NCLEX-RN: Medical–Surgical Nursing

Medical–Surgical Nursing: Respiratory system

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Treatment for Traumatic Injury

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Chest Tube

Focus topic: Medical–Surgical Nursing

Definition: Chest tubes remove air and fluid from lungs and restore normal intrapleural pressure so lungs can reexpand.+

Assessment
A. Before insertion.

  • Complete client procedure verification.
  • Obtain consent after physician explains procedure.
  • Perform baseline cardiopulmonary assessment.
  • Monitor vital signs (VS) and pulse oximetry.
  • Observe chest excursion.
  • Assess changes in level of consciousness (LOC).
  • Obtain a preprocedure chest x-ray if ordered.
  • Assess anxiety and medicate 30 minutes prior to insertion.
  • Prepare necessary equipment and supplies, including two rubber-tipped hemostats for each chest tube at bedside and to travel with client should he or she leave the unit.
  • Position client according to physician’s specifications.

B. During insertion.

  • Evaluate client’s safety while tubes inserted.
  • Assess patency of chest tubes.
  • Observe for mediastinal shift.
  • Auscultate breath sounds for air flow.
  • Observe for bilateral chest expansion.
  • Evaluate chest drainage, color and amount.

Implementation
A. Purpose: To reestablish negative pressure in pleural space by the evacuation of air and fluid.

  • Uses: Used for pleural effusions, pneumothorax and hemothorax.
  • Safety measure: Always keep rubber-tipped Kelly clamps and Vaseline gauze at bedside. There should be two Kelly clamps per chest tube.

B. Assist physician in placement of tubes.

  • Tubes placed in pleural cavity following thoracic surgery.
  • Provides for removal of air and serosanguineous fluid from pleural space.

C. Attach to water-seal suction—maintains closed system.

  • Tape all connectors.
  • Ensure that all stoppers in bottles are tight fitting.

D. Apply suction.

  • Keep unit below level of bed.
  • Keep suction level where ordered (be sure that bubbling is not excessive in the pressure-regulating chamber).
  • Maintain water level in chamber.

E. Nursing care immediately following procedure.

  • Obtain repeat chest x-ray.
  • Assess respirations.
  • Assess integrity of the system.
  • Assess drainage.
  • Assess for fluctuation in tubing during respirations.

F. Follow-up nursing care (hourly initially, once stabilized q 2 hours).

  • Respiratory rate and effort.
  • Bilateral lung sounds.
  • Symmetrical chest excursion.
  • Assess and medicate for pain.
  • Check integrity of dressing.
  • Subcutaneous emphysema (should ↓ unless air leak).
  • Tidaling with inspiration.
  • Water seal—no bubbling unless leak (client or system).

G. Facilitating drainage.

  • Keep tubing looped on bed—avoid dependent drainage.
  • Reposition every 2 hours or as ordered.
  • Encourage client to cough and deep-breathe.
  • Use gentle wall suction if ordered.
  • Monitor drainage (color, amount), initially every hour, when < 100 mL/hr, monitor q 2 hours. Document every 4 hours.
  • Drainage should be no more than 100 mL/hr or 500 mL in 8 hours.

H. Maintain integrity of system.

  • Keep water seal filled to the 2-cm level.
  • Keep suction control chamber to ordered level (usually 20 cm and check for evaporation of water q shift) or dry suction to ordered level.
  • Keep system below level of chest.
  • Tape all connections.
  • Secure drainage system to bed or floor.
  • If transporting, secure drainage system to stretcher or wheelchair (W/C).
  • Position system for safety prior to raising or lowering bed.
  • Never clamp unless ordered.
  • Milking of chest tubes is not done unless specifically ordered by physician.
    a. With specific physician’s orders, milk every 30–60 minutes.
    b. Milk away from client toward the drainage receptacle (Pleur-evac or bottles).
    c. Pinch tubing close to the chest with one hand as the other hand milks the tube. Continue going down the tube in this method until drainage receptacle is reached.
    d. Milking may be ordered—stripping should be avoided unless specifically ordered.

I. Change drainage system.

  • Prepare new drainage system.
  • Fill under water seal.
  • Fill suction control to desired level (if ordered).
  • Clamp and disconnect chest tube.
  • Attach to new drainage system.
  • Retape all tubing connections.
  • Open clamp.

J. Nursing care following removal of chest tubes.

  • Explain procedure to client.
  • Medicate 30 minutes prior to removal.
  • Prepare necessary equipment and supplies.
  • Postprocedure chest x-ray as ordered.
  • Perform baseline cardiopulmonary assessment.
  • Monitor VS and pulse oximetry.
  • Observe chest excursion.
  • Monitor insertion site.
  • Encourage cough, deep breathing, position change.

Medical–Surgical Nursing: Chest Drainage Systems

Focus topic: Medical–Surgical Nursing

Characteristics
A. The disposable water-seal drainage system is most commonly used.

B. General principles.

  • Used after some intrathoracic procedures.
  • Chest tubes placed intrapleurally.
  • Breathing mechanism operates on principle of negative pressure (pressure in chest cavity is lower than pressure of atmosphere, causing air to rush into chest cavity when injury such as stab wound occurs).
  • When chest has been opened, vacuum must be applied to chest to reestablish negative pressure.
  • Closed water-seal drainage is method of reestablishing negative pressure.
    a. Water acts as a seal and keeps the air from being drawn back into pleural space.
    b. Open drainage system would allow air to be sucked back into chest cavity and collapse lung.
  • Closed drainage is established by placing catheter into pleural space and allowing it to drain under water.
    a. The end of the drainage tube is always kept under water.
    b. Air will not be drawn up through catheter into pleural space when tube is under water.

Assessment
A. Assess client’s respiratory rate, rhythm, and breath sounds for signs of respiratory distress.
B. Check that all connections on tubing are airtight and suction control is connected.
C. Examine system to see if it is set up and functioning properly.
D. Identify any malfunctions in system (e.g., air leaks, negative pressure, or obstructions).

Implementation
A. Maintain chest drainage system.
B. Most pleural drainage systems have three basic compartments (see Figure 8-11).

  • Collection chamber (1). Fluid and air from chest cavity drain into chamber. Air in this chamber is vented to the second chamber.
  • Water-seal chamber (2). Acts as one-way valve so air drains from the chest cavity, but can’t return to the client. Air bubbles out into water. Water level fluctuates as intrapleural pressure changes.
  • Suction-control chamber (3). Amount of suction applied regulated by amount of water in chamber or depth of tubing in water, not by the amount of suction applied.
  • When drainage system pressure becomes too low, outside air is sucked into the system. Results in constant bubbling in the pressure regulator bottle.
  • Whenever suction is off, drainage system must be open (vented) to the atmosphere.
    a. Intrapleural air can escape from the system.
    b. Detach the third chamber tubing from the suction motor to provide the air vent.

C. A flutter or Heimlich valve may be used.

  • This is a one-way flutter valve within a rigid plastic tube with an attached drainage bag.
  • It is attached to the end of the chest tube.
  • Valve opens whenever pressure is greater than atmospheric pressure.
  • Can be used for emergency transport with small to moderate pneumothorax.
  • Allows for client mobility.
  • Can be hidden under clothes.
  • Clients can return home with Heimlich valves in place.

Medical–Surgical Nursing

Medical–Surgical Nursing

Assessment
A. Assess respiratory status for need to use mechanical ventilation.
B. Identify type of mechanical ventilation needed.

  • Negative-pressure ventilator.
    a. Helpful in problems of a neuromuscular nature, spinal cord injuries.
    b. Not effective in the treatment of increased airway resistance.
    c. Types—full body, chest, and chest–abdomen. Employs intermittent negative pressure around chest wall to pull wall out and decrease intrathoracic pressure.
  • Positive-pressure ventilator.
    a. Uses positive pressure (pressure greater than atmospheric) to inflate lungs. Primary use in acutely ill clients.
    b. Types.
    (1) Pressure cycle.
    (a) Pressure ranges from 10 to 30 cm of water pressure.
    (b) Air is actively forced into lungs.
    (c) Expiration is passive.
    (2) Volume cycle.
    (a) Uses physiological limits.
    (b) Predetermined total volume is delivered irrespective of airway pressure.
    (c) Positive end-expiratory pressure (PEEP) utilized to maintain positive pressure between expiration and beginning of inspiration.

C. Assess for complications of positive-pressure therapy.

  • Respiratory alkalosis.
  • Gastric distention and paralytic ileus.
  • Gastrointestinal bleeding.
  • Diffuse atelectasis.
  • Infection.
  • Circulatory collapse.
  • Pneumothorax.
  • Sudden ventricular fibrillation.
  • Ventilator-associated pneumonia (VAP).

Implementation
A. Monitor client for complications.
B. Suction client or check for kinks in tubing when pressure alarm sounds.
C. Monitor blood gas values frequently.
D. Maintain fluid therapy.

  • IV route.
  • Oral route if client able to swallow.

E. Monitor intake and output.
F. Follow VAP bundle protocol for prevention.

  • Proper hand washing technique.
  • Frequent and careful oral hygiene with chlorhexidine oral rinse.
  • Elevate head of bed 30–45 degrees.
  • Suction above the cuff.
  • Proper cuff inflation 25 to 30 cm H2O: use of minimal occlusion pressure.
  • Daily sedation vacations and assessment of readiness to extubate.
  • Stress ulcer prophylaxis.
  • DVT prophylaxis.
  • Increase use of noninvasive ventilation (NIV) (continuous positive airway pressure [CPAP], bilevel positive airway pressure [BiPAP]).
  • Insure assessment/performance of daily spontaneous breathing trial (SBT).
  • Use MDIs instead of small-volume nebulizer (SVN).
  • Orotracheal instead of nasotracheal intubation.

Medical–Surgical Nursing: Thoracic Surgical Procedures

Focus topic: Medical–Surgical Nursing

Assessment
A. Identify type of procedure done.

  • Exploratory thoracotomy: incision of the thoracic wall; performed to locate bleeding, injuries, tumors.
  • Thoracoplasty: removal of ribs or portions of ribs to reduce the size of the thoracic space.
  • Pneumonectomy: removal of entire lung.
  • Lobectomy: removal of a lobe of the lung (three lobes on right side, two on the left).
  • Segmented resection: removal of one or more segments of the lung (right lung has ten segments and left lung has eight).
  • Wedge resection: removal of a small, localized area of disease near the surface of the lung.

B. Assess for postoperative client care needs.

Implementation
A. Provide postoperative nursing management.

  • Closed chest drainage is employed in all but pneumonectomy. In pneumonectomy, there is no lung to reexpand, so it is desirable that the fluid accumulate in empty thoracic space. Eventually the thoracic space fills with serous exudate, which consolidates to prevent extensive mediastinal shifts.
  • Maintain patent chest tube drainage by chest tube milking—milk away from client toward drainage bottle, only with physician’s orders.
  • Maintain respiratory function.
    a. Have client turn, cough, and deep-breathe.
    b. Suction if necessary.
    c. Provide oxygen therapy.
    d. Provide incentive spirometry.
    e. Ventilate mechanically if necessary.
    f. Auscultate lungs.
    g. Observe for complications.
  • Ambulate early to encourage adequate ventilation and prevent postoperative complications. (Ambulate clients with pneumonectomies in 2 or 3 days to facilitate cardiopulmonary adjustment.)
  • Provide range-of-motion exercises to all extremities to promote adequate circulation.
  • Monitor central venous pressure with vital signs—watch for indications of impaired venous return to heart.
  • Position client correctly to maximize ventilation.
    a. Use semi-Fowler’s position when vital signs are stable to facilitate lung expansion.
    b. Turn every 1–2 hours.
    c. Pneumonectomy.
    (1) No chest tubes inserted (no lung to reinflate). Fluid left in space to consolidate.
    (2) Position on operative side to maximize ventilation.
    (3) Some physicians will allow positioning on either side after 24 hours.
    d. Segmental resection or wedge resection: Position on back or unoperative side (aids in expanding remaining pulmonary tissue).
    e. Lobectomy: Turn to either side (can expand lung tissue on both sides).
  • Maintain fluid intake as tolerated. Watch for overload in pneumonectomy clients.
  • Provide arm and shoulder postoperative exercises—prevent adhesion formation.
    a. Put affected arm through both active and passive range of motion every four hours.
    b. Start exercises within 4 hours after client has returned to room following surgery.

B. Monitor postoperative complications.

  • Respiratory complications.
    a. Causes of inadequate ventilation.
    (1) Airway obstruction due to secretion accumulation.
    (2) Atelectasis due to underexpansion of lungs and anesthetic agents during surgery.
    (3) Hypoventilation and carbon dioxide buildup due to incisional splinting because of pain.
    (4) Depression of CNS from overuse of medications.
    b. Tension pneumothorax.
    (1) Caused by air leak through pleural incision lines.
    (2) Can cause mediastinal shift.
    c. Pulmonary embolism.
    d. Bronchopulmonary fistula.
    (1) Air escapes into pleural space and is forced into subcutaneous tissue around incision, causing subcutaneous emphysema.
    (2) Caused by inadequate closure of bronchus when resection is done.
    (3) Another cause is alveolar or bronchiolar tears in surface of lung (particularly following pneumonectomy).
    e. Atelectasis and/or pneumonia: caused by airway obstruction or as result of anesthesia.
    f. Respiratory arrest can occur.
  • Circulatory complications.
    a. Hypovolemia: due to fluid or blood loss.
    b. Arrhythmias: due to underlying myocardial disease.
    c. Cardiac arrest: can occur from either of these conditions.
    d. Pulmonary edema: can occur due to fluid overload of circulatory system.

Medical–Surgical Nursing: Tracheostomy

Focus topic: Medical–Surgical Nursing

Characteristics
A. Bypasses upper airway obstruction.
B. Facilitates removal of secretions.
C. Permits long-term mechanical ventilation.

Assessment
A. Determine need for tracheostomy as compared to less intrusive methods of providing patent airway.
B. Assess client’s level of consciousness to determine client’s ability to understand explanation and instructions.
C. Observe client’s respiratory status: shortness of breath, severe dyspnea, tachypnea, or tachycardia.
D. Auscultate for presence and forced expiration of rhonchi, rales, or wheezes.
E. Observe for dried or moist secretions surrounding cannula or on tracheal dressing.
F. Observe for excessive expectoration of secretions.
G. Assess result of routine tracheal care to determine if routine care is adequate for this client.
H. Observe client’s ability to sustain respiratory function by ability to breathe through normal airway.
I. Assess respiratory status: breath sounds, respiratory rate, use of accessory muscles for breathing while tracheal tube is plugged (must be a fenestrated tube).
J. Assess for labored breathing, flaring of nares, retractions, and color of nail beds.

Implementation
A. Provide tracheal suction as ordered or prn. (See Suctioning.)

  • Always wear sterile gloves for these procedures.
  • Always apply oral or nasal suction first so that when cuff is deflated, secretions will not fall into lung from area above cuff.
  • Catheter must be changed before doing tracheal suctioning as a sterile technique.

B. Provide humidity by using tracheostomy mist mask, if client is not on ventilator.
C. Monitor for hemorrhage around tracheostomy site.
D. Change dressings (nonraveling type) and cleanse surrounding area with hydrogen peroxide at least every 4 hours.
E. Provide care for client with a cuffed tracheostomy tube.

  • Hyperoxygenate client before and after cuff is deflated with Ambu bag.
  • Deflate tracheal cuff (no longer a routine procedure).
    a. Suction airway before deflating cuff.
    b. Attach 10-mL syringe to distal end of inflatable cuff, making sure seal is tight.
    c. Slowly withdraw 5 mL of air. Amount of air withdrawn is determined by type of cuff used and whether air leak is utilized.
    d. Keep syringe attached to end of cuff.
    e. Suction if cough reflex stimulated.
    f. Assess respirations; if labored, reinflate cuff.
    g. If high-volume/low-pressure cuff is used, cuff is not routinely deflated. (In fact, deflating cuff does not help tracheal lining. The pooled secretions above the tracheal cuff are the problem.)
  • Inflate cuff.
    a. Suction airway before inflating cuff.
    b. Inflate prescribed amount of air to create leak-free system. Cuff is inflated correctly when you cannot hear the client’s voice or any air movement from nose or mouth.
    c. Remove syringe and apply rubber-tipped forceps to maintain air in cuff if there is no self-sealing.
    d. If high-volume/low-pressure cuff is used, cuff is not routinely deflated.

F. Administer inner cannula tracheal cleaning.

  • Suction before cleaning tracheal tube.
  •  Unlock the inner cannula by turning the lock to the right about 90 degrees and secure the outer cannula of the neck plate with your left index finger and thumb.
  • Gently pull the inner cannula slightly upward and out toward you.
  • Wash cannula thoroughly with cool, sterile water, saline, or hydrogen peroxide to remove secretions. (Tap water may be used if hospital policy allows.) Soak the cannula in a hydrogen peroxide–filled sterile bowl to further remove dried secretions.
  • Rinse cannula thoroughly with sterile water or saline, and gently shake to dry.
  • Replace the inner cannula carefully by grasping the outer flange of the cannula with your left hand as you insert the cannula. Lock the inner cannula by turning the lock to the left so that it is in an upright position.
  • Cleanse around the incision site with applicator sticks soaked in normal saline and/or hydrogen peroxide (one-half strength).
  • Apply tracheostomy dressing around insertion site, and change tracheostomy ties if needed.
  • If tracheostomy ties are to be changed, ask another person to hold the tracheal tube in place while you change the ties. This procedure prevents accidental extubation if the client coughs.
  • Repeat care tid and as needed.
  • Keep obturator at bedside for emergency use if tube is dislodged.

G. Current research advises against instilling saline into airway—increases chance of infection and causes hypoxemia.
H. Provide tracheostomy plugging.

  • Suction nasopharynx if cuffed tube is in place using clean technique.
  • Deflate tracheal cuff; if tracheostomy tube is plugged and cuff is not deflated, client has no airway.
  • Place tracheal plug in either the inner cannula or the outer cannula with inner cannula removed.
  • Observe client for respiratory distress.

Medical–Surgical Nursing: Suctioning

Focus topic: Medical–Surgical Nursing

Assessment
A. Determine need for suctioning.

  • Ineffective cough.
  • Thick, tenacious mucus.
  • Impaired pulmonary function.
  • Repressed level of consciousness.
  • Restlessness.

B. Observe vital signs for increases in pulse and respirations, and for changes in skin color.

C. Auscultate sounds to evaluate lung field.
D. Determine level of consciousness to assess hypoxia.

Implementation
A. Provide nasotracheal suction.

  • Gather equipment.
    a. Sterile suction catheter, usually no. 14 or no. 16 French.
    b. Sterile saline.
    c. Suction machine.
    d. Gloves.
  • Complete suctioning procedure.
    a. Hyperoxygenate (100% oxygen) before suctioning.
    b. Lubricate catheter with normal saline.
    c. Insert catheter into nose for 15–20 cm (clean technique is used when catheter does not extend to lower airway).
    d. Do not apply suction while introducing catheter.
    e. When advanced as far as possible, begin suctioning by withdrawing catheter slowly; if single-eyed catheter, rotate it with pressure applied. (Usually, a whistle-tip catheter or Y connector tube is used to apply pressure.)
    f. Withdraw catheter slightly if cough reflex is stimulated.
    g. Remember that hypoxia can occur if suctioning is done incorrectly.
    (1) More than 10 seconds of suctioning— oxygen will be decreased in respiratory tree.
    (2) Causes chemoreceptors to respond by increasing ventilation rate.
    h. Postoxygenate after suctioning.

B. Closed suction system.

  • Suction catheter attached directly to ventilator tubing presents advantages over open system.
  • More effective—no need to disconnect client from ventilator; thus, oxygenation is better.
  • Safer—catheter is enclosed in plastic sheath (a closed system) so risk of infection is decreased for both client and nurse.
[sociallocker]

Medical–Surgical Nursing: Passy-Muir Speaking Valve

Focus topic: Medical–Surgical Nursing

Characteristics
A. Used to help clients speak more normally.
B. One-way valve attaches to the outside opening of the tracheostomy tube.
C. Allows air to pass into the tracheostomy, but not out through it.
D. Valve opens when the client breathes in.
E. Valve closes when the client breathes out and air flows around the tracheostomy tube, up through the vocal cords, allowing sounds to be made.
F. The client breathes out through the mouth and nose instead of the tracheostomy.

Assessment
A. Assess as for tracheostomy.
B. Pay particular attention to client secretions.
C. If the client has a lot of secretions or very thick secretions, you may not be able to use the valve.

Implementation
A. Suction the tracheostomy tube as needed before placing the valve.
B. If the tracheostomy tube has a cuff, deflate it before placing the valve.
C. Suction the client’s mouth and nose as needed before deflating the cuff so that secretions do not trickle into the trachea (windpipe) and bronchi.
D. Attach the valve to the top of the tracheostomy tube with a twisting motion to the right (clockwise) approximately ¼ turn. This will prevent it from popping off with coughing.
E. To remove the valve, twist off to the left (counter clockwise).

Special Considerations
A. Humidity can be used with the valve in place.
B. Oxygen can be given with the valve in place.
C. Remove the valve during aerosol treatments. If left on, remove it and rinse it after treatment to remove any medications that could cause the valve to stick or not work well.

Care of the Valve
A. Wash the valve daily with mild soapy water.
B. Rinse thoroughly with cool to warm water. Hot water may damage the valve.
C. Let the valve air dry completely before using it again.
D. Do not use a brush, vinegar, peroxide, bleach, or alcohol on the valve.
E. Replace the valve when it becomes sticky, noisy, or vibrates.

Safety Precautions
A. Clients must not use the valve while sleeping.
B. The valve should only be used under direct supervision of caregivers who know how it works and how to correctly use it.
C. Remove the valve immediately if the client has difficulty breathing.
D. Suction and/or change the tracheostomy tube if needed.
E. The valve must not be used on tracheostomies that have the cuff inflated.

Medical–Surgical Nursing: Pulmonary Medications

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Sympathomimetic (Adrenergic) Bronchodilators

Focus topic: Medical–Surgical Nursing

Definition: Relax smooth muscle and increase respirations by effect on beta-adrenergic receptor in bronchus.

A. Adrenalin (epinephrine).

  • Beta and alpha stimulant; relaxes bronchial smooth muscle.
  • Routes: sub q, IV, MDI.
  • Used to treat severe bronchial attacks and for anaphylaxis.
  • May cause arrhythmias, increased BP, urinary retention, increased blood sugar, headache.

B. Ephedrine (ephedrine sulfate.)

  • Relaxes smooth muscle of the tracheobronchial tree.
  • Route: PO.
  • Used for mild bronchospasm.
  • Similar side effects as epinephrine.

C. Isuprel (isoproterenol).

  • Pure beta agonist; relaxes smooth muscle of tracheobronchial tree; relieves bronchospasms.
  • Routes: IV, MDI.
  • May cause marked tachycardia, arrhythmias, angina, palpitations.

D. Proventil, Ventolin (albuterol).

  • Very selective beta2 agonist with rapid onset of action.
  • Routes: PO, MDI (two to three puffs every 4–6 hours).
  • Minimal cardiovascular side effects.

E. Bronkosol, Bronkometer (isoetharine).

  • More beta2-specific than Isuprel; relaxes smooth muscle of the tracheobronchial tree; less potent.
  • Route: nebulized solution or MDI.
  • Side effects similar to Isuprel, but appear less frequently; may cause tachycardia.
  • Tolerance to bronchodilating effect may develop with too-frequent use of medication.

F. Alupent (metaproterenol).

  • Relieves bronchospasm, has rapid onset.
  • Routes: PO, MDI (two to three puffs every 4–6 hours).
  • Side effects same as isoetharine.

G. Bricanyl, Brethine, Brethaire (terbutaline).

  • Beta-adrenergic receptor agonist; bronchodilator; relieves bronchospasms associated with COPD, asthma. Slow onset with PO, MDI.
  • Routes: sub q, PO, Brethaire by MDI (two to three puffs every 4–6 hours).
  • May cause nervousness, palpitations; nausea if taken on an empty stomach.

Medical–Surgical Nursing: Anticholinergic Bronchodilators

Focus topic: Medical–Surgical Nursing

Definition: Agents that prevent bronchospasm caused by acetylcholine.

A. Atrovent (ipratropium bromide).

  • Greater bronchodilating effect than conventional beta agonists. Primarily local and site specific; more potent than sympathomimetics in COPD. Also used for severe acute asthma.
  • Route: MDI (two to three puffs every 4–6 hours).
  • Minimal side effects, dry mouth, cough.

B. Atropine.

  • Prevents bronchospasm associated with asthma, bronchitis, and COPD.
  • Routes: nebulizer three to four times/day.
  • Monitor for tachycardia and hypertension.

Medical–Surgical Nursing: Methylxanthine Bronchodilators

Definition: Relaxes smooth muscle of tracheobronchial tree. Less effective than inhaled beta agonists. Used later in treatment regimen, as an additional bronchodilator.

A. Truphylline (aminophylline).

  • Relaxes smooth muscle of the tracheobronchial tree; bronchodilator.
  • Routes: PO, IV, rectal suppository.
  • Therapeutic serum level 8–20 μg/mL.
  •  May cause tachycardia, hypotension, arrhythmias, GI distress, tremors, anxiety, headache.
  • Toxic levels cause arrhythmias, seizures.

B. Theo-Dur, Slo-Bid, Uni-Dur (theophylline).

  • Long-acting bronchodilator—relaxes smooth muscle of the bronchi and pulmonary vessels.
  • Routes: PO, rectally.
  • Therapeutic serum level 10–20 μg/mL.
  • Side effects similar to Truphylline.

C. Choledyl (oxtriphylline).

  • Similar to other bronchodilators.
  • Route: PO.
  • Less GI irritation than Truphylline.

Medical–Surgical Nursing: Leukotriene Inhibitors/Receptor Antagonists

Focus topic: Medical–Surgical Nursing

Definition: Inhibit formation of leukotrienes, which cause airway inflammation, edema, bronchoconstriction, and mucus secretion.

A. Accolate (zafirlukast), Zyflo (zileuton), and Singulair (montelukast sodium).

  • Basic action is anti-inflammatory.
  • Taken orally (not through MDI) so compliance is improved for long-term control, not for acute asthma episode.

B. Side effects: headache, nausea, diarrhea, dizziness, fever, and myalgia.

Medical–Surgical Nursing: Antimediators (Mast Cell Stabilizers)/ Anti-Inflammatory Agents

Focus topic: Medical–Surgical Nursing

Definition: Mast cell stabilizers inhibit release of histamine; glucocorticoids reduce inflammation and act as bronchodilators.

A. Intal, Nalcrom (cromolyn sodium).

  • Decreases airway inflammation and irritation— used for younger clients with asthma.
  • Route: MDI, nebulizer, nasal spray.
  • Prevents bronchospasm when used before exercise or exposure to cold air.
  • Can cause throat irritation.

B. Glucocorticoids: Beclovent, Vanceril, Beconase (beclomethasone dipropionate).

  • Used in conjunction with bronchodilators for treatment of bronchospasms; anti-inflammatory effects, decrease mucus secretion. Aerosol use prevents systemic side effects of steroids.
  • Routes.
    a. Deltasone (prednisone) PO.
    b. Medrol (methylprednisolone) PO, IV, Cortef (hydrocortisone) IV.
    c. Beclovent, Vanceril (beclomethasone dipropionate) MDI.
    d. Azmacort (triamcinolone) MDI.
  • Instruct client to rinse mouth after MDI use to prevent oral candidiasis.
  • Side effects include increased appetite, sore throat, cough, thrush, Cushing-like appearance.

Medical–Surgical Nursing: Mucokinetic Agents

Focus topic: Medical–Surgical Nursing

Definition: Reduce the viscosity of respiratory secretions by breaking down mucoproteins.

A. Mucomyst (acetylcysteine).

  • Used to loosen secretions; reduces viscosity.
  • Routes: inhaled or instilled.
  • May cause bronchospasm, nausea.
  • Instruct client to rinse mouth after use.

B. Mucinex (guaifenesin).

  • Commonly used expectorant.
  • Route: PO.

C. Iodide preparations: SSKI, Organidin (guaifenesin).

  • Expectorant liquefies tenacious bronchial secretions.
  • Route PO; bitter taste, give with juice or milk.
  • Do not administer if allergic to iodine or hyperthyroid.

Medical–Surgical Nursing: Antiprotozoal Drugs

Focus topic: Medical–Surgical Nursing

Definition: Interferes with biosynthesis of deoxyribonucleic acid, ribonucleic acid, phospholipids, and proteins in susceptible organisms.

A. NebuPent, Pentam 300 (pentamidine) for prevention.

  • Prevention of Pneumocystis jiroveci pneumonia (PJP).
  • Routes: nebulizer (300 mg every 4 weeks).
  • If client experiences fatigue, dizziness, or anxiety during inhalation, stop treatment and allow client to rest. Well tolerated, expensive. No systemic protection. Least effective form of prophylaxis.

B. NebuPent, Pentam 300 for treatment.

  • Treatment of PJP.
  • Route: IV or IM (4 mg/kg daily for 14–21 days). IV used for those clients who do not tolerate Bactrim, Septa (trimethoprim-sulfamethoxazole).
  • Closely monitor for hypotension—place client in supine position for IV administration.
  • Nephrotoxic; can cause hyperglycemia, pancreatitis.
  • Screen for active TB before treating moderate to severe PCP.
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