Week 10 – Medication Summary

The Common Cold

Viral infection of the upper respiratory tract
Virus invades mucosa causing upper respiratory infection (URI)
Excessive mucus production results from the inflammatory response to viral invasion
Fluid drips down the pharynx into the esophagus and lower respiratory tract, causing cold
symptoms: sore throat, coughing, upset stomach
Mucosal irritation causes release of several inflammatory and vasoactive substances
causing nasal congestion and sneeze reflex

Treatment of the Common Cold

Treating the common cold involves the combined use of antihistamines, nasal
decongestants, antitussives, and expectorants
Treatment is symptomatic only

Pediatric Concerns

In 2009, Health Canada issued recommendations that over-the-counter (OTC) cough and
cold products not be given to children younger than 6 years of age
Not effective in small children, and parents are advised to consult their pediatrician on the
best ways to manage these illnesses
Week 10 – Medication Summary

Drugs used to treat Upper Respiratory System

Antihistamines
-ines

Decongestants
 Oral
 Topical
o Rebound effect
 Nasal

Pseudoephedrine sumo-F-adrine

Antitussives
 Suppress the cough reflex
 There are opioids and non-opiods
Dextromethorphan
Week 10 – Medication Summary

 For DRY COUGHS DEXTER-making METH- in PAN

Expectorants
 A medication that helps bring up mucus and other material from the lungs, bronchi, and trachea.
Guaifenesin

Histamine

Major inflammatory mediator in many allergic disorders

Allergic rhinitis

Anaphylaxis
Week 10 – Medication Summary

Angioedema

Drug fevers

Insect bite reactions

Urticaria (pale red, raised, itchy bumps)

Antihistamines
 Drugs that directly compete with histamine for specific receptor sites
 Histamine antagonists
 H1-antagonists (or H1-blockers)
 H2-antagonists (or H2 -blockers)
 Antihistamines have several properties
 Antihistamini
 Anticholinergic
 Sedative

Traditional Antihistamines
 Older
 Work both peripherally and centrally
 Have anticholinergic effects, making them more effective than nonsedating drugs in some cases
 diphenhydramine (Benadryl®)
Week 10 – Medication Summary

Antihistamines “tidine”
Mechanism of Action

 Block action of histamine @ H1 receptor sites

 Compete w. histamine for binding at unoccupied receptors
 Cannot push histamine off the receptor if already bound (therefore, take before coming into contact with the “histamine”) =
more effective in preventing the actions of histamine

Indications

 Nasal allergies
 Allergic rhinitis (hay fever)
 Symptoms of the common cold
 Allergic reactions
 Parkinson’s disease (balance out the high levels of acetylcholine vs. dopamine (pt. has more acetylcholine))
 Vertigo , Motion sickness, these drugs slighty suppress the CNS, and help with vertigo and motion sickness


Contraindications

 Allergy
 Acute asthmatic attacks
 Acute-angle glaucoma
 Cardiac disease, HTN (these drugs pretend to be SNS which worsens cardiac disease & HTN)
 Kidney disease
 Bronchial asthma, chronic obstructive pulmonary disease (COPD) = difficult for pt. to cough up the secretions (the
adrenergic drugs will cause the drying effect and pt. can’t cough)
 Benign prostatic hyperplasia (BPH)
 Pregnancy

Interactions
Week 10 – Medication Summary

 Any drug that causes CNS depression

 Inhibited metabolism when taken with drugs that are cytochrome P450 inhibitors

Adverse Effects

 Drowsiness/sedation
 Anticholinergic effects
o Dry mouth, nose & throat
o Difficulty urinating
o Constipation
o Blurred vision
 GI effects
o N+V

Drug Mechanism of Indications Contraindications Interactions Adverse Effects

Action
Diphenhydramin  Produces  Allergic  Allergy  Alcohol  Allergic reaction
e anticholinergic, reactions  Asthma  CNS depressants 
antipruritic,  Parkinson’s*  Premature infants  Anticholinergics
antitussive,  Antitussive  Beast feeding (^ effect)
antiemetic,
antidyskinetic,
sedative effects
Fexofenadine  Relieves  Relief of  Allergy  Antacids ~ Al +  Allergic reaction
allergic rhinitis symptoms ~  Renal impairment Mg = decrease
symptoms allergic  Children under 6 absorption
rhinitis  Fruit juices ~
decrease
bioavailability
Loratidine  Prevents  Relief of  Allergy  Clarithromycin  Headache
allergic nasal, non-  Renal-hepatic  Erythromycin  Fatigue
responses nasal impairment  Fluconazole  Drowsiness
Week 10 – Medication Summary

medicated by symptoms of  Foods ~

histamines seasonal decreased
allergic absorption
rhinitis
 Treatment of
itching ~
hives

Decongestants

Oral Adrenergic
 Prolonged decongestant effects, but delayed onset
 No rebound congestion

Topical Adrenergic
 Prompt onset
 Potent effect
 Rebound congestion (gets worse)

Nasal Decongestants

Mechanism of Action

 Site of action = blood vessels surrounding nasal sinuses

 Adrenergics/sympathomimetics
o Constrict small blood vessels that supply upper respiratory tract structures
o As a result, these tissues shrink, and nasal secretions in the swollen mucous membranes are better able to drain
 Nasal steroids
o Anti-inflammatory effect
o Work to turn off the immune system cells involved in the inflammatory response
o Decreased inflammation results in decreased congestion
Week 10 – Medication Summary

Indications

 Relief of nasal congestion associated w.:

o Rhinitis
o Common cold
o Sinusitis
o Allergies
 May also be used prophylactically before surgery or certain procedures

Contraindications

 Allergy
 Acute-angle glaucoma
 Uncontrolled cardiovascular disease, HTN (these drugs will make these conditions worse)
 Diabetes & hyperthyroidism (metabolism is increased)
 Hx of cerebrovascular accident or transient ischemic attacks
 Cerebral arteriosclerosis
 Long-standing asthma
 Benign prostatic hyperplasia

Interactions

 Systemic sympathomimetic drugs + sympathomimetic nasal decongestants = toxicity when given together
 Monoamine oxidase inhibitors and sympathomimetic nasal decongestants raise BP

Adverse Effects

 Adrenergic  nervousness, insomnia, palpations, tremors

 Steroids  local mucosal dryness & irritation, epistaxis (nose bleed)
Week 10 – Medication Summary

Drug Mechanism of Indications Contraindications Interactions Adverse Effects

Action
Pseudoephedrine  Produces Temporary relief of  Allergy  Decrease effects  Tachycardia,
vasoconstriction nasal congestion  Use of MOAIs of palpitations
 Causes bronchial due to common w/in 14 days antihypertensive,  Light-
relaxation cold, URT  HTN beta blockers & headedness
 ^ allergies, sinitus  CAD diuretics  N+V
HR/contractility Enhances nasal &
sinus drainage

Antitussives
Mechanism of Action

 Opioids
o Suppress the cough reflex by direct action on the cough center in the medulla
o Analgesia, drying effect on the mucosa of the respiratory tract, increased viscosity of respiratory secretions, reduction
of runny nose and postnasal drip
o Antidote is naloxone

 Nonopioids
o Dextromethorphan: works in the same way
 Not an opioid
 No analgesic properties
 No CNS depression

Indications

 To relieve nonproductive coughs

 Opioid
 Nonopioid
Week 10 – Medication Summary

Contraindications

 Allergy

Adverse Effects

 Opioids
o Sedations, N + V, lightheadedness, constipation
 Nonopioids
o Dizziness, drowsiness
o GI upset

Drug Mechanism of Indications Contraindications Interactions Adverse Effects

Action
Dextromethorphan  Relieve cough ~  Dry cough  Productive  Alcohol  Drowsiness
common cold + cough  N+V
flu  Cough ~ disease
 Asthma
 COPD
 Pneumonia

Expectorants
Mechanism of Action

 Reflex stimulation
o Irritation of the gastrointestinal tract
o Loosening and thinning of respiratory tract secretions occur in response to this irritation
 Direct Stimulation
o The secretory glands are stilmulated directly to increase their production of respiratory tract fluids
Week 10 – Medication Summary

Indications

 Used for the relief of productive coughs associated with…

o Common cold
o Bronchitis
o Laryngitis
o Pharyngitis
o Pertussis
o Influenza
o Measles

Contraindications

 Allergy

Adverse Effects

 GI  N + V, gastric irritation

Drug Mechanism of Indications Contraindications Interactions Adverse Effects

Action
Guaifenesin  Promotes  Helps loosen  Allergy  N+V~
removal of phlegm and  Children under overdose
viscous thin bronchial 2
mucous secretions,
making cough
more
productive

Before administering the traditional antihistamines such as diphenhydramine, chlorpheniramine, or bromphe-

niramine, the nurse must ensure that the patient has no allergies to this group of medications, even though these
Week 10 – Medication Summary

drugs are used for allergic reaction. Contraindications, cautions, and drug interactions need to be assessed with
this and all other drugs.

Use of the antihistamines is of concern in patients who are having an acute asthma attack and those with lower
respiratory tract disease or who are at risk for pneumonia. The rationale for not using these drugs in these
situations is that antihistamines dry up secretions; if the patient cannot expectorate the secretions, the
secretions may become viscous (thick), occlude air- ways, and lead to atelectasis or further infection or occlu-
sion of the bronchioles. It is also important to know that these drugs may lead to paradoxical reactions in the
older adult, with subsequent irritability as well as dizziness, confusion, sedation, and hypotension.

Most nonsedating antihistamines (e.g., fexofenadine, loratadine, desloratadine, cetirizine) are not to be used in
patients younger than 6 years of age. Allergies and other contraindications, cautions, and drug interactions
should be assessed prior to use. With the traditional and nontraditional antihistamines, it is important to
remember that if allergy testing is to be performed, these medications should be discontinued at least 4 days
before the testing, but only with a physician’s order.

With antitussive therapy, assessment is tailored to the patient and the specific drug. Most of these drugs result
in sedation, dizziness, and drowsiness, so assess- ment of the patient’s safety is important. A history of allergies,
contraindications, cautions, and drug inter- actions should be completed and documented. Respira- tory
assessment (as with all of the drugs in this chapter) should include rate, rhythm and depth, breath sounds,
presence of cough, and description of cough and spu- tum if present. For individuals with chronic respiratory
disease, the physician may order serum levels of carbon dioxide, PaO2, and other blood gas information (e.g.,
blood pH).

Use of decongestants requires assessment of contra- indications, cautions, and drug interactions. Because
decongestants are available in oral, nasal drops and sprays, and eye drop dosage forms, any condition that could
affect the functional structures of the eye or nose may be a possible caution or contraindication. Decon-
Week 10 – Medication Summary

gestants may increase blood pressure and heart rate, so the patient’s blood pressure, pulse, and other vital para-
meters should be assessed and documented.

Inhaled intranasal steroids and anticholinergic drugs are not generally associated with rebound congestion but
may be used prophylactically to prevent nasal congestion in patients with chronic upper respiratory tract symp-
toms. Contraindications, cautions, and drug interactions, as with all the drugs in this chapter, need to be
thoroughly assessed prior to use. For patients who have a cough and need to mobilize secretions more easily,
expectorants are often recommended or prescribed. Assessment of cough and sputum, if present, should be
noted in addition to all of the previously identified parameters.

Antihistamines, Decongestants, Antitussives, and Expectorants CHAPTER 36 679

Nursing Diagnoses
• Impaired gas exchange related to the disorder, condi- tion, or disease affecting the respiratory system and
respiratory-related signs and symptoms

• Deficient knowledge related to the effective use of cold medications and other related products due to lack of
information and patient teaching

• Ineffective airway clearance related to diminished ability to cough or a suppressed cough reflex (with
antitussives)

• Risk for injury related to sensory-perceptual altera- tions from drug-induced drowsiness or the sedating effects
of many of these drugs Planning Goals
• Patient will state the rationale for the use of an anti- histamine, expectorant, antitussive, or decongestant.
Week 10 – Medication Summary

• Patient will state the adverse effects of the medication.

• Patient will state the importance of adherence to the therapy regimen.

• Patient will identify symptoms to report to the physician.

• Patient will state the importance of follow-up appoint- ments with the physician.

• Patient will convey relief of symptoms with treatment.

• Patient will regain near-normal or normal (baseline) respiratory patterns and function.

• Patient will remain free of excessive drowsiness or sedation. Outcome Criteria

• Patient remains adherent to the antihistamine, antitus- sive, decongestant, or expectorant medication regi-
men until symptoms are resolved or the physician orders discontinuation.

• Patient takes medications exactly as prescribed to avoid complications of therapy, experience maximal
effectiveness, and minimize adverse effects.

• Patient reports any of the following symptoms to the physician immediately: increase in cough, congestion,
shortness of breath, chest pain, fever (a temperature above 38°C), or any change in sputum production or
colour (i.e., if not clear or if a change from baseline).

• Patient identifies specific safety precautions to help pre- vent injury related to drug-induced CNS-depressant
adverse effects, such as moving purposefully and slowly, asking for assistance as needed, minimizing the
use of other CNS-depressant drugs, and, if an older adult or at high risk for injury, obtaining assistance
with activities of daily living and with mobility.
Week 10 – Medication Summary

• Patient reports resolution of symptoms and an improved health status, such as return of temperature to
baseline, return of secretions or sputum to clear col-

our and normal consistency, return to normal breath- ing rate and patterns, and clearing of breath sounds.

Implementation
Patients taking traditional antihistamines (e.g., diphenhy- dramine) should take the medications as prescribed.
Most of these medications, including the over-the-counter anti- histamines, are best tolerated when taken with
meals. Although food taking may slightly decrease absorption of antihistamines, it has the benefit of minimizing
the gastrointestinal upset that the drugs may cause. Patients who experience dry mouth should be encouraged
to chew or suck on candy (sugar-free if needed) or over-the- counter throat, cough, or cold lozenges, or to chew
gum. Patients should also perform frequent mouth care to ease the dryness and related discomfort. Because of
the poten- tial for serious drug interactions, other over-the-counter or prescribed cold or cough medications
should not be taken with antihistamines unless they were previously approved or ordered by the physician.
Dosage amounts and routes may vary depending on whether the patient is an older adult, young adult, or child
under the age of 12 years, so proper dosing and usage should be encour- aged. Blood pressure and other vital
signs should be monitored as needed. Older adults and children should be monitored for any paradoxical
reactions, which are common with these drugs.

If patients are receiving any of the newer second- generation nonsedating antihistamines, the drugs should be
taken carefully and as directed. Reduced dosages may be needed for patients who are older adults or have
decreased kidney functioning. These newer H1 receptor antagonist drugs do not cross the blood–brain barrier as
readily as do older antihistamines and are therefore less likely to cause sedation. They are generally well
tolerated with minimal adverse effects.
Week 10 – Medication Summary

With antitussives, chewable or lozenge forms of the drugs should be used exactly as ordered. Drowsiness or
dizziness may occur with the use of antitussives; therefore, patients should be cautioned about driving a car or
engaging in other activities that require mental alertness until they feel normal again. If the antitus- sive contains
codeine, the CNS-depressant effects of the narcotic opiate may further depress breathing and respiratory effort.
Other antitussives, such as dextro- methorphan, as well as the codeine-containing drugs should be given at
evenly spaced intervals so that the drug reaches a steady state.

Patients taking decongestants, such as pseudoephe- drine or phenylephrine, are generally using the drugs for
nasal decongestion. These drugs come in oral dos- age forms, including sustained-release and chewable forms.
With the use of any of the drugs discussed in this chapter and with the respective disorders or diseases they are
intended for, it is also important to encour- age fluid intake of up to 3000 mL a day, unless contra- indicated. The
fluid helps liquefy secretions, assists in