vSim H Williams Part 1 Clinical Packet Latest Update 2025

DESCRIBE DISEASE PROCESS AFFECTING PATIENT (Include Pathophysiology of Disease Process) COPD is a progressive and irreversible condition characterized by diminished inspiratory and expiratory capacity of the lungs. It is a chronic respiratory condition that obstructs the flow of air to or from the patient’s bronchioles. COPD includes emphysema and chronic bronchitis. These diseases are characterized by chronic airflow limitation. EMPHYSEMA Etiology and Pathophysiology Emphysema symptoms usually develop when the patient is in his or her 40s, with disability increasing by age 50 to 60. This condition is characterized by changes in the alveolar walls and capillaries: thus, emphysema is primarily an alveolar disease. Emphysema is an abnormal, permanent enlargement of the alveoli distal to the terminal bronchioles, accompanied by destruction of their walls. There is usually an overlap between chronic bronchitis and emphysema. The bronchi, bronchioles, and alveoli become inflamed because of chronic irritation. Because of bronchiole lumen narrowing, air becomes trapped in the alveoli during expiration, causing alveolar distention. The alveoli then rupture and scar, losing their elasticity. Oxygen in the arterial blood decreases and carbon dioxide increases. This process is worsened by cigarette smoking and other inhaled irritants. There is a lag of 30 to 35 years, on average, between taking up smoking and the onset of signs and symptoms. Cigarette smoking is by far the most common cause of emphysema and chronic bronchitis; 90% of COPD cases are caused by smoking, whereas as few as 25% of nonsmokers develop the disorder. This suggests that genetic susceptibility may play a role in the risk for COPD. Risk factors for emphysema are the same as for chronic bronchitis, with one addition: heredity. An inherited form of emphysema is caused by a deficiency of alpha1 antitrypsin (ATT), a lung- protective protein produced by the liver, which acts predominantly by inhibiting neutrophil elastase in the lungs. ATT deficiency accounts for less than 1% of emphysema in the United States. The patient with emphysema is disabled because all available energy must be used for breathing. COPD can lead to cor pulmonale, an abnormal cardiac condition characterized by hypertrophy of the right ventricle of the heart because of hypertension of the pulmonary circulation. Cor pulmonale results in edema in the lower extremities and in the sacral and perineal areas, distended neck veins, and enlargement of the liver with ascites. Cor pulmonale is a late complication of emphysema. CHRONIC BRONCHITIS Etiology and Pathophysiology Chronic bronchitis is characterized by a recurrent or chronic productive cough for a minimum of 3 months/ year for at least 2 years. It is caused by physical or chemical irritants and recurrent lung infections. Cigarette smoking is by far the most common cause of chronic bronchitis. Workers exposed to dust, such as coal miners and grain handlers, also are at higher risk. The underlying process is an impairment of cilia, so they can no longer move secretions. Mucous gland hypertrophy causes hypersecretion, altering cilia function. Excessive mucus is trapped in edematous airways, obstructing airflow. The lining of the bronchial tubes becomes inflamed and eventually scarred. The patient cannot clear tenacious mucus, and it becomes a medium for bacteria and infection. This increased airway resistance leads to bronchospasm. The condition results in altered oxygen–carbon dioxide exchange, hypoxia (an inadequate, reduced tension of cellular oxygen), and hypercapnia (greater than normal amounts of carbon dioxide in the blood). DIAGNOSTICS TESTS (Reason for Test and Results) An important goal of the diagnostic workup is to determine the major disease component of COPD, the severity of the disease, and the impact of the disease on the patient’s quality of life. A history and physical examination are extremely important. PFTs measure total lung capacity, which is decreased with COPD. Residual volume is increased, as are compliance and airway resistance. Ventilatory response is decreased. Pulse oximetry is useful in assessing oxygen saturation in arterial blood. ABGs usually are assessed in the severe stages and are monitored in hospitalized patients with acute exacerbations. ABGs reveal respiratory acidosis. A chest radiographic examination shows hyperinflation of the lungs, widened intercostal spaces, and flattened diaphragm with increased anteroposterior diameter (barrel chest). Hematologic studies determine whether the patient is positive for AAT deficiency (a deficiency that causes airway abnormalities, resulting in emphysema); this is present in an inherited form of emphysema. CBC reveals elevated erythrocytes and hemoglobin and hematocrit levels (secondary polycythemia, as a compensatory response to chronic hypoxia). This is also a late manifestation of emphysema. PATIENT INFORMATION Henry Williams, 69-year-old African American retired Engineer. Only son died 10 years ago, Married. History of smoking, recurrent colds, bronchitis, asthma, COPD, HTN, Anxiety, Dyspnea, hyperlipidemia. Patient admitted for progressive shortness of breath, him and his wife live in a small apartment. ANTICIPATED PHYSICAL FINDINGS The primary symptom of emphysema is dyspnea on exertion, which becomes progressively more severe. Over time the dyspnea worsens and becomes present even at rest. Initially there is little sputum production, but later it becomes copious. Many patients assume a barrel-chested appearance (an increased anteroposterior diameter caused by overinflation) and begin using accessory muscles for breathing. Spontaneous pursed lip breathing and chronic weight loss with emaciation ensue. ASSESSMENT Collection of objective data includes assessment of presenting signs, such as tachycardia, tachypnea, orthopnea, peripheral cyanosis, clubbing of fingers, and a barrel chest. The most outstanding feature of clubbing is a lateral and longitudinal curvature of the nails accompanied by soft tissue enlargement, presenting a bulbous (bulb-shaped), shiny appearance. A barrel chest, which occurs late in the disease, is more difficult to distinguish. Have the patient sit so that the health care provider will have a lateral view of the patient; this makes the assessment of a barrel chest easier. Hypoxemia (especially during exercise) may be present, but hypercapnia does not develop until late in the disease. The patient with COPD often begins to exhibit weight loss. The patient is in a hypermetabolic state with increased energy requirements that are due partly to the increased work of breathing. A therapeutic posture for the patient with COPD is the tripod position (leaning forward with the head forward and the arms resting on the patient’s legs or a table). Expiration is prolonged as the patient forces his or her breath out through obstructed airways. ANTICIPATED NURSING INTERVENTIONS ▪ Assess patient’s ability to mobilize secretions, intervening as needed ▪ Encourage coughing and deep breathing, frequent position changes, and increased oral intake (up to 2– 3 L/day) ▪ Elevate head of bed; suction as needed ▪ Assist with respiratory treatments Auscultate lungs, and report any changes in lung sounds ▪ Organize care so that periods of activity are interspersed with at least 90 min of undisturbed rest ▪ Assist patient with active range-of-motion exercises to build stamina ▪ and prevent complications of decreased mobility ▪ Monitor patient’s respiratory response to activity. Activity intolerance is indicated by excessively increased respiratory rate (e.g., increased more than 10 breaths/min above patient’s baseline) and depth, dyspnea, and use of accessory muscles of respiration. ▪ Instruct the patient and the family on o The importance of not smoking and of reducing exposure to other inhaled irritants o Effective breathing techniques (such as pursed-lip breathing) o Relaxation exercises for anxiety control. Teach the patient about the dangers of increased oxygen intake for a patient dependent on hypoxic drive (stimulation of respiration by low PaO2) for ventilation. ▪ Also teach the patient and the family how to prevent infection and symptoms that should be reported to the health care provider. ▪ Nursing interventions are directed toward decreasing the patient’s anxiety and promoting optimal air exchange. Such measures include elevating the head of the bed and administering low-flow oxygen (1 to 2 L by nasal cannula) as ordered. This is extremely important for patients with COPD because a higher flow of oxygen delivery can be dangerous, because it diminishes the responsiveness of the brain’s respiratory (regulatory) center, leading to decreased respiratory drive and respiratory failure. ▪ Avoid use of respiratory depressants to ensure adequate alveolar ventilation. ▪ Assist with chest physiotherapy, which includes percussion, vibration, and postural drainage. All three techniques help loosen secretions to be expectorated; sometimes it takes several hours after chest physiotherapy before the patient can expectorate loosened secretions. ▪ Increasing oral intake of fluids liquefies secretions, thus aiding in their removal. In addition, the use of a humidifier enhances this process. ▪ Allow sufficient rest periods and assist the patient in activities of daily living to prevent a decrease in oxygen saturation levels. ▪ Assist the patient in maintaining nutritional intake by advising rest for 30 minutes before eating. This conserves energy and decreases dyspnea. The patient with emphysema has a markedly increased need for protein and calories to maintain an adequate nutritional status. A high-protein, high-calorie diet should be divided into five or six small meals a day. ▪ Oral fluid intake should be 2 to 3 L/day unless contraindicated (e.g., because of congestive heart failure). Instruct the patient to drink fluids between meals, rather than with meals, to reduce gastric distention and pressure on the diaphragm. Perform frequent oral hygiene to freshen the patient’s mouth after coughing exercises and before meals. ▪ Cessation of cigarette smoking in the early stages is probably the most significant factor in slowing the progression of the disease and improving pulmonary function. Use of nicotine replacement therapy or medications to assist with smoking cessation may be required. ▪ These therapies should be combined with other modalities such as support groups, education materials, and behavior modification programs. ▪ The patient with COPD should receive an influenza virus vaccine yearly and a pneumococcal revaccination every 5 years. VSIM ISBAR ACTIVITY Student Worksheet INTRODUCTION Milagros Ballesteros, LPN, Hospital Your name, position (RN), unit you are SITUATION Henry Williams is a 69-year-old retired rail system engineer who lives in a small apartment with his wife. He was admitted during the night with progressive shortness of breath. Patient’s name, age, specific reason for visit BACKGROUND Patient is here for a COPD exacerbation episode. Admitted on 10/04/21 Bed rest, bathroom privileges with assist, Regular low fat diet, I & O Respiratory treatment: Albuterol nebulizer treatment 2.5mg and ipratropium bromide 0.5 mg in 3 mL normal saline every 20 minutes x 3, followed by albuterol 2.5 mg and ipratropium bromide 0.5 mg in 3 mL normal saline every 2 hours (decrease frequency, as tolerated) Oxygen per nasal cannula at 2 liters per minute Lactated Ringer’s IV at 50 mL/h Labs: Complete Blood Count (CBC), Brain Natriuertic Peptide (BNP), Basic Metabolic Profile (BMP), Arterial Blood Gases (ABG’s) Chest X-Ray Continue home medications and add: Prednisone 40 mg PO daily x 10 days Lisinopril 12.5 mg PO daily Metoprolol tartrate 50 mg PO daily Acetylsalicylic acid 81 mg PO daily Rosuvastatin calcium 20 mg PO every evening Montelukast 10 mg PO every evening Home medications: Fluticasone propionate 250 mcg every 12 hours nebulized Patient’s primary diagnosis, date of admission, current orders for patient ASSESSMENT PATIENT EDUCATION WORKSHEET Current pertinent assessment data using head-to-toe approach, pertinent diagnostics, vital signs. History of COPD and coronary artery disease and is hard of hearing. His oxygen saturation is 88% on 2 L/min by nasal cannula. His respiratory rate has been 24-30/min. Blood pressure has been 134/88 mmHg, pulse was 112/min, and respirations were 28/min. He is alert and oriented. On his chest X-ray there is hyperinflation, but no evidence of pneumothorax. The heart is not enlarged. There are no signs of congestive heart failure. There are no areas of consolidation. The mediastinum is normal. Family is at bedside: wife and daughter in law. RECOMMENDATION Patient should be assessed and monitored for oxygen saturation. Order for oxygen should be administered as per order. Medications should also be given if needed as per order. SPICES tool should be performed and documented. Also, the Geriatric Depression Scale (Short Form) assessment tool should be performed. This patient is at risk for depression and after assessed the appropriate referrals/consults should be initiated. Any orders or recommendations you may have for this patient NAME OF MEDICATION, CLASSIFICATION AND INCLUDE PROTOTYPE MEDICATION: Lactated Ringers CLASSIFICATION: Intravenous nutritional products PROTOTYPE: Lactated Ringers CONTRAINDICATIONS: Newborns, In patients older than 28 days (including adults), ceftriaxone must not be administered simultaneously with IV calcium-containing solutions, including Lactated Ringer's Injection, through the same infusion line. Patients with a known hypersensitivity to sodium lactate. ADVERSE EFFECTS: Immune System Disorders: Hypersensitivity/infusion reactions, including anaphylactic/anaphylactoid reactions, and the following manifestations: angioedema, chest pain, chest discomfort, decreased heart rate, tachycardia, blood pressure decreased, respiratory distress, bronchospasm, dyspnea, cough, urticaria, rash, pruritus, erythema, flushing, throat irritation, paresthesia, hypoesthesia oral, dysgeusia, nausea, anxiety, pyrexia, headache. Metabolism and Nutrition Disorders: Hyperkalemia. General Disorders and Administration Site Conditions: Infusion site reactions, including phlebitis, infusion site inflammation, infusion site swelling, infusion site rash, infusion site pruritus, infusion site erythema, infusion site pain, infusion site burning. BLACK BOX WARNINGS: PATIENT EDUCATION WORKSHEET Although Lactated Ringer's Injection has a potassium concentration similar to the concentration in plasma, it is insufficient to produce a useful effect in case of severe potassium deficiency; therefore, it should not be used for this purpose. Lactated Ringer's Injection is not for use for the treatment of lactic acidosis or severe metabolic acidosis. Lactated Ringer's Injection should not be administered simultaneously with citrate anticoagulated/preserved blood through the same administration set because of the likelihood of coagulation. The infusion must be stopped immediately if any signs or symptoms of a suspected hypersensitivity reaction develop. Appropriate therapeutic countermeasures must be instituted as clinically indicated. Hypersensitivity reactions are reported more frequently during pregnancy. SAFE DOSE OR DOSE RANGE, SAFE ROUTE Route will be IV; rate and amount will be ordered by MD. PURPOSE FOR TAKING THIS MEDICATION Lactated Ringer's Injection, USP is a sterile, nonpyrogenic solution for fluid and electrolyte replenishment in single dose containers for intravenous administration. It contains no antimicrobial agents PATIENT EDUCATION WHILE TAKING THIS MEDICATION Notify if any signs of infiltration at IV site. Advise patient to notify if they are taking sodium lactate. Advise of symptoms of fluid overload: shortness of breath, edema, distended abdomen. NAME OF MEDICATION, CLASSIFICATION AND INCLUDE PROTOTYPE MEDICATION: Albuterol Sulfate CLASSIFICATION: Bronchodilator PROTOTYPE: Beta 2 agonist CONTRAINDICATIONS: Contraindicated in patients hypersensitive to drug or its ingredients. Use cautiously in patients with CV disorders (including coronary insufficiency and HTN), hyperthyroidism, or diabetes mellitus and in those who are unusually responsive to adrenergics Use extended-release tablets cautiously in patients with GI narrowing. ADVERSE EFFECTS: CNS: tremor, nervousness, headache, hyperactivity, insomnia, dizziness, weakness, CNS stimulation, malaise. CV: tachycardia, palpitations, HTN, chest pain, lymphadenopathy, edema. EENT: conjunctivitis, otitis media, dry and irritated nose and throat (with inhaled form), nasal congestion, epistaxis, hoarseness, pharyngitis, rhinitis. GI: nausea, vomiting, heartburn, anorexia, altered taste, increased appetite. GU: UTI. Metabolic: hypokalemia. Musculoskeletal: muscle cramps, back pain. Respiratory: bronchospasm, cough, wheezing, dyspnea, bronchitis, increased sputum. BLACK BOX WARNINGS: 1. Paradoxical Bronchospasm: Inhaled albuterol sulfate can produce paradoxical bronchospasm that may be life threatening. If paradoxical bronchospasm occurs, Albuterol sulfate inhalation aerosol should be discontinued immediately, and alternative therapy instituted. It should be recognized that paradoxical bronchospasm, when associated with inhaled formulations, frequently occurs with the first use of a new canister. 2. Deterioration of Asthma: Asthma may deteriorate acutely over a period of hours or chronically over several days or longer. If the patient needs more doses of Albuterol sulfate inhalation aerosol than usual, this may be a marker of destabilization of asthma and requires re-evaluation of the patient and treatment regimen, giving special consideration to the possible need for anti-inflammatory treatment, e.g., corticosteroids. 3. Use of Anti-inflammatory Agents: The use of beta-adrenergic-agonist bronchodilators alone may not be adequate to control asthma in many patients. Early consideration should be given to adding anti- inflammatory agents, e.g., corticosteroids, to the therapeutic regimen. 4. Cardiovascular Effects: Albuterol sulfate inhalation aerosol, like other beta-adrenergic agonists, can produce clinically significant cardiovascular effects in some patients as measured by pulse rate, blood pressure, and/or symptoms. Although such effects are uncommon after administration of Albuterol sulfate inhalation aerosol at recommended doses, if they occur, the drug may need to be discontinued. In addition, beta-agonists have been reported to produce ECG changes, such as flattening of the T wave, prolongation of the QTc interval, and ST segment depression. The clinical significance of these findings is unknown. Therefore, Albuterol sulfate inhalation aerosol, like all sympathomimetic amines, should be used with caution in patients with cardiovascular disorders, especially coronary insufficiency, cardiac arrhythmias, and hypertension. 5. Do Not Exceed Recommended Dose: Fatalities have been reported in association with excessive use of inhaled sympathomimetic drugs in patients with asthma. The exact cause of death is unknown, but cardiac arrest following an unexpected development of a severe acute asthmatic crisis and subsequent hypoxia is suspected. 6. Immediate Hypersensitivity Reactions: Immediate hypersensitivity reactions may occur after administration of albuterol sulfate, as demonstrated by rare cases of urticaria, angioedema, rash, bronchospasm, anaphylaxis, and oropharyngeal edema. SAFE DOSE OR DOSE RANGE, SAFE ROUTE Route: PO-Inhalation, tab, syrup Dosage: Tablets (extended-release): Adults and children older than age 12: 4 to 8 mg PO every 12 hours. Maximum, 32 mg daily. Tablets: Adults and children older than age 12: 2 to 4 mg PO t.i.d. or q.i.d. Maximum, 32 mg daily. Solution for inhalation Adults and children age 12 and older: 2.5 mg by nebulizer, given over 5 to 15 minutes, t.i.d. or q.i.d. To prepare solution, use 0.5 mL of 0.5% solution diluted with 2.5 mL of NSS. Or, use 3 mL of 0.083% solution. Syrup: Adults and children older than age 14: 2 to 4 mg PO t.i.d. or q.i.d. Maximum, 32 mg daily. Inhalation aerosol: Adults and children age 4 and older: 1 to 2 inhalations every 4 to 6 hours as needed. Regular use for maintenance therapy to control asthma symptoms isn’t recommended. PURPOSE FOR TAKING THIS MEDICATION To prevent or treat bronchospasm in patients with reversible obstructive airway disease PATIENT EDUCATION WHILE TAKING THIS MEDICATION ▪ Warn patient about risk of paradoxical bronchospasm and advise patient to stop drug immediately if it occurs. ▪ Teach patient to perform oral inhalation correctly. ▪ If prescriber orders more than 1 inhalation, tell patient to wait at least 2 minutes before repeating procedure. ▪ Tell patient that use of a spacer device with appropriate inhaler may improve drug delivery to lungs. PATIENT EDUCATION WORKSHEET ▪ If patient is also using a corticosteroid inhaler, instruct patient to use the bronchodilator first and then to wait about 5 minutes before using the corticosteroid. ▪ Tell patient to remove canister and wash aerosol inhaler with warm, soapy water at least once a week. ▪ Warn patient not to wash or place any part of powder inhaler in water. If mouthpiece needs cleaning, advise patient to gently wipe it with dry cloth or tissue. ▪ Advise patient not to use more than prescribed and not to increase dose or frequency without consulting physician. Fatalities have been reported from excessive use. ▪ Instruct patient to report worsening symptoms. ▪ Advise patient not to chew or crush extended-release tablets or mix them with food. ▪ If you use an albuterol inhaler, ask your pharmacist or doctor to check that you are using it correctly. You will need to prime your inhaler before you first use it, or if you haven't used it for a long time, by test spraying (three for ProAir HFA: four times for Ventolin HFA or Proventil HFA) into the air. Always test spray Ventolin HFA if you have dropped it. Follow the instructions provided with the inhaler. ▪ To use the inhaler, exhale slowly and place the mouthpiece of the inhaler well into the mouth with the lips closed around it. As you push down on the inhaler, inhale slowly and deeply through the mouth. Hold your breath for as long as possible, withdraw the mouthpiece, and exhale slowly. Allow 1 minute between doses if you are prescribed two doses at once. ▪ Most inhalation devices require regular cleaning or else they will clog. Follow the instructions provided on how to clean your device and mouthpiece. Discard canister after the labeled number of actuations used. ▪ Store your device at room temperature away from heat, cold, open flames and moisture. Do not puncture or burn an empty canister. ▪ Before using your inhaler, shake it well. Avoid spraying into the eyes. Rinse eyes with water if this happens by accident. ▪ Albuterol extended-release tablets should be swallowed whole and not chewed or crushed. ▪ Albuterol relieves breathlessness but does not reduce inflammation. Needing to use albuterol more frequently than usual may be a sign that your asthma is destabilizing and you should seek immediate medical advice for a re-evaluation of your treatment regimen and the possible need for anti- inflammatory treatment (such as corticosteroids) to heal the airways. Deterioration of asthma can occur quite quickly over several hours, or it may take days or weeks. ▪ Albuterol alone is usually not enough to achieve good asthma control in most adults and children with asthma. Corticosteroids (such as budesonide [Pulmicort] or fluticasone [Flovent]) are often also needed. ▪ Always keep albuterol on hand at all times, and refill your prescription before you run out completely. Keep using all other medications as prescribed by your doctor. ▪ Seek emergency help if you have signs of an allergic reaction (breathing difficulties, facial swelling, hives), chest pain or fast heart rate, pain or burning when you urinate, signs of high blood sugar (increased thirst, increased urination, hunger, dry mouth), or signs of low potassium (such as leg cramps, irregular heartbeat). NAME OF MEDICATION, CLASSIFICATION AND INCLUDE PROTOTYPE MEDICATION: CLASSIFICATION: PROTOTYPE: Ipratropium Bromide Anticholinergics Bronchodilator Selective beta 2-agonist CONTRAINDICATIONS: Hypersensitivity to drug/class/component, caution if prostatic hypertrophy, caution if bladder neck obstruction caution if glaucoma, angle-closure ADVERSE EFFECTS: Serious Reactions: bronchospasm, paradoxical, anaphylaxis, hypersensitivity reaction, glaucoma, angle- closure Common Reactions: cough, nervousness, nausea, xerostomia, dyspepsia, dizziness, headache, COPD, exacerbation, oral irritation, rash, urticaria BLACK BOX WARNINGS: PATIENT EDUCATION WORKSHEET WARNING: This medication contains ipratropium. Do not take Atrovent or Atrovent HFA if you are allergic to ipratropium, or any ingredients contained in this drug. SAFE DOSE OR DOSE RANGE, SAFE ROUTE Route: Inhaled Dosage: NEB (0.02%): 0.5 mg per 2.5 mL COPD, maintenance treatment: [0.5 mg NEB q6-8h] Info: may mix neb solution w/ albuterol, levalbuterol, or metaproterenol if used w/in 1h asthma exacerbation, mod-severe: [0.5 mg NEB q20min x3 doses, then prn] Info: for adjunct tx; may mix neb solution w/ albuterol, levalbuterol, or metaproterenol if used w/in 1h; no proven additional benefit once hospitalized PURPOSE FOR TAKING THIS MEDICATION Ipratropium is a bronchodilator that is used to prevent bronchospasm in people with COPD (chronic obstructive pulmonary disease), including bronchitis and emphysema. PATIENT EDUCATION WHILE TAKING THIS MEDICATION ▪ Follow all directions on your prescription label and read all medication guides or instruction sheets. Use the medicine exactly as directed. ▪ Do not use more than 12 inhalations in a 24-hour period. ▪ If you are using this medicine with a nebulizer, space your doses 6 to 8 hours apart. ▪ Read and carefully follow any Instructions for Use provided with your medicine. Ask your doctor or pharmacist if you do not understand these instructions. ▪ Before your first use of ipratropium inhalation aerosol, prime the inhaler with 2 test sprays into the air, away from your face. Prime again whenever the inhaler has not been used in longer than 3 days. You do not need to shake this medicine before each use. ▪ Ipratropium is not a rescue medicine for bronchospasm attacks. Use only fast-acting inhalation medicine for an attack. Seek medical attention if your breathing problems get worse quickly, or if you think your medications are not working as well. ▪ Store at room temperature away from moisture, heat, and light. ▪ Keep the cover on your inhaler when not in use. Keep away from open flame or high heat. The canister may explode if it gets too hot. Do not puncture or burn an empty inhaler canister. ▪ Throw away the inhaler canister when the dose indicator reaches 0, even if it feels like there is still medicine inside. ▪ Store unused vials in the foil pouch. ▪ If I miss a dose use the medicine as soon as you can but skip the missed dose if it is almost time for your next dose. Do not use two doses at one time. ▪ Do not use more than 12 inhalations in a 24-hour period ▪ Do not get this medicine in your eyes, especially if you have glaucoma. Ipratropium inhalation accidentally sprayed into the eyes can cause blurred vision or eye irritation and may make glaucoma worse. ▪ This medicine may cause blurred vision and may impair your reactions. Avoid driving or hazardous activity until you know how this medicine will affect you NAME OF MEDICATION, CLASSIFICATION AND INCLUDE PROTOTYPE MEDICATION: Prednisone CLASSIFICATION: Corticosteroid PROTOTYPE: Prednisone CONTRAINDICATIONS: Hypersensitivity to drug/class/components, systemic fungal infection, cerebral malaria, avoid abrupt withdrawal (high-dose or long-term use) caution in pediatric or adolescent pts, caution if pregnancy 1st trimester, caution if immunosuppressed, caution if active infection, caution if TB infection, active or latent, caution if infection risk, caution if measles or varicella exposure, caution if HTN, caution if pheochromocytoma risk, caution if CHF, caution if recent MI, caution if diabetes mellitus, caution if PUD, caution if ulcerative colitis, caution if diverticulitis, caution if recent intestinal anastomosis, caution if GI perforation risk, caution if seizure disorder, caution if psychiatric disorder, caution if thyroid disorder, caution if osteoporosis, caution if osteoporosis risk, caution if myasthenia gravis, caution if optic neuritis, caution if ocular HSV, caution if renal impairment, caution if cirrhosis ADVERSE EFFECTS: Serious Reactions: anaphylaxis, adrenal insufficiency, steroid psychosis, steroid myopathy, Cushing syndrome Infection, diabetes mellitus, pseudotumor cerebri, ICP increase, seizures, hypokalemic alkalosis, HTN, CHF pancreatitis, GI perforation, PUD, exophthalmos, osteonecrosis, tendon rupture, osteoporosis (long-term use) glaucoma (long-term use), cataracts (long-term use), immunosuppression (long-term use), Kaposi sarcoma (long-term use), withdrawal surgery if abrupt D/C (high-dose or long-term use), growth suppression (long- term use in peds pts) Common Reactions: Cushingoid appearance, hirsutism, weight gain, erythema, abdominal discomfort, appetite changes, emotional lability, rash, urticaria, nausea, vomiting, sodium retention, fluid retention, hypokalemia BP elevated, edema, diaphoresis, muscle atrophy, impaired wound healing (long-term use), skin atrophy (long-term use), petechiae, ecchymosis, skin pigmentation abnormality, acne, headache, dizziness, vertigo, insomnia Depression, anxiety, glucose intolerance, Cushing syndrome (long-term use), menstrual irregularities, IOP increase BLACK BOX WARNINGS: SAFE DOSE OR DOSE RANGE, SAFE ROUTE Route: Dosage: DR TAB: 1 mg, 2 mg, 5 mg corticosteroid-responsive conditions: [5-60 mg/day PO divided qd-qid] Info: dose, frequency varies by condition; give w/ food; do not cut/crush/chew tab; taper dose gradually to D/C if high -dose or long-term use asthma, acute: [ED/hospital management] Dose: 40-80 mg/day PO divided qd-bid; Info: cont. until peak flow 70% predicted; give w/ food; do not cut/crush/chew tab asthma, severe persistent: [7.5-60 mg PO qd-qod] Info: give w/ food; do not cut/crush/chew tab; taper dose gradually to D/C if high-dose or long-term use adrenal insufficiency: [4-5 mg/m^2/dose PO qd] Info: give w/ food; do not cut/crush/chew tab; taper dose gradually to D/C multiple sclerosis, acute exacerbation: [1250 mg PO qd x3-5 days] Info: give w/ food gout, acute: [0.5 mg/kg/day PO x5-10 days] Info: give w/ food; do not cut/crush/chew tab alcoholic hepatitis, acute: [40 mg PO qd] Info: give w/ food; do not cut/crush/chew tab; taper dose gradually to D/C leprosy reaction, type 1 (reversal reaction): [1 mg/kg/day PO divided qd-bid x12wk] Alt: 40-60 mg/day PO divided qd-bid; Info: consider 3-9mo treatment if severe reaction; reassess q2wk; give w/ food; taper dose gradually to D/C leprosy reaction, type 2 (erythema nodosum leprosum): [1 mg/kg/day PO divided qd-bid] Alt: 40-60 mg/day PO divided qd-bid; Info: may use w/ thalidomide if mod-severe neuritis; may use w/ clofazimine in severe refractory cases; reassess q2wk; give w/ food; taper dose gradually to D/C PCP, adjunct treatment: [40 mg PO bid x5 days, then 40 mg PO qd x5 days, then 20 mg PO qd x11 days] Start: w/in 72h of antimicrobial treatment; Info: give w/ food; do not cut/crush/chew tab Prednisone is a steroid that reduces inflammation in the body and suppresses your immune system. Prednisone is used to treat many different conditions such as hormonal disorders, skin diseases, arthritis, lupus, psoriasis, allergic conditions, ulcerative colitis, Crohn's disease, eye diseases, lung diseases, asthma, tuberculosis, blood cell disorders, kidney disorders, leukemia, lymphoma, multiple sclerosis, organ transplant rejection, swelling from a brain tumor or injury. PATIENT EDUCATION WHILE TAKING THIS MEDICATION ▪ You should not use prednisone if you are allergic to it, or if you have a fungal infection anywhere in your body. ▪ Steroid medication can weaken your immune system, making it easier for you to get an infection or worsening an infection you already have. Tell your doctor about any illness or infection you've had within the past several weeks. ▪ Long-term use of steroids may lead to bone loss (osteoporosis), especially if you smoke or drink alcohol, if you do not exercise, or if you do not get enough vitamin D or calcium in your diet. ▪ It is not known whether this medicine will harm an unborn baby. Tell your doctor if you are pregnant or plan to become pregnant. ▪ You should not breastfeed while using prednisone ▪ Follow all directions on your prescription label and read all medication guides or instruction sheets. Your doctor may occasionally change your dose. Use the medicine exactly as directed. ▪ Prednisone is taken daily or every other day, depending on the condition being treated. You may need to take the medicine at a certain time of day. Follow your doctor's instructions about when and how often to take this medicine. ▪ Take with food if prednisone upsets your stomach. ▪ Measure liquid medicine carefully. Use the dosing syringe provided, or use a medicine dose-measuring device (not a kitchen spoon). ▪ Swallow the delayed-release tablet whole and do not crush, chew, or break it. ▪ Prednisone can weaken (suppress) your immune system, and you may get an infection more easily. Call your doctor if you have signs of infection (fever, weakness, cold or flu symptoms, skin sores, diarrhea, frequent or recurring illness). ▪ If you have major surgery or a severe injury or infection, your prednisone dose needs may change. Make sure any doctor caring for you knows you are using this medicine. ▪ If you use this medicine long-term, you may need medical tests and vision exams. ▪ In case of emergency, wear or carry medical identification to let others know you use a steroid. ▪ You should not stop using prednisone suddenly. Follow your doctor's instructions about tapering your dose. ▪ Store at room temperature away from moisture, heat, and light ▪ If you miss a dose, take the medicine as soon as you can, but skip the missed dose if it is almost time for your next dose. Do not take two doses at one time ▪ High doses or long-term use of prednisone can lead to thinning skin, easy bruising, changes in body fat (especially in your face, neck, back, and waist), increased acne or facial hair, menstrual problems, impotence, or loss of interest in sex. ▪ Do not receive a "live" vaccine while using prednisone. The vaccine may not work as well and may not fully protect you from disease. Live vaccines include measles, mumps, rubella (MMR), polio, rotavirus, typhoid, yellow fever, varicella (chickenpox), zoster (shingles), and nasal flu (influenza) vaccine. ▪ Avoid being near people who are sick or have infections. Call your doctor for preventive treatment if you are exposed to chickenpox or measles. These conditions can be serious or even fatal in people who are using steroid medicine. ▪ Avoid drinking alcohol.