Chapter 39: Drugs for Allergic Rhinitis and the Common Cold

Question 1

Identify the major functions of the upper respiratory tract.

Answer 1

The upper respiratory tract consists of the nose, nasal cavity, pharynx, and paranasal sinuses. It warms, humidifies, and cleans the air before it gets to the lungs. It is lined with ciliated epithelium that traps particulate matter and pathogens and moves them to the esophagus to be swallowed.

Question 2

Describe common causes and symptoms of allergic rhinitis.

Answer 2

Cause: inflammation of the nasal mucosa due to exposure to allergens (there is a strong genetic predisposition).

Allergen: anything that is recognized as foreign and provokes a response from the body’s defense system (pollen, mold, dust mites, animal dander).

Symptoms: tearing eyes, sneezing, nasal congestion, postnasal drip, itching of the throat.

Question 3

Differentiate between H1 and H2 histamine receptors.

Answer 3

H1 receptors: cause allergy symptoms

H2 receptors: cause peptic ulcers (found in gastric mucosa)

Question 4

Compare and contrast the oral and intranasal decongestants.

Answer 4

Oral decongestants: do not produce rebound congestion, slower onset, less effective at relieving severe congestion, possibly systemic effects (hypertension, CNS stimulation)

Intranasal decongestants: produce rebound congestion, few systemic effects, should only be used for 3 to 5 days

Question 5

Discuss the pharmacotherapy of cough.

Answer 5

Two methods:
Act on the Medulla of the CNS to suppress the cough reflex
Anesthetize stretch receptors in the lungs to suppress cough reflex

Question 6

Describe the role of expectorants and mucolytics in treating bronchial congestion.

Answer 6

Mucolytics loosen thick bronchial secretions by breaching down the chemical structure of mucus.

Question 7

What is the H1-receptor antagonists (antihistamine) drug representative, MOA, primary actions on the respiratory system, and important adverse effects?

Answer 7

Drug: diphenhydramine (Benadryl)
MOA: H1-receptor antagonist (antihistamine). Stops production of histamine.
Actions: Treat minor symptoms of allergy and the common cold.
Adverse Effects: Significant drowsiness, paradoxical CNS stimulation and excitability (in children)

Question 8

What is the mast cell stabilizers drug representative, MOA, primary actions on the respiratory system, and important adverse effects?

Answer 8

Drug: cromolyn (NasalCrom)
MOA: inhibits histamine production from mast cells
Actions: nasal decongestion; prophylactic for allergies
Adverse Effects: few

Question 9

What is the intranasal corticosteroids drug representative, MOA, primary actions on the respiratory system, and important adverse effects?

Answer 9

Drug: fluticasone (Flonase, Veramyst, others)
MOA: decreases the secretion of inflammatory mediators, reduces tissue edema, and causes a mild vasoconstriction
Actions: Seasonal allergies, decrease local inflammation. Topically used for: eczema, atopic dermatitis, psoriasis, and contact dermatitis
Adverse Effects: rare for nasal (nasal irritation, epistaxis)l ingested has potential for systemic effects

Question 10

What is the decongestants drug representative, MOA, primary actions on the respiratory system, and important adverse effects?

Answer 10

Drug: oxymetazoline (Afrin, others)
MOA: activates alpha-adrenergic receptors int he sympathetic nervous system
Actions: Constricts arterioles in the nasal passage drying mucous membranes
Adverse Effects: rebound congestion, minor stinging and dryness

Question 11

What is the antitussives drug representative, MOA, primary actions on the respiratory system, and important adverse effects?

Answer 11

Drug: dextromethorphan (Delsym, Robitussin DM, others)
MOA: acts on Medulla in the CNS to suppress cough reflex
Actions: cough suppressant
Adverse Effects: dizziness, drowsiness, and GI upset

Question 12

What is the expectorants, mucolytics, and drugs for cystic fibrosis drug representative, MOA, primary actions on the respiratory system, and important adverse effects?

Answer 12

Drug: acetylcysteine (Acetadote, Cetylev, Mycomyst)
MOA: Loosen thick bronchial secretions by breaking down their chemical structure
Actions: Mycolytic; can be used in cystic fibrosis and chronic bronchitis
Adverse Effects: Bronchospasms

Question 13

Use the nursing process to care for patients who are receiving pharmacotherapy for allergic rhinitis and the common cold.

Answer 13

Assess history, vitals, and appropriate lab findings, continue to monitor throughout therapy. Assess for desired effects. Teach for seasonal allergies to take prior to getting symptoms and increase fluid intake to help loosen mucus.

Question 14

The patient has been prescribed oxymetazoline (Afrin) nasal spray for seasonal rhinitis. Which instructions will the nurse provide?

a. Limit use of this spay to 5 days or less
b. The drugs may be sedating so be cautious with activities requiring alertness
c. This drug should not be used in conjunction with antihistamines.
d. This is an over-the-counter drug and may be used as needed for congestion

Answer 14

a. Limit use of this spay to 5 days or less

Prolonged use of oxymetazoline (Afrin) causes hyper-secretion of mucus and worsening nasal congestion, resulting in increased daily use. This medication should not be used longer than 5 days unless otherwise directed. It may be used with antihistamines for symptomatic relief and it is not sedating.

Question 15

A patient has a prescription for fluticasone (Flonase) for allergic rhinitis. Place the following instructions in order in which the nurse will instruct the patient to use the drug.

1. Instill one spray directed high into the nasal cavity
2. Clear the nose by blowing
3. Prime the inhaler prior to first use
4. Spit out any excess liquid that drains into the mouth

Answer 15

3. Prime the inhaler prior to first use
4. Clear the nose by blowing
5. Instill one spray directed high into the nasal cavity
6. Spit out any excess liquid that drains into the mouth

When an intranasal inhaler is used, the device should be primed prior to the first use. The nasal passages should be cleared by blowing. The drug should be instilled by spray directed high into the nasal passages. Any liquid that drains should be spit out.

Question 16

A man, age 67, reports taking diphenhydramine (Benadryl) for hay fever. Considering this patient’s age, the nurse assesses for which findings?

a. A history of prostatic or urinary conditions
b. Any recent weight gain
c. A history of allergic reactions
d. A history of peptic ulcer disease

Answer 16

a. A history of prostatic or urinary conditions

Diphenhydramine (Benadryl) and other antihistamines are contraindicated in patients with BPH or lower urinary tract obstruction because anticholinergic effects may worsen these conditions. Diphenhydramine (Benadryl) is a common treatment for allergic conditions and has no effects on weight gain or peptic ulcer disease.

Question 17

The nurse is teaching a patient about the use of dextromethorphan with guaifenesin (Robitussin-DM) syrup for a cough accompanied by thick mucus. Which instruction should be included in the patient’s teaching?

a. Lie supine for 30 minutes after taking the liquid
b. Drink minimal fluids to avoid stimulating the cough reflex
c. Take the drug with food for best result
d. Avoid drinking fluids immediately after the syrup, but increase overall fluid intake throughout the day

Answer 17

d. Avoid drinking fluids immediately after the syrup, but increase overall fluid intake throughout the day

The syrup base of dextromethorphan will help soothe throat irritation, and fluids should be avoided immediately following administration. Overall fluid intake should be increased throughout the day. The patient does not need to remain supine after taking this drug, take the drug with food, or avoid fluid intake.

Question 18

A patient has been prescribed fluticasone (Flonase) to use with oxymetazoline (Afrin). How should the patient be taught to use these drugs?

a. Use the fluticasone first, then the oxymetazoline after waiting 5 minutes
b. Use the oxymetazoline first, then the fluticasone after waiting 5 minutes
c. The drugs may be used in either order
d. The fluticasone should be used only if the oxymetazoline fails to relieve the nasal congestion

Answer 18

b. Use the oxymetazoline first, then the fluticasone after waiting 5 minutes

The oxymetazoline (Afrin) should be used first, followed by the fluticasone (Flonase) after waiting 5 to 10 minutes. When a decongestant and corticosteroid nasal spray are used together, the decongestant spray should be used first to allow time for the nasal passageway to open, allowing the corticosteroid to reach deeper into the nasal passageway. The drugs are ordered in combination for better control of nasal rhinitis. The oxymetazoline should not be used for over 5 days unless otherwise instructed.

Question 19

Which of the following is the best advice that the nurse can give a patient with viral rhinitis who intends to purchase an over-the-counter combination cold remedy?

a. Dosages in these remedies provide precise dosing for each symptom that you are experiencing
b. These drugs are best used in conjunction with an antibiotic
c. It is safer to use a single-drug preparation if you are experiencing only one symptom
d. Since these drugs are available over the counter, it is safe to use any of them as long as needed

Answer 19

c. It is safer to use a single-drug preparation if you are experiencing only one symptom

Single-symptom OTC preparations are preferred over multi-use preparations to avoid additional drugs that are not needed for symptom relief and to decrease risk of additional adverse effects. Dosing of any OTC preparation is carefully calculated to provide precise dosage for age and symptoms. Antibiotics may be required for serious infections, but for common symptoms OTC remedies are recognized as safe and effective. However, they should not be used indefinitely without consultation with a healthcare provider.

Question 20

George Orlanski, who is 60 years old, has had bronchitis with coughing for several days. He has been losing sleep because of the severity of the cough, and it is starting to affect his work. He finally goes to the local urgent care clinic for treatment. He is diagnosed with acute viral bronchitis and is given a prescription for an antitussive.

As the nurse, of the two antitussive medications, dextromethorphan and codeine, which is the drug of choice for this patient? Why?

Answer 20

Dextromethorphan

Although codeine is a more powerful antitussive, it can cause dependence and constipation. Dextromethorphan is a more appropriate choice for this patient initially, with codeine syrup as a potential alter choice for more severe cough symptoms.

Question 21

George Orlanski, who is 60 years old, has had bronchitis with coughing for several days. He has been losing sleep because of the severity of the cough, and it is starting to affect his work. He finally goes to the local urgent care clinic for treatment. He is diagnosed with acute viral bronchitis and is given a prescription for an antitussive.

George asks why the provider did not have him an antibiotic prescription. What is the best answer to his question?

Answer 21

It is a viral infection not bacterial.

Antibiotics are used to treat bacterial infections and will not be effective for viral conditions.

Question 22

George Orlanski, who is 60 years old, has had bronchitis with coughing for several days. He has been losing sleep because of the severity of the cough, and it is starting to affect his work. He finally goes to the local urgent care clinic for treatment. He is diagnosed with acute viral bronchitis and is given a prescription for an antitussive.

What additional measures can George use to relieve his cough and what additional information does he need?

Answer 22

In addition to the antitussive, George should increase his fluid intake throughout the day to help moisten his airway and liquify any mucus present. Using hard candy or lozenges may prevent the dryness in his throat and decrease coughing. A humidifier at night may also reduce the dryness in his airways. As the nurse, you would also teach George to check his temperature periodically, and if he develops a fever or if he has increasing sputum production, he should return to the provider to be reassessed.

Question 23

a 74-year-old male patient informs the nurse that he is taking diphenhydramine (Benadryl) to reduce seasonal allergy symptoms. This patient has a history of BPH and mild glaucoma (controlled by medication). What is the nurse’s response?

Answer 23

The nurse should ensure that the patient understand the potential side effects related to the anticholinergic effects of this medication. This patient, based on his age, is at higher risk for urine retention, glaucoma (or other visual changes), and constipation. The nurse should complete a health assessment for these conditions and provide patient education about the need to report any changes to the healthcare provider.

Question 24

A 67year-old patient has allergic rhinitis and always carries a handkerchief in his pocket because he has nasal discharge nearly every day. Sometimes his nose is stuffy and dry. The healthcare provider prescribes fluticasone (Flonase). He is to take one spray intranasally at bedtime. The patient starts to take fluticasone and a week later calls the provider’s office and talks to the nurse. He says, “This Flonase is not helping me.” What is the nurse’s best response.

Answer 24

Intranasal corticosteroids, such as fluticasone (Flonase), may take as long as 2 to 4 weeks to work The medication should not be discontinued prematurely. If a decongestant spray is being used along with the Flonase, the decongestant should always be administered first to clear the nasal passages, which will facilitate adequate application of the fluticasone.

Question 25

Alcohol should be avoided by a patient who is taking antihistamines. Does this hold true for second-generation antihistamines, or does it just apply to the first-generation drugs?

Answer 25

Alcohol and other CNS depressants should be used with caution when taking antihistamines, because of their sedating effects may be additive. This also applies to the second-generation drugs.

Question 26

What does the nasal mucosa contain? What do they do?

Answer 26

Mast cells (connective tissue that releases histamine) and basophils (leukocytes).
Recognizes allergens as they enter the body and releases histamine and other inflammatory mediators.

Question 27

What is the therapeutic goal of preventers in allergic rhinitis? What drugs are used?

Answer 27

Used prophylactically; includes histamines, intranasal corticosteroids, leukotriene modifiers, and mast cell stabilizers. To prevent symptoms from occurring. Begin taking before allergy season.

Question 28

What is the therapeutic goal of relievers in allergic rhinitis? What drugs are used?

Answer 28

Provides immediate, temporary, relief of symptoms; includes oral and intranasal decongestants (sympathomimetic class). Take when symptoms occur.

Question 29

What do antihistamines cause?

Answer 29

Anticholinergic effects: increased heart rate, urinary retention, constipation, and blurred vision
CNS stimulation can occur causing insomnia, nervousness, and tremors

Question 30

Compare first-generation antihistamines to second-generation

Answer 30

More adverse effects in first generation. Second generation is considered safer.
First generation drugs include: Benadryl
Second generation drugs include: Zyrtec, Allegra, Claritin

Question 31

Besides allergic rhinitis, what are antihistamines used for?

Answer 31

Vertigo and motion sickness (suppresses the vomiting center in the medulla and depresses the neurons of the vestibular apparatus of the inner ear)

Parkinson’s disease (treat tremor and adverse effects of conventional antipsychotic drugs)

Insomnia (first generation drugs cause drowsiness)

Urticaria (hives) and other skin rashes (topical cream)

Question 32

What did corticosteroids largely replace?

Answer 32

Antihistamines for allergic rhinitis

Prophylactically

Question 33

What do corticosteroids do?

Answer 33

Decrease secretion of inflammatory mediators, reduce tissue edema, and cause mild vasoconstriction

Question 34

What are mast cell stabilizers?

Answer 34

Drugs that inhibit the release of histamine from mast cells.

Used prophylactically.

Question 35

Nasal decongestants are typically what kind of drug?

Answer 35

Sympathomimetic with alpha-adrenergic activity (activates the sympathetic nervous system)

Question 36

What is the purpose of a cough?

Answer 36

Natural reflex mechanism that forcibly removes excess secretions and foreign materials from the respiratory system. Certain diseases should not have a cough suppressed (emphysema, aspiration, bronchitis)

Question 37

What do expectorants do?

Answer 37

Reduce thickness of bronchial secretions and increase mucus flow
Most effective in nonproductive coughs

Question 38

What do mucolytics do?

Answer 38

Loosen thick bronchial secretions by breaking down the chemical structure

Question 39

What causes cystic fibrosis? What is it? Is there treatment?

Answer 39

Two defective copies of the cystic fibrosis transmembrane conductance regulator (CFTR) gene causing poor water flow, chloride, and salt out of cells leading to buildup of thick, sticky mucus causing chronic lung infections, tissue damage, and a shortened life.
Medications improve lung function and quality of life.