# A nurse is teaching an adult patient newly prescribed inhaled fluticasone twice daily for asthma maintenance. Which patient instructions should the nurse include? Select all that apply.

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> subject: Adverse Effects/Contraindications/Interactions  
> category: PPT

## Question

A nurse is teaching an adult patient newly prescribed inhaled fluticasone twice daily for asthma maintenance. Which patient instructions should the nurse include? Select all that apply.

1

Keep your short-acting beta-2 agonist (albuterol) available and use it as the rescue inhaler for acute symptoms.

2

Use this inhaler as your first response when wheezing or chest tightness develops to relieve the acute attack.

3

Use a spacer with the metered-dose inhaler and rinse the mouth with water and spit after each dose to prevent oral candidiasis.

4

Stop the corticosteroid abruptly when symptoms improve and restart only when symptoms return.

5

Use the inhaled corticosteroid daily even when you feel well, because it works as a controller and takes 2–4 weeks to reach full effect.

## Explanation

Option 1 is correct because a short-acting beta-2 agonist such as albuterol is the rescue medication for acute symptoms. Option 2 is incorrect because inhaled fluticasone is a controller and does not provide rapid bronchodilation during an acute attack. Option 3 is correct because a spacer improves medication delivery, and rinsing the mouth and spitting after each dose reduces oral candidiasis and dysphonia. Option 4 is incorrect because stopping and restarting the controller according to symptoms prevents consistent anti-inflammatory control. Option 5 is correct because the corticosteroid should be used every day even when the client feels well, and full benefit may take 2-4 weeks.

## In-depth explanation

A spacer increases lung deposition (4–6 times more drug reaches the lower airways), reduces oropharyngeal deposition, and lessens the risk of oral candidiasis. Rinse-and-spit is the simplest preventive step; do not swallow the rinse. Common ICS adverse effects: oral candidiasis (thrush), dysphonia, and (at high doses) systemic effects including HPA axis suppression, growth suppression in children, and possible decreased bone mineral density. Step-up therapy: low-dose ICS → medium-dose ICS or low-dose ICS+LABA → medium- or high-dose ICS+LABA → add tiotropium or biologics. The two-medication household model — controller (ICS daily) plus rescuer (SABA as needed) — is taught with a written asthma action plan that includes green/yellow/red zones based on peak flow or symptoms.

## Clinical scenario

An adult patient is newly prescribed **inhaled fluticasone twice daily** for **asthma maintenance**. The nurse provides teaching about correct use of the metered-dose inhaler and the role of the medication.

## Key concepts

- **Inhaled Corticosteroid (ICS)** — Anti-inflammatory controller medication for persistent asthma. Examples: fluticasone, budesonide, beclomethasone. Daily use even when asymptomatic; full effect develops over 2–4 weeks. Adverse effects: oral candidiasis, dysphonia, and at high doses systemic effects including HPA suppression.
- **Spacer Use and Rinse-and-Spit** — A spacer increases lower airway drug deposition and reduces oropharyngeal deposition. Rinsing the mouth with water and spitting (not swallowing) after each dose markedly reduces oral candidiasis and dysphonia.
- **SABA Rescue Inhaler** — Short-acting beta-2 agonists (e.g., albuterol) are bronchodilators used for acute symptoms. Onset within minutes. Frequent use (>2 days/week or >2 canisters/year) signals poorly controlled asthma and the need to step up controller therapy.

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