Corticosteroids, Bronchodilators Respiratory Agents Flashcards
asthma
○ Chronic airway inflammation, causes bronchial constriction
○ Wheezing and difficulty breathing
○ Tightness of chest
- inspiratory wheeze
chronic bronchitis
○ Continous inflammation of bronchi
○ Excessive secretion of mucus
Blue bloater – pts appear cyanotic and often have edema
Emphysema
○ Alveolar wall destruction and enlarged air spaces
○ Impaired gas exchange
○ Smoking is the primary causation
Permanent inflation of the air sacks – decreases perfusion, impaired gas exchange.
Pink puffer – body compensates by hyperventilating, pts look pinkish & thin (use a lot of extra energy)
Bronchodilators include
○ B-Adrenergic Agonists
○ Anticholinergic Drugs
○ Xanthine Derivatives
Non-Bronchodilators include
○ Corticosteroids
○ Leukotriene Receptor Antagonists (LTRAs)
Bronchodilators:
B-Adrenergic Agonists
Indication for Use
○ Used to treat severe bronchospasm
○ For quick relief of symptoms** fastest acting bronchodilators
- immediate onset of action for acute attacks
Bronchodilators:
B-Adrenergic Agonists
Mechanism of Action
○ Stimulates B2-Adrenergic receptors in the lungs
○ Relaxes bronchial smooth muscles which causes dilation of the bronchi and bronchioles
Bronchodilators:
B-Adrenergic Agonists
medications
○ Salbutamol (Ventolin), short acting (BLUE COLOR = used first) Onset of action (inhaled) is IMMEDIATE
○ Salmeterol xinafoate (Serevent), long acting
○ Combination: Steroid and B-Adrenergic (Symbicort or Advair)
Salbutamol (Ventolin)
■ Onset of action (inhaled) is IMMEDIATE
- It is sympathomimetic*** (Imitates norepinephrine on the b-cells and causes vasodilation and increases ventilation)
o Comes in IV & inhalation (puffer/aero chamber: metered dose inhaler; or nebuliser)
- Can be given on a regular basis but mostly in combination (with a long acting), used mostly for quick relief of bronchospasms.
Adverse Effects of B-Adrenergic Agonists
○ Tachycardia
○ Palpitations
○ Tremor
○ Nervousness/anxiety
○ Hypertension/hypotension
○ Headache
- If used too frequently, dose-related adverse effects may be seen because B-Adrenergic loses it’s B2 specific action, especially at larger doses
Bronchodilators:
Anticholinergics
Indication for Use
Maintenance and prevention of bronchospasm
Bronchodilators:
Anticholinergics
action
Prevents bronchial constriction by blocking acetylcholine receptors
Bronchodilators:
Anticholinergics
medication
○ Ipratropium bromide (Atrovent) GREEN COLOR - used second
○ Tiotropium bromide monohydrate (Spiriva - it is a pill !!)
○ Salbutamol and ipratropium combination (Combivent)
Bronchodilators:
Xanthine Derivatives
indications for use
○ Prevention of symptoms/maintenance
○ Used with mild/moderate asthma
○ Used with chronic bronchitis and emphysema
Adverse Effects of Anticholinergics
○ Dry mouth/throat
○ Nasal congestion
○ Heart palpitations
○ Urinary retention
○ GI problems
○ Increased intraocular pressure
○ Headache
○ Coughing
○ Anxiety
Bronchodilators:
Xanthine Derivatives
Action
Causes bronchodilation by inhibiting phosphodiesterase enzyme results in smooth muscle dilation
Bronchodilators:
Xanthine Derivatives
medications
○ Theophylline (oral): narrow therapeutic window (chronic COPD)
○ Aminophylline (IV only - metabolized as theophylline): used for status asthmaticus** (when asthma attack does not stop no matter what interventions**)
Adverse Effects of Xanthine Derivatives
○ Cardiac irregularities
■ Tachycardia
■ Palpitations
■ Ventricular dysrhythmias
○ GERD
■ Nausea
■ Vomiting
■ Anorexia
○ Increased urination
○ Hyperglycemia*
Non-Bronchodilators:
Corticosteroids
indications for use
○ Anti-inflammatory
○ For management of difficult to treat asthma/respiratory illnesses
○ Allergic rhinitis
○ Mainly inhalation, sometimes PO (more localized tx & less SE)
Non-Bronchodilators:
Corticosteroids
Action
○ Prevent non-specific inflammatory processes by acting on the 5 types of WBC
○ Controls inflammatory responses
○ Increases the effects of B-Agonists (bronchodilation)
Non-Bronchodilators:
Corticosteroids
medications
○ Budesonide (Pulmicort)
○ Fluticasone propionate (Flovent) ORANGE COLOR (used third)
○ Prednisone
○ Combination with B-Agonist (Advair)
Adverse Effects of Corticosteroids (bronchodilators)
○ Pharyngeal irritation
○ Cough and dry mouth
○ Oral fungal infections (yeast on the tongue, roof of mouth, buccal cavity)
■ PO provides more systemic effects, therefore adverse effects are more systemic
■ Susceptibility to infection
■ Fluid and electrolyte imbalance
■ Endocrine effects (hyperglycemia)
■ Osteoporosis
Non-Bronchodilators:
Leukotriene Receptor Antagonist
indications for use
○ Used for the prophylaxis and long-term treatment and prevention of asthma
○ Seasonal allergies/asthma
Non-Bronchodilators:
Leukotriene Receptor Antagonist
medications
○ Montelukast (Singulair) PO
○ Zafirlukast (Accolate) PO
■ Both are dosed once daily
Nursing Assessment respiratory
- Respiratory assessment
- Environmental exposures and allergens
- Smoking habits
- Emotional status (anxiety/fear/stress)
- Allergies
- Caffeine intake
Adverse Effects of Leukotriene Receptor Antagonist
○ Nausea
○ Diarrhea
○ Headache
○ Nightmares
○ Liver dysfunction
Nursing Interventions respiratory
- Discuss adherence to medication regimen
- Demonstrate proper administration of inhaled drugs
- Reassess respiratory system and breath sounds
- Instruct patient to rinse mouth with water after use of inhaler or nebulized drug
- Especially with use of steroids and anticholinergic to prevent dryness and muscosal irritation
- Wash inhaler, spacer, and nebulizer every week with warm soapy water
How to Use:
- A metered dose inhaler (MDI)
2 puffs of same, requires 1-2 minute break in between doses
- puffs of different medications, requires 2-5 minute break in between doses
How to Use:
- A metered dose inhaler (MDI) with apcer/aerochamber
Place the 2 puffs of one medication, until patient inhales all medication, then add second medication puffs to aerochamber
Corticosteroid levels regulated by the ?
the hypothalamic-pituitary-adrenal (HPA) axis
the hypothalamic-pituitary-adrenal (HPA) axis
There is a negative feedback between the hormones
■ Hypothalamus produces corticotropin releasing hormone (CRH) then
■ Anterior pituitary produces adrenocorticotropic hormone (ACTH) then
■ Adrenal cortex produces glucocorticoids (CORT) then the negative
feedback continues
Adrenal Gland
Adrenal Cortex (80-90%)
- Corticosteroids
- Glucocorticoids
- Mineralocorticoids
Adrenal Medulla (10-20%)
- Epinephrine
- Norepinephrine
Corticosteroids
- Glucocorticoids
- Mineralocorticoids
Glucocorticoids
- Major anti-inflammatory actions
- Regulates carbohydrate, protein, and lipid metabolism
- Maintenance of normal BP
- Stress effects
- Immune response
Mineralocorticoids
- BP control
- Maintenance of pH levels in the blood
- Maintenance of serum K levels
- Sodium and water reabsorption
Cushing’s syndrome
an oversecretion of adrenal hormones
- Glucocorticoid hypersecretion: redistribution of body fat from arms and legs to
face, shoulder, trunk, and abdomen, characteristic ‘moon face’ - Aldosterone hypersecretion: increased water and sodium retention, and muscle
weakness from potassium loss - Causes: tumor, excessive administration of steroids (medications)
Addison’s disease
an under secretion of adrenal hormones
- - Decreased blood sodium and glucose levels, increased potassium levels
Addison’s disease S&S
- hyperpigmentation, weakness, headache, fatigue, nausea, vomiting, anorexia, dehydration, weight loss, confusion, fever, abdominal pain, increased HR, diaphoresis, decreased BP
- Often vague, chronic, and non-specific complaints
Mineralocorticoids
indications for use
○ Used for Addison’s disease
○ Promotes hydrogen and potassium excretion
○ Helps regulate blood pH
Mineralocorticoids
Action
Acts on distal kidney tubule, leading to sodium reabsorption into blood, which pulls water and fluids, helping to regulate edema and BP (hypertension)
Mineralocorticoids medication
Fludrocortisone 21-acetate (drug replacement)
Glucocorticoids
indictions of use
○ Bronchospasms (inhalation using fluticasone-flovent)
○ Allergic rhinitis (nasal route using fluticasone-flonase)
○ Inflammation of ear, eye, and skin (topical route using betamethasone)
○ Exacerbations of chronic respiratory illnesses (asthma and COPD) (inhalation using methylprednisolone (SOLU-MEDROL [4mg]) or hydrocortisone (SOLU-COTEF [20mg]). Not interchangeable !!!
○ Bacterial meningitis
○ Cerebral edema
○ Collagen diseases; systemic lupus erythematosus
○ Dermatological diseases
○ Endocrine diseases; thyroiditis
○ GI diseases; ulcerative colitis
○ Ocular disorders
○ Leukemia and lymphoma
Glucocorticoids
Action
○ Promotes breakdown of protein, production of glycogen in liver, and redistribution of fat from peripheral areas to central areas of body
○ It inhibits inflammatory and immune responses
○ Inhibits or controls inflammatory response by
(1) stabilizing cell membranes of inflammatory cells,
(2) decreasing permeability of capillaries to inflammatory cells,
and (3) decreasing migration of WBCs into inflamed areas
○ Some mineralocorticoid-like activity such as fluid and water retention
Glucocorticoids medications
○ Adrenocorticotropic hormone (ACTH)
○ Betamethasone
○ Cortisone
○ Dexamethasone
○ Hydrocortisone
○ Methylprednisone
○ Prednisolone
○ Triamcinolone
Dexamethasone (PO, IV, IM)
class: Synthetic, long acting glucocorticoid
indications:
○ Variety of endocrine, rheumatic, collagen, dermatological allergic, ocular,
respiratory, hematological, neoplastic, GI, nervous system disorders
○ Inflammation
Fludrocortisone 21-acetate (PO)
class: Synthetic mineralocorticoid
indications:
○ Addison’s disease
○ Salt losing adrenogential syndrome
Hydrocortisone (PO, IV, IM)
class: Natural short-acting glucocorticoid
indications:
○ Adrenocortical insufficiency
○ Many inflammatory conditions
Prednisone (PO)
class: Synthetic, immediate acting glucocorticoid
indications:
○ Variety of endocrine, rheumatic, collagen, dermatological allergic, ocular,
respiratory, hematological, neoplastic, GI, nervous system disorders
○ Inflammation
Adverse Effects of Corticosteroids
- Worse effects are seen in glucocorticoids !!!
- Increased risk of infections
- Hyperglycemia
- Mania/psychosis
- Insomnia
- Akathisia
- Depression
- Euphoria
- Osteoporosis
- Gastritis
- Fluid retention
- Hypertension
- Arrhythmias
- Acne
- Weight gain
- Skin thinning
Adrenal Drugs: Corticosteroids Nursing Process
- Assess nutritional and hydration status, baseline weight, intake and output, VS, skin condition, and immune status
- Assess muscle strength and stature
- Baseline laboratory values
- Growth suppression in children and adrenal suppression in older adults
- Benefits outweight risks of drug’s adverse effects
- Best time to give glucocorticoids is early morning between 0600 and 0900, which
minimizes adrenal suppression - Avoid alcohol, caffeine, aspirin, and NSAIDs
- Healing may be decreased with long term therapy (immunocompromised)
- Assess therapeutic response and adverse effects to monitor effectiveness
- Observe for Addisonian crisis***
Adrenal Drugs: Corticosteroids Nursing Process Routes
- Oral
- Give with milk, food, or antacids
- IM
- Administered into large muscle with rotation of sites
- Topical
- Skin should be clean and dry, gloves are worn for application
- Nasally
- Clear nasal passage first, patient breathes in through the nose with administration
- Inhaled
- Fungal infections common, rinse mouth with lukewarm water
Adrenal Drugs: Corticosteroids Nursing Process Patient Education
- NEVER stop taking medications abruptly or alter dose
- Long term effects of glucocorticoid therapy
- Bone health and prevention of falls
- S&S of acute adrenal insufficiency
- Document response to treatment, BP, daily weight, adverse effects
- Maintian low-sodium and high-potassium diet
What is the rationale for using inhaled budesonide (Pulmicort®)?
It provides an anti-inflammatory response.
Combivent
Combination Anticholinergic and B-Adrenergic
Symbicort
Combination B-Adrenergic and Corticosteriod
budesonide (Pulmicort)
Inflammatory response and synergistic response of B-agonist
true or false: Peak flows are used during times of acute illness
false
true or false: Peak flow is used to assess patients ability to breath out
true
true or false: Peak flow reading reflects the patients degree of obstruction
true
true or false: Peak flows are used prior to the inhaler
true
When teaching a patient who has been prescribed a daily dose of prednisone, the nurse knows that the patient will be told to take the medication at which time of the day to help reduce adrenal suppression?
In the morning
