Question

Lillian has been on her medication for pneumonia for 24 hours. The physician says the pneumonia is improving, but she also is having an acute exacerbation of her COPD and a chronic irregular heart rate. Her vital signs are T 37C, B/P 140/87, P 82 and irregular, R 12, and pulse oximetry 92% on 2L O2 per nasal cannula. The physician is concerned about her blood pressure and wants to continue to watch it. She feels that Lillian will benefit from regular medication for her COPD while in the hospital and when she goes home. Lillian also is complaining of cigarette cravings and constipation. The physician is urging her to quit smoking.  

The physician leaves the following orders.

Albuterol MDI two puffs every 6 hours

Ipratropium MDI two puffs every 6 hours

Nicoderm 7 mg/24 hr transdermal patch daily

Bisacodyl 10 mg suppository now x1 then 10 mg po daily

Bathroom privileges

Respiratory therapist to determine need for O2 at home  

Cardiologist, Dr. B, to consult for irregular heart rate

1. How does albuterol MDI work? Make sure to include drug category, mechanism of action, onset and duration of action, and safety considerations.
2. How does ipratropium MDI work? Make sure to include drug category, mechanism of action, onset and duration of action, and safety considerations.
3. How would the nurse properly administer the two MDIs when both have been scheduled at the same time of day?
4. Lillian asks the nurse why she is on two inhalers for her COPD when she used to use just one. What points would the nurse want to cover to answer her question, considering her history of noncompliance?

Answer 1

1. How does albuterol MDI work? Make sure to include drug category, mechanism of action, onset and duration of action, and safety considerations.
ANS: Albuterol is a bronchodilator that relaxes muscles in the airways and increases air flow to the lungs. Albuterol inhalation is used to treat or prevent bronchospasm in people with reversible obstructive airway disease. Albuterol is also used to prevent exercise-induced bronchospasm. Albuterol therapeutic classification is bronchodilator and its ppharmacological classification is adrenergics. Albuterol Binds to beta2-adrenergic receptors in airway smooth muscle, leading to activation of adenyl cyclase and increased levels of cyclic-3', 5'-adenosine monophosphate (cAMP). Increases in cAMP activate kinases, which inhibit the phosphorylation of myosin and decrease intracellular calcium. Decreased intracellular calcium relaxes smooth muscle airways. Its onset is anywhere from 5-15 minutes with the peak at 60-90 minutes and duration of 3-6 hours. You would want to use cautiously in people who have:

Cardiac disease;

Hypertension;

Hyperthyroidism;

Diabetes;

Glaucoma;

Seizure disorders

2. How does Ipratropium MDI work? Make sure to include drug category, mechanism of action, onset and duration of action, and safety considerations.

ANS: Ipratropium oral inhalation is used to prevent wheezing, shortness of breath, coughing, and chest tightness in people with chronic obstructive pulmonary disease (COPD; a group of diseases that affect the lungs and airways) such as chronic bronchitis (swelling of the air passages that lead to the lungs) and emphysema (damage to the air sacs in the lungs). Ipratropium is in a class of medications called bronchodilators. It works by relaxing and opening the air passages to the lungs to make breathing easier. Ipratropium therapeutic classification is bronchodilator and its pharmacological classification is anticholinergic. Ipratropium is an anticholinergic agent. It blocks muscarinic cholinergic receptors, without specificity for subtypes, resulting in a decrease in the formation of cyclic guanosine monophosphate (cGMP). Most likely due to actions of cGMP on intracellular calcium, this results in decreased contractility of smooth muscle.Its onset is 15 minutes with the peak at 1-2 hours and duration of 4-6 hours.

3. How would the nurse properly administer the two MDIs when both have been scheduled at the same time of day?

ANS: Ipratropium and albuterol combination reduces bronchospasm through both anticholinergic and sympathomimetic mechanisms. The combination of albuterol and ipratropium comes as a solution (liquid) to inhale by mouth using a nebulizer and as a spray to inhale by mouth using an inhaler. As the nurse you would follow the directions carefully and ask questions if you don’t understand a part. Because both medications are on the same schedule time I would administer the albuterol inhalations first followed by the Ipratropium because the albuterol onset happens just a little quicker than the Ipratropium.

4. Lillian asks the nurse why she is on two inhalers for her COPD when she used to use just one. What points would the nurse want to cover to answer her question, considering her history of noncompliance?

ANS: The nurse should explain to Lillian that her symptoms seem to be getting worse and the Simultaneous administration of both drugs produces a greater bronchodilator effect than when either drug is used alone at recommended dosages.

References:

Vallerand, A. H. &Sanoski, C. A. (2013). Davis’ drug guide for nurses. (13th ed.). Philadelphia, PA: F. A. Davis Company

Lilley, L., Snyder, J., & Collins, S. (2014). Pharmacology and the nursing process. (7th ed.). St. Louis: Elsevier, Inc.