Dextromethorphan 10 mg/5 mL Dextromethorphan 30 mg/tablet Guaifenesin 100 mg/ 5 mL Dextromethorphan 10 mg/tablet Dextromethorphan 20 mg/pack Dextromethorphan 10 mg/capsule Guaifenesin 200 mg/ tablet son of harvesting. Also, which constituents of the plants are pharmacologically active is unclear. Some studies indicating effectiveness of echinacea in preventing or treating colds are considered flawed in methodology, but may indicate the use of different products with different chemical components. A double-blind, placebocontrolled study showed no benefit of using echinacea for preventing the common cold or respiratory infection. However, once a cold occurred, the symptoms did not last quite as long in the echinacea group. In general, randomized, placebo-controlled research studies indicate no significant differences between echinacea groups and placebo groups in the incidence, duration, or severity of upper respiratory infections. Thus, there is no convincing evidence that echinacea is effective. Moreover, the purity and potency of echinacea products are unknown or variable among products. Although generally considered safe, allergic reactions, including anaphylaxis, have been reported. Vitamin C, usually in large doses of more than 1000 mg daily, is used to reduce the incidence and severity of colds and influenza. However, such usage is not recommended or justified by clinical data. In general, high doses of vitamin C demonstrate little or no benefit in shortening the duration of symptoms or reducing viral shedding. In addition, they may cause adverse effects and about 90% of large doses is excreted in the urine. Very little is absorbed and blood levels of vitamin C are raised only slightly. Zinc gluconate lozenges are marketed as a cold remedy. However, some studies indicate beneficial effects and others do not. Most of the studies suggesting benefit are considered flawed in methodology. For example, although some studies were supposed to be blind, the lozenges’ distinctive taste likely allowed the drug to be distinguished from placebo. Nursing Process Assessment Assess the client’s condition in relation to disorders for which the drugs are used. • With nasal congestion, observe for decreased ability to breathe through the nose. If nasal discharge is present, note the amount, color, and thickness. Question the client about the duration and extent of nasal congestion and factors that precipitate or relieve the symptom. CHAPTER 49 NASAL DECONGESTANTS, ANTITUSSIVES, AND COLD REMEDIES • With coughing, a major assessment factor is whether the cough is productive of sputum or dry and hacking. If the cough is productive, note the color, odor, viscosity, and amount of sputum. In addition, assess factors that stimulate or relieve cough and the client’s ability and willingness to cough effectively. • Assess fluid intake and hydration status. Nursing Diagnoses • Risk for Injury related to cardiac dysrhythmias, hypertension, and other adverse effects of nasal decongestants • Noncompliance: Overuse of nasal decongestants • Deficient Knowledge: Appropriate use of singleand multi-ingredient drug formulations Planning/Goals The client will: • Experience relief of symptoms • Take drugs accurately and safely • Avoid overuse of decongestants • Avoid preventable adverse drug effects • Act to avoid recurrence of symptoms Interventions Encourage clients to use measures to prevent or minimize the incidence and severity of symptoms: • Avoid smoking cigarettes or breathing secondhand smoke, when possible. Cigarette smoke irritates respiratory tract mucosa, and this irritation causes cough, increased secretions, and decreased effectiveness of cilia in cleaning the respiratory tract. • Avoid or limit exposure to crowds, especially during winter when the incidence of colds and influenza is high. • Avoid contact with people who have colds or other respiratory infections. This is especially important for clients with chronic lung disease because upper respiratory infections may precipitate acute attacks of asthma or bronchitis. • Maintain a fluid intake of 2000 to 3000 mL daily unless contraindicated by cardiovascular or renal disease. • Maintain nutrition, rest, activity, and other general health measures. • Practice good handwashing techniques. • Annual vaccination for influenza is recommended for clients who are elderly or have chronic respiratory, cardiovascular, or renal disorders. Evaluation • Interview and observe for relief of symptoms. • Interview and observe for tachycardia, hypertension, drowsiness, and other adverse drug effects. • Interview and observe for compliance with instructions about drug use. PRINCIPLES OF THERAPY Drug Selection and Administration Choice of drugs and routes of administration are influenced by several clientand drug-related variables. Some guidelines include the following: 1. Single-drug formulations allow flexibility and individualization of dosage, whereas combination products may contain unneeded ingredients and are more expensive. However, many people find combination products more convenient to use. 2. Withnasaldecongestants,topicalpreparations are often preferred for short-term use. They are rapidly effective because they come into direct contact with nasal mucosa. If used longer than 7 consecutive days or in excessive amounts, however, these products may produce rebound nasal congestion. Oral drugs are preferred for long-term use . For clients with cardiovascular disease, topical nasal decongestants are usually preferred. Oral agents are usually contraindicated because of cardiovascular effects . 3. Antihistamines are clearly useful in allergic conditions , but their use to relieve cold symptoms is controversial. First generation antihistamines have anticholinergic effects that may reduce sneezing, rhinorrhea, and cough. Also, their sedative effects may aid sleep. Many multi-ingredient cold remedies contain an antihistamine. 4. Cough associated with the common cold usually stems from postnasal drainage and throat irritation. Most antitussives are given orally as tablets or cough syrups. Syrups serve as vehicles for antitussive drugs and may exert antitussive effects of their own by soothing irritated pharyngeal mucosa. Dextromethorphan is the antitussive drug of choice in most circumstances and is the antitussive ingredient in almost all OTC cough remedies . However, as discussed previously, some authorities question the effectiveness of antitussives and do not recommend them for use in children or adults. 5. Ipratropium , an anticholinergic drug, in a 0.06% nasal spray, is Food and Drug Administration approved for treatment of rhinorrhea associated with the common cold. 6. Cromolyn, a mast cell stabilizer, used by oral or intranasal inhalation, seems effective in reducing the symptoms and duration of the common cold but it is not FDA approved for this purpose. In one study, it was used every 2 hours for the first 2 days, then 4 times daily. The nasal solution is available OTC. 7. For treatment of excessive respiratory tract secretions, mechanical measures cold remedies should not be used longer than 1 week. Do not use nose drops or sprays more often or longer than recommended. Excessive or prolonged use may damage nasal mucosa and produce chronic nasal congestion. ✔Do not increase dosage if symptoms are not relieved by recommended amounts. ✔See a health care provider if symptoms persist longer than 1 week. ✔Read the labels of OTC allergy, cold, and sinus remedies for information about ingredients, dosages, conditions or other medications with which the drugs should not be taken, and adverse effects. ✔Do not combine two drug preparations containing the same or similar active ingredients. For example, pseudoephedrine is the nasal decongestant component of most prescription and OTC sinus and multi-ingredient cold remedies. The recommended dose for immediate-release preparations is usually 30 to 60 mg of pseudoephedrine; doses in extended-release preparations are usually 120 mg. Taking more than one preparation containing pseudoephedrine may increase dosage to toxic levels and cause irregular heartbeats and extreme nervousness. ✔Note that many combination products contain acetaminophen or ibuprofen as pain relievers. If you are taking another form of one of these drugs , there is a risk of overdosage and adverse effects. Acetaminophen can cause liver damage; ibuprofen is a relative of aspirin that can cause gastrointestinal upset and bleeding. Thus, you need to be sure your total daily dosage is not excessive . Self-Administration ✔Take medications as prescribed or as directed on the labels of OTC preparations. Taking excessive amounts or taking recommended amounts too often can lead to serious adverse effects. ambulation, chest physiotherapy, forcing fluids) are more likely to be effective than expectorant drug therapy. Use in Children Upper respiratory infections with nasal congestion, sore throat, cough, and increased secretions are common in children, and ✔Do not chew or crush long-acting tablets or capsules . Such actions can cause rapid drug absorption, high blood levels, and serious adverse effects, rather than the slow absorption and prolonged action intended with these products. ✔For OTC drugs available in different dosage strengths, start with lower recommended doses rather than “maximum strength” formulations or the highest recommended doses. It is safer to see how the drugs affect you, then increase doses if necessary and not contraindicated. ✔With topical nasal decongestants: 1. Use only preparations labeled for intranasal use. For example, phenylephrine is available in both nasal and eye formulations. The two types of solutions cannot be used interchangeably. In addition, phenylephrine preparations may contain 0.125%, 0.25%, 0.5%, or 1% of drug. Be sure the concentration is appropriate for the person to receive it . 2. Blow the nose gently before instilling nasal solutions or sprays. This clears nasal passages and increases effectiveness of medications. 3. To instill nose drops, lie down or sit with the neck hyperextended and instill medication without touching the dropper to the nostrils . Rinse the medication dropper after each use. 4. For nasal sprays, sit or stand, squeeze the container once to instill medication, and rinse the spray tip after each use. Most nasal sprays are designed to deliver one dose when used correctly. 5. If decongestant nose drops are ordered for nursing infants, give a dose 20 to 30 minutes before feeding. Nasal congestion interferes with an infant’s ability to suck. ✔Take or give cough syrups undiluted and avoid eating and drinking for approximately 30 minutes. Part of the beneficial effect of cough syrups stems from soothing effects on pharyngeal mucosa. Food or fluid removes the medication from the throat. ✔Report palpitations, dizziness, drowsiness, or rapid pulse. These effects may occur with nasal decongestants and cold remedies and may indicate excessive dosage. the drugs described in this chapter are often used. However, there are differences of opinion regarding use of the drugs and most authorities agree that more research is needed regarding dosage, safety, and effectiveness of cough and cold mixtures in children. Some considerations include the following: • Mostinfectionsareviralinoriginandantibioticsarenot generally recommended. For sore throat, a throat culture for streptococcus organisms should be performed and CHAPTER 49 NASAL DECONGESTANTS, ANTITUSSIVES, AND COLD REMEDIES the results obtained before an antibiotic is prescribed. For bronchitis, which is almost always viral, antibiotics are not usually indicated unless pneumonia is suspected or the cough lasts 10 to 14 days without improvement. • Cough medicines are not considered effective by some authorities. • With nasal decongestants, pseudoephedrine is considered effective in children older than 5 years of age, but research studies are inconclusive about its effectiveness in younger children. One consideration is that the low doses found in children’s preparations may be insufficient to produce therapeutic effects. As a result, some pediatricians do not recommend usage while others say the drug may be useful in some children. • Nasal congestion may interfere with an infant’s ability to nurse. Phenylephrine nasal solution, applied just before feeding time, is usually effective. However, excessive amounts or too frequent administration of topical agents may result in rebound nasal congestion and systemic effects of cardiac and central nervous system stimulation. Therefore, the drug should be given to infants only when recommended by a pediatric specialist. • Parents often administer a medication for pain and fever when a child has cold symptoms, whether the child has pain and fever or not. Some pediatricians suggest treating fevers above 101 degrees if the child seems uncomfortable but not to treat them otherwise. Parents may need to be counseled that fever is part of the body’s defense mechanism and may help the child recover from an infection. Use in Older Adults A major consideration is that older adults are at high risk of adverse effects from oral nasal decongestants . Adverse effects from topical agents are less likely, but rebound nasal congestion and systemic effects may occur with overuse. Older adults with significant cardiovascular disease should avoid the drugs. Also, as in other populations, antitussives and expectorants have questionable effectiveness. Home Care These drugs are used primarily in home settings and household members may ask the home care nurse for advice about OTC remedies for conditions such as allergies, colds, coughs, and sinus headaches. Before recommending a particular product, the nurse needs to assess the intended recipient for conditions or other medications that contraindicate the product’s use. For example, the nasal decongestant component may cause or aggravate cardiovascular disorders . In addition, other medications the client is taking need to be evaluated in terms of potential drug interactions with the remedy. The home care nurse also must emphasize the need to read the label of any OTC medication for ingredients, precautions, contraindications, drug interactions, administration instructions, and so forth. NURSING ACTIONS Nasal Decongestants, Antitussives, and Cold Remedies NURSING A CTIO NS RATION A LE/EXPLANATION Administer accurately a. Withtopicalnasaldecongestants: Use only preparations labeled for intranasal use. Use the drug concentration ordered. For instillation of nose drops, have the client lie down or sit with the neck hyperextended. Instill medication without touching the dropper to the nares. Rinse the medication dropper after each use. For nasal sprays, have the client sit, squeeze the container once to instill medication, avoid touching the spray tip to the nares, and rinse the spray tip after each use. Give nasal decongestants to infants 20–30 min before feeding. Intranasal preparations are usually dilute, aqueous solutions prepared specifically for intranasal use. Some agents are available in ophthalmic solutions as well. The two types of solutions cannot be used interchangeably. Some drug preparations are available in several concentrations. For example, phenylephrine preparations may contain 0.125%, 0.25%, 0.5%, or 1% of drug. To avoid contamination of the dropper and medication Most nasal sprays are designed to deliver one dose when used correctly. If necessary, secretions may be cleared and a second spray used. Correct usage and cleansing prevents contamination and infection. Nasal congestion interferes with an infant’s ability to suck. SECTION 8 DRUGS AFFECTING THE RESPIRATORY SYSTEM NURSING A CTIO NS RATION A LE/EXPLANATION b. Administer cough syrups undiluted and instruct the client to avoid eating and drinking for approximately 30 min. Observe for therapeutic effects a. When nasal decongestants are given, observe for decreased nasal obstruction and drainage. b. Withantitussives,observefordecreasedcoughing. c. With cold and allergy remedies, observe for decreased nasal congestion, rhinitis, muscle aches, and other symptoms. Observe for adverse effects a. Withnasaldecongestants,observefor: Tachycardia, cardiac dysrhythmias, hypertension Rebound nasal congestion, chronic rhinitis, and possible ulceration of nasal mucosa b. Withantitussives,observefor: Excessive suppression of the cough reflex Nausea, vomiting, constipation, dizziness, drowsiness, pruritus, and drug dependence Nausea, drowsiness, and dizziness with non-narcotic antitussives c. With combination products , observe for adverse effects of individual ingredients Observe for drug interactions a. Drugs that increase effects of nasal decongestants: Cocaine, digoxin, general anesthetics, monoamine oxidase inhibitors, other adrenergic drugs, thyroid preparations, and xanthines Antihistamines, epinephrine, ergot alkaloids, MAO inhibitors, methylphenidate b. Drugsthat increase antitussiveeffectsofcodeine: CNS depressants c. Drugs that alter effects of dextromethorphan: MAO inhibitors Part of the therapeutic benefit of cough syrups stems from soothing effects on pharyngeal mucosa. Food or fluid removes the medication from the pharynx. Therapeutic effects depend on the reason for use. The goal of antitussive therapy is to suppress nonpurposeful coughing, not productive coughing. These effects may occur with any of the adrenergic drugs . When adrenergic drugs are used as nasal decongestants, cardiovascular effects are more likely to occur with oral agents. However, topically applied drugs also may be systemically absorbed through the nasal mucosa or by being swallowed and absorbed through the gastrointestinal tract. Adverse effects on nasal mucosa are more likely to occur with excessive or long-term use. This is a potentially serious adverse effect because retained secretions may lead to atelectasis, pneumonia, hypoxia, hypercarbia, and respiratory failure. These are adverse effects associated with narcotic agents . When narcotics are given for antitussive effects, however, they are given in relatively small doses and are unlikely to cause adverse reactions. Adverse effects are infrequent and mild with these agents. Adverse effects are rarely significant when the products are used as prescribed. There may be subtherapeutic doses of one or more component drugs, especially in over-the-counter formulations. Also, the drowsiness associated with antihistamines may be offset by stimulating effects of adrenergics. Ephedrine, for example, has central nervous system –stimulating effects. These interactions are more likely to occur with oral decongestants than topically applied drugs. Increased risks of cardiac dysrhythmias Increased risks of hypertension due to vasoconstriction Additive CNS depression. Codeine is given in small doses for antitussive effects, and risks of significant interactions are minimal. This combination is contraindicated. Apnea, muscular rigidity, hyperpyrexia, laryngospasm, and death may occur. CHAPTER 49 NASAL DECONGESTANTS, ANTITUSSIVES, AND COLD REMEDIES 737 NURSING ACTIONS RATIONALE/EXPLANATION Interactions depend on the individual drug components of each formulation. Risks of clinically significant drug interactions are increased with use of combination products. Review and Application Exercises 1. How do adrenergic drugs relieve nasal congestion? 2. Who should usually avoid OTC nasal decongestants and cold remedies? 3. Whatareadvantagesanddisadvantagesofmulti-ingredient cold remedies? 4. Givenaclientwithaproductivecough,whatarenondrug interventions to promote removal of secretions? 5. Given a client who uses echinacea, vitamin C, or zinc lozenges and asks you what you think about the products as cold remedies, how would you reply? SELECTED REFERENCES Drug facts and comparisons. . St. Louis: Facts and Comparisons. Echinacea for prevention and treatment of upper respiratory infections. . The Medical Letter on Drugs and Therapeutics, 44 . New Rochelle, NY: The Medical Letter, Inc. Guyton, A. C. & Hall, J. E. . Textbook of medical physiology, 10th ed. Philadelphia: W. B. Saunders. Kim, R. B. . Handbook of adverse drug interactions. New Rochelle, NY: The Medical Letter, Inc. Nix, D. E. . Upper respiratory infections. In E. T. Herfindal & D. R. Gourley , Textbook of therapeutics: Drug and disease management, 7th ed., pp. 1385–1401. Philadelphia: Lippincott Williams & Wilkins. Porth, C. M. . . Pathophysiology: Concepts of altered health states, 6th ed. Philadelphia: Lippincott Williams & Wilkins. d. Drugs that may alter effects of combination products for coughs, colds, and allergies: Adrenergic agents Antihistamines CNS depressants CNS stimulants How Can You Avoid This Medication Error? Answer: Sudafed is an adrenergic agent whose use is contraindicated in hypertensive clients because it significantly increases blood pressure. It is the nurse’s responsibility to know the contraindications to any medication she or he administers. When requesting an order from a physician who does not know the patient well, it is helpful to briefly outline significant medical problems or medications that may interact. Because Mr. Fell’s blood pressure and pulse rate are likely to go up, monitor vital signs more frequently and request a PRN order for an antihypertensive agent if necessary. Nursing Notes: Apply Your Knowledge Answer: Joan has the symptoms of a cold. Tell her to avoid combination products that may include medications she does not need and are generally more expensive. Because her cough is productive, an antitussive agent is contraindicated because expectorating retained secretions promotes recovery and prevents pneumonia and other respiratory complications. An expectorant, such as guaifenesin, may help liquefy respiratory secretions and aid their removal. A nasal decongestant could be used to decrease nasal stuffiness and discharge. Acetaminophen can be taken to reduce generalized discomfort. In addition to discussing medications, stress the importance of getting adequate rest and drinking lots of fluids. Drugs Affecting the Cardiovascular System chapter 50 Physiology of the Cardiovascular System Objectives AFTER STUDYING THIS CHAPTER, THE STUDENT WILL BE ABLE TO: 1. Review the functions of the heart, blood vessels, and blood in supplying oxygen and nutrients to body tissues. 2. Describe the role of vascular endothelium in maintaining homeostasis. 3. Discuss atherosclerosis as the basic disorder causing many cardiovascular disorders for which drug therapy is required. OVERVIEW The cardiovascular or circulatory system is composed of the heart, blood vessels, and blood. The general functions of the system are to carry oxygen, nutrients, hormones, antibodies, and other substances to all body cells and to remove waste products of cell metabolism . The efficiency of the system depends on the heart’s ability to pump blood, the patency and functions of blood vessels, and the quality and quantity of blood. HEART The heart is a hollow, muscular organ that functions as a twosided pump to circulate five to six liters of blood through the body every minute. Major components and characteristics are described in the following sections.