NSG 6005 Cough and Congestion History Discussion Responses

PEER #1Shodette

Mr. JD is a 24-year-old who presents to Urgent Care with a 2-week history of cough and congestion. He says it started out as a “normal cold” and it will not go away. He has a productive cough for green mucous and has green nasal discharge. He says he has had a low-grade temperature for the past 2 days. John reports an intermittent frontal headache with this cold. He is otherwise healthy, with no known allergies.

In his assessment it is found that his vital signs are stable, temperature is 99.9 degrees F, tympanic membranes (TMs) are clear bilaterally, pharynx is erythematous with no exudate; there is greenish postnasal drainage; turbinates are swollen and red; frontal sinus tenderness; no cervical adenopathy, and lungs are clear bilaterally.

Is there any additional subjective or objective information you need for this client? Explain.

A Sample Answer 2 For the Assignment: NSG 6005 Cough and Congestion History Discussion Responses

Title: NSG 6005 Cough and Congestion History Discussion Responses

I will ask Mr. JD if he has any Shortness of breath, chest tightness? Any sore throat? Any dizziness? Ear pain? Are symptoms getting worse, better, or unchanged? Anything makes symptoms worse or better? What has he taken over the counter, and have they helped? Knowing medications patients have taken during the course of an illness will help prevent possible drug interactions with medications the current provider will prescribe for him or her. I would also ask about his PMH regarding seasonal allergies and smoking history, those are sometimes the causative reasons for rhinitis and cough.

Would you treat Mr. JDs cold? Why or why not?

Yes. Because it has been two weeks with consistent complaints of intermittent frontal headaches. From his assessment, he has an elevated temperature, erythematous pharynx, and frontal sinus tenderness, which are all indicative of sinusitis.

What would you prescribe and for how many days? Include the class of the medication, mechanism of action, route, the half-life; how it is metabolized in and eliminated from the body; and contraindications and black box warnings.

I will prescribe amoxicillin 875mg BID x 7 days. Amoxicillin is a new generation of penicillin. Adults, teenagers, and children weighing 40kgs or more—250 to 500 milligrams (mg) every 8 hours, or 500 to 875 mg every 12 hours (Palsdottir et al., 2020). Its mechanism of action is it acts by inhibiting bacterial cell wall synthesis. It has a half-life of 0.7-1.4 hours. Amoxicillin is metabolized and eliminated through the kidney in the urine. It is contraindicated for individuals allergic to penicillin, pregnancy, history of seizures, renal disease, and PKU. There are no black box warnings with amoxicillin.

Would this treatment vary if Mr. JD was a 10 year-old 78 lb child? Include the class of the medication, mechanism of action, dosing, route, the half-life; how it is metabolized in and eliminated from the body; and contraindications and black box warnings

The treatment will stay the same, but the dosage of amoxicillin will change based on the child’s weight. For this child’s weight of 78lbs, I would use the dosage of 250mg/5ml 25-60mg/kg/day, which is equivalent to 450mg/9ml every 8hours (Palsdottir et al., 2020). It is the same mechanism of action in an adult of inhibiting bacterial cell wall synthesis, with a half-life of 61.3 minutes. It is contraindicated for pediatric patients that have had allergic reactions to the antibiotic class of penicillin, history of seizures, renal disease, There are no black box warnings with amoxicillin.

What health maintenance or preventive education is important for this client based on your choice medication/treatment?

I would educate Mr. JD to avoid allergens that may have led to his cold and sinusitis. Proper handwashing and hydration with fluids will be emphasized. Mr. JD will be educated about signs and symptoms of C-dff, and about taking over-the-counter probiotics to prevent this infection from occurring. I would also educate him that he should take medication as directed. Skipping doses, or not completing the full treatment course of amoxicillin and other antibiotics will decrease the effectiveness of the immediate treatment and increase the likelihood that bacteria will develop resistance and will not be treatable by amoxicillin or other antibacterial drugs in the future (Woo, 2019).

References

Palsdottir, H. A., Jonsson, J. S., & Sigurdsson, E. L. (2020). Prescriptions of antibiotics in out-of-hours primary care setting in Reykjavik capital area. Scandinavian Journal of Primary Health Care, 38(3), 265–271. https://doi-org.su.idm.oclc.org/10.1080/02813432.2…

Woo, T. M. (2019). Pharmacotherapeutics for Advanced Practice Nurse Prescribers with 3-yr access to Davis Edge. [South University]. Retrieved from https://digitalbookshelf.southuniversity.edu/#/boo…

PEER#2 Yailin

The most important risk factors for developing acute bacterial rhinosinusitis include viral upper respiratory infection, allergic rhinitis, anatomic obstruction, mucosal irritants such as tobacco or chemicals, and abrupt atmospheric pressure changes (Rosenfeld et al., 2016). The most frequent signs and symptoms include cough, pain, post-nasal discharge, nasal congestion, fever, and nasal turbinate erythema, swelling, and discharge (Rosenfeld et al., 2016). The pain localization, precipitating factors, and characteristics help identify the affected area (Rosenfeld et al., 2016).

Frontal sinusitis worsens during the evening and when bending over while improving during the day due to anatomical drainage when standing (Rosenfeld et al., 2016). Rhinosinusitis courses with persistent symptoms, severe symptoms, or worsening symptoms comprising the main clinical presentations (Rosenfeld et al., 2016). Other important clinical evaluations include the presence of periorbital swelling with headache and vomiting, persistent intermittent vomiting beyond 24 hours, altered mental status, neurologic deficit, or meningeal irritation signs, all suggesting a potential intracranial expansion requiring hospitalization (Rosenfeld et al., 2016). Other complications include pre-septal or orbital cellulitis, epidural, brain, or subdural abscess, sinus thrombosis, and osteomyelitis (Rosenfeld et al., 2016).

The presented signs or symptoms may improve within ten days if untreated requiring further interventions when the clinical pictures worsened (Rosenfeld et al., 2016). Interventions target to mitigate nasal obstruction, rhinorrhea, fever, and fatigue, respectively (Rosenfeld et al., 2016). Most frequently used interventions to relieve nasal congestion include irrigation by NS, intranasal glucocorticoids, and anticholinergics, while NSAIDs are frequently used to mitigate associated pain and fever (Rosenfeld et al., 2016).

Three to five days therapies with an oral decongestant can favor patients with Eustachian tube dysfunction using precaution when comorbid CV conditions, angle-closure glaucoma, or bladder neck obstruction (Rosenfeld et al., 2016). The use of intranasal decongestant, antihistamines, and mucolytics are reserved for patients with subjective lack of nasal patency, limiting their use due to unsupported evidence in the literature to improve patient outcomes during ARS (Rosenfeld et al., 2016). The initiation of antibiotics depends on the patient’s ability to return after seven days of the first evaluation, the severity of symptoms, and evolution after the past seven days (Lemiengre et al., 2018).

Patients unable to return after seven days require immediate antibiotic initiation (Lemiengre et al., 2018). Patients returning after seven days of initial evaluation with improvements will not require additional interventions due to the self-limited characteristic of the condition (Lemiengre et al., 2018). However, patients worsening post-first interventions require antibiotics (Lemiengre et al., 2018). A general rule for the use of antibiotics requires lack of improvement at day ten after commencing with the condition or worsening during the initial seven days observational period, including fever 102 F, mucopurulent discharge, or long-lasting pain beyond three days (Lemiengre et al., 2018).

The first line of treatment in this patient with antibiotic includes Amoxicillin (500 mg) orally Q8h per five days, reserving the use of Augmentin for patients with risk factors for pneumococcal resistance (Lemiengre et al., 2018). Amoxicillin is oral penicillin, inhibiting bacterial wall synthesis when binding to PBPs, resulting in inhibited biosynthesis and lysis after autolytic enzyme activity (Lemiengre et al., 2018). This antibiotic, without imposed “black box,” immediate-release half-life equals sixty-one point three minutes compared to ninety minutes when using extended-release formulation after oral absorption (Lemiengre et al., 2018).

The medication distribution includes liver, lungs, prostate, muscle, middle ear effusions, maxillary sinus secretions, bone, gallbladder, bile, and into ascitic and synovial fluids (Lemiengre et al., 2018). The metabolism is currently unknown and mainly excreted by the urine (Lemiengre et al., 2018). The dose of Amoxicillin is prescribed to a ten years old child weighing seventy-eight pounds at a dose of 25 mg/kg equals 295 mg Q8h (Lemiengre et al., 2018).

Using oral suspension formulation containing 400mg/5mL equals 3.7 mL orally Q8h per five days (Lemiengre et al., 2018). Warning in pediatric populations includes elevated maculopapular rash incidence in the presence of EB virus, acute lymphocytic leukemia, or cytomegalovirus infection (Lemiengre et al., 2018). Any rash requires close evaluation to differentiate from a potential hypersensitivity reaction (Lemiengre et al., 2018). Patient’s education during the use of Amoxicillin includes informing other healthcare providers concerning the use of this drug, informing about allergic side effects, prolonged use requires blood sampling and frequent checking of glucose in the urine, inform if previously diagnosed with phenylketonuria, take as prescribed to avoid resistance or second infection, potential interference with hormonal birth control method, and immediately contact providers if pregnant or breastfeeding (Lemiengre et al., 2018).

References

Lemiengre, M. B., van Driel, M. L., Merenstein, D., Liira, H., Mäkelä, M., & De Sutter, A. I. (2018). Antibiotics for acute rhinosinusitis in adults. The Cochrane Database of Systematic Reviews, 9(9), CD006089. https://doi.org/10.1002/14651858.CD006089.pub5

Rosenfeld R. M. (2016). Clinical Practice: Acute sinusitis in adults. The New England Journal of Medicine, 375(10), 962–970. https://doi.org/10.1056/NEJMcp1601749