensively drug-resistant TB (XDR-TB): Resistant to first-line AND second-line drugs, with much worse treatment outcomes

The most common cause of drug-resistant TB is misuse or mismanagement of drug therapy - either from inappropriate selection or poor adherence.

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Nursing Focus

Adherence is challenging because of the long treatment duration. Provide:

• Simple, clear instructions

• Multiple formats (pamphlets, videos, worksheets)

• Emphasis on the importance of completing therapy

• Positive outlook for those who adhere

• Warning that incomplete treatment can lead to resistant infection

What is the drug combination purpose for TB?

Purpose of Combination Drug Therapy for TB

Primary Goals

1. Kill or Suppress Organisms as Quickly as Possible

Multiple drugs work together to attack MTB through different mechanisms, accelerating bacterial death or suppression.

2. Prevent Drug Resistance

This is the most critical reason for combination therapy.

• MTB is slow-growing and can develop resistance if exposed to a single drug

• Using multiple drugs simultaneously prevents resistant organisms from emerging

• If bacteria develop resistance to one drug, the other drugs continue to work

3. Improve Cure Rates

Combination therapy is the most effective method of treating active TB and preventing transmission.

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How It Works

Most TB drugs are bacteriostatic (inhibit growth) rather than bactericidal (directly kill):

• MTB grows very slowly, making cells less metabolically active

• Bactericidal drugs work best on fast-growing organisms with active metabolism

• Multiple bacteriostatic drugs together can achieve bactericidal effects

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Standard RegimensTraditional 6-9 Month Regimen:

• Isoniazid

• Rifampin

• Pyrazinamide

• Ethambutol

Shortened 4-Month Regimen (2022):

• Isoniazid

• Rifapentine

• Moxifloxacin

• Pyrazinamide

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Why Single-Drug Therapy Fails

⚠ Monotherapy leads to:

• Development of drug-resistant TB

• Treatment failure

• Relapse of infection

• Multidrug-resistant TB (MDR-TB)

• Extensively drug-resistant TB (XDR-TB)

The most common cause of drug-resistant TB is misuse or mismanagement of drug therapy.

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Bottom Line

Combination drug therapy ensures: ✅ Faster bacterial suppression
✅ Prevention of resistance
✅ Higher cure rates
✅ Reduced transmission
✅ Better long-term outcomes

Treatment success depends on: adequate dosing, sufficient duration, strict adherence, and effective drug combination.

Antitubercular combination therapy priority teaching

Priority Teaching for Antitubercular Combination Therapy

#1 STRICT ADHERENCE TO THE REGIMEN

Most critical teaching point:

✅ Take ALL medications exactly as prescribed
✅ Same time every day - consistent dosing around the clock maintains steady blood levels
✅ Complete the ENTIRE prescription (6-9 months or longer) - even if feeling better
✅ Never skip doses or stop early

Why this matters:

• Non-adherence is the #1 cause of multidrug-resistant TB (MDR-TB)

• Incomplete treatment can lead to extensively drug-resistant TB (XDR-TB)

• Successful treatment depends completely on compliance

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#2 MULTIPLE DRUGS IMPROVE CURE RATES

Explain that combination therapy:

• Kills organisms faster

• Prevents drug resistance

• Is the most effective treatment method

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#3 MANAGING SIDE EFFECTS

Nausea:

• Take once-daily drugs at bedtime

• Take with small snack of simple carbohydrates (if food doesn't interfere with absorption - check label)

• Antiemetics may be prescribed

Report immediately to prescriber:

• Liver dysfunction: fatigue, jaundice, nausea, vomiting, dark urine, anorexia

• Vision changes: altered color perception, changes in visual acuity (especially with ethambutol)

• Peripheral neuropathy: numbness, burning, tingling of extremities

• Gout symptoms: hot, painful, swollen joints (big toe, knee, ankle)

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#4 INDIVIDUALIZED EDUCATION

Provide information in multiple formats:

• Pamphlets

• Videos

• Drug-schedule worksheets

• Simple, clear, concise instructions

• Use translator if needed for patients from other countries/cultures

Assess understanding: Ask patient to describe treatment regimen, side effects, and when to call provider

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#5 POSITIVE OUTLOOK WITH REALISTIC EXPECTATIONS

• Adherence leads to positive outcomes

• BUT not taking drugs as prescribed could lead to drug-resistant infection with much worse treatment outcomes

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Key Takeaway

The entire prescription must be finished over the prescribed time, even if feeling better. This cannot be emphasized enough - it's the foundation of successful TB treatment.

Isoniazid labs to be monitored

Isoniazid (INH) Lab Monitoring

Primary Labs to Monitor

Liver Function Tests (LFTs)

Most important monitoring for isoniazid

• AST (Aspartate Aminotransferase)

• ALT (Alanine Aminotransferase)

• Bilirubin

• Alkaline phosphatase

Why: Isoniazid can cause hepatotoxicity and liver damage

Frequency:

• Baseline before starting therapy

• At least annually for routine monitoring

• More frequently (every 1, 3, or 6 months) for higher-risk patients or those on higher-risk drug regimens

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Renal Function Tests

• Serum creatinine

• BUN

Why: Assess ability to metabolize and eliminate medications; anticipate risk for toxicity and drug accumulation

Frequency: At least annually, more often if renal dysfunction present

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Clinical Signs of Hepatotoxicity to Report

⚠ Teach patients to immediately report:

• Fatigue

• Jaundice (yellowing of skin/eyes)

• Nausea and vomiting

• Dark urine

• Anorexia

• Abdominal pain

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Additional Considerations

Vitamin B6 (Pyridoxine) may be prescribed alongside isoniazid to prevent peripheral neuropathy - not a lab, but important related teaching

Higher-risk patients requiring more frequent monitoring:

• Older adults

• Pre-existing liver disease

• Alcohol use

• Concurrent hepatotoxic medications

• HIV/AIDS

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Key Nursing Actions

✅ Ensure baseline LFTs obtained before starting therapy
✅ Schedule and track follow-up lab appointments
✅ Educate on signs/symptoms of liver toxicity
✅ Reinforce importance of keeping lab appointments
✅ Review results and notify prescriber of abnormalities

Isoniazid patient teaching

Isoniazid (INH) Patient Teaching

PRIORITY: Medication Adherence

✅ Take exactly as prescribed, same time every day
✅ Complete the ENTIRE course (6-9 months minimum) - even when feeling better
✅ Never skip doses or stop early - causes drug-resistant TB
✅ Take on empty stomach 1 hour before or 2 hours after meals for best absorption (unless GI upset occurs)

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Managing Side Effects

Nausea/GI upset:

• Take at bedtime with small snack if needed

• Antiemetics may be prescribed

Peripheral neuropathy prevention:

• May receive vitamin B6 (pyridoxine) supplement

• Prevents numbness, tingling, burning in hands/feet

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REPORT IMMEDIATELY to Provider

⚠ Signs of liver toxicity (hepatotoxicity):

• Fatigue or weakness

• Jaundice (yellowing of skin or eyes)

• Nausea, vomiting, loss of appetite

• Dark urine

• Abdominal pain

• Clay-colored stools

⚠ Peripheral neuropathy:

• Numbness, tingling, or burning in hands/feet

⚠ Vision changes

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Important Precautions

Avoid or limit alcohol - increases risk of liver damage

Drug interactions:

• Inform all providers you're taking isoniazid

• May interact with antacids, anticonvulsants, and other medications

Keep all lab appointments:

• Liver function tests monitored regularly

• Essential for detecting problems early

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Additional Teaching

• Infection control: Cover mouth when coughing/sneezing; proper hand hygiene

• Follow-up appointments: Critical for monitoring treatment effectiveness

• Family/household contacts: May need testing and preventive treatment

• Pregnancy/breastfeeding: Notify provider if pregnant, planning pregnancy, or breastfeeding

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Positive Reinforcement

• TB is curable with proper treatment adherence

• Most patients feel better within 2-3 weeks

• You will not be contagious after 2-3 weeks of proper treatment

• Completing therapy prevents drug resistance and protects your health

Bedaquiline indications and side effects (most likely SATA)

Bedaquiline Mnemonics

INDICATION: "MDR"

Multidrug-resistant TB
Drug-resistant TB (specifically resistant to isoniazid AND rifampin)
Reserved for when other drugs won't work (not first-line due to serious side effects)

Additional: Also used for extensively drug-resistant TB (XDR-TB)

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SIDE EFFECTS: "CHAMP-QT"

Chest pain
Headache
ATP synthase inhibition (mechanism - blocks mycobacterial energy)
Mortality risk increased (compared to placebo) ⚠
Prolonged QT interval ⚠

QT = QT prolongation (BLACK BOX WARNING)

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KEY TEACHING: "FOOD & AVOID"FOOD:

Take WITH food - significantly increases absorption

AVOID:

• Alcohol

• Very strong CYP3A4 inhibitors

• Other QT-prolonging drugs

• Inappropriate use (mifepristone)

• Don't use as first-line (life-threatening side effects)

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Critical Points

⚠ BLACK BOX WARNING:

• QT prolongation → risk of fatal arrhythmias

• Increased mortality risk vs. placebo

Monitoring required:

• ECG monitoring for QT interval

• Electrolytes (especially potassium, magnesium, calcium)

Pregnancy: Category B

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Quick Memory Tip

"BED-QT" = BEDaquiline causes QT prolongation (its most serious effect)

"Eat in BED" = Take BEDaquiline with food

TB Patient teaching

#1 MEDICATION ADHERENCE ⭐

Most critical teaching:

• Take ALL drugs exactly as prescribed, same time every day

• Complete entire prescription (6-12 months) - even when feeling better

• Multiple drugs improve cure rates and prevent resistance

• Never skip doses or stop early - causes drug-resistant TB (MDR-TB, XDR-TB)

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#2 INFECTION CONTROL

Until no longer contagious (3 negative sputum cultures):

• Cover mouth/nose with tissue when coughing or sneezing

• Place used tissues in plastic bags

• Wear mask in crowds

• Practice social distancing

• Avoid inhalation irritants (smoke, pollution)

Family/household members:

• All need TB testing

• May need preventive treatment

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#3 MANAGING SIDE EFFECTS

Nausea:

• Take once-daily drugs at bedtime

• Take with small snack if food doesn't interfere with absorption

• Antiemetics available if needed

Report immediately:

• Jaundice, dark urine, fatigue (liver toxicity)

• Vision changes

• Numbness/tingling in hands/feet

• Severe nausea/vomiting

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#4 MONITORING & FOLLOW-UP

• Sputum specimens needed every 4 weeks once treatment starts

• Keep all lab appointments - liver/kidney function monitoring

• 3 consecutive negative cultures = no longer contagious

• Can return to normal activities after non-contagious

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#5 POSITIVE OUTLOOK

✅ TB is curable with adherence
✅ Most feel better within 2-3 weeks
✅ BUT - not taking drugs as prescribed leads to drug-resistant infection with much worse outcomes

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#6 RESOURCES & SUPPORT

• Use provided materials: pamphlets, videos, drug schedules

• Translation services available if needed

• Case manager/community health nurse for support

• Directly observed therapy (DOT/VDOT) may be recommended

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Key Message

"Take every dose, every day, for the full treatment period - your cure depends on it!"

Antitussives

What is the indication of Antitussives?

• Although they have other properties, such as analgesic effects for the opioid drugs, antitussives are used primarily to stop the cough reflex when the cough is nonproductive and/or harmful.

What is the MOA of Antitussives?

Mechanism of Action (MOA) of Antitussives

Antitussives work by suppressing the cough reflex through two different mechanisms:

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1. Centrally-Acting Antitussives

Suppress the cough center in the brain

Example: Dextromethorphan

How it works:

• Acts on the medulla oblongata (cough center in brainstem)

• Raises the threshold for cough stimulation

• Reduces the urge to cough at the central nervous system level

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2. Peripherally-Acting Antitussives

Desensitize nerve receptors in the lungs

Example: Benzonatate

How it works:

• Anesthetizes or desensitizes irritant receptors (C-fibers) in the respiratory tract

• Blocks the cough reflex at the receptor level in the airways

• Prevents the signal from reaching the brain

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The Cough Reflex (What Antitussives Block)

Normal cough reflex involves:

1. Irritant receptors (C-fibers) in airway epithelium are stimulated

2. Signal sent to brain

3. Inspiration occurs

4. Glottis and vocal cords close

5. Expiratory muscles contract

6. Glottis reopens → forceful expulsion of air

Antitussives interrupt this process either centrally (brain) or peripherally (receptors)

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Clinical Use

Appropriate for:

• Nonproductive (dry) cough

• Cough interfering with sleep or daily activities

• Chronic cough when underlying cause is being treated

Note: Guaifenesin combined with dextromethorphan also raises the cough threshold while helping thin mucus

What are the potential complications of Antitussives?

• The following are the common adverse effects of selected antitussive drugs:

  • Benzonatate: dizziness, headache, sedation, nausea, constipation, pruritus, and nasal congestion

  • Codeine and hydrocodone: sedation, nausea, vomiting, lightheadedness, and constipation

  • Dextromethorphan: dizziness, drowsiness, and nausea

  • Diphenhydramine: sedation, dry mouth, and other anticholinergic effects

• Very few drug interactions occur with benzonatate. Opioid antitussives (codeine and hydrocodone) may potentiate the effects of other opioids, general anesthetics, tranquilizers, sedatives and hypnotics, tricyclic antidepressants, alcohol, and other CNS depressants.

Decongestants

What are the 1st line of drugs for nasal congestion?

First-Line Drugs for Nasal Congestion

Nasal Decongestants

Nasal decongestants are the primary treatment for nasal congestion caused by upper respiratory tract infections (URIs).

How They Work:

• Cause vasoconstriction of dilated blood vessels in nasal sinuses

• Reduce swelling and mucus production

• Relieve nasal stuffiness

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Common First-Line OptionsOral Decongestants:

• Pseudoephedrine (most common)

• Phenylephrine

Topical/Nasal Spray Decongestants:

• Oxymetazoline

• Phenylephrine nasal spray

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Important Nursing Considerations

⚠ Key Warnings:

Do NOT use continuously - rebound congestion can occur

Avoid in older adults (Beers Criteria):

• CNS stimulant effects

• Risk of seizures, hallucinations, excitation

Do NOT use within 14 days of MAOIs

Avoid taking near bedtime - causes stimulation

Children: May cause excessive agitation

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Patient Teaching Points

Report immediately:

• Anxiety

• Fast or slow heart rate

• Difficulty breathing (dyspnea)

• Seizures

When to contact provider:

• Symptoms don't improve within 7 days

• Fever develops

Extended-release products:

• Do NOT divide, crush, chew, or dissolve

Check before combining with other products - drug interactions possible

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Monitoring During Treatment

• Blood pressure and pulse throughout treatment

• Lung sounds

• Check for tenacious bronchial secretions

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Special Populations

Pregnancy/Breastfeeding:

• Avoid in pregnancy

• Use caution in breastfeeding

Children under 2 years:

• FDA recommends NOT giving OTC cough and cold products

• Risk of oversedation, seizures, tachycardia, even death

• Not effective in small children

Patient teaching of an adrenergic decongestant

How to Take Your Medication

✅ Timing:

• Take early in the day - avoid bedtime dosing (causes stimulation/insomnia)

• Take at same time daily for consistency

✅ Administration:

• Extended-release products: Swallow whole - do NOT crush, chew, divide, or dissolve

• Can take with food if stomach upset occurs

• Follow exact dosing instructions

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Duration of Use

⚠ SHORT-TERM USE ONLY

• Use for 3-5 days maximum (topical sprays)

• Oral forms: follow provider recommendations

• Rebound congestion occurs with prolonged use - congestion worsens when you stop

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What to Report IMMEDIATELY

🚨 Contact your provider if you experience:

• Fast or irregular heartbeat (palpitations)

• Chest pain or difficulty breathing

• Severe headache or dizziness

• Anxiety, restlessness, tremors

• Seizures

• Hallucinations (especially in older adults)

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When to Follow Up

📞 Call your provider if:

• Symptoms don't improve within 7 days

• Fever develops

• Symptoms worsen

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Important Safety Information

❌ Do NOT use if you have:

• Uncontrolled high blood pressure

• Heart disease

• Hyperthyroidism

• Diabetes (use with caution - may affect blood sugar)

• Glaucoma

• Prostate enlargement/urinary retention

❌ Drug interactions:

• NEVER combine with MAOIs (or within 14 days of stopping MAOIs) - can cause hypertensive crisis

• Check with pharmacist before combining with other cold/allergy medications

• May interact with blood pressure medications

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Lifestyle Considerations

💧 Increase fluid intake (unless restricted) - helps thin secretions

🚫 Avoid caffeine - increases stimulant effects

🚗 Use caution with driving initially - may cause dizziness

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Special Reminders

• Keep out of reach of children

• Store at room temperature

• Check expiration dates

• Don't share medications

• Inform all healthcare providers you're taking this medication

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Antihistamines

Non-sedating histamines patient teaching

Contraindications of antihistamines

Diphyenhydramine patient teaching