Question

5. Discuss the actions, side effects, contraindications, and nursing implications of the following medications in the treatment of asthma: albuterol, atrovent, epinephrine, prednisolone, prednisone, solumedrol, magnesium sulfate, sodium bicarbonate.

Answer 1

ALBUTEROL

Action - Albuterol belongs to a class of drugs known as bronchodilators. It works in the airways by opening breathing passages and relaxing muscles.

Side effects -

• Nervousness
• Shaking (tremor)
• Headache
• Nausea or dizziness
• Trachycardia
• Elevated blood pressure

Contraindication -

• Hypersensitive to the drug or any of its components (i.e. CFC or HFA propellants)
• It should be used cautiously in patients with known coronary artery disease, history of arrhythmias, hypertension, hyperthyroidism, seizure disorders, diabetes, glaucoma, or hypokalemia.

Nursing Implications -

Assessment

• History: Hypersensitivity to albuterol; tachyarrhythmias, tachycardia caused by digitalis intoxication; general anesthesia with halogenated hydrocarbons or cyclopropane; unstable vasomotor system disorders; hypertension; coronary insufficiency, CAD; history of CVA; COPD patients who have developed degenerative heart disease; diabetes mellitus; hyperthyroidism; history of seizure disorders; psychoneurotic individuals; lactation
• Physical: Weight; skin color, T, turgor; orientation, reflexes, affect; P, BP; R, adventitious sounds; blood and urine glucose, serum electrolytes, thyroid function tests, ECG.

Interventions

• Use minimal doses for minimal periods; drug tolerance can occur with prolonged use.
• Maintain a beta-adrenergic blocker (cardioselective beta-blocker, such as atenolol, should be used with respiratory distress) on standby in case cardiac arrhythmias occur.
• Prepare solution for inhalation by diluting 0.5 mL 0.5% solution with 2.5 mL normal saline; deliver over 5–15 min by nebulization.
• Do not exceed recommended dosage; administer pressurized inhalation drug forms during second half of inspiration, because the airways are open wider and the aerosol distribution is more extensive.

Teaching points

• Do not exceed recommended dosage; adverse effects or loss of effectiveness may result. Read the instructions that come with respiratory inhalant.
• You may experience these side effects: Dizziness, drowsiness, fatigue, headache (use caution if driving or performing tasks that require alertness); nausea, vomiting, change in taste (eat frequent small meals); rapid heart rate, anxiety, sweating, flushing, insomnia.
• Report chest pain, dizziness, insomnia, weakness, tremors or irregular heart beat, difficulty breathing, productive cough, failure to respond to usual dosage.

ATROVENT

Action - The active ingredient in ATROVENT HFA is ipratropium bromide (as the monohydrate). It is an anticholinergic bronchodilator. It works by relaxing the muscles around the airways so that they open up and you can breathe more easily. Ipratropium bromide is an anticholinergic (parasympatholytic) agent which, based on animal studies, appears to inhibit vagally-mediated reflexes by antagonizing the action of acetylcholine, the transmitter agent released at the neuromuscular junctions in the lung. Anticholinergics prevent the increases in intracellular concentration of Ca++ which is caused by interaction of acetylcholine with the muscarinic receptors on bronchial smooth muscle.

Side effects -

• Dizziness, nausea, stomach upset, dry mouth, or constipation may occur
• Hypersensitivity reactions, including anaphylaxis
• Paradoxical bronchospasm
• Ocular effects
• Urinary retention

Contraindications -

• Hypersensitivity to ipratropium bromide or other ATROVENT HFA components
• Hypersensitivity to atropine or any of its derivatives
• Use cautiously with narrow-angle glaucoma, prostatic hypertrophy, bladder neck obstruction, pregnancy, lactation.

Nursing Implications -

Assessment

• History: Hypersensitivity to atropine, soybeans, peanuts (aerosol preparation); acute bronchospasm, narrow-angle glaucoma, prostatic hypertrophy, bladder neck obstruction, pregnancy, lactation
• Physical: Skin color, lesions, texture; T; orientation, reflexes, bilateral grip strength; affect; ophthalmic examination; P, BP; R, adventitious sounds; bowel sounds, normal output; normal urinary output, prostate palpation

Interventions

• Protect solution for inhalation from light. Store unused vials in foil pouch.
• Use nebulizer mouthpiece instead of face mask to avoid blurred vision or aggravation of narrow-angle glaucoma.
• Can mix albuterol in nebulizer for up to 1 hr.
• Ensure adequate hydration, control environmental temperature to prevent hyperpyrexia.
• Have patient void before taking medication to avoid urinary retention.
• Teach patient proper use of inhaler.

Teaching points

• Use this drug as an inhalation product. Review the proper use of inhalator; for nasal spray, initiation of pump requires 7 actuations; if not used for 24 hours, 2 actuations will be needed before use. Protect from light; do not freeze.
• You may experience these side effects: Dizziness, headache, blurred vision (avoid driving or performing hazardous tasks); nausea, vomiting, GI upset (proper nutrition is important; consult with your dietitian to maintain nutrition); cough.
• Report rash, eye pain, difficulty voiding, palpitations, vision changes.

EPINEPHRINE

Action - Epinephrine, an active principle of the adrenal medulla, is a direct-acting sympathomimetic. It stimulates α- and β-adrenergic receptors resulting in relaxation of smooth muscle of the bronchial tree, cardiac stimulation and dilation of skeletal muscle vasculature. Epinephrine is a hormone that has a big influence on your bronchial tubes. It helps keep the muscle in the walls of bronchi relaxed and your airway wide. Epinephrine also blocks your body from releasing substances like histamines that can make you wheeze and hard to catch your breath.

Side effects -

• anxiety,
• nervousness,
• headache,
• fear,
• palpitations,
• sweating,
• nausea and vomiting,
• pale skin,
• shortness of breath,
• dizziness,
• weakness, or
• tremors.

Contraindications -

Preexisting hypertension; occlusive vascular disease; angle-closure glaucoma (eye drops); hypersensitivity; cardiac arrhythmias or tachycardia.

Nursing Implications

Assessment

• History: Allergy or hypersensitivity to epinephrine or components of drug preparation; narrow-angle glaucoma; shock other than anaphylactic shock; hypovolemia; general anesthesia with halogenated hydrocarbons or cyclopropane; organic brain damage, cerebral arteriosclerosis; cardiac dilation and coronary insufficiency; tachyarrhythmias; ischemic heart disease; hypertension; renal impairment; COPD; diabetes mellitus; hyperthyroidism; prostatic hypertrophy; history of seizure disorders; psychoneuroses; labor and delivery; lactation; contact lens use, aphakic patients (ophthalmic preparations)
• Physical: Weight; skin color, T, turgor; orientation, reflexes, IOP; P, BP; R, adventitious sounds; prostate palpation, normal urine output; urinalysis, renal function tests, blood and urine glucose, serum electrolytes, thyroid function tests, ECG

Interventions

• Use extreme caution when calculating and preparing doses; epinephrine is a very potent drug; small errors in dosage can cause serious adverse effects.
• Protect drug solutions from light, extreme heat, and freezing; do not use pink or brown solutions. Drug solutions should be clear and colorless.
• Keep a rapidly acting alpha-adrenergic blocker (phentolamine) or a vasodilator (a nitrate) readily available in case of excessive hypertensive reaction.
• Have an alpha-adrenergic blocker or facilities for intermittent positive pressure breathing readily available in case pulmonary edema occurs.
• Do not exceed recommended dosage of inhalation products; administer pressurized inhalation drug forms during second half of inspiration, because the airways are open wider and the aerosol distribution is more extensive. If a second inhalation is needed, administer at peak effect of previous dose, 3–5 min.
• Use topical nasal solutions only for acute states; do not use for longer than 3–5 days, and do not exceed recommended dosage. Rebound nasal congestion can occur after vasoconstriction subsides.

Teaching points

• Do not exceed recommended dosage; adverse effects or loss of effectiveness may result. Read the instructions that come with respiratory inhalant products, and consult your health care provider or pharmacist if you have any questions.
• You may experience these side effects: Dizziness, drowsiness, fatigue, apprehension (use caution if driving or performing tasks that require alertness); anxiety, emotional changes; nausea, vomiting, change in taste (eat frequent small meals); fast heart rate. Nasal solution may cause burning or stinging when first used (transient).
• Report chest pain, dizziness, insomnia, weakness, tremor or irregular heart beat (respiratory inhalant, nasal solution), difficulty breathing, productive cough, failure to respond to usual dosage (respiratory inhalant), decrease in visual acuity (ophthalmic).

PREDNISOLONE

Action - Prednisolone is a corticosteroid that comes in oral or liquid form. It works by acting on the immune system to help reduce the inflammation in the airways of people with asthma.

Side effects -

• fluid retention
• increased appetite
• weight gain
• upset stomach
• mood or behavioral changes
• high blood pressure
• increased susceptibility to infection
• osteoporosis
• eye changes, such as glaucoma or cataracts

Contraindications - Hypersensitivity, serious infections (except tuberculous meningitis), varicella, systemic fungal infections.

Nursing Implications -

Assessment

• History: Infections; renal or liver disease, hypothyroidism, ulcerative colitis with impending perforation, diverticulitis, active or latent peptic ulcer, inflammatory bowel disease, CHF, hypertension, thromboembolic disorders, osteoporosis, seizure disorders, diabetes mellitus; hepatic disease; lactation
• Physical: Weight, T, reflexes and grip strength, affect and orientation, P, BP, peripheral perfusion, prominence of superficial veins, R, adventitious sounds, serum electrolytes, blood glucose

Interventions

• Administer once-a-day doses before 9AM to mimic normal peak corticosteroid blood levels.
• Do not give live virus vaccines with immunosuppressive doses of corticosteroids.

Teaching points

• Do not stop taking the drug without consulting your health care provider; take once-daily doses at about 9 AM.
• Avoid exposure to infections.
• Report unusual weight gain, swelling of the extremities, muscle weakness, black or tarry stools, fever, prolonged sore throat, colds or other infections, worsening of the disorder for which the drug is being taken.