Exam 2 Flashcards
Cold symptoms
Limited to upper respiratory tract
-Pharynx, nasopharynx, nose, and sinuses
Main cold season is Aug through early April
Cold risk factors
High population density such as shared workspaces
Respiratory allergies
Smoking
Sedentary lifestyle
Sleep deprivation
Getting Chilled –> common misconception
Cold symptom timeline
Day 1-3: sore throat first then nasal dominate days 2 & 3
-Red pharynx, nasal obstruction, mildly tender sinuses
-Nasal drainage: clear thing and watery
Days 4-5
-Cough in under 20% of people
-Secretions thicken and color may change to yellow/green
*Color due to myeloperoxidase
Day 6 and onward
Secretions return to clear as cold resolves
*Low grade fever possible especially in children
When to refer a patient for a cold
Oral temp greater than 100.4 F
Chest pain
Shortness of breath
Worsening of symptoms or new symptoms occur during self-care
Concurrent health conditions (asthma, COPD, CHF)
AIDs or chronic immunosuppressive therapy
Frail older adults of advanced age
Infants <3 months of age
Goals of therapy in Colds
Prevent transmission of cold viruses
Reduce bothersome symptoms
Treatment strategies
Nondrug therapies
Single entity OTC products to treat specific symptoms-because combo products because symptoms peak and resolve at different times no need to put chemicals in body if its not going to be helpful
Complementary and non pharmacologic options
Hydration: water, juice, broth, chicken soup (limited anti-inflammatory evidence), ice pop
Adequate rest
Nutritious diet: no evidence that withholding dairy decreases cough or congestion
Increased humidification:
-Humidifiers
-saline nasal spray or drops
-Saline gargles (1/4 - 1/2 tsp of table salt in 8 oz of warm water)
-Steamy showers
Aromatic oils: camphor, menthol, eucalyptus
Zinc and Vitamin C
Breathe right nasal strips: Temp relieve congestion
Antiviral disinfectant: helps prevent transmission
-hand hygiene
-body positioning
-nasal bulb syringe (can’t blow nose till age 4 and regularly clean bulb, soften mucous)
Zinc
-Method of action: Inhibits rhinovirus binding and replicating in the nasal mucosa thereby suppressing inflammation
-When administered within 24 hours of cold symptom onset, zinc reduces duration and severity
-Dosing: 1 lozenge (at least 13 mg/lozenge) every 2 hours while awake, initiate at first sign of cold
-Side effects: nausea, upset stomach, diarrhea, irritation of oral mucosa, distortion of taste, copper deficiency (high doses)
Vitamin C
Method of Action: antioxidant properties, stimulate neutrophil and monocyte activity
Efficacy for prophylaxis and treatment of colds has been debated for > 70 years
Preventative, high dose > 2 grams/day
(not helpful to prevent colds in general pop, except patients with severe physical stress)
Side effects: diarrhea, GI upset at 4 g/day or more
OTC treatment options
Congestion/rhinorrhea: saline nasal spray, decongestants, 1st gen antihistamine
Aches/pains: systemic analgesics
Pharyngitis: saline gargles or local anesthetic sprays/lozenges, systemic analgesics
Sleeplessness: nasal decongestant spray and 1st gen antihistamine or alcohol containing product
Follow up with Primary care provider if:
Sore throat longer than several days
Symptoms worse during OTC
Symptoms persist/worse, Fever greater than 101.5
Pseudoephedrine
Mechanism of action: alpha adrenergic agonists that constrict blood vessels, decreasing sinusoid vessel engorgement and mucosal edema or swelling
Indication: temporary relief of nasal and eustachian tube congestion and cough associated with post nasal drip
Pharmacodynamics: Immediate release
Onset- within 30 minutes
Duration- 4-6 hours
Side Effects: CV (elevated BP and HR, palpitations, arrythmias), CNS (tremor, insomnia, anxiety, irritability, dizziness, HA), other (rebound nasal congestion, nausea/anorexia, difficulty urinating)
Drug interactions: ergot derivatives, linezolid, MAOIs, SNRIs
Avoid: if taking MAOIs
Pseudoephedrine with Pregnanacy and Lactation
Generally ok for pregnancy in first trimester but it could possibly raise BP and cause digestive issues
In lactating women it can reduce the flow of milk
Pseudoephedrine on BP and HR
Effects on BP and HR infrequently clinically relevant
Only raise BP by 1 mmHg
Naphazoline, oxymetazoline, phenylephrine, propylhexedrine
MOA: alpha adrenergic agonists that constrict blood vessels, decreasing sinusoid vessel engorgement and mucosal edema or swelling
Indication: temporary relief of nasal and eustachian tube congestion and cough associated with post nasal drip
Pharmacodynamics:
onset - within a few minutes
duration - varies by agent between 4-12 hours
Side effects:
Rebound nasal congestion (limit to 3 days to avoid rhinitis) , nasal burning/stinging, nasal dryness
Drug interactions: Albuterol
Avoid: Getting spray in eyes
*Pregnancy: Ok to use Oxymetazoline poorly absorbed so preferred
*Lactation: Likely ok to use
Oxymetazoline (afrin)
Adults and children >= 12 years
NMT every 10-12 hours Max 2 doses/24 hours
Children 6 to <12 years
NMT every 10-12 hours Max 2 doses/24 hours
Propylhexedrine (Benzedrex)
Adults and children >= 12 years
2 inhalations each nostril NMT every 2 hours
Children 6 to < 12 years
2 inhalations each nostril NMT every 2 hours
Brompheniramine, chlorpheniramine, diphenhydramine
MOA: Blocks histaminic and muscarinic receptors in medulla
Indication: relieve runny nose and sneezing due to common cold
Pharmacodynamics:
Onset - 15 to 30 min
Duration - 4 to 6 hours
Side effects: Sedation, dry mouth/nose/throat, nausea, dizziness, difficult urination, constipation, blurred vision, cognitive problems, excitation
Drug interactions: duloxetine, alprazolam, MAOI, Parkinson’s medications
Avoid: Alcohol, driving or operating machinery
*Pregnancy: Avoid brompheniramine, caution with diphenhydramine, likely ok to use chlorpheniramine
*Lactation: Avoid brompheniramine, low doses as needed chlorpheniramine, Short term use of diphenhydramine is ok
Acetaminophen, ibuprofen, naproxen
Indication: relief of aches or fever or sore throat
Medications:
Acetaminophen-> 325 -1000mg every 4-6 hours PRN (max is 3250 mg/day)
Ibuprofen-> 200-400 mg every 4-6 hours PRN (max 1200 mg/24 hours)
Naproxen-> 220 mg every 8-12 hours PRN (may take 2 tab = 440 mg to start)
Avoid: aspirin in children younger than 18 due to Rye’s syndrome
Pregnancy: Acetaminophen preferred
Lactation: All 3 likely ok for short term use
Benzocaine, dyclonine HCL, phenol, menthol
MOA: local anesthetic effect to provide pain relief
Indication: temporary relief of sore throat
Pharmacodynamics
Onset->Within minutes
Duration–> 2-4 hours
Dosing-> every 2-4 hours
Side effects: altered taste sensation, nausea
Drug interactions: none
Avoid: if allergic to anesthetics
Pregnancy and lactation is likely ok to use
Colds and older adults
More sensitive to side effects of systemic decongestants
May exacerbate diseases sensitive to adrenergic stimulation
Ex: HTN, DM, CAD, BPH, glaucoma
Colds and young children
OTC cold products not recommended in young children (<6 years old)
-Recommend non drug therapies
-Avoid combo products
-Avoid use of siblings topic decongestant meds for younger children
Nondrug therapies for infants
-Upright positioning to enhance nasal drainage
-Maintain adequate fluid intake
-Increase humidity of inspired air
-Irrigate nose with saline drops
-Carefully clear nasal passageways with bulb syringe
Presenting symptoms
Description:
Productive
Wet and chesty
Effective -> easy to expel
Ineffective -> hard to expel
Nonproductive
Dry or hacking (viral, atypical bacteria, GERD, CV, some meds)
Classification:
acute-> viral URTI, bacterial sinusitis, pertussis, allergic rhinits, COPD, pnuemonia, environmental irritants
Subaccute: post infection, CHF/fluid
Chronic: asthma, GERD, COPD, chronic bronchitis
Common cough complications
Exhaustion, sleep deprivation, social discomfort, MSK pain, hoarseness, excessive perspiration, urinary incontinence
Appearance:
URTI –> clear
Bacterial –> purulent
When is a patient not a candidate for self-care?
Worsens after 3-5 days
Persists are 2-3 weeks
Children younger than 4 years old
Temp >=100.4 F
Temp >= 100 F for more than 3 days
Complementary and non-pharmacologic options
- Honey
- Nonmedicated lozenges/hard candies
-Stimulate saliva and decrease throat irritation - Humidification
-Increases inspired air moisture to soothe airways
-Vaporizer: humidifier with well/cup for volatile inhalants - Nasal drainage techniques
-Adults: variety of drainage systems but saline solution most notable
-Babies and young children: rubber bulb syringe; positioning via baby sleep in your arm, raise head of bed if little child - Hydration
-Promotes less viscous secretions; consider other health conditions
honey and cough
MOA: unknown maybe it increases salivation, soothes airway
Do not recommend honey use in children < 1 year due to risk for botulism
Cough frequency –> Cochrane review
Honey > placebo or no treatment
Honey = dexomethorphan
Honey > diphenhydramine
Dosing:
-2.5 to 5 ml in oral syringe or diluted in liquid (tea/juice)
-Can corn syrup by substituted? Yes
Saline for nasal irrigation
Water
-Warmed to body temp
-Distilled, sterile, or boiled (never TAP)
-1 to 2 cups or 8 to 16 oz
Salt
-1/4 to 1/2 tsp uniodized
-Non iodized
Baking soda
-Pinch
OTC treatment options for cough
1.Antitussives
Oral
-Codeine
-Dextromethorphan
-Diphenhydramine
Topical
-Camphor
-Menthol
2. Protussives (expectorants)
-Guaifenesin
3. No combination products
Follow up recommendations for cough
Follow up with primary care provider if:
-Symptoms worsen after treatment
-No improvement after 7 days
*Continue self care:
If cough improves but not gone within 7 days
Codeine
Schedule V narcotic
MOA: works centrally on the medulla to increase cough threshold
Indication: Suppression of NONPRODUCTIVE cough
Pharmacodynamics:
Onset–> 15-30 minutes
Duration–> 4-6 hours
Side effects: N/V, sedation, dizziness, constipation, respiratory depression; risk of addiction/abuse/misuse
Drug interactions: CNS depressants, alcohol
Avoid: codeine hypersensitvity (allergy, impaired respiratory reserve (people who have asthma or COPD)
*Avoid prolonged use during pregnancy (addiction issues to fetus)
*Avoid during lactation because of excretion into breast milk
Dextromethorphan
MOA: works centrally on the medulla to increase cough threshold
Indication: Suppression of NONPRODUCTIVE cough
Pharmacodynamics:
Onset-> 15-30 minutes
Duration-> 3-6 hours
Side effects: Slight drowsiness, N/V, stomach discomfort, constipation
Drug interactions:
-Strong CYP2D6 inhibitors
-SSRIs
-MAO inhibitors: Serotonergic syndrome (BP increase, Body temp increase)
Avoid: DM hypersensitivty, prior DM dependence, interacting drugs
*Pregnancy: no fetal risk in first trimester
*Lactation: no evidence its excreted through milk
Dextromethorphan, Robotripping
Abuse potential due to phencyclidine like euphoric effect
Abuse associated with psychosis and mania
S/Sx of intoxication:
-Tachycardia, HTN, vomiting,
-Hallucinations and zombie like walking, agitation, somnolence
Diphenhydramine
MOA: works centrally on the medulla to increase cough threshold
Indication: Suppression of NONPRODUCTIVE cough
Pharmacodynamics:
Onset: 15 minutes
Duration: 4-6 hours
Side effects: Drowsiness, disturbed coordination, respiratory depression, blurred vision, urinary retention, dry mouth, dry respiratory secretions
Drug interactions: CNS depressants and narcotics, alcohol, benzodiazepines, other tranquilizing agents
Avoid: hx hypersensitivity, medical conditions that can be exacerbated by anticholinergic effects such as people who have narrow angle glaucoma
*Pregnancy: no fetal risk, 3rd trimester caution
*Lactation: decrease flow of milk
Codeine dosing (less preferred option)
Adults >= 12 yrs
10-20 mg every 4-6 hours
*120 mg
Children 6 to < 12 yrs
5-10 mg every 4-6 hours
*60 mg
Dextromethorphan dosing
Adults/children >= 12 yrs
10-20 mg every 4 hours or 30 mg every 6-8 hours
*120 mg
Children 6 to < 12 yrs
5-10 mg every 4 hours or 15 mg every 6-8 hrs
*60 mg
Diphenhydramine dosing
Adults/children >= 12 yrs
25 mg every 4 hours
*150 mg
Children 6 to < 12 yrs
12.5 every 4 hours
*75 mg
Camphor and menthol
MOA: Inhaled vapors create local anesthetic sensation in sensory nerve endings in nose and mucosa for sense of improved air flow
Indication: Suppression of NONPRODUCTIVE cough
Pharmacodynamics unknown
Side effects: skin, nose or eye burning/irritation
Drug interactions: warfarin (possible with menthol –> decreased INR)
Avoid: using 1 hours before or 30 min after bath/shower; eye/nostril contact; heat/microwave; use with tight bandages; damaged skin
*Ok with lactation and pregnancy
Guaifenesin
*very limited data for efficacy so drink water instead
MOA: loosens and thins lower respiratory tract secretions
Indication: symptomatic relief of acute, ineffective productive cough
Pharmacodynamics: Not well understood
Onset: unknown
Duration: unknown
Side effect: nausea vomiting, dizziness, HA, rash, diarrhea, drowsiness, stomach pain
Drug interactions: none reported
Avoid: Guaifenesin hypersensitivity
*Pregnancy is ok to use
*Lactation it is not recommended for use
Guaifenesin dosing (as needed)
Adults and adolescents >= 12 years
200-400 mg every 4 hours as needed
Max: 2.4 g in 24 hours
Children 6 to < 12 years
100-200 mg every 4 hours as needed
Max: 1.2 g in 24 hours
Children 2 to < 6 years
50-100 mg every 4 hours as needed
Max: 600 mg in 24 hours
Product selection
little evidence that oral antitussives and expectorants are effective at treating acute cough
Large placebo response of 85%
Start with nondrug measures first
(water)
Cough and older adults
Golden rule: avoid cough meds
Diphenhydramine–> side effects more pronounced
Codeine and DM—> more susceptible to sedating effects
start at lower doses and titrate up
*cough is a symptom of many acute and chronic conditions
Administration guidelines for OTC Topical Antitussives (adults and children >= 2 years)
Ointments: Apply thick layer on throat and chest; repeat as needed up to 3 times daily, loosen clothing around throat and chest so vapors reach the nose and mouth
*Do not use in the nostrils, under the nose, by the mouth, on damaged skin or with tight bandages
Lozenges: Allow lozenge to slowly dissolve in mouth; repeat hourly or PRN
Inhalation: For products intended to be added to cold water for use in steam vaporizer–> add measured solution to cold water, place in vaporizer, breathe in vapors 3 times daily PRN
*For hot steam vaporizer–> same as above by no adding to cold water
Physical assessment of patient with cold symptoms
- Observe patient (look for signs of chronic conditions)
- Obtain vital signs
- Palpate sinuses and neck, observe for any pain/tenderness
- Visually examine throat for redness or exudates. Run strep test if strep throat suspected
- Auscultate chest to detect wheezing, crackles, and rapid or irregular heartbeat
Administration guidelines for Nasal dosage formulations
General instructions:
-Clear nasal passages before administering the product
-Wash your hands before and after use
-Gently depress the other side of the nose with finger to close off the non-receiving nostril
Administration for Nasal Sprays
Gently insert bottle tip into one nostril
-Keep head upright and sniff deeply while squeezing bottle, repeat with other nostril
Administration for nasal inhalers
-Warm the inhaler in hand just before use
-Gently insert the tip in one nostril
-Wipe the inhaler after each use, discard after 2-3 months
Do oral decongestants have a clinically significant effect on BP in patients with hypertension?
It is unclear
Pseudoephedrine causes an avg increase of 1.2 mmHg in systolic BP in patients with controlled hypertension
*However studies not adequately powered to provide evidence
Acute wounds
Usually from injury
Types:
Punctures: sharp objects pierces epidermis and lodges in dermis or deeper tissues
Abrasions: rubbing or friction injury to the epidermis may extend to upper layer
Lacerations: a cut in the skin
Burns: due to heat/chemical damage
*Can require up to a month to heal in otherwise healthy people
*Usually ok to self-treat if wounds do not extend below the dermis
Chronic wounds
anything other than acute wounds
*Older adult in nursing facility
Require triage and medical treatment
Beyond scope of this lecture
Exclusions to wound self care
-Deeper puncture wounds
+/- animal bites (Rabies and other bacteria)
-Gaping wounds that might need stitches
-Wounds showing fat/muscle/bone
-Wounds containing foreign material despite cleansing
-Severe pain or numbness
-Inability to move structures below wound
-New wounds in patients with bleeding disorders or diabetes (might need special treatment, slow healing)
-Chronic wounds
-Infected wound (swelling, redness, warmth, pus, red streaks radiating from wound
Minor wounds
Superficial - they happen to the outer layer of your skin, the epidermis
*not near the natural openings of your body
-Not heavy bleeders
-Small (size of a coin)
Stopping bleeding
What is the purpose of bleeding?
*Nature’s way of cleaning the wound
Which wounds bleed more?
*Head wounds (most high vascularize area of body)
Procedure
-Pressure
*Duration of pressure? Elevated above heart level steady pressure for 15 min
-Clean tissue/cloth/gauze
-Remove clothing/jewelry b/c wound may swell
*What if blood soaks through? Put another layer on
Wound cleansing
What (only use other methods when wound contaminated)
-Tap water with sufficient pressure (most suffice)
-Washcloth (around the wound)
-Soap
-Alcohol
Hydrogen Peroxide
-Iodine
*Wound only needs to be cleaned once
*clean around wound as needed
Antibiotic ointment
Purpose of antiseptics/antibiotics
-Prevent infection
Max amount of time to use: until wound is healed
Single/double/triple antibiotics
-Risk of allergic contact dermatitis from bacitracin
-Recommend single antibiotic because of antibiotic resistance
How to use
-Apply within 4 hours of injury
-Apply 1-3 times per day
How do you know if the wound is infected?
-Inflamed, thick/creamy drainage, red streaks, warm
*Avoid triple antibitoics
*Might have allergic reaction or neomycin hypersensitivity
Local Anesthetics and pain control
Use only if unbroken skin
Combination antibiotic and anesthetic products
Can use NSAID
Super adhesive polymer (MOA: seal off nerve endings, and reduce pain)
Alternatives: cold/ice pack (20 min on/off)
