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NSG 116 Pharmacology Chapter 31 Drug Therapy for Nasal Congestion and Cough

Drug Therapy for Nasal Congestion and Cough

Common Respiratory Disorders

  • Common Cold

    • Cause: Viral infection.
    • Mechanism: Virus invades mucous membranes.
    • Occurrence:
      • School-age children: Up to 10 occurrences per year (typical).
      • Adults: 2-4 occurrences per year (typical).
    • Survival: Viruses can survive several hours on skin and hard surfaces.

  • Sinusitis

    • Definition: Inflammation of the paranasal sinuses.
    • Common Cause: Rhinitis is the most common cause of sinusitis.

Signs and Symptoms of Common Respiratory Disorders

  • Nasal congestion.
  • Cough: Can be productive (with mucus/phlegm) or nonproductive (dry).

Respiratory Disorder Medications: General Characteristics

  • Cold Remedies (Combination Products)
    • Often contain: Antihistamines, nasal decongestants, and analgesics.
    • Some may also contain: Antitussives (cough suppressants), expectorants (help clear mucus), and mucolytics (thin mucus).
    • Availability: Many are over-the-counter (OTC) medications.
  • Antivirals (mentioned as a general category for respiratory disorders).

Nasal Decongestants

  • Mechanism of Action:
    • Release norepinephrine.
    • Cause vasoconstriction (narrowing of blood vessels), which shrinks nasal mucosa.
    • Result: Relieves nasal congestion and discharge.
  • Primary Use: Most often used for temporary relief of symptoms.
  • Mnemonic: Decongestants "DRY" you "OUT"
    • Respiratory tract mucosa vasoconstriction and bronchodilation.
    • "Yucky" congestion is reduced.
  • Contraindications (Severe Conditions):
    • Severe hypertension (HTN).
    • Coronary artery disease (CAD).
    • Narrow-angle glaucoma.
    • Concurrent use with Monoamine Oxidase Inhibitors (MAOIs).
  • Used with Caution (Specific Conditions):
    • Cardiac dysrhythmia.
    • Hyperthyroidism.
    • Diabetes Mellitus (DM).
    • Benign Prostatic Hypertrophy (BPH).
    • Glaucoma.
  • Adverse Effects:
    • Tachycardia (rapid heart rate).
    • Palpitations (awareness of heart beat).
    • Anxiety, excitability, nervousness.
    • Hypertension (HTN).
    • Dizziness, drowsiness.
    • Insomnia: Offer pseudoephedrine at least 2 hours before bedtime to decrease insomnia.
  • Specific Nasal Decongestants:
    • Pseudoephedrine (Sudafed)
      • Adrenergic (sympathomimetic) drug.
      • Mechanism: Vasoconstriction, which shrinks nasal mucosa membranes and reduces blood flow to nasal mucosa.
      • Onset: Approximately 30 minutes.
      • Half-life: 4-8 hours.
      • Effects: Can cause irritability of the heart muscle.
      • Restriction: Restricted use due to its illicit manufacturing into amphetamine.
    • Oxymetazoline (Afrin)
      • Topical Preparation (Nasal Spray): Often preferred for short-term use.
      • Direct Action: Rapidly effective because it comes into direct contact with nasal mucosa.
      • Mechanism: Acts directly on alpha receptors to produce vasoconstriction of arterioles in nasal passages.
      • Rebound Nasal Congestion: May occur if used longer than the recommended 3 days or in excessive amounts.
      • Systemic Effects: Topical decongestants are less likely to produce systemic effects.
      • Cardiovascular Disease: Usually preferred for patients with cardiovascular disease due to fewer systemic effects.

Nursing Considerations for Nasal Decongestants

  • Assessment:
    • Determine the indication for use.
    • Assess if it's an OTC medication and if the patient is aware of active ingredients.
    • Identify risk factors, review patient history, and assess for possible conditions that increase risks or adverse effects (e.g., Renal or Hepatic Impairment) or any contraindications.
    • Contraindications include: Hypertension, CAD, Narrow-angle glaucoma, Hyperthyroidism, DM, MAOIs.
  • Planning/Patient Teaching:
    • Increase fluid intake.
    • Do not increase the dose beyond recommendations.
    • Do not compound with other medications containing the same active ingredients.
    • Be aware of combination drugs that may contain acetaminophen or ibuprofen.
    • Prevent drug interactions, including with herbal medications.
    • Dietary Considerations:
      • Caffeine enhances the effects of decongestants.
      • Green and black tea may decrease the absorption of the drug.
    • Monitor nutritional status.
  • Implementation:
    • Cardiac monitoring.
    • Respiratory intervention.
  • Evaluation:
    • Adverse Effects: Monitor for cardiac symptoms (e.g., tachycardia, palpitations), anaphylaxis, insomnia, dizziness, HTN, anorexia, nausea and vomiting (N/V), headache (HA).
    • Therapeutic Effects: Observe for decreased nasal inflammation and congestion.

Cough Suppressants / Antitussives

  • Purpose: Suppress dry, hacking, nonproductive cough that interferes with rest and sleep.
  • Types of Antitussives:
    • Centrally Acting: Work on the cough center in the brain.
      • Narcotic: Hydrocodone, Codeine.
      • Non-narcotic: Dextromethorphan.
    • Peripherally Acting: Work on stretch receptors in the respiratory passages.
      • Benzonatate.
    • Locally Acting: Provide local soothing effects.
      • Throat lozenges, cough drops.

Non-Opioid Cough Suppressants

  • General Action: Suppresses cough.

  • Undesirable Effects: Mild dizziness, nausea, sedation may occur.

  • CNS Depression Risk: May occur with concurrent use of antihistamines, opioids, alcohol, and sedatives.

  • MAOI Interaction: Can increase the risk of serotonin syndrome (manifested by nausea, confusion, changes in blood pressure).

  • Dextromethorphan (Delsym, Robitussin - often labeled "DM")

    • Ingredient: Main ingredient in most OTC cough remedies.
    • Nature: Non-narcotic.
    • Mechanism: Centrally acting; depresses the cough center in the brain or elevates the threshold for coughing in the throat/trachea or lungs.
    • Normal Doses Adverse Effects: Nausea, drowsiness, rash, difficulty breathing (DIB).
    • Abuse Potential: Known to be abused for recreational purposes.
      • Doses exceeding recommendations can produce hallucinations and disassociation.
    • Assessing Therapeutic Effects: The nurse observes for decreased coughing.
    • Assessing Adverse Effects: The nurse observes for excessive suppression of the cough reflex, which can lead to an inability to cough effectively when secretions are present.

  • Benzonatate (Tessalon Perles)

    • Nature: Non-narcotic, but requires a prescription.
    • Mechanism: Peripherally acting; anesthetizes stretch receptors in the respiratory passages, thereby decreasing coughing.
    • Administration Note: Sucking or chewing the capsules may cause numbness of the throat or mouth.
    • Assessing Therapeutic Effects: The nurse assesses for decreased coughing.
    • Adverse Effects: Choking feeling, chest pain, numbness, dizziness, confusion, and hallucinations.

Narcotic Cough Suppressants

  • Hydrocodone and Codeine
    • Nature: Highly addictive; contains opioid.
    • Mechanism: Both are centrally acting, exerting antitussive effects in relatively small doses.
    • Assessing Therapeutic Effects: The nurse assesses for decreased coughing.
    • Adverse Effects:
      • Codeine Conversion: In the body, codeine is converted to morphine, which carries the potential for respiratory depression and death.
      • Other reactions: Nausea, vomiting (N/V), constipation, dizziness, drowsiness, pruritus (itching).
      • Drug Dependence: High risk due to opioid content.
      • Caution: Necessary in individuals, especially children, with asthma or other chronic breathing problems, who may be more susceptible to respiratory depression.
    • The "D's" for Opioids:
      • Depressed respirations.
      • Dizziness.
      • Drowsiness.
      • Decrease in BP = risk for falls.
      • Decrease in peristalsis = risk for constipation (alteration in elimination).
      • Duration to take should be short due to risk of abuse.

Nursing Considerations for Cough Suppressants / Antitussives

  • Assessment:
    • Determine the indication for use.
    • Assess if it's an OTC medication and related risk factors.
    • Review patient history and assess for conditions increasing risks or adverse effects, or any contraindications.
    • Assess vital signs (VS).
  • Planning/Patient Teaching:
    • Avoid eating and drinking for 30 minutes after taking some formulations (e.g., syrups, lozenges).
    • Do not increase the dose beyond recommendations.
    • Do not compound with other medications containing the same active ingredients.
    • Emphasize hand hygiene.
    • Monitor fluid and nutritional status.
    • Prevent Drug Interactions:
      • Avoid St. John's Wort.
      • MAOIs can increase the drug effect.
      • Avoid alcohol.
    • Report any adverse effects (CNS depression, cardiac symptoms).
    • Implement fall precautions due to potential dizziness/drowsiness.
  • Implementation:
    • Cardiac monitoring.
    • Neurological monitoring.
    • Respiratory monitoring.
  • Evaluation:
    • Adverse Effects: Monitor for excessive suppression of cough, hallucinations (especially with Dextromethorphan or Benzonatate overdose), difficulty breathing (DIB), constipation (especially with opioids).
    • Therapeutic Effects: Observe for decreased cough.
    • Monitor for signs of addiction/abuse, particularly with narcotic antitussives.

Expectorants & Mucolytics

  • General Purpose: Both help in the removal of respiratory secretions.

Expectorant (Guaifenesin - Mucinex)

  • Mechanism: Liquefy respiratory secretions, allowing for easier removal.
  • Key Nursing Considerations:
    • Stop guaifenesin and notify HCP if a rash occurs.
    • Risk for dizziness/drowsiness; do not drive prior to taking.
    • Increase fluid intake to help liquefy secretions effectively.
    • Take with food if gastrointestinal (GI) upset occurs.

Mucolytic (Acetylcysteine - Acedote)

  • Mechanism: Liquefy mucus in the respiratory tract.
  • Administration: Administered by inhalation; effective immediately after direct instillation.
  • Uses:
    • Treatment for patients with lung diseases (e.g., emphysema, cystic fibrosis).
    • Used as an antidote for acetaminophen overdose.
  • Key Nursing Considerations:
    • Unpleasant Odor: Has an unpleasant odor, often described as rotten eggs.
    • Discontinue medication if aspiration or bronchospasms occur.

Nursing Considerations for Expectorants

  • Assessment:
    • Indication for use, OTC status, risk factors, review history.
    • Assess for possible conditions that increase risks, adverse effects, or contraindications.
    • Assess baseline vital signs.
  • Planning/Patient Teaching:
    • Increase fluid intake.
    • Do not crush or chew extended-release medications.
    • Teach hand hygiene and vaccination importance.
    • Provide comprehensive drug therapy teaching.
  • Implementation:
    • Monitor fluid intake.
    • Teach smoking cessation strategies.
    • Provide infection prevention education.
    • Monitor rest and nutritional status.
  • Evaluation:
    • Adverse Effects: Rash, headache (HA), nausea/vomiting (N/V), GI upset.
    • Therapeutic Effects: Mobilization of secretions, compliance with treatment plan.

Nursing Considerations for Mucolytics (Inhalation, Acetaminophen O.D.)

  • Assessment:
    • Indication for use, OTC status, risk factors, review history.
    • Assess for possible conditions that increase risks, adverse effects, or contraindications.
  • Planning/Patient Teaching:
    • Increase fluid intake.
    • Do not crush or chew medication (if oral format).
    • Teach hand hygiene and vaccination importance.
    • Provide comprehensive drug therapy teaching.
  • Implementation:
    • Airway, Neurological, and GI monitoring.
    • Monitor fluid intake.
    • Avoid smoking.
    • Infection prevention.
    • Monitor rest and nutritional status.
  • Evaluation:
    • Adverse Effects: Nausea/vomiting (N/V), airway inflammation, chest tightness.
    • Therapeutic Effects: Secretion mobilization.

General Nursing Implications

  • Preventing Interactions.
  • Administering Medication safely and correctly.
  • Assessing for Adverse Effects promptly.
  • Assessing for Therapeutic Effects to ensure efficacy.
  • Patient Teaching is crucial for safe and effective self-management and adherence.