NURS 1009 Nursing Pharmacology

Question:

John is a 24-year-old who presents to Urgent Care with a 2-week history of cough and congestion. He says it started out as a “normal cold” and it will not go away. He has a cough productive of green mucous and has green nasal discharge. He says he has had a low-grade temperature for the past 2 days. John reports an intermittent frontal headache with this cold. He is otherwise health, with no known allergies.

In his assessment it is found that his vital signs are stable, temperature is 99.9 degrees F, tympanic membranes (TMs) are clear bilaterally, and pharynx is red with no exudate. There is greenish postnasal drainage, turbinates are swollen and red. Tenderness is present when the frontal sinuses are palpated, no cervical adenopathy, and lungs are clear.

Would you treat this patient for his cold? Why or why not?
If you were to treat this patient, what would you use? How many days would be appropriate?
How would this treatment vary if the patient was a child?

Zack, age 6, presents to the office with symptoms of worsening cough and wheezing for the past 24 hours. He is accompanied by his mother, who is a good historian. She reports that her son started having symptoms of a viral upper respiratory infection 2 to 3 days ago, beginning with a runny nose, low-grade fever of 110.5 degrees F orally, and loose cough. Wheezing started on the day before the visit, so Zack’s mother started administering albuterol metered-dose inhaler (MDI) two puffs before bed and then two puffs at around 2 AM. The cough and wheezing appear worse today, according to the mother. Zack had difficulty taking deep-enough breaths to inhale this morning’s dose of albuterol, even using the spacer.

Zack has been a patient at the clinic since birth and is up to date on his immunizations. His growth and development have been normal, and he is generally healthy except for mild intermittent asthma. This is his first asthma exacerbation of the school year, and his mother expresses a concern about sending him to school with an inhaler.

Answer:

Question-1

The clinical features of Mr. John suggest that he has acute sinusitis. He will be treated for acute sinusitis and not for his cold, as cold is one of the features of acute sinusitis. Additionally, treating acute sinusitis will cure cold and hence John will not be treated for cold. At first, John will be treated with antibiotics to treat infection. Decongestants will be administered to enhance drainage. Nasal corticosteroids to reduce inflammation as well as mucolytics to increase mucous flow will be given (Lewis, 2013). Classic anti-histamines (first-generation) will be avoided as they might increase the mucus viscosity and promote continued symptoms whereas second generation (non- sedating) anti-histamines will be administered as they do not cause this problem. Antibiotic therapy should be usually continued for 10 to 14 days for acute sinusitis. If symptoms do not resolve, the antibiotic should be changed to a broader- spectrum agent.

John will be advised to drink 6 to 8 glasses of water daily to liquefy secretions. He should be educated about nasal cleaning techniques that involves taking hot showers twice/day, blowing the nose, steam inhalation, bed-side humidifier or nasal saline spray to promote secretion drainage (Gershwin, 2012). He will be educated to avoid smoking as well as exposure to smoke as it is an irritant which could worse symptoms. In-case of children, they should be treated by saline sinus irrigation, nasal/systemic steroids (for allergic sinusitis) and nasal/topical decongestants (after 4-5 days of treatment to prevent re-bound vasodilatation) (Jeffe, 2012).

Question-2

2a). Zack should be administered with Oxygen through face mask or nasal cannule, even though the oxygen saturation was maintained to 93% and should be monitored by pulse oximetery or ABGs (if severe). At-first, short-acting ß_2-adrenergic agonists (Salbutamol) 5 puffs (0.1 mg/puff) should be administered with metered-dose inhaler (MDI) along with a spacer once in 20 minutes to four hours, which is more efficient as compared to a nebulizer (Lewis, 2013). Oral corticosteoirds (prednisolone) 1 – 2 mg/kg/day (max: 60 mg) or dexamethasone: 0.15–0.3 mg/kg/day (max: 10 mg) could be administered.

2b). Zack will be taught to identify environmental triggers with preventable measures, to avoid allergens and importance to maintain hand hygiene. He will be instructed about the method to use MDI as well as peak-flow meter. He will be demonstrated about the pursed-lip and diaphragmatic breathing techniques.

2c). Exacerbation plan includes GREEN- Go: which indicates that breathing is good and hence can continue regular medication; YELLOW- Caution: that indicates mild to moderate symptoms and hence should add reliever measures with regular medicine; Red- Danger: severe symptoms and hence add 2- 6 puffs of quick relievers and with very severe symptoms should call emergency (Ortiz-Alvarez, 2012).

2d). In follow-up, Zack and his care-taker will be explained about the importance of environmental control. Medication schedules with time-frames will be given. They will be instructed about the importance of nutrition, physical exercise, sleep and written asthma-management plan.

Question-3

3a). ß_–adrenergic blockers could be administered to the patient as it can reduce BP by reducing rennin secretion (Lewis, 2013).

3b). Drug Lisinopril should be avoided as it can cause hyperkalemia and reduce renal function.

3c). Stage 3 renal failure indicates that the patient has moderately decreased GFR and hence the certain cardiac medications should be used with caution to avoid further renal damage. Most of the drugs are excreted by the kidneys and stage-3 renal failure can cause accumulation of toxic substances in blood and tissues (Lewis, 2013).

3d). Aspirin therapy eases inflammation in this patient as the plaque may increase the chance of getting stroke, if it gets inflamed. Further, aspirin prevent blood clot formation.

Reference

Gershwin, M. E & Incaudo, G. (2012). Diseases of the Sinuses: A Comprehensive Textbook of Diagnosis and treatment. Retrieved from https://books.google.co.in/books?isbn=1461202256

Jeffe, J.S et al. (2012). Nasal saline irrigation in children: a study of compliance and tolerance: Int J Pediatr Otorhinolaryngol. 76(3):409-13

Lewis, S.M., Heitkemper, M. M., & Dirksen, S.R. (2013). Medical Surgical Nursing: Assessment and Management of Clinical Problems. (9^th ed.). Missouri: Mosby.

Ortiz-Alvarez, O. (2012). Managing the paediatric patient with an acute asthma exacerbation: Paediatr Child Health. 17(5): 251–256.a

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NURS 1009 Nursing Pharmacology

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