Question

Mrs. Shaw is a 54-year-old client who has been admitted with hypertensive crisis and tachycardia. She was diagnosed with hypertension 2 years ago and until now has been controlling her blood pressure with a thiazide diuretic. In taking Mrs. Shaw’s health history, you learn that Mrs. Shaw has recently started taking pseudoephedrine in oral form for sinus congestion, along with a phenylephrine nasal spray for nasal congestion. Mrs. Shaw tells you, “I don’t understand it; I have been taking my blood pressure medication regularly, as always. It has kept my blood pressure under control for 2 years. Why am I having these problems now?”

1. Explain the relationship between the pseudoephedrine and phenylephrine and Mrs. Shaw’s hypertension. What should the nurse teach Mrs. Shaw regarding the use of these drugs?
2. What additional adverse effects related to the pseudoephedrine and phenylephrine might the nurse expect to see in Mrs. Shaw?
3. Mrs. Shaw suddenly develops pulseless ventricular tachycardia, and resuscitation is begun. The physician orders vasopressin 40 units instead of epinephrine during the resuscitation. What rationale would the physician have for ordering the vasopressin?

Answer 1

The relationship between the pseudoephedrine and phenylephrine and the patient's hypertension can be explained as follows :

Phenylephrine and pseudoephedrine are sympathomimetic amines which activate alpha-adrenergic receptors seen on blood vessels and cause vasoconstriction ( nasal and other blood vessels in the body) and tachycardia.

Systemic vasoconstriction (narrowing of blood vessels) and tachycardia result in elevation of blood pressure whereas nasal vasoconstriction offers relief of nasal congestion by decreasing the blood flow through nasal mucosa.

  The patient should be taught about the following :

-Correct technique.

The patient should tilt the head back when applying nasal spray, and maintain this position for a few seconds after administration. This method ensures proper contact of medicine with the affected part of nasal mucosa and reduces the chances of reaching the medicine to the back of the throat, which may contribute to systemic adverse effects.

-Duration of intake.

Instruct the patient not to use the drug for longer than prescribed days and to seek medical help if there is no relief of symptoms after that time .

-Avoid overdose.

these drugs are part of many over-the-counter medicines and not to take such drugs to avoid overdose.

-Avoid hazardous activities

These drugs can cause dizziness and sleeping trouble . So don’t engage in hazardous activities to prevent injury.

-Comfort measures.

Use other comfort measures such as more intake of fluid, cool environment, avoidance of smoke etc. to get relief from nasal congestion.

Additional adverse effects related to the pseudoephedrine and phenylephrine the nurse might expect to see in this patient include :

1..Local effects such as nasal stinging and burning with nasal application in the beginning.

2. Systemic effects with oral administration –

• Nervousness
• Dizziness
• Breathing difficulty
• Restlessness
• Abnormal heart beat
• Abdominal pain
• Nausea and vomiting
• Sleeping problems

3. Rebound nasal congestion with overuse

Question :What rationale would the physician have for ordering the vasopressin instead of epinephrine during the resuscitation ?

Rationales are
1. Vasopressin has reduced risk for adverse effects compared with epinephrine.

2. It is believed that vasopressin produces cerebral vasodialation and thus increases cerebral perfusion giving additional benefit during resuscitation.