Category: Continuing Education

Quality Point of View on Nursing Care of Patients on Thrombolytic Therapy

EMERGENCY MANAGEMENT OF HYPOGLYCEMIA

known as Thrombolysis, is a treatment to dissolve dangerous clots in blood vessels, improve blood flow, and prevent damage to tissues and organs. Thrombolysis may involve the injection of clot-busting drugs through an intravenous (IV) line or through a long catheter that delivers drugs directly to the site of the blockage. Thrombolysis is often used as an emergency treatment to dissolve blood clots that form in arteries feeding the heart and brain.

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Systemic Nasal Decongestants

Systemic Nasal Decongestants

Nasal decongestants for administration by mouth may not be as effective as preparations for local application but they do not give rise to rebound nasal congestion on withdrawal. Pseudoephedrine is available over the counter; it has few sympathomimetic effects. Systemic decongestants should be used with caution in diabetes, hypertension, hyperthyroidism, susceptibility to angle-closure glaucoma, prostatic hypertrophy, renal impairment, pregnancy, and ischaemic heart disease, and should be avoided in patients taking monoamine oxidase inhibitors.

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Cough Preparations

Cough Preparations

Expectorant and demulcent cough preparations

Expectorants are claimed to promote expulsion of bronchial secretions but there is no evidence that any drug can specifically facilitate expectoration. The assumption that sub-emetic doses of expectorants, such as ammonium chloride, ipecacuanha, and squill promote expectoration is a myth. However, a simple expectorant mixture may serve a useful placebo function and has the advantage of being inexpensive.

Demulcent cough preparations contain soothing substances such as syrup or glycerol and some patients believe that such preparations relieve a dry irritating cough. Preparations such as simple linctus have the advantage of being harmless and inexpensive; pediatric simple linctus is particularly useful in children. Compound preparations are on sale to the public for the treatment of cough and colds; the rationale for some is dubious.

GUAIFENESIN:

Indications: Guaifenesin is used to help coughs caused by colds or similar illnesses clear mucus or phlegm (pronounced flem) from the chest. It works by thinning the mucus or phlegm in the lungs. Guaifenesin is used to reduce chest congestion caused by the common cold, infections, or allergies.

Contraindications: There are no adequate studies

Dose and Administration: Adults—200 to 400 milligrams (mg) every four hours. Children 6 to 12 years of age—100 to 200 mg every four hours. Children 4 to 6 years of age—300 mg every twelve hours. Children and infants up to 4 years of age—Use is not recommended.

Guaifenesin and Dextromethorphan:

Indications: The combination of dextromethorphan and guaifenesin is used to treat cough and chest congestion caused by the common cold, infections, or allergies.

Contraindications: if allergic to any ingredient in Guaifenesin DM Elixir, taking or have taken a monoamine oxidase inhibitor (MAOI) within the last 14 days or taking a selective serotonin reuptake inhibitor (SSRI).

Dose and Administration: Each 5ml contains 100mg Guaifenesin and 10mg Dextromethorphan. Children 6 to 12 years of age 5ml every four hours. Adults 10ml every four hours.

Guaifenesin and Theophylline:

Indications: Preventing and treating symptoms and blockage of airway due to asthma or other lung diseases such as emphysema or bronchitis.

Guaifenesin/Theophylline are a combination xanthine derivative and expectorant. The xanthine derivative works by relaxing the smooth muscle surrounding the bronchial tubes (air passages) of the lungs, allowing the tubes to widen, and making breathing easier

Contraindications: if allergic to any ingredient in Guaifenesin/Theophylline.

Dose and Administration: adults 15-30ml 2-3 times daily. Children over 45kg the same dose as adults. Over 8 years old 15ml 2-3 times daily. Under 8 years old 2.5ml per each 4.5kg body weight 2-3 times daily.

Guaifenesin/Dextromethorphan/Pseudoephedrine:

Indications: Relieving congestion, cough, and throat and airway irritation due to colds, flu, or hay fever.

Contraindications: if allergic to any ingredient in Guaifenesin DM Elixir, taking or have taken a monoamine oxidase inhibitor (MAOI) within the last 14 days or taking a selective serotonin reuptake inhibitor (SSRI).

Dose and Administration: Each 5ml contains 100mg Guaifenesin 30mg Pseudoephedrine and 10mg Dextromethorphan. Children 6 to 12 years of age 5ml every four hours. Adults’ 10ml every four hours.

Diphenhydramine/Menthol:

Indications: control of cough and allergy and hay fever and to reduce nasal congestion symptoms.

Contraindications: if allergic to any ingredient

Dose and Administration: children 1 to 6 years 5ml every 6 hours. From 6 to 12 years 10ml every 6 hours.

Diphenhydramine/Ammonium Chloride/Menthol:

Indications: for controlling cough due to colds and allergy and to reduce nasal congestion symptoms.

Contraindications: if allergic to any ingredient

Dose and Administration: each 5ml syrup contains 14mg Diphenhydramine, 135mg Ammonium chloride, and 1.1mg Menthol. Children 1 to 6 years 2.5ml every 6 hours, 6 to 12 years 5ml every 6 hours and for adults 5 to 10ml every 6 hours.

Cough Suppressants

Dextromethorphane:

Indications: Dextromethorphan is a cough suppressant. It works by loosening mucus and lung secretions in the chest and making coughs more productive. Temporarily relieving cough due to the common cold, upper respiratory tract infections, sinus inflammation, sore throat, or bronchitis.

Contraindications: if allergic to any ingredient in Dextromethorphan or taking or have taken a monoamine oxidase (MAO) inhibitor within the last 14 days.

Dose and Administration: each 5ml contains 15mg of Dextromethorphane. Children above 2 years 2.5ml to 5ml up to 4 times daily. Adult’s 5ml to 10ml 4 times daily.

Thyme fluid extract and primula root fluid extract:

Indications: used in cough, bronchitis, bronchial catarrh and mucous obstruction of the bronchi.

Contraindications: in case of allergy to thyme, primula root extract or any of the additives. Also in epileptic patients or liver impairment patients.

Dose and Administration: the usual adult dose is one spoon every 2-3 hours up to 6 times per day. Children half of the adult dose.

Thyme fluid extract:

Indications: used in whooping cough, bronchitis, and bronchial catarrh Contraindications: in case of allergy to thyme or any of the additives. Also in epileptic patients or liver impairment patients.

Dose and Administration: the usual adult dose is two spoons 3 times per day. Children half of the adult dose.

Respiratory Stimulants and Pulmonary Surfactants

Respiratory Stimulants and Pulmonary Surfactants

Pulmonary surfactants are used in the management of respiratory distress syndrome (hyaline membrane disease) in neonates and preterm neonates. They may also be given prophylactically to those considered at risk of developing the syndrome. Continuous monitoring is required to avoid hyperoxaemia caused by rapid improvement in arterial oxygen concentration. Pulmonary haemorrhage has been rarely associated with therapy especially in more preterm neonates; obstruction of the endotracheal tube by mucous secretions has also been reported.

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Mucolytics

Mucolytics

Mucolytics are prescribed to facilitate expectoration by reducing sputum viscosity. In some patients with chronic obstructive pulmonary disease and a chronic productive cough, mucolytics can reduce exacerbations; mucolytic therapy should be stopped if there is no benefit after a 4-week trial. Steam inhalation with postural drainage is effective in bronchiectasis and in some cases of chronic bronchitis.

Mucolytics should be used with caution in those with a history of peptic ulceration because they may disrupt the gastric mucosal barrier.

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Bronchodilators

Bronchodilators

The selective beta2 agonists (selective beta2-adrenoceptor agonists, selective beta2 stimulants) such as salbutamol or terbutaline are the safest and most effective short-acting beta2 agonists for asthma. Less selective beta2 agonists such as orciprenaline should be avoided whenever possible. Adrenaline (epinephrine) (which has both alpha- and beta-adrenoceptor agonist properties) is used in the emergency management of allergic and anaphylactic reactions and in the management of croup

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Corticosteroids

Corticosteroids

Corticosteroids are used for the management of reversible and irreversible airways disease. An inhaled corticosteroid used for 3–4 weeks may help to distinguish asthma from chronic obstructive pulmonary disease; clear improvement over 3–4 weeks suggests asthma. Corticosteroids are effective in asthma; they reduce airway inflammation (and hence reduce oedema and secretion of mucus into the airway). An inhaled corticosteroid is used regularly for prophylaxis of asthma when patients require a beta2 agonist more than twice a week, or if symptoms disturb sleep more than once a week, or if the patient has suffered exacerbations in the last 2 years requiring a systemic corticosteroidor a nebulised bronchodilator. Regular use of inhaled corticosteroids reduces the risk of exacerbation of asthma.

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Leukotriene Receptor Antagonists

Leukotriene Receptor Antagonists

Dose and Administration:Prophylaxis of asthma, adult and child over 15 years, 10 mg once daily in the evening; child 6 months–6 years 4 mg once daily in the evening, 6–15 years 5 mg once daily in the evening.

Seasonal allergic rhinitis, adult and child over 15 years, 10 mg once daily in the evening.

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Lipid Regulating Drugs

Lipid Regulating Drugs

Statins:

Simvastatin:

Indications: primary hypercholesterolaemia, homozygous familial hypercholesterolaemia or combined (mixed) hyperlipidaemia in patients who have not responded adequately to diet and other appropriate measures;

prevention of cardiovascular events in patients with atherosclerotic cardiovascular disease or diabetes mellitus.

Contraindications: Active liver disease, which may include unexplained persistent elevations in hepatic transaminase levels. Women who are pregnant or may become pregnant. Serum cholesterol and triglycerides increase during normal pregnancy, and cholesterol or cholesterol derivatives are essential for fetal development. Nursing mothers. It is not known whether simvastatin is excreted into human milk; however, a small amount of another drug in this class does pass into breast milk

Dose and Administration: Primary hypercholesterolaemia, combined hyperlipidaemia, 10–20 mg daily at night, adjusted at intervals of at least 4 weeks; usual range 10–80 mg once daily at night. Homozygous familial hypercholesterolaemia, 40 mg daily at night or 80 mg daily in 3 divided doses. Prevention of cardiovascular events, initially 20–40 mg once daily at night, adjusted at intervals of at least 4 weeks; max. 80 mg once daily at night.

Atorvastatin:

Indications: primary hypercholesterolaemia, heterozygous familial hypercholesterolaemia, homozygous familial hypercholesterolaemia or combined (mixed) hyperlipidaemia in patients who have not responded adequately to diet and other appropriate measures; prevention of cardiovascular events in patients with type 2 diabetes and at least one additional risk factor for cardiovascular disease

Contraindications: Active liver disease, which may include unexplained persistent elevations in hepatic transaminase levels. Women who are pregnant or may become pregnant. atorvastatin may cause fetal harm when administered to a pregnant woman.

Dose and Administration: Primary hypercholesterolaemia and combined hyperlipidaemia, usually 10 mg once daily; if necessary, may be increased at intervals of at least 4 weeks to max. 80 mg once daily; child 10–17 years usually 10 mg once daily. Familial hypercholesterolaemia, initially 10 mg daily, increased at intervals of at least 4 weeks to 40 mg once daily; if necessary, further increased to max. 80 mg once daily (or 40 mg once daily combined with anion-exchange resin in heterozygous familial hypercholesterolaemia); child 10–17 years initially 10 mg daily, increased if necessary after at least 4 weeks to 20 mg once daily. Prevention of cardiovascular events in type 2 diabetes, 10 mg once daily.

Fluvastatin:

Indications: adjunct to diet in primary hypercholesterolaemia or combined (mixed) hyperlipidaemia (types IIa and IIb); adjunct to diet to slow progression of coronary atherosclerosis in primary hypercholesterolaemia and concomitant coronary heart disease; prevention of coronary events after percutaneous coronary intervention.

Contraindications: in patients with active liver disease or unexplained, persistent elevations in serum transaminases. If the patient becomes pregnant while taking this class of drug, therapy should be discontinued and the patient apprised of the potential hazard to the fetus.

Dose and Administration: Hypercholesterolaemia or combined hyperlipidaemia, initially 20–40 mg daily in the evening, adjusted at intervals of at least 4 weeks; up to 80 mg daily may be required; child and adolescent under 18 years, not recommended. Prevention of progression of coronary atherosclerosis, 40 mg daily in the evening. Following percutaneous coronary intervention, 80 mg daily.

Rosuvastatin:

Indications: primary hypercholesterolaemia (type IIa including heterozygous familial hypercholesterolaemia), mixed dyslipidaemia (type IIb), or homozygous familial hypercholesterolaemia in patients who have not responded adequately to diet and other appropriate measures.

Contraindications: Patients with active liver disease, which may include unexplained persistent elevations of hepatic transaminase levels. Women who are pregnant or may become pregnant. Nursing mothers.

Dose and Administration: Initially 5–10 mg once daily increased if necessary at intervals of at least 4 weeks to 20 mg once daily, increased after further 4 weeks to 40 mg daily only in severe hypercholesterolaemia with high cardiovascular risk and under specialist supervision; elderly initially 5 mg once daily; patient of asian origin, initially 5 mg once daily increased if necessary to max. 20 mg daily.

Ezetimibe:

Indications: administered alone, is indicated as adjunctive therapy to diet for the reduction of elevated total cholesterol (total-C), low-density lipoprotein cholesterol (LDL-C), and apolipoprotein B (Apo B) in patients with primary (heterozygous familial and non-familial) hyperlipidemia. administered in combination with fenofibrate, is indicated as adjunctive therapy to diet for the reduction of elevated total-C, LDL-C, Apo B, and non-high-density lipoprotein cholesterol (non-HDL-C) in adult patients with mixed hyperlipidemia. The combination with simvastatin is indicated for the reduction of elevated total-C and LDL-C levels in patients with HoFH, as an adjunct to other lipid-lowering treatments.

Contraindications: Women who are pregnant or may become pregnant. Nursing mothers.

Dose and Administration: adult and child over 10 years, 10 mg once daily.

Simvastatin-Ezetimibe:

Indications: indicated for the reduction of elevated total cholesterol (total-C), low-density lipoprotein cholesterol (LDL-C), apolipoprotein B (Apo B), triglycerides (TG), and non-high-density lipoprotein cholesterol (non-HDL-C), and to increase high-density lipoprotein cholesterol (HDL-C) in patients with primary (heterozygous familial and non-familial) hyperlipidemia or mixed hyperlipidemia. indicated for the reduction of elevated total-C and LDL-C in patients with homozygous familial hypercholesterolemia, as an adjunct to other lipid-lowering treatments (e.g., LDL apheresis) or if such treatments are unavailable.

Contraindications: Active liver disease or unexplained persistent elevations in hepatic transaminase levels. Women who are pregnant or may become pregnant.

Dose and Administration: The recommended usual starting dose is 10/20 mg/day as a single daily dose in the evening, with or without food. Patients who require a larger reduction in LDL-C (greater than 55%) may be started at 10/40 mg/day.

Atorvastatin-Amlodipine:

Indications: indicated in patients for whom treatment with both amlodipine and atorvastatin is appropriate.

Contraindications: Pregnancy and Lactation. in patients with active liver disease or unexplained persistent elevations of serum transaminases.

Dose and Administration: Dosage should be adjusted according to each patient’s need. In general, titration should proceed over 7 to 14 days so that the physician can fully assess the patient’s response to each dose level.

Fibrates:

Gemfibrozil:

Indications: hyperlipidaemias of types IIa, IIb, III, IV and V in patients who have not responded adequately to diet and other appropriate measures; primary prevention of cardiovascular disease in men with hyperlipidaemias that have not responded to diet and other appropriate measures.

Contraindications: alcoholism, biliary-tract disease including gallstones; photosensitivity to fibrates; hepatic impairment; pregnancy; breast-feeding.

Dose and Administration: 1.2 g daily, usually in 2 divided doses; range 0.9– 1.2 g daily; child not recommended

Fenofibrate:

Indications: hyperlipidaemias of types IIa, IIb, III, IV, and V in patients who have not responded adequately to diet and other appropriate measures.

Contraindications: gall bladder disease; photosensitivity to ketoprofen; severe hepatic impairment; pregnancy; breast-feeding.

Dose and Administration: 200mg once daily.

Antihistamines

Antihistamines

All antihistamines are of potential value in the treatment of nasal allergies, particularly seasonal allergic rhinitis (hay fever), and they may be of some value in vasomotor rhinitis. They reduce rhinorrhoea and sneezing but are usually less effective for nasal congestion. Antihistamines are used topically in the eye, in the nose and on the skin. Oral antihistamines are also of some value in preventing urticaria and are used to treat urticarial rashes, pruritus, and insect bites and stings; they are also used in drug allergies. Injections of chlorphenamine (chlorpheniramine) or promethazine are used as an adjunct to adrenaline (epinephrine) in the emergency treatment of anaphylaxis and angioedema.

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