The patient in the case study is taking medications for the treatment of asthma. The first medication listed is salmeterol (Serevent). This medication is a bronchodilator. The pharmacological class is long-acting beta-2 agonist. Therapeutic use is the treatment of asthma and COPD. The mechanism of action is that salmeterol prevents the release of histamine, leukotrienes and prostaglandins from the lungs. The usual dosages for children with asthma greater than four years is 1 inhalation every 12 hours. Contraindications for this medication include hypertension, coronary artery disease, abnormal heart rhythm, diabetes and seizures. Drug – drug interactions include erythromycin, amiodarone, procainamide and many more. Side effects include dry mouth, GI upset, dizziness, nervousness and sweating. Adverse effects include productive cough, headache, sneezing, throat irritation and shortness of breath. Serevent has a pregnancy category of C and caution should be used when nursing as this medication is excreted in the milk. Patient teaching includes telling the patient never to exhale into diskus device and always to hold device in a horizontal position. The mouthpiece should be kept dry, it should not be washed. (Vallerand, Sanoski, Deglin, & Mansell, 2015)
The second medication listed for the treatment of asthma in the case study is montelukast (Singulair). This medication is a leukotriene inhibitor used for the prevention of asthma. It is used to prevent bronchospasm brought on by exercise. The mechanism of action is that it inhibits the chemicals in the body that are released in response to breathing an allergen such as pollen. The normal of for this medication for a seven year old child is a 5 mg tablet chewed once daily. Contraindications for this medication include:

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Singulair is not acceptable in the treatment of acute asthma. Do not abruptly substitute of stope use of this medication. Patients with phenylketonuria need to be informed that the chewable tablets contain phenylalanine. Drug – drug interactions include:

No dose adjustment is necessary when Singulair is administered with theophylline, prednisone, oral contraceptives, terfenadine, digoxin, Coumadin, thyroid hormones, sedative hypnotics, non-steroidal anti-inflammatory agents, benzodiazepines and decongestants, patients with known aspirin sensitivity patients should avoid non-steroidal anti-inflammatory agents while taking Singulair. Side effects include headache, abdominal pain, GI upset, fatigue, common cold symptoms and toothache. Adverse effects include itching, rash, swelling and difficulty breathing. The US FDA pregnancy category is B. Caution is advised during breast feeding because the medication is excreted in breast milk. Patient teaching includes that this medication can be taken with food or on an empty stomach. If a dose is accidently missed, do not double up on the next dose. (Vallerand, Sanoski, Deglin, & Mansell, 2015)

Another medication in the case study is triamcinolone (Azmacort). This medication has actually been taken off the market for environmental concerns. The following information is based on the last information prior to discontinuation of the drug. The drug class for this mediation is glucocorticoids. It is a steroid, and it is used for maintenance treatment of asthma and as a prophylactic treatment against acute asthma attacks. The mechanism of action is to provide anti-inflammatory effects locally without as many side effects as systemic steroid medications. Usual dosages (if it was still available for the 7 year old) is 1 or 2 inhalations (75 – 150 mcg) four times a day. The contraindication is a known hypersensitivity to triamcinolone acetonide Drug to drug interactions include diuretics, digoxin, estrogen, aspirin, phenobarbital and others. The most common side effects of this medication are anxiety, irritability, depression, mood changes, nervousness, weight gain, headache and dizziness. Adverse effects of this medication include shortness of breath, irregular heart rate, difficulty speaking and walking, etc. Effective patient teaching includes taking the medication as directed. Instruct the patient that this medication is not indicated in an acute asthma attack. The pregnancy category for this medication is category C.  It uncertain whether Azmacort is excreted in breast milk. Caution should be used in nursing mothers. (Vallerand, Sanoski, Deglin, & Mansell, 2015)

The last medication listed in the case study for the treatment of asthma is albuterol (Proventil). The classification for this medication is bronchodilator. The therapeutic us for this medication is quick relief of symptomatic asthma such as wheezing, chest tightness and shortness of breath. The mechanism of action for this medication is that it relaxes muscles in the airways and improves air flow to the lungs. The recommended dosage for this medication for a 7 year old child is 2 puffs (213 mcg) every 4 to 6 hours as needed. Contraindications for this medication include allergies to beta-adrenergic agents. This medication is contraindicated for conditions of hypertension, paradoxical bronchospasm, abnormal heart rhythm, hypokalemia and more. Drug to drug interactions for this medication include beta blockers, digoxin, diuretics, epinephrine and more. The side effects of albuterol include shakiness and nervousness, headache, nausea and vomiting, cough, throat irritation and muscle pain. Adverse side effects include difficulty swallowing, hives, hoarseness, swelling of the throat, tightness in chest and more. The pregnancy category for albuterol is a C according to the FDA. Currently, there is no data on the excretion of albuterol in the breast milk of nursing mothers. Patient teaching for this medication includes having the patient report immediately any signs and symptoms of hypokalemia. Educate the patient on the importance of keeping this rescue inhaler on hand and about the recognition of signs and symptoms of acute asthma attack. (Vallerand, Sanoski, Deglin, & Mansell, 2015)

When the child in the case study presents to the school nurse with onset of acute asthma with shortness of breath, chest tightness, scattered expiratory wheezes and a decreased peak flow, the nurse should administer albuterol (Proventil) as directed. This medication should be kept readily available for the child for acute asthma symptoms such as those mentioned. Abuterol is known as a rescue inhaler because it works immediately to relieve asthma symptoms by relaxing the airways and improving the airflow to the lungs. Improvements are sometimes seen with 5 minutes of administration of albuterol, unlike all the other medications in the patient’s therapeutic regimen. The other medications are for the overall control of the asthma and will have no effect immediately, on improving the child’s symptoms.

After administering albuterol to the child, the nurse should observe for improved lung sounds and increased air movement. As the airways open up, the child should have a decrease in chest tightness and a decreased shortness of breath. Peak flow meter readings should improve. The nurse should assess the child for shakiness and trembling which are common side effects. The child’s heartrate may increase in response to the medication. Less common side effects, that the nurse should asses for, are hives, rashes with redness, irritability, warm feeling, nausea and others.

After observing the child use the metered-dose inhaler (MDI), the school nurse wishes to reinforce administration technique with the child. The nurse should emphasize the following appropriate steps to MDI use:

Prior to use, shake the inhaler well. Remove the cap from the mouthpiece. Breathe out and then bring the inhaler to the mouth. Put the mouthpiece in the mouth and close mouth around it making a seal. Slowly, breathe in and press the inhaler at the top while taking a full breath. Next, take the inhaler out of the mouth and don’t breathe for approximately 10 seconds. Finally breathe out and repeat the process as needed for repeat puffs.

A spacer is sometimes used to slow the delivery of the medication from the inhaler. When a spacer is used with the inhaler, follow the same steps with a few minor changes. Again, shake the inhaler well and remove the cap from the mouthpiece. Next, place the inhaler inside of the spacer. All other steps are unchanged. Important teaching reinforcement about spacers is to never use it with a dry powder inhaler. Spacers must be properly cleansed after use with mild soap and water. Let the parts of the spacer air dry. If the spacer has a whistle and it sounds upon use, the user should be instructed to slow the breath down.

A teaching handout should be given to the child and the child’s parents on the treatment of asthma. It would need to be in simple language appropriate for a child and appropriate for parents of any education level. A teaching handout like the one following would be appropriate.