Download Ch. 24-Drugs Used to Treat Respiratory Diseases

CHAPTER 24
Drugs Used
to
Treat Respiratory
Diseases
respiratory system is a series of airways that start
with the nose and mouth and end at the alveoli in
the lungs
 respiratory system is divided into:
◦ upper respiratory tract: nose, sinuses,
nasopharynx, pharynx, tonsils, eustachian tubes
and larynx(fig 24-2 p. 301)
◦ lower respiratory tract: larynx,
trachea, bronchi, bronchioles,
alveoli (fig 24-3, p. 302)

Respiratory System: Structure and Function:
(Box 24-1 pg. 300-301)
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respiratory system brings oxygen (O2) into lungs and
removes carbon dioxide (CO2)
air enters body through nose
nose and it’s structures serve 2 functions:
◦ olfactory (smell): upper part of each nostril, cells contain microscopic
hairs that react to odors in the air. Hairs stimulate olfactory cells, send
signal to brain where sense of smell is processed
◦ respiratory: the nose warms, humidifies, and filters inhaled air, both
nasal passages have folds of skin called turbinates. These folds increase
the amount of nasal tissue. Turbinate tissue contains many blood
vessels, and are lined with membranes. Blood circulating through these
membranes warms and humidifies the inhaled air
◦ see picture of turbinates next slide
Respiratory System: Structure and Function cont…
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particles in the inhaled air are filtered by large hairs at
entrance
tubinates and narrow nasal passages cause turbulence of air
flow with each inhalation
all nose surfaces are coated with a thin layer of mucous
because of turbulent air flow, particles are “thrown” against
walls of nasal passages, they become trapped
cells lining back 2/3 of nasal passage contain cilia
cilia: small hair-like structures that project outward from the
surfaces of some cells, they sweep particulate matter
back toward naso-pharynx and pharynx
once in pharynx, particulate matter is swallowed or
expectorated
warming, humidifying, filtering continues as air passes into
trachea, bronchi and bronchioles
Respiratory System: Structure and Function cont…

ANS (autonomic nervous system) controls the nasal
structures, cholinergic stimulation causes vaso-dilation

blood vessels lining nasal mucous membranes dilate

when cholinergic fibers in secretory glands are stimulated,
serous and mucous secretions are produced

sympathetic stimulation causes vaso-constriction
Respiratory System: Structure and Function cont…
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sinuses are hollow air-filled cavities
they are in the cranial bones on both sides and behind the
nose
there are 8 sinuses, 4 on each side
sinuses are lined with same mucous membranes and cilia as
those of the upper respiratory tract
connected to nasal passages by ducts
drain into nasal
cavity
Respiratory System: Structure and Function cont…
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tonsils are on each side of pharynx, they are lymphatic
tissues
located where mucus filled with particulate matter collects
from ciliary action in the naso-pharynx
particulate matter includes virus particles and bacteria
lymph tissue is thought to play a role in immune defense
mechanisms of upper airway
sneezing: reflex that clears the nasal passages of particulate
matter, sneeze starts by irritation of nasal membranes
caused by particulate matter
air then passes into pharynx (throat), then from pharynx to
larynx (voice box)
piece of cartilage (epiglottis) acts as lid over pharynx,
prevents food from entering airway during swallowing
during inhalation epiglottis lifts up to let air pass over larynx,
air passes from larynx into trachea (wind pipe)
Respiratory System: Structure and Function cont…
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trachea divides at lower end into right/left bronchus
each bronchus enters a lung
upon entering lung each bronchi divides many times into
smaller branches called bronchioles
bronchioles eventually subdivide and end up in tiny onecelled air sacs called alveoli
alveoli look like small grape clusters, they are supplied by
capillaries
O2 and CO2 are exchanged between the alveoli and
capillaries
blood in capillaries picks up O2 from alveoli, then blood is
returned to the left side of heart and pumped to rest of
body
alveoli pick up CO2 from capillaries for exhalation
Respiratory System: Structure and Function cont…
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lungs are spongy tissue
filled with alveoli, blood vessels and nerves
each lung is divided into lobes
right lung has 3 lobes
left lung has 2 lobes
lungs are separated from abdominal cavity by a muscle called
the diaphragm
each lung is covered by a 2-layered sac called the pleura
outer layer is attached to lung and other to the chest wall
pleura secretes a very thin fluid that fills the space between
layers, fluid prevents the layers from rubbing together
during inhaling/exhaling
ribs, sternum, vertebrae make up bony framework, protects
lungs
Respiratory System: Structure and Function cont…

respiratory tract fluids come from glands that line the tract,
mucous glands (goblet cells) and serous glands:
◦ goblet cells: produce gel-like mucous that forms thin layer over inner
surfaces of trachea, bronchi, bronchioles. mucous secretion is caused by
exposure to irritants (smoke, particles, bacteria)
◦ serous glands are controlled by cholinergic nervous system (ch.14)
when stimulated they secrete a watery fluid to the interior surface of
the trachea, bronchi and bronchioles
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secretions from both types of glands form respiratory tract
fluid, this fluid forms a protective layer over trachea,
bronchi, bronchioles
foreign bodies are caught in fluid, swept upward by cilia to
larynx and then removed by cough reflex
Respiratory System: Structure and Function cont…
the expectorated (coughed up) matter has pulmonary
mucous secretions, foreign particles, and cells from the
airway lining (coughed up matter called sputum, phlegm)
 respiratory fluid can become thick and sticky and form
mucous plugs (fig. 24-3)
 causes:

◦ cilia destroyed by chronic smoke inhalation
◦ dehydration dries the mucous
◦ anti-cholinergic agents inhibit water secretions from the serous glands
(drying effect)

thick mucous plugs are hard to remove by coughing,
microbes can grow in lower respiratory tract, this causes
more secretions. Pneumonia can develop from trapped
bacteria
Respiratory System: Structure and Function cont…

smooth muscles of trachea, bronchi, bronchioles are
controlled by ANS (parasympathetic and sympathetic
systems)
◦ stimulation of cholinergic (parasympathetic) fibers causes bronchial
constriction and increased mucous secretion
◦ stimulation of adrenergic (sympathetic) fibers causes dilation of the
bronchi and bronchioles, mucus secretion decreases
*see box 24-2 pages 302-303 for
common respiratory disorders*
Delegation Guidelines
Drugs Used to Treat Respiratory Diseases:
Some drugs used to respiratory diseases are
given parenterally- by subcutaneous,
intramuscular or intravenous injection. Because
you do NOT give parenteral dose forms, they
are NOT included in this chapter. Should a
nurse delegate the administration of such to you,
you must:
- remember that parenteral dosages are often
very different from dosages other routes
-Refuse the delegation. Make sure to explain why.
Do NOT just ignore the request. Make sure the
nurse knows that you cannot give drug and why

Drug Therapy for Upper Respiratory Diseases:

antihistamines are drug of choice for allergic rhinitis:
◦ given orally and distributed through body
◦ reduce symptoms of nasal itching, sneezing, rhinorrhea,
tearing and itchy eyes
◦ do NOT reduce nasal congestion

decongestants cause vaso-constriction of nasal mucosa,
greatly reduces congestion

anti-inflammatory agents (p. 306) are given intra- nasally, used
to treat nasal symptoms caused by mild-mod allergic
rhinitis, not used to treat cold symptoms
Sympathomimetic Decongestants:
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stimulate the alpha adrenergic receptors of nasal mucous
membranes
causes vaso-constriction, blood flow reduced to nasal area,
sinus drainage is promoted
decongestants are drug of choice for relieving congestion
from common cold and rhinitis
often given with antihistamines to:
◦ reduce nasal congestion
◦ reduce sedation caused by antihistamines
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oral and topical dose forms available (table 24-1)
topical are nasal sprays/drops, no systemic effects, no NOT
relieve other symptoms, can cause rhinitis
medicamentosa
nasal decongestants provide temporary symptom relief, at
first stuffiness is relieved and can ease breathing
Assisting With the Nursing Process
Nasal Decongestants:
ASSESSMENT: measure vital signs
PLANNING: see table 24-1 Pg. 305 for “Oral Dose Forms”
IMPLEMENTATION: see table 24-1 Pg. 305 for “Adult
Dosage Range”, see ch. 12 for how to apply topical nose
medications
EVALUATION: report and record:
- burning or stinging of nasal membranes: weaker solution may
be needed
- hypertension: may occur from excessive use, measure BP
Antihistamines:
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compete with released histamine for receptor sites in
arterioles, capillaries and glands in mucous membranes
do NOT prevent histamine release, they reduce symptoms of
an allergic reaction if the amount of antihistamine is
greater than the amount of histamine
antihistamines more effective if taken:
◦ before histamine is released
◦ when symptoms first appear
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drugs of choice for treating allergic rhinitis and conjunctivitis
conjunctivitis is inflammation of eye tissues
◦ caused by bacterial or viral infections, allergies or environmental
factors
◦ signs/symptoms: red eyelids, itching, thick discharge, sticky eyelids in
morning
Antihistamines cont…
drugs reduce rhinorrhea, tearing, eye itching and sneezing
 do NOT stop nasal congestion
 best taken on a schedule for allergies
 more effective if taken before exposure to allergen (45-60
minutes before going outside during pollen season)
 all anti-histamines have anti-cholinergic side effects:

◦ dilation of pupil, increased intraocular pressure in persons with
glaucoma
◦ dry, thick secretions of mouth, nose, throat, bronchi
◦ decreased secretions and motility of GI tract
◦ increased heart rate
◦ decreased sweating
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persons with asthma, prostate enlargement, glaucoma should
only take antihistamines with medical supervision
goals of therapy: reduce sings/symptoms from allergic rhinitis
Assisting With the Nursing Process
Antihistamines:
ASSESSMENT: observe for nasal congestion, measure
intake/output
PLANNING: see table 24-2 Pg. 305 for “Oral Dose Forms”
IMPLEMENTATION: see table 24-2 Pg. 305 for “Adult
Dosage Range” and “Maximum Daily Dose”
EVALUATION: report and record:
- sedation, cognitive impairment, memory problems,
coordination problems: sedation most common side effect,
tolerance may develop over time, provide for safety
- drying effects: observe person’s cough and sputum
production, because of drying effects anti-histamines may
impair expectoration
- blurred vision, constipation, urinary retention; mouth,
throat, nose dryness: nurse may allow person to chew gum,
suck on ice chips or hard candy. Provide safety if person
has blurred vision. Follow care plan for constipation
Respiratory Anti-Inflammatory Agents:
 agents used to treat upper respiratory diseases:
◦ intra-nasal cortico-steroids
◦ cromolyn sodium (Nasalcrom)
intra-nasal cortico-steroids:
given to reduce inflammation
persons with allergic rhinitis who do not respond to
other drugs may be given these
 they help control nasal symptoms associated with
mild-moderate allergic rhinitis
 used for short courses of therapy for acute seasonal
allergies
 goals of therapy are to reduce:
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rhinorrhea
rhinitis
itching
sneezing
Assisting With the Nursing Process
intra-nasal cortico-steroids:
ASSESSMENT: observe for nasal congestion
PLANNING: see table 24-3 Pg. 306 for “Oral Dose
Forms”
IMPLEMENTATION: see table 24-3 Pg. 306 for
“Adult Dosage Range” full therapeutic effect
requires regular use, usually evident in a few days.
Advise person to clear nasal passages before topical
application. A decongestant may be ordered for use
right before a topical cortico-steroid, promotes
adequate penetration
EVALUATION: report and record:
- nasal burning: usually mild and tends to resolve with
continued therapy
cromolyn sodium (Nasalcrom):
anti-inflammatory agent
 inhibits release of histamine and other substances of
inflammation
 to be effective, must be used before body receives a stimulus
to release histamine
 used with other drugs that prevent release of histamine
 does NOT relieve nasal congestion
 antihistamine or nasal decongestant may be needed when
treatment is started
 treatment is continued only if there is a decrease in
symptoms
 goals of therapy are to reduce:

◦ rhinorrhea
◦ itching
◦ sneezing
Assisting With the Nursing Process
cromolyn sodium (Nasalcrom):
ASSESSMENT: observe for nasal congestion
PLANNING: dose forms: nasal spray: 40mg/mL in 13 mL
(gives 100 sprays), aerosol spray: 800mcg from an 8.1g
container (112 metered sprays), oral concentrate:
100mg/5mL
IMPLEMENTATION: adult dose: 1 spray in each nostril 34x/day at regular intervals, maximum dose is 6 sprays in each
nostril daily (2-4 weeks for therapeutic effect to be evident),
advise person to clear nasal passages of secretions before
topical application
EVALUATION: report and record:
- nasal irritation- sneezing, itching, burning, stuffiness. Tolerance
usually develops
Drug Therapy for Lower Respiratory Diseases:

expectorants: drugs that liquefy mucus to promote the
ejection of mucus from lungs
◦ stimulate secretion of natural fluids from serous glands, flow of serous
fluids helps liquefy thick mucous plugs
◦ ciliary action and coughing expel phlegm from respiratory system
◦ used to treat non-productive cough, bronchitis and pneumonia

antitussives (cough suppressants): drugs that suppress the
cough center in brain
◦ used when person has a dry, hacking, non-productive cough
◦ cough is not stopped completely but should decrease frequency and
suppress severe spasms that affect sleep
Drug Therapy for Lower Respiratory Diseases cont….
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brocho-dilators: drugs that relax smooth muscles of trachea,
bronchi and bronchioles
◦ bronchiole and alveolar ducts open, which decreases resistance to
airflow
◦ used to treat COPD
◦ anti-inflammatory agents- drugs that reduce inflammation, used for
asthma. Cortico-steroids are most effective, commonly given by
inhalation.

mucolytic agents: drugs that redcuce stickiness and thickness
of pulmonary secretions
◦ act directly on mucous plugs to cause them to dissolve
◦ this eases the removal of secretions by cough, postural drainage, and
suction
◦ agents used to treat acute/chronic respiratory disorders, before and
after bronchoscopy, after chest surgery, and as part of tracheostomy
care
◦ Muco-myst is often given by nebulizer (fig 24-5, p. 308) Nebulizer is a
device that produces a fine spray
Delegation Guidelines
Drugs for Lower Respiratory Diseases:
Many states and agencies do NOT let the
MA-C’s give drugs by nebulizer. If allowed to do
so, make sure you receive the necessary
education and training. Also make sure that a
nurse is available to supervise your work.
Drug Therapy for Lower Respiratory Diseases ...
Expectorants:
 the following expectorants are used to treat lower
respiratory diseases:
◦ guaifenesin (Robitussing)
◦ postassium iodide (SSKI)
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guaifenesin (Robitussin)
enhances output of respiratory tract fluid
increased flow of secretions decreases mucous thickness and
promotes ciliary action (ciliary action and coughing expel
phlegm from respiratory tract)
used to relieve dry, non-productive cough and to remove
mucous plugs
often used with broncho-dilators, decongestants,
antihistamines or antitussive agents to make a nonproductive cough productive
goal of therapy is to reduce the frequency of non-productive
cough
Assisting With the Nursing Process
guaifenesin (Robitussin):
ASSESSMENT: note persons cough: productive or nonproductive; what is color, consistency, amount and appearance
of sputum
PLANNING: oral dose forms:
100, 200, 400, 600mg tablets
200mg capsules
100 and 200mg/5mL liquid
IMPLEMENTATION: adult dose: is 100-400mg every 4-6
hours, dose should not exceed 2400mg per day. Person
should drink 8-12 8oz glasses of water daily
EVALUATION: report and record:
- GI upset, nausea, vomiting: side effects are rare
Drug Therapy for Lower Respiratory Diseases ...
potassium iodide (SSKI):
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stimulates increased secretion from bronchial glands
this decreases thickness of mucous plugs
easier for person to cough up dry, hardened plugs blocking
bronchial tubes
used in treatment of COPD when thick mucous is present,
often used with other drugs to remove mucous
goals of therapy:
◦ reduce thickness of mucous
◦ allow a more productive cough to remove phlegm
Assisting With the Nursing Process
potassium iodide(SSKI):
ASSESSMENT: note persons cough: productive or nonproductive; what is color, consistency, amount and appearance
of sputum
PLANNING: oral dose forms:
solution: 1g/mL I 30, 240 and 480mL containers
syrup: 325 mg/5mL in 480mL containers
IMPLEMENTATION: adult dosage:
solution: 0.3mL (300mg) to 0.6mL (600mg) diluted in one
glassful of water, juice or milk, 3-4x/day
syrup: 5-10mL 3x/day, give with food/milk
person should drink 8-12 8oz glasses of water/day
EVALUATION: report and record:
- nausea, vomiting, diarrhea: usually mild, give with food or milk
to help gastric irritation
Antitussives:
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cough suppressants, depress the cough center in brain
codeine is an effective cough suppressant
low-dose, short-term use for a cough should not produce
addiction
goal of therapy: reduce frequency of a non-productive cough
Assisting With the Nursing Process
antitussives:
ASSESSMENT: note persons cough: productive or nonproductive; what is color, consistency, amount and
appearance of sputum
PLANNING: see table 24-4 (p. 309) for “oral dose
forms:
IMPLEMENTATION: see table 24-4 (p. 309) for “Adult
Oral Dosage Range”
Benzonatate must be swallowed whole, drug numbs the
tongue if chewed or crushed. Creates a choking hazard
EVALUATION: report and record:
- drowsiness, sedation: provide for safety
- constipation: codeine is most constipating of antitussives,
give stool softeners as ordered, follow care plan for fluid
intake
Beta-Adrenergic Broncho-Dilating Agent:
relax smooth muscles of trachea, bronchi, bronchioles
 opens airways to greater amounts of air
 drugs used to reverse airway constriction caused by acute
and chronic asthma, bronchitis and emphysema
 drugs have many side effects, because they stimulate
receptors in heart, blood vessels, uterus, GI, urinary and
central nervous systems
 those given by inhalation usually have fewer side effects
(lower doses are used, drug placed at site of action)
 goals of therapy:

◦ ease breathing
◦ reduce wheezing
Assisting With the Nursing Process
Beta-Adrenergic Broncho-Dilating Agent:
ASSESSMENT: measure vitals, note pulse rate and rhythm,
observe for confusion and orientation to person, time and place
PLANNING: see table 24-5 (p. 310) for “oral dose forms:
IMPLEMENTATION: see table 24-5 (p. 310) for “Adult Oral
Dosage Range”
person waits at least 10 minutes between inhalations, allows drug
to dilate the bronchioles. The 2nd dose can be inhaled more deeply
into lungs, follow manufacturers instructions
EVALUATION: report and record:
- tachycardia, palpitations: dose related, measure heart rate and
rhythm, report an increase of 20 beats or more per minute
after a treatment. Report dysrhythmias and palpitations
- tremors: dosage may need adjusted
- nervousness, anxiety, restlessness, headache
- nausea, vomiting: give drug with food and full glass of water
- dizziness: provide for safety
Anti-Cholinergic Broncho-Dilating Agent:

2 agents:
◦ ipratropium bromide (Atrovent, Atrovent HFA)
◦ tiotropium bromide (Spiriva)
ipratropium bromide (Atrovent, Atrovent HFA):
 act on bronchial smooth muscle
 produce bronchodilation
 used for long-term treatment of broncho-spasm associated
with COPD
 initial effect seen within first few minutes after inhaled
 broncho-dilation lasts for 4-6 hours
 nasal spray used for rhinorrhea from rhinitis and common
cold
 does NOT relieve nasal congestion, sneezing or post-nasal
drip
 goals of therapy:
◦ ease breathing (dose metered inhaler)
◦ reduce rhinorrhea (nasal spray)
Assisting With the Nursing Process
ipratropium bromide (Atrovent, Atrovent HFA):
ASSESSMENT: measure vitals
PLANNING: aerosol canister: 18mcg/metered dose inhaler (200
inhalations)
nasal spray pumps: 0.03% (21mcg/spray) or 0.06% (42mcg/spray)
IMPLEMENTATION: inhalation: usual dose is 2 inhalations 4x/day,
additional inhalations may be taken as required, should not exceed
12 inhalations in 24 hours.
nasal spray: for rhinitis 2 sprays of a 0.3% solution in each nostril 23x/day; for common cold 2 sprays of 0.6% solution in each nostril
3-4x/day
EVALUATION: report and record:
- tachycardia, urinary retention, worsening of respiratory symptoms
- mouth dryness, throat irritation: usually mild and tend to resolve
with continued therapy. Provide oral hygiene, nurse may allow hard
candy or ice chips
tiotropium bromide (Spiriva)
given by dry powder inhalation
• causes bronchial smooth muscles to relax, resulting in
broncho-dilation
• drug used as a once-daily broncho-dilator to treat bronchospasm associated with COPD.
• broncho-dilating effect does NOT happen at once, therefore
the drug is used for maintenance treatment
• goal of therapy: easier breathing with less effort
•
Assisting With the Nursing Process
tiotropium bromide (Spiriva):
ASSESSMENT: measure vitals
PLANNING: inhalation dose form is 18mcg
capsules for use in supplied HandiHaler
IMPLEMENTATION: usual dose is 1 capsule
daily given through the HandiHaler.
EVALUATION: report and record:
- tachycardia, urinary retention, worsening of
respiratory symptoms
- mouth dryness, throat irritation: usually mild and
tend to resolve with continued therapy. Provide
oral hygiene, nurse may allow hard candy or ice
chips
Xanthine-Derivative Broncho-Dilating Agents:

act directly on the smooth muscle of the trachea, bronchi
and bronchioles, to dilate the bronchi

increased the airflow in and out of alveoli

used with sympathomimetic broncho-dilators to reverse
airway constriction caused by COPD

goal of therapy: breathing with less effort
Assisting With the Nursing Process
Xanthine-Derivative Broncho-Dilating Agents:
ASSESSMENT: measure vitals, note heart rate and rhythm,
observe orientation to person, time and place. Observe for
anxiety and nervousness.
PLANNING: see table 24-5 (pg. 310) for “Dose Forms”
IMPLEMENTATION: see table 24-5 (pg. 310) for “Adult
Dosage Range”
EVALUATION: report and record:
- nausea, vomiting, epigastric pain, abdominal cramps. These
occur from irritation caused by the stimulation of gastric
acid secretion. Give drug with food/milk.
- tachycardia, palpitations: usually dose related, measure heart
rate and rhythm
- tremors: a dosage adjustment may be needed
- nervousness, anxiety, restlessness, headache: observe for
changes in mental status
Respiratory Anti-inflammatory Agents:
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cortico-steroids are given to reduce inflammation (ch. 28)
highly effective in treating COPD
they:
◦ relax smooth muscles
◦ enhance effects of beta-adrenergic broncho-dilators
◦ inhibit inflammatory responses that may cause broncho-constriction
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agents may be added to a dry therapy program if person
does not respond to other broncho-dilators
goal of therapy: easier breathing with less effort
Assisting With the Nursing Process
inhalant cortico-steroids:
ASSESSMENT: observe mouth for signs/symptoms of
infection
PLANNING: see table 24-6 (pg. 312) for “Inhalant Dose
Forms”
IMPLEMENTATION: see table 24-6 (pg. 312) for “Adult
Dosage Range”. Full therapeutic effect requires regular use,
usually evident within a few days. Persons receiving bronchodilators by inhalation should use them before the corticosteroid inhalant., this enhances inhalation.
EVALUATION: report and record:
- hoarseness, dry mouth: usually mild and tend to resolve with
continued therapy
- signs and symptoms of mouth infection: Provide oral hygiene.
Follow care plan for using a mouthwash
Anti-Leukotriene Agents:
inflammatory cells are in the membrane lining the airway
 a series of chemical reactions occur when the inflammatory
cells are triggered by irritants
 irritants include: smoke, allergens and viruses
 one reaction is the release of leukotrienes
 Leukotrienes are substances in the white blood cells. White
blood cells are called leukocytes
 leukotrienes produce allergic and inflammatory reactions
similar to histamine
 they produce many signs/symptoms of asthma (box 24-2)
 these are anti-leukotriene agents:

◦ montelukast (Singulair)
◦ zafirlukast (Accolate)
montelukast (Singulair):
competes for receptor sites that trigger asthma symptoms
 it reduces:

◦ broncho-constriction
◦ daytime asthma symptoms
◦ night-time awakening

goal of therapy: fewer episodes of acute asthma symptoms
Assisting With the Nursing Process
montelukast (Singulair):
ASSESSMENT: measure vital signs
PLANNING: oral dose forms: 5 and 10mg tablets, 4mg chewables,
4mg granules
IMPLEMENTATION: adult dose is 10mg give once daily in the
evening
EVALUATION: report and record:
- headache, nausea, indigestion: usually mild and resolve, give drug
with food or milk
zafirlukast (Accolate):


competes for receptor sites that trigger symptoms of asthma
helps to reduce:
◦ broncho-constriction
◦ daytime asthma symptoms
◦ night-time awakening

goal of therapy: fewer episodes of acute asthma symptoms
Assisting With the Nursing Process
zafirlukast (Accolate):
ASSESSMENT: measure vital signs
PLANNING: oral dose forms 20mg tablets
IMPLEMENTATION: adult dose is 20mg, 2x/day
EVALUATION: report and record:
- headache, nausea: usually mild and resolve, give drug with
food or milk