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Ii b ""T of Con V"'" Catqns_in_Pu on Do ..
MKh..1
for DlU!e1 : a po\hoplrysioloJk OWlOoch / Mi<hoel
Patrick ulrnd Nonn"" HoU""d M.
p.:<m.
Include. bibliographical aod inOO.
ISBN 978..().]J_508981_]
l. Pbormorology. 2. NurAng. l. HoI!md. uland Normm.ll. Tid,.
[DNLM: l. Dru, lhuapy--<lurAog. 2. Plurmaa>logy_ N"""'"
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_. pearsonhlglH!ri!d.com
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ISBN lJ: 978_0 lJ_508981 1
ISBN IO: O lJ_5089816
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About the Authors
- .
Michael Patrick Adams, PhD, is an acoompJished educator, author, and national speaker. The
National Institute for Staff and Organizational Development in Austin, Texas, named Or.
Adams a Master Teacher. He has published two other textbooks with Pearson Publishing: Core
Concepn in Pharmacology and PharmarolOjy: COImlcrums to Nursing Practict.
Dr. Adams obtained his Master's degree in Pharmacology from Michigan Slate University
and his Doctorate in Education at the University of South Florida. Dr. Adams was on the fac-
ulty of Lansing Community College and 51. Petf."rsburg College, and w;u IXan of Health Pro-
grams at Pasco- Hernando Community College fo r IS years. He is currently Professor of
Biological Sciences at Pasl -Hernando Community College.
I dedicate this book to nursing educators, who contribute every day to maki"g the wurld a
anti more caringplact.
-MPA
leland Norman Holland,Jr., PhD (Norm) over 20 years ago started out like many
scientists, plarming for a career in basic s.:-ienuo resean;h. He was quickly drawn to
the field of teaching in higher medica.! education, where he has spent most of his
career since thelL Among the areas where he has been particularly effective are
preparatory programs in nursing, medkine, dentistry, pharmacy, and allied health.
Dr. Holland is both an affiliate and supporter of nursing eduation nat ionwide. He
brings to the profession a depth of knowledge in biology, chemistry, and medially
related subjects such as microbiology, biologial chemistry, and phannacology. Dr.
Holland's doo:toral degree is in medical pharmawlogy, He is very much dedkated
to the sua:essof students and their preparation for readiness. He
ues to motiv:ate students in the lifelong pursui t oflearning.
I wOllld to thank rhewillful rncollmgt'mem of Farrell and Norma Jean Stalcllp.1 dedicate this book ro my beloved wife, Knrr!1l.
and my three wonderful childreH, Alatmdria Noelle, my double-deuce dttugiller, Caleb James, my Humber-one SOIl, arid Joshua
my nllmber three
-LNH
NURSE CONTRIBUTOR
Carol Quam Urban, PhD, RN is the Assistant Dean for Undergraduate Nursing and an Assistant Professor in the School of
Nursing, Collese of Health and Human Servires at George Mason University where she teaches undergraduate courses in
pharmacology and pathophysiology. Her current research interests focus on improving learning for students at-risk for ac-
ademic difficulties, outcomes-based education, effective educational mCKlels using computer-based learning, and service-
based learning. She has also publ ished articles on the ethial needs of at-risk students,
She is a member of Sigma Tau - Epsilon Zeta chapter, Alpha Chi, the National for Developmental
Education, National College Learning Center Association. and the College Reading and Learning Association. At Grorge
Mason University, she sel'Vl.'S on the General EduOition Committee and the Distance Education Council.
To my daughter, Joy, an extraordinary, resilient yvung woman. And ill memory of my son, Keith, the brawst and happiest soul I
know.
-CQU

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The authors wish to oonvey their special thanks to the many
nurse contr ibutors and reviewers who provided their
unique knowledge and expertise 10 this project. Their in-
suggestions, eye for detail, and dedication to quality
nursing education were evident and enabled us to prepare
an accurate, relevant, aoo useful phar maCOlogy textbook.
SUPPLEMENT CONTRIBUTORS
Rosem ary Ba kasa, RN, MSN, PhD
Bry"nt and Stratton College-
Easdab: Campul
Easdak<:, Ohio
Imtruaar. Rnouru M.,nual
PuwtrAlin"
Mar ge Ging r ich , RN, MSN
Harrisburg Area Community College
Harrisburg,
MyNursinglAb
Sandnl L. Gu st a fson, RN, MA
Hibbing Community College
Hibbing, Minnesota
MyNllrsinglAb
Frank Lyerla, PhD, RN
Southern Illinois UnMnity Edwardsville
Edwardsvill<:,lIIinoi.
Te.t Bank
Ba rba ra Maxwell , RN, MS, LNC
Slal<: University of NY at ill.tn"
SlOfl<: Rids<', N<:w York
Imtructor' Rnollru Mam"d
Pamela Newland, PhD, BSN. MSN
Southcro illinois University Edwardsville
Edwardsville, Illinois
Ttst Balik
MyNu"inglAb
Ja nine Ray, SA, BSN, MSN, RN,CRRN
CiKO College
CiKo, Tent
MyNursinglAb
REVIEWERS
Joy Ache- Reed, RN, MSN
Indiana Waley,,," Univo:rsity
Marion, Indiana
Eneli a O. Alfred, RN, BSN, MA, MEd
Kmt State UniV<:rsi ty, TUKaTaW'iU
N<:w Philadelphia, Ohio
Rosem a r y Babsa, RN, MSN, PhD
Bryant and Stratton College-
Eastlili Campus
Eastlake, Ohio
"
Kat hy Bl ack, MSN
Iowa W ... t<:rn CommunityCoIl<u
Council Bluff .. Iowa
Il e ne Bone, RN, MS
Gat<:WaY Community CoIleg<:
Phoenix, Arizona
Donna 1.. Bumpus, RN,MSN
Lamar Univenity
BcaunlOnt, Tens
D,ul en e Cla rk, RN, MSN
P"nnsylvania Stat" University
University
Lucille Di r k, RN, MSN
AT'S lnstitut" ofThnology
Highland H<'ighu, Ohio
Ma.r yAnn Edelman, RN, MS, CNS
Kingsborough CommunityConege
Brooklyn, N<:w York
Jacqueline Frock, RN, MSN
Oklahoma City Community CoLkg"
Oklahoma City,Oklahoma
Me ki JncobsGrah aJII , RN,MSN
Univel'lily of North Carolina
at Pembro"
Pembroke, North Carolina
Sa ndn L Gus t a rson, RN, MA
Hibbing Community College
Hibbing, Minnesota
Lorr ie S. Jo nes,ARNPC
Polk State Coll<u
Winter Ha ....... , floridd
Kathl een Krov, RN, MSN, CNM, CNE
Raritan Community College
Somervill<:, New Jersey
Lora J. Leona rd, RN, MSN
Mnt Stale Uni'"efsity,A.htabula lkgional
Campus
Ashtlbula, Ohio
Ba rba n Maxwell , RN, MSN, LNC
State UniV<'l"sity of NY at Ulster
Stone Ridge, New York
t o ra McGuire, RN, MS
Joliet Junior Colleg<:
IoIi<:l , llIinois
Cydney King Mull en, RN, PhD
Community Colleu
Pinehurst, North Carolina
Ca rol O lson , RN. MSN
Antonio College
Antonio, TeDS
Janice Ramirez, RN, MSN, BC, CRRN,
eNE
North Idaho CoUeg ..
Coeur Idaho
La uri e Simmo ns, BSN, MSN, MEd
Kirkwood Community College
Cedar Rapids, Iowa
Ann Underwood Smith, RN, MSN,
FNP,CNOR
Piedmont Virginia CommunityCollege
Charlottrsvi!k, Virginia
Mari a n ne E Swi har t , RN, BSN, MEd,
MSN, CRNJ, WCON, PCCN
Pu:;o-Hernando Community CoIkg<:
New Port Richey, Florida
Anni e Thotllll 5, RN, PhD
MaKdla Niehoff School of Nursing
Chicago, lllinois
Kathy Trumme r, RN, MS,CNS
Front Range Community College--
Westminster Campus
Westminster, Colol1ldo
Keith T. Veltri, as, PH, PharmD
Addphi School of Nursing
Garden Gty, New York
DarylI' Wan e, PhD,ARNP, FNpBC
Pasco-HcrlUlndo CommunityColkge
New Pori Richey, Rorida
Nancy Lynn Whit e head, MS,
FNPC,CSN,CLNC
Milwauktt Thnical College
Milwauktt, Wi5C(lnsin
LibraryPirate
WhenSludl.'nts an.asked which subject in their nllning pro-
gram is the most challenging, pharmacology always appears
ncarlhe top orlhe list. Thesludyof pharmacology demands
that students apply knowledge from a wide variety of the
natural and applied sciences. Successfully predicting drug
action requires a thorough knowledge of anatomy. physiol-
ogy, chemistry, and pathology as WI.'Il as the social sciences
of psychology and sociology. Not properly applying phar-
macology can result in immediate and direct harm to the
palient; thus, the Slakes in learning the subject are high.
Pharmacology ClInnal De made easy, but it can be made
understandable, if the proper cormt'Clions are made to
knowledge learned in these other disciplines. The vast ma-
jority of drugs in clinical pr.l("tice are prescribed for spedfic
diseases, yet many pharmacology twbooks fail 10 recognize
the complex interrelationships between pharmacology and
pathophysiology. When drugs are learned in isolation from
their associated diseases or conditions, students have diffi-
culty connecting phamlacotherapy to therapeutic goals and
patient wellness. The pathophysiology approach of this text-
book gives the stlKlent a dearer picture of the importance of
pharmacology to disease, and, ultimately, to patient Qre. The
approach and rationale of this lenbook fOQls on a holistic
perspective to patient care, which clearly shows the benefits
and limitations of phannacotherapy in curing or preventing
illness. Although difficult and challenging. the study of phar-
macology is truly a fascinating, lifelong journey.
ORGANIZATION AND STRUCTURE-
A BODY SYSTEM AND DISEASE APPROACH
Pharmacology for Nurs($; A Pathophysiologic Approach is
organized according to body systems (units) and diseases
(chapt ers). Each chapter provides the complete informa-
tion on the drug classifications used to treat the disease{s)
classes. SpeciaUy designed numbered headings describe
key concepts and cue students to each drug classification
discussion.
The pathophysiology approach clearly places the drugs
in context with how they are used therapeutically. The stu-
dent is able to locate easily all relevant anatOIllY, physiology,
pathology, and pharmacology in the sallle chapter in whim
the drugs are discussed. This approach provides the student
with a clear view of the connection between pharmacology,
pathophysiology, and the nursing care learned in other clin-
ical courses.
Preface
The vast number of drugs available in clinical practice
is staggering. To facilitate learning, we use prototypes where
the one or two ffi05t representative drugs in each classifica-
tion are introduced in detail in the chapter. Smdents are less
intimidated when they can focus their learning on one rep-
resentative drug in each class.
New to This Edition
The third edition of Pharmllcology for Nurses: A Ptlthophys-
iologicAppflXlch has been thoroughly updated to reflect cur
rent pharmacologic drugs and pt()l;esse5.
NEW'! Research boxes provide evidence-based practice as
it is applicable to pharmacology.
EXPANDED! Complementary and Alternative boxes
now include 20 of the top natural therapies.
EXPANDED! Pharmacother.apy lUustrated diagr.ams to
help students visualize the connection between
pharmacology and the patient.
NEW! Pharmacologic and therapeutic drug classes have
been added to all prototype drug boxes.
NEW! Lifespan boxes discuss specific considerations for
specific population groups.
NEW! Treating the Diverse Patient features discuss the
nursing considerations of a diverse population.
Updated! Nursing Pt()l;ess Focus Charts
Enhanced and Revised! End of chapter NQ.EX
questions now include alternative format items and
complete rationales.
NEW! Appendix on the ISMP' List of High-Alert
Medications has been added.
NE\'11 Information on weighl-l05S drugs and obesity has
been added.
A Note Abo ut Terminology
The term "health care provider" is used to denote the physi-
cian, nurse practitioner, and any other health professional
who is legally authorized to prescribe drugs.
vii
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ACKNOWLEDGMENTS
When authoring a textbook such as this, a huge number of
dedicaled and lalented professionals are needed 10 bring the
inilial vision to reality. Kelly Trakalo. Senior Acquisitions
Editor, and Maura Connor, Edi tor- in-Chief, are responsible
for helping us sculpt the vision for the teJI:1. Our Develop-
mental Edilor. Mich;ael Giac.obbt.supplied the upet"t guid-
;ance and Indership to keep everyone on I2$k and to be
cul;ain il reached ilS fruition on time. Providing the neus-
sur expertise for our comprem-nsive supplement package
was UUfft"l Sweeney, Editorial Assistant.
1'he design staff OI l Pearson, especi;ally Cluis Weigand.
crealed magnifICent text and rover designs. Ovel'K'eing the
production pfOCtSS wi lh finesse was Anne Garcia, Produc_
lion Liaison. Barb Tucker and the slaff at S4Cartisle pro-
vided expert and professional guidance in all aspects of the
art and production process.
Although difficult and challenging. the study of phar-
macology is truly a fascinating. lifelong ,iourney. We hope
thai we have written a lextbook thai helps make that study
easier and more understandable so that nursing sl uden15
will be able to provide safe, effective nursing care 10 patien15
undergoing drug therapy. We hope students and faculty w,ill
share with US theirexperitnces using this textbook and aU L15
resources.
LibraryPirate
,
Learning Pharmacology in Context
25.2 Pathoge nesis
of Angina Pectoris
Tho daWc pr ....... tion of onp... pI<>n. i.1tNdJ; u-. ..
pain Ia tbt .", .. io, cbnI,......u.n.. """""'1'""0..:1 by
m .. 11;", or "'lIJtrictin,omAlion. Tho diKomfon IN'/' n
dja.,tD 1M WIt JIoouidrr """ pru<ftd d.-.. tb< J.tt or ... aoo
it .... yata><1pootalor 10 tbt LborKic 'pUIr ot """" upwat<!
10 Iht jaw. In tome pllrimu. tho poin i. aper;"nted ill It..
mlcl.pig;onrinm 0< '-miool a..a. !Iran' Jtudia ;"dlu
1Iw wcmtII do DO' always po .... , with thrdlHicoympiomf
... The organization by body systems (units) and diseases
clearly places the drugs in context wi th how they are used
therapeutically. You can e35ily locate al l relevant anatomy, physiology,
pathophysiology, and pharmacology in the same chapter in which we
present complete information for the drug classifications used to
treat the disease(s) in each chapter. This organization builds the
connection between phannacology, jtoophysiology, and the
nursing care you learn in your clinical nursing courses.
Drugs at a Glann prest'nts a quid: way for you 10 see ...
the classifications and prototypes that are revered in the
chapler. organized by disorder drug class.
DRUGS AT A GLANCE
OIl6ANlCIllWU .. 1<1

c... .. "-.I .. I
PIIARMFACTS

1M! 9 ntIIon AlHllunlIIM lI9III pKln; 5(11,000 lIN a!fI tall
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_ 6O!ri If 1ho p6nU wile cIfd!Udc11!f7 0111 Iud lit pr!IM
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Prototype Approach and ,.
Prototype Drug boxes clearly
summarize important medications.
They Indude:
Act ions and Uses
Administration Alerts
Pharmacokinetics, induding onset
of action, duration, half-life, and
peak effect, when known
Adverse Effects and
Contrai ndications
Interactions with drugs, herbs. and
food
Treatment of overdose and
antidotes, where applicable
lEr"'AI*IIlI&K 1.00:ElS{AII1A6OII1ST1l
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... PharmFacts present pertinent faman<! statistics reb-ted 10 the disease,
providing you with a social and economk perspective ofthedisease.
N:lIOII$ AND 1,111[5
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LibraryPirate
Vivid and colorful illustrations help you review specific anatomy,
physiology, and pathophysiology for a body system to help you better
understand the Impact of disease on that system.
PHARMACOTHERAPY ILLUSTRATED
14.1 Actl wotlng and Rebt. d RRgIon.1n the Brain ant Imporbnt
ANal of Focus for Drugs Uslto r rut A .... '-ty Anx'-tyRl latad Symptoms
--.. ........
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.... Pharmacotherapy Illustrated
bo.les viSU3!1y illustrate the drug ther
al')' process and its impact on the dis-
1'3.'ie, showing you specifically how the
drug 3cts to counteract the effects of
dlseaseon the body.
Mechanism of Action anim3wd tutorials featured in MyNurskingKit clearly drug
action at the molecular, tissue, OI"8an, and system II'YeIs.. ....
M ECHANI SM OF A CTION A NIMATI ONS
Acetiminophell (11.33 Donzosil Ch.23
lQ)QQ> (IL 19
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Acyck:Nil
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Epinl'Phrine (h.29 lisi11Op"iI (h.24 Reteplas.e
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AmirXI.UOlle
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Epoietin alta (U8 Metllotrexate (h.3l Salll1l'leroI Ch.39
AIolYastatIt C<12 EsdUq,ram
(h. 14
Meth>1phenidale (IL 16 SaquinaYi" C>.l6
(ajotriol (11.47 EstrJdiol (1L45
MoIJII*"Ie
(IL 18 Sildenalil
C>."
(iprotioum
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Fluconamie (ILJS Napro.m (h.B C>.30
(ydobenuptillf (hll FllJClleline (h.16 Nifedipine (h.23
T_
Ch.41
(ydoph:Jsphamide (h17 FurosemiJe (h.24
0,,,,,,,,,,
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ValproK<Ki;! (h.IS
Diazepam (II. 15 Glipizidt Ch.44 Oxycodollt elL 18 Venlafaxine (h. 16
Digoxin (11.24 Hepalin (1L27 Pmidlin eh.34 Warfarin (h.27
Oiphen/ty!;kamine
"
lntefiell)fl alfa (h.ll PixalJlillf
(1L49 ZickJfudine C>.l6
Dopamine 19 lmdo ..
(U1l PropmtOiol (1L26 lolpidem
(h.i(

LibraryPirate

Providing a Nursing Focus
Once you understand how a drug works on the body-i.e., its actions, therapeutic effects.
potential side effects and interactions, and more-you begin to understand the of the
interventions you will take as the nurse. Each chapter guides you to the content that is essen-
tial for you to provide safe, effective drug therapy.
NUrsing Process Focus charts present need-to-know nursing actions ....
presented in a way that helps the student or new practitioner think like a
nurse about medicat ions--from assessment, nursing diagnoses, planning,
implementation with interventions and rationales, through evaluation-
and induding patient teaching and discharge planning.
---
.---

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-,
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. .... _----
Additional Nursing Process Focus charts are available on MyNur5ingKit .
1110_ ....... ....... "'_ ....... _ ..... ___
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.... NEW! Research Boxes
have been added throughout
to provide evidence-based
practke as it is appliQlble to
pharmacology.
.... Avoiding Medication
Errors are brief patient-
based scenarios that illus-
trate potential pitfalls that
nurses encount er and can
lead to medication errors.
Each scenario ends with a
question asking you to iden-
---
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._.
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----
tifywhat went wrong, enabling you to watch for similar 5ituations and deliver
medications safely.
.... NEW! Complementary and Altemative Therapies boxes present popular
herbal or dietary supplements patients may use along with convent ional drugs.
As a nurse, you need to assess dienls to see if they are using any natural reme-
dies that may have interactions with medications they are taking.
lifespan Considerations boxes present a
variety of special issues related to age, gender,
and psychosocial concerns that nurses must
consider during drug therapy. ...
NEW! Treating the ....
Diverse Patient Ixnes
provide additional coverage
related to culture and ethnicity.
N_"""'''IJIi .... SpooI!ing
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Considerations alert you
to concern.s and teaching
implications for care settings
outside the hospital.
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_.ao ....... _ .... IOIn"I ...............
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The tools at the end of each chapter and on the aompanyi ng media resources help you test
your understanding of the drugs and nursing care presented in that chapter. Using these
tools will help )UU su eoo in your pharmacology course, in the di ni cal set ting, on the
NCLEXRN", and ultinlauly in professional nursing practice.
lbt"' ...... __ ._ ..... _'"
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-
.... Key Cone.", Summary provides ex-
jnded summaries of eonceplS that
correlate to sections wi thi n the chap-
ter. You , an use this sucdnct sum-
mary to erusure that you understand
the concepts before moving on to the
next chapter. The numbering of these
concepts helps you easil y locate that
se"ion within the chapter if you need
further review.
..... -v ........... .............
boto 1IDIn-......,-........... priooMy- ,..,
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__ __ ____________ J
,.
NClEX-RN- Review Que$tion$ prepare you for ... 1.
course exams on the chaptt'l' content using all
NCLEXIt fo rmats. Appendix D provides answers
and rational es.
CRITICAL THINKING QUESTIONS
L A potitt>t (,ovid> " 1"'0 1) i.ailmill<'d 10 th.
lobo .nd doIm.y unit and .... "" thot m. II '-inf! <OIl
lnC"O .... Sbo It It '2 _ka8'N'iot:t. Tbt obt,<trkiut lnI
liolly tqin. toeol)'li.";'h ",..,...awn ouIW .... d ' hea
M'lICbn liar potionl 10 I<obutaliao (Br<thmo). TOg PO
....,. 4 houn OItIIIIId the doeL The n ...... rec:ogaizes
trrbutoli.,. II . boIol'ail.......pc "Il""" Wh. , n ... ""s ...
_ .... , Ibould he maIl.,.;,1I a f"Iiont ..uirirtt! t..bu
..... lhfropJt \O,'lul education don 11K I .... nl ..... in
. . .
MyNursingKIt Each chapter

provides a reminder to visi t
MyNursi ngKit
nt
(www.myn ursingkit.com) for
additional chapter review and
resoun::es.
xli
.. A patien' __ ""til hfldn-
...,'.diot ... 4 _ Ho l.t wilh ...
oIlltW1ud1 ... (S)m ..... on It>dIrtct-actill opoml ...
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n .... .. Coe<D1iII .. OIl .....
\O,'lu,lhouIdlhenllfJO ...... 'hi. patltnt fori DiIC ... ,he
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.-. ...
-
.... CritlUlI Thinking
Questions help you
apply the essenti al
components of nursi ng
care through case-based
scenarios. Appendix D
provides answers .
LibraryPirate
CHAPTER 1
CHAPTER 1
CHAPTER J
CHAPTER4
CHAPTER 5
1
Core Concepts
in Pharmacology
Introduction to Pharmacology: Drug Regulation and Approval
Drug Classes and Schedules
Principles of Drug Administration
Pharmacokinetics
Pharmacodynamics
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KEY TERMS
biologjn (X1gt4
dinical investigation fUJI6
diniGlI trials JX!gt6
complementary and alternative therapies
"",
drug {!all 4
Food and Drug Admini stration (FDA) rcgt 5
Introduction to
Pharmacology: Drug
Regulation and Approval
LEARNING OUTCOMES
Aher reading this chapter, the student should be oble to:
1. Identify key events in the history of pharmacology.
2. Explain the interdisciplinary nature of pharmacology, giving examples
of subject needed to learn the discipline well.
3. Compare and contrast therapeutics and pharmacology.
4. Compare and contrast traditional drugs, biologics,and alternative
therapies.
S. Identify the advantages and disadvantages of prescription and over-
the-counter (OTC) drugs.
6. Identify key U.S. drug regulations that have ensured the safety and
efficacy of medications.
7. Discuss the role of the u.s. Food and Drug Administration (FDA) in the
drug approval process.
8. Explain the four stages of approval for therapeutic and biologic drugs.
9. Discuss how the FDA has increased the speed with which new drugs
reach consumers.
, O. Identify the nurse's role in the drug approval process.
FDA's Criti ca l Path Initiatiw ptTJt6
formulary
Inftstigational New Drug Application UNO)
fRi"
mfdication PQl}f4
NDArnifw plqtl
pharmacology ptTJt J
pharmacopoeia ftlf/l' 4
pharmacotherapy ptTJt4
postmarbting surveilluce
predinkal inwst igation pq;16
therapeutics (!11;!4
LibraryPirate
M
ore drugs are being IIdmlnlstered to patients than
ever before. More than 3 bllnon preS(:flptlons are
each year In the united States. About one half of
all Americans take one prescription drug regularly, and one
out of persons takes at least three pres<rlptlon drugs.
The pu"pose of this chapter is to Introduce thl!' subject of
pharmocology ld to tmphaslze the role of gcM.'mment in
ensuring that drugs, herbals, and other nal","1 alternatives
are safe and effective for pd>Ilc use.
1.1 History of Pharmacology
Thestoryofphannacology is rich and exdting. f.lled with ac-
cidental di500verie:o> and landmark events. Its history likely
began when humans fint used plants to rdievesymptoms of
disea\.e. One 01 the oldest lonns 01 heallh care, herbal medi
cine has been practiced in virtually every culture dating to
antiquity. The Babylonians recorded the earliesl surviving
on cl3)'tablets in 3000 S.c. At aboullhe same
time, the recorded the fbI Tsao (Great Herb;Il), a
volume oompendium of pl3nt remedies d3ting to 2700 Soc.
The Egyptians followed in 1500 B.C. by archivi ng their
dies on a document known as the Ebers PaPYW$.
Little is known about pharmacology during the Dark
Ages. Although it is likelyth.at herbal medicine continued to
be practiced. few historical evenl5 related to this topic were
recorded. Ph.armacology. and indd medicine, could not
adYance until the discipline of science was eventually viewtd
as legitimate by the religious doctrines of the era.
The first recorded reference to the word pharmacology
was found in a text entitled - Pharmacologia sen
tio aoo. Materiam Medicum: by Samuel Dale, in 1693. Be-
fore this date, the study of herbal remedies was called
- Materia a term that penisted into the early 2OI:h
century.
Although the ex:Iict starting date is obscure, modern phar-
maoology is thought to have begun in the early 1800s. At
that time, chemists were rnakingremarbble progress in is0-
lating spKific substances from complex mixtures. This en
abled scientists to isolate the active agents morphine,
colchicine, curare, cocaine, and other early phannacologic
agents from their natural products. Using standardized
amounts, pharmacologists could then study their effects in
animals more precisely. Indeed, some of the early re-
searchers used themselves u test subjects. Frooerich
turner, who first isolated morphine from opium in 1805,
injected himself and three friends with a huge dose (100 mg)
of his new product. He and his colleagues suffered acute
morphine intoxication for several days afterward.
Pharmacology as a distinct disdpline was officiaUy
nized when the first department of pharmacology was
tablished in Estonia in 1847. John Jacob Abel, who is
considered the father of American pharmacology owing to
his many contribut ions to the field, founded the first phar-
macology department in the United States at the University
of Michigan in 1890.
Choplfl 1 Introduction to Pham...:oIogy: DNg RegulUIon 1
In the 20th century, the pace of Change in all areas of med-
icine continued exponentially. Pharmacologists no longer
needed to rely on the slow, laborious process of isolating ac-
tive agents from Karce natural products; they could synthe-
size drugs in the Laboratory. Hundredsof new drugs muld be
synthesized and tested in a relati'"ely shor t time. More impor_
tantly. it became possible 10 uoo.erstand now drogs produced
their effects,down to their molecular mechanism of act ion.
The current practice of phannacology is extremely com
plex and far advanced compared with its earl y, primitive his_
tory. Nurses who consult with pharmacists in the use of
pharmacologic substances aoo. other health professionals
who practice it must never forget its eolrly roots: the applica.
tion of products to relieve human suffering. Whether a sub-
stance is extracted from the Pacific yew t ree, isolated from a
fungus, or created totaDy in a laboratory, the central pur_
pose of phannacology is to focus on the patient and to im
prove the quality of life.
'.2 Pharmacology: The Study
of Medicines
The word pharma(ology is derived from two Grk words,
pharmakon, which means "medicine," and logos, which
means "study." Thus, pharmJcology is most simply defined
as the study of medicine. Pharmacology is an expansivesub-
jed: ranging from understanding how drugs are adminis-
tered, to where they travel in the body. to the actual
responses produced. To learn the discipline well, nursing
students need a thorough understanding of concepts from
various foundation areas such as anatomy and physiology,
chemistry, microbiology, and pathophysiology.
More than 10,000 brand-name drugs, generic drugs, and
combination drugs are currently available. Each has its own
characteristic set of therapeutic appliwtions, interactions.
side effects, and mhanismsof action. Manydrugs are pre_
scribe<! for more than one <1lWase, an<! most produce mul
tiple effects on the body. The study of pharmacology is
further complicated by knowing that drugs may elici t differ.
ent responses depending on ioo.ividual patient factors such
as age, sex, body mass, health status, and genetia Indf't'd,
learning the applications of existing medications and stay.
ing current with new drugs introduced every year is an
enormous challenge for the nurse. The task, however, is a
critical one for both the patient and the health care praCli_
tioner. If applied properly, drugs an dram:ltially improve
the quality of life. If applied improperly, drugs can produce
devastating consequences.
1.3 Pharmacology and Therapeutics
[t is obvious that a thorough study of is irn_
porumt to health care providers who prescribe drugs on a
daily basis. Nurses are most often the health nre providers
directly involved with patient are and are in educat-
ing, managing, and monitoring the proper use of drugs.
This applies not only 10 nurses in clinics, hospitals, and
home health care settings but also to nurses woo teach and
!
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i
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!
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-
i



"


t

4 urjt 1 COO' eor.c"Pt, In Pharmac:oIogy
to new students entering the nursing profession. In all these
cases, it is necessary that individuals have a thorough knowl -
edge of pharmacology to perform their duties. As nursing
students progress toward their chosen specialty, pharmacol-
ogy is at the core of patient care and is integrated into every
step of the nursing process. Learning pharmacology is a
gradual, continuous process that does not end with gradua-
tion. One never completely masters every facet of drug ac-
tion and application. That is one of the motivating
challenges of the nursing profession.
Another important area of study for the nurse, sometimes
challenging to distinguish from pharmacology, is the study
of therapeutics. Therapeutics is slightly different from the
field of pharmacology, although the disciplines are closely
connected. Therapeutics is the branch of medicine ooncerned
with the prevention of disease and treatment of suffering.
Pharmarothera py, or pharmacotherapeutics, is the application
of drugs forthe purpose of disease prevention and the treat-
ment of suffering. Drugs are just one of many tools available
to the nurse for these purposes.
' .4 Classification of Therapeutic
Agents as Drugs, Biologics, and
Alternative Therapies
Substances applied for therapeutic purposes fall into one of
the following three general categories:
Drugs or medications
Biologics
Alternative therapies
A drug is a chemical agent capable of producing biologic
responses within the body. These responses may be desir-
able (therapeutic) or undesirable (adverse). After a drug is
administered, it is called a mrdication. From a larger perspec-
tive, drugs and medicat ions may be considered a part of the
body's normal activities, from the essential gases that we
breathe to the foods that we eat. Because drugs are defmed
so broadly, it is necessary to clearly distinguish them from
other suh,tances sllch '" fooil" hOIl",hold prodllct<, and
cosmetics. Many agents such as antiperspirants, sunscret'ns,
toothpaste, and shampoos might alter the body's normal ac-
tivities, but they are not necessarily considered medically
therapeutic, as are drugs.
Although most modern drugs are synthesized in a labo-
ratory, liolOlj ics are agents naturally produced in animal cells,
by microorganisms, or by the body itself. Examples of bio-
logies include hormones, monoclonal antibodies, natural
blood products and components, interferons, and vaccines.
Biologics are used to t reat a wide variety of illnesses and
conditions.
Other therapeutic approaches include (omplemrntaryand il l-
ternativetherapirs. These involve natural plant extracts, herbs,
vitamins, minerals, dietary supplements, and many tech-
niquesconsidered by some to be unconventional. Such ther-
apies include aCUplUlcture, hypnosis, biofeedback, and
massage. Because of their great popularity, herhal and alter-
native therapies are featured throughout this text wherever
they show promise in treating a disease or condition. Herbal
therapies are presented in chapter l ()OO.
'.5 Prescription and
Overthe-Counter Drugs
Legill drugs are obtained either by a prescription or over the
counter (0Te). There are major differences beTween the two
methods of dispensing drugs. To obtain prescription drugs,
the person must receive a written orderfrom a person with the
legal authority to write such a prescription. The advantages to
requiring an authorization are munerous. The physician or
nurse practitioner has an opportunity to examine the patient
and determine a specific diagnosis. The practitioner can max-
imize therapy by ordering the proper drug for the patient's
condition, and by conveying the amoWlt and frequency of
drug to be dispensed. In addition, the health care provider has
an opportWlity to teach the patient the proper use of the drug
and what side effects to expect. Ina few instances,a high mar-
gin of safety observed over many years can prompt a change
in the status of a drug from prescription to OTC.
In ,ontcast to prescription drugs, ore drugs do not re-
quire a physicians order. In most cases, patients may treat
themselves safely if they carefully follow instructions in-
cluded with the medication. If patients do not follow these
guidelines,OTe drugs can have serious adverse effects.
Patients prefer to take OTe drugs for many reasons. They
are obtained more easily than prescription drugs. No ap-
pointment with a physician is required, thus saving time
and money. Without the assistance of a health care provider,
however, choosing the proper drug for a specific problem
can be challenging for a patient. aTe drugs may react with
foods, herbal products, prescription medications, or other
arc drugs. Patients may not be aware that some aTe drugs
can impair their ability to function safely. Self-treatment is
sometimes ineffectual, and the potential for harm may in-
crease if the disease is allowed to progress.
1.6 Drug Regulations and Standards
Uotilthe 19th cemnry, there were few standards or guide_
lines in place to protect the public from drug misuse. The
archives of drug regulatory agencies are filled with examples
of early medicines, including rattlesnake oil for rheuma-
tism; epilepsy treatment for spasms, hysteria, and alco-
holism; and fat reducers for a slender, healthy figure. Many
of these early concoctions proved ineffective, though harm-
less. At their worst, some contained hazardous levels of dan-
gerous or addictive subst ances. It became quite clear that
drug regulations were needed to protect the public.
The first standard commonly used by pharmacists was
the formulary, or list of drugs and drug recipes. In the United
States, the first comprehensive publication of drug stan-
dards, called the U.S. Pharmacopoeia (USP), wasestablilhed
in 1820. A pharmac:opof ia is a medical reference sununarizing
standards of drug purity. strength, and directions for syn-
thesis. In 1852, a national professional society of pharma-
cists called the American Pharmaceutical Association
LibraryPirate
(MhA) was founded. From 1852 to 1975, two major com-
pendia maintained drug standards in the United Stat es, the
U.s. Phurmacopoeiu and the Nutionul Formulary (NF) es-
tablished by the APhA. All drug products wne covered in
the USP; pharmaceutical ingredients were covered in the
NF. In 1975. the two entities merged into a singl e publi ca-
tiOll , the U.S. Pharmilco/'Mill- Niltionill Formlda,y ( USP-
NF) . The current document of about 2,400 pages contains
3,777 drug monographs in ]64 chapters. Official mono-
graphs and interim revision announcements for the USP-
NF are published regularly, with the full bound venion
printed every 5 years. Today, the USP label can be found on
many medications verifying the purity and e.xact amounts
of ingredients found within the container. Sampl e labels a re
illU5trated in Figure 1.\.
In the early 1900s, the United States began todevdop and
enforce tougher dr ug legislation to protect the publ ic. In
19UZ, the BiolOSlcS Control Act helped to standardI ze the
quality of serums and other blood- related products. The
Pure Food and DrugAct of]906 gave the government power
to control the labeling of medicines. In 1912, the Sherl ey
Amendment prohibited the sale of drugs labeled with false
therapeutic claims that were intended to defr:lUd the con-
sumer. In 1938, Congress passed the Food, Drug, and Cos-
metic Act. This was the first law preventing the sale of drugs
that had not been thoroughly tested before marketing. Later
amendments to this law required drug companies to prove
the safet y and effi OKY of any drug before it could be sold
within the United SUtes. In reacliOll to the rising popularity
of dietary supplements, Congress passed the Dietary Supple-
ment Health and Education Act of 1994 in an attempt to
COlIIroI misleading indu.my daims. A brief timdine of ma-
jor events in U.S. drug regulation is shown in Figure 1.2.
.... -,
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Ooop!tf 1 Inuoductlon to PhiollTlKoIogy: Ofll9 . od S
PHARMFACTS
Consumer Spending on Prescription Drugs
10'110olMioNl he.ttto
......
.t.t 1M tInI 01 tht 21st <tl'illll")' dNg
opflufnwn inuMfd by mort m.n 200'lIo comjlilfd to !be NIIy
T1If aYl'ligf lIUmberof pmaiption drugs takrn per ",timt
UIlIM of" 1m 12.0 (ompartd to 8.0 pr=riptions per penon in
thtmid-199Oi.
Theavmge lOSt of. presaiption drug now aft( $65.00 (omp.ml to
thr micl-199Os, wlltn the cost pmcription was ibout $29.00.
101.11 p/Iamo.KeUtiu1 nprllditurtS in tilt Unitrd SUtts 1wY!'
from 51901 biioo in 2001 to _ sm bilion in lOO8.
1.7 The Role of the Food and Drug
Administration
Much has changed in the regulation of drugs in the past 100
years. In ]988, the Food and Drug Adminismtion (FDA) was offi-
cially established as an of the U.S. Department of
Health and Human Services. The Center for Drug Evalua-
tion and Research (COER), branch of the FDA, exercises
control o'er whether prescription drugs and OTC d rugs
may be used for therapy. The CDER states its mission as fa-
cilitating the availability of safe, effecti ve drugs; keeping un-
safe or ineffective drugs off the market; improving the
health of Americans; and providing clear, easily under-
sundable drug information for safe and effective use. Any
pharmaceutiaJ laboratory, whethel'" private, public, or aca-
demic, must solicit FDA approval before marketing a drug.
Another branch oflhe FDA, the Centerfor Biologi a; Eval -
uation and Research (CBER), regulates the use of biologics
including serums, vaccines, and blood products. One his-
torical achievement involving biologics was the 1986 Child-
hood Vaccine Act. This aet authorized the FDA to acquire
information about patients taking vaccines, to recall biolog-
ics, and to recomme nd civil penalties if guidelines
biologia; were not followed.
The FDA also oversees administration of herbal products
and dietary supplements through the Center for Food Safety
and Applied Nut rition (CFSAN). Herbal products and di -
etarysupplements are regulated by the Dieury Supplelllent
Health and EducalionACI of 1994. This act does nol provide
the same degree of prot Klion for consumers as the Food,
Drug, and Cosmeti c Act of 1938. For example, herbal and
dietary supplement s can be marketed without prior ap-
proval from the FDA. This act is discussed in more detail in
chapter 1()Ci1C>.
1.8 Stages of Approval
for Therapeutic and Biologic Drugs
Theamount of time spent by the FDA in the review and ap-
proval process for a particular drug depends on sewnl
checkpoints along a well-developed and organized plan.
LibraryPirate
6 urjt 1 Co<e COOC"PIS In Pharmac:o!ogy
A gtOUp 01 physicians Hlllbliahed the fim ce>rnpNhansi"" pubfication cI drug standards calfed the U.S. P "'rmecopeioo
,....,.
t l62 A group of pharmscists b.r.dotd, nationaf p""-icnal society called !he A .... ricen P ........... ulic. AHOC_ion (APIIA).
The APhA then Hlllblished the Nstion.l l Formultory (NFl, e standardized publiClltion fOCUlling on phrirmroceuliClll
ingredients. The USPconIi.-.-l to catalogue all drug MlBIed substanou and ptOduc:ta.
1162 This was the beginning 01 the Flde ... 1 Bureau crI Chemistry. Istablishod !6Iderthe lidrrinml"lllicn 01 PNlsideni Uncaln. CNer
Ih' Y""'" and with added dutiH. it gl"lldUllily became the Food and Drug Adminilllnltion (FDA).
11112 Congreas!>'lssed the Biologics Conlrot Act tocontrcl!he qUlllity of Hnms and otharbfoodmlalld producta.
tlOl The PUIS Food a nd Drug Act ga1l8 the gllYllmmen\ powe' tooontrol the Itobeing 01 medicines.
1812 The S ... rtey A .... ndment made medici""" ... te, by prohibiting the sal, 01 drugs lab<lled with false thempevticclaimr;.
1131 Coogre55 p1155ed the Food, Drug. and Coe meti c .... ct.lt W!III the firm law prevenling the lTliIIketing 01 drug' not thoroughly
Tested. TWs law now provides lor the reqliremen1 thel drug """"anI_ "",51 a New Drug AppIk:lltion (NDA) to the
FDA prior to marf<eting a new drug.
1144 Congraas passed the Publ ic Hedh Service Act. CCM!Iring many health issues inclo.rding bioIogiCIII ptOdllCla and the oonlrot
oIlXlITWTIIInicabie diseases.
1175 The U.s. PhllfmllCOfNl's and National Fo<mulsry amco.rr><:e<l their union. The USP-NF became a single standardized
publiClltion.
lilli Congreas pas.sed the Childhood Vaccine Act. 11 owthorized lhe FDA to acquire information ebout pllliento laking vaccines, to
recall biologics. and to """"""",nd civit penalti_ if guidelines regarding biologic""" wore not foIlowod.
11188 The FDA we officirtly Hlablished as an agoncy 01 the U.S. Deputment of Hedh a nd Hume n Servicea.
10112 Congraas passed the Prescription Drug Us er Fee Act. tt required thai """!I8neric drug and biologic manufacturers pay Ieee
to be used tor impra.oement. in the drug review prooesa.
10114 Congress!>'ls.sed lhe Dietery Suppfement H_ lth a nd Educ ation Act thai ,e qui,,"s clear tabeii"9 of dietary supplemenls.
This act giV'llS lhe FDA the power to """""'" supplements that CIIuse a significant risk 10 lhe pWtic.
10117 The FDA Modernizat ion Act reaulhorized Ihe Pmsaiplion Drug User Fee Act. The eet rep"""",led the la'9"st ",form effort
oIlhe drug review process sillC8 t 938.
2002 The Biote rroriam Act irnpleme nled guideli ..... for registralion 01 oolected loxins !hat oculd p""" a threat to human. animal,
or plant .... fety end MBIth.
2007 n ... FDA Ame ndme nts Act r",,"YftKl, ..... u,,.j (uoslfi"" .. <lI"lioi u1i"" tu all"", lur .. .. 1 """'I"<tI, .. , ....... ,"" .. _ uI
oow drugs and medical products. Thia eldended the reforms from 1997. The FDA. PIIth was a
part 01 !his re!O<ITI.
Figure 1.1 A hlstortcal ttmellne of regulatory acts, standards,and organizations
Therapeutic d rugs and biologics are reviewed in four phases.
These phases,summarized in Figure 1.3, are as follows:
1. Preclinical investigation
2.Clinical investigation
J. Review of the New DrugApplication (NDA)
4. Postmarketing surveillance
Prrdinical mitigation involves extensive laboratory research.
Scientists perform many tests on human and microbial cells
cultured in the laboratory. Studies are performed in several
species of animals to examine the drug's effectiveness at dif-
ferent doses, and to look for adverse effects. Extensive test-
ing on cultured cells and in animals is essential because it
allows the pharmacologist to predict whether the drug will
cause harm to humans. Because labomtory tests do not al-
ways reflect the way a human responds, preclinical investi -
gation results are always inconclusive. Animal testing may
overestimate or underestimate the actual risk to humans.
In January2007, the FDA restated its concern that a num-
ber of innovative and critical medical products had de-
creased sinc"" the 19905. The FDA's Critia l Path InitiatiYl! was an
effort to modernize the sciences to enhance the use of bioin-
formation to improve the "safety, effectiveness, and manu-
facrurability of candidate medical products." Listed areas of
improvement haw been the fields of genomics and proteo-
nomics, imaging, and bioinformatics.
CliniGlI inYl!stigation, the second stage of drug testing, takes
place in three different stages termed dink. l phaSl' trials. Clin-
ical phase trials are the longest part of the drug approval
process. Clinical pharmacologists fi rst perform tests on
healthy volunteers to determine proper dosage and to as-
LibraryPirate
Pr"",linical
Inves tigation
(Stage 1)
Rar>gfI: 1-3
,N'
Avemge: 18
..
I.,;tial
Synthesis
Animal
Testing
II
"
I
,
Clinicel
Investigation
(Stage 2)
Range: 2-10 y ......
Aw"'9": 5 ye""

CNplfll Inuoductlon to Ph,uTnacology: DN9 Re<}ulotlon 00<1 .<.pproval 7
NOli. Review
(Stage 3)
FIMge:2

-,
... ' .....
i""
Postmarketing
Studies
(Stage 4)
Adwf'&8
Reaction
Reporting
Survey",
Sampli"9'
Tasting
Inspections
3DDay FDA T""" c::::J NDA
Safety Review IndustryT""" c:::::::::J Submitted
Figure 1.3 A new drug development IImellne, with the four pha5l's of dlug approval
sess for adverse effects. Large groups of selected patients
with the particular disease are then given the medication.
Clinical investigators from different medical specialties ad
dress concerns such as whether the drug is effective, wors-
ens other medical conditions, intel1lcts unsafely with
existing medications, or affects one t)1le of patient more
than others.
Clinical phase trials are an essential component of drug
evaluations due to the variability of responses among pa-
tient<. If nrng tn he effective withnnt ... rinn<
side effects, approval for marketing may be accelerated, or
the drug may be used immediately in special cases with care-
ful monitoring. If the drug shows promise but precautions
are noted, the process is delayed until the pharma.:eutical
company remedies the concerns. In any case, a New Drug
Application (NDA) must be submitted before a drug is al-
lowed to proceed to the next stage of the approval process.
An hrmtigatimal New DrugApplication(lND) may besubmitted for
Phase I clinical trials when it is determined there are signif-
icant therapeutic benefits, and the product is reasonably 501fe
for initial use in humans (e.g., HlV-positive patients). Com-
panies usually begin developing a bl1lnd name for drugs
during Phase I of the IND process.
The NDA review is the third stage of the drug approval
process. During this stage, the drug's brand name is final-
ized. Clinical phase III trials and animal testing may con-
tinue depending on the results obtained from preclinical
testing. Bylaw, the FDA is permitted 6 months to initially reo
view an NDA.lfthe NDA is approved, the process continues
to the final stage. If the NDA is rejected, the process is sus
pended until noted concerns are addressed by the pharma
ceutical company. The average NDA review time for new
drugs is approximately 17-24 months.
Postmaticl!"ting sutveillancf. the fmal stage of the drug approval
process, begins after clinical trials and the NDA review have
been completed. The purpose of this stage is to SlIJ"\ley for
harmful dnlg <.>ff""ts in a larger population. Some adw ....... f
fects take longer to appear and are not identified until a drug
is circulated to large numbe ... of people. One example is the
diabetes drug troglitazone (Rezulin), which was placed on the
market in 1997. In t998,Britain banned its useafterdisoover
ing at least one death and several cases of liver failure in dia
betic patients taking the medication. The FDA became aware
of a numbt'rof cases in the United States in which Rezulin was
linked with liver failure and heart failure. Rezulin was recaUed
in March 2000after health care provide ... asked the FDA to re
oonsider its theropeutic benefits versus its identified risks. The
FDA withdrew 11 pres.:ription drugs from the market be
tween 1997 and 2000. Drug recalls continue to occur.
The FDA holds public meetings annually to receive feed
back from patients and professional and pharmaceutical or
ganizations regarding the effectiveness and safety of new
drug thel1lpies. If the FDA discovers a serious problem, it
will mandate that the drug be withdl1lwn from the market.
LibraryPirate
8 urjt 1 Co .... Cor.cepts In Pha,mac:oIogy
Question: AIt the,t areolS of patient drug therapy wiler! <lcfvtorw drug
fWnli hal'!' (Onsisttfltly(onlributfd to
The Study: Rr5emhrB I'Krmly oomp!etfd <I re'litwof all <ldvrrw drug
eY!'nli reporlrd to till' FDA 2006.ln looking al mtdiulions for <I
rangt of disorden, ind:Jding hun failure, asthlllil, (oagulation drifin,
bipolar dilOrder, depl'tSsion, tpileps" and pain llNDntntl, dinic:ians
found 1 0 It; fm I dnJ9!: dioin, b.lndronate, {Iorwepam, heparin.
rntth<ldooe, riton.J'lir, iIotretinoin, ftnta nyI, <I nd
beta. In 101M innanfrS,drug fmlitits moc:iatfd with
(omplimions of drug deliYery, slKh as OI'l'Btrength tabll'n or <iefe<tiYl'
medi<al dtYic:H. ln omt ' mrs, poltf1ty Ily adYl'l5e drug re.Ktiolll wrre
reponsible-. TIll' mon (om roon reoKtions (iroioK dysrhythmia!,
depression with stlf-injury, and Inere MilltOU! reactions.
Nursing Nurws should oollltantly reviewtill' littrarure to look
for drugs lhaolMYl' ,eportfd, recalled, or umidem:i dangerous dU!'
to manufa(\urio9 isluts.ln are.J1 of drug tlll'I<IPY wlll're mmmon
or reptlitift advt rw re.Ktionl hal'!' bttn ooted,lpWil uutions Ihould
b!o otn:ised
XlII!l': Mor:wr, r 1. R., & flJrtltrg. C D. 1.
lmlllurt rrx 5I!'" I./tdkJllion I'rI/(es.Ja/iJilyI5,1iJ09. ht1p:/
ruarlfrWatdll2OO9O l.pcf
The FDA has a free email subscription service to alert the
consumer regarding drugs and products withdrnwn from
the market. Special committees also address important is-
sues such as potential prescription errors and the screening
of drug names. Proprietary drug names may be changed if
considered a significant safety risk. The naming of drugs is
discussed more thoroughly in chapter 200.
1.9 Recent Cha nges to the Drug
Approval Process
The process of isolating or synthesizing a new drug and test -
ing it in cells, experimental animals, and humans can take
many years. The NDA can include dozens of volumes of ex-
perimental and clinical that must be examined in the
drug review process. Some NDAs contain more than
l00,O<Xl pages. Even after all experiments have been con-
cluded and clinical data have been gathered, the FDA review
process can take several years.
Expenses associated with development of a new drug can
cost pharmaceutical manufacturers millions of dollars. A re-
cent study estimated the cost to bring a new drug to market
at $802 million. These companies are often critical of the
regulatory process and are anxious to get the drug marketed
to recoup their research and development expenses. The
public is also anxious to receive new drugs, particularly for
diseases that have a high mortality rate. Although the criti-
cisms of manufacturers and the public are certainly under-
standable-and sometimes justified- the fundamental
priority of the FDA is to ensure that drugs are safe. \Vithout
an exhaustive review of scientific data, the public could be
exposed to dangerous medications,or those that are ineffec-
tive in treating disease.
L IFESPAN CONSIDERATIONS
Prescription Drug Costs and the "Doughnut
Hole"" for Senior Citizens
In January 2006, prescription drug (OYtIage through Mfdiure Pan D Wtflt
imo effffi, in part to help prottd seniorcitiztns (mOlt _r age 65) from tat-
olStrophK drug elptllditurH. Amt riu ns older tha n age 65 (Onstitule only 13%
of till' population but i({OUm for i bout 14% of all prHriptions disptllSfd a nd
mot allOT( mMKitions.Molt than 8091. of all seniors t.IU at Imtont prt-
s<ribed medKalion mh day. rhe avtr<lgt older penon is 1.1 ki ng roore ma n fou,
prel(ription mfdiutions at plus two ore mfdKitions. Many of thrll'
I1lI'dic:iJlfS--ilJ(h olS those for diab!oll'l, hypl'lllffiSion, and hun dMall'-
are uun on a pmnanenl basis.
While- Mfdic:are Pan 0 did make IOmt substantial difiert'JI(6 in III'lping
ll'llioB j)ay for their meditaoOll!, a gap in (_,agr whtfl drug IpI'nd-
ing totals art betWl'tn $2,250 and $5,100. This gap MS been tt noo:! till'
' doughnut OOIe' and stuclif"s MI'!' suggrntd that re,uhing tMt
doughnut holewill redKe spending on their medic:atiolll by 14% t04O'll.,dt
pl'nding on whether tilt haYl' insu,a II(t (_ragt. With most se
niors taking daily mediutions for (hronic: (onditions, this dtUUIl' in IpeOd-
ing may l1lI'an thit ll'llioo are foregoing their most nffiied medic:atiolll.
In the early 1990s, owing to pressures from organized con-
sumer groups and various drug manufacturers,gowmmen-
tal officials began to plan how to speed up the drug review
process. Reasons identified for the delay in the FDA drugap-
proval procer.s included outdated guidelines, poor commu-
nication,and in'lufficient staff to handle the workload.
In 1992, FDA officials, members of Congress, and repre-
sentatives from pharmaceutic:al companies negotiated the
Prescription Drug User FeeActon a 5-yeartrial basis. Thisact
required drug and biologic manufacturers to provide yearly
product user fees. Thisadded income allowed the FDA to hire
more employees and to restructure its org;mization to more
efficiently handle the processing of a greater number of drug
applications. The result of restructuring was a resoWlding
success. From 1992 to 1996, the FDA approved double the
number of drugs while cutting some review times by as much
as half. In 1997, the FDA ModemizationAct reauthorized the
Prescription Drug User Fee Act. Nearly 700 were
added to the FDA's drug and biologics program, and more
PHARMFACTS
Time Length for New Drug Approvals
It uk6 about II YUB of ft'Itmh and deveIopmenl btfore a drug is
subminfd to the FDA for rtYitw.
Phase I dinKil trials ukl' <lbout 1 yea, and inOtve 20 t080 OOIlllilI.
hrakhy
Phase II dinKal trials Ian about 2 involl'!' 100 to 300 volunteer
patitnn with tlll'disull'.
Phasr III dinic:,11 triall take about 1 1,000 to 1.000
patitnli in hospiulland dinic: <lgtrKits.
For tvery 5,000 (hemiuls moll emer predinic:al only 5 mau it to
human these 5 pottfltial dfU9!,only 1 is finally ipprowd.
LibraryPirate
TABLE 1.1 SttO!ps of Approval for Drugs MarktO!ted
Within Canada
Step 1 Prffiilical5llKiesOl 9ptrinents in rulUre. hing tissue.and small
Jnmak JIl' mrnsift d nical uiak or
tffiilg door il humans.
Step 2 A drug oompany (ompltlrsa drug to lfIoakh
This !!pOIt dtt,iis imporlilrt lift!)' ,nd dffflimlffi information
ilduding ttstilg data,how thr drug prtdxtwil lit productd
padtagtd.and mfilland rNCtioos.
Step 3 A (ommitttl' of drug 9pfflS ilduding mrdical drug sdfotists
II'Yiews thr drug to idffitify potrotial bffiri"ttsand drug

Step4 uoada Ift'iews infoonatiooabout thr drug prodlKl and
passe 00 impormt dttai s to hrakh prattitionm and
Step S CoJoada illlltS i HotiCl' ofCompiiantt (HOC} and Dru]
Idffitifitatioo N!I1lbrr lOIN). Both prrrrit thr manufacum to
market tilt drug produn.
Step 6 Canada rnoritors thr rtkaivffirs5 ofthr drug
((IOO1nsaftrr it has bffiJ rnarRtm Tlisis donr by rtguar
illpKlioo, notites, nN5itum, and from torI\Umm and
hrakh CilIl' pIaCIitiOllrl"l.
than $300 million was collected in user fees. The FDA
Amendments Act expanded the reform effort in 2007 byal-
lowing more U.S. resources to be used for oomprehensiye re-
views of new drugs. In 2008, the target base revenue for new
drugs was over $392 million.
1.10 Canadian Drug Standards
The drug approval process in Canada is illustrated in
Table 1.1. In Canada as in the United States,drugtesting and
risk assessment is a major priority. Health Canada is thefed-
ernl department working in partnership with provincial and
territorial governments. The Health Products and Food
Brnnch ( HPFB) of Heallh Canada is responsible for ensur-
ing that health products and foods approved for sale to
Canadians are safe and of high quality. The HPFB regulates
the use of thernpeutic products through directorates. The
CNpltl t Inuoductlon to Ph,um<KoIogy: 0"'9 Regulation . 0<1 ... pproval 9
Therapeutic Products Directornte (TPD) authorizes mar-
keting of a pharmaceutical drug or medical device, once a
manufacturer presents sufficient scientific evidence of the
product's safety, efficacy, and quality as required by the
Canadian Food and DrugsAct and Regul.1lions. The Biolog-
ics Cenetic (BCTD) ",suhtes bi _
ologic drugs (drugs derived from living sources) and
rndiopharmaceuticals. Products regulated by the BGlD in-
clude blood products, vaccines, tissues, organs, and gene
therapy products. The Natural Health Products Directorate
( NHPD) is the regulating authority for natural health prod-
ucts for sale in Canada.
The Canadian Food and Drugs Act is important regu-
latory document specifying that drugs cannot be marketed
without a Notice of Compliance (NOC) and Drug Identifi-
cation Nwnber (DIN) from Health Canada. Foods, drugs,
cosmetics, and therapeutic devices must follow established
guidelines for approval . Any drug that does not comply with
standards established by recognized pharmacopoeias and
formularies in the United States, Europe, Britain, or France
cannot be labeled, packaged, sold, or advertised in Canada.
1.11 Nurses and the Drug Approval
Process
In nursing, it is during the postmarketing surveillance pe-
riod of Phase IV (Step 6 in Canada) that nurses have the
most frequent opportunities to participate in the drug ap-
proval process. \VhiIe nurses working at larger, urban med-
ial centers may participate in administering medications
during Phase II and III trials, all nurses administering med-
ications monitor for thernpeutic effects and adverse reac-
tions from the drugs they to their patients. \'/henever a
possible drug reaction is noted, nurses are responsible for re-
porting the reaction to the prescriber and appropriate health
care agency persormel (e.g., risk management , pharmacist).
By monitoring for and reporting adverse effKts, nurses can
ensure that better postmarketing surveillance is achieved.
The role and responsibilities of the nurse in drug adminis-
trntion are discussed in more depth in chapter JOO.
.. ;':1 Chapter REVIEW JILCl _ __ ________________________________________________________________________________________ __
KEY CONCEPTS
The numbered key concepts provide a succinct summary of the important points from the oorresponding numbered section
within the chapter. If any of these points are not clear, refer 10 the numbered section within the chapter for review.
1.1 The history of pharJrul.oology began thousands of years
ago with the use of plant products to treat disease.
1.2 Pharmacology is the study of medicines. It includes the
study of how drugs are administered and how the body
responds.
1.3 The fields of pharmacology and therapeutics are closely
connected. Pharmacotherapy is the application of drugs
to preVl'nt disease and ease suffering.
1.4 Therapeutic agents may be classified as traditional drugs,
biologics, or alternative therapies.
LibraryPirate
10 UnKl Cote Concepts In I'hirmKo!oqy
1.5 Drugs are awilable by prescription or over the counter
(OTC). Prescription drugs require an order from a health
ClIre provider.
1.6 Drug regulations were created to protect the public from
drug misuse, and 10 assume conti nuous evaluation of
safety and effectiveness.
1.7 The regulatory agency responsible for ensuring that drugs
and medical devices are safe and effective Is the Food and
Drug Administration (FDA).
1.1 There are four.stages of approval fOl'" thefllpeutic and blo
logic drugs. These progress from ceUular and animal test ing
to use of the experlmental drug In patients with the disease.
CRITICAL THINKING QUESTIONS
1, Explain why a patient might seek trelltment from an OTe
drug instead of a more effective prescription drug.
2. How does the FDA ensure the safety and effectivenes.s of
drugs? How has this process dJanged in recent
1. In many respects, the role of the FDA continues long after
the initial drug approval. Explain the conlinued involve
ment ofthe FDA
1.9 Once critidzed (or being 100 slow, the FDA has stream
lined the process to get new drugs to market morequidly.
1.10 Drugstandards also ensure the effectiveness and safety of
drugs for Canadlan consumers.
1.'1 Nurses may partidpate in several phases of the drug ap-
proval process but will have the most frequent opportuni-
ties during Phase IV, posll1lllrketing surveillance.
4. Identify opportunities that nurses have in eduClIting, ad
ministering, and monitoring the proper use of drugs.
See Appendix D for answerJ and mtionuks for all activities.
EXPLOflE
Is JOlI' one $lOp lor dlapler t'f'Oiew mal!rills artd
mwlcaS- lor IM,ItC8SS <MIt! ilddiliooal practictr
Que5IIons. Intt;raCllve _grmen15 and web Iin<.s,
and videos. and more!
yoo- I!CUS.'r mtIIllmm the lrant d)OJ! bDOIC at
...... "'I.a.gkit.cam.
LibraryPirate
KEY TERMS
biOilvailability plgt14
chtmicillnamr M ill
combination drug {XiIj 111

pu;t 14
Drug Classes and Schedules
LEARNING OUTCOMES
After rmding this the student should be abk to:
1 . Explain the basis for placing drugs into therapeutic and pharmacologic
dasses.
2. Discuss the prototype II pprollch to drug cI.nslflclIllon.
3. Describe what Is meant by II drug's mec:hanlsm of action.
4. Distinguish between a drug'S chemical name, generic name,and
trade name.
S. why generic drug names are preferred to trade name drugs.
6. DiSCUSS why drugs IIrf sometimes placed on /I restrictive list,and the
cont roversy surrounding this issue.
7. Explain the meaning of a controlled substance.
8, Explain the U.S. Controlled Substance Act of 1970 and the role of the
u .s. Drug Enforcement Agency In controlling drug abuse and misuse.
9. Identify the five drug schedules and give examples of drugs at each
level.
fll9t'1J
mechanism of action {!alt 12
pharma(ologi( dassifiution Jllf/l'l;
prototype drug fJ<1jt 1]
drugs {!alt 14
classification po:jt 1]
trail! name pi1IIf 13
withdrawal fUJl 14
LibraryPirate
n Unft 1 Core Concepl$1n Phorm.rology
T
he student beginning the study of pharmKoIogy 11
quickly confronted with hlnireds of drugs having
sprcific dosages. $Ide effects, and me<:hanisms of action.
Wrthout a means 01 grOYping Of OC9I'lizing this InfOOl'latiof\
most students would be overwhelmed by the yast amounts
of new data. Drugs can be clauified by a number of different
methods thllt provide Iogkal systems for identifying drugs
and determining the limitations of their U5e. This chapter
presents methods of grouping drugs: by therapeutic or
pharmacologic cla1slflCatlon, and by drug schedules.
2.1 Therapeutic and Pharmacologic
Classification of Drugs
Une usetul method ot organizing drugs is based on their
therapeutic in treating particular diseases. This is
referred to :lS a theflptutK daSlification. Druss may also be Of-
ganized by phrna(oiogir: cinsiication. A drug's pharmacologic
classification refers to the wayan agent works at the mole<:
ular. tissue. and body system level. Both types of c1assifica.
tion are widely used in categorizing the thoU5Jnds of
available druss.
Table 2.1 shows the method of therapeutic classification,
using cardi<lc C1re as an example. Many different t ypes of
drugs affect ardiovascular function. Some drugs influence
blood dolling. whereas others lower blood choles terol or
prevent the onset of stroke. Drugs may be uwd to treat ell'
vated blood heart failure, abnonnal rhythm. chl'St
pain, heart att:Jck, or circulatory shock. Thus, drugs that
treat cardiac disorders may be placed in several types of
therapeutic classes, for example, anticoagulants, antihyper-
lipidemi a. and antihypertensives.
A therapeutic classification need not be complicated. For
example, it is appropriate to simply classify a mcdiClltion as
a "drug used for stroke" or a "drug used for shock." The key
to therapeutic classification is to clearly state what a partic.
u1ar drug does clinically. Other exampll'S of therapeutic
classifications include antidepressants, antipsycilotia,
drugs for erectile dysfunction, and antineoplastics.
The pharmacologic classification a drug's
mrdwnisIn of Ktion. or how a drug produces its effect in the
Organizing Drug Information
by Therapeutic Classification
THERAPEUTIC FOCUS:CARDIAC CARE I DRUGS AFFECTING
CARDIOVASCULAR FUNCTION
Therapeutic
inIkJem blood donilg

_ ........
reilft IICIIIIWI urM rhythni
n_iI9N
Therapeuttc CllIssJtlcaaon
M11ial191NOO
Mlli/!)'perIipidmIiG


Riln.jnah
lAHLEll Organizing Drug Infonnation
by Pharmacologic Classification
FOCUSING 00 HOW A THERAPY IS APPUED:
PHARMACOTHERAPY FOR HYPEmtNSION MAY BE N:.ItEVED BY:
MKhiilntsm of Al::UOIl
IowfI'I
block! hr.n (,1100111 chInntls
block! hmrmaI.ctiviIy
block! ph)'liologit rmtiom to SlItSI

Phafmacologk da5s1f1callon

CikiII1I chInnri bIod.rr
angicrlmsill-{OlWff\jng
inhibitor
.1iRntr9ic:maqonilt
vl\odilalDr
body. Table Z.Z shows a variety of pharmaoo1ogic
Dam using hypertension as an example. A diuretic treats hy-
pertension by lowering plasma mlume. Calcium channel
blockers treat thi!; disorder by decreasing cardiac oontractility.
Other drugs block intennediates of the renin-angiotensin
pathway. Notice that each example describes how hyperten
sion might be controlled. A drug's pharmacologic classifiCll-
tion is more specific than a ther:Jpeutic classification and
requires an llilderstanding of biochemistry and physiology. In
addition, pharmacologic classifications may be described
with varying degrees of complexit y, sometimes taking into
account drugs' chemical naml'S.
\Vhen classifyill8 drugs, it is common practice to select a
single drug from a class and compare all other medications
with thh representative drug. A. proto!Jpt drug is the well-
understood drug model with whichothl'l'drugs in its repre-
sentative class are compared. By learning the characteristics
of the prototype drug, studmu may prediCi the actions and
adverse effects of other drugs in the same class. Forexample,
by knowing the effects of penicillin V, students can extend
this knowledge to the other drugs in the penicillin class of
antibiotics. The ori8inal dru8 prototype is not always the
most widely used drug in its class. Newer drugs in the same
class may be more effective, have a more famrable safety
profile, or have a longer dUl7otion of action. These factors
may sway health care providers from w;ing the original pro
totype drug. In addition. health care providers and pharma-
cology textbooks IIOmetiml'S differ as 10 which drug should
be the prototype. In any case. becoming familiar with the
drug prototypes and keeping up wit h newer and more pop-
ular drugs is an essential pan of mastering drugs and drug
classes.
2.2 Chemical, Generic, and Trade
Names for Drugs
A major challenge in studying: pharmacology is learning the
thousands of drug naml'S. Adding to this difficulty i!; the fact
that most drugs have multiple na!Tll'5. The three basic types
of drug names are chemical, gmeri" and trade names.
A dIenIiGJI_ is assigned using slandard nomenclature
est:Jblished by the Union of Pure and Applied
Chemistry ( IUPAC). A dru8 has only one chemical name,
LibraryPirate
which is sometimes helpful in predicting asubstance's phys-
ical and chemical properties, Although chemical names
convey a clear and concise meaning about the nature of a
drug, tln,y are un"" U>lIJpliUlh,u a"u dilli"ull Iu n::Ill"lIJU'"
or pronounce, For example, few nurses know the chemical
name for diazepam: 7-chloro-J,3-dihydro-I-methyl-5-
ph,myl-2H-I,4-benzodiazepin-2-one, In only a few cases,
usually when the name is brief and easily remembered, will
nurses use chemical names, Examples of useful chemical
names include lithium carbonate, caJciwn gJuconate, and
sodium chloride,
More practically, drugs are sometimes classified by a
portion of their chemical structure, known as the chemical
group tl.1me, Examples are antibiotics such as the fIuoro-
quinolones and cephalosporins, Other common examples
include the phenothiazines, thiazides, and benzodiazepines,
Although chemical group names may seem complicated
when first encountered, knowing them will become invalu-
able as the nursing student begins to learn and understand
major drug actions and adverse side effects,
The generic name of a drug is assigned by the U,S, Adopted
Name Council. With few exceptions, generic names are less
complicated and easier to remember than chemical names,
Many organizations, including the Food and Drug Admin-
istration ( FDA), the U,S, Pharmacopoeia, and the World
Health Organization (WHO), routinely describe a medica -
tion by its generic name, Because there is only one generic
name for each drug, health care providers often use this
name, and students generally must memorize it.
A drug's trade name is assigned by the company marketing
the drug, The name is usually selected to be short and easy
to remember, The trade name is sometimes called the pro-
prietary or product or brand name, The term proprietary
suggests ownership, In the United States, a drug developer is
given exclusive rights to name and market a drug for 17
years after a new drug application is submitted to the FDA.
Because it takes several for a drug to be approved, the
amount of times pent in approval is usually subtracted from
the 17 years, For example, if it takes 7 years for a drug to be
approved, competing oompanies will not be allowed to mar-
ket a generic equivalent drug for another 10 years, The ra-
tionale is that the developing company should be allowed
sufficient time to reooup the millions of dollars in research
and development costs in designing the new drug, After J7
years, competing companies may sell a generic equivalent
deug, sometimes using 3 diff .. rent name, which the FDA
must approve,
Trade names may be a challenge for students to learn be-
cause of the dozens of product names containing similar in-
gredients, A rombination drug contains more than one active
generic ingredient. This poses a problem in trying to match
one generic name with one product name, As an example,
Table 2,3 considers the drug diphenhydramine (generic
name), also called Benadryl (one of many trad .. names),
Diphenhydramine is an antihistamine, Low doses of
diphenhydramine may be purchased over the counter
(OTC); higher doses require a prescription, When looking
for diphenhydramine, the nurse may fmd it listed under
O\.apur I Drug Cb.", 00 SdM'dule. 13
TABLE 2 3 Examples of Brand-Name Products
...
Containing Popular Generic
Substances
Generic SubstancE'
ispiin
ibuprofeon
8rand Names
&aye', Butmil,
Ecotrin. Empiril, [x(edin. Maprin, NOOjfIic.
Salatin, SaJocoi. Sallprin, Ialwin.
T napt,eo.l 0, 'mqLim, Venn, ZORpin
AIIeIdryI. Benahist.
Ulidryl, Compol. DiaJi st.
ffnyIJist. Hydramine. H)UiJ.
I nsoJIIIaI, NoOOryI, NordryI, Nytol,
""""
AdYil, Ammoi, Aplifen, Brufen. Hakran.
Mtdipml. MidoIlOO, Mouin,
No\ooprofen, ltJprin. B, Rufen,
T""",,
many trade names, such asAllerdryl and Compoz. provided
alone or in combination with other active ingredients,
Ibuprofen and aspirin are additional drug examples with
different trade names, The rule of thumb is that the active
ingredients in a drug are described by their generic name,
The generic name of a drug is usually lowercased, whereas
the trade name is capitalized,
2.3 Differences Between Brand-Name
Drugs and Their Generic Equivalents
During its 17 years of exclusive rights to a new drug, the
pharmaceutical oompany detennines the price of the med-
ication, Because there is no competition, the price is gener-
ally quite high, The developing company sometimes uses
legal tactics to extend its exclusive rights,sincethis can mean
hundreds of millioll'l of dollars per year in profits for a pop-
ular medicine, Once the exdusive rights end, competing
oompanies market the generic drug for less money, and con-
sumer savings may be considerable, In some states, pharma-
cists may routinely substitute a generic drug when the
prescription calls for a brand name, In other states, the phar-
macist must dispense drugs directly as written by a health
care provider or obtain approval before providing a generic
substitute. Drugs not apf>rowd are placed on a r .... trictive 1iS-t.
The companies marketing brand-name drugs often lobby
aggressively against laws that might restrict the routine use
of their brand-name products, The lobbyists claim that sig-
nificant differences exist between a trade-name drug and its
generic equivalent, and that switching to the generic drug
maybe harmful for the patient, Consum('r advocates, on the
other hand, argue that generic substitutions should always
be permitted because of the cost savings to patients,
Are there really differences between a brand-name drug
and its generic equivalent? The answer is unclear, Despite
the fact that the dosages may be identical, drug formulations
are not always the same, The two drugs may have different
LibraryPirate
14 linK I Cort Conc.pU III Pho,moa>1ogy
PHARMfAcrS
MarkQting and Promotional Spending
Whrn of (lam/) bIoumt"oub!e.
IrgilIiCtics by Brislol-Mym Squibb dNytd M Tht
Mrli1l!d cost IIHDII5UJIIm b 211101l! ,"!lof potr ..
mrfllionlQllIIOIl!lI'un SI biIon.
PromOliorul on pmaiption dlJl9S r= II _ S28 billion ill
2008,up from S 16.6 bimon in 2000 000 $9.2 bi11"KIII in 1996-
Sptndill\l on (DIISUmt' drug adftrlMmfnts on ttlrmion in print
mtdio incrustd to O'/ef H.l billion in 2008, up from S2.$ billion in 2000
ondS791 million in 1m
Consurnt! (Ioiim thlt dri\le up
drllliOO foI tilt tljItmm drugs _thr oIdrtlesl cost,
drugs m.t migM be ."tlrKtM.
inert ingredient.!. For example, if the drug is in ublet form,
the active ingredients may be more tighdy comprtss.ed in
one of the prepal"lltions.
The 1r::ey to comparing brand-name drugs and their
generic equivalents li es in measuring the bi03v:ail3bility of
the M) prepmtions. B.ioavailabil ity is the physiologic abilityof
the drug to reach its tlUge! cells and produce its elTect.
Bioavailability may indeed be affected by inert ingredient.!
and tablet compression. Anything that absorption of
a drug, or its distribution to the targe! cells, can certainly af-
fect drug :!Clion. Meuuring howlonga drug lakes lo exert its
effect gives phann;lCOlogisll; a crude measureofbioaV1lilabi l-
ily. For example, if a patient is in circulatory shock and it
taUs the generic-equivalent drug 5 minutts longer to pro-
duce it.! effect, that is indeed s.ignificant; however, if a generic
medication for arthritis pain relief tues 45 minutes to act,
compared with the brond-name drug, which b1r::ts 40 min-
utes, it probably does not mailer which drug is prescribed.
To address this issue, some states (Florida, Kentucky,
Minnesota, and Missouri, for example) have compiled a
negalive formulary list. A negative formulary lisr is a list of
lcade_name drugs that phannacists may fror dispense as
generi c drugs. These drugs must be dispensed exactly as
wrillen on the p.CKr;ption, using the Ir..de_name drug the
phy!;ician prescribed. In some cases, phannacislS must in-
fonn or norify p;1tienlS of substitutions. PhannaceuticaJ com-
panies and some health care practitioners have supported this
action, claiming th3t generic drugs---even that have
small differences in bioavailability and bioequivalence-
could adversely affect patient outcomes in {hose with criti-
cal cond itions or illnesses. However, laws frequently change,
and in many instances, the efforts of consumer advocacy
groups have led to changes in or elimination of negative for-
mulary lists.
2.4 Controlled Substances
and Drug Schedules
Some drugs are frequendy abused or have a high potential for
addiction. TedmicaUy, nddicriorr refers to the overYlhelming
feel.i"8that drives someone to use a drug n'peatedly.
is a related term, often defined as a physiologic
or psydloJogic need for a substance. Physical dependence
refers to an allued physical condition caused bylhe adapta_
tionofthe nel"Yl)US system to repeated drug use. In this case,
when the drug is no longer aV1lilable, the individual ex-
presses physical signs of discomfort known as wiMawai. In
contrast, when an individU31 is psychoJogicnlly deperldenr,
there are few signs of physical discomfort when the drug is
withdrawn; however, the individual feels an intense com-
pelling desire to continue drug use. These concepts are dis-
cussed in dt'lail in chapter I JOO.
According to law, drugs that have a significant pOlentiaj
for abuse are placed into five categories called schedules.
These drllgs are classified according to their poten-
tial for abuse:Schedule I drugs have the highest polential for
abuse, an..! Schedule V drugs have the lowest polential (or
abuse. Drugs with lhehighest potential for abuse (Sdledule I)
are restricted for use in sitU3tions of medical necessily, if at
aU aUowed. They h3ve little or no therapeutic value or are in-
tended for research purposes only. Drugs in the other four
schedules may be dispensed only in cases in which thera_
peutic value has been determined. Schedule V is the only
category in which some drugs be dispenred without a
prescription because Ihe quantities of the controlled drug
are so low thatlhe possibility of Colusing dependence is ex-
tremely remote. Table 2.4 gives the five drug Mfledules wilh
examples. Not all drugs with an abuse potential are regu_
lated or placed into schedults. Tobacco, alcohol, and caf_
feine are significant examples.
In the United States, a conln!lcdwbstance is a drug whose
use is restricted by the Controlled Subtances Act of 1970
and later revisions. The Controlled Substances Act is also
called the Comprehensive DrugAbuse Preventionand Con-
trol Act. H06pitals and pharmaCies must register with the
Drug Enforcement Administration (DEA) and then use
their assigned registration numbers to purchase scheduled
drugs. Hospital s and pharmacies must maintain complele
records of all quantities purchased and sold. Physicians,
PHARMFAcr S
Extent -of Drug Abuse
In 1008, mort dun 11.5 m_ drimg IIldH thr
inlkltlKf drugs cUing thr prMiu:I JUt
In 2008, _ 29J'Ko 01 thr U.S. population 12100 oIdtr {70.8 miDion
people) had smoVd (irJarelltl during tht Pllt month. This figUrf indudei
3.6 million)'DUng Pfople 12 to it is in thf Unittd
Slalei 10 srll tohmo to undrrq in molt Ule Ihe)' Iff able to
thtrn prnonally.
From 191M to 1008, tmr"}rflq ilbIMd s.ubnlnc:ts
sud! II glmmiI kid {GIIB;stlftl RllImw,
(rntfI nlmesj,Juptfari4Spid.l; l moll\l OIhtn),lnd MDMA
{dItmiYllIoIlIIf

n 2008, 1l'IOII' man 18 rrilion Amtrich.tMtd or_dfprndrm 0/1
ei1lIfr IkohoJ
LibraryPirate
ABlE2.4 1 U.S. Drug Schedules and Examples
PotenUal for Potential for
Orug

Physical
Schedule Potential Dependency Dependency Examples Therapeutic Use
hight\l high
h"
hftOil,iyltrgic Jod ditlhylamide {LSOl, Umittd or 00 therJpMK UII'
rnan"juani,and
high high
h"
}
IMthador'ot, Jnd IMlhamphnamilll'
'"

h"
anabolic h)'ltocodone Ultd thtrJpNtiul1 with
aspiril or Tylmol, and !OIIII' barbiturate !OIIII' rtugs oolongft" UII'd
,
...
.... ,
1- dextropropolyphtnt,pmtizocine,
diiztpam, ilpruolam
y
-.
.... ,
1-
OTC(oogh medicile with (orIrine, IIstd therapMil:aly without
with atropine
nurse practitioners, and others with prescriptive authority
must also register with the DEA and re<:eiw an assigned
nwnber before prescribing these drugs. Drugs with higher
abuse potential have more restrictions. For example, a spe-
cial order form must be used to obtain &;hedule II drugs,
and orders must be written and signed by the health care
provider. Telephone orders to a pharmacy are not permit-
ted. Refills for Schedule II drugs are not permitted; patients
must visit their health care provider first . Those convicted of
unlawful manufacturing, distributing, or dispensing of oon-
trolled substances face severe penalties.
2.5 Canadian Regulations
Restricting Drugs of Abuse
In Canada, until 1996 controlled substances were those drugs
subject to guidelines outlined in Part III, Schedule G, of the
Canadian Food and Drugs Act. Acoording to these guidelines,
a health care provider dispensed these medications only to
patients suffering from specific diseases or illnesses. Rgulated
drugs included amphetamines, barbiturates, methaqualone,
and anabolic steroids. Controlled drugs were labeled clearly
with the letter C on the outside of the container.
Restricted drugs not intended for human use were cov-
ered in Part IV,Schedule H, ofthe Canadian Food and Drugs
Act. Theseweredrugs used in the course of a chemical oran-
alytical procedure for medical, laboratory, industrial, educa-
tional, or research purposes. They included hallucinogens
such as lysergic acid diethylamide (LSD), MDMA, and 2,5-
dimethoxy-4-methylamphetamine (DOM; street name
STp). Schedule F drugs were those drugs requiring a pre-
scription for their sale. Examples were methylphenidate (Ri-
talin), diazepam (Valium), a nd chlordiazepoxide (Librium).
Drugs such as morphine, heroin, cocaine, and cannabis were
covered under the Canadian Narcotic Control Act and
amended schedules. According to Canadian law, narcotic
drugs were labeled clearly with the letter N on the outside of
the container.
Today Canada's federal drug control statute is the Con-
trolled Drugs and Substances Act. It repeals the Narcotic
Control Act and Parts III and IV of the Food and DrugAct.
It further establishes eight schedules of controlled sub-
stances; two classes of pre<:ursors are covered in one sched-
ule. For a complete listing of drugs, see http://laws.justice
,g"calenlC-J8,8/, The Controlled Drugs and Substances
Act provides broad latitude to the Governor in Council to
amend schedules as determined to be in the best interest of
Canadas citizens. Drugs and substances covered in the
Controlled Drugs and Substances Act correlate with agents
named in three United Nations treaties: the Single Con-
vention on Narcotic Drugs, the Convt'ntion on Psy-
chotropic Substances, and the United Nations Convention
Against Illicit Traffic in Narcotic Drugs and Psychotropic
Substances.
Throughout Canada, both prescription and nonprescrip-
tion drugs must meet specific criteria for public distribution
and use. Nonprescription drugs are provided according to
guidelines and acts established by the respe<:tive Canadian
provinces. One recent system establishes three general drug
schedules (Table 2.5). Phannacies must monitor those
drugs used specifically to treat self-limiting discomforts
such as cold, flu, and mild gastrointestinal or other symp-
toms. Other nonprescription drugs may be sold without
monitoring.
J Three-S,hedule System for Drugs Sold
-.... inCanada
Drug Schedule
'"
Drug"'"
,lJ1 pl!saiplioo rtugs
Drugs with no pottn!ial for abust
Connollfd !tug!
Narrolic rtugs
All drugs by
phalllliOsts
All drugs 001 rnooitorrd fur sa'" by
phalllliOsts
LibraryPirate
16 UnK I ( .... Concepts III Plarma<ology
" '
ljt) Chapter REVIEW
KEY CONCEPTS
The numbered key concepts provide a succinct summary of Ihe important points from the corresponding numbered section
within the chapter. If any of theM' points are not dear, refer to the nWllbered section within the chapter for review.
2.1 Drugs may be organized by their therapeutic or pharma-
cologic classification.
2l Drugs have chentical, generic, and trade names. A drug
has only one chemical or generic name but may have mul -
tiple trade names.
13 Generic drugs are less expensive than brand-name drugs,
but they may differ in thcir biooVllilability; that is,theability
of the drug to reach its targetlissue and prOOuce its action.
CRITICAL THINKING QUESTIONS
1. What is the difference between therapeuti' and pharma-
cologic classifications! Identify the following classifica-
tions as therapeutic or pharmacologic: beta-adrenergic
blocker, oral contraceptive, laxative, folic acid antagonist,
and antianginal agent.
2. What is a prototype drug, and how does it differ from
other drugs in the same class?
3. A pharmacist decides to switch from a trade-name drug
that was ordered by the physician to a generic-equivalent
drug. What advantages does this substitution have for the
patient! What disadvantages might be caused by the
switch?
4. Why are certain drugs placed in schedules? What extra
precautions are health care providers required to take
when prescr ibing scheduled drugs?
2.4 Drugs with a potential for abuse are restricted by the
Controlled Substances Act and are categorized into
schedules. Schedule I drugs are the ntost tightly con-
trolled; Schedule V drugs have less potential for addiction
and are less tightly controlled.
2.5 Canadian regulations restrict drugs as covered in its foo -
eral drug control statute: the Canadian Controlled Drugs
and SubstancesAct.
S. A nurse is preparing to giYI! a patient mediutions and
notes that a drug to be given is marked as a Schedule III
drug. What does this information tell the nurse about this
ntedicnion?
See Appendix D for answers and mtionaies for all activities.
EXPLORE
M)"f'llrsir1g1(i t is )WI one stop kr onli ne ctlapter I!-.lew materialS and
",so"ce .. lor ="'" w;lh a<ldi tiono! IlClf)(- S1)lo p!1!Cli ""
Ques1Io!1S, assi(rfllents a"ld BClMtfes. web links. snlmatlollil
arid ,ideos. and mael
Fl!gISIe! )'GIl" OllIe !rom front oI)'D!I" bxik 11\
WWW.nlI.ll .. siRgkilclIfII .
LibraryPirate
KEY TERMS
/l4}tla

apolhwryS)'Slfill {Id'JIll
ASAPortier JXII}tlO
dff(( pogt 15
buuaI route {II19t 2J
aKIIpIiilD(t p:1qt19
tnlenlroute ptlJtll
tnlmuoatrd {II1IJtll
Principles of Drug
Administration
LEARNING OUTCOMES
Aher rtoding this the studtnt should be! able to:
1. DiKUSS drug administration as II component of afe,effective nursing
(Me,utl lizlng the nursing process.
2. the roles and r6pOnsibilities of the nurse regarding drug
administration.
3. Explain how the five rights of drug administration affect patient safety.
4. Giw- 5peciflC examples ofhow the nurse can increase patient
compli ance In taking mediclliions.
5. Interpret drug orders that contain abbreviations.
6. Compare and contrast the three systems of meawrelTlE'fll used in
phanTIacology.
7. Explain the proper methods of adminh lering enteral, topical, and
parenteral drugs.
8. Compare lind contrast the advantages and disadvllnU!ges of each route
of drug administration.
fj", rights of drug .dminiltr.Jlion P'9t 19
houwhold systftJI pogt 11
inllldtrm3l(lD) 1XJ9t}8
inlrilllUKUIarIlM) pogt}9
inlrll'ltfl(lus(1Y) ,.J'
meb'K ptl9tll
parflllHalroutt ptl9t 18
PRNorder pillJtlO
roolm ordfl'S 1XJ9t lO
mgif order fJIIV lO
slandi ngorder ptl9tlO
ST'" ",der fXI}t 10
subnrlalleOUl fJIIV 18
ptl9tl]
IlIIIiiMdrelease pogt ll
thrft dlKks of chg lIdministratiol f'JI}t 19
LibraryPirate
18 UnK I Co<e COO(ept< III Ph.,macology
T
he primary role of the nurse in drug administration is
to ensure that prescribed medications are delivered
in a safe manner. Drug administration is an important
component of providing comprehensive nursing care that
incorporates all aspects of the nursing process. In the
course of drug administration, nurses will collaborate
closely with physicians, pharmacists, and, of course, thei r
patients. The purpose of this chapter is to introduce the
roles and responsibilities of the nurse In delivering
medications safely and effectively.
3. 1 Medication Knowledge,
Understanding, and Responsibilities
of the Nurse
Whether administering drugs or supervising the use of
drugs by their patients, the nurse is expected to understand
the pharmacotherapeutic principles for all medications
given to each patient. Given the large number of different
thi! r.f meiliC:ltion erroN;.
this is indeed an enormous task. The nurse's responsibilities
include knowledge and Wlderstanding of the following:
What drug is ordered
Name (generic and trade) and drug classification
Intended or proposed use
Effects on the body
Contraindications
Special considerations (e.g. , how age, weight, body fat
distribution, and individual pathophysiologic states
affect pharmacotherapeutic response)
Side effects
\'/hy the medication has been prescribed for this
particular patient
How the medication is supplied by the pharmacy
How the medication is to be administered, including
dosage ranges
\'/hat nursing process considerations related to the
medication apply to this patient
Before any drug is administered, the nurse must obtain
and process pertinent information regarding the patient's
medical history, physicala"""",ment, disease processcs, and
learning needs and capabilities. Growth and developmental
factors must always beconsidered. It is important to remem-
ber that a large number of variables infl uence a patient's re-
sponse to medications. Having a firm understanding of
these variables can increase the success of pharmacotherapy.
A major goal of studying pharmacology is to limit the
nwnber and severity of adverse drug events. Many adverse
effects are preventable. Professional nurses can routinely
avoid many serious adverse drug effects in their patients by
applying their experience and knowledge of pharmacother-
apeutics to clinical practice. Some adverse effects, however,
are not preventable. It is vital that the nurse be prepared
PHARMFACTS
Potentially Fatal Drug Reactions
Toxic Epidermal Necrolysis (TENI
,nd ,Ut"l ic:
Charamrizrd II)' epid!11l1i11 sloughing, WIled by
ofkemiOOC)'les
Sevm tpmrmal dtU{hment irrroiYing thetop oftht skin and
mIKGm
o"lan invo/wmt nt and iltht il 001
and diagooSfd
(KarIS when the Imr fails to prop!1t; brl'ik down.J drug, whim tlltn
(,nnol be tJ(rdM normally
Assori.JIM with usr of IOmt antKoowiI.Jnt< (plltnytoin (DilantinJ,
tht ,mibiotic: trimelhoprirnlsuNamtthowolf
(Bactrim, Seplral, and other but a n Offill with tht lilt of a ny
prtsaiption or OK in{krding ibuprofen (AdYil Motrin)
Risk of dNth offending drug ilquidly withdrawn and
illllilint.Jintd
Skin !laughing of 30% or more of lilt boil)'
Stevens-Johnson Syndrome (SJS)
Uswlly promptM by tilt samt or similardrugs.JS TEN
Btgins 1 to 14 days of ph,rmacotherap)'
Start ofSJS usually signaled II)' nonspKiIK upp!1 inre.:tion
(URI) with dlills, frftr"nd m,laise
blinmiM, Itsions follow within a fN days
Skin !laughing of 10% body
to recognize and respond to potential adverse effects of
medications.
Allergic and anaphylactic reactions are particularly serious
effects that must be carefully monitored and prevented,
when possible. An aHergi{ T9ction is an acquired hyperresponse
of body defenses to a foreign substance (allergen). Signs of al-
lergic reactions vary in severity and includeskin rash with or
without itching, edema, rWIny nose, or reddened eyes with
tearing. On discovering that the patient is allergic to a prod-
uct, it is the nurse's responsibility to alert all pecsotulel by
docwnentingtheallergy in the medical record and byappro-
priately labeling patient records and the medication admin-
istration record (MAR). An appropriate, agency-approved
bracelet should be placed on the patient to alert all caregivers
to the spc.oific drug allergy. Infonnation related to drug al -
lergy must be communicated to the physician and pharma-
cist so the medication regimen can be evaluated for
cross-sensitivity among various pharmacologic products.
Anaphyluis is a severe type of allergic reaction that in-
volves the massive, systemic release of histamine and other
chemical mediators of inflammation that can lead to life-
threatening shock. Symptoms such as acute dyspnea and
the sudden appearance of hypotension or tachycardia fol-
lowing drug administration are indicative of anaphylaxis,
which must receive immediate treatment. The pharma-
cotherapy of allergic reactions and anaphylaxis is covered
in chapters 38 and 2900, respectively.
LibraryPirate
3.2 The Rights of Drug
Administration
The traditional rights of drug administration form the opera-
tional basis for the safe deliveryof medications. The five rights
offer simple and practical guidance for nurses to use during
drug prep<lration,delivery, and administration, and focus on
individual performance. The five rights are as foUows:
I.Right patit'nt
2. Right medication
3.llight d""e
4. Right route of administration
S. Right time of delivery
Additional rights have been added over the years, de-
pending on particular academic curricula or agency poli-
cies. Additions to the original fivt' rights include
considerations such as the right to refuse medication, the
right to receive drug education, the right preparation, and
the right documentation. Ethical and legal considerations
regarding the five rights are discussed in chapter 900.
The thl''(' chub of drug administration that nurses use in con-
junction with t he five rights help to ensure patien t safety
and drug effectiveness. Traditionally these checks incorpo-
rate the following:
1. Checking the drug with the MAR or the medication
information system when removing it from the
medication drawer, refrigerator, or controlled substance
locker
2. Checking the drug when preparing it, pouring it, taking
it out of the unit-dose container, or connecting the IV
tubing to the bag
I. Checking the drug before administering it to the
patient
Despite all attempts to provide safe drug deliyery, errors
continue to occur, some of which are fatal. Although the
nurse is held accountable for preparing and administering
medications, safe drug practices are a result of multidiscipli-
nary endeavors. Responsibility for accurate drug adminis-
tration lies with multiple individuals, including physicians,
pharmacists, and other health care practitioners. It should
be noted that computerized scanning systems of medication
administration do not relieve the health care provider of the
responsibility to continue the three checks and the use of the
five rights. Scanning a bar code does not replace these
checks and could result in serious medication errors. Fac-
tors contributing to medication errors are presented in
chapter 9OC>.
3.3 Patient Compliance and
Successful Pharmacotherapy
Compliance or adherence to drug regimen is a major factor
affecting pharmacotherapeutic success. As it relates to phar-
macology, is taking a medication in the manner
prescribed by the health care provider, or in the case ofOTC
01",1<,1 Pr1ndpl ... ofONgAdmlnlmatlon 19
AVOIDING M EDI CATION ERRORS
Tht FDA "Id !hi- Amt riun Hospital k soc:iation Ir.Kk drug emlB thu occu, in
hNkh Till' fiVl' roost OlmmOll G1!M1of rntdiution moB
llKompielr patient inform.tion (e.g., not knowing.bout patitllB'
.llelgie, olher mtditifltl they ale taking. [RI'ious or lab
=.)
Un.v.ilable drug infonnation (e.g.,aJmont warnings iswtd by till' FDA)
M&ommunituion of drug ordm (e.g., iIlrgible h.ndwritten ordeB,
oonfusion bft\\ftn drugs with similar namtl, miswe of lI'fWI.nd
riKimal points,unde.r abbrMtions)
Luk oI ' ppropri,1lt Iobc:ling whon 0 drug is ,,",porod.nd ropod,ogod inlo
smallel unih
Environmental fidoB (t.g.,IIOM 01 intffTUptionl that distr.u till'
.slll' or sill' .dministtr!hl- mtdiutions)
ikuUIf the nufW is often the final he.lth ClIlf in !hi- (hain of merf..
iution .dminislration,txlf' c.ution must bf taun lo.void these Ry WOKe
of efTOf".
drugs, following the instructions on the label. Patient non-
compliance ranges from not taking the medication at all to
taking it at the wrong time or in the wrong manner.
Although the nurse may be extremely conscientious in
applying all the principles of effective drug administration,
these strategies are of little value unless the patient agrees
that the prescribed drug regimen is personally worthwhile.
Before administering the drug, the nurse should use the
nursing process to formulate a personalized care plan that
will best enable the patient to become an active participant
in his or her care (ch.1pter 600). This allows the patient to
accept or reject the pharmacologic course of therapy, based
on accurate information that is presented in a manner that
addresses individual learning styles. It is imperative to re-
member that a responsible, well-informed adult always has
the legal option to refuse to take any medication.
In the plan of care, it is important to address essential in-
formation that the p.1tient must know regarding the pre-
scribed medications. This includes factors such as the name
of the drug, why it has been ordered,expected drug actions,
L IFESPAN CONSIDERATIONS
The Challenges of Pediatric Drug
Administration
Administmng mtdication 10 inf.nn .nd young (hildrm roquif!S
knowltdgt .nd tfChn;que. The flJBe must h .... !' knowltdgt 01 growth ,nd
patteffll. Whf n possibit, till' child lhould bt giffl <I (hoic:f fl'-
garding W UIt of. spoon, or syrill9f. A m.llfl-of-fllct Mlitude
should bf pfl'lfnltd in giving. child rntdit.tions: Using ordisOOntll)'
is unacctp"ble. 0,<11 rntditations that must lit aW.td for dlildto
low can bf mill'd with ILIYofl'd syrup,jflly,or fruit 10.void unpleNnl
\altt!. Medications lhould not bf miJtd with (ert.in dielal)' prodKl5, IlJ(h <II
potItoe, milk,or fruitjuim 10 rnollk till' laste,btcause tlll'(hild m<l Y dmlop
.n unpleas.Jnl asIQ(ialion with tIII'!t iterm.nd 't hMlO(onlUme IIII'm in
lulUfl'. To pll'\'l'llt naUlt<l, rntdications c<ln bf .nd followed with sij)l
of <I wbonattd bt>imgt th" is poured 0Yff aushtd itt.
LibraryPirate
20 linK I Core III Pho,moc:ology
associaled side effects, pott'lltial interacliollS with other
medicatioos, foods, herbal supplements, or alcohol. Pat ients
need to be remi nded that they share an active role in ensur-
ing their own effe<:tiveness and safery.
Many factors can inllut'llu whether patients romply with
pharma'Olhl'rapy. The drus may be 100 e:rpfflsive or may
not be approved by the patient's health insur:r.nce plan. P.d-
tients sometimes forget doses of medications, espteiall y
when they must be taken three or four times per day. Pa-
tients often discontinue the use of drugs that have annoying
side effects or those that impair major lifestyle chokes. Ad-
verse effects that often prompt nonrompliance ue
headache, diuiness, naus.ea, diarrhea, or impotence.
Pati ents oflen Illke medi cations in an unexpected man-
ner, somerimes self-adjusti ng their doses. Some pat ients be-
lieve that if one Illblel is good, tYm must be better. Others
believe they will become dependent on the medication if it
is uun as prescribed; thus, they take only half Ihe required
dose. Patients are usually reluclllntto admit or report non-
compliance to the nurse for fear of being Il'prim;J.nded or
feeling embarr<tssed. Because the reasons for noncompli-
ance are many and varied, the nurse must be vigilant in
questioning p3tients about their medications. \\fhen phar-
macotherapy fails to produce the expected outcomes, non-
compliance should be considered a possible t'}lpJanalion.
3.4 Drug Orders and Time Schedules
Health care providers use accepted abbreviations to rom-
munKate the directions and times for drug administr.ation.
Table 3.1 lists common abbreviations that relate to univer-
sally scheduled times.
A HAT onItr refers to any medication that is needed im-
mediately, and is to be given only once. [t is of un associ-
ated with emergency medications that are needed for
Iife.threatening si tuations. The term STAT comes from
statim, the latin word meaning The phys i-
cian normally notifies the nurse of any STAT order so it
PHARMFACTS
GrapefruitJuice and Drug Interactions
Grlprfnit;..ice II\iJ no! be SIR b peopIrwho IiR (fruin lIIfdiutiom.
liktlylllronoids) in!jIJprfnit juiu kIwPr me.-iYity of
SjIfdr: in Ittt inmIiwI WI ramttiIy Imkdown
IMIiutions. This iIows I imount of mrdic.Jtion to tht
in drug tiviry.
Drugs chit be lfltfd b, grilpefruitjuia inWde miduoJ.m
(Vtntd); ()'(Iosporint (SiIndimmunt, NtoraO; antihyptrlipidem its III<h n
krlnmin (MtviCOt) and sim\\lltatin (1oco,);(enain i ntihilumints III<h
as I5ttm iloIt (HismUIII); (ertlin antibiotia s.uc:h as rrythll)mydn;.nd
{main IntifiJnglls s.uc: h itJl(otllz* (Spolanox), RtoxoJ'lllOie
(N'IZInI), ilnd (JIo!icor).
Glilprfnit;..ice .. 1Nst 2hoursbrfoltor Shoun
ifterumg I rnediuriontlut inBin wid! it.
Sam. 11mb t!Iat M! tWwmI with fnAt;..u CDUId (Qllliin 9'olPriMt
juire._ if 9'apthuit is JIOI part of Iht medrN. (he(k me

TA8lf 3.1 Drug Admlillstration Abbn!viations
_ .... -
Meaning


i6 dtsimllilSlllfard
..
.......
.. twiceperlWy
up up!U1e
'"
'mp
horhr ...

mtrilmUKUlar
"
..
00 .......
"
lilt\' mNIi; lilt\' HliIg
"'

PM

PRH

"
(W, rime per IWy
q2h emy 1 hoo.n (r'ltn ",whtn firll gWen)
,Ih MI)' 4 hoo.n [r'ltn)
q6h MIl6hoo.n(t'ltn)
.. MIl' hoo.n (fYtII)

Ml)'llholn
...
SW 1nrneIia1tlr, .. ona
.. .-
.. thmti'nts prr IIiJ
nw, InIlitUlr r", Safr Mtdul rtcOmmtllCb thit cllt fdlowing
abbrtilticllI be _oidrd beuuIe the)' Ql'lleld to medication trrOI1: cr. imcrld
lilt "t'ltry"; qh: inllrld lilt "hou"Y' or" MI)' hoII' "; qd: inllNd lilt ' daily" or
"emy day": qhs:inlleld other day:For
o1htr rommrndllions, 1ft the otIidil Joint Corrmissioo"Do Not Ust li5f:
can be obtai ned from the pharmacy and administered im-
mediately. The timebetwn writi ng the order and admin_
istering the drug should bf 5 minutes or less. Although not
as urgent , an ASAP onIt. (as soon as possible) should be
available for administration to the patient within 30 min_
utes of the ordn.
The single onItr is for a drug that is to be given only onct,
and at a specific time, sud! as a preoper:r.tive order. A PRNor
(Latin: pro re IIOrD) is administered as reqlliredby the pa_
tient's condition. The nurse makes the judgment, based on
patient assessment,as 10 when such a medication is to bead_
ministered. Orders not written STAT, ASAP, NOW, or
PRN are called routint 0Idtn.. These are usually carried OUI
within 2 hours of the time the order is written by the physi_
cian. A is wr itten in advance of a situation thai
is to be carried out under specific circumstances. An exam_
ple of a standing order is a set of postoperative PRN pre_
scriptions that art written for all patienl5 who have
LibraryPirate
undergone a specific surgical procedure. A common stand-
ing order for patients who have had a tonsillectomy is
elixir 325 mg PO every 6 hours PRN sore throat."
Because of the legal implications of putting all patients into
a single treatment category, standing orders are no longer
pennitted in some facilities.
Agency policies dictate that drug orders be reviewed by
the attending physician within specific time frames, usu-
ally at least every 7 days. Prescriptions for narcotics and
other scheduled drugs are often automatically discontin-
ued after 72 hours, unless specifically reordered by the
phpician. Automatic order, do not generally apply
when the number of doses or an exact period of time is
specified.
Some medications must be taken at specific times. If a
drug causes stomach upset, it is usually administered with
meals to prevent epigastric pain, nausea, or vomiting. Other
medications should be administered between meals because
food interferes with absorption. Some central nervous sys-
tem drugs and antihypertell'iives are best administered at
bedtime, because they may cause drowsiness. Sildenafil (Vi-
agra) is unique in that it should be taken 30 to 60 minutes
prior to expected sexual intercourse, to achieve an effective
erection. (Note: Sildenafil is also prescribed to hospitalized
patients for pulmonary hypertension.) The nurse must pay
careful attention to educating patients about the timing of
their medications, to enhance compliance and to increase
the potential for therapeutic success.
Once medications are administered, the nurse must cor-
rectlydocwnem that they have been given to the patient and
this documentation is completed only after the medications
have been given, not when they are prepared. It is necessary
to include the drug name, dosage, lime administered, any
assessments, and the nurses signature. If a medication is re-
fused or omitted, this fact must be recorded on the appro-
priate form within the medical record. It is customary to
document the reason, when possible. Should the patient
voice any concerns or complaints about the medication,
these should also be included.
3.S Systems of Measurement
Dosages are labeled and dispensed according to their weight
or volume. Three systems of measurement are used in phar-
macology: metric, apothecary, and household.
The most common system of drug measurement uses the
metri(systrmofmeasurement. The volume of a drug is expressed
in terlIl.'i of liters (L) or milliliters (mLl. The cubic centime-
ter (cc) is a measurement of volume that is equivalent to I
mL of fluid, but the c( abbreviation is no longer used be-
cause it can be mistaken for the abbreviation for unit (u)
aud "Trurs. Th" mdrie w"ijjht uf drug i,
stated in kilogralIl.'i (kg), grams (g), milligrams (mg),or mi-
crogralIl.'i (mcg). Note that the abbreviation pg should not
be used for microgram, because it too can be confused with
other abbreviations and cause a medication error.
The apothl'Glry and household systems are older systems of
measurement. Although most physicians and pharmacies
"' ... l<r3 Prlndple<oION9Admlnlnr. tIon 21
use the metric system, these older systems are still encoun-
tered. In 2005, the Joint Commission (JCAHO), the accred-
iting organization for health care agencies, added
"apothecary units" to its official "Do Not Use" list. But be-
cause not all health care agencies are accredited by JCAHO
and until the metric system totally replaces the other sys-
tems, the nurse must recognize dosages based on all three
systems of measurement. Approximate equivalents between
metric, apothecary, and household units of volume and
weight are listed in Table 3.2.
Because Americans are very familiar with the teaspoon,
tablespoon,and cup, it i, important for the nnrse to be able
to convert between the household and metric systems of
measurement. In the hospital,a glass offluid is measured in
milliliters--an 8-oz glass of water is recorded as 240 mL. If
a patient being discharged is ordered to drink 2,400 mL of
fluid per day, the nnrse may instruct the patient to drink 10,
8-oz glasses or 10 cups of fluid per day. Likewise, when a
child is to be given a drug that is administered in elixir
form, the nurse should explain that 5 mL of the drug is ap-
proximately the same as I teaspoon. The nurse should en
courage the use of accurate medical dosing devices at
home, such as oral dosing syringes, oral droppers, cylindri-
cal spoons, and medication cups. These are preferred over
the traditional household measuring spoon because they
are more accurate. Eating utensils that are commonly re-
ferred to as teaspoons or tablespoons often do not hold the
volume that their names imply. Because of the differences
in volwnes between standard teaspoons, dessert spoons, ta-
blespoons, and "salt spoons,n it is recommended that a
measuring spoon used for cooking be used rather than
..
I
Metric, Apothecary, and Household
Approximate Measurement
Equivalents
Metrlc
1.1
4-SmL
lH6mL
lO-11mL
240-250mL
SOI.I
Il
I.,
60-64.,
300-1151119
I,
I.
Apothl!Glry
lS- 16milims
1 Hliddram
4nliddrams
8 Hlid dramsor 1 ftuid
8 Hlid (Ilms 1112 pin)
1 pint
31 Hlid Olme Of 1 quirt
1/6Ograin
1 grain
Sgrains
15- 16grails

lH6drops
1 INSpoon Of 60 ttops
1 tabirlpOOll Of
l-4twpoOlls
2 tablrlpoons
19lalSOfCl4l
2 gLtsItSOf 1 rups
4 gLtsItS Of 4 (UP! Of
"-
10 (OIIl'l'rt grains tograms:Diidt grains by 15 Of 16. ToWlll'l'rl gram! lograins:
Multi:Jly grams by 15 or 16.10 (0II1'l'rt mirims to mililiun: lli'Iidr minim by 15
or16.
LibraryPirate
22 UnK 1 Concept<; In Ph.,macology
household eating utensils if a more accurate dosing device
is not available. Many OTC liquid medications now come
with a pre-packaged medication cup to avoid under- or
over-dosage problems.
ROUTES OF DRUG ADMINISTRATION
The three broad categories of routes of drug administration
are enteral, topical, and parenteral, and there are subsets
within each of these. Each route has both advantages and
disadvantages. \'lhereas some drugs are formulated to be
given by several routes, others are specific to only one route.
Pharmacokinetic considerations, such as how the route of
administration affects drug absorption ;md distribution, are
discussed in chapter 400.
Certain protocols and techniques are common to all
methods of drug administration. Thestudent should review
the drug administration guidelines in the following list be-
fore proceeding to subsequent sections that discuss specific
routes of administration:
Review the medication order and check for drug
allergies.
Wash your hands and apply gloves, if indicated.
Use aseptic technique when preparing and
administering parenteral medications.
In all cases of drug administration, identify the patient
by .... king the to state hi.. or her full name (or by
asking the parent or guardian), checking the
identification band, and wmparing this information
with the MAR or scanner and computer.
Ask the patient about known allergies.
Inform the patient of the drug's name and method of
administration.
Position the patient for the appropriate route of
administration.
For enteral drugs, assist the patient to a sitting
position.
If the drug is prepackaged ( Wlit dose), remove it from
the packaging at the bedside when possible.
Unless specifically instrncted to do so in the orders, do
not leave drugs at the bedside.
Document the medication administration and any
pertinent patient responses on the MAR
3.6 Enteral Drug Administration
The routf includes drugs given orally and those admin-
istered through nasogastric or gastrostomy tubes. Oral drug
administration is the most common, most convenient, and
usually the least costly of all routes. It is also considered the
safest route because the skin barrier is not compromised. In
cases of overdose, medications remaining in the stomach
can be retrieved by inducing vomiting. Oral preparations
are available in tablet, capsule, and liq uid forms. Medica-
tions administered by the enteral route take advantage of
the vast absorptive surfaces of the oral mucosa, stomach, or
small intestine.
TABLETS AND CAPSULES
Tablets and capsules are the most common forms of drugs.
Patients prefer tablets or capsules over other routes and
fUTIII" uf tl, .. iT .... St" uf us ... i" SUIll" tabId, lllay
be scored for more individualized dosing.
Some patients, particularly children, have difficulty swal -
lowing tablets and capsules. Crushing tablets or opening
capsules and sprinkling the drug over food or mixing it with
juice will make it more palatable and easier to swallow.
However, the nurse should not crush tablets or open cap-
sules unless the manufacturer specifically states this is per-
missible. Some drugs are inactivated by crushing or
opening, whereas others severely irritate the stomach mu-
cosa and cause nausea or mmiting. Occasionally, drugs
should not be crushed because they irritate the oral mucosa,
are extremely bitter, or contain dyes that stain the teeth.
Most drug guides provide lists of drugs that may not be
crushed. Guidelines for administering tablets or capsules
are given in Table 3.3 (section A).
The strongly acidic contents within the stomach can
present a destructiw obstacle to the absorption of some
medications. To overcome this barrier, tablets may haw a
hard, waxy wating that enables them to resist the acidity.
These tablets are designed to dissolve in the al -
kaline enviromnent of the intesti.ne. It is important
that the nurse not crush enteric-coated tablets because the
medication would then be directly exposed to the stomach
environment.
Studies have dearly demonstrated that compliance de-
dines as the number of doses per day increases. With this
in mind, pharmacologists have attempted to design new
drugs that may be administered only once or twice daily.
tablets or capsules are designed to dissolve
very slowly. This releases the medication over an extended
time and results in a longer duration of action for the
medication. Also called extended-release (XR), long-acting
(LA), or slow-release (SR) medications, these forms al-
low for the convenience of once- or twice-a-day dosing.
Extended-release medications must not be crushed or
opened.
Giving medications by the oral route has certain disad-
vantages. The patient must be conscious and able to swal-
low properly. Certain types of drugs, including proteins,
are inactivated by digestive enzymes in the stomach and
small intestine. Medications absorbed from the stomach
and small intestine first travel to the liver, where they may
be inactivated before they ever reach their target organs.
This process, called first-pass metabolism, is discussed in
chapter 4010. The significant variation in the motility of
the GI tract and in its ability to absorb medications can
create differences in bioavailability. In addition, children
and some adults have an aversion to swallowing large
tablets and capsules, or to taking oral medications that are
distasteful.
LibraryPirate
01",1<,1 Pr1ndpl ... ofON9Admlnl",atlon 23
TABlElJ I Enteral Drug Administration
Drug Form Administration Guidelines
...
A. I. MIffi that paliffit is alffi aod Iu s ibility to swalloloi.
1. titbltlS or into mfdication G4l
1 IUquid, shakr to mil mmul! tht dw illo rup 011

llaod tht patimt rtII'diulion rup .
s. otm i 01 wattr to lwalowing tfNo mfdK.Jtion. Mi. or nwy oifmod il oot (ontraiodicatm
,
patienl mftkatioo isswalowtd.
-
8. lUblinqual I. MIffi thit patiffit iSaiffi aod luI ibilityto hold !lldft"tonqut.
1. sublinguallabltlllldtftooglll'.
1 10ItrIKI patim: oot 10 dItw or swillow tilt tlbltl, or tabltl around with tooglIt.

IlIItrIIu to aHow titl!let to 1il\OM bcfort lWillowing wlil'a .
s. Rmlaio palienl to dumriot that oi l mfdK.Jlion Iu I dil5Olvfd.
,
Offer i d6i1!1.
0- I. that patiffit aod lui abilityto hold btI'IIftO Iiii' I1Jms aod tfNo dltrl.
1. Plac:t bucullibltt btI'IIftO Iiii' I1Jm lint ald dIt6.
1 10lIruc\ oot 10 dItw or swallow or tabltl around with tooglIt.
.. 1011100 10 alow titbltt 10 dslOMo aHIlpluely bcfort lwalowing wwa .
s. paliffil toduemiot thatal oltfNo mfdication lui dis5Olvfd.
,
otm i !itsill'l.
D. I. Adrrioist liquid forms wIIfII (mliblt to il'(ljd dogging till'
1. If 1Oid.<rIIIh find, inlo powdtr and mix thoroughly with allml30 mLofWilnn dislOl"lfd.
1 vffify lUbe pIi(emtOt.

TlI1I offlft' ding. ff 10 palient .
s. SiomKil (ootmll iod meillR volurtll'. Hgruttr than 100 mLlor in adJlt,dIKk igl'M' policy.
,
Rttum rtsiduallii gram, aodflUlh with water.
,.
fOIl" loto syrtIrJe tlant! aod illowto ftowloto III! lID' bygral'lly.GIw 00 IIlI'dkalloo
belWfffl with water.
,
Kft'p lINd albed dt'latftl for ll111Jr 10 plumt aspiralion.

Refltiblilh (ontillUil fffiing. asldltdultd. Kft'p iII'..:I of bed ril'mftl4,' to .
SUBLINGUAL AND BUCCAL DRUG
ADMINISTRATION
to move the drug with the tongue, nor to eat or drink any-
thing until the medication has completely dissolved. The
sublingual mucosa is not suitable for extended-release for-
mulations because it is a relatively small area and is con-
stantly being bathed by a substantial amolUlt of saliva.
Table J .J (section B) and ,.. Figure 3.1a present important
points regarding sublingual drug administr:ltion.
For sublingual and buccal administration, the tablet is not
swallowed but kept in the mouth. The mucosa of t he oral
cavity contains a rich blood supply that provides an excel-
lent absorptive sumce for certain drugs. Medications given
by this route are not subjected to destructive digestive en-
zymes, nor do they undergo hepatic first-pass metabolism.
For the sublingual route, the medication is placed under the
tongue and allowed to dissolve slowly. Because of t he rich
blood supply in this region, the sublingual route results in a
rapid onset of action. Sublingual dosage forms are most of-
ten formulated as rapidly disintegrating tablets or as soft
gelatin capsules filled with liquid drug.
When multiple drugs have been ordered, the sublingual
preparations should be administered after oral medications
have been swallowed. The patient should be instructed not
To administer by the buccal the tablet or capsule is
placed in theor:ll CllVity between the gum and the cheek. The
patient must be instructed not to manipulate the medication
with the tongue; otherwise, it oould get displaced to the sub-
lingual area, where it would be more rapidly absorbed, or to
the back of the throat, where it could be swallowed. The buc-
cal mucosa is less permeable to most medications than the
sublingual area, providing for slower absorption. The buccal
route is preferred over the sublingual route for sustained-
release delivery because of the greater mucosal surface area
of the former. Drugs formulated for buccal administration
LibraryPirate
24 UnK 1 Co<e Concepts In Plarma<ology
,.)
'b' .... _____ _
Figure l . T (al Sublingual drug admlnlmallon;(b) buccal drug administration
generally do not cause irritation and aresmall enough to not
cause discomfo rt to the patient. As with the sublingual route,
drugs administered by the buccal route avoid first-pass me-
tabolism by the liver and the enzymatic processes of the
stomach and small intestine. Table 3.3 (section C) and
,. Figure 3.1b provide important guidelines for buccal drug
administration.
NASOGASTRIC AND GASTROSTOMY DRUG
ADMINISTRATION
Patients with a nasogastri, tube or enteral feeding
nism such as a gastrostomy tube may have their medications
administered through these devices. A nasogastric (NG)
tube is a soft, flexible tube inserted by way oflhe nasophar
YIU: with the tip lying in the stomach. A gastrostomy (G)
tube is surgically placed dirt'Clly into the patient's stomach.
Generally, the NG tube is used for short-term treatment,
whereas the G tube is inserted for patients requiring long-
term care. Drugs administered through these tubes are usu-
ally in liquid form. Although solid drugs can be crushed
or dissolved, titer tend to cause clogging within the tubes.
Sustained-release drugs should not be crushed and admin-
istered through NG or G tubes. Drugs administered by this
route are exposed to the same physiologic processes as those
given orally. Table 3.3 (section D) gives important guide-
lines for administering drugs through NG or G tubes.
3.7 Topical Drug Administration
Topical drugs are those applied locally to the skin or the
membranous linings of the eye, ear, nose, respirator y tract,
urinary tract, vagina, and rectum. These applications in-
clude the following;
- DermatoJagic preparations: Drugs applied to the skin,
the topical route most commonly used. Formulatiorts
include creams, lotions, gels, powders, and sprays.
- Instillations and irrigatioll5: Drugs applied into body
cavities or orifices. These include the eyes, ears, nose,
urinary bladder, rectwn, and vagina.
TREATING THE DIVERSE PATIENT
Religious Fasting and Compliance
with MlKlication Administration
Pftgiws fallilg periods; a feallft of IIUny ohht worId's l!iiliJns. DIJing
rMs of l!iiliJUlla!ling 5U(h is Ramadan or Yom KiPPJt the patimt obsming a
fall may ncx take tift meOOtions, indu:lilg nonoral rrROOti:rn
well is tyr drops, to l'IOid 'brrakDf the fiSl Diffmnt reigi:rn and reijous au-
thoritits may aIow the taking of I!qJRd medirniJns daing the but dr-
ptndilg on tilt adt-o-xt to pI'I"lOO<lll!iiliJus brim, all mediati:rn
may beaYOidedMn ifthtir reigiceauthority .JIM thtm.
By reoognizilg knovm periods of It' iljrul liSting and disrussing the obser-
RMf of futing pffl:>ds with tht tilt rU"II' un Bpkne to
deYrIop suatf9its with tilt for !l.IrI.Sft.j meOution Ult. For wmpll', an
alimlateform of tlltmflitation maybeordeml if Milablt(t.g.,a 12-hruroolt
1M rould be taken btbe ilf9innilg aoo after ffiling the mhtr than an
M'I)' 6 hw- dole). K the patifnt i s unable to romp!)' with medUiiJn administra-
tion rbi19 futing pfflxIs dut to l!iilioui beim, the pmuibing lItalth
prOOirr shluldal50 beootifitd.
_ Inhalations: Drugs applied to the rcspi .... toryt .... ct by
inhalers, nebulizers, or positive-pressure breathing
apparatuses. The mos t common indication for inhaled
drugs is bronchocortstriction dut' to bronchitis or
asthma; however, a number of illegal, abused drugs are
taken by this route because it provides a very rapid onset
of drug action (set' chapter 1100). Additional details
on inhalation drug administration can be fOWld in
chapter 3900.
Manydrugs are applied topicaUy to produce a local effect.
For e.umple, antibiotics may be applied to the skin to treat
skin infections. Antineoplastic agt'nts may be irtstilled into
the urinary bladder via catheter to treat tumors of the blad-
dt'r mucosa. Corticosteroids are into the nostrils to
reduce inflammation of the nasal mucosa due to allergic
rhinitis. Local, topical deli-'ery produces fewer sidt' effects
compared with oral or parentt'ral administration of the
same drug. This is becaust' topically applied drugs are ab-
LibraryPirate
(.)

..

;;,9,
,
01",1<,3 Prlndple<oION9Admlnlnr. tIon 25
(b) L.. _ __ .... .ro.o:k,:::;; _ ___ -....I
FlgureJ.2 Transdermal patch administration: (a) protective coaling removed from palch;(b) patch Immediately applied to dean,
dry, halrlesi skin and labeled with date, time, and Inilials
Source: PeaWfi
sorbed very slowly, and amounts reaching the general circu-
lation are minimal.
Some drugs are given topically 10 provide for slow release
and absorption of the drug in the general circulation. These
agents are administered for their systemic effects. For exam-
ple, a nitroglycerin patch is applied to t he skin not to treat a
local skin condition but to treat a systemic condition, coro-
nary artery disease. Likewise, prochlorperazine (Com-
pazine) suppositories are inserted rectally not to treat a
disease of the rectum but to alh.'viate nausea.
The distinction between topical drugs givt'n for local ef-
fects and those given for systemic effects is an importantone
for the nurse. In the case of local drugs, absorption is unde-
sirable and may cause side effects. For systemic drugs, ab-
sorption is essential for the therapeutic action of the drug.
With either type of topical agent, drugs should not be ap-
plied to abraded or denuded skin, unless directed to do so.
TRANSDERMAL DELIVERY SYSTEM
The use of traIl'idennal patches provides an effective means of
delivering certain medications. Examples include nitroglyc-
erin for angina pectoris and scopolamine (Transdeml-Scop)
for motion sickness. Although transdermal patches contain a
specific amount of drug, the rate of delivery and the actual
dose received may be variable. Patchesare changed on a regu-
lar basis, using a site romtion routine, which should be docu-
mented in the MAR Before applying a tnmsdermal patch, the
nurse should verify that the previous patch has been removed
and disposed of appropriately. Drugs to be administered by
this route avoid the first-pass effect in the Iiverand bypassdi-
gestiw enzymes. Table 3.4 (section A} and Figure 32 illus-
trate the major points oftraIl'idennal drug delivery.
OPHTHALMIC ADMINISTRATION
The ophthalmic route is used to treat local conditions of the
and surrounding structures. Common indications in-
clude e:essive dryness, infections, glaucoma, and dilation of
the pupil during eye examinatioIl'i. Ophthalmic drugs are
available in the form of irrigations, drops, ointments, and
medicated disks. Figure 3.3 (a) and (b) and Table 3.4 (sec-
tion B) give guidelines for adult administration. Although
the procedure is the same with a child, it is advisable to enlist
the help of an adult caregiver. In some cases, the infant or
toddler may need to be inunobilized with anns wrapped to
prevent injury to the eye during administration.
For the young child, demonstrating the procedure using a
doU facilitates cooperation and decreases anxiety.
OTIC ADMINISTRATION
The otic route is used to treat local conditions of the ear, in-
dud.ing infections and soft blockages of the aud.itory canal.
Otic medications include eardrops and irrigations, which
are usually ordered for cleaning purposes. Administration
to infants and young children must be perfonned carefully
to avoid injury to sensitive structures of the ear. Figure 3.4
and Table 3.4 (section C) present key points in administer-
ing otic medications.
NASAL ADMINISTRATION
The nasal route is used for both local and systemic drug ad-
ministration. The nasal mucosa provides an exceUent ab-
sorptive surface for certain medications. Advantages of this
route include ease of use and avoidance of the first -pass ef-
fect and digestive enzymes. Nasal spray formulations of cor-
ticosteroids have revolutionized the treatment of allergic
rhinitis owing to their high safety margin when adminis-
tered by this route.
Although the nasal mucosa provides an excellent surface
for drug delivery, there is the potential for damage to the
cilia within the nasal cavity, and mucosal irritation is com-
mon. In addition, unpredictable mucus secretion among
some individuals may affect drug absorption from this site.
Drops or sprays are often US<'d for their local astringent tffro;
that is, they shrink swollen mucous membranes or loosenS<'-
cretioIl'i and facilitate drainage. This brings immediate relief
from the nasal congestion caused by the COllUllon cold. The
noseaIso provides the route to reach the nasal sinuses and the
eustachian tube. Proper positioning of the p.1tient prior to
instilling nose drops for sinus disorders depends on which si-
nusesare being treated. The same holds true for treatment of
LibraryPirate
26 Unft 1 Core ConeoplS In Phorm..colagy
TABLE 3.4 111 Topical Drug Admrnlstratlon
Drug Form
A. trlnlodtfraal
B. ophlhi1n:
C.
D.
E.
AdmlnlstraUon Guldeilnl!'l
I. Obtain tlitll6tn"lWl patd\, MId rtIm/I.([,-,tr'sguldtliM1.. AppIicJtion ,,1(1 hqJtncy of dlinging Iifftr monlilg to m(lflQ\loft.
Z. Apply btfort ha-Jdfil. uu'lOid .b\orpIion of1hu9!!11 by lhf 1IInI'.
l. Rtmovt pmlous melliatioll 01 iru.
4. .1nn!dtrrN1 CJIm.mt, apply lhf ordmd MTwnI. of mftic.Jtion in .n f'lrn IR dirffily on tile jIffIIItiSll"rd P'9" that
'OIIIpilinmeI1lfdiQliGnl .
s. Pres patd'I 01 apply IIIt\IQte4 to dr .... dry,.r.;IlwiIIfM skin.
,. ROWt II prMIII.!tin iIrir.tion.
7.
1. Instruct pHimI to lit l4Ift1ll iii with hud tiftd bad..
Z. With nondoIIinant hind.lMllowtf lld down 10 expose me COft;,Mjy.1 podeI.
l. o\sk patimt 10 i0oi:. upward.
4. Hold fYt\!1OpIlff 1I4-llSinchaIxNe me COftjl.l:lClr.iI W<.Do!lOl hold dlOflpel ovtI f')t,at 1lIIY M1Wle thf blQtftflex.
5. InRil preaibrd numbft"eI drDpS Inlo the emt!"! oflllt pocRt. A"IOiII tllUdlilg eonjlJlctiYal SlCwith tip
,. W applying lintmmt apPJ. thillile ohimm!"!l1 f'leNy"'9 infl!1 of Iowtr lid rnM9i1. film to l1',li(1' QflthIJl,.
1. Instruct lilt todolf gtnIlt prtSSlft with firIge!" to the at Iht irlMf unthlll for 1-2 mlnuttl,.
10 a'IOid owrIIow drainigt iIIo n(llt .and dwoat, thlll nininizilHJ riIk of abIorption into I hf 11IIm1ic dmNtion.
. With enss fM1Ikation IIOI.Ild eyt.
,.
1. Instruct patitnl to lit on sick 0110 with he.d so tIIIl.fftctrd NO" is l.ti:Ig up.
Z. dun 1 he pimI of the tar and Iht n\fatus with J <It.n w.a!hdoth 10 p!M!1I "" disdl.Jrgt tom bfing "died Inl0 lhe NI
dwilg Ihe Instl!;jtionllthe
l. Hold drawer 114 indt KIo"totNr til\il,iII'Id Instill pmuIlfd n!l"nbtfof dropIlnto theWif oflhe t .. llvwin9l11tdrops to 111M'
downwillll.Moid pI.lciJg drop! dirffiIJ on mr, I)'mpinic IMIIbrilll'.
4. Geotty JpPJ imermittrnt pmSUrt to lhe mgus of the tit Ittltt 01 11M limn.
5. Instruct pi6mI to fmIiIm on sid! for to 10 minutHto pIft!!lt kruof mrdicatiOll.
,. W(O\1Oll bilk ind inIrn _ irtolttt .... tmIOst pin rJ
1. WPt lIrf Wlkrtiort that rfIIJMt liipped from theNr eN with. tInue.
1. All: thl piliem toblow the IIOIt to (y pisligfl..
Z. Draw 1(1'. mntc1 of mug imo drowtr.
l Instruct Iht pitirnt IOqlfII iIId br!atht tIwoogh 1ht IHlIlIL
4. HoIdlhe tip of!he drqlp just IIw IIOIri.ind Mhout ,mini tile IIOIt willi the dirf<1 ,lie soknion literaly tllWild Iht
midilll'lIlIIt supm.:.- mndII rtlm:id bonf.--.rd Iht blStofthe IINI c.Jrity; whm ilwl run down thf throaI.nd ilto tile
Mtachiin wilt.
5. o\sk!he piIimt tornnail in poIition for 5 moutt!..
'- DiIcMd.., mnaining DUn that n in 1ht chlppet
1. Instruct Iht patirnt 10 _ i supilll' poIition with trim stpamtd
L Plm _-dJbIt hDianI: into alp.
l
4. ElpOIt 1ht oriI'u bJ Itpirnirlg 1ht Iibia ...mh noncSominant hind.
5. Inltft 1ht IlIlIndtd rnddtlw lIIppOSitay 8- 10em along Ihe p!&trior wall lithe Yigila,or.as fiI.as itwil p.m..
'- K Ulingi 1MI".,ltj.or il5fI1 ijlpIic.Jt0l5 CIII.1onij the Win.nd sicM1ypus/llhe pI\IIqff urtil ffIIplJ.
tIw applicator and pIar;r on i pipft" tClll'd.
1. o\sk the pilimt tol_ and f(l'Nin IJDJ iI the III lor 5-10 minutn foIowing instnian.
LibraryPirate
01",1<,1 Pr1ndpl ... ofON9Admlnl",.tlon 27
TABLE3.4 Topical Drug Administration (Contlnutdj
Drug Form
F. rMilsuppWrOOts
Idmlnlstratlon Guidelines
1. InSIrUCI tilt palimt 10 lie on 1m
2. Apply glove;opm and lubriutt bhlll mI.Suppositorifs afl' for tilt rouoded ffid to be out, toum Itss
on inlM\al All tilt to push iI OUI.
3. fOfl'fingrr of Ihr dominaniliand with walrrsoIubil' l!briunt
.. Inform tIM! lhe stppOIilory iSlo be illll'fll'd;irrstnKt tIM! to take bmJths email! wring
inlffiion, to rriix anal5phinctrr.
s. Gtnlly inll'rt tilt IWiYttd mI II supp&Silory into tilt fl'{\lIr\ be)'Ond anal- rMaI ridljl' 10l'rllllfl'
6. patient 10 fl'main in lilt Sim(p&Sition or lie supilM' to prMnt 9poJsion II.ppOsilory.
7. InSIrUCI tilt patimt 10 fl'tlin tilt supposiroryfor . ,Iull 30 toalow absorption tOO((\I",1II1ts111it llppJIiIory iladmirillefl'd
to lIimlbtt dtfKilion.
--
Ib(

.. Flgure.3J (3) Inl\llilng an ointment Into the lowerconjun(\lval sac;(b) pressing on the nasolacrimal duct
Source: 0 JennyTllomas Phorography.
,.. Flgure J.4 Instlilingeardrops
Source: 0 EJena D:xlioon.
the eustachian tube. Table 3.4 (section D) and .. Figure 3.5 il-
lustrateimportant facts related to nasal drug administration.
VAGINAL ADMINISTRATION
The vaginal route is used to deliver medications for treat-
ing local infections and to relieve vaginal pain and itching.
Vaginal medications are inserted as suppositories, creams,
jellies, or foams. It is important that the nurse explain the
purpose of treatment and provide for privacy and patient
dignity. Before inserting vaginal drugs, the nurse should in-
struct the patient to empty her bladder, to lessen both the
discomfort during treatment and the possibility of irritat-
ing or injuring the vaginal lining. The patient should be of-
fered a perineal pad following administration. Table 3.4
(section E) and ,.. Figure 3.6 (a) and (b) provide guidelines
regarding vaginal drug administration.
LibraryPirate
28 Unft 1 (o<e Concepl5 In PtmmKology
1.5 Nasal drug admlnlstr.Uon
Souruo: ProfV.X! fducaflOt'Vf'H colltge.
RECTAL ADMINISTRATION
The rectal route may be used for either loul or systemic
drug administration. It is a 5;lfe and effective means of de-
lin'ring drugs to patients who ate comatose or who are ex-
periencing nausea and vomiting. Rectal drugs are normally
in suppository form. although a few laxatives and diagnos.
tic agents are via enema. Although absorption is
slower than byother routes, it issteady and reliable provided
the mediution can be retained by the patient. Venous blood
from the lower rectum is not tronsportcd liv",";
thus, the first-pass effect is avoided, as are the digestive en-
zymes of the upper Cl tract. Table ).4 (Stion F) gives se-
lected details regarding rect;ll drug administ ration.
3.8 Parenteral Drug Administration
Parenteral administration refers to the dispensing of med-
ications by routes other than oral or topical. The pamllffal
routt delivers drugs via;l needle into the skin byers, subcu-
taneous tissue, muscles,or veins. More advanced parenteral
delivery includes administration into arteries, body cavities
'"
(such as intrathecal),and organs (such as intracardiac). Par
enteral drug administration is much more invasive than
topical or enteral. Because of the potential for introducing
pathogenic microbes directly into the blood or body ti$Sul.'S.
aseptic teclmique!i must be st rictly applied. The nurse is ex-
pected to identify and use appropriate materiai.s for p.a r.
enteral drug delivery, including specialized equipment and
techniques innllved in the prep.aration and administ rat ion
of injectable product!;. The nurse must know the correct
anatomical locations for parenteral administration, and
procedures regarding hal<lrdous equipment disposal.
INTRADERMAL AND SUBCUTANEOUS
ADMINISTRATION
Injection into the skin deliven druS' to the blood vessels
thai supply the various layen of the skin. DruS' be in-
jected either intradermally or subcutaneously. The major
difference between these methods is the depth of injection.
An advantage of both methods is that they offer a means of
administering druS' to patients who are unable to take them
orally. DruS' administered by thl.'Se routes avoid the hepatic
first-pass t'ffect and digestive enzymes. are
that only small volumes can be administertd, and injections
can cause pain and swelling at the injection site.
An intradfrmal ([D) injection is administered into the dermis
layer of the skin. Because the dermis contains more blood
vessels than the deeper subcutaneous layer, drugs are more
easily absorbed. Intradermal injection is usually employed
tor allergy and disease screening or lor local anesthetic de
livery prior to venous cannulation. Intradermal injections
are limited to very small volumes of drug. usually only 0.1
toO.2 mL. The U'lual sit es for ID injections are the nonhairy
skin surfaces of the upper back, over the scapulae, the high
upper chest, and the inner forearm. Guidelines for
mal injections are given in Table 3.5 (Stion A) ( page 30)
and ,. Figure 3.7.
A injection isdeli"ered to the deepest byers of
the skin. Insulin, heparin, vitamins, some vaccines, and
other medications are given in this areol because the site!i
,. 1.6 VaglMI drug Instilling a V3gtnal supposltory;(b) using an applkiltorto Insnna viglrlal (ream
Sourer. ProfV.X!fducotJorVPH College.
LibraryPirate
,.,
Epjderm ..
Subcutaneous
....
OI ... lfrJ PrtndpiesoiONgAdmtnlnratlon 29
10"_15
lei
FlgureJ.7 Intradermal drug administration: (aJ (ross section of skin showing depth of needle Insertion; (b) the administration site
Is prepped;(c) the needle Is Inserted,bevel up at 10_lS0;(d) the needle Is removed and the puncture site Is (overed with an adhesive
bandage
Source: PffIwn fdIKar/oo/PHCoIlege.
easily accessible and provide rapid absorption. Body sites
that are ideal for subcutaneous injections include the fol-
lowing:
Outer aspect of the upper arms, in the area above the
triceps muscle
Middle two thirds of the anterior thigh area
Subscapular areas of the upper back
Upper dorsogluteal and ventrogluteal areas
Abdominal areas, above the iliac crest and below the
diaphragm, 1.5 to 1 inches out from the wnbilicus
Subcutaneous doses are small in volume, usually ranging
from 0.5 to 1 mL. The needle size varies with the patient's
quantity of body fat. The length is usually half the size of a
pinchedlbunched skinfold that can be grasped betwet'n the
thwnb and forefmger.1t is important to rotate injection sites
in an orderly and docwnented manner to promote absorp-
tion, minimize tissue damage, and alleviate discomfort. For
insulin, however, rotation should be within an anatomical
area to promote reliable absorption and maintain oonsistent
blood glucose levels. \'lhen performing subcutaneous injec-
tions, it is usually not necessary to aspirate prior to the injec-
tion. It depends upon what is being injected, and the
patient's anatomy. Aspiration might prevent inadvt'rtent ad-
ministration into a vein or artery in a thin person. If the
medication should not beadministered directly into a vessel,
aspiration is recommended. For example, long-acting in-
sulins should not be given IV; therefore, aspiration is justi-
fied. Heparin, on the other hand, can be safely administered
IV, and so aspiration is not required. Note that tuberculinsy-
ringes and insulin syringes are not intt'rchangeable, so the
nurse should not substitute one for the other. Table 3.5 (sec-
tion B) and Figure 3.8 include important information re-
garding subcutaneous drug administration.
INTRAMUSCULAR ADMINISTRATION
An intramuscular (1M) injection delivers medication into spe-
cific muscles. Because muscle tissue has a rich blood supply,
medication moves quickly into blood vessels to produce a
more rapid onset of action than with oral, ID, or subcuta-
neous administration. The anatomical structure of muscle
permits this tissue to receive a larger volume of medication
than the subcutaneous region. An adult with well-developed
muscles can safely tolerate up to 3 mL of medication in a
large muscle, although onlyl mL is recommended. The del-
toid and triceps muscles should receive a maximum of 1 mL.
A major consideration for the nurse regarding 1M drug
administration is the selection of an appropriate injection
site. Injection sites must be located away from bone, large
LibraryPirate
10 UnK I (Of" (""(epl:< 10 Pho,ma<:ology
ABLE 3J I Parenteral Drug Administration
Drug Form
A.
Administration Guidelines
I. Prtpal! mtdi<lllion in J luberwin or l mL IYrinljt with J prultadItd 16- to to Sl$.indJ 1IffiI1I'.
1. Appy ard dUII\e injKIion wilh antiltplic swab il , arrulilr malion. Allow 10 ai dJ.
1. With tho ,n:! indufingtrofllOlllbninanl hand, sprNd lkin taut
4. illffi bel'ri fuilg upwa!d.al all9l1'of 10- 15".
S. urtil beI'ri isunder mn; donol ,spi"alt.
6. Slowly injKI rmi<a1ion 10 form !mil wlltal or bltb.
7. Withdraw quidl):and pat grntlywirh 51ffill' 1 x 1 pad. Do noI mmagl'all'i.
8. il5lnrcl noI to lID or !ratd!
9. Drawcirdt a'OIInd perimeterofinjKtion in 48 to 72 hoIn.
1. Prtp.lll' IlriGliion in J I-to lillL Iyringt J 23- to ZS--gauqc, In-to Sf8.i1Kh nmIlr.For
lI'(ommrndl'd nffilt is 1/8 jndJ and
1. W, Jl':idog ill'as of bony prorrioerKl', major Jnd I'I'slfk. For IItparin, dIW: with agmcy
policy fortht ptfrrrtd injKtion !itrs.
1. Chk prt'Iiousroution sdffi a nfW all'a for injKtion.
4. Appy if d jnjKIion with antiltplic swab il , drrulilr malion.
S ..... owtoJirdJ.
6. BIIlth 5kin ilttWferl jndex finger of nondorrifUnt hand or tM !ltIstJntial
5lbrutantOUl
7. illffi at 4,'or 90' i oglultprndiog 00 bocIy ff obeIr;45" ff wright Ktht '/try thin.
gather 5kin at ilU of nffill' jfllfflion and idminilttr at 90'
8. For 111 Jlliiog bad: on plungtr. W blood withd,aw 1IffiIt,liKaro tht
J new jnjtaion.for htparin, 00 not un dilmaqe SlI"KIIIUlinq tillUtland (jIM

9.
10. Remol'l' grntly malQljt For htpiril,oo noIlIIiISIigt
-----4-- may G1U\1' bnisilg or
( intramUICWr 1. Prtpal! mtdi<lllion uling i 10- to 11-9ilUljt,1-IO 15indJ f"ftIIt.
{difftortrlt admiri mition guidelillfl 1. App, ard I'I'nIrt9ulul injKIioo with antiltplic !Wib in a mular mon. Allow to af dJ.
-':I apply lotht dooogk/lul,
vaSlU! IiIleralil,and delloid 1. site 111 JUdng tilt handwirh I"ftI on grutertnKhanler Jnd thlll1b ItrIIIJrd urrbikus.Poinl totlltanlerior"
musdt iii(!pilll' withtllt indufinger, sprridilg fingerto pointtoward ilii( Ues! {formingJ V).lnjKI
tlltY-!hiptd al!a oftlw induand how to Iwte
4. illffi nffilt with smooth,dilrtlike!1lOl'l'llltrltata 90' Vshaptdarra.
5. ,l.spirate. Jndttlerw br bIood.HIHIod iPpUn,witlltawllR nffiIIo.dm tIw I)'riflljt.and ntWinjKtion.
6. iljta !lowly ,ndwith prtSllR on tilt plungtr.
7. P.trno\'I'
8. Appy lilt with i dry, ster'it 2 x 2 gauzt Jnd IlliISiIjt viqJrously warmth and
abIorpIion of te into tilt musdt.
1. Toarkldrugto.nlVftlidumtailN'l:
a. Verify ordtrand with IV Hlid.
b. rrriwion ina,- to 2O-mL syrilljt ulingJ I-to I.Hndl. 19-10 {Typiully in an ildull.a
i! UII'd for Hlid iltniniltration,but tIw may ViryWith patitnl's body silr ilnd tIw l!a5Oll
for IV admiristration.j
(. Apply glon, Jnd 'SItlS injtaion for ligfll and symptoms ofinllammation or 9tranlOtion.
d. pori on IV tkJid (ontailN'l with antiltptic: swilb.
(.urfUly in!ffi or i(ms inlo port and injKl mtdiution.
Wtthdraw and mix!Olution by routing (OIluintr!"lld 10 rnd.
g. H'ng(QIluiItr and dIM inflllion
----'----"---
LibraryPirate
0I ... l<r1 Pr1ndpl ... ofON9Admlnl",.tlon 31
2. Toadd aug 10 an IV bolus 11'.1 pYIh) uling aistilg IV iotor IV Iod:
i . 'krify unltr and tompatibilily ofdlllC) with IV ftuid.
b. DnrrmiottM: torrt'd ofioflllion.
Co Dnermint ff IVfl!ithil! infilling it proptr rail' 11'.1 lint) and IhilllI!
d. drug in a ,)Tiogt.
t . Apply p,andassm injffiioo,iI< for >9ts ind !)'mptom, of inflammation or 9trilllsalion.
f. SdK! injKlion port, on tlDog,do5o!Slloilllfflion IIV
9- tubing or Iod: pori withartilrptit IWaband ilM1 inlo pori.
h. H admiri >lffiog mtdititioo IhltlUljh 010 9isIing IV li nt, otdlJll!, titling by pinching just lilt iljKlioo port.
SIoII'Iy iojKt mtllic.Jtion!l'm dt5i9:laltll 001 fi>ltr tllan 1 mUmin, unlm Iptdfm
j. WiIhdr.w !)'!iogt. tubing.nd mill!! proprr IV infuyoo if lIIDj.o 9istilg IV
l I I j.
blood vessels,and nt'rves. The sire and length ofnet'dlt' are
dett'rminoo by body size and muscle mass, the type of drug
to be administered, tht' amount of adipose tissue ovt'rlying
the muscle, and the age of the patient. Information regard-
ing 1M injections is given in Table 3.5 and Figu re 3.9.
The four conunon sites for intramuscular injections are as
follows:
1. Velirrogillteal site: This is the preferred site for 1M
injections. This area provides the greatest thickness of
gluteal mur.cles, contains no large blood vessels or
nt'rves, is sealed off by bone, and contains less fat than
the buttock area, thus eliminating the need to
determine the dt'pth of subcutaneous fat. It is a suitable
site for children and infants owr 7 months of age.
f
\'0
Epidermis
j
0." ..
.
. -
Muscle
1'1
Ib)
1<1
Id)
Flgure3.B Subcutaneous drug admlnlmatlon:(al cross section of skin showing depth of needle Insertlon;(blthe administration
site Is prepped;) the needle Is Inserted at a 4S angle; (d) the needle Is removed and the puncture site Is (overed with an adhesive
bandage
Source: Pxson fducor/oo/PHCoI/eg{'.
LibraryPirate
32 UnK I C ... e Concepts In Plarma<ology
2. Deltoid site: This site is used in weU-deVl'loped teens
and adults for volumes of medication not to eJKeed 1
mL. Because the radial nerve lies in dose proximity, the
ut:lluiu is ]JU( g"""rally ust:<.l, [ur
vaccines, such as for hepatitis B in adults.
1. Dorseglmeal site: This site is used for adults and for
children who have been walking for at least 6 months.
The site is safe as long as the nurse appropriately locates
the injection landmarks to avoid plUlcture or irritation
of the sciatic nerve and blood vessels.
4. Yam,s latemlis site: The vastus iateralis is usually thick
and well developed in both adults and children. The
middle third of the muscle is the site for 1M injections.
INTRAVENOUS ADMINISTRATION
(IV) medications and fluids are administered di-
rectly into the bloodstream and are immediately avaiL1ble
for use by the body. The IV route is used when a very rapid
onset of action is desired. So with other parenteral routes, IV
medications bypass the enz.ymatic process of the digestive
system and the first-pass effect of the liver. The three basic
types of IV administration are as follows:
1. Large-volume infusion: This type of IV administration
is for fluid maintenance, replacement, or
t
.,.
J

jj
0"'''''5


Muscle
(.(
(
supplementation. Compatible drugs may be mixed into
a large-volume IV oontainer with fluids such as normal
saline or Ringer's lactate. Table 3.5 (section D) and
'" Figur" 3.10 ilJ""(nu,, (hil; ("dllli<ju".
2. Intermittent infusion: This is a small amolUlt of IV
solution that is arranged tandem with or piggybacked
to the primary large-volume infusion. Used to instiU
adjunct medications, such as antibiotics or analgesics,
over a short time period. ,. Figure 3.1 J shows a Baxter
infusion pwnp.
1. N bolus (push) administration: This is a concentrated
dose delivered directly to the circulation via syringe to
administer single-dose medications. Bolus injections
may be given through an intermittent injection port or
by direct IV push. Details on the bolus administration
technique are given in Table 3.5 (section D) and
,. Figure 3.12.
Although the IV route offers the fastest onset of drug ac-
tion, it is also the most dangerous. Once injected, the med-
ication cannot be retrieved. If the drug solution or the
needle is contaminated, pathogens have a direct route to the
hlood.tream and hodytis",,,'_<_ who reciving IV
injections must be closely monitored for adverse reactions.
Some adverse reactions occur immediately after injection;
yt
(b(
,. Figure l.1l Int ramuscular drug admlnlstratlon:(a) (fOSS section of skin showing depth of needle Insenlon;(b) the administration
site Is prepped;(c) the needle Is Inserted at a 90" angle;(d) the needle Is removed and the puncture site Is covered with an adheSive
bandage
Source Pruoon fducariofl/PH Ca leqe.
LibraryPirate
(" .... _---'
(b)
01 ... 1<, j Prlnd pleo; 01 ON9 Admlnlnr.tIon 33
'\ -,
~

-
--f
/
,
I
,
"
,
,
/
-
-
~
""""" >",'
f(}
\ ~
4
C",,"-
-/
Piggyback
'"'

Primary
Piggybar;
k"
pri mary
with bac
valva
C"""'
"\,
(!
"'"
kcheck
~ FlgureJ.IO Si!'Condary Intravenous lines: (a) a tandem Intravenous allgnment; (b) an Intravenous piggyback (IVPB) alignment
others may take hours or days to appear. Antidotes for drugs
that can cause potentially dangerous or fatal reactions must
always be readily available.
~ FlgureJ.l I A Baxter Infusion pump
(,' '---
(b)
~ Figure J.12 IV bolus admlnlstratlon. (a) The part Is cleaned;
(b) the drug Is administered through the port using a needleless
syringe
LibraryPirate
14 Unft t Core CorK""", In Pho,m":oIogy
;(;'JI Chapter REVIEW
KEY CONCEPTS
The numbered key concepts provide a sua:inct summary of the impor1ant points from the corresponding numbered section
within the chapter. If any of tht'S(' points are 1\01 refer to the numbered section within the for review.
3.1 The nun;(' mll5t boaVI' a oomprehensive knowledge oflile ac-
tions and sJ de efftcts of before they are administered
to limit the number and adver.;edrug events.
l.2 The five riglmand threecheckureguidelines for safe drug
admlnlstntlon, which Is a calhboTlltive effort among
nurses, physicians, and other health care professionals..
3J For pharmacologic campHance, the patient must under-
stand and aa:ept the value aSSOCiated with the
pteS(;ribed drug regimen. Understanding the reasons for
noncompliance nn help the nurse Increase the SUe5S of
pharmacotht'tapy.
lA There are established orders and time schedules by which
medlntlons are routinely administered. Documentation
of drug administntion and reporting of side effects are
responsibilit ies oflhe nurse.
NCLEX-RN REVIEW QUESTIONS
o What is the primary role of a nurse in medication admin
istr:.lUon?
1, Ensure medications are admlnistel'l.'d and delivered In a
safe manner.
2. Be c:enain that physid.1n ordersare accurate.
), Inform the patient that prescribed mediatioll5 need be
taken only if the p.atient agrees with the treatment plm.
4. Ensure po1tient compliance bywatchlng the patient
swallow all prescribed medications.
o Before administering drugs by the enteral route, the nurse
should evaluate which of tilt foll owing!
1. Ability of the patient to lie supine
2. CompatibilityoftM drug with IV fluid
J. Abilityofthepatien.ttoswaDow
4. PAtency of the injection pon
o Which of the following is the highest nursing priority
when a patient has an allergic reaction to a newly pre-
scribed medication?
I . illSlruct the to remain calm.
2. Document the ailerEY in the medical rewrd
J. Notify the physician of the allergic reaction.
4. Place an allergy bracelet on the patient
D The order reads, 40 mg IV of the fol -
lowing actions should the nurse take!
I . Administer the medication ",ithin 30 minutes of the
0"",_
35 Systems of measurement used in phar macology include
the metric, apothecary, and household systems. Although
the metrk system is most commonly used, the nurse must
be able (0 conlll'rt dosages among the three systems of
measurement.
3.6 The enteral route includes drugs given orally and those
administered through nasogastri c or gastrostomy tubes.
This Is the most rommon route of drugadmlnistration.
3.1 Topical drugs are applied locally to the skin or membra-
nous linlngs of the eye, ear , nose, respiratory tract, urinary
tract, v.lgina. and rectum.
3.1 Parenteral admini$tration is the dispensJng of medica-
tions via a needle, U5ually Into the ski n ([D), suoot-
taneoU5 tissue, muscles (IM), or veins (IV).
2. Administer the IDl'dication within 5 minutes of the
0"",_
3, Administer the medication as required by the
oondition.
4. Assess thepatient'surinaryOOlput prior to
administration and hold medication If output is less
than 3OmUh.
o Whlchoft he following medications would not be admin-
istered through a nasogastrk tube! (Select aU that apply. )
I . liquids
2, Enteric-coated tablets
J. Sustained-release tablets
4. Finely crushed tablets
5. IV medications
o A diabelk patient has been NPO since midnight for sur-
gery in the morning. He usually takes an oral hypo-
glycemic drug to control his diabetes. Whal would be the
mx action fo r the nurse to take concerning the adminis-
tration of his medication!
I . Hold aD medications as ordered.
2. Giw him the medication with a sip of water.
3. Giwhimhalftheoriginaldose.
4. Olntaa the ph)'likian for funher orders..
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CRITICAL THINKING QUESTIONS
1. Why do errors continue to occur despite the fuet thalllw.>
nurse follows the five rights and three checks of drug ad-
ministration!
2. What strategies can the nUrliel'mpJoytoensul'l'drug com-
pllaoce for a patient who Is refusing to lake hisor her med-
ication!
3. Compare the on], topical, 1M, subcutaneous, and tv
routes. Which has lhe fastest onset of drug action? Which
routes 3\'oid the he p,alic first-pass effect? Which require
strict aseptic technique-?
OIIpltll PrII\dplI'S of DNg l S
4. What ue the adv.mtages oflhe metric S)'5tem of measure.
menl over the household or apothecary systems?
Sf( Appttrdix D jpr ansll'tTl Ilnd rationales for all activities.
EXPLORE fiii!iilllilln3!fir'------,
M'jIiu""gKllIll ytu' t'I!\e SID(Ilor Q1'IIIIlI! duJ(lIer "',.... 1IIIl1lri!!:I arid
mo\JfctS, Prepil' 101 Wt;Ce51 IMth addilioNl r.ICI..fxf'-UyIe IQCbe.
QI,IIISIiJnI;, i"lnelM! ..sag""" iI/'II actMIies. wttllinio:;, ""im.lUons
and I'Idcos ana more!
Reglibr '/WI wdIIl<\Im Ihti hilt of IW' book at
_....,., .. l>IoogkJt"""' .
LibraryPirate
KEY TERMS
amorption {!alt J!
ilflinity (X1IJt J9
blood-brain barrier paqt 39
conjugates p1IJt40
distribution (X19t 19
drug-protein [om pin (O;1J9
enterohrpatic r!cirrulation paqt41
Pharmacokinetics
LEARNING OUTCOMES
After reading this chapter, me student should be able to:
1. Explain the applications of pharmacokineti cs to clinical practice.
2 . Identif)' the four components of pharmacokinetics.
3 . Explain how substances travel across plasma membranes.
4 . Discuss factors affecting drug absorption.
5 . Explain the metabolism of drugs and its applications to
pharmacotherapy.
6 . Discuss how drugs are distributed throughout the body.
7 . how prol";,,. "/f"cl drug di.triuutiull.
8. Identify major processes by which drugs are excreted.
9 . Explain how enterohepatic recirculation might affect drug activity.
10. Explain the applications of a drug's plasma half-life (t,,.,) to
pharmacotherapy.
11 . Explain how a drug reaches and maintains its therapeutic range in the
plasma.
12. Differentiate between loading and maintenance doses.
induction patIf 0/0
enmion f!'JI}t o/O
fetil--pla(ental barrier patIf J9
firstpass effed patIf 0/0
hepatic microsomal enzyme system patIf 0/0
loading dose Ill'll' 41
maintman(f dost patIf 41
metabolism
minimum (oncentration
pharma(okinflics
plasmahalf life (t",)
prodrug meo/O
therapeuticrange fOJI42
toxinon(entration patIf 41
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M
edications are given to achieve a desirable effect. To
produce this effect, the drug must reach its target
cells. For some medications,such as topical agents used to
treat superficial skin conditions, this is II relatively simple
task. For others, however, the process of reaching target
cells in sufficient quantities to produce II physiologic
change may be challenging. Drugs are exposed to a
myriad of different barriers and destructive processes
after they enter the body. The purpose of this chapter is to
examine factors that act on the drug as it travels to reach
its target cells.
4.1 Pharmacokinetics: How the Body
Handles Medications
The term pharma(okinftiu; is derived from the root words
phannaco. which means and kinetics, which
means "mo"ement or Pharmacokinetics is thus the
study of drug movement throughout the body. In practical
tenus, it describes how the body deals with the medications.
Pharmacokinetics is a core subject in pharmacology, and a
firm grasp of this topic allows nurses to better Wlderstand
and predict the actions and side effects of medications in
their patients.
Drugs face numerous obstacles in reaching their target
cells. For most medications, the greatest barrier is crossing
the many membranes that separate the drug from its target
cells. A drug taken by mouth, for example, must cross the
plasma membranes of the mucosal cells of the gastroin-
testinal tract and the capillary endothelial cells to enter the
bloodstream. To leave the bloodstream, the drug must
again cross capillary cells, travel through the interstitial
fluid, and depending on the mechanism of action, the drug
may also need to enter target cells and cellular organelles
such as the nucleus, which are surroWlded by additional
membranes. These are examples of just some of the barri-
ers that a drug must successfully penetrate before it can
produce a response.
While moving toward target cel!sand passing through the
various membranes, drugs are subjected to numerous phys-
iologic processes. For medications given by the enteral
route, stolllilch add and digestive enzymes often act to
break down the drug molecules. Enzymes in the liver and
other organs may chemically change the drug molecule to
make it less active. If the drug is seen as foreign by the body,
phagocytes may attempt to remove it, or an immWle re-
sponse may be triggered. The kidneys, large intestine, and
other organs attempt to excrete the medication from the
body.
These examples illustrate pharmacokinetic processes:
how the body handles medications. The many processes of
pharmacokinetics are grouped into four categories: absorp-
tion, distribution, metabolism, and excretion, as illustrated
in .. Figure 4.1.
PNrm;orokl .... l\n 37
4.2 The Passage of Drugs
Through Plasma Membranes
Pharmacokinetic variables depend on the ability of a drug
to cross plasma membranes. With few exceptions, drugs
must penetrate these membranes to produce their effects.
Like other chemicals, drugs primarily use two processes to
cross body membranes:
t .Active tmnsport: This is movement of a chemical
against a concentration or electrochemical gradient;
cotransport involves the movement of two or more
chemicals across the membrane.
2. DiffUlion or passive transport This is movement of a
chemical from an area of higher concentration to an
area of lower concentration.
Plasma membranes consist of a lipid bilayer, with pro-
teins and other molecules interspersed in the membrane.
This lipophilic membrane is relatively impermeable to large
molecules, ions, and polar molecules. These physical char-
acteristics haw direct application to pharmacokinetics. For
example, drug molecules that are small, nonionized, and
lipid soluble will usually pass through plasma membranes
by simple diffusion and more easily reach their target cells.
Small water-soluble agents such as urea, alcohol, and water
can enter through pores in the plasma membrane. Large
molecules, ionized drugs, and water-soluble agents, how-
will have more difficulty crossing plasma membranes.
These agents may use other means to gain entry, such as
protein carriers or active transport. Drugs may not nero to
enter the cell to produce their effects. Once bound to recep-
tors, located on the plasma membrane, some drugs activate
a second messenger within the cell, which produces the
physiologic change (chapter 500).
4.3 Absorption of Medications
Absorption is a process involving the movement of asubstance
from its site of administration, across body membranes, to
circulating fluids. Drugs may be absorbed across the skin
and associated mucous membranes, or they may move
across membranes that line the GI or respiratory tract. Most
drugs, with the exception of a few topical medications, in-
testinal anti-infectives, and some radiologic contrast agents,
must be absorbed to produce an effect.
Absorption is the primary pharmacokinetic factor deter-
mining the length of time it takes a drug to produce its ef-
fect.ln general, the more rapid the absorption, the faster the
onset of drug action. Drugs that are used in critical care are
designed to be absorbed within seconds or minutes. At the
other extreme are drugs such as the contraceptive Mirena
(levonorgestrel- releasing intrauterine system), which is a
polyethylene tube placed in the uterus. The drug is ab-
sorbed slowly and can provide contraceptive protection for
up to 5 yall"S.
Absorption is conditional on many factors. Drugs in elixir
or syrup formulations are absorbed faster than tablets or
LibraryPirate
38 UnK I Co<e Concepts III Plarma<ology
0"".
J
Distribution
Kidney
j
Urine
Flgure4.1 The four proces!ies of pharmacoklnellcs:absorptloll,dlstrlbutlon, melabollsm,and excretion
capsules. Drugs adminislered in high doses are generally ab-
sorbed more quickly and have a more rapid onset of action
Ihan those given in low concenlrations. The speed of diges-
tive motility, exposure to enzymes in the digestive truct, and
blood flow to the site of drug administration also affect ab-
sorption. Due to the fact that drugs administered IV directly
enter the bloodstream, absorption to the tissues after the in-
fmion i. very rapid. 1M medicatiom take long<'r to absorb.
The degree of ionization of a drug also affects its ab-
sorption. A drug's ability to become ionized depends on
the surrolUlding pH. Aspirin provides an excellent exam-
ple of the effects of ionization on absorption, as depicted
in Figure 4.2. In the acid environmem of the stomach,
aspirin is in its non;on;zed form and thus readily absorbed
and distributed by the bloodstream. As aspirin enters the
alkaline environment of the small intestine, however, it be-
comes ionized. In its ionized form, aspirin is not as likely
to be absorbed and distributed to target cells. Unlike acidic
drugs, medications that are weakly basic are in their non-
ionized form in an alkaline environment; therefore, basic
drugs are absorbed and distributed better in alkaline envi-
ronments such as in the small intestine. The pH of the lo-
cal environment directly influences drug absorption
through its ability to ionize the drug. In simplest terms, it
may help the nurse to remember that acids are absorbed in
acids, and bases are absorbed in bases.
Drug----drug or food-drug interactions may influence ab-
.orption. Many ex.omplK of these interaction. have been di._
covered. For example, administering tetracyclines with food
or drugs containing calcium, iron, or magnesiwn can signif-
icantlydelayabsorption of the antibiotic. High-fat meals can
slow stomach motility significantly and delay the absorption
of oral medications taken with the meal. Dietary supple-
ments may aIso affect absorption. Common ingredients in
herbal weight-loss prooucts such as aloe leaf, guar gum,
senna, and yellow dock exert a laxatiw effect that may de-
crease intestinal transit time and reduce drug absorption
(Scott & Elmer, 2002). The nurse must be aware of drug in-
teractions and advise patients to avoid known combinations
offoods and medications that significantlyaffect drug action.
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ASA- .. HCI
j
""
(nooionized)
(a) Stomach (pH " 2)
ASA .. HCO.
j
ASA-
(io";zed)
(b) Small intestine !pH" 8)
Plllsma '" (pH" 7.4)
Flgure4.2 Effea of pH on drug absorpllon:(a) a weak acid
such as aspirin (ASAl Is In a non Ionized form In an acidic
environment and absapllon occurs;(b) In a basic environment,
aspirin Is mostly In an ionized form and absorption Is prevented
4.4 Distribution of Medications
Distributim involves the transport of pharmacologic agents
throughout the body. The simplest factor determining distri
bution is the amount of blood flow to body tissues. The
heart, liv .... , kidneys, and brain receive the most blood supply.
Skin, bone, and adipose tissue receive a lower blood supply;
therefore, it is more difficult to deliver high cOlKentrations of
drugs to these areas.
The physical properties of the drug greatly influence how
it moves throughout the body after administration. Lipid
solubility is an important characteristic, because it deter-
mines how quickly a drug is absorbed, mixes within the
bloodstream, crosses membranes, and be.:omes localized in
body tissues. Lipid-soluble agents are not limited by the bar-
riers tbat normally stop water-soluble drugs; thus, they are
more completely distributed to body tissues.
Some tissues have the ability to accumulate and store
drugs after absorption. The bone marrow, teeth, eyes, and
adipose tissue have an especially high affinit y, or attraction, for
certain medications. Examples of agents that are attracted to
adipose tissue are thiopental (Pentothal), diazepam (Val-
iwn), and lipid-soluble vitamins. Tetracycline binds to cal
(lIopl" ! Phann.KOklnetk. 39
dum salts and accwnulates in the bones and teeth. Once
stored in tissues, drugs may remain in the body for many
months and are released very slowly back to the circulation.
Not all drug mole.:ules in the plasma will reach tar-
get cells, because many drugs bind reversibly to plasma pro-
teins, particularly albumin, to form drug-protein
Drug-protein complexes are too large to cross capillary
membranes; thus, the drug is not available for distribution
to body tissues. Drugs bound to proteins circulate in the
plasma until they are released or displaced from the
drug- protein complex. Only unbound (free) drugs can
reach their target cells or be excreted by the kidneys. This
concept is illustrated in Figure 4.3. Some drugs, ,uch as
the anticoagulant warfarin (Cownadin) are highly bound;
99% of the drug in the plasma is bound in drug-protein
complexes and is WIavailable to reach target cells.
Drugs and other chemicals compete with one another for
plasma protein-binding sites, and some agents have a
greater affinity for these binding sites than other agents.
Drug--drug and drug-food interactions may OCCUI when
one drug displaces another from plasma proteins. The dis-
placed medication can immediately reach high levels in the
ann pmnllCl' effect . Omz a.._
pi rin or valproates for example, displace Coumadin from
the drug- protein complex, thus raising blood levels of free
and dramatically enhancing the risk of hemor-
rhage. Most drug guides give the percentage of medication
bound to plasma proteins; when giving multiple drugs that
are highly bound, the nurse should monitor the patient
closely for adverse effects.
The brain and placenta possess special anatomic barriers
that prevent many chemicals and medications from enter-
ing. These barriers are referred to as the blood-br. in barrifr and
barritr. Some medications such as sedatives,
antianxiety agents, and antioonvuisants readily cross the



Freo dfUII
mclecules
(.)
::;1'


(')

,



TI_
Capillllriu



,




,
4

TI_
Figure 4.1 Plasma protein binding and drug availability:
(a) drug exists In a free state or bound to plasma protein;
(b) druQ- proteln complexes are too larQ*! to (fOSS membranes

o
,



1
,
,

i
LibraryPirate
.

,
40 UtIlI! COffCooCeptslllPNrmoc"logy
blood-brain barrier to produce actions in the central ner-
w)us system. In <ontrast, most antitumor mt<!ialtions do
not easily cross this barrier, making brain alnctn difficult to
tre:u.
The fetal-placental barrierservesan important protl'l:tive
firncrinn.""""'''-'I'' il prevenl" pol .. h"rmful .<uhlr:mC"-'
from from the mother's bloodstream to the felWi.
Substances s uch as alcohol, cocaine, caffeine, and certain
prescription rued ications, however, easily cross the placental
barrier and can potentially harm the fetus. Consequently, no
prescription medication, OTe drug, or herbal therapy
should be taken by a patient who is without first
consulting with a health care provider. The health care
provider should always question female patients in the
childbtaring years regarding their pregnancy status before
prescribing a drug. Chapter 700 pres.ents a list of drug
pregnancy categories for assessing fetal risk.
4.5 Metabolism of Medications
called biommsformllrion, is the process of
chemicaUy converting a drug to a fonn that is usually more
easily removed from the body. Metabolism involves com-
plex biochemial pathways and reactions that alter drugs,
nutrients, vitamins, and minerals. The liver is the primary
site of drug metabolism, although the kidneys and reUs of
the intestinal tract also have high metabolk rates.
Mt<!ialtions undergo many l)'peS of biochemiall reac-
tions 35 they p"" through the liver, including hydrolysis, ox
idation, and reduction. During metabolism, the addition of
side chains, k oown as makes drugs more water sol-
uble and more easily excreted by the IOOneys.
Most metabolism in the liver accomplished by the
This enzyme complex is some-
times callt<! the P-450 system, named after cytochrome
P-450, which is a key component of the system. As they re-
late to pharmacotherapy, the primary actions of the hepatic
microsomal enzymes are to inactivate drugs and accelerate
their excretion. In wme cases, however, metabolism can
produce a chemical alteration that makes the resulting mol-
ecule more a..:tive than the original For example, the nar-
cotic analgesic codeine undergol':'l biotransformation to
morphine, which has significantly greater ability to relieve
pain. In fact, Wille agents, known as prod"'9'> have no phar-
macologk unless they are first metabolized 10 their
active form by the body. Examples of prodrugs include be-
na:upril ( lotensin) and losartan (Cozaar).
Changes in the function of the hepatic mkrosomal en-
zymes can significantly affl'l:t drug metabolism. A fewdruss
have the ability to increase metabolic activity in the liver, a
process called tRzymt induction. For example, phenobarbital
causes the liver to synthesi:u more enzyrnl':'l. By
doing so, phenobarbital increases the ratt'of its own nlelab-
o]ism, as well as that of other drug'> metabolized in tht' liver.
]n these patit'nts, higher doses of medication may be re-
quirt<! to achieve the optimum tht'rapt'utic effect.
urtain patients have decreased ht>patic metabolic activ-
it y. which may alter drug action. HepatK enzyme activity is
PoI,,1 vein
Firs11"'_
melaooism
Flgure4.4 First-pass etfect:(a) drugs are absorbed;(b) drugs
enter hepatic circulation and go directly to liver;
Ie) hepatic microsomal enzymes metabolize drugs to InactIve
fOffTlS;ldl drug cooJugatfS, leaving IlYer; (1,'1 drug Is distributed
to goenefal circulation
generally reduced in infants and elderly patients; th .... efore,
pediatric and g .... iatric patients are more sensitive to drug
therapy than patients. Patients with liver
damage, such as that a used by cirrhosis, will require reduc-
tiom in drug dosage because of the decreased metabolic ac-
tivity. urtain genetic disorders have been recognized in
which patienl$ lack specific metabolic enzymes; drug
dosages in these patients must be adjusted accordingly. The
nurse should pay alreful attention to laboratory values
may indicate Jiver so that doses may be adjll5ted.
Metabo]ism has a numbeTof additional therapeutic <on-
sequences.. AI; illustrated in Figure 4.4, drugs ab50rbt<! af-
teroral adminiuration cross directly i nto the hepatic POrlal
circulation, which arries blood 10 the liVl.'r before it is dis-
t ributed toother body tissues.. Thus,as blood passes through
the liver circulation, some drugs can be completely meubo-
lized to an inactive form before they ever reach the general
circulation. This flfl\pass effect is an important mechani sm,
since a large number of oral drugs are rendered inactive by
hepatic metabon, fn"ioll'. Al1ernative lOut", <:If delivery
that bypass the first-pass effect (e.g. , sublingual, rectal, or
parenteral routes) may need consider:ation for these drugs.
4.6 Excretion of Medicat ions
Drugs all.' removed from the body by the procl'SSof elOfliIHI.
The rate al which medic:.ations are excreted detennines Iheir
concentration in the bloodstream and tissues. This is im-
portant because the concentration of druW; in the blood-
LibraryPirate
stream determines their duration of action. Pathologic
states,such as liver disease or renal failure, often increase the
duration of drug action in the body because they interfere
with natural excretion mechanisms. Dosing regimens must
be carefully adjusted in these patients.
Although drugs are removed from the body by numerous
organs and tissues, the primary site of e.u:retion is the
ney.ln an average-size person, approximately 180 L of blood
is filtered by the kidneys each day. Free drugs, water-soluble
agents, electrolytes,and small molecules are easily filtered at
the glomerulus. Proteins, blood cells, conjugates, and
drug- protein complexes are not fIltered because of their
large size.
After filtration at the renal corpuscle, chemicals and
drugs are subjected to the process of reabsorption in the
nal tubule. Mechanisms of reabsorption are the same as ab-
sorption elsewhere in the body. Nonionized and
lipid-soluble drugs cross renal tubular membranes easily
and return to the circulation; ionized and water-soluble
drugs generally remain in the filtrate for excretion.
Drug- protein complexes and substances too large to be
filtered at the glomerulus are sometimes secreted into the
t1ln1lle of Ihe nephMn. For enm]'!le, only 10% of
dose of penicillin G is filtered at the glomerulus; 90% is se-
creted into the renal tubule. As with metabolic enzyme ac-
tivity, secretion mechanisms are less active in infants and
older adults.
Certain drugs may be excreted more quickly if the pH of
the filtrate changes. Weak acids such as aspirin are excreted
faster when the ftltrate is slightly alkaline, because aspirin is
ionized in analkalineenvirotunent, and the drug will remain
in the filtrate and be excreted in the urine. Weakly basic
drugs such as diazepam (Valium) are excreted faster with a
slightly acidic filtrate, because they are ionized in this envi-
rorunent. This relationship between pH and drug excretion
can be used to advantage in critical care situations. To speed
the renal excretion of acidic drugs such as aspirin in an over
dosed patient, an order may be written to administer sodium
bicarbonate. Sodium bicarbonate will make the urine more
basic, which ionizes more aspirin, causing it to be excreted
more readily. The excretion of diazepam, on the other hand,
can be enhanced by giving anunonium chloride. This will
acidify the filtrate and increase the excretion of diazepam.
Impairment of kidney function can dramatically affect
pharmacokinetics. Patients with renal failure will have di-
minished ability to excrete medications and may retain
drugs for an e.'l:tended time. Doses for these patients must be
reduced, to avoid drug toxicity. Because small to moderate
changes in renal status can cause rapid increases in serum
drug levels, the nurse must constantly monitor kidneyfunc-
tion in patients receiving drugs that may be nephrotoxic
{low margin of safety}. The pharmacotherapy of renal fail-
ure is presented in chapter J OOO.
Drugs that can easily be changed into a gaseous form are
especially suited for excretion by the respiratory system. The
rate of respiratory excretion is dependent on factors that af-
fect gas exchange, including diffusion, gas solubility, and
pulmonary blood flow. The elimination ofvolatileanesthet-
(lIopltl4 Plaml;KOkllM'!Ic:. 41
ics following surgery is primarily dependent on respiratory
activity. The faster the breathing rate, the greater the excre-
tion. Conversely, the respiratory removal of water-soluble
agents such as alcohol is more dependent on blood flow to
the lungs. The greater the blood flow into lWIg capillaries,
the greater the excretion. In contrast with other methods of
excretion, the lungs excrete most drugs in their original WI-
metabolized form.
Glandular activity is another elimin.1lion mechanism.
Water-soluble drugs may be secreted into the saliva, sweat, or
breast milk. The odd taste that patients sometimes experi-
ence when given IV drugs is an example of the secretion of
agents into the saliva. Another example of glandular excre-
tion is the garlic smell that can be detected when standing
next to a perspiring person who has recently eaten garlic. Ex-
cretion into breast milk is of considerable importance for ba-
sic drugs such as morphine or codeine, as these can achieve
high concentrations and potentially affect the nursing in-
fant. Nursing mothers should always check with their health
care provider before taking any prescription medication,
OTC drug, or herbal supplement. Pharmacology of the preg-
nant or breast-feeding patient is discussed in chapter 700.
Some u.:r<':ted in Ihe hill.', known
biliary excretion. In many cases, drugs secreted into bile will
enter the duodenum and eHmtually leave the body in the fe-
ees. However, most bile is circulated back to the liver by
as illustrated in ,. Figure 4.5.A percent-
age of the drug may be recirculated numerous times with the
bile. Biliary reabsorption is extremely influential in prolong-
ing the activity of cardiac glyoosides, some antibiotics, and
phenothiazines. Recirculated drugs are ultimately metabo-
lized by the liver and excreted by the kidneys. Recirculation
and elimilliltion of drugs through biliary excretion may con-
tinue for sewral weeks after therapy has been discontinued.
4.7 Drug Plasma Concentration
and Therapeutic Response
The therapeutic response of most drugs is directly related to
their level in the pbsma. Although the concentration of the
medication at its target tiHue is more predictive of drug
LIFESPAN CONSIDERATIONS
AdY,nse Drug Effects and Older Adults
Ad"""" drug off\>.", ""'''' <ommonly Il'",rdod in olckr adull> th .. in
100119 adull> or middlNge paritnn, the older adull poJllllation
""'Il' drugs .imukllltOUSly (an a"'rage of 1I'1'ffi) than otht r ige and
of norma I in hepatio: and Il'IlII function. (hronic di SNII'S thit
affrct ph"macokinetia 1ft' 1110 ""'ft' in older adults. In addi-
tion, older adults may not Il'pon IMI"II' drug tifls or may [onsmo-
tht m 01 a9in9 or of their [oooilion. Oflt study (Lamptla t1 oiL,
2007) Ioond lhal when (omp;lring adYl'M rifr[U Il'ported b)' !)Mitnu age 7S
or okll>r with <I MI"II' rifrrts ooted b)' a hukh call' adVl'I"II' fifro:1"I
well' ft'poned by only 11.4'11. of the patifnts oompared to rifr[U ollll'rYed by
tht health care proYider in 24% of Thf study aUlhor. ft'(ommend
thit [oJre providm inquift' aboul pD\.Siblt drug-related problems eI'II
though older <Idull"l may not [amp!.in olor II'II-ft'porl IlKh
LibraryPirate
42 UnK 1 Co<e Concepts III Plarma<ology
BOle Mils eb50rbed aod circulated
back to lh6 li_ by wa.y 01 the
capilla .... 01 !he d;gesti .... lr8Cl
and h9patic porIal win
". Flpure4.5 Enterohepatlc recirculation
action, this quantity is impossible to measure in most cases.
For example, it is possible to conduct a laboratory test that
measures the serwn level of the drug lithiwn carbonate (Es-
kalith) by taking a blood sample; it is a far different matter to
measure the quantityofthis drug in neurons within the eNS.
Indeed, it is oonUllon practice for nurses to monitor the
plasma levels of certain drugs that have a lowsafetyproftle.
Several important pharmacokinetic principles can be il -
lustrated by measuring the serum level of a drug following
a single-dose administration. These pharmaookineti c values
are shown graphically in ". Figure 4.6. This figure demon-
strates two plasma drug levels. First is the minimum (on-
(entration, the amount of drug required to produce a
therapeutic effect. Second is the loxi(ron(fnuation, the level of
drug that will result in serious adverse effects. The plasma
drug concentration between the minimum effective amcen-
lration and the toxic conct'ntration is called the therapfulic
range of the drug. These values have great clinical signifi-
cance. For example, if the patit'llt has a severe headache and
is giwn half of an aspirin tablet, the plasma level will remain
l>.,]uw II", miui m ulIl 3llJ IiI",
will not experience pain relief. Two or three tablets will in-
crease the plasma level of aspirin into the therapeutic range,
and the pain will subside. Taking sixor more tablets may re-
sult in adverst' effects, such as GI bleeding or tinnitus. For
each drug administered, the nurse's goal is to keep its plasma
concentration in the therapeutic range. For some drugs, the
BOle t.anspo.ted from !he
IMIt to the small ,ntesl,ne
by wey of the gallbladde.
StOJTllld!
Smllil intestine
therapeutic range is qui te wide; for other medications, the
difference between a minimum effective dose and a toxic
dose may be dangerously narrow.
4.8 Plasma Half-Life and Duration
of Drug Action
The most common description of a drug's duration of ac-
tion is its plasma defined as the length of time re-
quired for the plasma concentration of a medication to
decrease by one-half after administration. Some drugs have
a half-life of only a few minutes, whereas others have a half-
life of several hours or days. The greatt'T tht' half-life, the
longer it takes a medication to be excreted. For example, a
drug with a '11' of 10 hou rs would take longer to be excreted
and thus produce a longer effect in the body than a drug
with a til' of 5 hours.
Tht' plasma half-life of a drug is an essential pharmacoki-
netic variable with important clinical applications. Drugs
with relativt'ly short half-lives, such as aspirin (t,,, = 15 to
20 ",illUl.,,;) musl [..., <:vny 3 lu 4 huurs. DruK' wilh
longer half-lives,such as felodipine (Plt'lldil) (t", = 10 hours),
need be given only once a day. If a patient has extensive re-
nal or hepatic diseaSt', the plasma half-life of a drug will in-
crease, and the drug ooncentration may reach toxic levels. In
these patit'nts, medications must be given less frequently, or
the dosages must be reduced.
LibraryPirate
"
T""
I::
___
0
i
1
Thenlp8Ulic
,n,'II"
,

i
!
,


Dum!"", 01 action
"
,


TMIT'Ii
Nltion
.,
elled;""
concentmlion

<
,
.-
,
, , , ,
" Time (hours)
,.. flgure4.6 Single-dose drug administration:
pharma{oklnetlc values for this drug are as fall om: onset of
action = 2 hours;duratlon of aclion = 6 hours;lermlnatlon of
action = 8 hours afler admlnlstrallon;peak plasma
concentration = 10 mcg/mL;lIme 10 peak drug effect =
5 hours; !'/ , = 4 hours
4.9 Loading Doses
and Maintenance Doses
"
Few drugs a .... administered as" single dose. Repeated doses
result in an accumulation of drug in the bloodstream, as
shown in ,.. Figure 4.7. Eventually, a plateau will be reached
where the level of drug in the plasma is maintained continu-
ouslywithin the therapeutic range. AI this level, the amOWli
administered has reached equilibriwn with the amount of
drug being eliminated, resulting in the distribution of a oon-
tinuous therapeutic level of drug to body tissues. Theoreti-
cally, it takes approximately four half-lives to reach this
equilibrium. If the medication is given as a continuous infu-
sion, the plateau can be reached quickly and be maintained
with little or no fluctuation in drug plasma lewIs.
C\ , ' -
Ll ' " Chapter REVIEW
KEY CONCEPTS
D,
(lIopltl4 Plaml;KOkllM'!Ic:. 43
----Th!;.;.-
,...,


12 24 gs 411 GO 72 114 9S 108 120 132
Time (hours)
Figure 4.7 Multlple-dose drug admlnlstratlon:drug A and
drug 8 are administered every t2 hours;drug 8 reaches the
therapeutic range faster,becaust' thenrst dost' Is a loading

The plateau may be reached faster by administration of
loading doses followed by regular maintenance doses. A
lOildingdos! is a higher amown of drug, often given only once
or twice to the bloodstream with a sufficient level of
drug. Before plasma levels can drop back toward zero, inter-
mittent mlintenanc. do ... wven to keep the drug
ooncentration in the therapeutic range. Although blood lev-
els of the drug fluctuate with this approach, the equilibrium
state em be reached almost as rnpidly as with a continuous
infusion. Loading doses are particularly important for drugs
with prolonged half-lives and for situations in which it is
critical to raise drug plasma levels quickly, as might be the
case when admin istering an antibiotic fora severe infection.
In Figure 4.7, notice thM it takes almost five doses (48 hours)
before a therapeutic level is reached using a routine dosing
schedule. With a loading dose, a therapeutic level is reached
within 12 hours.
The numbered kt>y concepts provide a succinct summary of the important points from the oorresponding nWllbered section
within the chapter. If any of these points are not clear, refer to the numbered section within the chapter for review.
4. 1 Pharmacokinetics focuses on the mowment of drugs
throughoU1the body after they are administered.
4.2 The physiologic properties of plasma membranes deter-
mine movement of drugs throughout the body. The four
components of pharmaookinetics are absorption, metab-
olism, distribution, and excretion.
4.3 Absorption is the process by which a drug moves from the
site of administration to the bloodstream. Absorption de-
pends on the size of the drug molecule, its lipid solubility,
its degree of ionization, and interactions with food or
other medications.
LibraryPirate
44 t Con Concepts 111 PN,mxoiogy
U Dimibution comprises the methods by which drugs are
transported throughout the body. Distribution depends
on the formation of drug-protein complexes and spedal
barriers such as the placenta or brain barriers.
45 Metabolism is a process that changes a drug's activity and
makl-s it more likely 10 be excreted. Changes in hepatic
metabolism can significantly affect drug action.
4.6 El;crelion processes remo\"e drugs from the body. Drugs
are primarily excreted by the kidneys but may be e:mele<l
into bile, by the lung, or by glandular secretions.
NCLEX-RN' REVIEW QUESTIONS
U A patient has an order for a tetracyclJneantiblotlc and has
been instructed to avoid taking the medication with
foods. beverages, or drugs that cont ain calcium. iron, or
magnesIum. What stage of the pharmaooklnetk processes
is behind the rationale for thi!; instruction?
I. Absorption
2. Distribution
J. Metabolism
4. Excretion
o The patient has a malignant buin tumor. What property
of pharmacokinetics may cause difficulty in treating her
tumor?
I. Blood-br.lin barrier
2. Drug-prolein complexes
J. Affinltyfor neoplasms
4. Utd ohcti'"I' transport
o A patient with cirrhosis of the liver exhibits dreased
metabolic activity. This will require what possible change
in her drug regimen?
1. A reduction in the dosage of drug.s
2. A change In the timlng of medication administr.ltion
J. An increased dost'of prescribed drug'i
4_ AU preKribed drugs begiven by lntr.lmusro1ar
Injtion.
CRITICAL THINKING QUESTIONS
1. Describe the types of obstacles drugs face from the time
they are administered until they reach their target
2. Why is the drug's plasma half-life lnlportant to the nun;e?
3. Howdoes the ionization of a drug d fea its distribution in
the body?
4.1 The ther.lpeutic response of most drugs depends on their
concentration In tht plasma. The difference between the
minimum effective amcent ration and the toxic concen-
tration Is called the ther.lpeutic range.
4.1 Plasma half-life represents till.' duration of action for
most drugs.
U Repeated dosing alkr.o.-s a plateau drug pbsma level to be
reached Loading do5es allow a therapeutic drug k-o,'e! to
be reached ra pldly.
o Solm: drugs may be completely metabolized by the liver
circulation before ever reachIng the general circulation.
This effect is known as what?
I . Conjugation of dnlgs
2. Hepatic miclOliOfl'lai enlyIDL' system
J. Blood-brain barrier
4. Flrst-passeffect
o A patient who is in renal failure may haveadiminished ca-
pacIty to excrete medications. [t Is Imperative tbalthls pa-
tient be assessed (or ",'hat development?
I . [JH.Te3St'd creatinine lewis
2. [ocreased levelsofblood urea nitrogen
J. Oms toxicity
4. Increased levels of potassium
o The nurse understands that with activIty, '"ter-
soluble drugs may be secreted into (select all that apply):
I . saliva.
2. sweat.
J. breast milk.
4_ bUe.
5. feces..
4. EIplain why drUg<; metabolized through the first-pass ef-
fect might need to be administered by the parenteral route.
SuAppendix D for answers and rationales for a/1 activiria.
EXPLORE [ij;(illlifln3!fiJ'------,
fIlursilgKt is ycu' one _ fo, online d\apter reiew matflrill.lS Jnd
reaxJ rCfi. l'repara la! IilICC9&S wi1!l DliIionaI praclica
QUr:STilnS.ImtJll:tMl 2lIII!JmenlS and 1dv1lie8. willi IIllmellOnS
and ifId more!
yoor au:e!I:I COdo! from 1M Iron! fl yrur IlOOlc at
www.myn .. "ngkllc .... .
LibraryPirate
KEY TERMS
agonist fll}tSO
antagonist pq50
dficacy piJl}f49
rur'fl' patjl'46
gradrd {XIgt 47
idiosyncratic response 50
Pharmacodynam ics
LEARNING OUTCOMES
After reading this chapter, the student should be able to:
1. Apply principles of pharmacodynamics to clinical practice.
2. Discuss how frequency response curves may be used to explain how
patients respond differently to medications.
3. Explain the importance of the median effective dose (ED",) to clinical
practice.
4. Compare and contrast median lethal dose (LD,;o.l and median toxicity
dose (TD,J.
S. Discuss how a drug's therapeutic index is related to its margin of safety.
6. Identify the significance of the graded dose- response relationship to
dinical practice.
7. Compare and contrast the terms potency and efficacy.
8. Distinguish between an agonist,a partial agonist,and an antagonist.
9. Explain the relationship between receptors and drug action.
10. Explain possible future developments in the field of pharmacogenetics.
median effl'Ctivedosr (ED,J [JIlIIt0/6
median {II19t0/6
median toxkitydoSf(TD,.l filXJf47
nons(lfcifK crllular {OJ/ SO
partial agonist
pharmacodynamics fXXlI' 0/6
pharmacogen!tics {l!9t 51

pu;e49
sKond mrsstng!r fllI}t49
thrraprutic index P:!9t 47
LibraryPirate
46 Unft 1 (o<e Concepl5 In PtmmKology
I
n clinical practice, nurses quickly learn that medications
do not affect all patients In the same way: A dose that
produces a dramatic response in one patient may have no
effect on another. In some cases, the differen<:es among
patients are predictable, based on the pharffiiKokinetic
prindples discussed in chapter 4010. In other cases, the
differences in resp:mse lire not easily explained. Despite
this patient vilfillbility, health care provldeJ$ must choose
optimal doses while avoiding ",nnecessary Otdveue effects.
1his 15 not an easy ta:lk given the wide variation of patient
re5pOnses within a popuilition. Thi s chapter examines the
mechllnisms by which drugs affect patients, lind how the
nurse can itppIy these prindples to cllnkal practice.
5.1 Pharmacodynamics
and InterpatientVariability
The term pharmmxlynamks comes from the root words
pharmuco, which means "medicine," and dYllamics, which
means "change.
H
In simplest temlS, pharmacodynamics
refers to how a medicine changes the body. A more complete
definition explains pharmacodynami cs as the branch of
pharmacology concerned with the mochanisms of drug ac
tion and the relationships between drug concentration and
responses in the body.
Philrmaaxiynamics has important dinical applications.
Health care providers must be to predict whether a drug
will produce significant ch.ange in Although dini-
wn. Ih.,,-;,, ... 1 wilh ,",Vt'l'''''t\'' I.u...,u (rum '"'
drug guide, intuitM experience often becomes the practical
method for determining which doses of medications will be
effective in a given patient. Knowledgeof therapeUlic indexes,
dose-response rdatiollShips. and drus-rereptor interactions
will help the nurse provide 5:IIfe and effective treaunenl.
Interpatient variabi lity in res ponses to drugs can best be
understood by examining a frequency distribution curve. A
ftquNtylislrilMltiOllaa-w. shown in J> Figure 5.1, is a graphical
representation of the number of patients responding to a
drug action at different doses, Notice the wide range in doses
that produced the patient responses shown on the curve. A
few patients responded to the drug at very low doses. As the
dose was increased, more and more patients responded.
Some patients required very high doses to elicit the desired
response. The pe;lk of the curve indicates the largest num-
ber of patients responding to the drug. The curve does not
show the nwgnitudeof response, only whether a measurable
response occurred among the patients. As an example,think
of the given response tO.ln antihyper tet"lsiVl" drug iU bt.ing a
reduction of20 mmHg in systolic blood pressure. A few pa
tients experienced thedesired 20mm reduction at a dose of
only 10 mg of drug. A SOmg dose gave the largest number
of patients ZO mm reduction in blood prtSsure; however,
a few patients needed as much as 90 mg of drug to produce
the same 20 mm reduction.
'"
Do ... of rMd>cation (mg)
,.. FigureS.' Frequencydfstrfbutfon curw: fnterpatlent
varfabllfty fn drug response
The dose in the middle of the frequency di stribution
curve represents the drug'S medianffftcti"ftdose (ED,J. The EDl<)
is the dose required to produce specific therapeutic re_
sporue in SO% of a group of patient s. Drug guides some_
times report the EDl<) as the or dose.
The interpatient variability shown in Figure 5.1 has im.
portant clinical implications. Fi rst, the nurse should realize
that the standard or average dose pred icls a sat isfactory
therapeutic response for only hal/the popUlat ion. In other
words, will require more or less than the avo
erage dose for optimum phannacotherapy. Using the sys
tolic blood pressure example, assume a group of
patients is given the average dose of SO mg. Some of these
patients will e.'{perience toxi city at this levtl btaUSt they
needed only 10 mg to achieve blood pressure reduction.
Other in this groupwill proJ,bly haVl" no reduction
in blood pressure. By observing the patient, taking vi tal
signs, and monitoring associ ated laboratory data, the nurse
uses skills that are critical in det ennining whether the aver-
age dose is effective for the patient. It is not enough to sim_
ply memorize an average dose for drug: the nurse must
know when and how to adjust this dose to obtain the opti.
mwn therapeutic response.
5.2 Therapeutic Index
and Drug Safety
Administering a dose that produces an optimum ther3peu.
ti .. repuu"" fur "" .. h pOlli"lIl uuly uu" .. urnp'-'
nent of effective pharmacother3py. The nurse must also be
able to predict whether the dose is safe for the p3tient.
Frequency distribution curves 3lso be used to repre.
sent the safety of a drug. For example, the II'ltdiu IeIQI do\f
(LO,.! is often determined in preclinical tri.3ls, as P3rt of the
drug de"elopment process discussed in 1010. The
LibraryPirate
LO'jQ is the dose of drug that will be lethal in 50% of a group
of animals. As with ED"" a group of animals will exhibit
considerable variability in lethal dose; what may be a non-
toxic dose for one animal may be lethal for another.
To examine the safety of a particular drug, the LO", can
be compared with the EO"" as shown in Figure 5.2a. In
this example, 10 mg of drug X is the average effective dose,
Illl! j, lh .. j.,thu/ n .. , ED", LD",
used to calculate an important value in pharmacology, a
drug's theraprutic indel, the ratio of a drug's LO", to its ED","
median lethal dose L0
50
Therapeutic index =
median effective dose E0
50
The larger the difference between the two doses, the
greater the therapeutic index. In Figure 5.2a, the therapeutic
index is 4 (40 mg..;. \0 mg). Essentially, this means that it
would take an error in magnitude of approximately 4 times
the average dose to be lethal to a patient. Thus, the therapeu-
tic index is a measure of a drug's safety margin: The higher
the value, the safer the medication.
'".
co.
,.,



""

]
,
i
"'"
z
'"
,
,
'" " '" " '" " '" " '"
mg 01 drug X
(a.) Drug X
T1"
to
,''- CD.
,.,



''''

,


"'"
l
'"
,
,
'" " '" " '" " '" " '"
mg 01 drug Z
(b) Drug Z
:TI", "gQ,,2
ED.. to
,.. Flgure5.2 Therapeutic Index: (a) drug X has a therapeutic
Index of 4;(b) drug Z has a therapeutic Index of 2
Choptfl; l'h.1rmac:odyn.mk:. 47
As another example, the therapeutic index of a second drug
is shown in ,.. Figure 5.2b. Orug Z has the same EO", as drug
X but shows a different LO,... The therapeutic index for drug
Z isonly2 (20 mg..;. \0 mg). The difference between an effec-
tive dose and a lethal dose is very small for drug Z; thus, the
drug has a narrow safety margin. The therapeutic index offers
the nurse practical information on the safety of a drug, and a
fll<"dlJS lu Ufl" Ufl'K will,
Because the LO", cannot be experimentally determined in
humans, the mrdiantoxidtydose(lD,J is a more practical value
in a clinical setting. The TO", is the dose th.1t will produce a
given toxicity in 50% of a group of patients. The TO", value
may be extrapolated from animal data or based on adverse
effects recorded in patient clinical trials.
5.3 The Graded Dose-
Response Relationship
and Therapeutic Response
In the previous examples, frequency distribution curves were
used to graphically visualize patient differences in responses
to medications in a population. It is also useful to visualize
the variability in responses observed within a single patient.
The gradrddo.r-rriipons! relationship is a fundamental con-
cept in pharmacology. The graphical representation of this
relationship is called a dose-response curve, as illustrated in
,.. Figure 5.3. By observing and measuring the patient's re-
sponse obtained at different doses of the drug, one can ex-
plain several important clinical relationships.
The three distinct phases of a dose-resporu;e c:urve indicate
essential pharmaoodynamic principles that have relevance to
clinical practice. Phase I occurs M the lowest doses. The flat-
ness of this portion of the curve indicates that few target cells
have yet been affected by the drug. Phase 2 is thestraight-line
portion of the curve. This portion often shows a linear
'"

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Phase 2

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,
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10,000
Oose (log)
". Flgur! 5.3 Dos ...... response relationship
LibraryPirate
48 UnK 1 C ... o Concepts III PIa,marology
relationship between the amount of drug administered and
the degree of response obtained from the patient. For exam-
ple,if the dose is doubled, twice as much response is obtained.
This is the most desirable range of doses for pharmaoothera-
peutics, since giving more drug results in proportionately
more effect; a lower drug dose gives less effect. In phase 3, a
plateau is reached in which increasing the drug dose produces
no additional therapeutic response. This may occur for a
nwnber of reasons. One aplanation is that aU the receptors
for the drug are occupied. Practically it means that the drug
has brought 100% relief, such as when a migraine headache
has been termirulted; giving higher do .... produces no addi_
tional relief. In phase 3, although increasing the dose does not
result in more therapeutic effect, the nurseshouJd be mindful
that increasing the dose may produce adverse effects.
5.4 Potency and Efficacy
\Vithin a pharmacologic class, not aU drugs are equally ef-
fective at treating a disorder. For example, some antineo-
plastic drugs kill more cancer cells than others; some
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antihypertensive agents lower blood pressure to a greater
degree than others; and some analgesics are more effective
at relieving severe pain than others in the same class. Fur-
thermore, drugs in the same class are effective at different
doses; one antibiotic may be effective at a dose of I mglkg,
whereas another is most effective at 100 mg/kg. Nurses need
a method to compare one drug with another so that they
can administer treatment effectively.
There are two fundamental ways to compare medications
within therapeutic and pharmacologic classes. First is the
concept ofpotrncy. A drug that is more potent will produce a
the"'peutic effect al a lower dose, compared with another
drug in the same class. Consider two agents, drug X and
drug Y, that both produce a 20-mm drop in blood pressure.
If drugX produces this effect at a dose of 10 mg, and drug Y
at 60 mg, then drug X is said to be more potent. Thus, po-
tency is a way to compare the doses of two independently
administered drugs in terms of how much is needed to pro-
dm:ea particular response. A useful way to visualize the con-
cept of potency is by examining dose-response curves.
Compare the two drugs shown in ~ Figure 5.4a. In this ex-
Dotted indicates the
sa"", dOGe lor both drugs
"'00
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10.000
0"""
0"",.
1"19>'"
EFFICACY
, ~ .
(b) to tOO 1000 10,000
COO'"
.. Flgure5.4 Potency and efficacy:(a) drug A has a higher potellcythan drug B;(b) drug A has a higher efficacy than drug 8
LibraryPirate
ample, drug A is more potent because it requires a lower
dose to produce the same response.
The second method used to compare drugs is called
efficacy, which is the magnitude of maximal response that can
be produced from a particular drug. In the example in
>- Figure 5.4b, drug A is more efficacious because it pro-
duces a higher maximal response.
Which is more important to the success of pharma-
cotherapy, potency or efficacy? Perhaps the best way to un-
derstand these conC!'pts is to use the specific example of
headache pain. Two common OTC analgesics are ibupro-
fen (100 mg) and aspirin (650 mg). The fact that ibupro-
fen relieves pain at a lower dose indicates that this agent is
more potem than aspirin. At recommended doses, however,
both are equally effective at relieving headache pain; thus,
they have the slime efficacy. If the patient is experiencing
severe pain, however, neither aspirin nor ibuprofen has
sufficient efficacy to bring relief. Narcotic analgesics such
as morphine have a greater efficacy than aspirin or ibupro-
fen and can effectively treat this type of pain. From a phar-
macotherapeutic perspective, efficacy is almost always
more important than potency. In the previous example,
the average dose is lUlimportant to the patient, but
headache relief is essmtial. As another comparison, the pa-
tient with cancer i, much more concerned about how
many cancer cells have been killed (efficacy) than what
dose the nurse administered (potency). Although the
nurse will often hear claims that one drug is more potent
than another, a mOle compelling concern i, whether the
drug is more efficacious.
5.5 Cellular Receptors
and Drug Action
Drugs act by modulating or changing existing physiologic
and biochemical processes. To exert such changes requires
that drugs interact with specific molecules and chemicals
normally found in the body. A cellular macromolecule to
which .. medication binds in order to initiate its effects is
C'lOed a rurptor. The concept that a drug binds to a receptor
to cause a change in body chemistry or physiology is a fun-
damental theory in pharmacology. Receptor theory explains
the mechanisms by which most drugs produce their effects.
It is important to understand, however, that these receptors
do not exist in the body solely to bind drugs. Their normal
function is to bind endogenous molecules such as hor-
mones, neurotransmitters, and growth factors.
Although a drug receptor can be any type of macromole-
cule, the vast majority are proteins. As shown in Figure 5.5,
a receptor is depicted as a three-dimensional protein asso-
ciated with the cellular plasma membrane. The extracellu-
lar structural component of the receptor usually consists
of several protein subunits arranged around a central canal
0 1" channel. Other receptors consist of many membrane-
sparming segments inserted into the plasma membrane.
A drug attaches to its receptor in a specific manner, much
like a lock and key. Small changes to the structure of a drug,
or its receptor, may weaken or even eliminate binding be-
tween the two molecules. Once bolUld, drugs may trigger a
, .. rie. of :wcond m ...... nger event, within the celi, ,uch as the
conversion of adenosine triphosphate (ATP) to cyclic
N Ion po!
Binding
.. ,
(a) Voltage"9"tod chanool
One .trand with
....., transmmrbrane
... '"".
(c) channel
Flgure5.5 Cellular receptors
c
C
Fiw st......-.!o, joined in
8. penta""" , _ell willi
lou, t,ansmembrane
segmant.
(b) Chemical-gatod channel
Binding site
/
Ion PO'" (Gprol . in-
linked channel)
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,
'1
"
i
i
o
,
i
I

50 UnIII CO<O (OO(epl'; III Phormoc:ology
adenosine monophosphate (cyclic AMP), the release of in-
tracellular calcium, or the activation of specific G proteins
and associated enzymes. These biochemical cascades initiate
the drug's action by either stimulating or inhibiting normal
activity of the cell.
Not all rectptors are bound to plasma membranes;
some are intrncellular molecules such as DNA or en-
zymes in the cytoplasm. By interacting with these types
of receptors, medications are able to inhibit protein syn-
thesis or regulate cellular events such as replication and
metabolism. Examples of agents that bind intracellular
components include steroid medications, vitamins, and
hormones.
Receptors and their associated drug mechanisms are ex-
tremely important in therapeutics. Receptor subtypes are
h"ing di.cnv,,1"I'<l and n..w medic.",inns a,." h"ing d"wlnped
at a faster rate than at any other time in history. These sub-
types permit the of pharmacology. For ex-
ample, the first medications affecting the autonomic
nervous system affected all autonomic receptors. It was
discovered that two basic receptor types existed in the
body, alpha ani beta, and drugs were then developed that
affected only one type. The result was more specific drug
action, with fewer adverse effects. Still later, several sub-
types of alpha and beta receptors, including alpha" alpha"
beta" and beta" were discovered that allowed even more
specificity in pharmacotherapy. In recent years, researchers
have further divided and refined these subtypes. It is likely
that receptor research will continue to result in the devel-
opment of new medicatioilli that activate very specific re-
ceptors and thus direct drug action that avoids
unnecessary adverse effects.
Some drugs act independently of cellular receptors. These
agents are associated with other mechanisms, such as
changing the permeability of cellular membranes, depress-
ing membrane excitability, or altering the activity of cellular
pwnps. Actions such as these arc described as non'pocifi.l1u
lar Il'sponses. Ethyl alcohol, general anesthetics, and osmotic
diuretics are examples of agents that act by nonspecific
mechanisms.
5.6 Types of Drug-Receptor
Interactions
When a drug binds to a receptor, several therapeutic conse-
quences can result. In simplest terms, a specific activity of
the cell is either enhanced or inhibited. Theactual biochem-
ical mechanism underlying the therapeutic effect, however,
maybeextremelycomplex.ln some cases, the mechanism of
action is not known.
\'/hen a drug binds to its receptor, it may produce a re-
sponse that mimics the effect of the endogenous regulatory
molecule. For example, when the drug bethanechol (Ure-
choline) is administered, it binds to acetylcholine reptors
in the autonomic nervous system and produces thesameac-
tions as acetylcholine. A drug that produces the same type
of response as the endogenous substance is called an agonist.
Agonisls sometimes produce a greater maximal response
than the endogenous chemical. The term partial agonist de-
scribes a medication that produces a weaker, or less effica-
cious, response than an agonist.
A second possibility is that a drug will occupy a receptor
andprevetllthe endogenous chemical from acting. This drug
is called an antagonist. Antagonists often compete with ago-
nisls for the receptor binding sites. For example, the drug at-
ropine competes with acetylcholine for spific receptors
associated with the autonomic nervous system. If the dose is
high enough, atropine will inhibit the t'ffeds of acetyl-
choline, because acetylcholine cannot bind to its receptors.
Not all antagonism is associated with receptors.
FUllctional antagonists inhibit the effects of an agonist not
by competing for a receptor but by changing pharmacoki-
netic factors. For example, antagonists may slow the absorp-
tion of a drug. Ry lip or eXCTet"ion,
antagonist can enhance the removal of a drug from the
body. The relationships that occur between agonists and an-
tagonists explain manyofthedrug-drug and drug-food in-
teractions that occur in the body.
5.7 Pharmacology of the Future:
Customizing Drug Therapy
Until recently, it was thought that single drugs should pro-
vide safe and effective treatment to every pllient in the
same way. Unfortunately, a significant portion of the pop-
ulation either develops unacceptable side effts to certain
drugs or is unresponsive to them. Many scientists and cli-
nicians are now discarding the one-size-fits-all approach
to drug therapy, which was designed to treat an entire
population without addressing important interpatient
variation.
With the advent of the Human Genome Project and
other advances in medicine, pharmacologisu; are hopeful
that future drugs can be customized for patients with spe-
cific genetic sinlilarities. In the past, lUlpredictable and
lUlexplained drug reactions were labeled idiosyncratic Il'-
sponsel. Jt is hoped that performing a DNA te>t before ad-
ministering a drug may someday address idiosyncratic
differences.
TREATING THE DIVER5E PATIENT
Enzyme Deficiency in Certain Ethnic
Populations
has identiIifd a numberofptoprwho in thel'fl-

boh)drall' melabolism. Mairs 01 MtditmalH'an ard African d!scent
IRlyto thisdf,filinKy. h rstimall'd to 400 mili:n workl-
wid!'. Thf disorder GIUIed by IIIIIlItions n the DNA ItrIKtlR that fIICOde for
G6PQ reulting in ontor moll' oImioo oKij mangrs in tilt pro1I'in moItoR .FalION-
ing administmoo of (min drugs. such as prifNQUifll',suifonaridrs, or nitrdu-
rintoin, an oIClI1I' hnnoIysis; of ml bbod cells 01111 due 10 the brNking of
(hemi:al bonck in the hl'lII09bbin Up 10 50% of thecirwlating RIls
may lit df,stro)'fd. Geon:i: typing does oot always prtekt \OI:i:ity; thus, the lUSt
must obserw pa1il'flu Cilmutj foIklwiTf!j the administrililn d thrsr ml'dica-
lions. "- good akM\atiYr choiu5 b thrst ml'dications.
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Pharma(ogenetin is the area of pharmacology that examines
the role of heredity in drug response. The gre.1lest advances
in pharmacogenetics have been the identification of subtle
genetic differences in drug-metabolizing enzymes. Genetic
differences in these enzymes are responsible for a significant
portion of drug-induced toxicity. It is hoped that the use of
<>. '
.;t; Chapter REVIEW
KEY CONCEPTS
CNpttr5 I'hormac:odyn.min 51
pharmacogenetic information may someday allow for cus-
tomized drug therapy. Although therapies based on a pa-
tien!"s genetically based response may not be cost effective at
this time, pharmacogenetics may radically change the way
pharmacotherapy will be practiced in the fumre.
The numbered key concepts provide a succinct summary of the important points from the corresponding numbered section
within the chapter. If any of these points are not dear, refer to the numbered section within the chapter for review.
5. 1 Pharmacodynamics is the area of pharmacology con-
cerned with how drugs produce change in patients, and
the differences in patient r"'pon""s to medications.
5.2 The therapeutic index, expressed mathematically as
TD'iO 7 ED'iO> is a value representing the margin of safety
of a drug. The higher the therapeutic index, the safer the
drug.
5.) The graded dose-response relationship describes how the
therapeutic response to a drug changes as the medication
dose is increased.
NCLEX-RN" REVIEW QUESTIONS
D What is the term for unpredictable and unexplained drug
reactions?
1. Adverse reactions
2. Idiosyncratic reactions
3. Enzyme--specific reactions
4. Urutltered reactions
D A drug that occupies a receptor site and prewnl5endoge-
nous chemicals from acting is ca.J.led alan:
I. antagonist
2. partial agonist.
3. agonist.
4. promgonist .
o In considering the pharmacotherapeutic perspective,
which property is considered to be of most importance?
I. Potency
2. Efficaq
3. Toxicity
4. Interaction with other drugs
D The term used to describe the magnitude of maximal re-
sponse that can be produced from a particular drug is:
1. efficacious.
2. toxic.
3. polent.
4. comparable.
5.4 Potency. the dose of medication required to produce a par-
ticubr response, and efficacy, the magnitude of maximal
response to a drug, orc means of compo ring medications.
5.5 Drug-receptor theory is used to explain the mechanism of
action of many medifriltions.
5.6 Agonists, partial agonisl5, and antagonists are substances
that compete with drugs for receptor binding and can
cause drug-drug and drug-food interactions.
5.1 In the future, pharmacotherapy will likely be customized
to match the genetic makeup of each patient.
D Morphine has a greater efficaq than either of the OTC
drugs, aspir in or acetaminophen. Based on what the nurse
knows about efficaq, what patient condition might re-
quire a dose of morphine rather than either aspirin or
acetaminophen?
1. A patient who is in mild pain but does not like to take
aspirin or acetaminophen
2. A patient who rouIinelyusesacetaminophen at home
for pain relief
3. A patient who quickly develops allergies to multiple
medications
4. A patient in moderate to seo,'ere pain after the other
drugs have been ineffeaive for pain relief
1:1 A nurse reads that the drug to be giwn to the patient has
a n r r o w therapeutic index." This means that the drug:
I . has a narrow range of effectiveness and may not give
this patient the desired therapeutic results.
2. has a narrow safety margin and even a small increase in
dose may produce adverse or toxic effects.
3. has a narrow range of oonditionsordiseases that the
drug will be expected to treat successfully.
4. has a narrow segment of the population for whom the
drug will work as desired.
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52 lInKt CoreConc<!pl$tnPN,miICOIogy
CRITICAL THINKING QUESTIONS
1. lrthe ED,. Is the dose required 10 produce an effeclive reo
sponse in 50% of a group of patients, happens in the
SO% oflhe patients after a dose has been adminis-
1....001
2. T","O drugs au C(Hl'Ipetlng lOr a a masl ceO that
will cause the release of histamIne when actiY1lted. Com-
pare the effects of an agonist versus an antagonist on this
reu'J'lOr. Whkh WQU]d likely be called an antihistamine,
the agonist or the antagonlstr
!in A.ppmrliJr D for m.slWf'J ,,,,II Mllo.,,'/e! for al/ naMlirs.
EXPLORE -----,
tlyttursngKit is ftII,I' lIr1e *'" k:f 0t*It dl.er It'<iew mlle1&is and
rnout ..... Pt __ Ito" OU<CAI will> NClEX"'1ofYIo
Ip'Stim. tnttnlClll.\Ol ard acII_ wtillli'M,
iIItd rideos. iIId morel
-=-mc!e frt)m !!Ie d ytlUt" IiIK* II
_....,., .... kito:Glll.
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CHAPTER 6
CHAPTER 7
CHAPTER 8
CHAPTER 9
CHAPTER 10
CHAPTER 11
CHAPTER 12
The Nursing Process in Pharmacology
2
armacology
nd the
Nurse-Patient
Relationsh ip
Drug Administration Throughout the life Span
Psychosocial, Gender, and Cultural Influences on Pharmacotherapy
Medication Errors and Risk Reduction
Herbal and Alternative Therapies
SubstanceAbuse
Emergency Preparedness and Poisonings
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KEY TERMS
phil! plJlJr55
baseline dna fII1!' 55
e'liluation phiW {I/Jqd9
goal fIIlI1'57
The Nursing Process
in Pharmacology
LEARNING OUTCOMES
Afrer froding this chapter, the 5Ndent should be able 10:
1. Compare and contranthe different steps of the nursing process.
2 . Identify that is pertinent to medication administration.
3. o..wlopappropriat .. nu"ing diagno.". for pati"nu ""<living
medications.
4. Plan realistic goals and OUtCOlTM!5 for patients receiving medications.
S. Discuss key intervention strategies 10 be implemented for patients
receiving medications.
6. Evaluate the outcomes of medication administration.
implementation phaw jllJlTjIJ
nur1ing diigOOIM fIIl1' 57
proem {11IJ<'55
objectivto data 1'1111'"
outrom. f'JI1'jIJ
planning phis. fIIJI1' 57
l ubjKtive dilla fill!' 55
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T
he nursing prOC:fsl is <I systematic method of problem
solving that forms the foundation of nursing practice.
The use of the nursing process is particularly important for
patients receiving medications. By using the steps of the
nursing process, nurses can ensure that the interdiscipli-
nary practice of pharmacology results in safe,effective,and
individualized medication administration and outcomes
for patients under their care. These steps are illustrated in
,. Figure 6.1.
Most nursing students enter a pharmacology course after
taking a course on the fundamentals of nursing. during
which the steps of the nursing process are discussed in detail.
This chapter focuses on how the steps ofthe nursing process
can be applied to pharmacotherapy. Students who are unfa-
miliar with the nursing process are encouraged to consult
one of the many excellent fundamentals of nursing text-
books for a more detailed explanation.
6. 1 Assessment of the Patient
The aSltsSmenl p h ~ of the nursing process is the systt'matic
collt'ction, organization, validation, and documentation of
patit'nt data. Assessment is an ongoing process that begins
with the nurse's initial contact with the patient and contin-
ues with every interaction thereafter.
A health history and physical assessment are completed
during the initial meeting between a nurse and patient.
~ Flgure 6. ' The flvt' overlapping phast's oflhe nursing
proct'ls. Each phase depends on the accuracy otlhe olher
phases.
Banlinedata are gathered on the patient that will be compared
to information obtained from later interactions, during and
following treatment. Assessment consists of gMhering
subjec:tive data, which include wh.,1 the patient says or pt'r-
ceives, and objec:tive dati gathered through physical assess-
ment,laboratory tests, and other diagnostic sources.
The initial health history is tailored to the patient's din-
ical condition. A complete history is the most detailed., but
the nurse must consider tht' appropriatt'ness of Ihis his-
tory given the patient's condition. Often the nurse takes a
problem-focused or "chief oompJaint" history that focuses on
the symptoms that led the patient to seek care. In any history,
the nurse must assess key components that could potentially
affect the outcomes of drug administration. Essential ques-
tions to ask in the initial history relate to history of drug al-
lergy; past medical history; medicatioru currently used;
personal and social history including the use of alcohol, to-
bacco, or caffeine; health rilks such as tht' ust' of street
drugs or illicit substances; and ft'productive health ques-
tioru such as the pregnancy slatus of women of childbear-
ing age. Assessment should always include the use of
over-the-counter (OTC) drugs, dietary supplements, and
herbal products because these agents have the potential to
affect drug tht'rapy. Table 6.1 provides perlinent questions
that the nurse may ask during an initial health history that
provide baseline data before medications are administered.
Nurses must remember that what is not being said may be
as important as what is being said. For instance, a patient
may deny symptoms of pain while grimacing or guarding
a certain area from being touched. Nurses must use their
obst'rvation skills during the history to gather such critical
data.
Along with the health history, a physical asse:ssmenl is
oompleted to gather objective data on Ihe patient's condi-
tion. The nurse may obtain vital signs, height and weight, a
head-to-toe physical assessment, and laboratory specimt'ns.
These provide the baseline data to compare with future as-
sessments and guide the health caft' provider in deciding
which medications to prescribe. Because many medications
can affect the heart rail' and blood pressure, the nurse
should carefully document chronic conditions of the car-
diovascular syslem. Baseline electrolyte values are impor-
tant parameters to obtain, because many medications affect
electrolyte balance. Renal and hepatic function tests are es-
sential for many patienls, particubrlyolderadults and those
who are crilically ill, because kidney and liver disease often
ft'quift's adjustment in drug dosages (chapter fPIO).
Once phamlaootherapy is initiated, ongoing assessments
are conducted to detennint' the effectiveness of the medica-
tions.Assessment should first focus on determining whether
tht' patient is experiencing the expected therapeutic benefits
from the medications. For example, if a drug is givetl for
symptoms of pain, has the pain subsided? If an antibiotic is
given for an infection, have the signs of that infection im-
proved over time? If a patient is not experiencing the thera-
peutic effects of the medication, then the nurse must conduct
further assessment to determine possible reasons. Dosages
are reviewed, and serum drug levels may be obtained.
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56 UnK2 J>ha,mKolog)r ind the NUfW-P.tient R .... tlonmlp
TABLE 6.1 Health History Assessment Questions Pertinent to Drug Administration
Health History Component Areas Pertinent Questions
(hid" complaint Ibv do
hit mtlkal histOil
folmiylillory
Drug liltory
Pl'rsonal- sodal histOil
ri51:. hiltOil
haYiog artf plin?lDtsaibl')
uptrimciog Ollltr s)TIlproms?l Espffialy pffiiOffit to mtdicitiolllolrt' naw.a, vomiting. iidJing.
diu inm, !horlMn 01 brt'ath, ntI'/OU!rItSS or inxiouwsl, or "IIunning. "and or filtigUl'.)
Alt )'Oll illffijil toartf mrdicitions?
Alt)'Oll allffijil to artf ffil'ilonmffitil IltIruncrs (t.g., pollffi or"lNlOIIar alltl9its), tapt. !lips. or dNOIm?
Whal spe<ifKollIy analtrg)'?
Do)'OU hal'! a hiltOil of thoot5, hNIl or valCWr or nl'urologic: (onditions?
Do)'OU hal'! artf dmniIloIogic: (onditions?

Hi! artfOlH' in )'OU,fimily with in, mftkations? (DeaitJIo)
OoHafl)'Olll' in yOII' filmily hol'l t an,Yljnifi(,lnt mtdi<al probItms?
Whal prtIIJiption mtdicition S ile you amnlly tilting? (Lilt drug naml', dosq, and lil'qumq of
What tilting? (Lilt IIolme,tIoIaqt. i nd
What pr&riprion or OK. hal'!')'011 takrn willin!hl' plit month or two?
100 Mr UpnitlKN iny sidttllemor !JllllWls)TIlproms with in, (DeaitJIo)
Whal do 100 U-, or what Wl'1I')W mftkations?
Do)'OU Ulfan, hfflIal or homropathic: lI'IIltde? Artf IlUtritiolloJl IUbstance or Yilamins?
idtnlify all hNkh GIrt' pnr.'idtrs you hal'!sttn lor issue.
When was thtLlIt timt)'OU 'ioI'Ii i htalth (,Irt' proYidtrl forwhat IUIOO did you this prwidtr?
What is 1QI.J IlOIIOOI diet?
Do)'OU hal'! artf tl\Jltllt slttping?
Is lhere irtf poIIibiily )'011 all' prtgnant? (Alt ewry woman 01 dljlibariog ige.)


WllatisYOOSllOflll.ltikoholintoktl
What is yoos normal uflrinl' intake?
Do)'OU 11M .rtf ll'igious or (u/nnI brlid"s or proKtie (omming mI'lkalkm or yotI' htollth tholt '11'1' !hoWl know about?
Whal is yotI'CKG4JoIlionlWhatlloun do 100 'IIOJII::?
Do)'OU hal'!.rtf (OII(ffl)I rrgaidog or !hi' to ifford mNicilions?
Do)'OU hal'!artf lisl:oryofdtpresion or o!hl'r mentil IllII'Ss?
Do)lOO U\uny!lrM drugs or iltidt
Assessment during pharmacotherapy should also identify
any adverse effects experienced by the patient. Assessment
should include the patient's perceptions of the ad\'t'rse ef-
fects, as weU as follow-up vital signs and laboratory reports.
Here again, baseline data are compared with the current as-
sessment to determine what changes have occurred since
the initiation of pharmacotherapy. The Nursing Process Fo-
cus flowcharts provided in chapters 13 through 4900 illus-
trate key assessment data that the nurse should gather that
are associated with specific medications or classes of drugs.
tion. Will the patient require assistance obtaining or pur-
chasing the prescribed medications, or with taking them
safely? \'/hat kind of medication storage facilities exists and
are they adequate to protect the patient. others in the home,
and the efficacy of the medication! Does the patient under-
stand the uses and effects of this medication and how it
should be taken! Do assessment data suggest that the use of
this medication might present a problem, such as difficulty
swallowing large capsules or an inability to administer par-
enteral medications at home, when necessary?
Finally, it is important to assess the ability of the patient
to assume responsibility for self-administration of medica-
After analyzing the assessment data, the nursedetermines
patient-specific nursing diagnoses appropriate for the drugs
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prescribed. These diagnoses will form the for the re-
maining steps of the Nursing Process.
MEDICATION ERRORS
AND DIETARV SUPPLEMENTS
Herbal and vitamin supplements can have powerful effects
on the body that can inl1uen<:e the success of prescription
drug therapy. In $Ome cases.o\"tr-the-counter suppl ements
cr.n enhance the effects of prescription drugs, whereas in
other insran<:es supplements may cancel the ef-
fectsofa medication. Fore.umple.many patients with heart
disease take garlic supplements in addit ion to warfarin
(Cownadin) to pre\"tnt clots from forming. Because garlic
and warfarin are both antiroagulants. taking them together
could result in abnormal blK'ding. AI. another example.
high doses of calcium supplements can cancel the beneficial
antihyperteru;ive effects of drugs such as nifedipine (Procar-
dial, a cr.lciwn channel blocker.
Few controUed studies have ex:lmined how concurrent
use of natural supplements affects the therapeullc effects of
prescription drugs. Patients should be encouraged to report
use of all over-the-counter dietary supplements to the
health care provider.
6.2 Nursing Diagnoses
Hooing are clinical judgments of a patient's actual or
potential health problem that is within the nurse's scope of
practice to address. Nursing diagnoses provide the ba5is for
establishing goals and outcomes, planning interventions, and
evaluating the effectiveness of the care given. Unlike medical
diagnoses that focus on a di5e;lseor condition, nursingdiag-
noses focus on a patienl's response to actual or potential
health and life processes. The North American Nursing Diag-
nosis Association (NANDA) defines nuningdiagnoses as;
A clinical judgment about individual. family. or commu-
nity responses to actual or potential healthllife processes.
Per NANDA, nUf$ing diagnoses provide the basis for se-
lection of nursing inlerventions 10 outcomes for
which the nurse is accountable.
Nursing diagnoses are often the most challenging part of
the nursing process. Sometimes the nurse identifies what is
believed to be the patien!'s problem, only 10 discover from
further assessment that the pbnned goals, outcomes, and
interventions have not solved" the problem. A key point to
remember is nursing diagnoses focus on the patieut's
needs, not the nurse's needs. A primHY nursing role is to en-
able patients to become active participants in their own
care. Byincluding the patient in identifying needs, the nurse
encourages the patient to take a more role in working
toward meeting the identified gools.
Whenapplioo to the diagnosis phase of
the nursing process addresses three main areas of concern.
Promoting therapeutic drug effects
Minimizing adverse drug tffects and to."(jcity
Maximizing the ability of the patient for self-care,
including the knowledge, skills, and resources necessary
for safe and effective drug administration
NUf$ing diagnoses that focus on drug administration
may address actual probll'l11$,such as the of pain;
focus on potential problems such as a risk for deficient Ouid
volume; or concentrateon maint:lining the patient's current
level of well ness. Thediagnosi s is wriut'l1 as a one-. two-,or
three-part st:ltement df"J'("nding on whether the nurse has
identified a wellness, nsk,oractual problem. Actual and risk
problems include the diagnostic st:ltement and a related fac-
tor, or inferred cause. Act ual diagnoses al$O contain a third
part, the evidence gathered to support the chosen statement.
There are many diagnoses appropriate to medication ad-
ministration. Some are nursing specific that lIle nurse can
manage independently, whereas other problems are multi-
disciplinary and require collaboration with other members
of the health care team.
Two of the most common nursing diagnoses for med-
ication administration are Klrowlcdge and NOII-
compliallce. Knowledge deficit may occur when the patient
was given a new prescription and has no previous uperience
with the medication. This diagnosis may also be appliCllble
when a patient has not received adequate eduClltion about
the drugs being prescribed. \Vh.en obtaining a medi(;ltion
history, the nurse should assess the knowledge re-
garding the drugs currently being taken and evaluate
whether the drug edu(;ltion was adequate. Noncompliance,
aJso called nonadherence, assumes that the patient was prop-
erly e.:IU(;lte.:l about the medication but has made Ihe deci-
sion not to t:lke it. It is vit:ll that the nurse assess possible
factors leading to the noncompliance before establishing this
diagnosis. Does the patient understand why the medication
was prescribed? Was dosing and scheduling information ex-
plained? Are adverse effects causing the patient to refuse the
medication? Arecultural, religious.or social issues impacting
the decision not to take Ihe medication? Is the noncompli-
ance related to inadequat e fi nancial resources?
Table6.2 providesan abbrrnatoo list of $Orne of the com-
mon nursing diagnoses appropriate to drug administration.
Although the list contains actuat numng dIagnoses, these
may also be identified as risk diagnoses. This is not an ex-
haustive list of all NANDA_approved diagnoses, and the es-
tablishment of new diagnoses is ongoing. The nurse is
encouraged 10 consult books on nursing diagnoses for more
information on establishing, writing, and researching other
nursing diagnoses that may apply to drug administration.
6.3 Planning: Establishing Goals
and Outcomes
The planning phUI' of the nursing process prioritizes diag-
noses, formulates desired outcomes, and selects nursing
interventions that can assist the patient to return to estab-
lish an optimum level of weUness. Short- or long-term goali
are est ablishe.:l that fOCll'S on what the patient will be able
to do or achieve, not what the nurse wi)) do. The objective
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58 UnK2 J>harmKoIogy.nd tl>eNufW-Pati<'nt R .... tlonmlp
NANDA-Approved Nursing Diagnoses
ActiYity IntoWmn
Intffffiift /-jrwlf1 C1t.inu

Hilt 101
IntfI'ffiivt Blulhill9 Panm
Dffiustd CardioKDuIpU
for Erha'xtd (omfort
'krtIi1 {ommurimion
umtipation
Risk for {onlaminalion

[hrrllei

RiskforFilk
Fitigue
Ddioml Fluid
FluidVolume
Gas Enhill4}e
Intffffiivt HNIth MiinlenaOO'
Risk for CompromMd HUllliln Digrity
H)'pffihmnii
Hypothffinii

Risk for Infection
Rill::forlnjul}
Offidtnt I(nowld9!'
Rill:: for Impaiml Lim" FlIKIim
Impaird Ph)'lical Mobility
HiUIN

ImbiliuKtd
ImpaRd Oril MocOUl MembrilN'
""
RiIUorPoilOlling
StIHn DtfKil
Oimrlltd StoIOI)' i'mrplion
Stxuai OyIfunction
ImpaRd Skin
Oimrlltd Sl tep Pinffll
Strns<lvfllNd
Rill::forSlidde
ImpaRd SwilioowilHJ
ThtrapMK
Manogellltllt

Oimrlltd 'fhou9:lt
TMUI' Pmulion
Uriniry Relention
measures of t hose goals, or out(Omfl, specifically define
what the patient will do, under what circumstances, and
within a specified time frame. The nurse also discusses
goals and outcomes with the patient or caregiver, and these
are prioritized to address immediate needs first. Planning
links the strategies, or interventions, to the established
goals and outcomes.
Before administering medications, nurses should estab-
lish clear, realistic goals and outcomes so that planned inter-
ventions ensure safe and effective use of these agents. The
nurse establishes priorities based on the assessment data
and nursing diagnoses, with high-priority needs addressed
before low-priority needs.
\\fith respect to pru.nnacotherapy, the planning phase in-
volves two main components: drug administration and [XI -
tient teaching. The overall goal of the nursing plan of care is
the safe and effective administration of medication. The
nurse may focus goals related to pharmacotherapy for the
short term or long term, depending on the setting and situ-
ation. For a patient with a thrombus in the lower extremity
who was placed on anticoagulant therapy,a short-term goal
may be thm the patient will not experience an increase in
dot size, as evidenced by improving circulation to the lower
extremi ty distal to the dot. A long-term goal might focus on
teaching the patient to effectively administer parenteral an-
ticoagulant therapy at home.
Like assessment d.1la, pharmacotherapeutic goals should
focus first on the therapeutic outcomes of medications, then
on the prevention or treatment of adverse effects. For the [XI-
tient on pain medication, relief of pain is a priority estab-
lished before treatment of the nausea, vomiting, or dizziness
caused by the medication. The nurse should remember, how-
ev\T, that planning for the prevention or treatment of ex-
pected adverse effects is an integral step of the plalllling phase.
Outcomes are the specific criteria used to measure attain-
ment of the selected g0.11s. They are written to include the
subject (usually the [XItient), the actions required by that sub-
ject, under what circWl15tances. the expected performance,
and the specific time frame in which the subject will accom-
plish that performance. in the example of the patient who will
be taught to self-administer anticoagulant therapy at home,
an outcome may be written as: "Patient will demonstrate the
injection of enoxaparin (Lovenox) using the preloaded sy-
ringe provided, given subcutaneously into the anterior ab-
dominal areas, in 2 days (l day prior to discharge)." This
outcome includes the subject ([XItient), actions {demonstrate
injection},circumstances (using a preloadedsyringe), perfor-
mance (SC injection into the abdomen), and time frame
(2 days from now- l day before discharge home). Writing
specific outoomes also gives the nurse a concrete time frame
to work toward assisting the patient to meet the goals. i n the
case of children or the mentally impaired, the pharmacother
apeutic outcomes include the caregiver responsible for ad
ministering the medication in the home setting.
After goals and outcomes are identified based on the
nursing diagnoses, a plan of care is written. Each agency de-
termines whether this plan will be communicated as either
nursing centered, interdi5ciplinary, or both. All plans should
be patient focused and include the patient or caregiver in
their development. The goals and outcomes identified in the
plan of care will assist the nurse, and other health care
providers, in implementing interventions and evaluating
the effectiveness of that care.
6.4 Implementing Specific
Nursing Actions
The Jilasr is when the nurse applies the knowl-
edge, skills, and principles of nursing care to help move the
patient toward the desired goal and optimal wellness. imple-
mentation involves action on the part of the nurse or patient:
administering a drug, providing patient teaching, and initiat
ing other specific actions identified by the plan of care. \'lhen
applied to phannacotherapy, the implementation phase in
volves administering the medication, continuing to assess the
patient and monitoring d rug effects, and carrying out the in-
terventionsdeveloped in the planning phase to maximize the
therapeutic response and prevent adverse events.
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TREATING THE DIVERSE PATIENT
Non- English-Speaking
and Culturally Div@ulitPatilitnu
MIne shaul:! kIIov< in mOO', wh.n tranWfun sel'lim aoo iotrrpmm
Milablt in hNhh cart faciity to alUit with COOlllUlication. The nuBl'
shlUd use interpreter's Sft'/i;:e Milablt, 'Ridating with
that lItor w iI ablt to the patitntMany dialects similar but no!
thf. same,aoo blowilg anothtr IiIlHJIagt is lid: 5:a0ll' lIlderllindilg
Can tht intrrprfter undmtand the patient's Ianglllge ard rulwral expm-
lions or nUilrns W!"I mJUljh for COOlllUlimion to 011"1 H a famil)o
OII'IIIber is if a chid is for a PftIll or matiYe.
be th.n tilt tht information 100; to
tht ruse bekftexpiaining it in thl' patitot's own is rspHialy im-
portantifthttrartliation isa SlIIlmaryofwh.nwn said rather than a
translation.Bmrean is availablf,orif one is ullmilabie,UII' pi:1Urrs,

tient. of rulwral)- btifd I"ICHI'Ierbal romllUlication brhaioo (r.g.,UIe
of pMOOal eye or lack of f)'f (OOt.J(\). Gender sensitivitirs rrLltfd
to (e.g.,mar 1lUBl' or physic:iall for fmar patients) aoo the Uleof ttu:h
;n oftrn sensitM> isslltS. III thl' llritfd Stairs, an informal and pmonalltylt is of-
ttll norm. WhfII \\Olrting with patitnh of other rufnfts,arIop:ing a IIIOIl' b-
mal styrmay be lIIOIl'appropriatl'.
Monitoring drug effects is a primar y intervention that
nurses perform. A thorough knowledge of the actions of
each medication is necessary to carry out this monitoring
process. The nurse should first monitor for the identified
therapeutic effect. A lack of sufficient therapeutic effect sug-
gests the need 10 reassess pharmacotherapy. Monitoring
may require a reassessment of the patient's physical condi-
tion, vital signs, body weight, lab values, and/or serum drug
levels. The patient's statements about pain relief, as well as
objective data, such as a change in blood pressure, are used
to monitor the thernpeutic outcomes of phannacotherapy.
The nurse also monitors for side and adverse effects and at -
tempts to prevent or limit these effects when possible.
The intervention phase includes appropriate documenta-
tion of the administrntion of the medication, as well as any
adverse effects observed or reported by the patient. The
nurse may include additional objective assessment data,
such as vital signs, in the documentation to provide more
details about the specific drug effects. Statements from the
patient can provide subjective detail to the documentation.
Each health aue facility determines where, when, and how
to docwnent the administrntion of medications and any fol-
low-up assessment data that the nurse has gathered.
Patient teaching is a vital oomponent of the nurse's inter-
ventions for a patient receiving medications. Knowledge
deficit, and even noncompliance, is directly related to the
type and quality of medication education that a patient re-
ceives. State nurse practice and regulating bodies such as
the Joint Commission on Accreditation of Healthcare Orga-
nizations (JCAHO) consider teaching to be a primary role
for nurses,giving it the weight of law and key importance in
accreditation standards. Because the goals of pharmacother-
apy are the safe administration of medications, with the best
therapeutic outcomes possible, teaching is aimed at provid-
ing the patient with the information necessary to ensure this
occurs. Every nurse-patiem interaction can present an op-
portWlity for teaching. Small portions of education given
an, HJur ... lhaH alJJuWll, uf ill -
formation given on only one occasion. Discussing medica-
tions each time they are administered is an effective way to
increase the amount of education accomplished. Table 6.3
sununarizes key areas of teaching and provides sample ques-
tions the nurse might ask, or observations that the nurse can
make, to verify that teaching was effective. The Nursing
Process Focus flowcharts in chapters 13 through 4900 also
supply information on specific drugs and drug classes that is
important to include in patient teaching.
Providing written material assists the patient to retain
the information and review it later. Some medications
come with a self-contained teaching program that in-
cludes videotapes. The nurse must always assess whether
the patient is able to read and understand the material
provided. Patient educational materials are ineffective if
the reading level is above what the patient can understand,
or is in a language Wlfamiliar to the patient. The nurse
may have the patient summarize key points after provid-
ing the teaching to verify that the patient has Wlderstood
the information.
Pediatric patients often present special challenges to pa-
tient teaching. Specialized pediatric teaching materials may
assist the nurse in teaching these patients. of chil-
dren must be included in the medication administrntion
process. The nurse must base medication administrntion in
pediatric patients on safe pediatric dosages and limiting po-
tential adverse drug reactions. Medication research often
does not include children, so data are often Wldear on safe
pediatric doses and potential adverse drug reactions in this
population. There is also a greater risk for serious medica-
tion errors, since drug administrntion in children often re-
quires drug calculations using smaller doses. The nurse
must be vigilant to ensure the dosage is correct because
small errors in drug doses have the potential to cause seri-
ous adverse in infants and children.
The elderly population also presents the nurse with addi-
tional nursing considerations. Age-appropriate teaching
materials that are repeated slowly and provided in small in-
crements may assist the nurse in teaching these patients. It
is often necessary to co-t each the patient's caregiver. Elderly
patients often have chronic illnesses and age-related changes
that may cause medication effects to be unpredictable. Be-
cause of chronic diseases, elderly patients often take multi-
ple drugs that maycause many drug-drug interactions.
6.S Evaluating the Effects
of Medications
The tvaluiltion phair compares the patient's current health sta-
tus with the desired outcome. This step is important to de-
termine if the plan of care is appropriate, if it was met, or if
it needs revision. If it was met, the plan of care was appro-
priate, and the problem or risk was resolved. The nurse and
patients can then address the next highest priority health
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60 UnK2 P'harmKology.nd theNurse--p. lil'nt Relationship
ABLE 6.3 I Important Areas of Teaching for a Patient Receiving Medications
AII'<! ofTl'<!chlng
lberapwlil: UII' and OUUOIlII'S
Moniloring
Medication ministration
OIiN'r monitoring and spffial
Important Questions and Observations
(an)'Oll tiN' 1IiI0II! of 1011" IMdiulionand whal is ustdfor?
Whal will)'Oll look fOlio knOll' llialtht is di'Mift? {Howwill)'Oll kIKIII' WI 1IM'Ii<inl' is 'IIOJIking?!
Whidl dIMS (in ytI'J by)'OUN'lf? lIiIultl,diarrhN)
Whidl dIMS s.houId you rtpOIt to 1001 health 0:;11"1' provider? (ilt! OfllilUll'i 01 YOIllitinq.nirrllM'

(an)'Oll hOI\' mum oftht IIM'IiGflion)'OU should numbl'r
(an)'Oll how shoWd
Whal ntmSlIl wIIffi)'Oll take this lIM'Iiution? a fUlglassofwalef, uu- on an
empty SIOmad1, and remain upri9:lt for 30 minUll'sj
k thffl' i loptdrK OIdtrin whim you sIlood taU- 1011" medications? brondIodilator using a
imller)
(an)'Oll shOll' ml' how you willljft YIMI"ltIf!he mtdKation? (r .g., r)'l' rtops, SltxUlanaus injraions)
What spffial monitoring is btfOll')'OII takethis OII!diution? Can you this fOlIlM'?
Bastd on tllal wIIffi should )'OIl nor
Do you know how,orwllefr. to ROR' this mtdkadonl
What should)'OU rb ff yoo misl! doSI'?
AII'!he1l' i OY sptdal ttlts )'OU should rriaRd to this lIM'Iiution? -Slid. gllKose ltoIrk.lhffilpeutic drug
'''''
lIowoft!"n shoUd til' done?
Whal OIiN'r lIM'Iiutiom should)'OU oortakr with this mtdkation?
AII' !he1l' aoy foods 01 beomagtl)'OU mUR not 11m this
need. If the goo.l was partially met, the patient is moving to
ward the goal, but the nurse may need to continue interven
tions for a longer time,orsomehow modify interventions to
completely resolvt' the problem. The nur.;ing process comes
full circle as the nurse reassesses the patient, reviews the
nursing diagnoses, makes necessary changes, reviews and
rewrites goals and out,ome.s, and carries out further inter
ventions to meet the stated goals and outcomes.
require revision. The drug dose may need to be increased,
more time may be needed to achit'Ye therapeutic drug lev-
els, or a different or additional drug may be needed. The
nurse also evaluates the effectiveness of teaching provided
and notes areas where further drug education is needed.
Evaluation is not the end of the process but the beginning
of another c)'de as the nurse rontinues to work to ensW"e safe
and effective mediCltion use and active patient involvement
in his or her care. It is a checkpoint where the nurse consid-
ers the overall goal of safe and effective administration of
medications and takes the steps ne<:essary to maximize the
success of phannacotherapy. The nursing process acts as the
overall framework for working toward this success.
As it relates to phanlL1cotherapy,evaluation is used to
termine whether the therapeutic effects of the drug were
achieved, as well as whether adverse effects were prevented
or kept to acceptable levels. If the evaluation data show no
improvement over the baseline data, the interventions may
Chapter REVIEW
KEY CONCEPTS
The numbered key concepts provide a succinct summary of the important points from the corresponding numbered section
within the chapler. If any of these points are not clear, refer to the nWllbered section within the chapter for review.
6.1 Assessment is the systematic oollectionofpatient dahl.As-
sessment of the patient receiving medications includes
health history information, physical assessment data, lab
values and other measurable data, and an assessment of
medication effe<:ts, including both therapeutic and side
effe<:ts..
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6.2 Nursing diagnoses are writtl'n to address thl' patil'nt's re-
sponses related to drug administration. They are devel-
oped after an analysis of the assessment data, are focused
on the patient's probll'ms, and are wrified with the patient
or caregiver.
6.3 Goal. and outcome.., which "'" from the
ing diagnoses, direct the interventions required by the plan
of care. Goals focus on what the patient should be able to
achieve, and outcomes provide the specific, measurable
criteria that will be used to measure goal attainment.
6.4 The implementation phase involves administering the
drug, and carrying out interventions to promote a thera-
NCLEX-RN" REVIEW QUESTIONS
D Which of the following is an incorrect statement regard-
ing nursing diagnosis?
1. It identifies the medical problem experienced by the
patient.
Z. It is a dinical judgment made by the mm;e.
3. It idl'ntifies the patient'sresponsetoactual or potential
he-alth and Ufe processes.
4. It detennines nursing interventions for which the nurse
is accountable.
D An appropriately stated goo.l for a patient with type I dia-
betes mellitus is:
1. the nurse will tt>Ach the patient 10 recognize and
respond to the signs and symptomsofhyposlycemia
prior to discharge.
2. the patient will demonstrate self-injection of insulin,
using a preloaded syringe, into the sulx.utanOO\ls tissue
of the tbigh prior to discharge.
3. the nurst' will teach the patient to accurately draw
up the insulin dose in a syringe.
4. the patient will be able to self-manage his diabetic diet
and medications.
o A IS-year-old adoles.:ent with a history of type I diabetes
presents to thl't'llll'rgencydt>partment in diabetic ketoaci -
dosis. Shl' has successfully self-managed her diet and in-
sulin therapy for the past 2 years. She confides in the nurse
that she deliberntely skipped some of her insulin doses be-
cause she did not want to gain l'il'ight,and shl' is afraid of
CRITICAL THINKING QUESTIONS
1. A 13-year-old patient from .1 rural community who is a
cheerleader was diagnosed with type I diabetes. She is sup-
ported by a single mother who is frustrated with her
daughtl'T's eating habits. The patient has lost weight since
beginning bl'r insulin regimen. The nurse notes that the
patil'nt and her mother, who is wry well dressed, are both
extremely thin. Identify additional assessml'nt data that
peutic response and minimize adverse effects of the drug.
Key interventions required of the nurse include monitor-
ing drug effects, documenting medications, and patient
teaching.
6.5 The evaluation phase of the nursing process compares the
pati"nt'. current h".lth stat""' with the d.,.ired outcom".
This step is important to determine if the pla.n of care is
appropriate, if it was met, or if it needs revision. Nursing
diagnoses are reviewed or rewritten, goals and outcomes
are refined, and new interventions are carried out.
needle marks. Which of the following nursing diagnoses is
most appropriate in this situation! (Select all that apply.)
1. Deficient Knowledge
2. Self-Care Deficit
3. Noncompliance
4. Ineffective Coping
5. Dtsbel.tef
o Which factor is most i mportant forthe nursetoas.sesswhen
evaluating the effectiveness of a patient's drug thenlpy!
1. Patient's promise to comply with drug therapy
2. Patient's satisfaction with the drug
3. Cost of the mediauion
4. EvidenCl' of theJ<lpeutic benefit
II Which ofthl' following put of the nursing process is whl're
the nurse assesses the effectiveness of the medication?
I. Assessment
2. Implementation
3. Diagnosis
4. Evaluation
1:1 During the evaluation phase of drug administration, the
nurse completes which responsibilities?
I. Prepares and administers drugs correctly
2. &tablishes goals and outcome criteria related to drug
therapy
3. Monitors the patient for therapeutic and adwrseeffects
4. Gathers data in .1 drug and dietary history
the nurse would need to obtain before /lUI.king the nursing
diagnosis Noncompliance.
2. The drug regiml'n ofthe patient in question I is evaluated,
and the health care providl'r suggests a subcutaneous in
sulin pump to help control the patient"s fluctuating blood
glucose levels. Write three nursing diagnoses related to this
new therapy.
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J. A nursing student isasslg.ned toa ikensed preplofwho is
administtringoral nvdlcations.. The student notes that the
preceptor admlnistl'fS tbedrup;s safety but routinely falls to
offer the Information about thedrug being Jdmln-
IsteraL kIoentify the information that the nurse should
teach thl! patient during medication administr.lllon.
SAppfndix D foran$WtTS and rAtionaks for aD activities.
EXPLOflE . -------,
/t.)'I'lItSirIg1CI is )WI' __ lor onL'Ie aaptef moiI!w II'IIItl!rilis _
mwrces. I'HIpi<t lor 11.10: .. wiIh IIQCIiI;t
IIIIInc:IIiIIe an:! wdI Hs, RIlIIIXnI
and >'deos.'" lII0I11
1'.fV.*I')WI' ICCe!I COIle frtJn k billie 11\

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KEY TERMS
f'OIT 71
embryoniqM!riod f'Il1"65
fllJlY65
infilnCY fllJlJ'68
middle ildukhood fX1IT 7l
Drug Administration
Throughout the life Span
LEARNING OUTCOMES
After re/ldlng Ih/s chapler, Ille sludenl should blr able to:
1 . Describe physiological changes during pregnancy thai may affect the
absorption, distribution, metabolism, and excretion of drugs.
2. Describe thl! placentaltran5fl!f of drugs from motherlo infant.
3. Match the five FDA pregnancy risk categories with their definitions.
4. Identify factors that influence the transfer of drugs Into breast milk.
5. Identifyte<:hniquM Ihat the breastfeeding mother can use to reduce
drug exposure to the newborn.
6. Explain how differences In pharmacoklnetic variables can impact drug
response In pediatric patients.
7. Discuss the nursing and pharmacologic Implkationsassociated with
each pediatric di!wlopmental age group.
8. Describ@physiologicaland biochemical that occur in thl' older
adult.and how these affl'Ct pharmilcotherapy.
9. Develop nursing Interwntlons that maximize pharmacotherapeutic
outcoml's in thl' older adult.
older adulthood fX19' li
polyphmnacy fXJI" 7l
period fXJI"65
prfl(oool child fXJIJ' 70
Khoolage child PJt 70
Imlogen JI09'65
loddlerhocxl JII1F69
young adulthood fX1IJ' 7]
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B
eginning wtth conception, and continuing throughout
the lire span. of9illls and body systems undergo pre-
dictable physiologlc.al c;hanges that influena the IIbsorptlon.
metabolim\ distribution, and elimination of medlc.1tlon$.
Nurws must recognize such changes 10 ....... ul'1II that drug. "I'
in II safe lind effectivE' manner to patients of ;,I11Ige'S.
This chapter examines how prindples of developmentlll phys-
iology and life sPlln psyc; hology apply to drug administration.
7.1 Pharmacotherapy Across
the Life Span
Growth is a term that characterizes the progressive incre:ll5e
in pilpicili size. Dewlopmenr is a related term that refers 10
the junctional changes in the physical, psychomotor, and
cognitive C.lp"'hilities of a person. Stages of growth and
physical development ru;ually go hand in hand, in a pre-
dictable sequence, whereas psychomotor and cognitive de-
velopment have a tendency to be more variable.
To provide optimum care, nurses must understand
normal growth and developmental patterns that occur
throughout the life span. It is from this benchmark that
devi<ltions from the norm can be recognized,50 that health-
pattern impairmenLS c:r.n be appropriately addressed. For
pharmacotherapy to achie, ... its desired outcomes, such
knowledge IS essenual.
The devdopmenl of a person is a complex process thai
liob the biophyskal with the ps)'I:hosocial, ethnoculturaJ,
and spiritual componenlS to make each individual a unique
human being. This whole-person view is essential to holis-
tic care. The very nature of phannacology requires that the
consider the individuality of each patient and the
specifics of age, growth, and development in relation to
pharmaCOkinetics and pharmacooynamics.
DRUG ADMINISTRATION DURING
PREGNANCY AND LACTATION
Health care providers elU'rcise great caution when ini tiat-
ing pharmacotherapy during pregnancy or lactation
(>- Figure 1.2). ''-/hen possible, drug thCf"Dpy is postponed
until after pregmnq and lactation, or nonpharmacologic al-
ternatives are implemented. There are wme serious rondi-
tions, however, tlut may require pharmacotherapy in such
patienlS. For example, if the patient has epilepsy, hyperten-
sion, or a psychi3t rk disorder prior to the pregnancy, it would
be unwise to disrontinue therapy during pregnancyor lacta_
tion. Conditionssuch ao; gestational diabetes and gestational
hypertension occur during pregnancy and must be treated
for the safety of the growing fetus. Antibiotics may be
sary to treat during pregnancy; acute urinary tnet
infections and tnl15mined infections aTe relatively
common and can hann the fetus. In aU cao;es, health care
,.. Flgutel,1 TrHtlngthepregNntpatient
5oo1E': C Jmny thomasPhcXog/tf)hj.
pnctitioners mw;t weigh the therapeutic benefilS of a given
medication against ilS potential adverse effeclS.
7.2 Pharmacotherapy
of the Pregna nt Patient
Drug therapy in a pregnant ]Xltient requires that the nurse
coruider the effects of the drug 011 both the mother ao; weU as
on the growing fetus. The plx,nta isa semipermeable mem-
brane: Some substances readily pass from m()ther to fetus,
whereas the transport of other substances is blocked. The fe-
W merrbl"lllles rontain enzymes tlut detoxify certain sub-
stances ao; they eross the membrane. For example, insulin
from the mother is inactivated by placental enzymes during
the early stages of pregnancy, preventing it from reaching the
fetus. In general, drugs th.:lt are wate!" soluble, ionized, or
bound to plasma proteins are less likely to cross the placenta.
PHYSIOLOGICAL CHANGES DURING PREGNANCY
THAT IMPACT PHARMACOTHERAPY
During pregnancy, major physiologic:r.l and anatomic
changes occur in the ,odocrine, gastrointestinal (GI), car-
diovascular, circulatory, and renal systems of women. Some
of these changes alter drug pharmacokinetics and pharma-
codynamics and may affect the success of therapy.
ABSORPTION HormCInaJ clungt'S as well n the prosure of
the expanding uterus on the blood supply to abdominal
organs may affect the absorption of drugs. Gastric emptying
isdelayed,and transit time forfood and drugs in the Gltraet
is slowed by progesterone, which allows a longer lime for
absorption of oral drugs. Gastric acidity is also decreased,
which can affect the absorption of some drugs. Changes in
the respiratory system during pregnancy.........jncreased tidal
mlume and pulmonary v;J.S()(IiJ.ation-may cause inhaled
drugs to be absorbed to a gr,ater extent.
DI STRIBUTION AND METABOLISM Hemodynamic changes
in the pregnant patient increase cardiac output, increase
plasma mlume, and change regional blood How. The
increased blood volume in the mother causes dilution of
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drugs and decreases pl asma protein ooncentl':ltions,
affecting drug distribution. Blood now to the uterus,
kidneys, and skin is increased, whereas now to the skeletal
mlL'lCles is diminished. in lipid levels m.ayalter
drug transport and distribution, especially during the third
trimester. Drug metabolism iocreases for (er tain drugs,
most notably anticonvulnts such as (arbamazepine,
phenytoin, and valproic acid. which may require higher
doses during Fat -soluble drugs are distributed
into the Lipidrich breast milk and are ultinutdy passed to
the lactating infant.
EXCRETION By the third tri mester of pregnancy, blood flow
through the mother's kidneys 40% to 50%. This
in( reae has a direct effect on renal plas ma flow, glomerular
ftllnltion nile, and renal tubular absorption. Thus, drug
e.xcretion nltes may be increased, affecting dosage timing
and onset of action.
GESTATIONAL AGE AND DRUG THERAPY
A teratogel is a substance. organism, or physical agent to
which an embryo or fetus is ex posed that produces a perma-
nent abnormality in structure or function, causes growth
retardation, or alliSeS death. The baseline incidence of ter-
atogenic evenl5 is approximately 3% of all pregnancies. Po-
tt'ntial ft'lal consequences include intrauterine fetal death,
physical malformations, growth impairment, behavioral
abnormalities, and neonatal toxicity.
lbere no teratogens. Whether or not a drug
prodlKes a teratogenic effect dcpfnds upon multiple, complex
factors. Like other effects of drugs, there is a dose-responw
relationship, with risk increasing with higher doses. The
timing of drug therapy and the stage o f fetal development
critically affed the risk for possible fetal oonsequences.
Because of the constant changes that occur during feul de-
velopment, the specifK r isk is dependent on whm during
gestation the drug is administered. A well-known example is
the drug thalidomide, which a uses fetal defects during
pregnancy if it is administered day 350 to 48 after the last
menstrual period. ThespedfK malformation is linked to the
lime 01 exposure to the drug: 35 to 37 days, no ears; 39 to
41 days, no anns; 41 to 43 days, no uterus; 45 to 47 days, no
tibia; and 47 to 49 days, tripha13ngeal thumbs.
Prrimplantation pniod: Weeks I to 2 of the first trimester are
known as the preimpluwion period. Before implantation, the
developing embryo has not yet established a blood supply
with the mother. This is sometimes called the
period because exposure to a teratogen eithercauses death of
the t'mbryo or has no effect. Drugs are less likely to cause
congenital malformations during this period because the
baby'sorgan systems have not yet begun to form. Drugs such
as niootine, however, a n create a neg3tive environmnrt for
the embryo and potentially cause intrauterine growth
retardation.
EmbrYUlitperiod: During the embryonic period, from 3 to
8 postcOllception, there is rapid of in-
ternal strudures. This is the period of tnaltimum sensitivity
CNp1fll Drug Admllllm.tlOll Throughoot the Sp;on 55
to teratogens. Teratogenic taken during this phase
ca.n lead to structural malformation and spontaneous abor_
tion. Thespecific abnormality depends upon which organ is
fonning at the time of exposure.
FmI period: The fetal phase is from 9 to 40 weeks postconcep-
tion or until birth. During this time, there is continued
growth and matunltion of the baby's organ systems. Blood
flow to the placenta increases and placental vascular mem-
branes bewme thinner. Such alterations maximize the trans-
fer of substances from the maternal cirrulation 10 the fetal
blood. As a result, the fetus may recei\'c brgerdoses of med-
icatioru; and other substances taken by the mother. Because
the felus lacks mature metabolic mzymes and efficient excre-
tion medtanisms, medialtiom will have a prolonged dura_
tion of adion within the unborn child. Exposure to
lenltogms during the fetal period is more likel y to produce
slowed growth or impaired organ function, r.ilher than gross
structural malfonnatiom.
PREGNANCY DRUG CATEGORIES AND REGISTRIES
Fortunately, the number of prescription drugs that are
strong!ysuspected or known to be teratogeni c is sm3Jl.ln ad
dition, for most clinical condit ions, there a re altern.;Jtivedrugs
that can be given with relative safet y. New or infrequently
used drugs for which there is inadequate information
should not be given to pregfl<lnt women unless the benefits of
drug therapy dearly outweigh any theoretical risk".
The FDA has developed drug ategorits th.at
da:i-:lity medica.tioru; according to their risks during preg-
lWlCy. Table 7.1 lisl5 the fi w pregnancy categorits, which
guide the health alee tealll the pat ient in selecting drugs
that are least hazardous for the fetus. Examples of prescr ip-
tion drugs that are as.sodated with teratogenic effects are
shown in the table. In addition 10 prescription medications,
alcohol, niootine, and ill icit drugs such as cocaine will affecl
the unborn child.
Testing drugs in human subjects to determine their teroua-
genicity is unethic.al and prohibited by law. Although drugs
are tested in pregnant IabonltOl'Y animals, the structull'ofthe
human placenta is unique. This is problematic bOOluselabo-
ratory animals have different physiological, metabolic, and
gmetic charaderistia. Most about fctal malfor-
mations and abnonnalities is atnlpolated from these animal
data and may only be crude of the risk to a
human fetus. The actual risk to a human fetus may be much
less, or magnitudes greater, than that predicted from animal
data. In a few cases, human data are available to show preg-
nancy risks. The following statement bears repeating: No pre_
scription dnlg, over-the-counter (OTC) medklllion, herbal
product, or dietory Jupplemem should be mketl during prt>g_
/lancy III/less the physician verifies that tht IlttrdptJlti, bet/tfits
to ,lte mother tlte potl'l.ti(ll risks for Ihe /Inborn.
The current A, B, C, D, and X pregnancy labeling system is
simplistic and gives no spific clinical infornution to help
guide nurses or their patients about a medication's safety.
lbe system does not india te how the dose should be adj usted
during pregnancy or lactation. Most drugs are category C
LibraryPirate
66 UnK2 J>ha,mKology.nd tiseNufW-p.Uent R .... tlonmlp
TABLE7.1. Current FDA Pregnancy Category Ratings with Exampli!s
Risk Category Interpretation
""",

Wfi,ontrolN 5Iudits iI VIOOItil nOi !hownan Pmlat.ll mukMtilrins, iflllAin. th)fOlint, folic: . OO
ilKrelll'd risk 01 fl'taI abnormalititl to tile fttUi in any trirtlt\ttt of prtgllilrK1.

Animal5llKil's JMiltd 01 hilm to thl' thm
.1"1' 00 odtquall' aOO wtll-<ontrolltd m.odits in pl"l'9nant WIIIIIffi. ibI.prof m in firlt aOO Ittond tri"nfstm
OR
adYers!' rfl'ta. but
5Iode in haft to risk to
thl' .ny tri"nfSil'r.
(
/l.nimalltlKil's . dYersr rfl'K1aOO!herr no and M&St prl'saiprion meditinrs;aminitrotials SIKh is -
5ILde in darittromydn, nuoroquinolone, aOO 8.Ktrim; srlKti..,.
OR
SI'fOtonin mlptal::t inlibitors lSSRIs); rortit&Steroids; and
most amilypenrnsiffi
IH 0 .. "..1 uudi!-< tu .. hNon ,ondllnl'd .nd t/II'", .", no .d>q.ut nd
stLde in
0 or obstrvational5ludits iI VIOOItil ACE inlibiton, an9ioll'lllin rmptor blod:fts (ARBs) in thI'
demOllltlall'd . rill:: to thl' fl'tus. Ittond and thild gtllamitil, ibuprofl'n in thl'
risk.Fwm""',
tlinl trirtlt\ttt; tetrar1dilltl, l'rrmilrin, alrohol. aOO nic:otilH'
thl' tro;t lIIiIy b.- oJ(rtpt.lilll' if ndfd in a lifHl"Rail'llitllj or Sl'rious
disease for whidt life- tro;tlUmot b.- used IX <R
X or obltrvilional5ludits iI anilllilk or prtgnant Ao:cutant, misoprostol,.OO thalidonidlo
WOOltIItuft dmlonsuatfd positi..,. u ideitCl' ti fttil.bnormailil's or mu.
TheUSI' tithl' product is rontraiOOic:atN in WOIntil whoaJl' IX may IIe<orM
is 00 iKiwion for uS!' in prtgnanq.
because very high doses in laboratory animals often pro-
duce teratogenic effects. All category D and X drugs should
be avoided during pregnancy due to their potential for caus-
ing serious birth defects. Because a woman may obtain a
prescription before she knows she is pregnant, it is crucial
that the nurse ask all women of child-bearing age if there is
the possibility of pregnancy as part of the routine teaching
that accompanies giving a patient their prescription.
PREGNANCY REGISTRIES
Pregnancy registries help identify medications that are safe
to be taken during pregnancy. These registries gather infor-
mation from women who took medications during preg-
nancy.lnformation on babies born to women not taking the
medication is then compared with data on babies born
while medication was taken during pregnancy. The effects
of the medication taken during pregnancy are then evalu-
ated. Registries may be maintained by drug companies,gov-
ernmental agencies, or special -interest groups. Examples of
pregnancy registries include the following:
Antipsychotic medicines: http://www.motherisk.orgl
womenlindex.jsp
Antiretroviral medicines: http://www.apregistry.coml
who.htm
Asthma medications: http://otispregnancy.orgl
Epilepsy medications: http://www2.massgeneral.orglaedl
Autoimmune disease medications: http://www
. otispregnancy.orgllunlinside. php?sid= 7&id=40
7.3 Pharmacotherapy
of the Lactating Patient
A large nwnber of drugs are secreted into breast milk. For-
tWlately, there are relatively few instances where drugs se-
creted into breast milk have been found to cause injury to
infants. For the few drugs that are absolutely contraindi-
cated during lactation, equally effective, safer alternatives
a", u.ually available. Although mo.t medication. probably
cause no harm to the breast-feeding baby, their effects have
not been fully studied.
As with the placenta, drugs that are ionized, water solu-
ble, or bOWld to plasma proteins are less likely to enter
breast milk. Central nervous system (CNS) medications are
very lipid soluble and thus are more likely to be present in
higher concentrations in milk and can be expected to have a
greater effect on an infant. Although concentrations ofCNS
drugs in breast milk are fOWld in higher amounts, they of-
ten remain at subclinical levels. Regarding the role of pro-
tein binding, drugs that remain in the maternal plasma
bound to albumin are not able to penetrate the mother's
milk supply. For example, warfarin is strongly bound to
plasma proteins and thus has a reduced milk level because it
is unable to transfer into the maternal milk.
The American Academy of Pediatrics (AAP) Committee
on Drugs provides guidance on which drugs should be
avoided during breast-feeding to protect the child's safety.
Medications that pass imo breast milk are indicated in drug
guides. Nurses working with pregnant or breast-feeding
women should give careful attention to this information .
LibraryPirate
ABLE 7.2 Selected Drugs Associated
with Adverso Effects During
" Breast-Feeding
Effect 01 Rtason5
Drug for Concem

iIIiodMant((onInnt)

aljlijn alii OIhlr
atenokJl {lmlmIinj (j1l'lOlls:
Imr10aiptinf (hrIodtI) IIWII' lit hmrdousUlIIIf
.....
CoaInt il'll0IDuc1on: klbl;litJ.

rf9OIl11inr (EJgDltat) UIfd in
migrW.e
(Prout") fffclingard disorders.rMuudlWiQh!
9Iin.coic
haloptridol (HaIdd) in developrntnt.ll
lithiLm (Elbith) OnHhhd to bIoOO
COf(ctntJition In Infuts
p/lffiindioM AnticoagulaM:iI{I!astd proIhrombin and

phfnobarbilal(wminil) Sffition;lnfantilt from
contili'lng Fi'enoNlbitil.
melhtmoglobilemia
(Mpdine) probItms
IlMNiziIe (AnMdne) 1I'*" .... nm
SrxNtr.fIOOI"TM Jra" CIf()ugsand OIlIer
Mit"b!' ArHIi<MI ""'_CIf ComIIittft on 0r\r9S.
J, pp. m- 7Il. Rtprirtmw'itt1 ptmIissIon.
Selected drugs that enter the breast milk and have been
shown to produce adverse effects are listed in Table 7.2.
It is important to understand facton that innuence the
amollnl nf tlnl!! MCretM ;nln milk. the
nurse to aid the patient in making respon5ible choices re-
garding lactation and in reducing exposure of her newborn
to potentially harmful substances (.- Figure 7.2). The same
guidelines for drug use apply during the breast_feeding pe-
riod as during pregnancy-drugs should be taken only if
the benefits to the mother dearly outweigh the potential
risks to the infant . The nurse should explore the possibility
of postponing pharmacotherapy until the baby is weaned,
or perhaps selecting a safer, nonpharmacologk therapy. If a
drug is indicated, it is sometimes useful to administer it im-
mediately after breast-feeding, or when the infant will be
sleeping for an xtended period, so thai time elapses before
the next feeding. This will usually reduce the concentration
of active drug in the mother's milk when she later breast-
feeds her infant. The nurse c;rn assist the mother in protect-
ing the child's S<lfety by teaching her to avoid iUidl drugs,
a1oohol , and tobacco products during lactation.
CNp1fll Drug Admllllm.Uon Throughootthe Spin 67
.- Figure 7J Treating the bl"eat-feedlng mother
So/xCl: Clmnt 1homas
When considering the effects of drugs on the breast-
feeding infant, the 1UIWlint of drug that actually reaches the
infant's tissues must be considered. Some mediauions pro-
duce no adverse effects beawe they are dest royed in the in-
fant's GI or are unable to be absorbed across theGI
tract. ThlH, although many drugs .!rctro in bt-U.51
milk, some are present in such small amounts that they
cause no noticeable harm.
The last key fa ctor in the effect of drugs during bClation
relates to the infant's ability to metabolize small amounts of
drugs. Premature, neonatal, and seriously ill infants may br
at greater risk for adverse effects bec;ruse they lack drug me-
tabolizing enzymes.
Some recommendations regarding mediutions given
during lactation are as follows ( Halt, 2004):
Drugs with a shorter half-life are preferable. Peak levels
are rapidly reached and the drug is qukkly cleared from
the maternal plasma, which reduces the amount of drug
exposure to the infant. The mother should not breast-
feed while the drug is at its peak level.
Drugs that ha'e long half- lives (or active metabolites)
should be a'oided beause they c;r n accumulate in the
LibraryPirate
6B Unftl Ph.lfmKology lind The Nutse-PILUen!
infant's plasma. Examples include barbiturates,
benzodiazcpines. mepnidine, and f1uoxetine.
Whene"er possible, drugs with high
ability should be Sf lected bau.se they a re not secreted
as readily to the milk.
All arc herbal products and dietary suppLements should
be avoided duri ng l;actation, unless pre$Cl"ibed
by the health are provider bea.use the safE'lyoflTlO!\! of
these products 10 t!"le infant has not been determined.
7.4 Patient Teaching During
Pregnancy and lactation
Patient education during pregnango and lactation is critical to
the success of pharmacotherapy and to the safety of the
mother and baby. The nurse should an in_depth his-
tory and prenatal asstSSment to eilmlnate potentially haz-
ardous substances, substitute alternative drugs, or adjust
medication dOSOlges. The patient needs to be thoroughly in-
formed about the risks to both herself and her unborn child
related to the use of drugs, alcohol, tobao, alternative thera-
pies, and ore mediations. Indude the foUowing points
when teaching p<ltient5 about drug therapy during pregnancy:
Keep all scheduled physician appointments and
laboratory visits for testing.
Do not take other prescription drugs, OTC medications,
herbal remedies, or dietary suppl ements without
notifying your health care provider. Your health care
provider may need to change a prescribed drug to
another similar drug or change the drug dosage.
Take iron, folic acid, and multivitamin supplements as
prescribed during pregnancy.
Eliminate alcohol and toba<:co u.se.
PHARMhCTS
Fetal Effects Caused by Specific Drug Usa
During Pregnancy
IoVrijuan.: bibie!. risk 04" prtlllilm d/,liftry,
withdrlW.1 (oying.nd uembrll"l\l)
Cwinr:inat.Jstd risk d ITiKimq, dtlNrry,1lIi1formalioM of
Rttl rmm.nd kiItyI, bthiYioo-.1 ijitltl)', irriLlbir, {r,Wig}
inc:rti!ed mk of habits,
.. fffl\ ItIming, )'aWning, trtmol"l,
ill!gul.r brtithing,.nd initability, ill(fNstd mk of
inf,nt death Iyndlllmt ($IDS)
Tob,a:o: inc:fNstd rilk of nillbirthl. premaNrt
iocrnr.td risk of infjnt death Iyrdn:rnt (SlDS)
birth dtfuts flIngng fu:lm !lilbirth
10 iIcohoIlYnd_{ltIIIn IUNrt;joint PftIbIrms.,,;m
attmtion, mmIOf); inteIigmcf, (oonIirWln, and Pfl)bli!m dving)
SWIlr. 1,1009.
Join a pregnancy registry if you:tre taking prescription
drug>.
Understand that the adverse effects o( drug treatment
may be confused with common discomfortli of
pregnango because they may be similar. These wmmon
discomforts include nausea, vomiting, heartburn,
coll'ltipation, hypotension, heart palpitat ions,and
fatigue.
Use nonpharmacologic altemati\'es such as massage for
pain or calming music for anxiety, whenever possible, to
minimize the need for drug therapy.
DRUG ADMINISTRATION
DURING CHILDHOOD
As a child develops, physiC4l1 growth and physiological
changes mandate adjustments in the administration of
medications. Although children may sometime-s receive
similar drugs via the same routes as adults, the nursing
management for children is very different from that for
adults. Normal physiologic changes during growlh and de_
velopment can markedly affect pharmacokinetics and
pharmacodynamics. Factors for the nurse to consider
dude physiological variations, maturity o( body systems,
and greater fluid distribution in children. Drug dosages are
vastly different in children.
For the purpose!; of medication administration, the pedi_
atric patient is defined as being any age from birth to 16
years and weighing less than 50 kg. Additionally, children
may be classified as neonates, infants, toddlers, prt'$Chool ,
sdiool age, and adolescent.
7.5 Pharmacotherapy of Infants
I.IIIKJ is me period from birth to 12 months of age (,.
urI,' 7.2). The first 28 days of life are referred to as the
neonatal period During this time, nursing care and phanna-
... direct...! tow:lrd s:lfelyof the infant , proper 00._
ing of prescribed drugs, and teaching p<lrents how to
administer medications properly. A primary goal is to have
the child ingest the entire dose of medication without spitting
it oul because it is difficult to estimate thumount lost. If the
child vomits after taking the drug, the dose
may be reordered. The following nursi ng interventions and
parental teaching points are important for this age group:
The infant 5hould be held and cuddled while
administering medications, and offered a pacilier if the
infant is on fluid restrictions caused by vomiting or
diarrhea.
Medications are often administered to infants via
droppers into the eyes, ears, nose, or mouth. Oral
medications mould be directed to the inner cheek and the
child given time to swaUow the drug to avoid aspiration.
If rectal suppositories are administered, the buttocks
LibraryPirate
.. Figure 7.] Treating the Infant
Source: Persson fdKar/ooJPHCoilege.
should be held together for 5 to 10 minutes to
expulsion of the drug before absorption has occurred.
In very young infants, the medication may be given via a
nipple. Some believe this is controversial since the infant
may associate the nipple with medication and refuse
fet'dings.
Special considerations must be observed when
administering intramusruiar (1M) or intravenous (IV)
injections to infants. Unlike adults, infants lack well-
developed muscle masses, so the smallest needle
appropriate for the drug should be used. For volumes
less than 1 mL, a tuberculin syringe is appropriate. The
vastus lateralis is a preferred site for 1M injections,
because it has few nerves and is relatively well
in infants. The gluteal site is usually contraindicated
because of potential damage to the sciatic nerve, injury
to which may result in permanent disability.
Because of the lack of choices for injection sites, the
nurse must rolllte injection sites from one leg to the next
to avoid overuse and to prevent inflammation and
pain.
For IV sites, the feet and scalp veins may provide more
easily accessible and preferred venous access sites.
7.6 Pharmacotherapy of Toddlers
Toddlerhood is the age perioo from 1 to 3 years. During this
time, a toodler begins to explore, wants to try new things,
and tends to place everything in the mouth. This becomes a
major concern for medication and hoUS<:'hold product
safety. The nurse must be instrumental in teaching parents
that poisons come in all shapes,sires,and forms and include
medicines, cosmetics, cleaning supplies, arts and crafts ma-
terials, plants, and food products that are improperly stored.
Parents should be instructed to request child-resistant con-
CNplfl1 Dfug Admllll'tnllon Th'oughoot t"" ute Sp;In 69
tainers from the pharmacist and to stow all medications in
secure cabinets.
Toddlers can swallow liquids and may be able to chew
solid medications. When prescription drugs are supplied as
flavored elixirs, it is important to stress that the child not be
given access to the medications. Drugs must never be left at
the bedside or within easy reach of the child. A child who
has access to a bottle of cherry-flavored acetaminophen
(Tylenol) may ingest a fatal overdose of the IlIsty liquid.
Nurses should educate parents about the following means of
protecting their children from poisoning:
Read and carefully follow directions on the label before
using drugs and OTC products.
Store all drugs and harmful agents out of the reach of
children and in locked cabinets.
Keep all household products and drugs in their original
containers. Never put chemicals in empty food or drink
containers.
Always ask the pharmacist to place the medications for
everyone in the household in child-resistant containers.
Never tell children that medicine is candy.
Keep the Poi..on Control Center num!>..r ncar phone.,
and call immediately if poisoning is suspected.
Never leave medication unattended in a child's room or
in areas where the child plays.
Administration of medications to toddlers can be chal-
lenging. At this stage, the child is rapidly developing in-
creased motor ability and learning to assert independence,
but has extremely limited ability to reason or underslllnd the
relationship of medicines to health. Giving long, detailed ex-
planations to the toodler will prolong the procedure and cre-
ate additional anxiety. Short, concrete explanations followed
by immediate drug administration are best for this age
LibraryPirate
70 UnK2 P'harmoc:ology.oo theNu......-P.tk>nt Relationship
group. Physical comfort in the form of touching, hugging,or
verbal praise following drug administration is important.
Oral medications that taste bad should be mbred with a ve-
hicle such as jam, syrup, or fruit puree, if por.sible. Encourage
parents to mix the medication in the smallest amount possi-
ble to ensure that the toddler receives all of it. The medication
may be followed with a carbonated beverage or mint-flavored
",,"uy. Nu,,"", .huulcll"",;.h I"'",nls lu avoiu pia<.inl!
in milk, orange juice, or cereals, because the child may associ-
ate these healthful foods with bad- tasting medications. Pbar-
maceutical companies often formulate pediatric medicines in
sweet syrups to increase the ease of drug administration.
1M injections for toddlers should be given into the vas-
tus lateralis muscle. IV injections may use scalp or feet
veins; additional peripheral site options become available
in late toddlerhood. The toddler presents additional safety
ir.sues to the nurse who is administering IV medications.
The nurse must firmly secure the IV and then educate the
parents about the dangers of the toddler trying to pull away
too quickly from the IV pump. It is often helpful to put
longer tubing on a toddler's IV to give the child more play
room. Suppositories may be difficult to administer because
of the ,hild's resistan,e. For any of these invasive adminis-
tration procedures, having a parent in dose proximity will
usually reduce the toddler's anxiety and increase coopera -
tion, but ask the parent prior to the procedure if he or she
would like to assist. The nurse should take at least one
helper into the room for assistance in restraining the tod-
dler if nece' .... ry.
7.7 Pharmacotherapy
of Preschoolers
and SchoolMAge Children
The chil d ranges in age from 3 to 5 years. During
this period, the child begins to refine gross and fine motor
Lt FESPAN CONStDERATtONS
Iron Poisoning
One of tht It.lding WIllS of poilonings in thildrm undu "9t of 6 is iron
poisoning.lron il oltm found in vitaminl of .11 kincb: ptdialrit..lnd
aduk vitaminl.Ptdiatric vitaminl may bI' tmpting and may hal'!'
tht mtt and .lpptmn, of a ndy that tht ,hild il familiar with. Plt'lWtal vi-
tamins molY hold .l amounts ofiron and
011itr romponenll. And vit.minl all' not ronlideft'd"mtdicilll' or Iod:ed
INlay with other pmription mtdiationl. 0Idtr ,hild Il'n may optII tilt bottlt, 0
yoong{hild mayoutwita"{hild-rt5ist,m"top,or .. bot1lt is ItIt within tilt mild's
rNth.llfpendilg on tht oJ9I.' oltht mild,aI IN aI 1M irolKont,ining
all' known to t,lISI' iron poiloning.
SymplOml ofiroo poiIonil"f;l intkJlt nau!I'.l, l'OIIIitinq. diarrhN,gastrointe tinal
blHfii"'J, ond u n fK"'JJP In rMkI.nd .... nh.Fw-n if inn poi<nninoJ i< <II<-
peatd,tht mid IhoUd bel.lktn br mtdic.il f"l<\Wtion brallSl' symplOml may
bl'drb)'edPaft'llU!hoo1d be tIKOUfoJ9I.'d to be ,n,in rnediution, ird:rding
OK dnJ11 5U1h as vitamins,.l1l' Iod:ed away and rntdi:irr bonlt topUIl' StnUM
And....t.tn viliting aoother horne or hawil"f;l .l visitorwithin tlr bI' lUll' ,II
meditation is out of .J mid's INth and mbbility, Mfl vitamrn.
skills and develop language abilities. The child initiates
new activities and becomes more socially involved with
other children.
Preschoolers can sometimes comprehend the difference
between health and illness and that medications are admin-
istered to help them feel better. Nonetheless, medications
and other potentially dangerous products must still be safely
,luww uul uf Lht" dr.ilcl',
In general, principles of medication administration that
pertain to the toddler also apply to this age group. Preschool"
en; woperate in taking oral medications if they are crushed
or mixed with food or flavored beverages. After a child has
walked for about a year, the ventrogluteal site may be used for
1M injections, because it causes less pain than the vastus lat-
eraiis site. The scalp veins can no longer be used for IV accer.s;
peripheral veins are used for IV injections.
like toddlers, preschoolers often physically resist medica-
tion administration, and a long, detailed explanation of the
procedure will likely promote anxiety. A brief explanation
followed quickly by medication administration is usually
the best method. Uncooperative children may need to be re-
strained, and patients older than 4 years may require two
adults to administer the medication. Before and after med
ication procedures, the child may benefit from opportuni-
ties to play-act troubling experiences with dolls. When the
child plays the role of doctor or nurse by giving a doll
a pill or injection, comforting the doll, and explaining that
the doll will now feel better, the little actor feels safer and
more in control of the situation.
The child is between 6 and 12 years of age. Some
refer to this period as the middle childhood years. This is the
time in a child's life when rapid physical, mental, and social
development occur, and early ethical- moral development
begins to take shape. Thinking processes become progres-
sively more logical and consistent.
During this time, most children remain relatively healthy.
Respiratory infections and GI upset are the most oommon
complaints. Because the child feels well most of the time,
there is little concept of illness or the risks involved with in-
gesting a hannful substance offered to the child by a peer or
older person.
The nurse is usually able to gain considerable cooperation
from school-age children. More detailed explanations may
be of value , because the child has developed some reasoning
ability and can Wlderstand the relationship between the
medicine and feeling better. When children are old enough
to welcome choices, they can be offered limited dosing alter-
natives to provide a sense of control and to encourage coop-
eration. The option of taking one medication before
another or the chance to choose which drink will follow a
chewable tablet helps distract children from the issue of
whether they will take the medication at all. It also makes an
otherwise strange or unpleasant experience a little more en-
joyable. Making children feel that they are willing partici-
pants in medication administration, rather than victims, is
an important fOWldation for compliance. Praise for cooper-
ation is appropriate for any pediatric patient and sets the
LibraryPirate
Figure 7.4 Treating thl! younger school -age child
5o/JrCI': PeaWfl fliJcQr/ooJPHCoilege.
PHARMFACTS
Poisoning
"'cording 10 tht National Erntf9t1K)' Ikdiul MlOXialion (NEIM):
Yc:h 2 million Ameriunull'
Poisoning "n bf plt'Vrnltd tfJrough nd aWilll'ntU.
poisonings 0((111 in (hildren under6 )'ears of illt.
hlukl (in bf poisontd b)' taking wrong dose of mtdiution, ronliJling
mtdkations,or splashing a poison on 11M- skin or in

stage for successful medication administration in the future
( .. Figure 7.4).
School-age children can safely take chewable tablets and
may even be able to swallow tablets or capsules. Because
many still resist injections, it is best to have help available
for these procedures. The child should never be told that he
or she is "too to cry and resist. The ventrogluteal site
is preferred for 1M injections, although the muscles of
older children are developed enough for the nurse to use
other sites.
7.8 Pharmacotherapy
of Adolescents
occurs between ages 13 and 16 years. Rapid phys-
ical growth and psychologic maturation have a great impact
on personality development. The adolescent strongly relates
o..p1tl1 Drug Admllll'tnllon Throughoonhl' life Spoon 71
to peers, wanting and needing their support, approval, and
presence. The strong sense of indep!.'lldence leads teens to
seif-m<"dkate, either with or withoul their parent's knowl-
edge. Treatment objectives for the nurse should include
teaching parents to keep their medications safely stowed out
of sight from inquisitive, experiment-minded adolescents.
Parents should also be taught the signs and symptoms of
drugs commonly abused by teens such as marijuana, in-
halents, and methamphetamine.
The most common needs for the pharmacotherapy of
teens are for skin problems, headaches, menstrual symp-
toms, eating disorders, contraception, alcohol and tobacco
use, and sports-related injuries.
Of primary concern to the adolescent is the initiation of
sexual intercourse and the avoidance of pregnancy and
sexually tl1lnsmitted infections. The nurse must be
prepared to addres.s a variety of to pia; related to sexuality,
induding the importance of responsible sexual practices,
condom use, and other contraceptive methods.
Eating disorders commonly occur in this population;
therefore, the nurse should carefully question
adolescents about their eating habits and their use of
OTC appetite suppressants or laxatives that may be
conlributing to bulimia or anorexia.
Alcohol, tobacco use, and other illicit drug
experimentation are common in this population.
Teenage athletes may use amphetamines to delay the
onset of fatigue, as well as anabolic steroids to enhance
performance. The nurse assumes a key role in educating
LibraryPirate
72 UnK2 J>harmKology.nd theNufW-p.Uent R .... tlonmlp
adolescent patients about the hazards of tobacco use and
illicit drugs.
The adolescent has a need for privacy and control in
drug administration. The nurse should communicate
with the teen more in the manner of an adult, than as a
child. Teens usually appreciate thorough explanations of
their treatment, and ample time should be allowed for
them to ask '1uestions.
Despite the adolescent's need for confidentiality and
privacy, confidentiality laws differ from state to state.
Nurses working with the adolescent population need to
be familiar with their state laws affecting confidentiality
and informed consent.
Despite their need to have independence and the desire
to self-medicate, teens haw a very poor understanding
of medication information (Buck, 2007). Adolescents
are reluctant to admit their lack of knowledge, so the
nurse should carefully explain important information
regarding their medications and expected side effects,
even if the patient claims to Wlderstand.
DRUG ADMINISTRATION
DURING ADULTHOOD
When considering adult health, it is customary to divide this
period of life into three ouses: I"' ung .dulthood (IS to 40 year>
of age), middle.dulthood (40 to 65 years of age), and older adult-
hood (over 65 years of age). Within each of these divisionsare
similar biophysical, psychosocial, and spiritual characteris-
tics that affect nursing and pharmacotherapy.
7.9 Pharmacotherapy of Young
and Middle-Aged Adults
The health status of younger adults is generally good; ab-
sorption, metabolic, and excretion mechanisms are at their
peaks. There is minimal need for prescription drugs unless
chronic diseases such as diabetes or immune-related condi-
tions exist. The use of vitamins, minerals, and herbal
dies is prevalent in YOWlg adulthood. Prescription drugs are
usually related to contraception or agents needed during
pregnancy and delivery. Medication compliance is positive
within this age range, because there is dear comprehension
of benefit in terms of longevity and feeling well.
Substance abuse is a cause for concern in the IS to 24 age
group, with alcohol, tobacco products, amphetamines, and
illicit drugs a problem. For young adults who are sexually
active, with multiple partners, prescription medications for
th" ofh"rp"',l'!ulJurrl,,,a, syphilis, HIV
tions may be necessary.
The physical status of the middle-aged adult is on a par with
that of the young adult until about 45 years of age. During this
period of life, numerous trunsitions occur that often result in
excessive stress. Middle-aged adults are sometimes referred to
Figure 7.S Treating the middle-aged adult
SoufCl>.l'Moon fdU(QrIon/PH College
as the "sandwich generation" because they are often caring for
aging parents as well as children and grandchildren. Because
of the pressures of work and family, middle-aged adults often
take medication to control health alterations that could best be
treated with lifestyle modifications. The nurse must
entphasize the importance of overall health oflifest)'le choices,
such as lim.iting lipid intake, maintaining optimum weight,
and exercising Figure 7.5).
Health impairments related to cardiovascular disease, hy-
pertension, obesity, arthritis, cancer, and anxiety begin to
surface in late middle age. The U'ieof drugs to treat hyperten-
sion, hyperlipidemia, digestive disorders, erectile dysfunc-
tion, and arthritis art' common. Respiratorydisorders related
to lifelong tobacco use or exposure to secondhand smoke
and environmental toxins may develop that require drug
therapies. Adult-onset diabt'les mellitus oftE"ll emerges dur-
ing this time of life. The use of antidepressants and antianx-
iety agents is prominent in the population older than 50.
7.10 Pharmacotherapy
of Older Adults
DurinI'! ll,,, 20lh L,,"tury, anllllpruvoo ufli[" lh"
ability to effectively treat many chronic diseases contributed
to increased longevity. The age-related changes in older
adults, however, can influence the patiE"llt's response to
drugs, altering both the therapeutic and adverse effects, and
creating special needs and risks. As a consequence of aging,
LibraryPirate
Figure 7.6 T\'I'atlngtl\v oIdl'f adult
5oixcI': T'Pa500 EMaflol!lPHCoJIegt.
patients experience an incrNsi ng number of chronic health
disorders, and more drugs are prescribed to trealthem.
The taking of multiple drugs concurrentl y, known as
polyphillmaq, has become commo nplace among older adults.
Patients who visit multiple physicians and use different
pharmacies may experience polypharmacy because each
doctor or pharmacist may not be aware of aU the drugs or-
dered by other practitioners. Polypharmacy dramatically in-
creases the for drug interactions and si de effects. Nurses
should urge the patimt to report all prescription and OTC
products o n each offICe visi t and teach the p<ltient to useone
pharmacy for their prescription needs.
Al though predictable phystologkaJ and
changes occur with aging, signifi cant variabil ity exists
among pati t'lm. Fol e:umple, al though cognitive dedine
and memory 10$5 certainly occur along the agi ng contin-
uwn, there is a greal variation in geriatrk pat ients. Some
older iDdividuals do not experience cogniti" e impairment
at all. The nurse should avoid preconceived oot ions that
elderly patients wiU have physical or cognitive impai r ment
simply because they have reached a certain age. Careful as-
sessment is alw3}'5 ntCes.sary ( . Figure 7.6).
\\lhen administering medications to older adults. the
nurse should offer the patient the same degree of indepen-
dence and dignity that would be afforded middle- aged
adults, unless otherwise indicated. Like their younger
COWlierparls, older patients have a need to understand why
they are receiving a drug and what outcomes 3re expected.
Accommodations must be made for older adults who have
certain impairments. Visual and audi tory changes make it
important for the nurse to providedrug instructions in large
type and to obtain pltient feedback to be certain that med-
ication instructions are understood. Elderly patients with
cognitive de.::line and memory loss can benefit from aids such
as alarmed pill containers, medicine management boxes, and
Choplfl7 Drug Admtnlm. Uon It\'ooghounhe Span 73
delily written instructions. During assessment. the nurse
should determine if the patient is capable of self-administering
medications in a consistent, safe, and effe.::tive manner. A5
long as small childrt'O are not present in the hoU5ehold,
ol der patients with arthritis should be encouraged 10 ask the
pharmacist for regular screw_cap medi C1lt ion bottles for
ease of opening.
Gn-iatrk patients expn-ience more adverse effects from
drug thenpy than othe!" age groups.. Although some of these
effects are due to polypharmacy, many of the adverseevents
are predictable, based on normal physiological processes
that occur during aging. The principal complications of
drug therapy in theoldfT adult population are d ue todcgen-
eration of organ systems, multipl e and .severe illness.
polypharmacy, and unreliable compliance. By understand-
ing th"""change., the avni(! drngef_
feets in older patients.
[ngeriatric patients, the functioning ability of all major or-
gan systems progressively declines. For this reason, all phases
of pharmacokinetics are affected, a nd appropriate adjust-
ments in therapy need to be implemented. Although most of
the pharmacokinetic changes are due to reduced hepatic and
renal drug elimination, other systems may also initiate a va-
rietyof changes. For example, immune system function di-
minishes with aging, so autoimmune diseases and infoctions
occur more frequently in elderl y patients. Thus, there is an
increased need for influenza and pneumoni a vaccin.:ations.
Normal physiological changes that affe<:t pharmacotherapy
of the older adult are summarized as follows:
Absorpt ion: In general, absorption of drugs is slower in the
ol de!" ad ult due to diminished gastric motility and decreased
blood How to digestive organs. Becaun of increased gastric
pH,orailablets and capsules that require high levels of acid
fnr aMorpri,m may lake In diAAOlVl'. and. t'-"'( ..... e
take longer to become available to the tissues.
Distr ibut ion: Increased body fat in the geriatric patient pro-
a larger storage compartment for lipid-50luble d rugs
and .. itamins. Plasma levels are reduced,aDd the therapeutic
response is diminished. Older adul l$ have less body w.atet,
making the effects of dehydration more dramatic and in-
creasing the for drug toxicily. For example, elderly pa-
tient> who have reduced body Huid experience more
orthostatic hypotension. The decline in lean body mus and
totalbody water leads to an increased concentration of water-
soluble drugs, because the drugis distributed in a smaJlervol-
umeof w.ater. The aging liver produces less albumin, result-
ing in decreased plasma protein-binding ability and
increased levels of free drug in the bloodstream, thereby in-
creasing the potential fordrug--drug interactions. Theaging
cardiovascular system has decreased cardbc o utput and less
efficient blood circul ation, which slow drug distribution.
This makes it important to initiate pharmacotherapy with
smaller dosages and slowl y increase the amount to a safe, ef-
fective level.
Metabolism: Enzyme production in the liver decreases and
the visceral blood flow is diminished, resulting in reduced
I
LibraryPirate
74 UnK2 P'harmKology . nd theNurse--p. lil'nt Relationship
hep.1tk drug metabolism. This change leads to an increase
in the half-life of many druSS, which prolonss and intensi-
fies drug response. The decline in hepatic function reduces
first-pass metabolism. (Recall that first-pass metabolism re-
lates to the amount of a drug that is removed fro m the
bloodstream during the first circulation through the liver
after the drug is absorbed by the intestinal tract.) Thus,
plasma levels are elevated, and tissue ooncentratioilli are in-
creased for the particular drug. lhis change alters the stan-
dard dosage, the interval between doses, and the duration of
side effects.
Excretion: Older adults have reduced renal blood fl ow,
glomerular filtration rate, active tubular secretion, and
nephron function. This decreases drug excretion for drugs
that are eliminated by the kidnE")'S. \'/hen excretion is re-
duced, serum drug levels and the potential for toxicity
tuarkedly increase. Administration schedules and dosage
amounts may need to be altered in many older adults due to
these changes in kidney function. Keep in mind that the
moot common etiology of drug re<l.ction< in older
adults is caused by the accumulation of toxic amounts of
drugs secondary to impaired renal excrt'1:ion.
....
Chapter REVIEW
KEY CONCEPTS
TREATING THE DIVERSE PATIENT
Patients with Speaking. Visual,
or Hearing Impairments
(OIIUlllIlitation dilordrn may makf obuining I!SpOIIItS from tht patient
diflirult ComlllJniU!Dn II\a)' be faciilaled U, h.ning 1M p"ient writt or thw re-
sp:.nse. Cbrify U, paraphramg 1M tepOlIiI' badt to tht patitnt UII' gestures.
bod)' bnglligt. "Ill 'fl"SIno if writi1g or dtawing is tif'Iiam. AlkJw .dr-
quale tine br l'IjIKialy avml' of W>s,!lJ(h grill\a(-
inq.....t.m pet"bnning inteMnti:rn that IN)'UUII' diKombt or pail.
I'rviitJe ligIrting b patitnU with ilual impairmtlluantl be <l Wire
of row tre phtaling oil'l'tbal tOtnllUlication aflem tilt message tOlM)'fli Rr-
me_ that 1M IItHMfbal rurs ill'OIwd iI romllUlKation II\a)' be missrd U, tre
patient. Piltaplnll' re!pJIllI'5 badt to patients to be Ilft' they lIIIImtood thr
mes:sat}r in the of tIOfM'tbal rues.Uptain in bebre
impltrnenting prot:tIbes or Ktivitits with the patient.
Pititl1u with lItaing mpailllll'llB bent.fit from romlllJlliution lhat is!plkrn
(rarl)o <Inti !kJwl)o in <I kJw-pittMd YOKt.Sit tre patient inti ol'IOil spNlting

grouoo noist.n possib!!'. or thw to (brify...erbal rommulli"iJn,am
UlfIlOllYMJ'lgtSturesaoo
UII., lor lOInllululiun dId re>p<II ..... Alallllh.r 1I .. ,rUn .. hNW, ",.
INm that tilt patitI1t hils <I litiring mpailfllelll anti may not he<lf , I'I'tbal anlWff
to tht IIU.w'S a l light giYt11 <Mf <III ilteroom \)'Item.
The numbered key concepts provide a succinct summary of the important points from the corresponding numbered section
within the chapter. If any of these points are not dear, refer to the nWllbered section within the chapter for review.
7.1 To contribute to safe and effective pharmacotherapy, it is
essential for the nurse to understand and apply funda -
mental concepts of growth and development.
7l The effects of drugs on a growing embryo or fetus depends
on gestational stag<' and the 3moUllt of drug received. Phar-
macotherapy during should be conducted only
when the benefits to the mother outweigh the potential
risks to the unborn child. Pregnancy categories guide the
health care provider in prescribing druss for these patients.
73 Breast -feeding women must be aware that many drugs
and other substances can appear in milk and cause ad-
verse effects to the infant.
7A Patient education is especially critical during pr<'gllancy
and lactation for the safety of the mother and baby and to
pharmawlogk outcome<;.
7.5 During infancy, pharmacotherapy is directed toward the
safety of the child and teaching the parents how to prop-
erly administer medications and care for the infant.
7.6 Drug administration to toddlers can be challenging;
short, concrete explanations followed by immediate drug
administration are usually best for the toddler.
7.7 Preschool and younger school -age children can begin to
a.,ist with medication administration.
7.8 P}wrntacologic compliance in the adolescent is depen-
dent on an understanding of and respect for the unique-
ness of the person in this stage of growth and
dewlopment.
7.9 Young adults constitute the healthiest age group and gen-
erally need few prescription medications. Middle-aged
adults begin to suffer from stress-related illness such as
hypertension.
7.10 Older adults take more medications and experience more
adverse drug events than any olher age group. For drug
therapy to be successful, the nurse must make accommo-
dations for age-related changes in physiological and bio-
chemical functions.
LibraryPirate
(MhA) was founded. From 1852 to 1975, two major com-
pendia maintained drug standards in the United Stat es, the
U.s. Phurmacopoeiu and the Nutionul Formulary (NF) es-
tablished by the APhA. All drug products wne covered in
the USP; pharmaceutical ingredients were covered in the
NF. In 1975. the two entities merged into a singl e publi ca-
tiOll , the U.S. Pharmilco/'Mill- Niltionill Formlda,y ( USP-
NF) . The current document of about 2,400 pages contains
3,777 drug monographs in ]64 chapters. Official mono-
graphs and interim revision announcements for the USP-
NF are published regularly, with the full bound venion
printed every 5 years. Today, the USP label can be found on
many medications verifying the purity and e.xact amounts
of ingredients found within the container. Sampl e labels a re
illU5trated in Figure 1.\.
In the early 1900s, the United States began todevdop and
enforce tougher dr ug legislation to protect the publ ic. In
19UZ, the BiolOSlcS Control Act helped to standardI ze the
quality of serums and other blood- related products. The
Pure Food and DrugAct of]906 gave the government power
to control the labeling of medicines. In 1912, the Sherl ey
Amendment prohibited the sale of drugs labeled with false
therapeutic claims that were intended to defr:lUd the con-
sumer. In 1938, Congress passed the Food, Drug, and Cos-
metic Act. This was the first law preventing the sale of drugs
that had not been thoroughly tested before marketing. Later
amendments to this law required drug companies to prove
the safet y and effi OKY of any drug before it could be sold
within the United SUtes. In reacliOll to the rising popularity
of dietary supplements, Congress passed the Dietary Supple-
ment Health and Education Act of 1994 in an attempt to
COlIIroI misleading indu.my daims. A brief timdine of ma-
jor events in U.S. drug regulation is shown in Figure 1.2.
.... -,
r..oc"""',_
Rlblln-Sli '
Idb
_0 ___
__ __ tI
II
Ih1fu
'00_
' II I
- ..
Ii Un
--
!
-,---
.... _--.--






n.....,. _ _
--,
Restoril"
"".
_ .. _ ....
-_ ........
temazepam

- --

...... _.-
. es.USP

-.-
- ,
--,
"".i!.
-,
-
- -
.... _--
--"'-


--
b_
. -.110 . ...
-
- ,-
Ar.tIinotIr1odf
.. Flgure l . 1 EJc ..

MaIItrcbodf PtIoImocrotlcois.
-

I
,
I
"
Ooop!tf 1 Inuoductlon to PhiollTlKoIogy: Ofll9 . od S
PHARMFACTS
Consumer Spending on Prescription Drugs
10'110olMioNl he.ttto
......
.t.t 1M tInI 01 tht 21st <tl'illll")' dNg
opflufnwn inuMfd by mort m.n 200'lIo comjlilfd to !be NIIy
T1If aYl'ligf lIUmberof pmaiption drugs takrn per ",timt
UIlIM of" 1m 12.0 (ompartd to 8.0 pr=riptions per penon in
thtmid-199Oi.
Theavmge lOSt of. presaiption drug now aft( $65.00 (omp.ml to
thr micl-199Os, wlltn the cost pmcription was ibout $29.00.
101.11 p/Iamo.KeUtiu1 nprllditurtS in tilt Unitrd SUtts 1wY!'
from 51901 biioo in 2001 to _ sm bilion in lOO8.
1.7 The Role of the Food and Drug
Administration
Much has changed in the regulation of drugs in the past 100
years. In ]988, the Food and Drug Adminismtion (FDA) was offi-
cially established as an of the U.S. Department of
Health and Human Services. The Center for Drug Evalua-
tion and Research (COER), branch of the FDA, exercises
control o'er whether prescription drugs and OTC d rugs
may be used for therapy. The CDER states its mission as fa-
cilitating the availability of safe, effecti ve drugs; keeping un-
safe or ineffective drugs off the market; improving the
health of Americans; and providing clear, easily under-
sundable drug information for safe and effective use. Any
pharmaceutiaJ laboratory, whethel'" private, public, or aca-
demic, must solicit FDA approval before marketing a drug.
Another branch oflhe FDA, the Centerfor Biologi a; Eval -
uation and Research (CBER), regulates the use of biologics
including serums, vaccines, and blood products. One his-
torical achievement involving biologics was the 1986 Child-
hood Vaccine Act. This aet authorized the FDA to acquire
information about patients taking vaccines, to recall biolog-
ics, and to recomme nd civil penalties if guidelines
biologia; were not followed.
The FDA also oversees administration of herbal products
and dietary supplements through the Center for Food Safety
and Applied Nut rition (CFSAN). Herbal products and di -
etarysupplements are regulated by the Dieury Supplelllent
Health and EducalionACI of 1994. This act does nol provide
the same degree of prot Klion for consumers as the Food,
Drug, and Cosmeti c Act of 1938. For example, herbal and
dietary supplement s can be marketed without prior ap-
proval from the FDA. This act is discussed in more detail in
chapter 1()Ci1C>.
1.8 Stages of Approval
for Therapeutic and Biologic Drugs
Theamount of time spent by the FDA in the review and ap-
proval process for a particular drug depends on sewnl
checkpoints along a well-developed and organized plan.
LibraryPirate
KEY TERMS
rull1nl compnolKf pi1Jt J8
-,....
mMcitypqlB
Psychosocial, Gender,
and Cultural Influences
on Pharmacotherapy
LEARNING OUTCOMES
After reading r ~ J chopfer, rhe student $hoold be DOlt to:
1. Describe fundamental conceptS underlying a holistic approach to
pali1!nt care and wir imponance \0 pharmacother.lpy.
2. Desaibe thecompooentsofthe human integration pyramid model
3. Identify P5Ychosodai and spiritual factol'li that can affect
pharma(Otherapeutics.
4. Elcplaln how ethnkllycan affect pharmacotherapeutic outcomes.
5. Identifyexampies ofhowcultural values and beliefs an influenc::e
pharma(otherapeutk outcomes.
6. Explain how community and environmental factors can affect health
care outcorroes.
7. (onW)' tlow genetic polylTlOfpnisms can Influence pharmacotherapy.
8. Relate the Implkalionsof gendefto the actions of certain drugs..
geHticpolymorp/IMI p i J t ~
holillK ,., 17
hlllllMillegratiol 'JfK1id poqrll
phamiCttHetia JIIlIJ'1JO
psydlosMiil tnT II
spiriluily fIIJ9t II
LibraryPirate
C1up1frl P5y<:ho",,"l """" ..... 00 Culrur.llnfluenc:e< on I'h.1rmocothe<ap)" 77
I
t is convenient for a nurse to memorize an average drug
dose,administer the medication, and expect all patients to
achieve the same outcomes. Unfortunately, this is rarely the
case. For pharmacotherapy to be successful, the nurse must
assess and evaluate the needs of each individual patient. In
chapter 400, variables such as absorption, metabolism,
plasma protein binding.and excretion mechanisms were ex-
amined to help explain how these modify patient responses
to drugs. In chapter SOlO ,variability among patient responses
was explained in terms of differences in drug-receptor in-
teractions. Chapter 7010 examined how pharmacokinetic
and pharmacodynamic factors change patient responses
to drugs throughout the life span. This chapter examines
additional psycholoqical,sodal, and bioloQic variables that
must be considered to achieve optimum outcomes from
pharmacotherapy.
8. 1 The Concept of Holistic
Pharmacotherapy
To deliver the highest quality of care, the nurse must fully
recognize the individuality and totality of the patient. Each
person must be as an integrated biologic, psychoso-
cial, cultural, communicating whole, existing and function-
ing within the commWlal environment. Simply stated, the
recipient of care must be regarded in a holisti(context to bet-
ter understand how established risk factors such as age, ge-
netics, biologic characteristics, personal habits, lifestyle, and
environment increase a person's likelihood of acquiring
specific diseases. Pharmacology has taken the study of these
characteristics one .step further--to examine and explain
how they influence pharmacotherapeutic outcomes.
The human imegratioo pyramid, shown in Figure 8.1, serves as
a conceptual framework in dealing with patients in a holistic
mallller. This model provides a useful approach to addressing
the nursing and pharmaoologic needs ot patients within the
health care delivery system. All levels of the pyramid are inter-
oollllected and interdI"]Jendent. Thus, when considering a pa-
tient's pharmacologic treatment plan, aU levels of the pyramid
are oonsidered. For example, when giving a medication for
the treatment of hypertension, an elderly man may experi-
ence greater effects from the medication than a younger man
(age corollaries) or a woman in )'OWlg adulthood (age and
gender). FurthernlOre, patients may have different treatment
outoomes related to cultural/ethnic differences because they
may metabolize drugs to a different extent. By considering the
levels of the human integration pyramid, the nurse can help
ensure that the pharmacotherapy is not only treating symp-
toms, but is addressing issues related to the total patient.
By its very nature, modem (\Vestern) medicine as it is
practiced in the United States is seemingly incompatible
with holistic medicine. Western medicine focuses on spe-
cific di.!casc., their cau.e.,and treatment . Di,ease i, viewed
as a malfunction of a specific organ or system. Sometimes,
the disease is viewed even more specifically, and categorized
as a change in DNA structure or a malfunction of me en-
zyme. Sophisticated technology is used to identify, image,
and classify the specific structural or fimctional abnormal-
ity. Somehow, the total patient is lost in this focus of catego-
rizing disease. Too often, it does not matter how or why the
patient developed cancer, diabetes, or hypertension, or how
he 01 she feels about it; the psychosocial and cultural dimen-
sion! are lost. Yet, these dimensions can have a profound im-
pact on the success of pharmacotherapy. The must
consciously direct care toward a holistic treatment of each
indiyidual patient, in his or her psychosocial, spiritual, and
communal context.
8 .2 Psychosocial Influences
on Pharmacotherapy
The term psy<hosocial is often used in health care to describe
one's psychological development in the oontext of one's social
environment. This involves both the social and psychological
aspects of a person's life. Spirituality incorporates the capacity
to love, to compassion and empathy, to give and for-
give, to enjoy life, and to find peace of mind and fulfillment
in The spiritual life overlaps with component! of the
emotional, mental, physiClI, and social aspects of living.
From a health care perspective, every human being
should be considered as an integrated psychosocial, spiritual
being. Health impairments related to an individual's psy-
chosocial situation often require a blending of individual-
ized nursing care and therapeutic drugs, in conjunction
with psychotherapeutic cOWlseling. The term psycho-social-
spirimal is appearing more frequently in nursing literature.
It is now acknowledged that when patients have strongspir-
itual or religious beliefs, these may greatly influence their
perceptions of illness and even affect the outcomes of phar-
macotherapy. When illness imposes threats to health, the
patient commonly presents with psychological, social, and
Age COIO'aries
Geode. Detarrnnants
Community-Environmantal Fact ....
Cultural and Ethnic PerapectiYea
Psychoiogiclll-5ocial-Spiritual Dimanaion
Figunt!:8.1 The human Integrnlon pyramid care

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o
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78 UnK2 J>ha,mKolog)r .nd the NUfW-P.tient R .... tlonmlp
spiritual issues along with physical symptoms. Patients face
concerns related to ill health, suffering, loneliness, despair,
and death, and at the same time look for meaning, value,
and hope in their situation. Such issues can have a great im-
pact on wellness and preferred methods of medical treat-
ment, nursing care, and pharmacotherapy.
The psychosocial history of the patient is an essential com-
ponent of the initial interview and assessment. This history
delves into the personal life of the patient, with inquiries di-
rected toward lifestyle preferences, religious beliefs, sexual
practices, alcohol intake, and tobacco and nonprescription
drug "-"'. The nw,e lllu,1 demon,lrate .sen,itivitywhen gath-
ering these types of data. If a trusting nurse-patient relation-
ship is not quickly established, the patient will be reluctant to
share important personal data that could affect nursing care.
The psychological dimension can exert a strong influence
on pharmacotherapy. Patients who are convinced that their
treatment is important and beneficial to their well-being
will demonstrate better compliance with drug therapy. The
nurse must ascertain the patient's goals in seeking treat-
ment, and determine whether drug therapy is comp.11ible
with those goals. Past experiences with health care may lead
a patient to distrust medications. Drugs may not be accept-
able for the social environment of the patient. For example,
having to take drugs at school or in the workplace may cause
embarrassment; patients may fear that they will be viewed
as weak, unhealthy, or dt>pendent. Some patients may be-
lieve that certain medications, such as antidepressants or
anti5Cizure medications carry a social stigma, and therefore
theywill resist using them.
Patients who display positive attitudes toward their per-
sonal health and have high expectations regarding the results
of their phamtacotherapy are more like1yto achieve positive
outcomes. The nurse plays a pivotal role in encouraging the
patient"s positive expectations. The nurse must always be
forthright in explaining drug actions and potential side ef-
feets. Trivializing the limitations of pharmacotherapy or min-
imizing potential adverse effects can cause the patient to have
unrealistic expectations regarding treatment. The nurse-
patient relationship may be jeopardized, and the p.1tient may
acquire an attitude of distrust. As discussed in chapter 900,
the patient has an ethical and legal right to receive accurate in-
fonnation regarding the benefits and effects of drug therapy.
8.3 Cultural and Ethnic Influences
on Pharmacotherapy
Although often used interchangeably, thedefinitions of cul-
ture and ethnicity are somewhat different. An ethnic group
is a community of people that share a common ancestry and
similar genetic heritage. Ethnicity implies that people have bi-
is sd uf belief"
ues, and norms that provide meaning for an individual or
group. People within a culture have common rituals, reli-
gious beliefs, language, and certain expectations of behav-
ior. Cultural and ethnic variables are important aspects of
patient care that directly relate to pharm.1cotherapy. Both
have a profound influence on patient outcomes and the oc-
TREATING THE DIVERSE PATIENT
Medication Adherli!nce
Poor adhertOO' to.J pre5aibtd mtdirnion is known >IS Ammca's" other
drug probltm" but roe that has hNlth ind fillinciil MIl 'lNler
thin ilKu.lt is estin.Jttd that appro:lirwel)o oftht 2 bilion PII'-
scriptions filfd )'N' all' taktn inrorrectIy; while Oil!' third of P.Jtiftm talr i l
of thei" mtOOtion.roe llird talr sornt, ind OIl!' thid do IDtIiR.JOY .J1 i l or
13%ofrmilgllomeadmMionlmaybe
cU to poor rneO!ation adhertoo' and is many is 10% of al hospiLJl admissions.
Iht mtOOly urdersernd popuIition,A'lltn[,lRsof all erhric badqoonds who
all' pool; Lrl; hNlth inlUl<ll"a, or h.M oJ((fIS to heikh GIli', all' Oil!' 01
!ht 91tl.p1111011 il risk.
Ibz Il'I'/e a vitil "* in mtdK.imn mll'ra, both btcaust 01
!ht trustIU II'Lnionship nurse rstablish with their P.J00rts, and betause they all'
oftrn the main 01 medication tdJGItion for tht P.Jtimt and thei,
PMYiditg simpif drug inbnnation to help thr P.Jtitnt urderst.wl why J mtdia-
tion is 1I'qUiRd, I'IIIffi and row it shedd be taktn, and when to ull!ht hNkh Ull'
proMie, is vitalilbrmation to help illONll' mtdiGItion mltoo'. With SIK-
(filM hNlth UII' Yisit. the Gin go OY!'I the rneO!ation tptI-
tions ibM pmcribtd mtdirnions, being alert to reports thai the P.Jtimt iI not
takitq. or is net tal:i1g rorrectIy, tilt preaibrd drugs. As KOOOIIlK (onditiJns
sometimrs II'IUk iI tifIiam t1Ki!ions belWfen mtdK.J1ions and other
lI'qUill'd the hNlthull' proYidmil tlltbrrirontol
proYiIitg mtdiGItion mation ind foIllw-t4J that willlI'IUk iI poMtr..r rut-
rollrl to htalth and prMnlilg nrgatiYe hNlth
tull'l,asa II'IUkoi poor III!'ditation adhererl(f.
currence of specific drug effects as pCTcci""d and inter-
preted by the user.
Although non-Caucasians comprise more than 25% of the
U.S. population, modern clinical pharmacology has been
based largely on research and clinical experiences with Cau-
casians. Some research now suggests that variations in meta-
bolic processes among various ethnic groups can significantly
impact drug therapy. Through technologic advancement, re-
searchers have identified specific regions on various chromo-
somes that influence ht>patic metabolism. Certain
antidysrhythmics, antidt>pressanl5, and opioids may be me-
tabolized differently in individuals of African, Native Anleri-
can, and Asian descent. As technology advances, nurses will
likely begin to see variations in the prescribed atnOWlts and
forms of medication based upon the ethnicity of the patient.
Although it is impossible to have complete knowledge
about the many cultural variations among patients, the nurse
can strive to Wlderstand the significance of the cultural tradi-
tions and their potential impact on the patient's care. People
hold cultural beliefs (religious or ideologic) that may chal-
I,mge or conflict with what the health care provider believes
to be in the best interesl5 of the patient. How illness isdefined
can be based on the cultural beliefs of an individual. One ex-
[hat illustr"t-.; u,i.>; puirrt is tit .. irr Udi .. r sys-
terns between age groups--each with il5 own unique culture.
in health care is the ability of practition-
ers to provide care to people with diverse values, beliefs,and
behaviors, including the ability to adapt delivery of care to
meet the needs of these patients. Cultural competence re-
quires knowledge of this diversity, as well as an attitude of
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CNplfrl Psyc:ho<oclalGende< oo (ulru .. llnnu..nc:", on PNrmocothe<apy 79
openness and sensitivity. Understanding and respecting the
beliefs of the patient are keys to establishing and maintain-
ing positive therapeutic relationships in culturally sensitive
nursing care. Therapeutic commlUlication mandates that all
health care providers bear in mind the cultural, racial, and
soci,,1 fioctors th"t comprise "",ch person, "nd how these "f_
fed behavior. Nurses can instill trust by attentiveness to in-
dividual patient beliefs "nd support patients' desires to seek
adequate medical care when it is needed.
The nurse must keep in mind the following variables
when treating patients from different ethnic groups.
Dietary wIIsiderations: Cultures vary in their dietary
preferences and practices. Diets that include (or exclude)
certain foods have the potential to increase or decrease
the efftiveness of a medication. Cer tain spices and
herbs important to a patient's culture may affect
pharmacotherapy. For example, some cultures include a
diet with abundant amounts of cheese, pickled fish, or
wine that can interact with medications. Certain herbs
can affect antidepressants, anticoagulants, and beta
blockers. Assessing the primary foods of a patient's
culture is an important component of the patient's
psychosocial history .
Alrematil'e therapies: Various cultural groups believe in
using alternative therapies, such as vitamins, herbs, or
acupWlcture, either along with or in place of modern
medicines. Some folk remedies and traditional
fur uf
helped form the foundation for modern medical
practice. For example, Chinese patients may consult
with herbalists to treat diseases whereas Native
Americans may collect, store, and use herbs to treat and
prevent disease. Certain Hispanic cultures use spices and
herbs to maintain a balance of hot and wId to promote
wellness. The nurse can assess the treatments used and
interpret the effect of these herbal and alternative
therapies on the prescribed medications to maximize
positive outcomes. The nurse can explain that certain
herbs or supplements may cause potential health risks
when combined with prescribed drugs.
Beliefs about health and disease: Cultures view health and
illness in different ways. Individuals may seek assistance
from people in their own wmmlUlitywho they believe
have healing powers. NativeAmericans may consult with
a tribal medicine man while Hispanics seck a folk healer.
African Americans sometimes practice healing through
the gift of laying- on- of-hands. The nurse's understanding
of the patient's trust in alternative healers is important.
The more nurses know about cultural beliefs, the better
they can provide support and guidance to patients.
8.4 Community and Envi ronmental
Influences on Pharmacotherapy
A nwnber of comnllmity and environmental factors have
been identified that influence disease and its subsequent
treatment. Population Rrowth, complex technoloRic ad-
PHARMFACTS
Minority Statistics and Health Care
In 2000, the m,jority group in United SUites was non-Hisp'nic:
Whites, .. 71%.
8y 2025,Ih. poput.tion of non-Hispanic: Whit ... is 10 10
61%"nd mu f,lItoS5'16 b)'
Sometime belM.n lOSO ,nd 2060, non-Hisp,nic:Whil. PfilOns will
memll't;es become a ' minoril)o,' !hrinking to irs! than half of ,II
Americans.
inf,nt dmh . mong Aroon i! m<n than doublr that
ofwhil:6. HNIt dill'.!I(' douh rates ,ft' lh,n-4O% higher for AhK.!n
Americans th,n d.am for ,II (all(ffl is 30% highu for
AfrKin Americans Ih,n for whiles; for prostlle it i! m<n than
double that for whil:6.
Hispanics Ijying in tlte United Stall'S are almost twil:eas todie horn
dia bet.! a! r. non-H isp,nic: whiles. Hi!opolnia olI!O h. W' higher rates of
high blood pft'!ruft' and obes.ity than non-Hi!panic whil:6.
N,lm American! h,W' an infant de.nh doublr that for whites.
The rat. of diabetes for this population group is lIIOft'wn twutha! for
whit.s.
5otru: 'Aboo! "'fJ1rIy IINIIIl. Ctmm frx DI!Mt (oolro!. RtI1IMd />Ny 1" lOO'J,

vances, and evolving globalization patterns have all affected
health care. CommlUlities vary significantly in regard to
population density, age distributions, socioeconomic levels,
occupational patterns, and industrial growth. In much of
the world, people live in areas lacl\ing adequate sanitation
and potable water supplies. All these community and envi-
ronmental factors have the polential to affect health and ac-
cess to pharmacotherapy.
Access to health care is perhaps the most obvious
commlUlity-related influence on phannacotherapy. There
are many potential barriers to obtaining appropriate health
care. Without an adequate health insurance plan,some peo-
ple are reluctant to seek health care for fear of bankrupting
the family unit. Older adults fear losing their retirement sav-
ings or being placed in a nursing home for the remainder of
their lives. Families living in rural areas may have to travel
great distances to obtain necessary treatment. Once treat-
ment is rendered, the cost of prescription drugs may be far
too high for patients on limited incomes. The nurse must be
aware of these variables and have knowledge of social agen-
cies in the local commlUlity that can assist in improving
health care access.
Literacy is another community-related variable that can
affect health care. Up to 48% of English-speaking patients
do not have functional literacy- a basic ability to read, un-
derstand, and act on health information (Andrus & Roth,
2002 ). The functional illiteracy rate is even higher in cer-
tain populations, particularly non- Englishspeaking indi-
viduals and older patients. The nurse must be aware that
these patients may not be able to read drug labels, lUlder-
stand written treatment instructions, or read brochures de-
scribing their disease or therapy. FlUlctional illiteracy can
result in a lack of understandinR about the importance of
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FI9ur,8.1 Anurse communicates with her non-Engllsh-speaklng patient through an Inlerpreler
SOUrce; A1000n EoPJCorloolPH College.
pharmacothenpy and can lead 10 poor compliance. The
nurse must atlempt to identify these patients and provide
them wi th brochures, instr uctions, and educalional mate-
rials that un be understood. For non-English-speaki ng
patients or those for whom English is their second lan-
guage. the nurse should have proper materials in t he pa-
t ient's primary language, or provide an interpreler who un
help with accurate translations (. Figure 6.1 ). The nurse
should ask the patient to repeat important instructions, to
ensure comprehension. The use of graphic-rich materials
is appropriate for certain therapies.
8.S Genetic Influences
on Pharmacotherapy
Although 99.8% of human DNA sequences are alike, the
remaining 0.2% may result in significant differences in
patienlJ' ability to handle cer tain medications. Some of
these differences are created when a mutation occurs in
the portion oi DNA responsible for encoding a certain
metabolic enzyme. A single base mutation in DNA may
result in an amino acid change in the eru:yme, which alters
il5 function. This creates a geMti c polymorphisrl-two or
more versions of the same enzyme. The best characterized
genetic polymorphism! have been discovered in enzymes
that metabolize drugs, and in proteins that serve as Te(ep-
tUl) fur oJ, U!!). Ph".'dwgnl!"liu (h" uf
ations that give rise to differences in the way patients
handle medicat ions.
Genetic polymorphisms are most often identified in spe-
cific ethnic groups, because people in an ethnic group have
been located in the same geographic area and have married
PHARMFACTS
Community !-Iealth Statistics
in the United States
Arntriurnhcr ir tilt sutuM btnrrir m.1I!Y Iaey
Iwh!r _th.n Ih.t. lift ir 1M most!WI and thr IIICIIt
......
Thost....no Iiw In me IUboJrbsoflMge metropolitan 'II'<JS Uw lilt Iowesl
irfnl moruJity rues ,tid itt men hltlylo hil't bt. hh iruu,all(und
lItilltlrt lifHty\es.
Dtuh ' atH forW!)rking-igt' jljulb are highrr in t!lf most rural and most
urban'lNl.
Tht highest death r"ft forchiklrtn itld YOOflg ildulb are in tilt mOil
M.t (ountir!.
Homicidt mH.re hightsl in !fie {ffIIlJi arootie lIftI"09Oliun

Suburbin lI'5idnts ilf moII'.-ut, 10 dOOog tWneand
trICIr! liktl, tl Iwh!r imInru.SuIub.n _ iretbr INst liktIy
lit MOW.
Both thr/llOlt MJl wi /IIOIt urII.r _Ill'll" ' !OU,.,
PffUIIt.lgr of tridenu wCtloutllNtIr imunru.
TffiYgI'R and idulu in IUI,I (ountil-ure the most hut,,, smokt.
RHidtnu of the most IUril communilits ha'll" t!lf fNtst vliu fo! dentill
"".
others wi thin the group for hundreds of generations.
Although geneti c poIymorphisms are generally rare in the
over:r.U population, specifK ethnic groups can sometimes
express a very high irKidence of these defects.
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Choplfrl Gellde< rod Culrur.llnlluenc:", on PNrm.mthe<apy 81
ABLE8.1. Enzyme Polymorphisms of Importance to Pharmacotherapy
Enzyme
A(tlyltralilferall'
Dtbrisoquin
Result of Polymorphism
Slow ac:tl1iation in Scaodilaviarn,Jew5, North MOOn
CauusiaOl; fast iKl'tylation in l.pallN
Poorly mmboliml i1 Asiam and Afritlll.lJnffitlm
Poorly mmboliml i1 Asiam and Afritlll Arnffitlm
The relationship between genetic make-up and drug re-
sponse has been documented for decades. The firsl poly-
morphism was discovered in acetyltransferase, an enzyme
that metabolizes isoniazid (INH), a drug prescribed for tu-
berculosis. The metabolic process, known as acetylation, oc-
curs abnormally slowly in certain Caucasians. The reduced
hepatic metabolism and subsequent clearance by the kid-
ney can cause the drug to build to toxic levels in these pa-
tients, who are known as slow acetylators. The opposite
effect, fast acetylation, is found in many patients of Japa-
nese descenl.
In recent years, several other enzynte polymorphisms
have been identified. Asian Americans are less able to me-
tabolize codeine to morphine due to a genetic absence of
the enzyme debrisoquin, a defect thai interferes with the
analgesic properties of codeine. Some persons of African
American descent have decreased effects from beta-
adrenergic antagonist drugs such as propranolol (Inderal),
because of genetic variances in plasma renin levels. Another
set of oxidation enzyme polymorphisms have been found
that alter the respollse to warfarin (Coumadin) and di-
azepam (Valium). Table 8.1 swnmarizes the three most
common polyrnorphisrns. Expanding knowledge about the
physiological impact of heredity on pharmacotherapy may
someday allow for personalization of the treatment
process.
8.6 Gender Influences
on Pharmacotherapy
There are well-established differences in the patterns of dis-
ease between males and females. For example, women tend
to pay more attention to changes in health patterns and seek
health care earlier than their male counterparts. However,
many women do not seek medical attention for potential
cardiac problems, because heart disease has traditionally
been considered to be a man's disease." Alzheimer's disease
affects both men and women, but studies in various popu-
lations have shown that between 1.5 and 3 times as many
women suffer from the disease. Alzheimer's disease is be-
iI:i a majur "wu[[Jt:n'li. ht:allh aluug
with osteoporosis, breast cancer, and fertility disorders.
Drugs U!oIng This Metabolic Enzyme/Pathway
1
tlffrint. IrJdraialillt, isoniazid,jl"mioamide
illipramin r. ptfJlhftwiot, halopffidoI. propranolol.
metoprolol. codtiIt,
dimpam, inipramint,b.ubi!!nte, warfirin
Adherence with the prescribed medication regimen may
be influenced by gender because the side effects are specific
to either males or females. A common example is certain an-
tihypertensive agents thai have the potential to cause or
wOl"S<'n male impotence. Several different drugs can cause
gynecomastia, an increase in breast size, which can be em-
barrassing for males. Similarly, certain drugs can cause mas-
culine side effects such as increased hair growth, which can
be a cause of nonadherence in women taking these medica-
tions.Also in females, the estrogen contained in oral contra-
ceptives causes an elevated risk of thromboembolic
disordeIli. With effective communication, gender-specific
concerns regarding drug adverse effects can be brought into
the open so alternative drug therapies can be considered.As
with so many areas of health care, appropriate patient leach-
ing by the nurse is a key aspect in preventing or aUeviating
drug-related health problems.
Local and systemic responses to some medications can
differ between genders. These response differences may be
based on differences in body composition such as the fat-to-
muscle ratio. In addition, cerebral blood flow variances be-
tween males and females may alter the response to certain
analgesics. An example is the benzodiazepines given for anx-
iety; women experience slower elimination rates and this
difference becomes more significant if the woman is taking
oral contraceptives.
In the past, the majority of drug research studies were con-
ducted usingonly male subjects. It was wrongly assumed that
the conclusions of these studies applied in the same marmer
to women. Since 1993, the FDA has formalized policies that
require the inclusion of subjects of both genders during drug
development. This includes analyses of clinical data by geu-
der, assessment of polential pharmacokinetic and pharmaco-
dynamic differences between genders, and, when appropriate,
conducting additional studies specific to women's health.
Also of concern is gender inequity regarding prescription
drug coverage. A common example is employer health plans
that exclude women's contraceptive medications. It was not
until a federal district court ruling in June 200] that exclu-
sion of prescription of female contraceptives by an em-
ployer's health care provider was deemed sex discrimination.
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82 UnK2 "".,miKolog)r and ....... P.U"'1 Rl'latlQnmlp
KEY CONCEPTS
The nu mbered key concepts provide a succinct summary of the important points from the corresponding numbered section
wIthIn the If any of these points are not dear, refer to the numbered section withln the chapter for review.
8.1 10 deliver effective treatment, the nurse must consider the
total patient in a holistic context.
8l The psychosocial domain must be considered when dellv.
erlng holistIc ore. PosItIve attItudes and hIgh expecta
tlons toward therapeutlc outcomes In the patient may
influence the success of pharmacotherapy.
83 CUhure and ethnicityare two interconnected perspectives
that on nursing care and pharmacotherapy. Differ
ences In diet, use of alternatIve thel1lples, I't'rceptlons of
.... -ellness, genetic makeup can influence patient drug
response.
NCLEX-RNO REVIEW QUESTIONS
D The patient informs the nurse that hewill use herbal com
pounds given by a family member to treat his hyperten-
sIon, The approprIate action by the nurse Is to:
1. Inform the patient tIlat the herbal treatments will be
inetrediVl'.
2. obtain more information and determine whether the
herbs are with medicatIons prescrIbed
3. notll)' the physlclan ImmedL1tely,
4. inform the patient that tile physician will not treat him
if he does not accept the use of traditional medicine
only.
D The nurse provIdes teaching about a drug to nn elderly
couple, To ensure thai the InstructIons are understood,
the nurse should: {Select all that apply.}
1. provide detailed written about the drug.
2. provide [.,bels and instructions in large print.
J. ;lS8e5S the reading have patIents repM
iUMrudiulIs tu
4. provide instructions only when family members are
present
D The nurse must understand gender issues related to drug
therapy. Important considerations include which of the
following fucts!
1. Men seek bealth care earlier than women.
2. Women suffer from Alzheimer'sdisease in greater
nwnbers than men.
3. Women are more likely to stop taking medications
because of side effects.
4. All drug trials are conducted on male subjects.
SA Community and environmental factors affect h..ahh and
the public's access to health care and pharmacotherapy.
Inadequate access to health care resources and an inabil.
ity to read Of understand Instructions may compromise
treatment outcomes,
S.5 Geneticdifferencesin metabolic enzymes that occur among
different ethnic groups must be considered for effective
pharmacotherapy. Small differences in the structure of en
zymes CIIn result In profound changes In drug response,
S,'; Gendercan influence manyaspectsofhealth maintenance,
promotion,and treatment,as well as medication response.
D Thepatient informs the nurse that she will decide whether
she will accept treatment after she prays with her family
and minister, The nurse recognlz..'S the role of spIrituality
in drug therapy as:
I. irrelevant because medicatiollSact on scientific
principles.
2. to the patient's 3oxeptanC(' of medical
treatment and response to ttl'<ltment ,
3. harmless If it makes the patient feel better.
4. hannful,especially if treatment is delayed.
o The nurse knows that patients characterized 3$ slow
acetylators:
1. are more prone to drug toxlclty,
2. require more time to absorb enteral medications.
3. must be given liquid mediotiollS only.
4. should beadvised to decrease protein intake.
D A patient undergoIng treatment for cancer complains
about nausea and fatigue. In approaching this patient
problem holistically, the nurse would:
1. givean antinausea drug as ordered and place the patient
on bedrest.
2. observe for specific instances of nausea or futigue and
report them to tile oncologist.
3. take a medication history on the patient, noting specific
medication or food triggers.
4. talk to the patient about the symptoms, the imp.1ct they
have on daily activities,and techniques that have helped
lessen the problem
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CRITICAL THINKING QUESTIONS
1. A 72-year-old Afrlnn American heart p.uitnt who has
been treated for Butler is taking warfarin
(Coumadin) 2.S mg PO once a day. He comes to thedlnk
for his routine Intem3110naJ normalized ratio (INR).
which is no longer In the tber.llpeutic range. The patient
lives in a runl area and has a large vegetable garden. What
questions would a nurse need 10 ask 10 eVllluate the cause
of the decreased drug effecti'\ll'ne:ss?
2. An 82-rear-old female patient is admitted 10 the tOler
gencydepartment. She has been laking furosemide (wlx)
40 mg PO daily as p,arl of a r<'gimen for oongestive heart
failure. Sbt is confused, dmydrated, and has lost 12
pounds this week.. What gender-related considerations
should the nurse make .... -hen assasing this patient?
1. A 19-yeaf-old male p<ltient of Mexican de5(:ent presents to
a health d inicformigrant farm workers. In broken English,
he describes severe p,ain in his lower jaw. An l!>SeSSII1ent re-
veals lwoabscessed moJarsandolheroraJ health problems.
Discuss the probable re3Soru; for thIs patient'scondilioIL
Su Appwdi:.c D [or DnJWf'1"$ mId rDtiol1lliu [Droll DClivilin
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KEY TERMS
rrwdication administration I'KlJ'd (MAR) fIIlI1'8iJ
m,dicatim 'ITOr fIIlI1'lJj
Medication Errors
and Risk Reduction
LEARNING OUTCOMES
After reading this chapter, ~ student should be oble to:
1. Define medication error.
2. Identity factors that contribute to medication errors.
3. Describe specific categories of medication errors.
4. Explain the impact of medication errors on all aspects of a health care
ag@ncy.
S. Describe methods of documenting medication errors and occurrences.
6. Describe strategies that the nurse can implement to reduce medication
errors and incidents.
7. Identity patient teaching information that can be used to reduce
medication errors and incidents.
8. Identity efforts recommended by the FDA to monitor medication errors
and incidents and provide information to health care providers.
9. Explain stl3tegies used by health care organizations to reduce the
number of medication errors and incidents.
medication elm" index fIIlI1'lJj
medication Il'(ondliation fIIlI1'!fJ
polypharmacy pogtl/(J
ri ll! management fIIlI1' 91
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I
n their clinical practice,nurses maximize patient safety by
striving to be 100% accurate when administering medica-
tions. Drug administration, however, requires multiple com-
plex steps by physicians, pharmacists, nurses, and patients
and can never be 100% error free. Occasionally medication
er rors are made that can significantly impact treatment out
comes.The purpose of this chapter is to examine the reasons
for medication errors and explore strategies the nurse may
use to prevent them.
9.1 Defining Medication Errors
According 10 the National Coordinating Cowlcil for
Medication Error Reporting and Prevention (Nee
MERP), a m!diGltion error is preventable event that
may or lead to inappropriate medication use or pa-
tient harm while the medication is in the control of the
health care professional, patient, or consumer." NCC
MERP also classifies medication errors and has developed
the f rrar indH. This index categorizes medication
errors by evaluating the extent of the harm an error can
Figure 9.1).
Stated simply, a medication error is any error that occurs
in the medication administration process whether or not it
harms the patient. These errors may be related to misinter-
pretations, miscalculations, misadministrations, handwrit-
ing misinterpretation, and misunderstanding of verbal or
phone orders.
9.2 Factors Contributing
to Medication Errors
To be successful, proper medication administration involves
a partnership between the health care provider and the pa-
tient. This relationship is dependent on the competence of
the health care provider, as well as the patient's full adher-
ence with the drug therapy regimen. This dual responsibil-
ity provides a simple, though useful, way to conceptualize
medication errors as resulting from health care provider er-
ror or patient error. Clearly, the purpose of classifying and
studying these errors is not to assess individual blame but to
prevent future errors.
Fa, tors ,ontributing to medication errors by health care
providen include, but are not limited to, the following:
Omitting one of the rights of drug administration
(chapter 400). Common errors include giving an
incorrect dose, not giving an ordered dose, and giving
the wrong drug.
Failing to perform an agency system check. Both
pharmacists and nurses must collaborate on checking
the accuracy and appropriateness of drug orders prior to
administering drugs to patients.
Failing to account for patient variables such as age, body
size, and impainnent in renal or hepatic function.
Nurses should always review recent laboratory data and
Chop''' 9 Me<ibdoo Errors .nd RI"" Reduc:tlon 85
other information in the patient's chart before
administering medications, especially for those drugs
that have a narrow margin of safety.
Giving medications based on verbal orders or phone
orders, which may be misinterpreted or go
undocwnented. Nurses should remind the prescriber
that medication orders must be in writing before the
drug can be administered.
Giving medications based on an incomplete order or an
illegible order, when the nurse is lUlsure of the correct
drug, dosage, or administmtion method. Incomplete
orders should be clarified with the prescriber before the
medication is administered. Written orders should avoid
certain abbreviations that are frequent sources of
medication errors, as listed in Table 9.1.
Practicing lUlder stressful work conditions. Studies have
correlated an increa.ed number of error. with the .tre""
level of nurses. Studies have also indicated that the mte of
medication errors may increase when individual nurses
are assigned to patients who are the most acutely ill.
Patients, or their home caregivers, may also contribute to
medication errors by:
Taking drugs prescribed by several practitioners without
informing each of their health care providers about all
prescribed medications.
Getting their prescriptions filled at more than one
pharmacy.
Not filling or refilling their prescriptions.
Taking medications incorrectly.
Taking medications that may have been left over from a
previous illness or prescribed for something else.
9.3 The Impact of Medication Errors
Medication errors are the most common cause of morbid-
ityand preventable death within hospitals. When a medica-
tion error occurs, the repercussions can be emotionally
devastating for the nurse and extend beyond the particular
nurse and patient involved. A medication error can
lengthen the patient's stay in the hospital, which increases
costs and the time that a patient is separated from hisor her
family. Th'" nurse or physidanmaking the medi,ationerror
may suffer from self-doubt and embarmssment. If a high
error rate occurs within a particular unit, the nursing lUlit
may develop a poor reputation within the facility. If fre-
quent medication errors or serious errors are publicized,
the reputation of the facility may suffer, because it may be
perceived as unsafe. Administrative personnel may also be
penalized because of errors within their departments or the
hospital as a whole.
There are no acceptable incidence rates for medication er-
rors. The goal of every health Clre organization should be to
improve medication administration systems to prevent
harm to patients due to medication errors. All errors,
whether or not they harm the patient,should be investigated
LibraryPirate
86 UnK2 P'harmoc:ology . nd theNurse--p. lil'nt Relationship
-

or .......malhat
ha .... capacity
10 causa erfOf

---.---

NCC MERP Index for
Categorizing Medication
Errors Algorithm
Impairment 01 the physical, emotional, or psychological
"'nction or structure 01 the bodyand/or pain r9sohing
therefrom,

To ob&etva or """,1'<1 "'levant physiological or
psychological signa,
Intervention
ItdIlY include change in theflll'Y or acti .... medical/surgical
t, .... tmont
Intervention Necessary to Sustain Lil.
1rn;ludeIi cardiOVllscUBr IIIld respiratory liUWOrt
(e,g" CPR, int<b&tion, ele,)
'An error 01 omiSS;Of1 does rel>Ch the I"'liont
----.----
Category F
Iho_--. .. ,) r ____ O'= O ____ --<
Figure 9. 1 Index for Categortzlng Medication Errors Algorlthm;see al'iO Figure 9,2,page 89
Sour,,,, 0 1001 Naflonal Coorrifiaflng Camell for Medlcaflon Error Reporrfig and Prwl'flr/oo, All rlghtl reserved,
with the goal of identifying ways to improve the medication
administration process to prevent future errors, The investi
gation should occur in a nonpunitive manner that will en
courage staff to report errors, thereby building a culture of
safety within an organization, Analysis of error p.1tterns can
alert nurses and health care administrators that a new policy
or procedure needs to be implemented to reduce or elimi
nate medication errors,
LibraryPirate
CNpta' 9 Me<i""1100 Errors and Risk Reduction 87
ABlE9.1. Abbreviations to Avoid in Medication Administration
Abbreviation Intended Meaning Common Error
"
Miltam. i l i moor i fOIl' (4) lI'5Uhing in mistakm for ' "' (cubM: whm poorly
'NIiIttfl.

Mimqallll Mislam. for"mcf Imiligramt) lI'5Uhing inan
.,
latn ibbrtoiiatiOO for "try day The pffiod _imtlbffiJ mimktn for ind iIH' aug has bffiJ gi'ml "OID'(kIII"
daly) rathtrthan daily.
.... !.itn ibbrtoiiatiOO for "try Milinterpreted as "Oil" (daily) or"OID' (fOIl" tiMl ).If "0' is pooIt1 'NIiItl'fl, it loot! i pfflod or "I:
OIhtrd.y
so
tiw
SubruuntOOl

Miltam. i lOSr whtn pooIfy wrinm.
Misintrrpreted as "thlff timtl a day" or"twite a wm."
"
Disdlirgt; 01110 ditoorlillUf htimft meditationliul'!' bffiJ prtINnm, dittontimll'd wIIffi O/C, (intfflied to "discharge") Won
foIowrd by i list of drug!.

W.Hnrtngth Misinl<'rpretod as tho .blnWtion"W,"(hOII" of lI .. p}.
UD::(mtiml'l<'n Mislam. il "U"(unin) whm poorly wrintfl.
AU,AS,AO latn for both Mitinl<'rpretod as abblniation ' 01./"' (both );"OS" (idt (rillt

'"
Inwnational unit Miltam. ulV or 10 (tm).
MS, MS04, MgS04 Confuted for 0lIl' inothtr un morpIint !UtiI<' or migntSiJm
Nort: From the Nationil Cocninating (0000 for MedK.ittion Error Rrponing and Cl I998- 100/i.AlI Rights Rl'sm'ed.
HOME & COMMUNITY CONSIDERATIONS
Preventing Medication Errors in the Home
U.S. Phannac:opty'S Saif: Meditation I.M Expert Comminte (Santell &
Coutim, lOMjlt'pOnt that meditation !'lron O((Um n9 in tilt aft' tilt
!Uk of (ommuniution probltllll (21%), know\edgt deIirit (19%), ind inade
or loKking roonitoring (4%). pen:tfIt of aft' {auted by lack of
(ffi to information. Warfarin is thf drug most frequently (9%) associated
with trron in tilt homl'; OOIt in ffl'quency jft' (7%), mor
phine (4%), and nncom)'Cin (4%). At thl' top 01 thr lilt 01 error typf ill' im
proper Ou (36%) and omislion !'l1Ol"l (28%).1 n this study,
or Cil"rgivrr is It'pOHed to 1It.ll fault in 399j, of the nurSl' in 36%, and
the or phifTlloKist in 11%. This ltudy poinn out thr nfed for betlef
educ.Jtion,a tolt in which the plays i lirgr pin.
9,4 Reporting and Documenting
Medication Errors
Vthen a health care provider commits or observes an error.
effects can be lasting and widespread. Although some errors
go unreported, it is always the nurse's legal and ethical re-
sponsibility to report all occurrences. In severe cases, ad-
verse reactions caused by medication trrors may require the
initiation of lifesaving interventions for the patient. After
such an incident, the patient may require follow-up super-
vision and medical treatments.
The Food and Drug Administration (FDA) has coordi-
nated the reporting of medication errors at the federal level.
The FDA Safety Information and Adverse Event Reporting
Program, known as MedWatch, provides important and
timely clinical information about safety issues involving
medical products, including prescription and owr-the-
counttr (OTC) drugs, biologics, medical and radiation-
emitting devices, and special nutritional products. The FDA
encourages nurses and other htalth care providers to report
medication errors for its database, which is used to assist
other professionals in avoiding similar mistakes. Medication
errors, or situations that can lead to errors, may be reported
anonymously directly to the FDA by telephone or online.
Since 1992, the FDA has received over 30,000 reports of
medication errors. The number of actual error6 may be
much higher.
A second organization that has been established to pro-
vide assistance with medication errors is the National Coor-
dinating Council for Medication Error Reporting and
Prevention (Nee MERP). This organization was formed
during the Pharmacopoeia Convention in 1995 to help
standardize the medication error reporting system, examine
interdisciplinary causes of medication errors, and promote
medication safety. Nee MERP coordinates information on
medication errors and provides medication error preven-
tion education.
DOCUMENTING INTHE PATIENT'S
MEDICAL RECORD
All facilities should have clear policies and procedures that
provide guidance on reporting medication errors. Docu-
mentation of the error should occur in a factual manner:
The nurse should avoid blaming or making judgmtnts.
Documentation does not simply record that a medical er-
ror occurred. Documentation in the medical record must
include specific nursing interventions that were imple-
mented following the error to protect patient safety, such as
monitoring vital signs and assessing the patient for possible
LibraryPirate
88 Unft2 PNr mocology R .... tlon$hlp
complicat ions. Failure to report nursing actions implies ei -
ther negligence ( i.e., no int erventions were taken) or lackof
acknowledgement that the incident ocwrred. The nurse
should also document all individuals who were notified of
the error. The mdiution adminillration IfCord {MAR) is another
source that should contai n information about what med-
ication was gi"en or omitted.
REPORTING THE ERROR In addition 10 documenting in the
patient's medical record, the nurse m:aking or observing
the medication error should complete a wriuen report of
the l'I"ror. Depending on the health care agency, these
reporlll m:ay be called " Incident MOccurrence
ReporIll,M or similar ti tles. The specific details of the l'I"ror
should be recorded in a factual and objective mannl'!". The
report th", nurse an opportunity to identify fmors
that OOlItributed to the medication error and assists in
identifying any spe<ific performance improvement
strategies that may need to be implemented. The wrinen
report is not included in the patient's medical record but is
uoed by the agency's risk management penonnd for quality
improvement and assurance and may be ustd by nursing
administration and education to identify common error
occurrences and the need for performance improvement or
educational intervention.
Accurate documentation in the medical record and in the
error report is essential for legal reasons. These documents
verify that the patient's safety was protected and serve as a
tool to improve medication administration processes. Legal
issues may worsen if there is an attempt to hidea mistake or
delay corrective action, or if the nurse forgets to document
interventions in the patient's char t.
Hospitals and health care agendes monitor medicat ion
errors through quality and perform:an<:e improvement pro-
grams. The results of quality improvement programs alert
staff and administrati\'e personnel abom trmds within
particular units and may serve as indicators of qUJIlity pa-
tient care. Through data collection, specific solutions can
becreated to reduce the number of mooication errors. Root
cause anal),!; is, or RCA, is being implemented in many
h""lt h a m: organiZlltioru as a method to prcv"nt fum...,
Il1i5takes. By answering three bask questions: What
pened, why did it happen, and what can be done to prevmt
it from happening again?, RCA seeks to prevent anotheroc-
currence. Many agencies also continue RCA with the ques-
tion, has the risk of recurrence actually been reduced?, by
analyzing data postoccurrence. The overall goal of report-
ing medication errors and conducting follow-up assess-
ments such as RCA, is safe and effective p<ltient care and
patient medication administration.
SENTINEL EVENTS The Joint Commission, which accredits
health care agencies, recognizes 1I form of event
termed events." Sentinel events are defined as
"unexpected occurrences involving death or serious physical
or psycllological injury, or risk thereof" (Joint Commission,
2(09). Not all errors are sentinel events and not all sentinel
events occur because of an error. But because of the grave
nature of the event, sentinel events are alW<lJ" invt5tigated
and interventioru put in place to ensure that the event does
not recur. Root cause analysis is utilized to identifythecauses
and required intervention to prevent a recurrence.
9.S Strategies for Reducing
Medication Errors
What can the nurse do in the clinical setting to avoid med-
ication errors and promote safe administration? The nurse
can begin by foUowing the steps oflile nursing process:
l..-\sjt:S5ment: Ask the patient about allergies to food or
medicatioru, current health concerns, and use ofOTC
medications and herbal supplements. For all medications
taken prior to assessment, ensure tNt the patient has
been melving the right dose-, at the right time, and by
the right route. A.>isess kidney, liver, and other body
system functions to determine if impairments are
present that could affect pharmacotherapy. Identify
areas of needed patient education with regnd to
medications.
2. Pialming: Minimize factors that contribute to
medication errors: Avoid using abbreviations that can
be misunderstood, question unclear orders, do not
accept verbal orders, .and follow specific facility policies
and procedures related to medication administration.
Have the patient restate dosing directions, including the
correct dose of medication and the right time to take it.
Ask the patient to demonstrate an understanding of the
gools of therapy.
Impiemenltlrion: Be aware of and eliminate potential
distractions during medication administration that
could result in an error. When engaged in a
medication- related task., focus ent irely on the task.
Noise,other events, and talking coworkers can distf'3C1
the nurses' attention and result in a medication error.
Practice the rights of medication administration: right
patient, right time and frequency of administration,
right dose, right route 01 administration, and right
drug. Keep the followi ng steps in mind as well:
Positively verify the identity of each patient using
two means (e.g., name and birthdate) before
administering the medication to facility
policy and procedures.
Use the correct procedures and techniques for aU
routes of administration. Use sterile materials and
ar.eptic techniques when administering parenteral or
eye medication.
Calculate medication doses correctly and measure
liquid drugs carefully. Some medications, such as
heparin, have a narrow safety margin. When giving
these medications, ask a colleague or a pharmacist to
check the calculations to make certain the dosage is
correct. Always double-check pediatric calculatiOIlS
prior to administration.
Open medications immediatel y prior to
administering the medicat ion and in the presence of
the patient.
LibraryPirate
Record the medication on the MAR immediately
after administration.
Always confirm that the patient has swallowed the
medication. Never leave the medication at the
bedside unless there is a specific order that they may
be left there.
Be aler t for long-acting oral dosage forms with
indicators such as LA, XL, and XR These tablets or
capsules must remain intact for the extended-release
feature to remain effective.lIl'itruct the patient not to
crush, chew, or break the medication in half, because
doing so could cause an overdose.
4. Evaluation: Assess the patient for expected outcomes
and determine if any adverse effects have occurred.
Nurses mould know the most frequent types of drug
errors and the severities of different categories of errors
(. Figure 9.2). The FDA ( Meadows, 2003) evaluated re-
ports of fatal medication errors that it received from 1993
to 1998. The most common types of errors reported in-
volved administering an improper dose (41%), giving the
wrong drug ( 16%), and using the wrong route of admin-
istration ( 16%). Almost half of the fatal medication errors
Chop''' 9 MedlGotloo Erro" .00 Risk Reduc:tlon 89
occurred in patients older than 60 years. There is an in-
crease in the risk for er rors in the elderly population be-
cause they often take nwnerous medications, have
multiple health care providers, and are experiencing nor-
mal age-related changes in physiology. Children are an-
other vulnerable population because they receive
medication dosages based on weight (which increases the
possibility of dosage miscalculations), and the thempeu-
tic dosages are much smaller.
Nurses must be vigilant in keeping up to date on pharma-
cotherapeutics and should never administer a medication
until they are familiar with its uses and side effects. There
are many venues by which the nurse can obtain updated
medication knowledge. Each nursing unit should have cur-
rent drug references available. Nurses can also call the phar-
macy to obtain information about the drug or, if available,
look it up on the Internet using reliable sources. Many
nurses are now relying on personal digital assistants ( PDAs)
to provide current information. These devices can be up-
dated daily or weekly by downloading information so that
the information is current . Nurses need to familiarize them-
selves with research on preventing medical errors to main-
tain evidence-based practice skills.
C.-gory t. c.r;....., A:
M error oocurred thE
may h_ contributed to
or ruoJted in the
paenfa d .... th

An e""r occurred lIlal
mquired int .. lVIIOtion
_ury 10 suclain ile
Cet egory G:
An ........ occu .... d thal
""'Y hit .... contribut .. d to or
... sulted in permanent
patient harm
Cetegory F:

M . "'" ocaMTed but
the error <id not ...,.,
... prien! 1M "..,..,.. 01
orrissian' doai reach !he
... ..,
C .. egoryC:
An . rror <>CaIfT1Id that
the p.-ient but did nee
".... pAtient harm
"-''''
An error ocaMTed thai
reAChed the patient and
moritoring to
An e ""r occu .... d that ""'Y
ha .... contributed to or
I"85OJtod in t .. mporary
harm to the pat .. nt and
reqli ... d or
... -
hospitalization
conIi rm thai it .--uIIed in no
harm 10 the pAlient and'or
required int--.tion
...... tedin
tomporvy harm to
the palilKllltnd
raquired inter .... ntion
to precIucIe herm
I 0 No Error 0 Error. No Harm 0 Error, Harm 0 Error, Death I
,.. Flgure9.2 NCC MERP Index for Categorlzll"l9 Medication Errors
Source: Cl lOO1 Nar/vool Coordinating Coonell f()( Med/aJll()(l Error Reporflng and Prl!vMrkxl.A11 rfghrJ
DefInitIons
Harm
Impairment 01 the
physical, emotional, or
p,!I)o'd>oIogicallunction 01
clNctu .. of the body
and/or pain reGuHing
thero/rom

To observe or ... cord
r .. l.......m physioIogiCilI
or psychological sign.
Int.rvention
May include change
in therapy 01 ltCtive
medicallsu'llical
tmalment
Int.rv.ntion
N.c .... ryto
Su.tain Life
Includes cardiova!IaJlar
and resp;ratory 5,-"""rt
(e .g., CPA, doIibrilation,
intubation)
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"




LifESPAN CONSIDERATIONS
Ag". R"lat"d InUlls in Drug Administration
The Pedi. tric: Popul. t ion
doubIt-dIKk YkubtioM will iI\Olht! IIIIISf b drug

.lk<liutions!lll)' fIftd to auWd or idminiltfl(C/ in a liquid Iotm.
NSt.iVn med'ationsin thepllt
,nd for Ihniques tNI h .... e bffillUtulul in adminisltling
mtdiulions.Some children willlNdily tair.to mtdiutions.1'Id tilt drug
m.ly not need to be di!guiRd.
Consid tilt dmlopmmtalst.igt of tilt patimt ,nd ifll'OM the child to
the extent possible.For forchiknn under 5, I}ivelirnpitchoic:H
,nd short elJlwnations{e.g.:1 hal'!' I00I'' rntdDIe for rw to dlint.
Would rwlilt to hold the arpn
Sf_ mimg mediutirn intoa CDIIdintnl, btUll!
th.lt tilt mtdiclrtian does nOl thu (e.f.,Kidio: food
_H Mf1 DflIIIgr rna, in!rrKI with p""').UstIll9'rie.s
bids .nd p.iUmu who oron ir.totogtnir: dim..
sucIr'ltt!ulor milk
bwust tilt child m., rWsr tht food IaIK
Whtn. mtthod of mtdiution .dmininration NI bI!tn II.I(HlIuI.
document the thnique in thf child's caff pwn ID ffWY the information
to
Rememberth.t mediclrtiom mly Me idiol)'flCruir: effeas on pediatric:
p.ititnu.Atry UIlIIU.1 should be inwstiglttd.nd. poIsibiedrug
effect comidmd.
The Elderl y Population
the frtqutlK)'of ad'I!'rst ftfr.cts of rntdiclrrions is
in tIderly pWftu baiM 10 tbsort
.nd meubob mtdiutions..
obHI eldert, pltirnb for ability ID swi:rw priaf 10 ....... isl!Jtian of
" tnt1iurions.
PllitnU!IIl)' r!'Iust mediartions for m.ny of the pill or
ublet.and Ital or pmeim:! ad'I!'IW efftm.Explort ff.lOns fo, Itfu1
,nd 'PPlOpriate !ion to ensult tht islUl' is rtSOI'I!'d (t.g., switth
from to sWil10w pill to. smliler formuwtion).1'Id that
p.ititnt .utonomy is 1npKItd.
ExplOIt tilt p.ititnt's normal.ctirity ,nd LIIIIiI sleeping ,nd waking
houl$.Xhed,* mtd'atiom iI'OUnd thrst 1M wilen poIlille.kIcrw.s
simple a dosino !dIrd,*n pcruiblr.
mtdiclrrions with the pKimton rmy hOOh Uff mc.Notr
'nyCOll'lpl,lints m.rttd to sptdic drugs b
YIIUiI dlitlgesllll)' IlliR bbrisliffir:u/t to IUd. Fo.-I\orM
adnWitrltio!'l. pIUI'idr largr-prinl itstnrr:tions, l1li. \tile
\Md if 1WOed,.1'Id rt<omrnrnd al with ltIe
PN rm.wist Nth time prescription is fiItd Mr W 1If. <o1or, a nd size of
the mtdir:,nion.
For It-homt urt,if stpI,ate pill (on"inm.rI' ustd othtr than tilt
original prI'scription bottle (f.'.j.,pill (onllill!'l'S divided by days of tilt
Wffij, bt Wit tilt patient, family, or <arl'1liYfr (ftlin wiginal bottles is
wtY II nOleitht color ofNch pill Should, Itaction 0(11\ I)t sltould.
miling)lOUng chid.ocm tlJe coruin morl' prtcise rtCOrd of wNt
drugs wtte poIrIrNJ, consumed wiI.id iluutirlgtllt pirifrt.
PII7iide lpe<ifir: instnKtions!of. mtdiclrrions howf!tqIlel'l"'"11
medic.tiom bt laizlr).En!Ift that the patitnt "-wNt
todo if, IMdir:IIion is bgottrn.
9.6 Medication Reconciliation
Many geriatrk patif nts ha\'e5eve!'al drronic medical disor-
ders,eac:h of which may be trtated by individual spfdaliSlS.
It is rommon for these patil'llts to receive multipl e pre-
sc:riptions, sometimes for thf same oondition, that have
conflicting pharmacologic actions, a condition
poinrilarrucy. AlthOUgh not unique to olde!' adults,
polypharmacy is most often seen in this age group. Keeping
track of multiple medications. their doses, indic:a tions,
routes, and of administration is a major chal-
lenge for both patients and health care providers. Failurt to
properly record mediation information, and oommuni-
Oitethat infonnation to hl'<llth Oire providers, is a potential
c:ause of medication errors.
Mtdic.atioolt(ol{iliatiorr is the process oC- keeping track" of
a patient's medications as they proceed from one health
c:are provider to another. Reconciliation ac:cur:r.tely lists all
medic:ations a patient is taking in an attempt to reduce
duplicat ion, omissions. dosing errors, or drug interac-
tions. For example, when a patient is admitted to c:are. the
nurse records all medications the patient has been taking
at home, induding their dose, route, and frequenc:y. Thi s
list is checked against admIssion orders and is cransrerred
to other prac:titioner s whenever the patient is moved to
different units within the hospital. It is also checked at
discharge. ThfSf - interf .. ces of are the most likely
placfS that medicat ion rfconciliation errors have bun
found to
In 2004, lCAHO identified hundreds of SfriOU!l medica-
tion ",rors attributed to mediation reconc:iliation and df-
veloped recomml'lldations for their prevention. Hospitals
are now encouraged to implement a process for doc:ument-
ing a complete list of the patil'llt's current medic:ations upon
the patient's admission. Medications should indude pre-
scription mooiClIions, ore medications, vitamins, and
herbal products. Thi s medication list should be oommuni-
cated to the next provider of service when a patient is re-
ferred or transferred to another setting, service, physician.
or level of art within or outside the organization. On dis-
charge from the faci lity, provide the patient with thf rom-
pletf list of medications [0 be takm, as weD as instructions
on how to bitt any newly prescribed medications.
9.7 Providing Patient Education
for Medication Usage
An essential strategy for avoiding medic:ation errors is to ed-
ucate the patif nt by providing written age-appropriate
handouts, audiovisual teaching aids about the medication,
and wlllact information about whom to notify in the eVfnt
of an adverse r(':lClion.
To minimize the potent ial for mediation errors, the nurse
should teach patienlSor their homfc:aregivers the following:
Know the names of all medic:ations they are taking. thf
uses, the doses,and when and how they should be taken.
Know what side effocts need to be reported immediat ely.
LibraryPirate
HOME & COMMUNITY CONSIDERATIONS
- --
OTe Drugs and Medication Errors
Patitnt ofOTC drugs and natural thtrapies is.! (ommon INson for
ind IIH'diution erron. For amibiotiu un toWl'r tilt
of oral rontrxeptim.OTC amihistamine un imer,l(t ldversely
with seriatiYel, amidepres wrm, and [MOO p'-
OOl1lto:
Carry a list of J II ilKluding Ole drugs, supplements.
,nd medic:inal hfrbs.
Br famil), and '/arious care provicltrs holl'r a rop)' of this list
vitlmins,lmriYl'S,steeping pilis,and binh (ontrol pills.
If pharmacy for all beulM tilt pharm.Kist
is an Il'SOUrn for providing information oIbout drug-1lrug and
IItrbil/food intrr ,dions.
- Read the label prior to each drug administration and use
the medication device that comes with liquid
medication.. rather than household mea.uring .poon .
- Carry a list of all medications, including OTC drugs, as
well a$ herbal and dietary suppl",ments that are being
taken. If possible, use one pharmacy for all
prescriptions.
- Ask questions. Health care providers want to be partners
in maintaining safe medication principles.
9.8 How Health Care Facilities Are
Reducing Medication Errors
There is a trend for health care agencies to use automated,
computerized, locked cabinets for medication storage on
patient-care units. Each nurse on the unit has a code for ac-
cessing the cabinet and removing a medication dose. These
automated systems also maintain an inventory of drug
supplies.
Larger health care agencies often have de-
partments to examine risks and minimize the nwnber of
medication errors. Risk-management personnel investigate
incidents, track data, identify problems, and provide recom-
mendations for improvement. Nurses collaborate with the
risk-management conunittees to seek means of reducing
medication errors by modifying policies and procedures
within the institution. Examples of policies and procedures
include:
_ Correctly storing medication (light and temperarure
control).
_ Reading the drug label to avoid using time-expired
medications.
CNpt .. 9 MedlGotloo Erro.uOO RiskRedualon 91
_Avoiding the transfer of doses from one container to
another.
_Avoiding overstocking of medications to prevent the
expiration of medications.
- Monitoring compliance with prohibited prescription
abbreviations.
_ Removing outdated reference books.
9.9 Governmental and Other
Agencies That Track Medication Errors
Both governmental and private agencies track medication
errors and provide updated reporting for consumers and
health care providers:
- The FDA's safety information and adverse-event
reporting program is MedWatch. Its toll"free number is
1-800-332-1088, and its website is www.fda.gov/
medwatchlhow.htm.
The Institute for Safe Medication Practices ( ISMP)
accepts reports from consumers and health care
professionals related to medication safety. It publishes
Safe Medicine, a consumer newsletter about medication
errors.
_ MEDMARX is the U.S. Pharmacopeia's anonymous
medication error reporting program used by
hospitals.
Th r QUfstion: What tilt moll common types of mediution mors
occurring in Pfdiitric Poltients?
Th r Study: A rnitw oftht b"k to 1969 found 32
,"YoInt paptrs in tllr !cimtifK literuull' tholt aoIminrdthe irKidence
and nalUll' of IMdic:nion rrrors in (ommon of
rrrorwM deliYering an inrormt ON.ln SOml' coIltS,this in'lOiYed
administering 10 times tilt Mnnal ON. The moll freqU!'nt drug
with thef'rors antibiotic:sand srdatiYes. Tlltadual mo.
rile WJI not po!sibietocakulatedU!' to tllr snull numherof studies.
Nursing Impli utions: The oIuthors a number of (ommon--srru
suggestions to oIwid medication errors in this population, ioduding
doubll'-<hfiking thf dostS, verifying J If)' or that
'ppm unuwa l chrd:ing 101 allergits btioll' adm inistrring tht drug,
ronfinning tilt p.ltient's Wl'ight is (orrro" nd providing ,deqwte
ill\efYic:ts for oI9I'nq ptrwnnel.
5aru: GIioI14 M.A., &lroer, N., Franurt. 8. 0.. 1ftlIIOj, l f. & I.
Sr;1i'mIIIt rni'w I1f IItdki1IioII 111m In ptdllffk pllIIf'IIB: 5uqgf5I/orI! III
pIl'lImfllldklllil1nmors.tldllH"tll 11M' MMliofPharmao:01IIf!ap):
1766-1776.
LibraryPirate
92 Unft2 PNrmocology R .... tlon$hlp
KEY CONCEPTS
TbI.' numbered key concepts provide a suinct summary of the important points from the corresponding numbered $tion
within the dlapter. lf any of these points are DO( dear, refer to the numbered section within the chapter lOr review.
9.1 A mediation error may be related to misinterpretations,
miscakubtions, misadminlstratlons. handwrIting misin-
terpretation, and misU!ldersundlng of verbal Of phone
onkrs. Wbether the patient ls In;ured or not, it is still a
medication e rror.
9.2 NumerolL'l facton cont ribute to medIcation t'rro!'$, in-
cluding mistakes in the five rights of drug admlnisu3tion,
failing to foUow agency procedures or consider patient
variables, giving medications baSlid on verbal ordt'1'S, not
confirming orders that are lI1eglble or lnoomplett', and
v..arking under stressful oonditlons. Patlt'nts also con-
tribute to erron by using more than oDt' pharmacy, not
informing nealth care provlden of aU medications tht'y
art' taking, or not following Instructions.
93 Nurse practice acts define professional nursi ng. Including
safe medication delivery. Standards of cart' are dt'fined by
nUf5e practl(e acts and tile rule of reasonable and prudent
action.
9A Nurse; are legally and etlilcaJly responsible for reporting
medication errors-wlletller or not they cause harm 10 a
patient-in the patient's medical reoord and on an inci-
dent report . The FDA and NCC MERP are IWO agencies
that tradr: medication erron and provide data to help in-
.... ilul .. p..........Jw"," lu IJlt'm.
NCLEX-RN- REVIEW QUESTIONS
o Each nUIlie is responsible for becoming f:amlliar with tht'
nurse practi.:eacts o(thestate In which be or she practices
becaw.e these acts:
I. protect the IIlIIlil' from malpractice suits.
2, contain national standards and responslbUlties..
3, contain jobdesc:riptions for all nurses.
4, define nursing prnctice and stuld.1fds of care for the
nurse practicing In a specJllc stat ...
D The nurse administers a medication to the wrong patient.
Tbe appropr iate nurSing action is to:
i. monitor thep;1tlent (or adl\.'l'Se reaction before
reporting the incident.
2. document the error If the ]Xltient bas an adverse
reaction.
J. report the error to tile physician, document the
medication in the p;ltient re(ord,andcomplaea repon
orlhe error for further folJow-upand anaiy5is.
95 Nurses can redlKe medicalion erron by adhering to the
four steps of the nursing process---assessment, pbnning.
implementation, and evaluation. Keeping up to date on
pharmacotherapeutics aoo knowing common erfOf types
are imt rumental to SOIfe medicatIon administratIon.
9.6 Medication reconcil iation is an important means of re-
ducing medication errors. Medication reconcUlatlon Is a
process of keeping track" of I p;ltlent's medications as
tbt')' proceed from one health care provider to another.
9.7 Patient teaching indudes providing age-appropriate nted-
ication handouts. and enoounglng patients to keep a list
of all prescribed medications, OTC drugs, herb.,j thera_
pies, and vitamins they are taking and to report them to
all healtb care providers.
9.8 Facilities use riskmanage ment departntents and agency
policies and procedures to decrease the Incidence of med-
ication errors. Automated, computerized, ltxked cabinets
for medication storage are a means of SOIfekeeplngofmed-
ications and keepirtg tra(k of Inventory at the unit k-vel.
9.9 The FDA (MedWatm), the Institute of Safe Medication
Practices (ISMP), and the U.s. Pllarmacopeia (MED-
MARX) arethree agencies that tndr: medication errors and
provide databases of error incidence, error types. and lev_
els ofbarm lOr bealth professionals and/Of consumers.
4. and document the error In a report
only.
o The patient wilh liver dysfunction experiences toxicity to
a drug following administ ration ofsevenJ doses. This ad-
verse reaction may bave been prevented If the nurse had
followed which phase of the nursing process!
]. Assessment
2. Planning
3. Implementation
4. Evaluation
D Nurses bave a legal and moral responsibility to report med-
j,ation errors. The steps of !\'pOrting thcscerrorslndude:
L punishing the nurse woo commltt..'d the error.
2. monitoring umafe medication ord .. rs.
3. identifying potential uDSolfe medication facilities.
4. examining interdisciplirlary caUSo!S of errors and
assisting profeWonais In Wll)'S to avoid mistakes.
LibraryPirate
o The nurse has admi nistered a medication to the wrong
patient. Which of the following is a correct action the
nurse must take! ($elect all that apply. )
I . Notify the physician.
2. Document that a medication error occurred in the
nurse's notes.
3. Assess vital signs.
4. Document medication on the medication
administration record (MAR).
S. Complete a facility report of the error.
o.,pt.' MedkooUon Errors iK1d Risk Redxuon 9)
o When the nurse enters the pat ient 's room with a medica-
tion, thepatien! the phone,just leave my pill
on the table there." What would be the 2g response by
the nurse!
I , Leave the pill at the bedside as requested.
2. Ask the patient to leI th(' nurse know ",-hen the phone
cill ismmp1eted so that the nurse can return with the
medication.
3. Instruct the patient to either tm the medication or
refuse it.
4. Chart the medication as "unable to give" and skip the
d"",.
CRITICAL THINKING QUEST'-'. IO"'N"'S=-______________ _
1. A registered nurse Is assigned to a team of ('Igbl patients.
Six of these palients have mediations scheduled foronee-
a.day dosing at ]();OO a.m. Explain how the nurse will be
able to administer these drugs to the patl('nts at the

2. A health care provider writes an order for 1)'lmol 3 PO
qJ-.4 for mild pain. The nurse evaluates this order and is
concerned that it is incomplete. Identify the probable con-
cern and describe what the nurse should do prior to ad-
ministering this medication.
1. A new nurse does not check an antibiotic dosage ordered
by a health care provider lOr a pediatric patit'nl. The nurst'
subsequently overdoses a 2-year-old patient, and an expe-
rlenced nurse notlces the error during the evening shift
change. Ident ify each person who is responsible for the er-
ror and how each is responsible.
Set Appendix D for answm and mtiollilies for all IIctivities.
EXPLORE fiigl1I!IJtili(3!tI::r------,
MyNursillgM is )'WI one stop tor ani fie CIlapttr rtYIe'W matMals and
ffSOUfatS. Pr epaf8 f(J 5UCCe6I will1 practice
ASSIgment'l tnl lClNiIIes. 'M:b 1Wls. Mlmatfons
i nc! nI meI
1II!gL'Ur you' CMe trom !lie fnw11 d )'GUf book at
www.mynursnglUt.c.n.
LibraryPirate
KEY TERMS
MIlIIliuI J'III"'1S
(_plementir)'iIIId ilblNtM! lIlfIIi: ine{o.M)
.....
ditlllryMlppkolll'M [JIlIJt9/J
Herbal and Alternative
Therapies
LEARNING OUTCOMES
AIrel' fMliing this coopt.." the student would be> ab/# to:
1. uplaln tIM! role of complementary and alternative ml!dlclne In
promoting patii>ntwelines5.
2. Analyze reasons wbyherbill and dietary supplements Mve intrea5e'd In
popularity.
3. Identify the parUofan herb thill may (ontain active ingredienUand
the typeS of formulati ons made from these parts.
4. Analyze the strengths and weaknesses of the Dietary Supplement
Health and Edu(ation Act (OSHEA) of 1994.
5. Desaibe adverse effects that may because<! by herbal and dietary

6. Discuss the role of the nurw in teaching patienUaboul complementary
and altematlve therapies.
7. Identify common drug-herbal interactions.
8. uptain how some herbal products are standardized based on spe<ific
actlvl! ingredients.
DiftarJSupplelllfl'll nlll Nonpmrn,tien Drug
CD115IIIIIl'fPre1titnAct Pl'9!I
Diftilf)' Supplelllfflf ilnd EiMaliin Act
(DSIO} of 19'J04 JII 9/J
herb JIIlIJ''1S
JIIIII''If!
LibraryPirate
H
erbal supplements and alternative therapies represent
II multibill ion-dollar industry. Sales of dietary supple-
mentsaloneexceed $17 bill ion annually,with morethan 158
million consumers using them. Despite the fact that these
therapies have not been subjected to the same scientific
scrutiny as prescription medications, consumers turn to
these treatments for II variety of reasons. Many people have
the impression that natural substances have more healing
power than synthetic medications. The ready availabi lity of
herbal supplements at a reasonable cost, combined with ef-
fective marketing strategies, has convinced many con-
sumers to try them. This chapter examines the role of
complementary and alternative therapies in the prevention
and t reatment of disease.
10.1 Alternative Therapies
Complementary and aitrmat i"ft' medicine (CAM) comprises an ex-
tremely diven;e set of therapies and healing systems that
are considered to be outside mainstream health care. Al-
though diverse, the major CAM systems have common
characteristics.
Focus on treating each person as an individual.
Considen; the health of the whole person.
Emphasizes the integration of mind and body.
Promotes disease prevention, self-care, and self-healing.
Recognizes the role of spirituality in health and healing.
Because of the popularityof CAM, considerable attention
has recently focused on determining its effectiveness, or lack
of effectiveness. Although research into these alternative
systems is underway, few CAM therapies have been sub-
jected to rigorous clinical and scientific study. It is likely that
some of these therapies will be found ineffective, whereas oth-
ers will become mairu;tream treaOTIt'fIts. The line between
what is defined as an altern.1tive therapy and what is consid-
ered mainstream is constantly changing. Increasing numben;
of health care providen; are now accepting CAM therapies
and recommending them to their patients. Table 10.1 lists
some of these therapies.
Nun;es have long known the value of CAM in preventing
and treating disease. For example, prayer, meditation, mas-
sage, and yoga have been used for centuries to treat both
body and mind. From a pharmacology perspective, much of
the value of CAM therapies lies in their ability to reduce the
need for medications. For instance, if a patient can find anx-
iety relief through herbal products, mar.sage, or biofeedback
therapy, then the use of antianxiety drugs may be reduced
or eliminated. Reduction of drug dose leads to fewer ad-
verse effects and improved adherence with the therapeutic
regimen.
The nurse should be sensitive to the patient's need for al-
ternative treatment and not be judgmental. Both advamages
TABLE 10.11 Complementary and Alternative
...... Therapies
Healing Method
AitrrnatiYr IINlth UI!
Manual healing
Mild- body
Spmual
Examples
Naturopathy

ChiropraaK
Ame!k.in !Wt.ll
Iod9rs, mrlkilll' whrtI)
(hilll'H tradtional mmnr (r.g.,
I(Upunct\R, Chiller hrrmJ
Hrrb.J1 thrrapir5
Ilnritional !Upplrmrou
SprdIl lirts
... ,""

Hand-lIIrchtrd
""
HypROlherapy
Guided imagrry
Biofffillldl
Momnmtorirntrd thrrapits (r 4, music,
".,
Shamans
Faithandf'1Yff

Qr,toxifying thrrapirs
Anilllillmistrd therapy
and limitations must be presented to patients so they may
make rational and informed decisions about their treat-
ment. Pharmacotherapy and alternative therapies can serve
complemenl:lry and essential roles in the healing of the to-
tal patient.
10.2 Brief History of Therapeutic
Natural Products
An herb is technically a botanical without any woody tissue
such as stems or bark. Over time, the terms botanical and
herb have come to be used interchangeably to refer to any
plant product with some useful application either as a food
enhancer, such as flavoring, or as a medicine.
The use of botanicals has been documented for thou-
sands of years. One of t he earliest re.:orded uses of plant
products was a prescript ion for garlic in 3000 B.C. Eastern
and Western medicine haw recorded thousands of herbs
and herb combinations reputed to haw therapeutic value.
The most popular current herbal supplements and their
claimed applications are listed in Table 10.2.
LibraryPirate
96 UntI2 I"ha"mKology . nd R ..... Uonmlp
TABLE 10.2 Best-Selling Herbal Supplements, in Rank Order
Herb Feature
",'
Herb Medicinal Part Pr1maI}'Uw(s) (Chapter)
(Iarb!lry PrfoItnl uinary 100 in'Klion 11
So
.." SOUIU of prolrin. ind mintrall; of IIItnOP<lHaI prMrt
(')lliO'iillWar
,
Garlic
., ..
bbxI dIoIeslmi, ItclOO' blood inliloaq.,jalion 21
4 Sawl"imeno
.""
TrUlmmtof btnign prOllilK Ir!pMrophy

Ginl::gt 1IIffiIOIY. rNw dizzn!'lS 17
,
EdJill!lU EnllaOO' inmullf symlll, inti-inllammator} 31

... ,
A .. protffiillll again Illi'll'r Ii least Il

St.Joirl'IW(II\ .I!ion.
" ,
"-
Roo'
immullf \yllI'm.lIKrNII' lS
10
... -
ROlli! Relidof mmopaUR symptoml 45
81 GrffiltN

ProYidt antioxidant the'aP1; IIIWtr LDI.. dIoIetftOi; prt'Itnt (,)1I(tr; Ilomam
prob!tllll,naUll'l, vomlng
Il Evtrir9 !limlOll' of ell'fltial fall)' of Of menopaUlaI
" of rhttmatoid a1hrilillnd Oilier inflamm.nCf)' i)'IIlIIlOfDl
13 VaieM RoolS IIttp 14
14 HomYlJGit 'IIftd n1la00' \9W1 finaiol
"
Graptlffil9100 ot ell'fllial lall)' add\, mitnxirruliltion to tislue ..
Souill': C. lIu, P., LyndJ, M. E. ind 8hllltnlhal. M. {2OO9):Htrbal Supprmtnl Sale Elipffltll(e Slighl naull' in lOO8 (Unill'd StiltS I: HlrlIa./Grom Ill:S$- 61.
\'/ith the birth of the pharmaceutical industry in the late
)8005, interest in herbal medicines began to wane. Synthetic
drugs could be standardized, produced, and distributed
more cheaply than natural herbal products. \'lhen regula-
tory agencies required that products be safe and labeled ac-
curately, many products were from the market. The focus of
health care was on diagnosing and treating specific diseases,
rather than on promoting wellness and holistic care. Most
alternative therapies were no longer taught in medical or
nursing schools; these healing techniques were criticized as
being lUlscientific relics of the past.
Beginning in the 1970s and continuing to the present,
alternative therapies and herbal medicines have experi-
enced a remarkable resurgence, such that the majority of
adult Americans are currently taking botanicals on a regu-
lar basis or hav .. tak<"n them in the past . This iner .. , .. e in
popularity is due to factors such as increased availability of
herbal products, aggressive marketing by the herbal indus-
try, increased attention to natural alternatives, and a re-
newed interest in preventive medicine. The gradual aging
of the population has led to an increase in patients seeking
therapeutic alternatives for chronic conditions such as
pain,arthritis, hormone replacement therapy, and prostate
enlargement. In addition, the high cost of prescription
medicines has driven patients to seek less expensive alter-
natives. Nurses have been instrumental in promoting self-
care and recommending CAM therapies for patients, when
applicable.
PHARMFACTS
Alternative Therapies in America
0111' of lirgest nonstitntifK studie of Initudts IOWlro arnnilNe thtra-
pie",rveyM 46,000 Wil rtpOI'lI'd in (omumtr May 2000.
Findings ofthillludy Mit' u foIloW5;
Siny-fi'/l!' of those IUrveyfd did not UR alttrnatr.!
primarily the)- milfied with ltandard
Thirty-fi'/l!' Ihtrapie, primarily to :tlie!'
symptoms that 001 SlK{esfully with IOlMntonal
ptOpIe mostliktly to try IlttrnatiYt- thmpits wm in
pain Ofwith llresl.
For llmost III mtdiol londitions. ft'Ipondtnts lIall'd that prestription
drugs WM' molt' elFecti'/l!' than Ihtrapie.
For balk pain and fibrom)'illgia, musd!- Illi\W wu r<lled molt'
rffKtift than prHUiption drugs.
oftholt who tried did 10 on the
of a Of nul'\t.Only 5% ofdcxto'J dilapplO'fed
of allmatNe thtrapie.
10.3 Herbal Product Formulations
The pharmacologically active chemicals in an herbal prod-
uct may be present in only one specific part of the plant, or
in all parts. Forexample, the active chemicals in chamomile
are in the above-ground portion that includes the leaves,
stems, and flowers. With other herbs, such as ginger, the un-
derground rhizomes and roots are used for their healing
LibraryPirate
LIFESPAN CONSIDERATIONS
Dietary Supplements and the Older Adult
Can dimlY IUpplellll'MI improw the health of older arultsl A growing body
of rl'idrncr is lhowing thit the 1M of rupplellll'flt; un poIitNely inlUtnce
senior< beahh. DirtaIY rupplellll'flU heen SlJ(Cf'llfu11y used to enhince
their immuor rMucr !horHffiIl rnrmolJ the risks of
Alzheimer'! dilulI', and improYr a<erall health. Nutrition.ll clefidencirs in-
(lNsegrwtlywith age. and supplements help prwem or eliminate these de-
rKirlKirl in In .Jdciition, !Ome reealth has lhown that older adults
who hi!' low ie'lel! offalate and vitamin Bu haft an ilKrused risk of devel-
oping Alzheimer! disrall'. The nurse Ihoold a\!rsltbe far sum rupple-
menu in all patirnu. The nulll' \hoold be awall' that hrrbal and dirtary
IUpplemenu (an he Hpemift; tiM, Ihould not be automatically in-
duded in tlNUllt m plim.ln .Jdciition, older adults !hould be f<luutf<l 01110
the risks of megavitamin
properties. In collecting herbs for home use, it is essential
to know which portion of the plant contains the active
chemicals.
Most modern drugs contain only one active ingredient.
This chemical is standardized, accurate] y measured, and de-
livered to the patient in precise amounts. It is a common
misconception that herbs also contain one active ingrOOient,
which can be extracted and delivered to patients in precise
doses, like drugs. Herbs actually may contain dozens of ac-
tive chemicals, many of which have not yet been isolated,
studied, or even identified. It is possible that some of these
substances work together synergistically and may not have
the same activity if isolated. Furthermore, the potency of an
herbal preparation may vary depending on where it was
grown and how it was collected and stored.
Recent attempts have been made to standardize herbal
products, using a marker substance such as the percent
flavone; in ginkgo or the percent lactones in kava kava.
Some of these standardizations are listed in Table 10.3. Un-
TABLE 103 j Standardization of Selected Herb
___ Extracts
"""
Standardlzatlon Percent
BIad:: (ohOlh mimme
"
Calura !a>grada barlr
""'""'"
Edinaru pulJl'.l"ea herb
_0
4
Gingrrrhizome PIIlgent aH!Ipooods Gruter than 10
Ginkgo lea/ 24-25

,
Ginll'll9root Ginseosidrs lU
Kava kan rhiKmt

4<-41
Milk tliule root Silymnin
Saw palmetta /nit Fatty aOdsand sterols 1>-00
St.John's'llOlt Hyperidns 0J-0.5
Hyper/orin >-S
o..plfllO Herb,1 ,00 The,ap5e< 97
til science can better characterize these substances, however,
it is best to conceptualize the active ingrOOienl of an herb as
being the entire herb itself, and not just a single chemical.
An example of the ingredients and standardization of
ginkgo biloba is shown in Figure 10.1.
The two basic formulations of herbal products are solid
and liquid. Solid products include pills, tablets, and cap-
sules made from the dried herbs. Other solid products are
salves and ointments that are administered topically. Liq-
uid formulations are made by extracting the active chemi -
cals from the plant using solvents such as water, alcohol,or
glycerol. The liquids are then concentrated in various
strengths and ingested. The various liquid formulations of
herbal preparations are described in Table lOA. Figure 10.2
illustrates different formulations of the popular herb
ginkgo biloba.
,.,
.,
Figure TO.T Two ginkgo blloba labels, note the lack 0/
standardization In (a) 60 mg 0/ extract,24%glnkgo flavone
glycosldes and 6% lerpenes;and (b) 50:1 ginkgo lea/extrac!,
24% Qlnkqo flavone Qlycosldes
LibraryPirate
98 UnK2 J>harmKology.nd theNufW-p. Uent R .... tlonmlp
TABLE 10.4 liquid Formulations of Herbal
Products
Product
Infusion
".
1ill(l!l'1'
()eoscrlptlon
Frt 5h or htrbs ,lit boiltd in Wittl' for -60 miMe IIllil
IIlKh of liqJid has off; '/trY
Acliv! ilgrtdiffiu ,lit using Of9anic: IOivtnlS 10 form a
highly (I'lI(ffiUiltd or sold form;wi'mIt may
rtrnlWfI:i or llt ofw fiNI prodoct
Frtsh or htrbs !OoJUd in hoi wa!tI' forloog
INstl5 milU!e;S!lllrIIjtrth.in tras
Frtsh or htrbs .. rt SOoJUd in hoi waltl'for 5--10 minUltl
btfurr ingtStion; aHlmliffil
Acliv! ilgrtdiffiu .. rt usingakohol by !OoJking lilt
htrb;akohol rt'm,illlas
,. Figure 10.2 Three different ginkgo formulatlon5:tableB, tea
bags, and liqUid extract
10.4 Regulation of Herbal Products
and Dietary Supplements
Since the passage of the Food, Drug, and Cosmetic Act in
1936,Americans have come to expect that all approved pre-
scription and arc drugs have passed rigid standards of
safety prior to being marketed. Furthermore, it is expected
that these drugs have been tested for efficacy and that they
truly provide the medical benefits claimed by the manufac-
turer. Americans cannot and should not expect the same
quality standards for herbal products. These products are
regulated by a far less rigorous law, the DietarySuwltml'nt HNlth
and lducat ion Act (DSHlA) of 1994.
According to the DSHEA, "dietary supplements" are
specifically exempted from the Food, Drug, and Cosmetic
Act. Dietary lupplements are dE1ined as products intended to
enhance or supplement the diet, such as botanicals, vita-
miru, minerals, or other extracts or metabolites that are not
already approved as drugs by the FDA. A major strength of
the legislation is that it gives the FDA the power to remove
from the market any product that poses a "significant or WI-
risk to the public. It also requires these products
to be clearly labeled by the manufacturer as "dietary supple-
ments." An example of an herbal label for black cohosh is
shown in ;o. Figure 10.3.
Ib)

..
. ,

..

;0. Figure 10.3 of black (ohosh:la) front label with
general health claim and (b) back with more health claims
and FDA disclaimer
Unfortunately, the DSHEA has several significant flaws
that have led to a lack of standardization in the dietary sup-
plement industry, and 10 less protection for the col15umer.
Effectivene .. doe. not have to b.. demonstrated by the
manufacturer prior to marketing.
The manufucturer does not have to prove the safety of
the dietary supplement. To be removed from the market,
the government has to provide the burden of proof to
show that the supplement is unsafe.
Dietary supplement labels must state that the product is
not intended to diagnose, treat, cure, or prevent any
disease; however, the label may make claims about the
product's effect on body structure and function, such as
the following:
Helps promote healthy immune sr-;tems.
Reduces. anxiety and .tr .... .
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Helps maintain cardiovascular function.
May reduce pain and inflammation.
The OSHEA does not regulate the accuracy of the label;
the product mayor may not comain the product listed,
in the amounts claimed.
Several steps have been taken to address the lack of purity
and mislabeling of herbal and dietary supplements. In an at-
tempt to protect comwners, Congress passed the
plt mfnt .nd Drug (onsulTII' r Protedion Act, which took
effect in 2007. Companies marketing herbal and dietary
supplements are now required to include contact informa-
tion (address and phone number) on the product labels for
conswners to use in reporting adverse events. Companies
must notify the FDA of any serious adverse event reports
within 15 days of receiving such reports. Under this Act, a
adverse is defmed as any adverse reaction re-
sulting in death, a life-threatening experience, inpatient
hospitalization, a persistent or significant disability or in-
capacity, or a congenital anomaly or birth defect, as well as
any event requiring a medical or surgical intervention to
prevent one of these conditions, based on reasonable med-
ical judgment. Companies must keep records of such
events for at least 6 years, and the records are subject to in-
spection by the FDA
Also in 2007, the FDA announced a final rule that requires
the manufacturers of dietary supplements to evaluate the
identity, purity, potency, and composition of their products.
The labels must accurately reflect what is in the product,
which must be free of contaminants such as pesticides, tox-
ins, glass, or heavy metals.
, 0.5 The Pharmacologic Actions
and Safety of Herbal Products
A key concept to remember when dealing with alternative
therapies is that does not always mean or
Asafe."There is no question that some botaniClIs contain ac-
tive chemicals as powerful as, and perhaps more effective
than, some currently approved medications. Thousands of
years of experience, combined with current scientific re-
search, have shown that some herbal remedies have thera-
peutic actions. Because a subslllnce comes from a natural
product, however, does not make it safe or effective. For ex-
ample, poison ivy is natural, but it certainly is not safe or
therapeutic. Natural products may not offer an improve-
ment over conventional therapy in treating certain disorders
and, indeed, may be of no value whatsoever. Furthermore, a
patient who substitutes an unproven alternative therapy for
an eslllblished, effective medical treatment may delay heal-
ing, suffer harmful effects, and endanger health.
Because some herbal prooucts contain ingredients that in-
teract with prescription drugs, nurses should include ques-
tions on dietary supplements when obtaining medical
histories. Patients taking medications with potentially seri-
ous adVl'rse effects such as insulin, warfarin (Coumadin), or
digoxin (Lanoxin) should bewarned never to take any herbal
proouct or dietary supplement without first discussing their
needs with a physician. In addition. pregnant or lactating
CNplfltO Herbal .J>d Ak ... n.U .... """,rap",", 99
women should never take these products without approval
of their health care provider. The nurse should also remem-
ber that the potential for any drug interaction increases in
olde, adults, especially those with hepatic or renal impair-
ment. Drug interactions with selected herbs are listed in
Tablt 10.5. Herbal-drug interactions are noted, where appli-
c'lble, in the prototype drug features throughout this text.
Another warning that be heeded with natural prod-
ucts is to beware of allergic reactions. Most herbal products
contain a mixture of ingredients, and it is not unusual to find
dozens of different chenticals in teas and infusiOn! made
from the flowers, leaves, or roots of a plant. Patients who
haV\' known allergies to certain foods or medicines should
seek medical advice before taking a new herbal product. It is
always wise to take the smallest amount possible when start-
ing herbal therapy, even less than the recommended dose, to
see if allergies or other adverse effects occur.
Nurses have an obligation to seek the latest medical infor-
mation on herbal prOOucts because there is a good possibil-
ity that their patients are using them to supplement
traditional medicines. Patientsshould beadvised to beskep-
tical of claims on the labels of dietary supplements and to
seek health information from reputable sources. Nurses
should never oondenm a patient's use of alternmive medi-
cine!, but instead should be supportive and seek to llIlder-
stand the patient's goals for taking the supplements. The
health CITe provider will often need to educate patients on
the role of CAM therapies in the treatment of their disor-
ders and discuss which treatment or combination of treat-
ments will best meet their health goals.
, 0.6 Specialty Supplements
Sprc:il ky supplemfnts are nonherbal dietary products used to
enhance a wide variety of body functions. These supple-
ments form a diverse group of substances obtained from
plant and anirnalsources. Theyare more specific in their ac-
tio n than herbal products and are generally targeted for one
or a smaller number of conditions. The most popular spe-
cialty supplements are listed in Table 10.6.
In general, speci.1lty supplements have a legitimate ra-
tionale for their use. For example, chondroitin and glu-
cosamine are natural substances in the body necessary for
cartilage growth and maintenance. Antino acids are natural
building blocks of muscle protein. Flaxseed and fL'ih oils
contain omega fatty acids thm have been shown to reduce
the risk of heart disease in certain patients.
As with herbal prOOucts, the link between most specialty
supplements and their claimed benefits is unclear. In many
cases, a normal diet supplies sufficient quantities of the sub-
stance and taking additional amoWlts may provide no benefit.
In other cases, the product is marketed for conditions for
which the supplement has no proved effect. The good news is
that these substances are generally not harmful, WJ..!ess taken in
large amoWlts. The bad news, howe,er, is that they can give
patients false hopes of an easy cure forchronic conditions such
as heart disease or the pain of arthritis. As with herbal prod-
ucts, the nurse should advise patients to beskeptical about the
health claims regarding the use of these supplements.
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100 Untl2 Phanna<:ology and ttl<> NufW-p. u .. m Refatlon,hlp
TABLE 10.5 I
Documented Herb-Drug Interactions
Common (Scientific) Name Interacts with
EdlinoKea (fcllirmtll (III{IIItQ) Amiodaronr,anabolic: melhoIrwtt
Alpirin and othtr NSAIIlI, IItparin, warfarin (Coumadin)
Garlic: (ABium >cniKlm) Alpirinand othtr NSAIIlI, warfarin
Itypo9y<rmkaqenll
Gingtr (ljngibfr offldoolt) Alpinn and othtr NSAlIlI, IItparin, warfarin
Ginkgo (Ginkycbiloba) Antitonvul!oanu
Alpinnand NSAIOI
}
IltplriHndwarfaril
Triqdit .nlidfpl!l!oant>
GiIlltll9 (1'ImI' ljIJinquefo6llllBltJlhfNxomlf
stOOfOlllJ)
OilJOlin (Lanmrin)
Oiurttiu
.nd DIal hypogl)'lmMt agffill
W;Jrf.ril
(I/jdrollilamildmlil) Oiurt tks
St. John., wort (I/)ptrirum ptl'fMllUmj eNS dtpm!oanu and opioid .nalqt5ia

Etwirmz. indinaYir
ProtUlt inhibitoo
SMnivt SffiIlonin triqdic:

Warfaril
\/al""n (VlIk.mauflfd",,/i>j &,,,bi\!I"ot ... 0100 CNS .q..-"ont>
"Strotonin IWUting.agitation
1iiJ1t: Il.JIi modifltd from www.pmlhalt.a:rnltrogguidtl
1ABLE 10.6 I Selected Specialty Supplements
Amino. rid,
Cimitilll'
Cotr\zyrM 01 0
"'"
Fish oil
lDcrobodllJil oodoplilus

VitaminC
Primary Uses
Blrild proten, mUldt !Irmglh,and m:hnlKt
ErNlKt mtr9)' and !pOfIl pffionnantr. htart htakh,IIItII"aY, immulll' flllaion,
. nd malt ftrtilily
PrMIII hurt diltu,prol'idtantiolidinltOOolp1
Boost immLnt functioMand IIlI'IIIOIY
Rrdutt dIoItstmll Ieoim. mhalKt' lI'ain flnaion, irm.J1t viIWI . a..ity ltlot to pl!ltntt
of OIIII'ga--l fatty adds)
Rrdutt ffioIroul"fOl Ieoil"k. ffihanrt' lI'ain flllnion, illITNw vkuill.nity (tloe to pR"Wntt
ofOllll'ga--lfattyaddsl
AlItoii.!tt arthritis and othtr joint probItms
Maintain inlt!iin.1 hukh
Rrdutt the rilk of trluin typtl o/Untrl
PrMIIlion of rokk
Comments
..
f\mible ilKl1'aIf!I IItpaloloxic:ity
rill!
rilk
Additivt hypogly.:mMt tffffii
nlk
intitOlTlu!oant
blffiing potmtial
fIJIliblt riZLn' thrNdd
Itdition
toxicity
flruible aUffiwled diLn'lic:
h)'pJglytmlic: tffffil
t ffffil
May diuretk dltas
Itdation
May dKrealt cydolporiM itl'tk
Otmi ltd inlirtlnMral aaivity
OMtaltd aaiYity ofindinavir
flJlsibie ltlOlonin I1ndKlllH"
Otmiltd antitoagulant dlffi,
F\IImtiot. ltdotion
Supplement Feature (Chapterl
"
II
II
"
"
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IlIoplfltO H<>mal .od Allem"tlW' Theuple, 101
""
. Chapter REVIEW
KEY CONCEPTS
The numkred kry concepM provide a of the important points from the corresponding numbered ""clion
within the chapter. If any of these points are not dear, refer to the numbered section within the chapter for review.
10.1 Complementary and a1ternati'e medidne is a set of di-
verse therapies and healing systems used by many people
for disease prevention and self-healing.
10.2 Natural products obtained from plants haw been used as
medicines for thousands. of years. Recenl years ha'e seen
resurgence in the popularity of Ihese products.
10.3 Herbal productsareavailable in a varietyofformulations;
some contain standardized extracts, and others contain
whole herbs.
10.4 Herbal products and dietary supplements are regulated by
the Dietary Supplemenl Heallh and Education Act of
NCLEX-RN" REVIEW QUESTIONS
D The nurse oblains information during the admission in-
lerview that the patient is taking herbal supplements.
Whal implications does this information ha'e for the pa-
tient's trealment?
1. This is not importanl , becaust' herbal products are
natuml and pose no risk to the patient.
2. These products are a welcome adjunct to conventional
tre:ltment.
3. The nurse mU'itobserve tbe patient for allergic
reactions.
4. The herbal products may interact with prescribed
medications and affect drug action.
D Appropriate teaching to provide safety for a patient who
is planning to use herbal products should include which
of the following!
1. Take the smallest amOWlI poSSIble when starting herbal
thempy, even less than the recommended dose, to see if
allergies or other adverse effects occur.
2. Read the labels to determine composition of the
product.
3. Research tbe clinical trials before using the products.
4. Read the labels to determine which diseases or disorders
the product has been proven 10 treat or cure.
D The patienl states he has been using the herbal product
S,1W palmetto. The nurse recognizes that this supplement
is often used to treat:
1. insomnia.
2. urinary problems associated with prostate enlargement.
3. symptoll\<; of menopaust'.
4. urinary tract infection.
1994, which does not require safety or efficacy testing
prior to marketing. Recent laws have been passed to safe-
guard consumer safety regarding dietary supplements.
10.5 Natural products may haw pharmacologic actions and
result in adverse effects, including significanl interactions
with prescription medications.
10.6 Specialty supplements are nonherbal dietary products
used 10 enbance a wide variety of body functions. Like
berbal products, most have not been subjected to con-
trolled, scien tific testing.
o A patient receiving warfurin (Coumadin) therapy reports
w;e of Ihe berb fewrfew. The nurse observes the patient
for evidence of:
1. liver toxicity.
2. increased. coagulation.
3. renal dysfunction.
4. increased. bleeding potential.
II The patient has been taking sertraline (Zoloft), bUI just
added St. John's wort for his depression. He now presents
10 the emergency department. The nurse recognizes the
signs and symptoms of serotonin syndrome as: {Select all
that apply.}
I. headache.
2. dizziness.
3. agitation .
4. weight 106S.
5. sweating.
o Wbal is the difference between an herbal product and a
""pplement1
I. An herbal product is safer to use than a specialty
supplement.
2. A specialty supplement tends to be more than
an herbal product.
3. A specialty supplement is a nonherbal dietary product
used to enhance a variety of body functions.
4. There are less adverse effects or risk of allergy with
specialty supplements than there are with herbal
products.
LibraryPirate
t 02 U"U Pllannacology ano:htllt Rebllonthlp
CRITICAL THINKING QUESTIONS
t. A 44-year_old breast !;aneer $urvivor is placed on (amOl-
ifen (No!vadel) 20 mg PO daily. Since receiving
themother.1py, the p.1tient has nO( had a menstrual.:y.::le.
She is wncerned about being menopausal and wonders
about the posslhUlty or using a soy-based produa as a
form of natural hormone replacement. How should the
nurse advise the patient!
2. A 62-year-old male p.1tlent Is re<:uperatlng from a myocar-
dial infaraion. He is on the anticoagulant warfurin
(Coumadin) and antidysrhythmic digoxin (lanOlin). He
talks to his wife about starting garlic to help lower his
blood lipid levels, and ginseng beocaUSl.' he has heard il
helps in coronary artery disease. DiKuss the potential con-
cerns about the use of garlic and ginseng by this patient.
3. The pallen! hasbeen takingS!. John'swort forsympiOUlSof
depression. He is now scheduled for an elective surgery.
What importam preopera\ ive teaehingshould be included!
5ee Appendix D for (lmw,," and mtiana/es far all activities.
EXPLORE
M'/t*lrsi"lgkil Is ywr me $lop lor oNine re.io!w materials arK!
fftQ\Jl eK PlIllar. let SUQ;e511 willi aclcIiIIoRal tQ.EX'-5l71e lQC\ice
Questirns. Inleracthie 9!JmU11S and .... !!IIIIr*s. mimtions
and mtlfe!
l\egISlI!l' JOUIICt:I'!SS mOl! from 1M from -,.rur booic at
wwwJllYT\Lnit!lkitcam.
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DRUGS AT A GLANCE
CNS DEPRESSANTS pq;Jt 101
Sedatives and Sedative-Hypnotics ,. /01
Opioids p!XJt 101
Ethyl Alcohol PJ1 101
CANNABINOIDS [QJo!t
Marijuana P190(})
HALLUCINOGENS p /OJ
LSD fill" 'I
Other Halludnogtns pq;Jt' 10
CNSSTIMUlANTS pogtl/()
Amphetamillts and Methy\pllenidate
Cocaine piY/t1ll
Caffeint pi/f 11/
HlmTlNE P'gtlll
TONco) 1M and pi1I}tlll
THENURSl'SROI.E IN SU8STANCUBUSE ,..I1}
KEY TERMS
addiction {!IJgt /()j
anPlltion df:fic ivllyptr a(tivky (ADH D I
PJttll
fWt 101
IJOSItolMucr PIt ns
dtliritnUff'HflS (OT) /'}tIll
Substance Abuse
LEARNING OUTCOMES
After reading this the student should be able to:
1. Explain underlying causes of addiction.
2. Compare and contrast psychologic and physical dependence.
3. Compare withdrawal syndromes for the various subsumee abuse
dasses.
4. Discuss how nurses can drug tolerance In patients.
S. In the following drug dalses,explaln the mlljor characteri sti cs of libuse,
dependence, and toll.'fancl.': alcohol. nicotine, marijuana, hallUCinogens,
eNS stimulant .. sedati"., .. and oplold, .
6. Describe the roll.' ofthi.' nurSl.' In delivering ellre to IndIYlduIIIs who have
substance abuse isSUE's.
dflta9-tetrllhydnxannabinol (THO pil l}t 1m
Msignfr drugs pajt 1IU
opioid pajt lUI
phJ\iCllldl.'pmdl.'rKe jllJtlOS
pS)'I:RdfIics pajt /09
pS)'l:ltoIogi[dl.'pmdl.'rKe pll}tIOS
rtticular fonnltion pajt 110
pajt 1C1
Iubilarn:ubule jllJt1()j
toi.rall(e pill}t
withdrawallJndromt fXJ}t /OS
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"

,



104 Untl2 Pharmac:ology and thfo Rel.otlomhlp
T
hroughout history, individuals have consumed both
natural substances and prescription drugs to increase
performance, assist with relaxation,alter psychologic: state,
and to enhance social interaction. Substance abuse has a
tremendous societal, economic:, and health impact. Al-
though the terms drug abuse and substance abuse have
been used interchangeably, substance abuse Is often con-
sidered more inclusive because of t he involved legal and il-
legal agents, misused household Items,and drugs available
tor medication purposes. By definition,substance a bu se in
this chapter will be considered the self-administration of a
drug in a manner toot does not conform to the norms within
the patient's own culture and society.
11.1 Overview of Substance Abuse
Abused subst ances belong to many diverse chemical classes.
Drugs have few structural similarities, but they all have in
common the ability to i.mP.1ct the brain and central nervollil
system. Some substances--.such as opium, marijuana, co-
caine, nicotine, caffeine, and alcohol- are obtained from
natural sources. Others are synthetic or created
in illegal laboratories for the purpose of profiting from illicit
drug trafficking.
Abused or misused substances au not always illegal
drugs. Alcohol and nicotine are two of the most commonly
abused drugs. Abused legal CNS-influencing drugs include
prescription medications such as methylphenidate (Ritalin)
and meperidine ( Demerol). Legal substances without pre-
scription involve agents such as volatile inhalants. Ketamine
and gamma hydroxybutyrate (GHB) are examples of mis-
used legal anesthetics. Athletes often abuse legal anabolic
steroids. Frequently abused illegal substances include mari-
juana, heroin (opioids), and hallucinogens such as lysergic
acid diethylamide ( LSD) and methamphetamines. Phency-
clidine hydrochloride ( PCP) is a hallucinogen with a history
of abuse but not so much presently. Huffing of organic,
household, or industrial chemical products is not Wlcom-
mono Aerosols and paint thinners are inhalants obtained
without prescription.
Several drugs once used therapeutically are now illegal
due to their high potential for abuse. Cocaine was once
widely used as a local anesthetic, but today nearly all the co-
caine acquired by users is obtained illegally. LSD is now ille-
gal, although in the 19405 and 19505, LSD was used in
psychotherapy. Phencyclidine was popular in the early
19605 as an anesthetic, but was withdrawn from the market
ill 1965, pati""ts r"purt"J
and anxiety a fter recovering from anesthesia. Many amphet-
amines once used for bronchodilation were discontinued in
the 19805 after unpleasant psychotic episodes were re-
ported. The swn of this information relates to the diversity
of substances within our culture, which patients can either
misuse or abuse.
11 .2 Neurobiologic
and Psychosocial Components
of Substance Abuse
Addict ion is an overwhelming compulsion that drives some-
one to take drugs repetitively, despite serious health and so-
cial consequences. It is impossible to accurately predict
whether a person will become a substance abuser. Attempts
to predict a person's addictive tendency using psychologic
proftles or genetic markers have largely been unsuccessful.
Substance abuse depends on multiple, complex, interacting
variables such as described in the following categories:
User-related factors: Genetic factors (e.g., metabolic
enzymes, innate tolerance), personality for risk-taking
beh.wior, prior experiences with drugs, disorders that
may require a scheduled drug
Environmental factors: Societal and community nonns,
role models, peer innuences, educational opportunities
PHARMFACTS
SubstanCl! Abuso in tho Unitod Statc!s
million Americans 11M iIIKit drugsat INst onct.
NUfVS ,lOd other ht akh providtrS all' <II rille for substanct
abust problerm with btnrodiuepine, opioids, i nd akohol.lt is
estimattd that 6% to 8'l(j of health proft-lSionak substanct abust
probltm.
25% of high hool <tudtnlS Ust an drug monthly.
Ivl tstimmd l 4 million Amtoom have ul>ell ht roin during thtir
About one in fi l't Americans has liffiJ with ao ikoholic: whilt growing up.
Childrtn of akoholic: p.lll'ot! all' four timts mOIl' liktly to bKorne
akoholic:s than of nonakDholic: P'll'Ots.
Akohol is an important f<Ktor io 68% of mansLlughttr"S,54% of murdtrs,
48% of robberits, ,nd
17, 7.2 million
akohol at Imt onct.Giris as liuly as 10 drink akohol.
is a fa(lOr in almost one third of all dru!l""ll'lated
deaths.
36% of 10th-glide student! and 46%of studt nts hm
Il'ported using I!Iirijuao, , nd hashish.
Almost8% ofhigh school stoiors hal't using (ouilll'.
1 million Amtriuns Mt Ustd (!luiIII' on a monthly basis;about 567,000
Me ustd (f,(k(ouint.
70% of the (!luiIII' tnttring the United rotneS from
Colombia and paslf"S thlOlHjh south Florid.!.
16% ofSth graders and 11% of 11th graders hal't usingvolatilt
iohaLints.
30% of all Amt riuOl in{Uding 25% who all'
bttwttn tht igtS of 11 and 25.
41% of 10th-glide studtnts and S4%of studtrtts hm
'rport..! .".,kin\! <iy.,. un. 8'l(j uf ,\udrn'" .,,,,,no roo",
than half a p.l(k or troll' Ndl clay.
8%of 12th-griikstudtrtll hal't Il'pOned using Eutasy (MOMAI.
I5D is oneoftht most pottntdrugt known, with only 25--150 mc:9
(onstiMing i dost.Almost 996 of 12th-gradt studtrtll hm Il'pOned
usinglSD.
LibraryPirate
Factors related to tile agent or drug: Cost, availability,
dose, mode of administration (e.g., oral, IV, inhalation),
speed of onset/termination, and length of drug use
In the case of legal prescription drugs, addiction may
gin with a legitimate need for pharmacotherapy. For
pIe, narcotic analgesics may be indicated for pain relief, or
sedatives maybe taken for a sleep disorder. These drugs may
result in such a favorable experience, or for whatever reason
patients determine to repeat the experience after the pre-
scription has expired.
There is often the concern that the therapeutic use of
scheduled drugs creates large nwnbers of addicted patients.
Because of this, medications having a potential for abuse
have been prescribed at the lowest effective dose and for the
shortest time neces.sary to treat the medkal problem. Pre-
scription drugs in fuct rarely cause addiction when used as
pr"-'Crihecl to mroic.al pmtocok A .
mentioned in chapters I and :ZOOO, nwnerous laws have
been passed in an attempt to limit substance abuse and ad-
diction. The risk of addiction caused by prescription med-
ications is primarily a fimction of dose and duration of drug
therapy. Nurses should be able to administer medications
for the relief of patient symptoms, without wmecessaryfear
of producing dependency.
, '.3 Physical and Psychologic
Dependence
Whether a substance is addictive is related to how easily an
individual can stop taking the agent on a repetitive basis.
When a person has an overwhelming desire to take a drug
and cannot stop, this condition is referred to as substance de-
pefulence. Substance dependence is classified into two cate-
gories, physical dependence and psychologic dependence.
Physkal refers to an altered physical condition
caused by the adaptation of the nervous system to repeated
substance use. Over time, the boor's cells become accus-
tomed to the presence of the Wlnatural substance. With
physical dependence, uncomfortable symptoms known as
withdrawal result when the agent is discontinued. Repeated
doses of opioids,such as morphine and heroin, mayproduce
physical dependence rather quickly, particularly when the
drugs are taken intravenously. Alcohol, sedatives, nicotine,
and CNS stimulants are additional examples of substances
that with extended use may easily cause physical dependence.
In comrast, refers to a condition where
no obvious physical signs of disoomfort are observed after the
agent is disoontinued. The user, however, will have an over-
whelming desire to continue drug-seeking behavior despite
obvious negative economic, physical, or social consequences.
Any associated intense craving may be connected with the
patient's home or social environment. Strong psychologic
craving may continue for month<; or even years and can be re-
sponsible for relapses during therapy. For psychologic de-
pendence to occur, relatively high doses of drugs are usually
taken fora prolonged period of time. Examples include mar-
ijuana and antianxiety drugs. On the other hand, psychologic
CNp1IIl1 Sobnan<l',o..bu... t 05
Th r QUfstion: Arr thf ll'(onneuions be_n a sedenlilry
Il'bted disorder\, Ind drug addiction?
Thf Stilly: Sc:iffitists ill' be9nning 10 bf,1ifwo that mrtisr may help
addi:ti:1II1O akohollnd drup, and this may apply 10 various dlMJiul
welLEmtra!lJl}gfsts thit fll't<ising tefmall' SO% less
to I/IlOke than their rooo\frp.lI15. Forty peltrrlt art IHs likrly
to apl'rimmt...mh IIIdrij:JaIld.AliJIts woomgq in somet)1leof regular
activity all' less lilrely lOabul!' akohol than thai!' who
frrtM.AerobH: flI'rtil!'lf11m to likrlihood thit IIIfIIIbmolthe
general popYlition willeH out ttw, l!Wan:ling of5l3mr illKitdrugs
5UdJ is (ouillf. Whit stu:lifs all' prrIiminary, m.lll)l briire ttw,1l' is a
UHlllf(\ion be1Wffn poIitiYf pl)':ho!orial actNity and thf naturilll'ifal!' of
brain dopamile. While it has bng bf,fII rltablished thit fll'KM pro01Otts
poIitM (In:lim!Wlir i nd hNkh,forustd physical actiYity
srems to drcrease tilt pre\'i1rn<r 01 (fllilir Stm5-rriated disordfflllKh is
hyptractivity in dlildirn.
Nursi ng Implications: Whfn (olllidrrtd benffKiil10 p,nifnts, nuflt1 should
flKourage 1l'!Jllar physical OfrtM. Physiul activity not only promotH
positiYegfllml hukh but also positiYe mflllill hfakh.Um:M lI"Iiy help
mitigate trndelKirS for drug abul!'.
5otIrt: Cin AaIl1\)' iIId ll>K1If PrfWIII Drug Abwl PromoIIng i
lotnloml F'lrIl'Iltloo. MMngltrfltNMtmilmdrrJ1I'ofOl!J9.'JItM
(NNW, Nrl!brollruttum It HNlrh (N11q, Bl>rt1rsd4 .Ill! BIt 54, 2tlIt
dependence may develop quickly after only one use, as with
crack CO(;aine, a potent, rather inexpensive, form of the drug.
11 .4 Withdrawal Syndrome
Once a person becomes physically dependent and the sub-
stance is discontinued, withdrawal s)'lldrome may occur.
scription drugs are often used to reduce the severity of
withdrawal symptoms. For example, alcohol withdrawal
might be treated with the short-acting benzodiazepine, ox-
azepam (Serax); opioid withdrawal might be treated with
methadone. Symptoms of nicotine withdrawal might be re-
lievt'd with replacement therapy in the form of nicotine
patches or chewing gum. For withdrawal from CNS stimu-
lants, hallucinogens, marijuana, or inhalants, specific phar-
macologic intervention might not be indicated.
Symptoms of withdrawal may be particularly severe for
those who are dependent on alcohol or sedatives. Because of
the severity of the symptoms, the process of withdrawal
from these agents is probably best accomplished in a sub-
stance abuse treatment facility. Examples of drugs and asso-
ciated withdrawal symptoms and characteristics are shown
in Table 11.1.
With chronic substance abuse, people will often associate
use of the substance with their conditions and surroundings,
including social contacts with other users who are also tak-
ing the drug. Users tend to revert to drug-seeking behavior
when they return to the company of other substance abusers.
Counselors often enoourage users to refrain from associating
with past social contacts or having relationships with other
substance abusers to lessen the possibility for relapse. The
LibraryPirate
106 Untl2 Pl\armacology and tt..> Nu.....-P.1k'n1 Ret.tklmhlp
TABLE 11 ,11
Select@d Drugs of Abuse, Withdrawal Symptoms, and Charact@ristics
Dru, Physiologic and Psychologic Effects Signs ofToxldty
" ..
TIflIIDn, fitigut, inxilly. abdominal CIi"'9ing,halludoat ions, ooofusion. ExurrM lOIIIloltw,Sfflf1' CNS
rrlpirator} dtpmWn
-
IlI\OIIInia,inutl1, wuknm,abdomilal CNS.s!ion, tl1'lllOl', vorriting, cy.Inosis,
skin h)'pel'loffiliti\'ity rOOions, halllKilations, delWiIlll lI'spi"ilionl
5rIiIivity 10 MghtJM !4Ur.:I, Sfl/MfIIMct, confulion, diminilhtd coma
mUldt lwitdlt!
CouilWJM MrotiIl dqmsion,anxiuy,mll'lIW h!llgl'r inlla-w,lkin
JmpMimillt!
1l.!l100n09ffil IYrrIy obstrffiI; rkopffidtnl on sprdfK drug PinK lI'actiom, (onfusion, Wn, in blood

"'-ri):Jaru Imubility,lI'stltslrH'I\illlOllllia, W!'ighllou wphw, paranoia, pank halllKiutiorK, p!)'(hotk Kkro
w"
r;-OtilW
-
HUrl palpit.Jtions,
10 in lItarl raltand blood preSIlft 5o!i11Rl
-
IWNti'l1j. rt\tItsl/lrlS, diiaRd agitation, goosttunps, 1Iflnor, RtspiralOl)' tyan&lil, UIR'Irlt IOOIndelKt, (OIIU
violml yawring.Oistd heart raR and blood prts!lJ'l',
ibdominil uamps inrl !pi!illli kilking
wftght Iosl
formation of new social contacts as a result of association
with self-help groups such as Alcoholics Anonymous helps
some people transition to a drug-free lifestyle. Residential
secondary treatment or "step down" from primary care may
be required for some patients who are not ready to return to
the commWlity after detoxification.
,1.S Tolerance
Tolfran(f is a biologic condition that occurs when the body
adopts to a substance after repeated administration. Over
time, higher doses of the agent are required to produce the
same initial effect. For example, at the start of pharma-
cotherapy,a patient may find that 2 mg of a sedative is effec-
tive for inducing sleep. After taking the medication for
several month<;, the patient notices that it takes 4 mg or per-
haps 6 mg to fall asleep. of drug tolerance is
common for substances that affect the nervous system. Tol-
eram:e should be thought of as a natural consequence of
continued drug use and not be considered evidence of ad-
diction or substance abuse.
Tolerance does not develop at the same rate for all actions
of a drug. For example, patients usually develop tolerance to
the nausea and vomiting produced by narcoticanalgesicsaf-
ter only a few doses. Tolerance to the mood-altering effects
of these drugs and to their ability to reduce pain develops
more slowly but eventually may be complete. On the other
hand, tolerance never develops to the drug's ability to con-
strict the pupils. Patients will often endure annoying side
effects of drugs, such as the sedation caused byantihista-
mines, if they know that tolerance to these effects will
quickly develop.
Once tolerance develops to a substance, it often e.'uends
to closely related drugs. This phenomenon is known as ClOSS,
toleran(f. For example, a heroin addict will become tolerant
to the analgesic effects of other opioids such as morphine
or meperidine. Patients who have developed tolerance to
alcohol will show tolerance to other eNS depressants such
as barbiturates, benzodiazepines, and some general anes-
thetics. This has important clinical implications for the
nurse, because doses of these related medications will need
to be adjusted accordingly to obtain maximwn therapeutic
benefit.
LIFESPAN CONSIDERATIONS
Abuse of Volatile Inhalants
by Children and Adolescents
pilt'llU IDrumed that thtir (hildlt'll willimoh tobai(o or mIn-
jwna or bKome addkttd to (rilk or Implitlimints.YetfM pilt'llUmnsider
that tht mon common IOUltH of aOOstd wbstalKH ill' lI'adily milabll- in
thtir own homts.1 nhaling wlatile known as hrJfing, is roost pR'{i-
lent in the 10- to 191' group and de<lines with a9l';olM'in
dlt'll h.J I done this by the eighth grarit .Virtuilly in, ol1}iln it mmpouOO GIn bt
1IJfftd, ilKluding nail polish 11'lII0'<<'I, spray paint, housthold gUt, (oll1'Ction
ftuid, plOp.llM',gasolinr,lnrI whipped crt'ilm propellants. These
irf aYiilablt in thr in ltorr-s, iM in the wortpLl(t.ihry 111' intxprmi'',
Itgalinrl GIn bt anytimt iM all)'Whell'. Childl1'O GIn dit Ifter a lingle
ullOlUlI'or suffer brain damage, whith may bt maniftsttd as slurred or !low
speeth, trrmor, memO!')' loss, or ptMnality (hangrs. who worlc with
ptdiatrit patients should bt /Mile of widespread nalUlI' of this typr of
iOOIl',IOO advisf to kerp a ,loll' watth on voIatilt substilKH.
LibraryPirate
The terms immullity and resiltallce are often confused
with tolerance. These terms more correctly refer to the im-
mune system and infections and should not be used inter-
changeably with tolerance. For example, microorganisms
become resistant to the effects of an antibiotic: They do not
become tolerant. Patients become tolerant to the effects of
pain relievers: They do not become resistant or immune.
11 .6 eNS Depressants
CNS dt'pressants are a group of drugs that cause patients to
feel sedated or relaxed. Drugs in this group include barbi-
turates, non barbiturate sedative-hypnotics, benzodi-
azepines, alcohol, and opioids. Although the majority of
these are legal substances, they are controUed due to their
abuse potential.
SEDATIVES AND SEDATIVE- HYPNOTICS
Sedatives, also known as tranquilizers, are prescribed for slt'ep
disorders and certain forms of epilepsy. The two primary
classes of sedatives are the barbiturates and the nonbarbitu-
rate sedative-hypnotics. Their actions, indicatioll'i, safety
proftles, and addictive potential are roughly equivalent.
Physical dependence, psychologic dependence, and toler-
ance develop when these agents are taken for extended peri-
ods at high doses (chapter 200) . Patients sometimes abuse
these drugs by faking prescriptions or by maring their med-
ication with friends. Sedatives are commonly combined
with other drugs of abuse, such as CNS stimulants or alco-
hol. Addi,ts often alternate between amphetamines, whi,h
keep them awake for several days, and barbiturates, which
are needed to help them relax and fall slet'p.
Many sedatives have a long duration of action: Effects
may last an entire day, depending on the specific drug. Users
may appear dull or apathetic. Higher doses resemble alcohol
intoxication, with slurred speech and motor incoordin.1 -
tion. Four commonly abused barbiturates are pt'ntobarbital
( Nembutal), amobarbital {Amy tal), secobarbital (Seoonal),
and a combination of secob.1rbital and amobarbital (Tu-
inal). The medical use of barbiturates and nonbarbiturate
,ooMive-hyl'notio; hu. declined markeclly over the 20
years. The use of barbiturates in treating sleep disorders is
discussed in chaptt'r 1400, and their w;e for epilepsy treat-
ment is presented in chapter 1500.
Overdoses of barbiturates and nonbarbituratt'
sedative-hypnotics are extremely dangerous. These drugs
suppress the respiratory centers in the brain, and the user
may stop breathing or lapse into a coma. Death may result
from barbiturate overdose. Withdrawal symptoms from
these drugs resemble those of alcohol withdrawal and may
be life threatening.
Btnzodiaztpines are another group of eNS depressants that
have a potential for abuse. They are one oftht' most widely
prescribed classes of drugs, and have largely replaced the
barbiturates for certain disorders. Their primary indication
is anxiety (chapter 1400), although they are also used to
prevent seizures (chapter 1500) and for muscle relaxation
(chapter 2100). Popular benwdiazepines include alpraw-
CNpttrll SobnaO<l',o..bY... 107
lam (Xanax), diazepam (Valiwn), temazepam (ReslOril),
triawlam (Halcion), and midawlam (Versed).
Although they are a frequently prescribed drug class,
benwdiazepine abuse is not uncommon. Individuals abus-
ing benzodiazepines may appear carefree, detached, sleepy,
or disoriented. Death due to overdose is rare, even with
high doses. Users may combine these agents with alcohol,
cocaine, or heroin to augment tht'ir drug experience. If
combined with other agents, overdose may be lethal. The
benzodiazepine withdrawal syndrome is less severe than
that of barbiturates or alcohol. Due to tht' longer half-life
of benzodiazepines, however, drug levels remain high for
6everal weeks. This makes abuse of benzodiazepines very
dangerous.
OPIOIDS
also known as lIarcotic allalgesics, are prescribed for
severe pain, persistent cough, and diarrhea. The opioid class
includes natural substances obtained from the wuipe seeds
of the poppy plant such as opium, morphine, and codeine.
Synthetic drug examples are propoxyphene (Darvon),
meperidine (Demerol), ox),codone (OxyContin), fentanyl
(Duragfsic, Sublimaze), methadone (Doiophine), and
heroin. The therapeutic effects of the opioids are discussed
in more detail in chapter 1800.
The effects of oral opioids begin within 30 minutes and
may last over a day. Parenteral forms produce immediate ef-
feels, including the brief, intense rush of euphoria sought by
heroin addicls. Individuals experience a range of CNS ef-
fe,Is from extreme pleasure to slowed body activities and
profound sedation. Signs include constricted pupils, an in-
crease in the pain threshold, and respiratory depression.
Overdose of opioids is extremely dangerous and fatal. The
pharmaoothel1lpy of opioid blocking drugs is covered in
chapter 1800.
Addiction to opioids can occur rapidly, and withdrawal
can produce intense symptoms. Although extremely Wl
pleasant , withdrawal from opioids is not lift' threatening,
oompared to barbiturate withdrawal. Methadone is a nar-
cotic sometimes used to treat opioid addiction. Although
h,,-< addiclive l'ml'er/i"" of it. own, il does nol
produce the same degret' of euphoria as other opioids, and
its effects are longer lasting. HE1"Oin addicts are switched to
methadone to prevent unpleasant withdrawal symptoms.
Since methadone is taken ol1llly, patients are no longer ex-
posed to serious risks associated with intravenous drug use,
such as ht'patitis and AIDS. Patients sometimes remain on
methadone maintenance for a lifetime. Withdrawal from
methadone is more prolonged than with heroin or mor-
phine, but the symptoms are less intense.
ETHYL ALCOHOL
Ethyl alcohol, commonly known as alcohol, is one of the
most commonly abused drugs. Alcohol is a legal substance
for adults, and it is readilyavaibbleas beer, wine, and liquor.
The economic, social, and health consequences of alcohol
abuse are staggering. Despitt' the enormous negative conse-
quences associated with long-term use, small quantities of
LibraryPirate
108 Unlll the Nurse-Pitlent AeL.lUomhlp
alcohol consumed on a basis have been found to re-
duce the risk of stroke hent
Alcohol is classified as a eNS depre5S;lnt because it slows
the region of the brain responsible for alertness and wake-
fulness. Alcohol easily ,rosses the blood-brnin barrier,so its
effects are within 5 to 30 minut es afte!' consump-
tion. Effects of alcohol dirlly proportional to the
amount consumed, and include relaxation, sedation, mem-
ory impairment, 10$$ of mOl:or coordination, reduced judg-
ment, and decreased inhibition. Alcohol also imparts a
characte!'istK odor to the breath and increases blood flow in
certain areas of the skin,causing a flushed face. pink cbeeks,
or red nose. Although these symptoms are easily recognized,
the nurse must beaware that other substances and disorders
may cause similar efftets. For ex:.tmple, many antianxiety
agents, sedati\le$, and ant idepressants can cause drowsines.o;,
memor y diffiruities, and loss of motor coordination. Cer
tain mouthwashes contain and cause the breath to
smell like alcohol. Duringasses.o;ment, the skilled nurse must
consider these factors before confirming alcohol use.
The presen,e offood in the stomach slows the absorption
of alcohol, thus delaying the onset of drug a,tion.
Metabolism, or detoxification of by the liver, occurs
at a slow, const:Jnt rate, which is not affected by the presence
of food. The average rate is about 15 mL per hour- the
practical equivalent of one alcoholic beverage per hour. If
consumed at a higher rate, akohol wiU accumulate in the
blood and produce greater depres.o;ant effects on the brain.
Acute overdoses of aloohol produce vomiting, severe hy-
potension, respiratory failure, and coma. Death due to alco-
hol poisoning is not unoommon. The nurse should teach
patients to neve!' combine aloohol consumption with other
eNS depressants because their effects are cumulative, and
profound sedition or 001Tl3 may resuh.
With acute a1oohol withdrawal. benzodiazepines are the
preferred drugdass for lTeatment (Valium or LLbrium ther-
apy). \'/hile the use ofbelUOdiazepines is more guarded for
longer-term therapy of akoholism, the reality is that many
alcoholics continue to receive benzodiazepines (or anxiety
disorders and insomnia serondary to ruoohol dq>endence.
Seizuresarealsoa risk to the patient. even after of ces-
sation from aloohol oonsumption: hence, benzodiazepine
step-down therapy is often beneficial.
Chronic alcoholoonsumption produces both psychologic
and physiologic dependence and resullS in a large number
of health effe,ts. Theorgan mOM affected by chronic
alcohol abuse is the liver. Akoholism is a common cause of
cirrhosis, a debilitating and often fatal failure of the liver to
perform its vital functions. Liver impairment causes abnor-
malities ill blood cloning and nutritional deficiencies. It also
sensitizes the patient to the effects of all medications metab-
olized by the liver. I=or alcoholic patients, the nurse should
begin therapy with reduced medkation doses until the ad-
verse effects of pharmacotherapy an be assessed.
(DT) may occur in individuals who have con-
stantlyconsumed alcohol for a longer period of time. Symp-
toms are hallucinations, confl.lSion, disorientation, and
COMPLEMENTARY AND ALTERNATtVE THERAPIES
Milk Thistle fOf Alcohollivef Damage
MiltdJillk iI iI pI.Int found IJOWIng in Horth Ameriu, from "4e:I:KolOul\id,).
Wt M bffiIlMd ill iln ht!biI mtdiciIt /of tctM ingrtditftt
in mr, milk tMtIr plant{Si,am,.-..um), been aH'IlinMdto

Stuclin 11m shown that .ilrin iI iI* to new.1izt the of ilkohol,
and iIOlIIty stitdlff' Mr If9I'ntmm It tcU II l ilncI
radUI 1U'fengrr.1t iI typiuIy tHnI/of"" cWrho!il.cltronic btpiltitil,ind
diIordm.The hnb hH INside eflect!. odie. thin mild ciillThti,
blcwting,.nd IlDmadL
MlHnll.inwn.1Dry ilnd propMies hil\le ilM been docu
IIIftItfil {Song H M ilk tNult lin bftn diinwd 10 lilt gIOWth
of (iJ1\(ff uk Most (liims mil tMtIr h.w not M mUd
through CO!ItroIHi mJcfe.
agitation. Many patients experience anxiety, panic, par.l-
noia, and sensations of something crawling on the skin.
Alcohol withdrawal syndrome is severe and may be life
threatening. Antiseizure medications may be used in the
treatment of alcohol withdrawal (dupler t SOC). Long-
term treatment for alcohol abuse includes behavioral coun-
seling and self-help groups such as Alcoholics Anonymous.
Disulfiram (Antabuse) may be given to disc:ourage
Disulfiram inhibits acetaldehyde dehydrogenase, the enzynle
that metabolizes alcohol. If a patient ,onsumes alcohol while
taking disulfiram, he or she bemmes violently ill within 5 to
10 minutes, with headache, shortness of breath, nausea!
wmiting, and other unpleasant symptonu. Disulfiram is ef-
fe.::tiveonlyin highly motivated patients,sin,e the success of
pharmacothe!'apy is entirely dependent on patient oompli-
ance. Alcohol sensitivilf continues for up to 2 weeks after
disulfiram has been discontinued. As a pregnancy ategory X
drug, disulfiram should neve!' be Imn during pregnancy.
In addition to disulfiram, ao;amprosate akium (Cam-
pral, I=orest) is an FDA.approved d.rug for maintaining alco-
hol abstinence in patients with alcohol dependence. Studies
comparing the therapeutic benefit of disulfiram with aat m-
have not b.oen full y drug mOlY
benefit patients who are not candidates for naltre.'tOnt ther-
apy. (Patients receiving naltrexone therapy or patients re-
ceiving methadone treatment are subject to withdrawal
symptoms. ) Acamprosate's mtehanism of action im'olves
the restoration of neuronal excitation-the alteration of
gammaaminobutyratt' and glutamate activity in the
CNS---and does not appear to have other central nervous
system actions. Adverse reactions to acamprosate include
diarrhea, flatulence, and nausea. The drug is contraindi-
cated in patients with seve!'e renal impairment but may be
used in patients at increased risk for hepatoto:cidty.
" .7 Cannabinoids
Cannabinoids are substances obtained from the hemp plant
CAnnabis sa.iva, which thrives in tropical climates.
Cannabinoid agents are usually smoked and include mari-
LibraryPirate
juana, hashish, and hash oil. Although more than 61
cannabinoid chemicals have been identified, the ingredient
responsible for most of the pS)'\:hoactive properties is
9-tetrahydrocannabinol (THO.
MARIJUANA
Marijuana, also known as grass, POt, weed, reefer, or dope, is
a natural product obtained from C. sariVll. It is the most
commonly used illicit drug in the United States. Use of mar-
ijuana slows motor activity, decreases coordination, and
causes disconnected thoughts, feelings of paranoia, and eu-
phoria. It increases thirst and craving for food, particularly
chocolate and other candies. Ont' haJlmark symptom of
marijuana use is red or bloodshot eyes, OlUSed by dilation of
blood THe accrunulates in the gonads.
When inhaled, marijuana produces effects that occur
within minutes and last up to 24 hours. Because marijuana
smoke is inhaled more deeply and held within the llUlgs for
a longer time than cigarette smoke, marijuana smoke intro-
duces four times more particulates (tar) into the llUlgs than
tobacco smoke. Smoking marijuana on a daily basis may in-
crt'ase the risk of lung cancer and other respiratory disor-
ders. Ouonic use is associated with a lack of motivation in
achieving or pursuing life goals.
Unlike many abused substances, marijuana produces lit-
tle physical dt'pendence or tolerance. WithdrawaJ symptoms
are mild, ifthory are experienced at all . Metabolites ofTHC,
however, remain in the body for months to years, allowing
laboratory specialists to easily determine whether someont'
has taken marijuana. For several days after ust', THe can
o
I
OP(OH),
I
W-CH.- CH, - N(CH.l.
,
I
H
Psilocybin
(4-phosphoryl-OMn
Choptflll Sobn.OCO' ... blue 109
also be dt'lected in the urine. Despite numt'rous attempts to
demonstrate therapeutic applications for marijuana, results
have bt'en controversial and the medical value of the drug
remains to be proved.
11.8 Hallucinogens
Hallucinogens consist of a diverse class of chemicals that
have in common the ability to produce an altut'd,dreamlike
state of consciousness. Tht' prototype substance for this
class, sometimes called psymrlielin. is LSD. All hallucinogens
are Schedult' I drugs: They haw no medical use.
LSD
For nearly all drugs of abuse, predictable symptoffi'i occur in
!:Wry user. Effects from hallucinogens, however, are highly
varia bIt' and dept'ndent on the mood and expectations of
the user and the surrolUlding environmt'nl in which the
substance is used. Two people taking the same agent will re-
port completely difft'rent symptoffi'i, and tht' same person
may reporl different symptoms with each use. Users who
take LSD and psilocybin (magic
( Figure 11.1) may experience symptoffi'i such as laughter,
visions, religious revelations, or deep personal insights.
Common occurrences are hallucinations and afterimages
projected onto people as they move. Users also report lUl-
usually bright lights and vivid colors. Some users ht'ar
voices; others report smells. Many experience a profound
sense of truth and deep-directed thoughts. Unpleasant ex-
perit'nces can be terrifying and may include anxiety, panic
attacks, confusion, severe depression, and paranoia.
I /H,, - CH.
C- N
\
CH. - CH.
CH,
LSD
11.1 Comparison of the chemical structures of psllocybln and LSD. Psilocybin (left) Is derived from a mushroom
So!.v"c e: )ames BlNf!rldijeNlsua/s lt1i!m!red.
LibraryPirate
11 0 Untl2 Phannac:ology tho> Nu......-P.tk>nt Relatklmhlp
Mescali ne
.. Figure 11.2 The cho>mlcal structure of mescallne,derlved
from the peyote cactus
Source Prooon fducafloo/PH Calleqf>.
LSD, also called add, thtbeast, blotter acid, and California
sunshine, is derived from a fungus that grows on rye and
other grains. LSD is nearly always administered orally and
can be manufuctured in capsule, tablet, or liquid form. A
common and inexpensive method for distributing LSD is to
place drops of the drug on paper, often containing the im-
uf uuluuJl ur lu <.Ieull
lUre. The paper is dried; users then ingest the paper
containing the LSD to produce the drug's effects.
LSD is distributed throughout the body immediately af-
ter use. Effects are experienced within an hour, and may last
from 6 to 12 hours. LSD affects the central and autonomic
nervous systems, increasing blood elevating body
temperature, dilating pupils, and increasing the heart rate.
Repeated use may cause impaired memory and inability to
reason. In extreme cases, patients may develop psychoses.
One Wlusual adverse effect is flashbacks, in which the user
experiences the effects of the drug again, sometimes weeks,
months, or years after the drug was initially taken. Although
tolerance is observed, little or no dependence occurs with
the hallucinogens.
OTHER HAllUCINOGENS
In addition to LSD, olher abused hallucinogens include the
following:
Mescaline: Found in the peyote cactus of Mexico and
Central America ( .. Figure 11.2)
MDMA (3, 4-mtthylentdioxymtthamphetamille; XTC or
EeJtasy): An amphetamine originally for
research purposes that has since become e."ltremely
popular among teens and YOWlg adults
DOM (2,5 dimethoxy-4-merhylamphetamine): A
recreational drug often linked with rove parties as a drug
of choice having the name STP
. MDA (3,4-methylenedioxyamphttamine): Called the
love drug because it is believed to enhance sexual desires
Phenylcyclohexylpiperidine (PCP; angel dust or
phencyclidine): Produces a trancelike state that may last
for days and results in severe brain damage
Ketamine (date rape drug or special coke): produces
Wlconsciousness and atrulesia; primary legal use is as an
anesthetic
11 .9 eNS Stimulants
Stimulants include a diwrse family of drugs known for their
ability to increase the activity of the CNS. Some are available
by prescription for the treatment of nan::olepsy, obesity, and
attention deficit/hyperactivity disorder (AD HD) . M drugs of
abU'll', CNS stimulants are taken to produce a sellSe of exhil-
aration, improve mental and physical perfonnance, reduce
appetite, prolong wakefulness, or simply high." Stimu-
lants include the amphetamines, rocaine, methylphenidate,
and caffeine.
AMPHETAMINES AND METHYLPHENIDATE
CNS stimulants have effects similar to those of the neuro-
transmitter norepinephrine (chapter 1300). Norepineph-
rine affects awareness and wakefulness by activating
neurons in a part of the brain called the rE"tkular formation.
High doses of amphetamines the user a feeling of self-
euphoria, a]e,tn""",, and empowerment; but ju,t
as short-term use induces favorable feelings, long-term use
often results in feelings of restlessness, anxiety, and fits of
rage, especially when the user is coming down from a "high"
induced by the drug.
Most CNS stimulants affect cardiovascular and respira-
tory activity, resulting in increased blood pressure and in-
creased respiration rate. Other symptoms include dilated
pupils, sweating, and tremors. Overdoses of some stimu"
lants lead to seizures and cardiac arrest.
Amphetamines and dextroamphetamines were once
widely prescribed for depression, obesity, drowsiness, and
congestion. In the 1960s, it became recognized that the
medical uses of amphetamines did not outweigh their risk
for misuse. Due to the development of safer medications,
the current therapeutic uses of these drugs are extremely
limited. Most substance abusers obtain these agents from il -
legal laboratories, which can easily produce amphetamines
and make tremendous profits.
Dextroamphetamine ( De."ledrine) may be prescribed for
short-term weight loss when all other attempts to reduce
weight have been exhausted, and to treat narcolepsy.
Methamphetamine, commonly called ice, is often used as a
recreational drug by users who like the rush that it gives
them. It usually is administered in powder or crystal form,
but it may also be smoked. Methamphetamine is a Schedule
II drug marketed Wlder the trade name Desoxyn, although
most abusers obtain it from illegal methamphetamine
(meth) laboratories. A structural analogue of methamphet-
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amine, methcathinone (street name, Cat) is made illegally
and snorted, taken orally, or injected IV. Methcathinone is a
Schedule I agent.
M"tllylpl",uiuat" (Ritaliu) i, a CNS ,tiJllulaut wiudr
prescribed for children diagnosed with attention deficit!
hyperilCtivity disorder (ADHD). Ritalin has a calming effect in
children who are inattentive or hyperactive. By stimulat-
ing the alertness center in the brain, the child is able to fo-
cus on tasks for longer periods. This explains the
paradoxical calming effects that this stimulant has on
children, which is usually the opposite of that on adults.
The therapeutic applications of methylphenidate are dis-
cussed in chapter 1600.
Ritalin is a Schedule II drug that has many of the same ef-
fects as cocaine and amphetamines. It is sometimes abused
by adolescents and adults seeking euphoria. Tablets are
crushed and used intranasally or dissolved in liquid and in-
jected IV. Ritalin is sometimes mixed with heroin, a combi-
nation called a speedixlll.
COCAINE
Cocaine is a natural substance obtained from leaves of the
ooca plant, which JIIOws in the Andes Mountains region of
South America. Docwnentation suggests that the plant has
been used by Andean cultures since 2500 B.G. Natives in this
region chew the coca leaves, or make teas of the dried leaves.
Becausecoca is taken orally, absorption isslow,and the leaves
oontain only 1 % cocaine, so users do not suffer the ill effects
caused by chemically pure extracts from the plant. In the An-
dean culture, use of coca leaves is not considered substance
abuse because it is part of the social norms of that society.
Cocaine is a Schedule II drug that produces actiolts simi-
lar to those of the amphetamines, although its effects are
usually more rapid and intense. It is the second most com-
monly abused illicit drug in the United States. Routes of ad-
ministration include snorting, smoking, and injecting. In
small doses, cocaine produces feelings of intense euphoria,
a decrease in hunger, analgesia, illusions of physical
strength, and increased sensory perception. Larger doses
will magnify these effects and also cause rnpid heartbeat,
sweating, dilation of the pupils, and an elevated body tern-
perature.After the of euphoria diminish, the user is
left with a sense of irritability, insomnia, depression, and ex-
treme distrust. Some users report the sensation that insects
are crawling WIder the skin. Users who snort cocaine de-
velop a chronic rWIny nose, a crusty redness aroWId the
nostrils, and deterioration of the nasal cartilage. Overdose
can result in dysrhythmias, convulsions, stroke, or death due
to respirntory arrest. The withdrawal syndrome for amphet-
amines and cocaine is much less intense than from alcohol
or barbiturate abuse.
CAFFEINE
Caffeine is a natural substance found in the seeds, leaves, or
fruits of more than 63 plant species throughout the world.
Significant amounts of caffeine are consumed in chocolate,
coffee, tea, soft drink>, and ice cream. Caffeine is sometimes
CNplfr II SUbstalKf ... b .. "e 111
added to OTC pain relievers because it has been shown to in-
crease the effectiveness of these medications. Caffeine trav-
els to almost all parts of the body after ingestion, and several
hou", u"t:<.It:<.I [or th" l.>oUy to ",,,talmliL,, auu dimiuat"
the drug. Caffeine has a pronoWlced diuretic effect.
Caffeine is considered a CNS stimulant because it produces
increased mental alertness, restlessness, nervousness, irri-
tability,and insonmia. The physical effects of caffeine include
broru:hodilation, increased blood pressure, increased produc-
tion of stomach acid, and changes in blood glucose levels. Re-
peated use of caffeine may result in physical dependence and
tolerance. \'/ithdrawal symptoms include headaches, fatigue,
depression, and impaired perfomlance of daily activities.
11.10 Nicotine
Nicotine is sometimes considered a CNS stimulant, and al-
though it does increase alertness, its actions and long-term
consoquences place it in a class by itself. Niootine is unique
among abused substances in that it is legal, stronglyaddic-
tive, and highly carcinogenic. Furthermore, use of tobacco
can cause harmful effects to those in the immediate area
who breathe secondhand smoke. Patients often do not con-
sider tobacco use as substance abuse.
TOBACCO USE AND NICOTINE
The most common method by which nicotine enters the
body is through the inhalation of cigarette, pipe, 01" cigar
smoke. Tobacco smoke contains morethan 1,000 chemicals,
asignificant number of which are carcinogens. The primary
addictive substance present in cigarette smoke is nkotine.
Effects of inhaled nicotine may last from 30 minutes to sev-
eral hours.
Nicotine affects many body systems including the ner-
vous, cardiovascular, and endocrine systems. Nicotine
stimulates the CNS directly, causing increased alertness and
ability to focus, feelings of relaxation, and
The cardiovascular effects of nicotine include an acceler-
ated he.1rt rate and increased blood pressure, caused by ac-
tivation of nicotinic receptors located throughout the
autonomic nervous system (chapter l3OO). These cardio-
vascular effects can be particularly serious in patients tak-
ing oral contraceptives: The risk of a fatal heart attack is five
time> greater in smokers than in nonsmokers. Muscular
tremors may occur with moderate doses of nicotine, and
convulsions may result from very high doses. Nicotine af-
fects the endocrine system by increasing the basal meta-
bolic rate, leading to weight loss. Nicotine also reduces
appetite. Otronicsmokingleads to bronchitis, emphysema,
and lung cancer.
Both psychologic and physical dependence occur rela-
tively quickly with nicotine. Once started on tobacco, pa-
tit'nt> tend to continue their drug use for many years,
despite overwhelming medical evidence that the qU.1lity of
life will be adversely affected and their life span shortened.
Discontinuation results in agitation, weight gain, anxiety,
headache, and an extreme craving for the drug. Although
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11 2 Untl2 Phannac:oiogy .00 ttl<> NufW-p. Uem Rel.1tlon,hlp
TREATING THE DIVERSE PATIENT
Ethnic Groups and Smoking
The iKidencr of tobai:oo 1M 'am among riIWl .nd tthnic: groups. The
Ameri<an Inciami nd AIasb Natim.Afri:an Americans i
hMjl kIwrIt Alian American and
Hiijlanic: womm. Of paMmar ((I!)(f!n is tilt 1M 01 oHhomising by the tobao in-
dUllry to targtt !pKifK agt Of ethnic: glOJps thrrugh mrming in magalintS
fthnicgroups DrOll Idta tebilion WrM.
SmokiIg and other tobHoo !Ill aft' major contributors of tilt thrfl' itading
QUItS of d9th iI African Americans- lltan and , . A!ritan
American men art at lealt SO% IIIOft' to rIMIop king call(ff than
diltall' as hMjl amongAfric:anAmfflcan men {om-
poalfd with White men.Afri:.n Amfflcan women do oot lart any bettff: The inci-
denuolltrokes
women. Nul>eS moukl mate thti" ethni!aly paOOm, poartiruLllfy
African Arnerians.. bout ther iKrtoud riskof.wall'.nd ft'{ommend ming
(esation programs.
nicotine replacement patches and gum assist patients in deal -
ing with the unpleasant withdrawal symptoms, only 25% of
patients who attempt to stop smoking remain tobacco-free a
year later.
11.11 The Nurse's Role
in Substance Abuse
The nurse serves a key role in the prevention, diagnosis, and
treatment of substance abuse. A thorough medical history
KEY CONCEPTS
must includ .. questions about substance abuse. In th .. case
of IV drug users, the nurse must consider the possibility of
HIV infection, hepatitis, tuberculosis, and associated diag-
noses. Patients are often reluctant to report their drug use,
for fear of embarrassment or being arrested. The nurse
must be knowledgeable about the signs of substance abus ..
and withdrawal symptoms, and develop a keen sens .. of
perception during the .... s ...... menl .tage. A trusting
nurse-patient relationship is essential to helping patients
deal with their dependence. By using therapeutic commu-
nication skills and by demonstrating a nonjudgmental,em-
pathetic attitude, the nurse can build a trusting relationship
with patients.
It is often difficult for a health care provider not to con-
demn or stigmatize a patient for his or her substance abuse.
Nurses, especially those in large cities, are all too familiar
with the devastating medical. economic, and social conse-
quences of heroin and cocaine abuse. The nurse must be
firm in disapproving of substance abuse, yet compassionate
in trying to help the patient rereive treatment. A list of so-
cial agencies dealing with dependency should be readily
available to provide patients. When possible, the nurs ..
should attempt to involw family members and other close
contacts in th .. treatment regimen. Educating the patient
and family members about th .. long-term consequences of
substance abuse is essential. Substance abuse also affects
members of the health care community. Nurses should be
aware of the ramifications of drug abuse and the impact this
would have on the nursing license.
The numbered kq conrepts provide a succinct summary of th .. important points from the corresponding numbered section
within the chapter. If any of these points are not clear, refer to the nWllbered section within the chapter for review.
11 .1 A wide variety of substances may be abused by individu-
als. All of these substances share th .. common characteris-
tic of altering brain physiology and/or perreption.
III Addiction is an overwhelming compulsion to continue re-
peated drug use that has both nt'Urobiologic and psy-
chosocial components.
113 Certain substanCf'S can calise both physical and psycho-
logic dependence, which result in continued drug-seeking
behavior despite negative health and social consequences.
11.4 The withdrawal syndrome is a set of uncomfortable
symptoms that occur when an abused substance is no
longer available. The severity of the withdrawal syndrome
varies among the different drug classes.
11. 5 Tolerance is a biologic condition that ocrurs with re-
peated use of certain substances, and results in the neces-
sity for higher doses to achieve the same initial response.
Cross-tolerance occurs between closely related drugs.
11.6 CNS depressants, which include sedatives, opioids, and
ethyl alcohol, decrease the activity of the brain, causing
drowsiness, slowed speech. and diminished motor coordi -
nation.
11 .7 Cannabinoids, which include marijuana, are the most
frequently abused class of illegal substances. They cause
less physical dependence and tolerance than the CNS
depressants.
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11 .3 Hallucinogoms, including LSD, cause an altered state of
thought and perception similar to dreams. Their effects
are extremely variable and unpredictable.
11 .9 CNS stimulants-induding amphetamines, methylpheni -
date, caffeine, and cocaine--increase the activity of the CNS
and produce tncreased w.tkefulness.
NCLEX-RN" REVIEW QUESTIONS
D Following a surgical procedure, the patient states he does
not want to take narcotic analgesics for pain because he is
afraid he will become addicted to the drug. Response by
the nurse is based on the knowledge that:
I. dependence on narcotics is common among
postoperative p.1tients.
2. addiction to prescription drugs is rare when used
according to protocol
3. female patients are more likeIyto beoomeaddicted.
4. addiction is rare if the patient has a high pain threshold
D Thepatient states she has been increasing theamount and
frequency of the an tianxiety drug she is using. The nurse
understands that the patient has most likely developed to
th"drug.
1. inununity
2. tolerance
3. rt'Sistance
4. addiction
D A l3-year-old boy has been showing signs of paranoia and
anxiety and, according to his parents, has been
very oddly," including recently being reclusive and locking
himself in his room. On occasion, the young man has
shown loss of coordination and an apparent distorted
sense of time. The parents are "ery concerned, since they
have been notified by the s<:hool nurse that their son has
been implicated in drug activity. [n the nurse's office, the
young man asks if he can have a drink of water for "dry
mouth."The nurse observes that his face is flushed and his
eyes reddened Which substance has the young man most
likely used?
1. Heroin
2. Crack
3. Barbiturates
4. Marijuana
o Th<' p"ticnt with a history of alcohol abuse is admitted to
the hospital. The nursing cu e plan includes assessment of
CRITICAL THINKING QUESTIONS
1. A l6-year-old female patient ishospitalized in the lCU fol -
lowing the ingestion of a high dose ofMDMA (Ecstasy) at
a street dance. Her mother cannot understand why her
daughter could have such serious renal and cardiovascular
complications afier one dose."' The nurse is con-
cerned that the mother lacks sufficient knowledge to be
helpful. What teachin]!. does the nurse conduct?
CNpUI" II SUb"."", Abu,,, 113
11 .10 Nicotine is a powerful and highly addicti"e cardiovascu-
lar and CNS stimulant that has serious adverse effects
with chronic use.
11 .11 The nurse serves an important role in educating patients
about the consequences of drug abl1St' and in recom-
mendlng approprtme treatment
the patient for which of the following symptoms indica-
tive of alcohol withdrawal?
]. Mental depression, headaches, and hunger
2. IllSOnmia, nausea, and bradycardia
3. Tremors, hallucinations, and delirium
4. Weakness, hypotension, and violent yawning
II The patient states that she is going to quit smoking cold
turkey." The nurse teaches the p.1tient to expect which of
the followin g symptoms during withdrawal from nico-
tine! (Select all that apply. )
I . Headaches and insomnia
2. Increased appetite
3. Tremors
4. IllSOmnia
S. Increased heart rote and blood pressure
1:1 What is the difference between physical and psychologic

t. Phpica[ d.".,ndeno. i.s the adaptation of the body to a
substance over tin-.e such that when the substance is
withdrawn, withdrawal symptoms will result
Psychologic dependence is the overwhelming desire to
continue using a substanceafier it isstopped or
withdrawn, but without physical withdrawal symptoms
ocrurring.
2. Physical and psychologic dependence are terms that
are used interchangeably. In both cases, physical
withdrawal symptoms will result if the substance is
withdrawn from use.
3. TIley ocrur together. psychologic dependence is the first
type of dependence to occur with a substance, folla.ved.
by physical dependence.
4. Psychologic dependence develops when the brain adapts
over time to the use of the substance. Physical
dependence is the active seeking of a SIlbstance
associated with a desire to oontinueusing the substance.
2. Thewifeof a 24-year-old professional football player isad-
milled to the emergency room after being beaten and ver
bally abused by her husband. She says that he is under a
great deal of stress and has been working hard to maintain
peak athletic fitness. She says she has noticed that her hus.-
band becomes irritable easily. What assessments and inter-
ventions should the nurse perform!
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11 4 UnII2 and tho> Nufw--P.ik'n1 Relallomhlp
1, A 44-year-old bushll'SSman travels weekly for 1115 rom-
p<l lIy and has h.ad difficulty skeping i n MOlle hotel an-
other: He oonsultNl his health care provider and lias been
taking secobarbital (Seoonal) nightly to help him skep.
The p<ltlent lias ,ailed the nurse at the healtll .;are
provider's offke and has said, . , ha."". just got 10 have
something Sl ronger: What does the nurse consider as plrt
of the assessment!
See Appendix D forall$wers and rationales for all activitlrs,
EXPLORE Liij;llI!Iftfflng!ft::r------,
hl:fl'trrsinSKit 15 y(lUJ one stDCIlor cnlLre ma1eItIls IIld
INIUrc:es. PI_I kif 'UIXeA WIth lIldtianaI pradU
q.JI'!'lfiIns. IrtfnaIoIe 1SSIgnmert5 '"' web anlrMtklns
indl'i:lecs, m mont
fIeg_ )l1li' IICC\!. 0'J0e fftWn die fmnI M \IDlJJ Mr* 81
www.mynll'lingtutcam,
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KEY TERMS
actiYated rnarroal poqt III
acute radiation s)'Ildromr pu;t I}()
anthral fX1}t 118
bil5icsupporti'ft' care pajt 1]1
bioterrori!ilT1 paqt 116
Emergency Preparedness
and Poisonings
LEARNING OUTCOMES
After readinf} this chapter, the student should be able to:
1. Explain why drugs are Important In the context of emergency
prep&redness.
2. Discuss the role of the nurse In preparing for and responding to a
bioterrorist act.
1. Identify the purpose and components of the Strategic National
Stockpile (SNS).
4. Explain thll threat of anthrax contOlminalion and how It is transmitted.
5. Discuss the clinical manifestations and treatment of anthrax exposure.
6. Identify specific virUSeS that would most likely be used In II
bloterrorlst act.
7. Explain the advantages and disadvantages ofvacclnation as a means of
preventing illness due to bioterrorist attacks.
8. Provide of chemical agents that might be used In a
bloterrorlsm Incident, and their treatments.
9. Describe the symptoms of acute radiation exposure and the role of
potassium iodide (KI) in preventing thyroid cancer.
10. list top substances that represent human polson
11. Explain fundamental elements of toxicity treatment provided by the
nurse.
12. Describe specific antidotes used to treat common overdosed
substances and toxins.
gastridavage and aspililtion paqt III
ionizing radiation paqt IlO
nernagenls {XljtllO
spr!r:ifitantidotes pa;t III
Strategit National Stoc:kpile (SNS) {Xljt 118
Syrupoflpr!cac {JOl}tlll
vaccine {XljO 19
vmdormanaged innntory (YMI) {Xljt 118
whole-bowel irrigation pq III
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11 6 Untl2 Phannac:oiogy .00 ttl<> NufW-p. Uem Rel.1tlon,hlp
I
t is important that nurses understand the role that drugs
play in preventing or controlling global disease and toxic
outbreaks. Drugs are the most powerful tools available to the
medical community for countering worldwide epidemics
and bioterrorist threats. If medical personnel could not iden-
tify,isolate, or treat the causes of global diseases,a major in-
cident could easily overwhelm health care resources and
produce a catastrophic loss of life. Drugs are a major compo-
nent of emergency preparedness plans. Drugs are also a
component of poison removal protocols, and some drugs
serve as antidotes to counteract the effects of specific poi-
sons. This chapter discusses the role of pharmacology in the
prevention and treatment of diseases or conditions that
might develop in the context of a biologic. chemical,or nu-
clear attack and the general management of poisonings in a
clinical setting.
12.1 The Nature of Bioterrorism
Prior to the September II, 2001 terrorist attacks on the
United States, the attention of health care providers regard-
ing disease outbreaks was focused mainly on the spread of
traditional infectious diseases. These included possible epi-
demics caused by influenza, tuberculosis, cholera, and HI V.
Table 12.1 lists the 10 most dangerous di,ea,,,,,
ranked according to which disorders caused the most deaths
worldwide in the year 2000. Other infectious diseases such
as food poisoning and sexually transmitted diseases were
also conunon though considered less important, because
they produced fewer fatalities.
The afterm3th of the September II, 2001 attacks
prompted the health care community to expand its aware-
ness of outbreaks and treatments to include bioterrorism
and the health effects of biologic and chemical weapons.
Bioterrorism may be defined as the intentional use of infec-
tious biologic agents, chemical substances, or radiation to
cause widespread harm or illness. The public has become
more aware of the threat of bioterrorism because such fed-
eral agencies as the Centers for Disease Control and Preven-
tion (CDC) and the U.S. Department of Defense have
stepped up efforts to inform, educate. and prepare the pub-
lic for disease outbreaks of a less traditional nature.
The goals of a bioterrorist are to create widespread public
panic and tocause asmanycasualties as possible. There is no
shortage of agents that can be used for this purpose. Indeed,
some of these agents are easily obtainable and require little
PHARMFACTS
Potgntial Chgmical and Biologic Aggnts
for Terrorist Attacks
Robtrt SttYMI, 63-)'Nr-01d rmplu,ft of whoditd in
Florida on October 5, 2001, wu the firl! jlfrwn to die from anthrax in
United Sme in 25
In 1979,ac:ddental reIN!I' of amhrax from a IflNrm lab in the Soviet
Union killed 68 ptOpIe. The problem was mred to a f, uk, air
Tht Ebola virus uusn dwh by hemormagK fewor in up to 9O%0lthe
patienn who !how dinic.!1 ofinmtion.
Eboia viruses found in {ffltral AfrKa.Akhough of
viruses in unknown. monkeys (Jig. homans) appm 10 br
to infection and as soon:ftof the ViM infected.
WtdtsplNd publK Im<lllpox I'aCdnations in the Unitt<!
in 1972.
It is fttimatt<! that7 million to 8 million dalft ohmalipoJ I'aCdneart in
!IOTag!' at the CDC. This ma cannot br mrl)- sinc:f all
ymine production facilities Yo'! dismantltd 1980, a nd Ruine
production 24 to 36 months.
MOlt agtnts produred in <I l1'arch for insKtilides,
bot bK.iUII' of their toJ:Kit)o, theyWffl' for military l/\('.
(hen!ic.!!s in bioterTorist olds need not tit or difficuk to
obtain: ToUt inckJstrial chtm Kals IlKh as chlorine, phosgtne, and
h)'drvgm cyanide used in (Qmmtrti.J1 m.nufolduring . nd rudiiy
,w<lilablt.
TABLE 12.1 The 10 Most Dangerous Infectious Diseases in the World. 2000
DIsease Causattve Agent Target Deaths per Year (mliltons)
IiMmDphiIuf ill1lwfllM Rt5piratoryl)'lll'll1 17
T!btn:ulosis Mywooatrium rubmlosis
"""
I.'
""ffi
'fibricrhoJtfUl' Oigfsti',or, UK! I.S
AI. Human imm!llOdtficitrq virus Immolll' l.l
Miltaria 6tooddisortltr
'.S
"',,'"
Rubtola l'irus L!IIgsand mtningts 0.%
IItpititis B IItpititis hM (H8V)
"'"
0.""
Whooping (oujl Son/ertlloperllJl5is 0.41
Tmnus
I OusDidum m.ID
body o.m
OengUl'ffflf Ral'iviM body (fe'ml 0.1 4
Soultt: .kJ1y 2001 rtpor1 by WIIOlindUllry Drug DMIopmtnt Working Group-WOOd Health ()garization: http:/,w-.who.int/en1
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or no specialized knowledge to disseminate. Areas of great-
est concern include acutely infectious diseases such as an-
thrax, smallpox, plague, and hemorrhagic viruses;
incapacitating chemicals such as nerve gas, cyanide, and
chlorinated agents; and nuclear and radiation emergencies.
The CDC has categorized the biologic threats, based on their
potential impact on public health, as shown in Table 12.2.
, 2.2 Role of the Nurse
in Emergency Preparedness
Emergency preparedness is not a new concept. For mOTe
than 30 years, the Joint Commission on Accreditation of
HealthcaTe Organizations (JCAHO) has required accredited
hospitals to develop disaster plans and to conduct periodic
emergency drills to determine readiness. Prior to the late
1990s, disaster plans and training focused on natural disas-
ters such as tornadoes, hurricanes and floods, or accidents
such as explosions that could cause multiple casualties. In
the late 1990s, the JCAHOstandards added the possibility of
bioterrorism and virulent infectious organisms as rare,
though possible, scenarios in disaster preparedness.
TABLE 121 I Categories of Infectious Agents
Category Descrtptton
In 2001 1CAHO issued new standards that shifted the fo-
cus from disaster preparedness to emergency management.
The newer standards included more than just responding to
the immediate casualties caused bya disaster, they also con-
sidered how an agency's health care delivery system might
change during a crisis, and how it might return to normal
operations following the incident. The expanded focus also
included how the individual health care agency would coor-
dinate its efforts with community resources, such as other
hospitals and public health agencies. State and federal agen-
cies revised their emergency preparedness guidelines in an
attempt to plan more rationally for a range of disasters in-
cluding possible bioterrorist acts.
Planning for bioterrorist acts requires dose cooperation
among all the different health care professionals. Nurses are
central to the effort. Because a bioterrorist incident may oc-
cur in any community without warning, nurses must be
prepared to respond immediately. The following elements
underscore the key roles of nurses in meeting the challenges
of a potential bioterrorist event:
Education: Nurses should maintain a current knowledge
and Wlderstanding of emergency management relating to
EXllmples


Agtnl> thilt: tan lit diSlminalrd or pmon 10 person; (,JIM hi91 BtxiIIu! onrhrud! [afthrax)
mortall1, with poIt nlial for m,p" poJIIic htakh impaa; rrighl (,JIM]I\tIIi( panic ,nd
Oosuidium IIorulioom lolin
social Ihruption; or rt!pire !pfdaI action for public htallh
Hmd5lllQ ruIoffn<is
map" [smalpox)
Viral hffiIorrhagicil'W'n lUlhas MarllJrg and EboIa
!miIb'Q

Agtnl> thilt:are modffilltly til)' 10 dilsffilinatt; catrlt lI"IOdtratt morbidly and low Broal/Q sptOO [brIn11oli1)
mortally; Of requll' spffiti( mnc:mlffill of (1)('\ diagl105IK (,Jpadty ,nd mlwlK td
IilJrklrolderiQ mo/Id
mlNlt IlrlrillalKt
IilJrktriJlderiQ /MudOlllQIIti (mdioidolis)
Chlanydio pfirrQQ (p5itt.Kosisj
CrUlM bixnfri [Q fMr)
fpsilon toxin of Cloroidium ptrfringtm
Food life!)' thll'atllum is SdIllOOt8Q and f.roi
Ridn toxin from RidrvJlMImuris
5rQphyloxws mt .... lOXil B
Vir,1 ffiltphallis
Waln-liftty IlRallludJ 011 V.modrolfflleand
ponum
( mt'rgilHj pathogl'nlthat (OWd lit tnginmtd for mall dilltminalion iIeGIultoithti" Hantavirul6
milolbilit): tilit 01 prooiKtion and ml'itlllmtion, and potential for tigh morbiditJ and
MutKtug-rristanl1Ubfflulosi I
mortall1 rate ,nd major htakh impam
Nipah Vlus [NiYJ
fld.-bomr vi'ul6
Ydowfl>oltr

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11 8 Untl2 Phanna<:olog)r .nd!two NufW-p.tlem Rel.1tlon,hlp
bioterrorist activities. Nurses can assist the public by
providing current and accurate information about
potential or real threats to public health and correcting
misinformation about these topics.
Resources: Nurses should maintain a current listing of
health and law enforcement contacts and resources in
their local conununities who would assist in the event of
bioterrorist activity. \'-1hen appropriate, nurses may
participate in local, hospital-related, or regional first-
responder teams as a resource to their commWlity.
and treatment: Nurses should be aware of the
early signs and symptoms of chemical and biologic
agents, and their immediate treatment, and report the
findings to the appropriate authorities.
Plannillg: Nurses should be involved in developing
emergency management plans for their own families,
assisting neighbors and their communities to develop
such plans, and participating through their health care
agencies in disaster preparedness drills.
12.3 Strategic National Stockpile
Should a chemical or biologic attack occur, it would likely be
rapid and unexpected, and would produce multiple casual -
ties. Although planning for such an event is an important
part of disaster preparedness, individual health care agen-
cies and local commWlities could easily be overwhelmed by
such a crisis. Shortages of needed drugs, medical equip-
ment, and supplies would be expected.
The Strategic National Stockpile (SNS), formerly called the Na-
tional Pharmaceutical Stockpile, is a program designed to
ensure the immediate deployment of essential medical ma-
terials to a community in the event of a large-scale chemical
or biologic attack. Managed by the CDC, the stockpile con-
sists of the following materials:
Antibiotics
Vaccines
Medical, surgical, and patient support supplies such as
bandages, airway supplies, and IV equipment
The SNS has two components. The first is called a push
package, which consists of a preassembled set of supplies
and pharmaceuticals designed to meet the needs of an Wl -
known biologic or chemical threat. There are eight fully
stocked 50-ton push packages stored in climate-controlled
warehouses throughout the United States. They are in loca-
tions where they can reach any conununity in the United
States within 12 hours after an attack. The decision to de-
ploy the push package is based on an assessment of the sit-
uation by federal goverrunent officials.
11",""""".1 SNS "",,,j,c,,, uf a ..,ncl .. -rndndYro in
ventory(YMl) package. VMI packages are shipped, if necessary,
after the chemical or biologic threat has more clearly been
identified. The materials consist of supplies and pharma-
ceuticals more specific to the chemical or biologic agent
used in the attack. VMI packages are designed to arrive
within 24 to 36 hours.
The stockpiling of antibiotics and vaccines by local hos-
pitals, clinics, or individuals for the purpose of preparing
for a bioterrorist act is not recommended. Pharmaceuti-
cals have a fmite expiration date, and keeping large stores
of drugs can be costly. Furthermore, stockpiling could
cause drug shortages and prevent the delivery of these
pharmaceuticals to communities where they may be
needed most.
AGENTS USED IN BIOTERRORISM ACTS
Bioterrorists could potentially use any biologic, chemical, or
physical agent to cause widespread panic and serious illness.
Knowing which agents are most likely to be used in an inci-
df.'nt hdps nurses plan and implement emerg,m,y prepared-
ness policies.
12.4 Anthrax
One of the first threats following the terrorist attacks on the
World Trade Centerwasanthral.ln the fall of2001,five people
died as a result of exposure to anthrax, presumably due to
purposeful, bioterrorist actions. At least 13 U.S. citizens were
infected, several governmental were threatened,
and the U.S. Postal Service was interrupted for several weeks.
There was initial concern that anthrax outbreaks might dis-
rupt manyother essential operations throughout the OOWltry.
Anthrax is caused by the bacteriwn Bacillus anthracis,
which norn,aUy affects domestic and wild animals. A wid"
variety of hoofed animals are affected by the disease, indud-
ing cattle, sheep, goats, horses, donkeys, pigs, American bi-
son, antelopes, elephants, and lions. If transmitted to hwnans
by exposure to an open wound, through contaminated food,
or by inhalation, B. aruhmds can cause serious damage to
booy tissues. Symptoms of anthrax infection usually appear
1 to 6 days after e."l:posure. Dependingon how the bacterium
is transmitted, specific types of anthrax "poisoning" may be
observed, each characterized by hallmark symptoms. Clini-
cal manifestations of anthrax are sUllUllariz.ed in Table 12.3.
B. aruhracis causes disease by the emission of two types of
toxins, edema toxin and lethal toxin. These toxins cause
necrosis and accwnulation of exudate, which produces
pain, swelling, and restriction of activity, the general symp-
toms associated with almost every form of anthrax. Another
component, the aruhrax binding receptor, allows the bac-
terium to bind to human cells and act as a "doorway for
both types of toxins to enter.
Further ensuring its chance for spreading, B. aruhracis is
spore forming. Anthrax spores can remain viable in soil for
hWldreds, and perhaps thousands, of years. Anthrax spores
are resistant to drying, heat, and some harsh chemicals.
'pur .... an, ",aill fur puuliL ],,,altl,
because they are responsible for producing inhalation an-
thrax, the most dangerous form of the disease. After entry
into the lungs, B. anthmcis spores are ingested by
macrophages and carried to lymphoid tissue, resulting in
tissue necrosis, swelling, and hemorrhage. One of the main
body areas affected is the mediastinum, which is a potential
LibraryPirate
TABLE 123 I Clinical Manifestations of Anthrax
Dl&r1ptlon Symptoms
MOil (0III00Il but lust (omplmd form of
ruraIJho fftrrattd wiltin lilt firstfN Wfffiof UpOSlR;
!!suks from dift(( (OIluaof (Olltaminattd produds with an
open WOIIId aran
Sma' skin Itsions rIMIop and lum inlO btidllabs; ilHllWt OIl
lam I6s than 1 Wffk; uonol lit spmld by ptrsoMU.ptIIOI
<0000
Gistroinl61inalanllnl Ra!! form of lit ltlhal in !4l 10
SOlI) of UI6; muks from t.!1ing oIIutril-rontaminatrd food,

diffirull1 swallowing. cramping diarrllN, and
ibOJrninallWl'lIiIg
In II lOIIlmOll but the most dangmvs form of anlhlax; un lit
IU(lf'IIfUfy UNltd ff idenlifil'd wiltin lilt filii fN ria)'! if! ft
9pOIII't; 16 '*S from inhalinginthrax spor6
Initially, folligut.oInd feoItl far Itmoll days, foIowtd by pmiIltlll
(ougholnd shortnm <an rmit
withil4-6 days
site for tissue injury and fluid accumulation. Meningitis is
also a common pathology. If treatment is delayed, inhala-
tion anthrax is lethal in almost every case.
B. anthracis is fOWld in contaminated animal products
such as wool, hair, dander, and bonemeal, but it can also be
packaged in other forms, making it transmissible through
the air or by direct contact. Terrorists have delivered it in the
form of a fine powder, making it less obvious to detect. The
powder can be inconspicuously spread on virtually any sur
face, making it a serious concern for public safety.
The antibiotic ciprofloxacin (Cipro) has traditionally bet>n
used for anthrax prophylaxis and treatment. For prophylaxis,
the usual dosage is 50) mg PO (by mouth), every 12 hours for
60 days. If exposure has been confirmed, ciprofioxacin should
immediatelybeadministered at a usual doseof400mg IV (in
travenously), every 11 hours. Otherantibiotics are also effec-
tive against anthrax, including penicillin, vancomycin,
ampicillin, erythromycin, tetracycline, and doxycycline. In the
case of inhalation anlhrax, the FDA has approvro the use of
ciprofioxacin and doxycycline in combination for treatment.
Many members of the public have become intensely con-
cerned about bioterrorism threats and have asked their health
care provider to provide them with ciprofloxacin. The public
should be discouraged from seeking lhe prophylactic use of
antibiotics in cases where anthrax exposure has not been con-
finned.lndiscrimina te, U1mecessaryuse of antibiotics can be
expensive, can cause !ignificant side effects, and can promote
the appearance of bacterial stI"3ins. The student
should refer to chapkr 3400 to review the precautions and
guidelines regarding the appropriate use of antibiotics.
Although anthrax immunization (vaccination) has been
licensed by the FDA fo r 30y""r5, it has not been widely used
because of the extremely low incidence of this disease in the
United States prior to September 2001. The va(ci nt has been
prepared from proteins from the anthrax bacteria, dubbed
Kprotective antigens.' Anthrax vaccine works the same way
as other vaccines: by causing the body to make protective
antibodies and thus preventing the onset of disease and
symptoms. Immunization for anthrax consists of three sub-
cutaneous injections given 2 weeks apart, followed by three
additional subcutaneous injections given at 6, 12, and 18
months. Annual booster injections of the vaccine are rec-
ommended.At this time, the CDC recommends vaccination
for only select populations: laboratory personnel who work
with anthrax, military personnel deployed to high-lisk ar-
eas, and those who deal with animal products imported
from areas with a high incidence of the disease.
There is an ongoing controversy regarding the safety of
the anthrax vaccine and whether it is truly effective in pre-
venting the disease. Until these issues are resolved, the use of
anthrax immUilization will likely remain limited to select
groups. Vaccines and the immUile response are discussed in
more detail in chapter 3ZOO.
'2.S Viruses
In 2002, the public wasastounded as researchers annoUilced
that they had "builCa poliovirus, a threat that U.S. health of-
ficials thought had essentially been eI"3dicated in 1994. Al-
though virtually eliminated in the Western Henlisphere,
polio was reported in at least 27 countries as late as 1998.
The infection persists among infants and children in areas
withcontaminated drinking water or food, mainly in under-
developed regions of India. Pakistan, Afghanistan, western
and central Africa, and the Dominican Republic. In the
United States, polio remains a potential threat in I of
300,000 to 500,000 patients who are vaccinated with the oral
poliovirus vaccine.
The current concern is that bioterrorists will culture the
poliovirus and release it into regions where people ruave not
been vaccinated. An even more dangerous threat is that a
mutated strain, for which there is no effective vaccine. might
be developed. Because the genetic code of the poliovirus is
small (around 7,500 base pairs), it can be manufactured in
a relatively simple laboratory. Once the virus is isolated,
hundreds of different mutant strains could be produced in
a very short time.
In addition to polio, smallpox is considered a potential
biohazard. Once thought to have been eradicated from the
planet in the 1970s, the variola virus that causes this disease
has been harbored in research labs in several coWltries.
Much of its genetic code (200,000 base pairs) has been se-
quenced and is public infornJation. The disease is spread
person to person as an aerosol ordropletsor bycontacl with
contaminated objects such as clothing or bedding. Only a
few "ira] particles are needed to cause infection. If the virus
is released into an unvaccinated population, as manyas one
in three people could die.
5

,


"
9
,
LibraryPirate
1 20 Untl2 Phannacology and ttl<> Nu,.....-Patient R .... t lon'hlp
There are no effective therapies for treating patients in-
fected by most types of viruses that could be used in a bioter-
rorist attack. For some viruses, however, it is possible to create
a vaccine that could stimulate the bodys immWle system in a
manner that could be remembered at a later date. In the case
of smallpox, a stockpile of the vaccine e.mts in enough quan-
tity to administer to every person in the United States. The
variola vaccine provides a high level of protection if given
prior to exposure, or up to 3 days later. Protection may last
from 3 to 5 years. The following are contraindications to re-
ceiving the smallpox vaccine, Wlless the individual has con-
firmed face-to-face COlllact with an infC\."ted patient:
Persons with (or a history of) atopic dermatitis or eC"Lema
Persons with acute, active, or exfoliative skin conditions
Persons with altered immWle states (e.g., HIV,AIDS,
leukemia, lymphoma, immunosuppressive drugs)
Pregnant and breast-feeding women
Children YOWlger than I year
Persons who have a serious allergy to any component of
the vaccine
It has been suggested that multiple vaccines he created,
mass produced, and stockpiled to meet the challenges of a
terrorist attack. Another suggestion has called for mass vac-
cination of the public, or at least those health care providers
and law enforcement employees who might be exposed to
infected patients.
Vaccines have side effects, some of which are quite seri -
ous.ln the case of smallpo.'t vaccination, for example, it is es-
timated that there might be as many as 250 deaths for every
million people inoculated. If the smallpox vaccine was given
to every person in the United States (approximately 300 mil-
lion), possible deaths from vaccination could exceed 75,000.
In addition, terrorists having some knowledge of genetic
structure could create a modified strain of the virus that
renders existing vaccines totally ineffective. It appears, then,
that mass vaccination is not an appropriate solution until
research can produce safer and more effective vaccines.
12.6 ToxicChemicals
Although chemical warfare agents have bet>n available since
\Vorld \Var I, medicine has produced few drug antidotes.
Many trrotments provide minin131 help other than to relieve
some symptoms and provide comfort following exposure.
Most chemical agents used in warfare were created to cause
mass casualties; others were designed to cause so much dis-
comfort that soldiers would be too weak to continue fighting.
Potential chemicals that could be used in a terrorist act in-
clude nerve gases, blood agents, choking and vomiting
"H"," ls, amI lhu, ... lhal UlU' ... ... [,ml ... ri"g. 12.4 1'''' -
vides a summary of selected chemical agents and known an
tidotes for chemical warfare and first-aid treatments.
The chemical category of main pharmacologic signifi-
cance is nern Exposure to these acutely toxic chemi-
cals can cause convulsions and loss of consciousness within
seconds, and respiratory failure within minutes. Almost all
signs of exposure to nerve gas agents relate to overstimula-
tion by the neurotransmitter acetylcholine (Ach) at both
central and peripheral sites located throughout the body.
Acetylcholine is normally degl1lded by the enzyme acetyl-
cholinesterase (AchE) in the synaptic space. Nerve agents
block AchE, increasing the action of acetylcholine in the
synaptic space; therefore, all symptoms of nerve gas exposure
such as salivation, increased sweating, muscle twitching, in-
vollUltary urination and defecation, confusion, convulsions,
and death are the direct result of Ach overstimulation. To
remedy this condition, nerve agent antidote and Mark I injec-
tor kit.. that contain the anticholinergic drug atropine ora re-
lated medication are available in cases where nerve agent
release is expected. Atropine blocks the allaciunent of Ach to
receptor sites and prevents the overstimulation caused by the
nerve agent. Neurotransmitters, synapses, and autonomic re-
ceptors are discussed in detail in chapter l JOO.
12.7 Ionizing Radiation
In addition to releasing biologic and chemical weapons, it is
possiblethat bioterrorists could develop nuclear bombs capa-
ble of mass destruction. In such a scenario, the greatest num-
ber of casualties would be due to the physical blast itself.
Survivors, however, could be exposed to high levels of ionizing
radiatim from hWldreds of different I1Idioisotopes created by
the nuclear explosion. Some of these radioisotopes emit large
amounts of radiation and persist in the environment for
years.As was the case in the 1986 Chemobyl nuclear accident
in Ukraine, the resulting radioi;;otopes could travel through
wind currents, to land thousands of miles away from the ini-
tial explosion. Smaller scale I1Idiation exposure could occur
lhruugh I'la!!l,uruy
lease of solid or liquid radioactive materials into public areas.
The acute effects of ionizing radiation have been well
docwnented and depend primarily on the dose of radiation
that the patient receives. radiation sometimes
called radiation sickness, can occur within hours or days af
ter extreme doses. Immediate symptoms are nausea, vomit-
ing, and diarrhea. Later symptolll'> include weight loss,
anorexia, fatigue, and bone marrow suppression. Patients
who survive the acute exposure are at high risk for develop-
ing various cancers, particularly leukemia.
Symptoms of nuclear and radiation exposure remain
some of the most difficult to treat pharmacologically. Apart
from the symptomatic treatment of radiation sickness, tak-
ing potassium iodide ( KI ) tablets after an incident or an at
tack is one of the few recognized approaches specifically
designed to treat nudear radiation exposure. Antidotes are
available to treat exposure to radioactive plutoniwn, ameri-
cium, curium, and cesiwn-\37, but these are more likely to
r""ull [rUlll i!!krll"l ralh ... r lhall ... r"al
(Table 20.600). One of the main radioisotopes produced
by a nuclear explosion is iodine-131. Because iodine is nat-
urally concentrated in the thyroid gland, 1-131 will immedi-
ately enter the thyroid and damage thyroid ceUs. For
example, following the Chernobyl nudear disaster, the inci-
dence of thyroid cancer in Ukrainejwnped from 4 to 6 cases
LibraryPirate
TABLE 11.4 1 Chti!mical Warfarti! Agti!nts and Trti!atmti!nts
Category Signs of Discomfort/Fatality AntldoteS/Flrst Aid
NERVE AGENTS
GA- Tibun(liquid)
GB- Sarin liquid)
GO-Somin (liqJidl
VX(ga\f(llJ\ lquid)
1lrpnIdir19 on the rotM S)'Rl!Ioms rna)' tit
to ind rumulatil'l' lkpmdr19 on 9posurt tiM:
miosis, runny nost, diflkWty bruthilg. tru:ssMo
Htrn intidott ind Mirl:: I injKtor with atropint oil!
aViilatkRush witer.AppIy sodi!lll
bimlHHlate or 5% iqJid blum soiUlion totht skin. Do oot
;r<Iooovomiling. ... Imtion. II>tu.I, aamping, invdmury
trinalion and ,lwildlir19 and jerking c(
(oma,death.
BLDOD AGENTS
IIydrogtn qarilk (liquid) Red of the skin, naulti,lIudidlrs,
wul:.nm, h)"pJXic: (oovu lsions, lkath
FkIsh ryfi and IIIaIh skin with Wit er. Fa" inhalation 01 mist.
oxygerl and amyl nilrite may III' gil'l'n.For ingestioo 01 cyarilk
liqJid. 1% mum tliosulfatt may be!j'/fll to indlKe vomilirl9.
Oxygen and amyl nitratt may be !j'/fll. Give patient mik Of
water. Do not indoce mtirHj.
tHoridt (gas) loss c( aWttite. irritation 01 the rnpiritOl)' tract.
poJrnonary edf,ma,duth
CHOKING/VOMITING AGENTS
Oiuinm, turir19 tlirs!, thrGaI irritation, mills, PrtMlk fmh iiI. Aanirister 0X)'900. Rush ryes with IIOIIIIiI
sailll' or patiml wann and cam. I! spilator) ind m .... 1Orl fil i!R, C)'illOlis,
"om
Adimsitt--DM (ay5lamlll' dsptnstd
inOoffilsol)
Irritation of the e)'esind rnpiratOll lri(\,IHjhmm of
thedlest, nausta,ind l'OrTIitirHj
i ndthllloit with !iIiIII', water, 10% solution of
sodium bKirbonate. T I!at the skin oo-ated IaIuJn
-.
BLiSTER/VESICANT AGENTS
oxillll' (aystillilt or
MU5laId- ltwisitt
MilI!R- fU
tlitroqm mUllard-----flM-l, HN-2, HM-l
Sulfur mustard
DrSlllKtion of mocousmerrbi"anrs, rye skin
(sWrutalll'OlJl edema), folowed by scab formation:
rritation oIthe ryrs, II> salllll'lllbranrs, and lungs;
n.llKN and fmn.nion rI bI;""" 011 thr ,kin:
(ytolOlk rei(\ion! in hematopoietic: tissoo indUling
IIoot mallOllt",11"Iph nodes, spIffiI, ind endocme
FkIsh affffitd i rei with (opious quanlities of water. H
ingtslN. do flO( indlKt vomiting. Rulli iflKted il"ta
water.Treat the S% solution of sodium h)"pXhlolite
Of hnolYhnld bI...m. (.iv, mil: 10 mol:. Do nnI inItJno
""",iting. Skin conti(\ with lewisite rna)' be treattd with 10%
soiutiOll 01 sodiun carbonate.
" ..
SouI!t:Chemic:a1 Fia Sheets at the U.S.,l.rmy (enttr for Htalth Promotion ind Mediolll' hl1p:l/mwm-www.ipgta .. umy.miVdll/dKhnnIs.htm
per million people to 45 cases per million. If taken prior to,
or immediately following, a nuclear incident, KI can prevent
up to 100% of the radioactive iodine from entering the thy-
roid gland. It is effective even if taken 3 to 4 hours after radi-
ation exposure. Generally,a single 130-mgdose is necessary.
Unfortunately, KI protects only the thyroid gland from
I-131.1t has no protective effects on other body tissues, and it
offers no protection against the dozens of other harmful ra-
dioisotopesgenerated by a nuclear blast. As with vaccines and
antibiotics, the stockpiling of KI by local health care agencies
or individuals isnot recommended. Interestingly, 1131 isalso
a medication used to shrink the size of an overactive thyroid
gland.1byroid medications are presented in chapter 4300.
12.8 Poisonings and Fundamentals
of Toxicity Treatment
In 2006, according to the American Association of Poison
Control Centers, there were 2,403,539 human poison expo-
sures in the United States. Of these exposures, both pharma-
ceutic and nonpharmaceutic agents were responsible for
over 1,200 fatalities (Bronstein et ai, 2(07). Table 12.5 shows
the top 25 substances involved. Among the substances, anal-
gesics, sedative-hypnotics, anti psychotics, cold and cough
preparations, antidepressants, opioids, and cardiovascular
drugs were at the top of the list.
When poisonings occur, nurses must be familiar with
basic elements of toxicity treatmem. Measures musl be
taken to prevent further injury or fatality to the patienl
and to make 3 proper diagnosis. When taken properly,
most pharmacologic agents do not have extremely ad-
verse characteristics. Most pharmacologic agents ap-
proach toxicity when their doses exceed recommended
ranges (chapler 4010). Recall that medications having a
lower therapeutic index are more likely to be toxic
(chapter 500).
Substances enter the body by a variety of
by inhalation, ingestion, injection, or absorption through the
skin (chapter 3010). Some posionings are intentional; most
are accidental. Sometimes the identity and doses of a poision
are not known. Often, laboratory methods are necessary to
identify contents of the stomach, bloodstream, and urine.
Basi:RJpportilecall! is one of the first elements of toxicity treat-
ment. Fwtdamental to the patient's survival is maintaining the
patient's airway, breathing, and circulation. In addition, it is
important to make sure t hat proper blood slumse levels are
LibraryPirate
1 22 UrdU Pharmacolog)r and ttwo NufSl'--P,tlent R .... tlon'hlp
TABLE 11.S 2006 Data: Top 2S Substances
Involved in Human Exposures
Substance Number ""r(rotagE'
... -
184,906 11.9
(05I1lI'00/ptMna1 LUI' prodoos 214,700
"
Grining !lbstiM!1 (hou5dlold) 214,091
"
Sediti'le-frfpootil:!/illipsydlolia 1(1,lSO
I.'
Fomgn 120,m
I.'
Cdd and tough prfpafaOOns m,m ...
Topkal 105,308
'.1.
Ptstidd!1 %.811

95,317

Bit!1and l"II'IffiOI1\itiom 82,lll 14
80,416 13
,,-
76,531 11
Antilillamint\ 75,07(1 11
Food prodxlS/lood poisoriog 66,115
1.'
Antiniuobiais 6,017 1.7
PianlS
M.'"
1.7
'fmmim 63,331
1.'
HonnOlltl ind hormont inta.goniru 51,875 1.1
Gastrointrstinal 50,914 1.1
"--
49,516 1.1
Chtmic.Jis 47,557
I.'
Slimw, m ind Ilrtl'l 46.139 I..
Antitol"MNnlS 40.476 L7
FUIIItS/gal!1i'1apoo 39,586 I.,
o\ruImftslctrn """,,,its 37,990
I..'
SOIilrt:lOO6 Anrual Rtpol"l ofthl' Ammn A>!Oditioo of Poison Control
CPnun'Nitiorul Poison D.Jli System lNPDS), hup:l/WwwJ apa.orglDNNJ
No!/!: "1'e"{l"IIti!ll1ifl' on 1,403.539 ruman npo!UlI's.
maintained and that arterial blood gases are stable. Treatment
of any developing seizures is important (chapter l SOO),
and management of any acid- base disturbances is critical
(chapter 3100). Agents may be used to alter the pH of the
urine, therebyfucilitating removal of some toxins. Sodium bicar-
bonate produces a more alkaline urine and enhances the acre-
tion of acidic (i.e.,aspirin and barbiturates); ammonium
chloride produces a more acidic urine and enhances the acre-
tion of alkaline drugs (i.e., amphetamines, phencyclidine).
For surface decontamination, it is important to remove
the patient's clothing and to cleanse any contaminates from
the body. The patient's eyes should be flushed with water,
and the hair should be washed with soap and water. If the
skin is not injured, alternate soap-and-water and alcohol
washes are recommended. If the patient is unable to per-
form this decontamination alone, the nurse or person pro-
viding the decontamination must protect themselves from
possible contamination as well.
Syrup oflpe<a{ has been used primarily to induce vomiting.
Ipecac syrup irritates the gastric mucosa and promoteseme-
sis by stimulating the medullary chemoreceptor trigger zone
located in the brain. Evidence is sparse indicating that
Ipecac actually helps the outcome of poisonings in many
cases and may actually cause more hann, such as in cases of
caustic poisionings, for example drain cleaners, which may
burn tissue again as they are vomited. In fact. the effects of
the Ipecac can often be mistaken for the poison itself and
deny the effe<:ts of other poi.oning . Common
symptoms experienced by the patient after Ipecac treatment
are sedation, lethargy, and diarrhea. Accidental overdose can
result when Ipecac is administered at the home. In 2003, this
prompted the American Academy of Pediatricians to with-
draw their support of Syrup of Ipecac for home use.
Gastridavagundaspiration may be a course oftreatment where
the patient has ingested a potentially life-threatening amount
of poison. In order to be effective, this procedure must be
performed within 60 minutesof ingestion, and if airway pro-
tective reflexes are lost, gastric lavage is contraindicated.
Single-dose adiYated rnarroal may be administered if the
poison is carbon based. u.rge carbon-based molecules ad -
sorb (adhere) to activated charcoal and minimize or pre-
vent poisons from absorption. Examples of substances that
do not adhere very well to charcoal are alcohols, hydrocar-
bons, cyanides, iron, boron, lithium, heavy metals, corro-
sives, and organophosphates (nerve agents and pesticides).
As with gastri, lavage, the effectiveness of activated charcoal
decreases with time; the greatest benefit is within 60 min
utes of ingestion. Routine use of a cathartic in lieu of or in
combination with activated charcoal is not endorsed.
irrigation may be considered for potentially toxic
ingestions of sustained-release or enteric-coated drugs. Pa-
tients seem to derive benefit from whole-bowel irrigation af-
ter being exposed to potentially toxic ingestions of iron, lead,
zinc, or illicit drugs. Whole-bowel irrigation is contraindi -
cated in patients with bowel obstruction, perforation, com-
promised airway, or hemodynamic instability. The
procedure should be used cautiously with debilitated pa-
tients or with patients whose medical condition might be
further compromised with this treatment. Whole-bowel ir-
rigation decreases the binding capacityof activated charcoal .
Spetifi{lntidote counter the effects of poisons or toxins in a
nwnber of cases. General areas of toxicity where antidotes
may be effective include heavy metals, radioactive exposure,
and overdosing of pharmacologic agents. Throughout the re-
maining chapters, Prototype Drug Boxes highlight a section
called Treatment of Overdose. TItis type of drug information
isan important topic that nurses should know. In most cases,
toxicity treatment includes the more routine elenlents of
nursing care such as health assessment and monitoring vital
signs; throughout the text, the Prototype:: Treatment
of Overdose boxes will remind the reader of specific antidotes.
Table 12.6 swrunarizes specific antidotes and their use for
particular overdosed substances and toxins.
LibraryPirate
TABLE 12.6 1 Examples of Specific Antidotes for Overdosed Substances or Toxins
Gi'nerl, Narm> Produ(\ Name OVerdosed Substanc:e or Toxin (Pharmacologk:/Toxlclly Group)
oKltylqSlNll M!Kom)'Sl Mllimioophfn (nonopioid aoalgtlic)
aUopine 5UHatl Atllykhoiine; imibitOl'llpilal)'mpathomimtliej
uk:i!lll !OrA Caloom OisOOium Vmtoall Lnd loOOty (hNyY IlII'taI poisonilg)
defrroxirrine Df:sltral Iron tOlidty (bravy melal poisoning)
digoJ:inimmllMfab Digibind OigoQn;dqtoxin (uldi.KglytOlidli
diMruproi BALinOiI ArsmK,goIdand roeKIf)' tOlioty (hli VY metal poisoning)
ftumurnil
.... -
8mzodimpine\ (!edatiR--h)1lllOlic)
fornepizol l Anlizoll 1hyIrnt' gl)lr:oIlO1idty lantiflffir poiIoniog}
......
ImUin
ltIKa.'om WdklWorin Metliotrwtl; foIitadd
.... ,

Opioid a9ffilS; morphilt (opioid aoalge5il:)
r.oo!tigmn. Pro.in
Ntu-omu"",llr blocking Igrnl> (nondo poIarizilg bIoclli)
ptneIratl uk:i!lll tri!Odium RadiooKtil'l' plUlooirm.americ:i!lll and turium
ptneIratl lin(\rilOdium RadiooKtil'l' plutooirm. americ:i!lll and turium 6pOIU1l' I
Pffiidliamint Cuprimn.. Dtpffi gad and mt lOlry 100idty [hNyY IlII'tlI poiIonilg)
CholinllgK 5UHltt
potmi!llliodrlt RadiooKtil'l' iodne tOlioty (nuOOr bomb;radiNOO 6pOIIR)
pralidoxime Pm ..... inhbitm; neOlli9:nine; ph)'lOlti9:nine (patal1fl'pathomimllit)
protarrine 5lA/atl Hlp.lrin antitoagjart)
prusManbhr RadiogardiSl' RadiooKtil'l' nooridioaoaive thali!lll (ridioaoaM tfSirm t lpollR; thallium p:i lOIliog}
IlKOIlll'l
--
ltad, and ilRllK toxidty (htavy metal p:i lOlling)
vitamin K Coumadin; warfarin letil antitOlqJiantl
KEY CONCEPTS
The numbered kt'y conCt'pts provide a succinct summary of the important points from the corresponding numbered section
within the chapter. If any of these points are not clear. ref",r to the numbered section within the chapter for review.
12.1 Bioterrorism is the deliberate use of a biologic or physical
agt'nt to cause panic and mass casualties. The health as--
pt'Cts of biologic and chemical ag<'llts have become im-
portant public issues.
12.2 Nurses play key roles in emergt'ncy preparedness, includ-
ing providing education, resources, diagnosis and treat-
ment, and planning.
12.] Th", Strategic National Stockpile {SNS} is used to rapidly
deploy medical nec:essities to communities experiencing a
chemical or biologic attack. The two components art' the
push package and the wndor-rnanaged inventory.
12.4 Anthrax can enter the body through ingestion or in-
halation, or by the uttaneous route. Antibiotic therapy
can be successful if given prophylactically or shortly af-
ter exposure.
12.5 Viruses such as polio, smallpox, and those causing hemor
rhagic fewrs art' potential biologic weapons. If available,
vaccines are the best treatments.
LibraryPirate
1 24 Untl2 Phannac:ology tho> Nu......-P. tIi'nt llelatklmhlp
12.6 Chemicals and neurotoxins are potential bioterrorist
threats for which there are no specific antidotes.
12.7 Potassium iodide (KI) may be used to block the effects of
arute radiation exposure on the thyroid gland, but it is not
eif&tive for prole\:ting other organs.
NCLEX-RN" REVIEW QUESTIONS
D The nllrse recognizes which of the following to be initial
symptoms of inhaled anthrax? (Select all that apply.)
1. Cramping and diarrhea
2. Skin lesions that develop into black scabs
3. Fever
4. He\tdache
5. Cough and dyspnea
D Potassium iodine (KI) takt'n immediatt'ly foUowing a nu-
clear incidt'nt can prevent 100% of radioacth-e iodine
from t'ntering which body organ?
1. Brain
2. Thyroid
3. Kidnt')'
4. liVl'T
D Soldit'rs who may havt' been exposed to nerve gas agents
can be expected to display which of these symptoms?
1. Convulsions and loss of consciousness
2. Memory loss and fatigue
3. Malaiseand hemorrhaging
4. Fel'<'rand headaches
D Which of these medications is primarily used for the
treatment of anthrax?
1. Diphtheria vaa:ine
2. Amoxicillin (Amoxil)
CRITICAL THINKING QUESTIONS
1. Why is the medical community opposed to tht' mass vac
cination of the general public for potential bioterrorist
threats such as anthrax and smaUpox?
1. Why does the protective effect ofKI not extend to body tis-
sut:>; Ihan Ih., Ihyruiu )\land!
3. What is the purpose of the SNS {Strategic National Stock-
pile}?What is the difference betwe<>n a "push package" and
a VMI {wndor-managed inWntory} package?
4. Why do nurses play sllch a central role in emergency pre-
paredness and treatment of poisonings?
See Appendix D for answers and rationales forall aCTivities.
12.8 Among human poison exposures, common pharmaco-
logic agents are at the top of the list. The nurse must be fa -
miliar with fundamental elements of toxicity treatmt'nt:
basic supportivt' measures, Syrup of Ipecac, gastric lavage
and aspiration, activated charcoal, whole-bowel irriga-
tion, and specific antidotes_
3. Ciprofloxacin (Cipro)
4. Smallpox vaccine
II The CDC catl"8orized biologic threats based on their:
1. potential ad\ll'fSt' effects.
2. potential inlpact on public health.
3. polt>ntial coS! of treltment.
4. potentiallossoflife.
1:1 Nurses playa key role in tht'event of a potential bioterror-
ist attack including: (Select all that apply. )
1. helping to plan and de'\o-elop emergrncy management
plm'
2. recognizjng and reporting signs and symptoms of
chemical or biologic agent exposure, and assisting with
treatment
3. storingantidOles, antibiotics, vaccines, and supplies in
thcir homes.
4. keeping a list of resources such as health and law
enforcement agencies and other contacts who ..uuld
assist in the event of a bioterrorist attack.
5. keeping up-to-date on emergency management
protocol and 'Ulunteering to become Illt'mbersof a
first -response team.
EXPLORE fiij"ll!lifing!tlJ------,
MyNursil1 gM is )'011" SlOp fur chapter materialS and
Prepare to! sua:ess wi1!J additiofJal NCLox"'-sl'/1e Il1Ictic9
In!""",,,," ..., ..-:tiItm""". wm link . I""'Tlm.
and and mOl e!
Regi ster )OOt moe !rom 1he IfMl \'OIlr IlOOJ< 81
...-.myn..-.-.gkit clII1I .
LibraryPirate
CHAPTER 13
CHAPTER 14
CHAPTER 15
CHAPTER 16
CHAPTER 17
CHAPTER 18
CHAPTER 19
CHAPTER 10
CHAPTER 21
UN I T 3
The Nervous
System
Drugs Affecting the Autonomic Nervous System
Drugs for Anxiety and Insomnia
Drugs for Seizures
Drugs for Emotional and Mood Disorders
Drugs for Psychoses
Drugs for the Control of Pain
Drugs for Local and General Anesthesia
Drugs for Degenerative Diseases of the Nervous System
Drugs for Nturomuscular Disorders
LibraryPirate
DRUGS AT A GLANCE
ADRENERGIC AGENTS (SYMPATHOMI MHICS)
""ou
Go) phenylephrine (Nro-5ynepl!rfne) (XJIJf m
AORENERGI(-BlOCXINGAGENTS /X'iIt1J6
Go) promsln (Mllllprf!!ss) (XJIJf IJl
CHOLI NERGIC AGENTS
(PARASYMPATHOMIMETlCS) (XJIJf 116
Direct-Act ing Pal1lsympathomimet ia ""]9
Q berhanedlol (DwoId, Urechol/ne)

Cholin!sterase Inhibitors (XJIJf /39
CHOLI NERGIC BLOCKING AGENTS
(ANTICHOl INERGICS) pilI/tl40
Go) atroplnr (Jolro-Ptn, AffOpalr,Alroplso/)
"" ,.
KEY TERMS
paJ019
(Ac:.[) fJ1JI}t m
JfJvt 110
HlrtMrgic antagonist (XJIJf IJ1
dphl re<eptor la rf<eptor) fX1/JI' 110
ntidMllinergic (XJIJf IJ1
illlO/lOl1it ntrvous system (X1Jt /J/l
{IJI}t/JO
CiJlHhobmi nu PIl'll! 110
M'rYoos system (CNS) pi1//t III
Drugs Affecting the
Autonomic Nervous System
LEARNING OUTCOMES
Aher Ta3ding this the student should !leobll! to:
1. Identify the basic: functions of the nervous system.
2. Identify Important divisions of the peripheral nervous system.
3 . Compare and ,ontraSI the actions of the sympathetic and
parasympathetic divisions of the autonomic nervous system.
4 . Explain the process of synaptic transmission and the neurotransmitters
important to the autonomic nervous system.
5. Compare and contrast the types of responses that occur when drugs
activate a alphal" OOta
1
-, or beta1-adrenergic receptors, and
nlcotlnk or muscarinic receptors.
6. Discuss the classification and naming of autonomic drugs based on
four possible actions.
7. Describe the nurse's role in the pharmacologic management of patients
receiving drugs affecting the autonomic nervous system.
8. For each ofthe drug classe s listed In Drugs at 11 Glance," explain the
mechanism of drug action,primary actions,and important adverse
effects.
9. Use the nursing procen to care for p.<)tients receiving adrenergic
agents, adrenerglc-biocklng agents, cholinergic agents, and cholinerglc-
blocking agents.
(holintrgic fIIX}t IJI
fight-o!'ftight rMpOme po:Jt l18
ganglionic sJ1'l.ljHt 119
Ilonoliline oxidase (MAO) fIIX}t
lluKarinic: fIIX}t III
IlJlStneniagrnis fD}t 139
.icorinic: fllX}tll1
JOlt119
paras1f1lpamttk lK'A'OtlS s,sttm ptXJt 118
paras)'nlpathomimeoo pogt III
peripheral nmous system po:Jt III
postganglion k neuron po:Jt 119
pngugfionic JOlt 119
rfiHld.digeltrfiponse pogt l18
somatic nemus system ptXJt III
sympilllteri( nmollS piXJt 118
SJlTlllillllolytic: fIIX}t III
SJlTlllillhonIimflic pogt m
s)'I'Iapse ptXJt 1]1}
synaptic tr.msrninion ptXJt I}I}
LibraryPirate
T
he study of nervous system pharmacology, or neuro-
pharmacology, extends overthe next eight chapters.Tradi-
tionally, neuropharmacology begins with a study of the
autonomic nervous system.A firm grasp of autonomic physiol-
ogy is necessary to understand cardiovascular, renal, respira-
tory; gastrointestinal, reproductive, and ophthalmic function.
Autonomic drugs are important because they mimic Involun-
tary bodily functions. A thorough knowledge of autonomic
drugs is essential to the treatment of disorders affecting many
body systems, induding abnormalities in heart rate and
rhythm, hypertension, asthma, glaucoma, and even II runny
nose. This chapter serves dual purposes.First,it is a condse reo
viewof autonomic nervous system physiology,a subject that is
often covered superficially in anatomy and physiology dasses.
Second,it is an introduction to the four fundamental classes of
autonomic drugs: adrenergic agents, cholinergic agents,
adrenergic-blocking agents,and cholinergic-blocking agents.
OIoplfl 11 Orug<Affealngthe ..... tooomIc Nervo'" Sylll'm 127
13.1 The Peripheral Nervous System
The nervous system has two major divisions: the central nero
YOussystem{CNS) and the peripheral nerYOussystem. The CNS con-
sists of the brain and spinal cord. The peripheral nervous
system consists of all nervous tissue outside the CNS, in-
cluding sensory and motor neurons. The basic functions of
the nervous system are as follows:
Recognizing changes in the internal and external
environments
Processing and intt'!!rating the environmental changes
that are perceived
Reacting to the environmental changes by producing an
action or resporu;e
Figure 13.1 shows the functional divisions of the
nervous system. In the peripheral nervous system,
neurons either reoogniz.e changes to the environment
(sensory division) or respond to these changes by
moving muscles or secreting chemicals ( motor
division). The somaticnervoussystr m consists of nerves that
I The Ne rvous System I
Centrel Nervous Syste m (CNS) Periplwr.t Nervous System (PNS)
(reootivM and processu information: (Inlnsmils signals between the CNS
inmalaa aclion) and the real 01 the body)
Bra in Spine l Cord Motor tieu'one Senaory Neurons
(rece;_ and processes (conduct. si gnals \0 and (carry signals from the (carry oignaLs 10
sensory infonnlllion; from the brain; controls CNS that control the Ihe CNS from
... sponsos; ...tIM ItCiMties) aclMt",s 01 """"""s """SO'Yorgans)
.\0",. memorie.; a nd glancb)
gene",'e. thoo.9>ts
and e motiOM)
j
Somatic Nervous System Autonomic Nervous System
M "" hfly (""nl''''''j' ..........
""""""",Is by ac:tiwIing by inlluencr.g organs, glands,
skeletal rnJSCIes) and s mooth rTUICIe)
Sympathetic Division Pa",sympathetic Division
(prepare. the body for (dominates dumg 01
stressful or _rgalic "rest and digestion";
aclMty; 'light or flighr) dirocta maintonance I>CIMtiH )
I
Ad .... ".,rgic ReceplDtS Cholinergic Receptors
j
I
....
I I
...
I
Figure 1.3.1 Functional divisions of the peripheral nervous system
LibraryPirate
128 Unlll "TheNelvoo.Sy.tem
provide voluntary control owr skeletal muscle. Nerves of
the autonomic nuyous system, on the other hand, exert
involwltury control over the contraction of smooth
muscle and cardiac muscle, and glandular activity.
Organs and tissues regulated by neurons from the
autonomic nervous system include the heart. digestive
tract, respiratory tract, reproductive tracts, arteries,
salivary glands, and portions of the eye.
'302 The Autonomic Nervous
System: Sympathetic and
Parasympathetic Divisions
The autonomic nervous system has two divisions: the sym-
pathetic and the parasympathetic nervous systems. \Vith a
few exceptions, organs and glands receive nerves from both
PARASYMPATliETIC
DIVISION
constricts
",,'
stimJlat ....
salivation
constricts
btonchi""'"
stimulates
digeslion
stimJlales
gallbladd."
conl ... ct.
.. ""'"
stimulates
sox of9lln5
rest lind digllst
{
, .... ,

branches of the autonomic nervous system. The major ac-
tions of the two divisions are shown in Figure 13.2.lt ises-
sential that the student learn these general regulatory
actions early in the study of pharmacology, because knowl-
edge of autonomic effects is helpful to predict the actions
and side effects of many drugs.
The sympathrticnerYoullystem is activated under conditions
of stress, and produces a set of actions called the fight orflight
Activation of this system will ready the body for an
immediate response to a potential threat. The heart rate and
blood pressure increase,and more blood is shunted toskele-
tal muscles. The liver immediately produces more glucose
for energy. The bronchi dilate to allow more air into the
lungs, and the pupils dilate for better vision.
Conversely, the parasympatheticnrrvoussystem is activated un-
der nonstressful conditions and produces symptoms called
the Ifttanddigest Iftponse. Digestive processes are promoted,
SYMPATHETIC
DIVISION
"fight DO" 119>1'"
dilatas pupil
inhibOls
saivation
dilates
bronchioles
inhibOls
digestion
.ti..uates
rela a .... at

sea .. t ....
"";.-...phri"" and
norepi.-...phri""
..
.. ... ,
inhibOls &Ox
organs
". Figure 13.1 Effects of the sympathetic and parasympathetic nervous systems
Source: BIology: A Gukle to the NatlJral World,2nd ed. (p. 558) oy David 2001. Upper Saddle RIver, NJ, Prenfke H111. Reprinted IIy pennlllkJn.
LibraryPirate
and heart rate and blood pressure decli ne. Not as much air
is needed, so the bronchi constrict. Generally, most of the
actions of the parasympathetic division are the opposite of
those of the sympathetic division.
A proper balance of the two autonomic branches is re-
quired for body homeostasis. Under most circumstances,
the two branches cooperate to achieve a balance of readi-
ness and relaxation. Because the branches produce mostly
opposite effects, homeostasis may be achieved by changing
one or both branches. For example, heart rate can be in-
creased either by increasing the firing of sympathetic nerves
or by decreasing the firing of parasympathetic nerves. TIlls
allows the body a meaIl'l of fine-tuning its essential organ
systems.
The sympathetic and parasympathetic divisions do not
always produce opposite effects. For example, the constric-
tion of arterioles is controlled entirely by the sympathetic
branch. Sympathetic stimulation causes constriction of ar-
terioles, whereas lack of stimulation ClUSes vasodilation.
Sweat glands are also controlled only bysympathetic nerws.
In the male reproductive system, the roles are complemen-
tary. For example, erection of the penis is a function of the
and hy
the sympathE1:ic branch.
13.3 Structure and Function
of Autonomic Synapses
For information to be transmitted throughout the nervous
system, neurons must communicate with one another, and
with m\lSCles and glands. In the autonomic nervollS system
this communication involves the connection of two neu-
rons, in series. Ai; the action potential travels along the first
nerve, it encounters the first synapst, or juncture. Because
this connection occurs outside the eNS, it is called the
ganglionicsynaps!. The basic structure of a ganglionic synapse
is shown in Figure 13.3. The nerve carrying the' impulse'
exiting the spinal cord is called the preganglionic neuron. The
nerve on the other side of the ganglionic synapse, waiting to
receive the impulse, is the postganglioni< Beyond the
postganglionic neuron is the second synapse. The second
synapse occurs at the target tissue.
A large number of drugs affect autonomic fWlction by
altering neurotransmitter activity al the second synapse.
Some drugs are identical with endogenous neurotransmit-
ters, or have a similar chemical structure, and are able to
directly activate the gland or muscle. Others are used to
block the activity of natural neurotransmitters. Following
are the five general mechanisms by which drugs affect
synapti ct ll nsmi ssion.
OIoplfl 11 Drug< Affeatng the ..... tooomk: Nervous Sylll'm 129
Drugs may affect the synthesis of the neurotransmitter in
the presynaptic nerve: Drugs that decrease the amoWlt
of neurotransmitter synthesis will inhibit autonomic
fWlction. Those drugs that increase neurotransmitter
synthesis will have the opposite effect.
Drugs can preverrt the stomge of the neurotransmitter in
Yesicles within the presynaptic neTYe: Prevention of
neurotransmitter storage will inhibit autonomic
fWlction.
Drugs can injluence the release of the neurorransmitter
from the presynaptic uerYe: Promoting neurotJ"3nsmitter
release will stimulate autonomic function, whereas
slowing neurotransmitter release will have the opposite
effect.
Drugs can prevent the normal destruction or reuptake of
the neurotransmitter: Drugs that cause the
neurotransmitter to remain in the synapse for a longer
time will stimulate autonomic function.
Drugs can bind tv the receptor site 011 the postsynaptic
wrget tissue: Drugs that bind to postsynaptic receptors
and stimulate target tissue will increase autonomic
function. thM Mtach to thi!
and prevent the natural neurotransmitter from reaching
its receptors will inhibit autonomic function.
The dassic smdy of drugs affecting autonomic function cen-
ters around the last two mechanisms. It is important for the
student to understand that autonomicdnrgsare not given to
correct physiologic defects in the autonomic nervous sys-
tem. Compared with other body systems, the autonomic
nervous system itself has remarkably little disease. Rather,
drugs are used to stimulate or inhibit target organs of the au
tonomic nervous system, such as the heart, lungs, glands, or
digestive tract. \Vith few exceptions, the disorder lies in the
target organ, not the autonomic nervous system. Thus, when
an Rautonomic drug" such as norepinephrine (Levarterenol,
Levophed) is administered, it does not correct an autonomic
disorder; it corrects dysfWlction of that target organ natu-
rally stimulated by the autonomic neurotransmitter.
13.4 Norepinephrine
and Acetylcholine
The two primary neurotrafl'lmitters of the autonomic ner-
vous system are nOl!pinrphrinr (NE) and acetylcholin r (Ac: hl. A de-
tailed knowledge of the underlying physiology of these
neurotransmitters is required for proper understanding of
drug action. When reading the following sections, the stu-
dent should refer to the sites of acetylcholine and norepi-
nephrine action shown in Figure 13.4.
p angliook: neuron
Ventral spinal cord
PostgangIionk: neuIOn
': J?"-
I
Figure 1.33 Basic structure of the autonomic pathway
Ganglionc
.,.,.,..
Target
--
LibraryPirate
130 Unlll TheNelv"",.Sy.tem
Sympathetic pathway
Aen Cholinergic
\ / ,eceplo, (nicotinic)
h-
Veol,al Cho/i""'9ic
sp;nal _anglionia
"""

Autonomic Adrenergic
po.tganglionje

Ach ChoIi""rgic Ach
\ / "'ceptor (nicotinic) \ /ChoIiMrgiC
I (::c)
ChoI;""rgic
preganglionic

Autonomic ChoI;nergic Targel
synapse post9anglionje tiSSUII

Ach '" Aca1y/chc>line
NE '" Norep;nephrine
Figure 13.4 Receptors In the autonomic nervous system:(a) sympathetic dlvlslon;(h) parasympathetic division
In the sympathetic nervous system, norepinephrine is the
neurotransmitter released at almost all postganglionic
nerves. The exception is sweat glands, in which acetyl-
choline is the neurotransmitter. Norepinephrine belongs to
a dass of agents allied natural cate<holamines, all of whi,h are
involved in neurotransmission. Natural catecholaminesalso
include epinephrine (adrenalin) and dopamine. Examples
of synthetic catecholamines are isoproterenol and dobuta-
mine. There are rroncatecholamirre dr ugs, which have a
slightly different chemical structure than the cate-
cholamines, such as ephedrine, phenylephrine, and terbu-
taline. All of these drugs bind to the same target tissues as
adrenalin. The receptors at the ends of postganglionic sym-
pathetic neurons are called adrenrrgic, which comes from the
word adrerralirr.
Adrenergic receptors are of two basic types, alpha reCfptors
(a. receptors) and brta receptors These receptors are
further divided into the subtypes alpha" alpha,. beta" and
beta,. Activation of each receptor subtype results in a char-
acteristic set of physiologic responses, which are generally
swnmarizedinTable 13.1.
The significance of these receptor subtypes to pharmacol-
ogycannot be overslllted. Some drugs are selective and acti-
vate only one type of adrenergic receptor, whereas others
affect all receptor subtypes. Furthermore, a drug may acti-
vate one type of receptor at low doses and begin to affect
ull,,,, ''''-''pluT ''" ll,,, Ju, .. i, im.,,, ..... J. Cummil-
ting the receptor types and their responses to memory is an
essential step in learning autonomic pharmacology.
Norepinephrine (NEl is synthesized in the nerve terminal
through a series of steps that require the amino acids pheny-
lalanine and tyrosine. The final step of the synthesis involves
the conversion of dopamine to norepinephrine. NE is stored
in vesicles Wltil an action potential triggers its release into the
synaptic cleft. NE then diffw;es across the cleft to alpha or beta
receptors on the effector organ. The reuptake of NE back into
the presynaptic neuron terminates its action. Once rcupmkc
o"urs, NE in the nerve temlinal may be returned to vesicles
for future use, or destroyed enzymatically by monoaminfraidasf
(MAO). The enzynre catecholamine-O-methyl transferase
(COMT) destroys NE at the synaptic deft. The primary
method for termination of NE action is through reuptakt'.
Many drugs affect autonomic function by influencing the
synthesis, storage, release, reuptake, or destruction of NE.
Theadrenal medulla is a tissue closely associated with the
sympathetic nervous system whose anatomic and physio"
logic arrangement is much different from that of the rest of
the sympathetic branch. Early in embryonic life, the adrenal
medulla is part of the neural tissue destined to become the
sympathetic nervous system. The primitive tissue splits,
however, and the adrenal medulla becomes its own func-
tional division. The preganglionic neuron from the spinal
cord terminates at the adrenal medulla, and releases the
neurotransmitter epinephrine directly into the blood. Once
released, epinephrine travels to target organs, where it elic-
its the dassic fight-or-flight symptoms. The action of epi-
nephrine is terminated through hepatic metabolism, rather
than reuptake.
Other types of adrenergic receptors exist. Although
w .... IllUught tu fUlldiull
precursor to norepinephrine, research has determined that
dopamine serves a larger role as a neurotransmitter. Five
dopaminergic receptors (0, through 0 ,) have been discov-
ered in the CNS. Oopaminergic receptors in the CNS are
important to the action of certain antipsychotic medicines
(chapter 1700) and in the treatment of Parkinson's disease
LibraryPirate
IlIop1fl 11 Drug< Affealng the ..... tooomk: Nerv"", Sylll'm 131
TABLE 13 1 I Types of Autonomic Receptors
Neurotranvnltter Receptor Primary Locations ResponSE's
.... , AI sympalhtlio: organ! hun (oOllooion of blood \'!'sld !ilation of plJpik
.... , Prtl)'lliplio: Imllinill Intibilion of rdta5l' of
'rn,
Hein and tiO'Itys lII'an and fmt of {ontriKlion; of rmn
'rn,
AI sympalhtlio: largtl organ! hun Intibilion of lnIOOIh
Nicotinio: fbIIlJin9ioriulturOlll of IIIIOOIh musdr and 1fmIi0lll
Musurinic:
H",
Drm.J1td heart ratr ind fOKl' of
fllrasympalhtlio: largel:organ! olhtfthan iI'It lItan of IIIIOOIh and stmIiOlll
(chapter 2(00). Dopamine receptors in the peripheral ner-
vous system are located in the arterioles of the kidney and
other viscera. Although these receptors likely a role in
autonomic fWlction, their therapeutic importance has yet to
be fullydisoovered.
13.5 Acetylcholine and Cholinergic
Transmission
Nerves releasing acetylcholine (Ach) are called rnolinrrgk
nerves. There are two types of cholinergic receptors, which
are generally classified after certain chemicals that bind to
them (Table 13.1).
Nicotinic receptors: Receptors that were first discovered
to bind to nicotine; located at the ganglionic synapse in
both the sympathetic and parasympathetic divisions of
the autonomic nervous system
Muscarinic receptors: Receptors that were first
discovered to bind to muscarine; located on target
tissues affected by postganglionic neurons in the
parasympathetic nervous system
Early research on laboratory animals found that the ac-
tions of Ach at theganglia resemble those of nicotine, theac-
tive agent found in tobacco products. Because of this
similarity, receptors for Ach in the ganglia are called nkotink
receptors. Nicotinic receptors are also present in skeletal
muscle, which is oontrolled by the somatic nervous system.
Because these receptors are present in so many locations,
drugs affecting nicotinic receptors produce profoWld effects
on both the autonomic and somatic nervous systems. Acti-
vation ofthesc cholinergic receptors causes tachycardia, hy-
pt'rtension, and increased tone and motility in the digestive
tract. Although nicotinic receptor blockers were somt' of the
first drugs used to treat hypertension, the only current ther-
apeutic application of these agents, known as gallglionic
blockerl, is to produce muscle rt'laxation during surgical
procedures (chapter 19010). Nicotinic blocking agents have
also been used in research to investigate the rolt' of nicotinic
receptors in learning and memory.
Activation of acetylcholine receptors affected by
pOlfganglionic nerve endings in the parasympathetic ner-
vous system results in the classic symptoms of parasympa-
tht'tic stimulation shown in Figure 13.2. Early research
discovered that these actions closely resemble those pro-
duced when a patient ingests the poisonous mushroom
Amanita muscaria. Because of this similarity, these Ach re-
ceptors were named rnulrarink receptors. Unlike the nicotinic
receptors, which havt' few pharmacologic applications,
muscarinic receptors art' affected by a number of medica-
tions,and these are discussed in subsequent sections of this
chapter.
The physiology of acetykholint' affords several mecha-
nisms by which drugs may act. Acetylcholine is synthe-
sized in the presynaptic nerve tt'rminal from choline and
acetyl coenzyme A. Once synthesized,Ach is stored in vesi-
cles in the presynaptic neuron. \'/b.en an action potential
=c.b.es the nerYe ending, Ach is released into the
cleft, where it diffuses across to find nicotinic or mus-
carinic receptors. Ach in the synaptic cleft is rapidly de-
stroyed by the enzyme atftyirnolinestrrne(khE), and choline
is reused. The choline is taken up by the presynaptic neu-
ron to make more Ach, and the cycle is repeated. Drugs
can affect tht' formation, release, receptor activation, or
destruction of Ach.
AUTONOMIC DRUGS
13.6 Classification and Naming
of Autonomic Drugs
Given theoppositt'actionsofthe sympathetic and parasym-
pathetic nervous systems, autonomic drugs are classified
based on on .. of four pOMibl .. action...
1. Stimulation of the sympathetic IIUVOU5 system: These
drugs are called adrenergic agents or syrnpathomimrtia,
and tht'y produce the classic symptoms of the fight-or-
flight response. Natural or synthetic agents that
produce a sympathomimetic response include the
catecholamines and lIoncatecholamine; .
2. Inhibition of the sympathetic nervous system: These
drugs are called adrenergic-blocking agents or adrenergit
antigonilts, and they produce actions opposite those of
the sympathomimetics. The term syrnpatholytiu is
another name for adrenergic antagonists.
LibraryPirate
132 Until TheNelv"",.Sy.tem
J.Stimularion of the parasympathetic nervous system:
These drugs are called cholinergic agents or
parasympathomimetics, and they produce the characteristic
symptoms of the rest-and-digest response.
4. Inhibition of the parasympathetic nervous system: These
drugs are called cholinergic-blocking agents,
ilntidtolinergics, parasympatholytics, or muscarinic
blockers, and they produce actions opposite those of the
cholinergic agents.
Students beginning their study of pharmaoology often
have difficulty understanding the terminology and actions
of autonomic drugs. Examination of the four drug classes,
however, makes it evident that one group needs to be
learned well, because the others are logical extensions of the
first. If the fight-or-flight actions of the sympathomimetics
are learned, the other three groups can be deduced, because
they are either the same or opposite. For example, both the
sympathomimetics and the cholinergic-blocking agents in-
crease heart rate and dilate the pupil. TIle other two groups,
the cholinergic agents and the adrenergic-blocking agents,
have the opposite effects--.slowing heart rate and constrict-
ing the pupils. Although this is an oversimplification and
exceptions do exist, it is a time-saving means of learning the
basic actions and adverse effects of dozens of drugs affect -
ing the autonomic nervous system. It snould be emphasized
again that mastering the actioru and terminology of auto-
nomic drugs early in the study of pharmacology will reap
rewards later in the course when these drugs are applied to
various
TABLE 13.2 1 Adrenergic Agents tSympathomimeticsJ
Adrenergic Agents (Sympathomimetics)
The adrenergic agents, also known as sympathomimetics,
stimulate the sympathetic nervous system and induce
symptoms characteristic of the fight-or-flight response.
These drugs have clinical applications in the treatment of
shock and hypoteruion.
13.7 Clinical Applications
of Sympathomimetics
produce many of the =ponse. a.
the anticholinergics. However, because the sympathetic ner-
vous system has alpha and beta subreceptors, the actions of
many sympathomimetics are more specific and have wider
therapeutic application (Table 13.2).
As mentioned, sympathomimetics may be described
chemically as catecholamines or noncatecholamines. The
catecholamines share the same biochemical structure as nor-
epinephrine and a short duration of action, and must be ad-
ministered parenterally. The noncatecholamines can be taken
orally and have longer durations of action, because they are
not rapidly destroyro by monoamine oxidase or COMT.
Sympathomimetics act either directly or indirectly. Most
sympathomimetics act directly by binding to and activating
adrenergic receptors. Examples include the three endoge-
now; catecholamines: epinephrine, norepinephrine, and
dopamine. Other medications in this class act indirectly, by
causing the release of norepinephrine from its vesicles on
the presynaptic neuron or by inhibiting the reuptake or de-
DN, Prtmary Receptor Subtypi! Prtmary USE'
Jlbuttrol Vmtolin) Bm, .....
doridilt (C,uapre) Alp/IJ, in CHS
dexmtdetornidM HO (PrradeJ:) Alp/IJ, in CHS Sfdation
dobutamiM (Dobutrrx) Bm, urdiK !limUafl
Alp/IJ, aod btli,
'M
tpiotPlrilll' othffil AIp/IJ ald bua urdiK arret.a!ltl ni
fonnottrol (Foradin Bm, Asthrru, COPD
Asthrru, hein failufl'
IIII'taproltfl'OOl (Alupmt) Bm, .....
IIII'taraminoi (AramilH') Alp/IJ, aod btlJ, ...
(Aldorntl) Alp/IJ, in CHS
rnidodriot (ProAmatiot) ....
lIOfl'PiotPlrilr u,YOphrd) AIp/IJ ald
'M
OI)'rtJetlloline (A/rin aod olhrrs) .... tQ5aI (ongtItion
Q phenyltphrilH' (Hro-S)'IItItlrilH') .... 1Q5aI (ongtItion
pltlldotptlrdiot (SlWftd aod Alp/IJ ald 1Q5aI ror.getion
rittdiot(Yutopu) Bm, Slowilg ofuttOlH'
lilrntlmll (5trMllt) Bm, OttongeSlifl
tffloutalilH' (BlI'thiot aod otllm) Bm, .....
LibraryPirate
struction of NE. Those that act by indirect mechanisms,
such as amphetamine or cocaine, are used for their central
effects in the brain rather than their autonomic effects. A
few agents, such as ephedrine, act by both direct and indi-
rect mechanisms.
Most effects of sympathomimetics are predictabLe based
on their autonomic actions, dependent on which adrenergic
ft:U:pl uf suulyp'" af" sli JJl urul"u. lh" ",,""p IUf f"-
sponses are so different, the student will need to memorize
the specific subcLass(es} of receptors activated by each sym-
pathomimetic. Specific subclasses of receptors and thera-
peutic applicat ions are as follows:
Alpha, receptor: treatment of nasal congestion or
hypotension; causes mydriasis during ophthalmic
examinations
Alpha, receptor: treatment of hypertension through a
crntraLly acting mechanism (Autonomic aLpha,
receptors are also located on presynaptic membranes of
postganglionic neurons and serve as autoreceptors for
naturally occurring NE in the sympathetic nervous
.... Prototype Drug I Phenylephrine (Nee-Synephrme)
Therapeutic (I ass: Nasal decongestant; mydriatic agent;antihypotensive
ACTIONS AND USES
Phenyltphrifl!' is a igonistthit ismilablt in !M'Iil
dili"t J!Ot formulations, including intr.l naul, ophthalmic, 1M, Mlbc:utl neous, and
IV. All in oKtionsand indic:ations ire ofin sympathetic: stimulation.
InWnaSil Administr ilion: WIIfn i11ri1n.!1ily by !play oollop!,
p/IfnyItphrilt n.!Iilrongntion by ronllridilgsmall 'IM'Is i1 1M

Administr ilion: Appifd tope-ally to 1M duill9 op/lhallric
mminalionl, p/II'n)Wphrine UIII diLl> 1M pupl without !MJVfiunt
-.
Pa_ ra l oIdrniristriltion <i phal)Wpw"iIf UIII
Y6Wf
p/IfnyIfphrilt laW. rei.Jwayfew
GlfdiiKoo.. lIIf'IiIpfIltK OOIeI.II!!oogfr dur.ltioo <i iKIiYity ind <i
silJjfiunt (Ml]iiK fflrm iji'/el phfnylfplniw IOfI1I' advolOligfi O'/H 01
i1 trNting h)'polfrllirn
ADMINISTRATION ALERTS
Parentt ral (an injury with rxtrav.llition.
Phenyltphrifl!' ophthalmic: drops fIIiIy dafllilgt soft (OIIUct
PrrgnilK)'utegory(
PHARMACOKINETICS
Onll"t: IV; 10- 15 min IM/suiKuuneous
5-10 min IV; 15- 10 min IV/MliKUlantoUl
Halflife: Irss than 15 min IV; 10-60 min IMisubcuufl!'OUs
Duration: 15- 20 min 1V;30-120 min h topical
IlIoplfl 13 0nJqs Affealng tt... ""lOooml< Ne,,,,,,,, SY'lem 1 n
system. Activation of alpha, receptors reduces the release
ofNE.)
Beta, receptor: treatment of cardiac arrest, heart failure,
and shock
Beta, receptor: treatment of asthma and premature
labor contractions
Sum" 'Ylllpali,ulllimd.iu.
th.1n one type of adrenergic receptor. For example, epinephrine
stimulates all four types of adrenergic receptors and is used for
cardiac arrest and astluna. Pseudoephedrine (Sudafed and oth-
ers) stimulates both alpha, and beta, receptors and is U'ied as a
nasal decongestant. Isoproterenol (lsuprel) stimulates both
beta, and beta, receptors and is used to increase the rate,
force, and conduction speed of the heart, and occasionally
for asthma. The nonselective drugs generally cause more
autonomic-related side effects than the selective agents .
The side effects of the sympathomimetics are mostlyex-
tensions of their autonomic actions. Cardiovascular effects
such as tachycardia, hypertension, and dysrhythmias are
particularly troublesome and may Limit therapy. Largedoses
Pharmacologic (lass: Adrenergic agent (sympathomimetic)
ADVERSE EFFECTS
Wht n tht drug is usN topically or inmnaally, sm Nler:n Jre uncommon. In-
tranaal un (an WM burning of tht mlK()\oJ and rebound (OIlgtltion if usN
for prolongfd ptriods {(hapter 11 00). Ophthalmi4: preparations (in (JIM
glaIKofllil IKondary to tlltir mydriatic: tffl High dose GIn
WISt ft'1I9 bradl'mdY tilt Mmion of blood pft'!!Urt (ausN b)' stim-
ulation of alpha, lKfIIIOfS.
usN drug should lit usN with GlUlion in patitnn
with adv.!ncN mranary artery disuse Of hyptnfllsion. Anlit!)"
and tft'mOf II\a)' O(QJr dut to tilt drug's stimulation t flen 011 tilt (NS. Patitnn
with h)'ptnhyroidism may I:lpenemt i 5eY!'rt increm in baal met.JboIi4: rut,
mulling in incrusN blood pft'Ssure and Vl'ntric:ular ti(h)'uroi.J.
Contr aindi wionl: This drug should oot lit usN in patitnn with arutt panmo-
atitis, hean dise.N, ht patitis, or n,IfTOW-inglt glaIKofllil.
INTERACTIONS
Drug-Drug: Drug iorar:ti005 1N),al"With MAO imbitM,(Minga
h)'pff1er6M> uilis.lnut.Nd etIKts mi)' iI!o 0((111 with triq<ir:
l'fgOI alkaloids, ftI OI)1och lrilibitory efIKts O(UI with j]pIw biodH'l ftI bm
inuwnpatibltwith ron prl'poIIationIlfflrir:saits).
PhtnyIfphrilll' rna, (auII' dysrll)1trrUl whfn tM in (ombi\alion with dgoxil.
LlbTl51s: Unknown
HflbaVFood: Unknown
Trrat mt nt of Overdose: may W ISt udlyr:ardia oInd h)'pffimsion.
Treatment with an alpha blo.:ker SIKh il plltntoi;!mifl!' (Regitifl!') fIIiIy lit
(attd to blood pres5Ure.
1Itff'f Ie M)NUIlIIrgm frIr Q Null/fill I'rrKm focuI ljIKlk Ie rNs drug.
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NURSING PROCESS FOCUS PATIENTS RECEIVINGADRE"ERGIC ISYMPATHOMIMETICITHERAPY
Assessment
Bilsfline azessment prior to administration:
Understand rNlOn tht drug his been prenriilfd in order to as:lf'l! for
therapMit ffferts.
Obtain a complete history indudi ng cardmaICular, crrfbrovaso:ular,
disease, or diabelO. Obu in a drug history irKluding
runrrn and OlC drugs,ind preparations.Be aIM to
possibit drug interactions.
EnkJate appropriate laboratory findings SIKh ill hepatit or
studios.
Obtain basfline viul "ftight,and urinary and wdiac output as
appropriate.
For tlNlment of nasal tht nasal muc:osa forutOriation or
biffiling prior to bt9inning therapy.
Aslffi the patient's ibilit)' to and undentand instruction.lndude tht
family and taregiYl'rs as neeritd.
Asst sslIlfnt thro ughout administration:
Aslffi for desired therapeutit effrrn dependrrlt on the INson for the drug
(t.g.,inlR'asrrl BPwithin nollllill range, nilsal
improYl'd).
ContinUl' and camill monitoring ofvitll and urinary and
cardiac output as appropriate, esprrially ij IV administration is used
Aslffi for and promptly adl'mf effKls: tlchyGlrdia, hypMension,
dysrhythmias, tremors, and drrft'aSfd urinary output.
Srftft' hypenension, sr1zUII'S,ind angina may signal drug tOOcity and
should be immediately reponed.
Potential Nursing Diagnoses
DrrlNsed Cardi", Output (tardiovasrular)
IneffrrtiYl'TtlSUI' Perfusion (cardiopulmonary)
Impaired Gas (cardiopulmonary)
Inefflil'(' AiIWZjClI'aralKe (illthlN or nasal (ongestion)
Risk for Injury (ft'lated to adl'mf eiflS of drug therapy or ildminisuation)
Riskfor Disturbed Sleep Pilnrm to ilcMlV eilrrll ofdrug thtrapy)
Deficient Knowledor (drug
Goal s Expected Outcomes
patirrlt will:
ExperiflKt theraPfUtit tffrrts dependent on tht ft'iIIOI1 tht drug is being giYl'll (t .g., implOVl'd blood pR"IWre, cardiac output, eil of breathing).
Be frrf from,or experience minimal. arlYl'Be tffrrts.
V .. bdlja, dn uf 110. druoj. U"', <HI ..... . rr .. b,."d ''''Iuirrd prrtduliu" .
Demon milte proper self.adminiruation oftiii' inhaitr, epinephrine injKtion kit, or nasa I or ophthilmit d rug instillation iedlniqUl'.
Implementation
Interventions and (Rationales)
Ens u ring thtr iI peutic efffrts:
ContinUl' ild\'S[riilfd earlier for thl'rapMic tffeds
dependent on the rNlOn thedrug thtrapy isgiYl'n.Pulse, blood
ft'Spiratory ratt should normallimiu orwithin till' paramettB m
by the health (iTt provider; H<ilill (oll9fstion should bf df(reasfd; reddene4,
irritated nitra should be
Provide <upport;;. nUl! iog mt.SUrH; f.g.. positioning for dy<pnN.
shock, Me. (liming sum ill raising hNd of till' bed d.Jring
dyspnea willsuppitment therapeutic drug eilfill and optimize till'
out(ome.)
Follow appropriatt administration trrh niqJts for subrutl neous. in hi fa
nasal. or ophthalm it Ous (S" chapter 3, PrilKiplts of Drug Administration
fort .... hniqll.'OO J
Patient and Family
Teach till' patient. family,omft'9iY1'r how to monitor tht pulse and blood
prffi Uft' ill appropriate. Ensuft' proper use and functioning of any home
eqJiprrll'Ot obtained.
Te ... h t .... patifm to "'port ilK"'iSiog r!yl.pou despite IIN'dim;'n thmpy
and to not tlke mo'" than pft'S(riilfd dost unitss instOKted O1i11'rwise by
the hukh caft' provider.
Instr\l(\ or in proptr \e(hniquts.
followrrl by Te",h the patient to follow the dire(tions
DO th. inh.lll'<"o pin.phrior iojminn kit . nd to haW" it on hand for
emergency use ill all tillN's.lf an epinephrine kit is needed and used, notify
the hukh caft' provider immediately after use.
LibraryPirate
NURSING PROCESS FOCUS PATIENTS RECEIVING ADRENERGIC (SYMPATHOMIMETlC)THERAPY lContInuPdJ
Impl ementation
and (Rat io nal es)
MinimlURg aclwrst tffeds:
Monitorfor signs of e.v::rssiw AIlS somlMtion "ld IIOIiythr he,lth
proYidtr if the bbd or pulst eKmj rst,blishrd pat',melm.
Continue Qrdi.K moftitoring (t .g..KG, w<b: OUIput) altd urine
output ifrvantrgio _ gi-Itn. (ilftMt ICIrtl\trglc: drugs stimut.tt me
hun rUt.nd filM blood prmurt, ttr, mUll: do!tIJ mooitortd Io.woid
ICIvmt tfffm. &Wnil ind rrrnNe rnooiroring will dert tarIy
signs of tfferu is wei,s monitoring for tMr,ptUti( efft<ts. )
ClosrlymonitDrthe IV
IClrenrrgicdrips shoo(d gi'ltn vii inMion pump.tBlMw:hing at tilt IV sirt
is ,n indiutorof mramoltlon .nd tilt lVinM.ion should immediatrly
Slopprd.nd tIw: providrr for btI!rr trNtment ord!:n.InMion
pumps -MIl dow prt<M domg of tilt mtdOtionJ
Continue III moftitor blood SUIjoIr ,nd i1pp1Opriitr I.Jb "MKl {AdrmHjr drugs
.ft"e<t iI widt IingtofbodysJSltms.llWbftia m.y oetd . dI.nge in diibtti<
mtdic:dion ordosing if rtINins tIrJ.ttdJ
Provide for err cornfon such as dnbrlfd room, 50ft c\odJ O'IfrrytS,R
sunglasses. Tmsitnt stinging .fter of tyt d!ops mayoc:cut
(Adrmrrgic: drug! tiln mydrmis and photO\emitMyto lightlouliztd
moronstrittion INy QUIt' iMging of the t)'tS.)
Insprtt nisal mutOl.l for irriution, rfrinorrhN,or bIding.1ter ni salIM.
Avoid ptolon9td 1M of .rkfnrrgic: n. salspr.J$. (Y<lIOCOIIStriction may CMf
b1nsitnt stnjng. eJaSiM drynts5,or blttding. Rtbound(ongrstion wItr
thronic rfrinorrhN may reuIt aftrr prolongtd tINUMnL)
Pfltint uncimtMldlngofd"gthm py:
1M opponuniOO cklrillll.dministrillioo of IIlI'diutions and cklring
assessmrnts to alKU55 litioniit fordtlrg
OIIt<Omt5,lIIOlt obserwd iHfIotne tfft<ts, p.lrnflettn fOfwMn to
rail the hNIth talf plllM..fId any M<rssary monitoring or pR'Giutiom.
(Using linw during QIe hdpslO opIimiluDd Itinfol(l! kty wdWIg

Pflt in t self ...... inistr. tion of drug tMUpY:
Yl'btn administering mediations, instruct 1M fImiIy,or artgM' in
proptr olin injKtion
orophlh.m.; drops.(Utjmgtimt dn.g of dJtsf
drugs htlpi 10 tthing.)
Pat ient and Family Educat ion
InstnKttM pUnt to shoftntnoflHNth, thet pain.
III'f"fOl/SIItSS or Imnon, 1It. darM,or Urillilry IHmIion
il!llllediattly.
10 .l\Iy pwilir ,nxiety,ludl d!f paMnt ibout tilt ratiooalt for.1I
I!quipment USfd ,nd tilt Mtd forhequrnt monitoring.
1NdJ lilt diabrtic: p.ltitnt 10 monitor tllti" blood SUIjoIIIIICft hequmtlr Md
tonotify tilt hNlth Qrt pfOWiIer if a incrwt is
II15U\1(t tilt p.ltiml that pilol(:Mfl5.itivi!), m., (l(cur.nd!l.lng1as1t5 m., b.r
flffiItd in brigbllighr or fOiouaidt IO:tMtit5. The proidelshould bt IIo6'itd
if mtuion orom bq:Jnd 12 houn ,fter drug M bttn
diKontinued Soft contl(f Irns usm should dItd with lilt provider bdm
some ma,u.in IenItS.
IRlU\I(t lilt paDml OOI ID UIt' rwsallpr.y longer than days wilhout
consuking tilt pmider.Ol( sa6r.t nNI spays ptOVidt comfort if
rnucm.J is dry.nd oral tbd irrl.!R may aha help with
hydlition.
TIlt patient, brriy,ortilrtgiwtr should ilbit to Stltr INIOn for
drug;' pproprialt clost and vAtill .dYt J1t t ffts to obstrvt for
and wlltn to rtpon;tquipmtnt nffiltd .uppIOpri.te and bow to mill
tqUipment; and the requimllrngth of IIlI'diution thtrapJ rwdtd with any
speOtl instrunions renewing or mntinuing prtSCription as
appropMt.
IRltl\K1 tilt patimt in ptOPff .dministration ttdiniques,1oIowed by tfI!tUrIt.
drrnorlltrllion.
TIlt patient, .It .blt 10 discuss.ppropMr dosing .nd
administlibon
Eva luation of Outcome Criteria
Ev.JIuatr tht of drug wr.1')' byconfirmillll tNt p.ltitnt 90'11 and OUKomfl hnt bttn mel: (_1'l.Jnning1.
5tr WW III tllIIIId! rI!e!t IIII'IitItJ IKliom
can induce eNS e.'lcitemenl and seizures. Other sympath-
omimetic responses that may occur are dry mouth, nausea,
and vomiting. Some of these agents cause anorexia, which
has led to their historical useas appetite suppressants. How-
ever, because of prominent cardiovascular side effects, sym-
pathomimetics are now rarely used for this purpose.
Drugs in this class are found as prototypes in many other
sections in this textbook. ror additional prototypes of drugs
in Ihis class, see dopamine (Intropin), epinephrine ( Adren-
alin), and norepinephrine (umphed) in chapter 2900;
oxymetaroLine (Afrin) in chaptet' 3goo; and salmetet'ol
(Serevent) in chapter J9OO.
LibraryPirate
136 U"IIJ 1he Ne<voos System
Adrenergi(-Blo(king Agents
Adrmergic-blocking agents or antagonists inhibit the sym-
pathetic nervous and produce many of the SOlme
rest -and..<Jigest S)Ulptoms as the parasympathomimetics.
They have wide the!"apeuti<: appli(;ltion in the treatllll'flt of
hypertension.
13.8 Clinical Applications
of Adrenergic Antagonists
Adrenergic antagonists act by directly blocking adrenergi c
receptors. The actions of these agents 3re specifIC to either
alpha or beta blockade. Medi(;ltions in this class great
therapt'UlK application and are the most widely prescribed
dass of autonomic drugs (Table I :U).
A1phaadrentrgic antagonists, or simply alpha bkx:kers,
are used for thtir tfftcts on vascuLar smooth mu.sde. By re-
laxing vascular smooth muso:le in srTl<lll arteries, alpha, block-
m; such as doxazosin (Cardura) cause vasodilation that
results in decreased blood pressure. They may be used either
alone or in combination with other agents in the treatment
of hypertension (chapter 2)00). A second use is in thetreat -
m,mt of benign prostatic (BPH), due to their
ability to increase urine now by relaxing smooth muscle in
the bladder neck, prost<lte,and urethra (chaptcr4600). The
most common adverse effect of alpha blockers is orthostatic
hypotension, which oc:<:ucs when a patient abruptly changes
from a recumbent to an upright position. Rellex tachycardia,
na!ial congestion, and Impotence are other Important side ef-
fects that may ()CCIlr as a consequence of increased parasym-
pathetic activity.
Beta-adrenl'gic antagonists may bkx:k beta, receptors,
beta, receptors,or both types of recepton. Regardless of their
TABU 1l.1 Adrenergl( Blodtlng Agents (Antagonists)
Drug PT1mary Receptor SUbtype
iCttuoIot (SKm/)
....
ItrnoIot (ltnoImil)
....

8$,ilndbN,
amdIoI (Corrg)

diIwosin [Cawrl)
.... ,
fSllloIoI (8rf'libloc)
'.,
ml'lOproiot IlDpmlOl', loprd)
'.,
nadoIot ICqird)

p/ltnlilbmilN' ...
Q pr.llO\ln lMlliprtU) ... ,
propranolol (lndtnll ,nd

'lid
tlm5U1oIin (Romn)
... ,
ttr.lWJ(IIytm)
... ,
IinoIaI [Brodrm, rrnoplir:]

receptor specificity, all beta blockers are used thel';)peutically
for their effects on the cardiovascular system. Btta blockers
decrease the rate and force of contraction of the heart, and
slow electrical conduction through the at rioventricular node.
Drugs that selectively block beta, receptors, such as atenolol
(Tenormin), are called agents. Beause they
have little effect on noncardiac tissue, they exert fewl' side ef-
fects than nonselective agents such as propranolol ( Indl'al ).
The primary use ofbtta bkx:Juors is in the treatment ofhy-
pertension. Although the exact me<:h:lIlism by which beta
blockers reduce blood pressure is not rompletely undl'-
stood, it is thought that the reduction may be due to de-
creased cardiac output or to suppression of renin release by
the kidneys.. The student should refl' to chapter 2)00 for
a more comprehensive description of the use of beta block-
m; in hypertension maTl3gemenl.
Beta-adrenergic antagonists have several other impoltlnt
therapeutic applications, disc1JS.!'ions of which appear in many
chapters in this textbook. Bydt'Cll'asing the cardiac workload,
beta blockers can ease the pain associated with migl';)ines
(chapter 1800) and angina pt'ctoris (chapter 2500). By
slowing electrical conduction across the myocardium, beta
blockers are useful in treating certain types of dysrhyth-
mias (chapter 2600) . Other therapeuti c uses indude the
treatment of heart failure (chapter 2400), myocardial
infarction (chapter 2SOC , and narrow-angle glaucoma
(chapter4900) .
Cholinergic Agents (Parasympathomimeti(s)
Parasympathomimetics are drugs thaI mimic action of the
parasympathetic nervoLl.'S These cholinergic agents
induce the rest-and-digest responsoe.
Pr1m.1ryUse


IIypmtnlion,tjuOlNO
IIJpfntnlion, lINn fliUrf
H)'lIftlrmion
IIyptrttMion. I
H)'lIfttrmion
HyllftttnSion
Wrf
H)'lIfttfllSion
blUff
Ilyllhythmial
BnJHjn proStlIir: h)ptflrophr
HypMtnSion

LibraryPirate
CUpttl' U Drug<l Affecting th@AutonomlcNervoUlSystem 1]7
.. , Prototype Drug I Prazosin (Min/press)
Therapeutic (I a5S: AnlihypertensiYl! Pha rmacologic (Ian: Adienergi( blo(king ilgent
ACTIONS AND USES
Prnasin is a StlKtiYf antagonist that CompttM with nortp-
inephrine at its on Y<H(uiar mlOOth muscle in arterioles and tins. In
major action isa rapid dKlNst in ptriphtral rMistancr tllat rtducM blood pres-
wre.1t has Iinif, effKt 00 caroiK output or hwt rite, and it UlHtS 1m Rflex
tach,wdia than some other drugs in this clus. Ttlltranct to pruosin's antihy-
ptrtensi'le niKt may occur. Its most mmmoo use is in mmbination witfl other
agents,sum as beta 01 diurttia, in the pharmacotherapy of hyperten-
sion. Prazosin has a short half-life and is ofttn taken two or three times per da)o.
ADMINISTRATION ALERTS
a low to avoid ilypotensioo.
Safety during Pl!9nancy (category 0 or lactation is not established.
PHARMACOKINETICS
Onset:lh
M : 2--4 h
Halflife:2-4 h
Duration: ms rlwn h
ADVERSE EFFECTS
like oillel alpha b!exkers, pruosin tends to (aUst orthostatic Itl'POtension due
to Ilphl\ inhibition in m(Uiar smooth muscle. In rire wes, this hypotension
can cause unconsciousness about 30 minutes alter the clost. To avoid this
situation, the fim dose should he ef)' low and giYfn at hedtimt.
drowsiness, Of light-htadtdness may ocrur. Reflel tachyunlia may frtIm
the rapid fall in blood prtssure.Alph.I b!exUde m.lyCilUst naul congestion or
inhihition of
\actllion is not esublished
INTERACTIONS
DrurDIIIj: Connrrmt ll!t of alii dh ... tks IUt! In !ltll'fllltJ
low blood sboIId tit Mided.
Lab Tests: Prnosin inul'oMi lI'inary mNboIif'! riYfll)tlwndfk add tYMA) MId
which iIIt mN:SItfd to screen lor p/IeIKhromocytoma (adJfflal
nmor).Prazom wi call!t f.wilQlitiw !!Sun.
HerblVI'ood: Donot use 5iNi pakMttoorMttlfroot prodoos,Saw palmetto bkKb
lKfIIIM.rMtiIgil dIf dlationribbodmsftl nI a hypo!fn!ivf 1I!IjlOMf.
Treat ment of Overdost: 0vetd0Sf maycause ilypott Mion.Riood pressure may
bteltvittd bythl! adminismtion oftkJid eXpindm such as 1lOI'm.J1 OfYill-
sopmsors such u dopamine 01 dobutamine.
IItflf 10 for a NulJlll9l'1tlms focus JptI< 10 1M drog.
NURSING PROCESS FOCUS PATIENTS RECEIVING ADRENERGIC-BLOCKER THERAPY
Assessment
Baseline assmment priollO administrat ion:
Undmund the the drug has betn plf5Cribtd in ordello mess for
thelipMiceffKn..
Oblain.l complete history including
RspiralOly distast. or diabttes.Obuin a drug history including allefgies,
current and Ole drugs, herbal prtparations,and .Imhol use. Be
alert topossibit: drug intefKtions.
Evaluate appropiWte liboratory findings iocluding elKtrolytts, glJCOSf, and
hepatic and Rnal function studies.
Oblain bistline wtight. yital signs, ind cardiac monitoring (e.g.,KG, wdiac
output al appropriate.)
For tfl'atment of btnign prostatic hY1M'nrophy (BPH), aS$fSS urinary output.
Assess tilt patient's ability to fl'(eive .nd inwuction.lndude the
family and as needed.
Aueumfnt throughout administrati on:
Assess for desired thtrapttllic effects drprndtnt on tht Itason for the drug
(e.g., BP within normal range. dysrhythmiaslpalpitationlRlined. greater
Nst in
Continue fnoquent and Cilreful monitoring of vitll sigm,diily weight. and
urinary and urdiac: output as appropriatl!,6pt(ially if IV administration is
.""
Assess for ind report idvtrse effe<ts:bradyQrtflil, hl'POtension,
d)'llhythmiis, fl'fltx tldJyQrdia (from too-rapid in BP or
hypotension), dizziness, heldache, and demased urinary output.Se'0'6e
hypotmion, seizultS, and dysmythmiaslpalpitalions m.ly drug signal toxicity
and should be immediately reponed
Pot ential Nursing Diagnoses
Oecreued Cardiac Output (wdiO'o\lscuiar)
lneffe<tive TiswePttfusion (caroiopulmooary)
Impaited Gu &mange (cardiopulmonary)
Intffe<tivt AirwayC!tarince (asthm.)
Impaired Uriniry Elimination (BPH)
Activity Intoleranct{catdioolamJlar)
RisHol Falls, Riskfor InjJry (related to adYeM effects of drug ther.!py)
Ris. for Oisturbtd Sleep Patltm (rewll'd to adYerst effn of drug theripy)
Sexual Dysfunction (related to .dvme effe<ts of drug ther.!py)
Deficient Knowledge (drug therapy)
(Continued)
LibraryPirate
138 Until TheNe<voo.Sy.tem
NURSING PROCESS FOCUS PATIENTS RECEIVING ADRENERGIC-BLOCKER THERAPY (Contlnuw)
Planning: Patient GOlll s llnd Expected Outcomes
Thr patimt wiH:
Experitnc:t therapeuti< t fftru dtpendent on thr It'ason the drug il bting giI'M (f.g.,dtumed blood Nil' of urination).
Bt mt from, or experitncr minimal, adl'tfSt tIftru.
an undentanding 01 tilt drug'1 uW', adl'tfSt rifem, a nd mjuilt'd pIfGIutionl.
DtlMnltralt ptoprr of thr rntdiution (r.g.dOlt, timing, wilen to notify provider).
Implementlltion
Interventi ons li nd (Rilti onil les) Plltient lind Fll mil y Educllti on
Enluring tht ril peutic tfftdl:

ContillJl' frelp'nt mesvnenll lS deluibtd t arlitr for thtrapeuti: rffr(\.

Ttach tilt patitnl, lamily,olUlI'9iYer how to monitorthr pulW' and blood
dtptodent on th t IN\OII thr drug thrr.lPY ilgi'leo. Daily 5hould remain PIffiUIt' as appropriatt . EIllUIt' tilt proptr UW' and funuioning 01 any homt
at or doW' to baseline wei.jll (Pukt. blood prtSlUlt', and It'Ipiratory ralt 5hoUd tqJipment obtained.
bt within normal imits or within par.lrntlM W'I bf the hrakh (,lit' proIIiler.

Havr tht patitnt wtigh \elf dail} il iang with blood pft5IUIt' and pulW'
Uriru ry hrsitanc:y or freqJtncy mould lit dtclt'il W'<I and unlit output imprttYed.
mealUrmtt ou. Repln a wtight gain or IoI.s 01 mort than 1 kg
An iMlt'ilW' inwtight OYI'r 1 kg ptrday may indutt mtOlil't Auid
(approximately 21b) in i 24../1oor period.

follow administr.ltion thniqJes for ophtll:olmic: doW'<. (S .. -

Instruct the f.mily, or .... r in propfl .dminisunion bNhniquo-<,
chapter 3, PriMipitsol Drug Mminilu<IIian for tt <hniques 00 J followfd by It'tum-dtmonsmtion.
-
Minimizing adftDt ri"ftct5:

Continue to monitorvital!iql!.. Tae bbod prtSllI"t lyinq. sittinq.and standng to

Ttach tilt patitm to rist from lying to lining or slowly to avoid
dttKt orthoslittic: hypottnlion. Bt paniWarly "utious with older who diuintSS orfalls.
alt' at iKlNItd risk for hypottoW!. Notify thr hNkh "It' proYidtr if tilt blood

In.truct tilt patitnt to nop taking medic:ation ifblood prt1IUrt il9OI60
pmstIlt' or!DW" beyondffiablMtd par.lrntlMor ifhypoltnsian iI
mmHg or 1It1ow, or paramt tt r> Sfl by tilt hr,kh (are
K(ortIpanitd by rt'fI9 oo)Urdia.(AdIffitlllic: drug. dtcruW' hrart rate and
immediately notify thr plOllidtr.
QIIW' 'IaIOdbtion, rmkilg il lJwtrtd blood pl!SlUlt'.Onhorutic hypo1fll1ion
IN)' iKll'.!II' tilt risk d fallsor injury.RellexIil<h)urdia may lignalthat tilt
blood prt!SUIl' hal topped too qtid:iy or too wbruntially.)

CominUl' "rdia<: mon itoting (f .g., ECG) as ordertd for in tilt

In.truct tilt patitnt to It'port palpit<llions,<iltst pain, or
hospilitliml patitm.(Extt mal monitoring will dttKl urly signs 01 immediately.
adw"W' ffl'tru.s well as monitoring forthfrapttrtic tfftruJ
Wtigh the patitnt Nily ,nd Il'port i Wl'ight gain or loss 011 kg

Havt tht patitnt Wl'igh ideally ill tilt wme timeol Ny, and r ord
(appmlimattly 21b) or mort in a 24-hour period. (Daily Wt'ight iI an ac(uratt weight along with blood pre su n' and measult'metlts.lial't the jlatitnt
mea.ureof fluid status i nd lite. intoac(ount inlitkt, output. and It'port' Wl'ight g,in or IoI.s of molt' than 1 kg 21b) in , 24-
IosW'l.Wt ight 9i1in or tdtma may lignal that blood pre.SUIt' 11:0. Iowt-red too hour period.
qJic:kIy, rumuliting It'nin re\ea.t or ilan adl'tlW' tfft.)

Monitor urint output.nd symptom< ofd)'Suria <u<h os hesit. ncy or It'tt mion

H .... tht I"titm promptly uri .. ,), hesit.ncy, f .. liogs ofbbddtr
wht n gi'leo for BPH. 1u110fS!, or diflirulty slaning uri nary ItrNm.

GiVI' the fir>t doW' 01 tilt drug ill btdtimt. (A fir>t-doW' It'oponst rruy It'lUlt in

Instruct tilt patitnt to take the lir>t dost of medic:ation it btdtimt,
a glt'ater initial drop in BP than lUbW'qutm doles.) immediately btioll' going to lItd,and to awid driving for 12 to 24 hour> alttr
fim dole orwhtrt tile is inaejlftj umil thr effemare known.

CominUl'to monitor blood IlJ90Ir and ,ppropriatt lib work.(Adrt nergic:-

Ttach tilt diabttic: patimt to monitor blood 1119" molt' mqJeOtIy and to lit
bloc:king drugs afft a wile r.1H}I' of body . Tht)' IN)' also imt rlelt' await' 01 .ubtlt lignlol pos.ible hypoglycrmia (f.g., nffilOUSntSS, initabilityl.
with IOOlt OIal diabttic: drugs or dlilH}l' tlltway a hypoglyamic Il'ac:tion iI TIlt patitm on or.1 amidi.bttic: drugs !hook! rt'pOn any ron.illtot <hange
percriYl'<l.) in blood IUgar Itftll to tilt 1It.1th "It' provider promptly.

AsW'lS tht patitnt's IIIl'IIIitI starus and mood. (Admlt "lic: bloc:ken may "USt Ttach the patitm to It'port unusual ietlingsof oopondtncy,apamy,
dtplfSwn or or dtpl!Swn that may wallant ,(halH}l' in medic:<ltion.

PIOl'idt forf)'t{omfort IlKh lS adequatt ly lighttd room.(AdIt'llel9ic:-

C,ution thr patimt bout driving or otlltr activitits in iow--fight <and itions or
bloc:king drugs an "uW' miolil ,nd difficulty Itfing in low light It nll.) at night until tht tIftru 01 drug ilt' known.

Do not ,bruptly stop thr meGKatioll (Rebound hyperttnsion and tac:h)Urdia Ttach tilt patitnl, family,omll'9iver not to stop tilt medic:<ltion abrupdy .nd
mayoc(IJr.) to "II tilt lItakh (;Ill' proviler if the patitnt iI urublt to take tilt medication
lor mOIl' than 1 Ny dUl' to illness.
LibraryPirate
IlIoplfl U DnI<1' ... lfoolngthe ..... tooomk:Nervou' SY'tem 139
NURSING PROCESS FOCUS PATIENTS RECEIVING ADRENERGIC-BLOCKER THERAPY (Cootlnul!d)
Implementation
Interventi ons and (Rati onales)
Patint understanding of drug thfrapy:
1M opplnunities during administration of during
asltSSIIIl'IIII todimll5 rationalt fordrug tlitraptUlic:
p.lrameter, forwhen to
call tilt health plO'lider, .J nd any ne<tssat)' monitoring or pl'rcautions.
(Using time during (il1l' htlps 10 optimireand key tNching

Patint Sflfadm inistril tion of drug tht rilPY:
administering tilt famil)o,orYrtgW!r in
tilt proper self-administration of drugs a nd ophthalmic: drops. (Uti liring time
during nurw..adminismtion 01 10 teaching.)
Pati ent and Fami ly Educlit ion
Tilt should br abif to lute tilt INson for tilt
and IChNuling; what for
and wlltn to as and how to use that
equipmtnt; and tilt rtquill'd length of therapy t"ftdtd with any
Ipt(iil in,tructions Il'9'Irding Il'newing or continuing prl'l(ription as
appropriate.
Instruct tilt palifnt in proPfr administration ttchniques,followed by Il'tum-
dtmonmation.
TIlt ill' to discuss doling and
administration netck.
Evalulltion of Outcome Criterill
the of drug thtrapy by confirming that p.ltitnt gNhand oUKomr, hn'e bren met. lsee"Planninif}.
5tf TtIbIt lJ.JrorQ htltihlJl rowlidl rheIt ooffinl} ti0fr5gpp1y.
, 3.9 Clinical Applications
of Parasympathomimetics
The classic parasympathomimetic is acetylcholine, the en-
dogenous neurotransmitter at (holinergic synapses in the
autonomic nt'r.'Ous system. Acetylcholine, however, has al-
most no therapeutic use because it is rapidly destroyed after
administration and produces many side effects. Recall thm
Ach is the neurotransmitter at the ganglia in both the
parasympathetic and sympathetic divisions, and at the neu-
roeffector junctions in the parasympathetic nervous system,
as well as in skeletal muscle. Thus, it is not surprisi ng that
administration of Ach or drugs that mimic Ach will have
widespread and varied effects on the body.
Parasympathomimetics are divided into two subclasses,
direct acting and indirect acting, based on their mechanism
of action (Table 13.4). Direct-acting agents, such as
bethanechol (Urecholine), bind to cholinergic receptors to
produce the rest-and-digest response. Because direct-acting
parasympathomimetics are relatively resistant to the de-
structiVl' effects of the enzyme acetylcholinesterase, tht')'
have a longer duration of action than Ach. Tht')' are poorly
absorbed across tltt' GI tract and generally do not cross the
blood-brain barrier. They have little effect on kh re<:eptors
in the ganglia. Be.:ausetht')' are moderately selective to mus-
carinic re;:eptors when used at tht'rapeutic doses, direct-
acting parasympalhomimetics may also be described as
muscarinic agorrists.
The indirect-acting parasympathomimetics, such as
neostigmine (Prostigmin), inhibit the action of AchE. This
inhibition allows endogenous Ach to avoid rapid destruc-
tion and remain on cholinergic receptors for a longer time,
thus prolonging its action. These drugs are called
cholirllistemse inhibitors. Unlike the direct-acting agents, the
cholinesterase inhibitors are nonselective and affect all Ach
sites: autonomic ganglia, muscarinic receptors, skeletal
muscle, and Ach sites in the CNS.
One of the first drugs discoVl'red in this class, physostig-
mine (Antilirium), was obtained from the dried ripe seeds
of Physostigma venenosum, a plant fOWld in West Africa.
The bean of this plant was used in tribal rituals. As research
continued under secrecy during \Vorld War II, similar com-
pounds were synthesized that produced potent neurologic
effects that could be used during chemical warfure. This
class of agents now includes organophosphate insecticides
such as malathion and parathion,and toxic nerve gases such
as Sarin. Nurses who work in agricultural areas may become
quite familiar with the symptoms of acute poisoning with
organophosphates. Poisoning results in intense stimulation
of the parasympathetic nervous systt'm, which may result in
death, if untreated.
Because of their high potential for serious adverse effects,
few parasympathomimetics are widely used in pharma-
cotherapy. Somt' haw clinical applica.tions in ophthalmol -
ogy, because they reduce intraocular pressure in patients
with glaucoma (chapter 4900). Others are used for their
stimulatory effects on the smooth muscle of the bowel or
urinary tract.
Several drugs in this class are used for their effects on
acetylcholine receptors in skeletal muscle or in the CNS,
rather than for their puasympathetic action. Myasthmia gravis
is a disease characterized by destruction of nicotinic recep-
tors in skeletal muscles. Administration of pyridostigmine
(Mestinon) or neostigmine (Prostigmin) stimulates skeletal
muscle contraction and helps reverse the severe muscle
weakness charactt'ristic of this disease. In addition,
LibraryPirate
140 Unlll TheNe<voo.Sy.tem
TABLE 13 41 Cholinti!rgic Agti!nts (Parasympathomimti!tics)
"'"
Drug PrImary Use
bethilll'mol Urffilolilll'l To mmuatt urin.tion
(t'liRll'lilll' 11(1 (h OJtO() Trtatmentofdly mouth
pikKarpint (llopto Carpilt, Salil/ffil GlalKomi
acting) ambffiooium (M)1N!e) Myallhtnii
dontpuil (Am pt) Alzhrime-\dilml'
lliignOlisof myulhffili grnn
golintlmilll' hydrobromidf, Alzhrime-\dilrase
(PlO5ligminj
phy\05lilJrint (Antiirium)
(M/'stinoo)
ril'aIligmint (Elflon)
ooint 1(ogou)
donepezil (Aricept) and tacrine (Cognex) are useful in
treating Alzheimer's disease because of their ability to in-
crease the amount of acetylcholine binding to receptors lo-
cated within the CNS (chapter 2(00).
p;.. Prototype Drug I Bethanechol (DUVOld, Urecho/me)
Myallhl'nii groWn
Trmment of 1I'I'!'It antidJoIintrgK tOlidty
lJiVis
Alzhl'ime-\diwII'
diwII'
Cholinergic-Blocking Agent s (Anticholinergi cs)
Cholinergic-blocking agents 3rt'drugs that inhibit parasym-
pathetic impulses. Suppressing the parasympathetic division
induces symptoms of the fight-or-flight response.
Therapeutic (lass: Nonobstruc:tive urinary retention agent Pharmacologic (lass: Muscarinic dlolinergic receptor agonist
ACTIONS AND USES
BetlYnediol is a direct-.Kting p.lrilymp.lthomirnWc that inttrOc\:S with mus-
carin ic: to UlM actions typic:al of piriSym Pithetic: nimulation.1ts ef-
fKb all' most notftl in the and urinary truts, whell' it nimuiatl's
smooth-mUl<It contraction. Thee actions all' useful in incll'iling smooth-
mUl<It tOnt and mUl<Uiar (ontractions in the GI mct following general anes-
thesia.ln addition.. it is UII'd to lINt oooobnllKtiYl' urinary retention in p.ltients
with ollonyofthe bladdttAlthough poorly ibsorbrd from thf GI it may bf,
adminiltl' ml orally or by S( injedion.
ADMINISTRATION ALERTS
NeYer administl' rlM or IV.
Oral and subrutantous n interclYngNblt.
Monitor blood pIl'S1U1l', pulse, and I!"Ipirations administration and
for at Itm 1 hour after subcutaneous administration.
Plf9nanq category (
PHARMACOKINETICS
Onm: 30-90 min PO;5--1 S min IUbrut.MOUS
Pl'ak: 60 min PO; 15- 30 min subcutantous
Halfli M: 2--4 h PO; 1m than 60 min subcutaneous
h PO;120min IUbcutifll'OUS
ADVERSE EFFECTS
The side ofbf,tlYlII'(hoi are pIl'dic:tftl from ill parasymp.nheric:
k should bf, UII'd with mlt'ml' caution in p.ltients with disotders thu (oold bf,
a991i'lillftl by illCll'all'd contractions of the digtstM wch as suspectftl
obstruction, or inAam m.nory The amI' caution mould bf,
in patienn with SUSPfited urinary obstruction or COPD. Side riff(ts in-
cUde inCll'all'd aliYuion, s'Mating. abdominal cramping. and hypotension
that could Itad to fainting.
Contraindications: Patienu with asthma,t-pilepsy, or parkimonilm mould oot
this drug.s.tfety in prtgnanq and ooition and in children )'OUngtr than 8
Ytars is not
LNTERACTIONS
I)ug-l)ug: Drug inteOOionlwith bKhanMol iKLudf inuNlfd
fff.m iilibiton and dKr&lIfddJoinergic fff.m from

lab TfSlS: Bfthanedlol mayauf oWl iKJf,If in lip.If.
IIfrbaVFoo:l: ChoIiIli'lr;t efffm t.lM by betlwofdlol may be intagonind by
jimlon wted, IJICOpiIIia.
of is a spl'(ifK antidott. Subrutantous
injfction of atropint is pIl'ferll'd UCI'pt in I' IIII'''lmcirs whm the IV may
btull'd.
R8'8' /II MytmbrgKI fer MnIftg Press fooIl Jllid/l( /111M Ihg.
LibraryPirate
CNpltl1J Drugs ,t.,ffoealng the ,t,utonomlc NerVOUI System 141
NURSING PROCESS FOCUS PATIENTS RECEIVING PARASYMPATHOMIMETIC THERAPY
Assessment
Bastline .Istslmtnt priorlo . dminl slr"lon:
Undentmd the INson drug !vi presc:ribtd in ordtr to for
tffKb.
I (omplett IItlhh ino:Uling
or thyroid diseastS,GI GU obstruction,or
diabttts.Obtain a drug history induding allergits,(urrtnt pltKription and
OK drugs,lnd htrNl prrplrltiom.8e alert to po!l;ible drug interl[tionl.
Evaluall'appropnatr Llboratary findinqs wch IS htpatic: or lI'Ilallunction
lIudits.
bistline signs,bowellOUnds,urillill1 mUKIe slltngth,and
mental staIUS n appropriate.
the patimt's ability ta I"Ktm.nd undtntand imtllKtion.lndude the
fI mily and yrtgmn as I"ftded.
Asstls ment thro ughout ildmlnlstradon:
for dtdltil thtraptUlK tl'lt<tsdtptndtm on the reason lor the dJllg
(e.g., incrtl sed em 01 urination, mus<1e strength and ulordination improYtr!,
improvtd mental status).
Continl,ll! and cartful monitoring 01 mental IID...,I
soun ds. urinary a nd mus<ulolktlelll function as a ppropriall'.
for and promptly n!port advtrlttl'lt<ts:bradyurdi., hypotension,
tremon, diuilltSS, urinary
output.abdominal pain,or dlangrs in mental
Potential NUl'$ing Diagnoses
IlItl'lectiYe AirwilY (lea rl no:r (myastlltnia g ravil)
Impairf<i Physical Mobility (myasthenia grais)
Urinary Ikttntion or Impairt<! Urinary Uimination (postoperatilll!ly,
poITpartum)
Incominrmt
for InjJry hflatt<! to adl'l'M tffto:ts ofdrug tlltrap)')
Dricitm Knowledgt (drug thtrapy)
Planning: PUlent Goals and Expected Out(omes
The patitm will:
uperitno:e tlltraprutic: eifto:ts dependtnt on rtiSOn the drug is bring giYtn (e.g., improYrd physical mobility ind (oordination, ino:rt.5ed raleofurination,
improvement in Jlll'ntal status and luoctioniog,Jnd self-<art
from, or dffCIs.
VerNlize an undetslindillQ ohhedrug's use, aaterlt eifto:ts,.and requittd p,euutm.
Demonstrate proper !eIi.oJdmini!lration of tilt meditation !e.g.,dole, timiog, when to notify provider) and properophth.lmK drug iMtillation
Implementati on
Interventi ons and (Rati o nales) Patient and Family Edu(lItlon
--'--
All Pillrasympilthomimetlcs
Ensuring thflilpeutic effects:
Continl,ll! aSstSSments as dtS(ribe\! earlitr lor the ' lprutic: effto:ts
dependenT on the reason the drug therapy is givtn. (Menul StilUS and ability
to arry out A[)u has impl"l7ftd; urinary elimination and output is implllftd;
mlJl(uloskeietal ...,aknffi, ptosis, diplopia,and (hMing ind swallowing art
improved)
Providt supportilll! nursing IlINSures; e.g., reguLir toiltting Khedull', wkty
mmurtl,eK. Jlll'alUltS SIKh as assisting patitnt to normal voiding
poIition willsuppltrnrnt theraptUlic: drug tfftmand optimize outCOJlll'.)
follow iPPropriall' administration Ioraphthalmit 0051'1.
tablets not b!' uushtd or drug
rtimll(f material on administration with arwithoUl food. 1,
Principles of DIU 9 Administration lor tto:h niqurs 00 . Sus taintd--rtltast
lormuLis must dissolve sIowIy.Food mJY impair tnhall(u))sorption
prM'nt aateJ"5e fifto:ts.)
tilt pJlitm, family,Of<Jregivtr to prl(tic:e supporti-le mrnurtS
along wiTh drug therapy to mlXimill! therapeutic: efftcts (e.g.,adtquJle ItSt
periods in myastlltniol grnis)
ASSffi patitnt's or family's to tarry out ADu at hoJlll' and upiono
tilt nffil lar Jdditional health {art rmrrals. [vJUate home winy netds.
ImtnKt tilt patient in proper Jdministration tto:hniques,lollowed by ft'tum-
demonstration.
(Continued)
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142 U,*l
NURSING PROCESS FOCUS PATIENTS RECEIVING PARASYMPATHOMIMETIC THERAPY (ConrkluedJ
Implementati on
Interventions and (Rationales) Patient lind Family Education
MWii..,idn9ldtotne fffectJ:
Monitor lor signs of ANS stimWlion and notify !fie health loll\!

InstlUd tM p.Dmt to promptly II!pCIrt ImnoIi, palpit.Jtions,diange5 in
proYidtr if 1M jalM is les rlIiII60 ootslmin or BP is bmw rstablishtd blood prelUR',diuinffi,um.vy rt'tenuon, Ibdominal diangH in
drugs the he! rm beh.lvior 1M patient to
ind blood 9r5sure, thtJ must bt ciostlr monitort<! to mid idYmf tfft<ts. rtpOft a,.spnH, ul;"ltion or SW!l!in!J,Of Ilt9Jt immtdi.ltely is
Atropint may Ir ordtl'td 10 (IUIImct drug ftl'tcts.) art' signs of poll'fltioll O'I'ftdon.
ContinUf to monitor hepatic ilnction lib IIIIOft (ParISYmp.lthomimttic G-ugs TfaCh the 1Htitnc, Ilmily,Of lbout the import.JIICf of returning!of
may UIM IMr t oxic:ity. nd IMf enl)'lllft nwy be rnonitcml weekly b up 10 follow-.up I.b Mil'S.
6wrrbJ
urtrully Clkvlitt and monitor dosn. (urrill ulcul.ltion wm . wid E_ the p.titnt ungivtr irt .dminislfring 1M COIlt<! dolt by
omdosaljt.) oInftving lfIUm.drmonnmion.
Pllifflt u.clmtllndin9 01 "" thmpr.
rurilg iIIImilistratiln of mrd'1U1icm IIId TIll' patitnt, fa miJ, 01 C<lmJiM s houkl be.ltw 10 stllr !fie /UIOIl ilr drug;
\D dilaru tilt rxilnalebdrug tberapMic apptopOattOOse Ind 'fIIIheIt
to 1I!pCIrt; eq.Iipment netded IS II ppI'Ilptia!e MId how to 1M that equipment;
and.nr III'mWl)' monitoring Of pl('Uutions. (lM1g iiIIII' !bing and till' I!quftd IrrJ:jlh of llII"Ifa:ation thtranlll'tdrd wid! MIl'
Mructions rtrII'WiIg OIlOminuing plrlCription ISlppropriatt.
'Ilient lelf-achinistl'iltion of drug tMriflJ:
When ring tilt mtdic.Jtion inwuct the family, 01 (,Irf9ivtr R$truct tilt patRm in prop" idministration ttdlOiqurs, foIIowtd by IftUm-
in lhe Propef lei l-idministration of d tu;llItId ophthalmic drops. (UtiliDng demonstruiolt.
tiI!II' ruling of drugs hflps 10 lI!infor{t
TIll' patient, firM" or to disaru dosing and
Ilffib,
Direct -Acting Drugs
ContinUf fftqI.II'nt monitoring ofbo'lrld ume output if drugs.1t klstruct the patiem 10 havt b.Jdtroom Idtirs nearby tdjng the drug.
givtn POSIOflNtiely or {ksesmrms..wl cRlf<\ early signs of The p.tient m.y nttd assmllCe to the mitt Of comll'lOdf if dimnfss 00ClII'$.
Wlrrw ffftm IS wt'Il as monitoring for d1mprutic rifrm.Drug OM is in
6(l minutts with in<ltand loIrin.tion and perisukis following.
Drugult IJlt gi\'tn if jJ medlaftical obstruction known or suspecltdJ
PIOI'idf b".. comfun IUdI adrquately lighttd room 1M Wion tilt pMimUboul in Iow-ight conditions, at if visDI
SlIftty fl'll'iSUlI!S .(Parasympathomimric drugs lin U\M miosis with is blumd.Niglltlight 1M at IIomf .nd saftty fl'll'alYltS may bt needed \D
difficulty SHing in low igbt Irm.lnd bt.md vision.' pmormfalls.
Hflp the patiellt to rM ftom IJing or sinillg 10 Itlnding I.WrtiI drug Instruct tilt patiem 10 riIf from t,-ing or sittiIg to ltanding slowly, and to
iSIffitd. {Dirt<t -acting parasympatllomirnms m I, UUIt significant a.oid prolor!gtd ltanding in OM place 10 lfIIid dizzifle5l or f. k
orthoswic hJPCJtensionJ
Cholinesterase Inhibitors
Cominut monCoring mlllOllosttleul rumgth, impro'ftrllftlt in ptosisOf Too lilt palirrw, flmily,or to !lOlly till' hu!zlr (,III! providft ..
dijllopiol,.Ind dINing and swalowing. (lmplll'lfllltnt short/ll'\.I fatigut,or diffKL*y with dltwing or swallowing
drmonstrlltS tbatthffilpMic ffffi:ts t.-1II'fn ac:hiMd.) 00ClII'$ or is wonming.
Too tilt patim, flmily,Of about apjlropri.!rt sdII'IkJling of drug
fonnuLllioos should III' takrn with foocl [r.,g..ambenonium),oliltn oo in around lIII'iltirM'l.
fmpl)' nomKlr [f.g.,lacrinr).food m.I')' inpair or absorption Of
Pf"tnt rifects.)
Monitor for nrusdr wtaknrss airtr thf dosf is gMon. on 1M limt R$truct tM patimt to rtport 10)' nvm rnusdt 'M'aklll'Sl that occurs 1 hour
ofonset,mis symptom indDrrs (holillflgio: uisis [omdostL or myasthenic afttf taking the drug or iii'! ocwn 1 or mon hours altft uking tht drug.
crisis [undrtdose)J
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IlIoplfl 13 0nJqs Affealng It... .<.utoooml< Ner""", SY'lem 143
NURSING PROCESS FOCUS PATIENTS RECEIVING PARASYMPATHOMIMETIC THERAPY (Contlllued)
Implementati on
Interventi ons and (Rati onales)
xhedule activities Jnd allow for adftl wte ptriods of Il'st 10 Jwid
(uml fatigU!' can lead 10 either a or m)\lsthtoic (1M.)
Pati ent and Fami ly Educlltion
IrIIlrun lilt patitnl 10 plan oKliYiliHoK{ording 10 mlJS(1e mength and
faligU!' and 10 allow forireqU!'llt .J nd adequate Il'st prriods.
Irlltrun tilt patitnl to immtdiately Il'pJM dyspnea, salivation or or

Evaluation of Outcome Criteria
[valualuhu frect il'erless of drug liltrapy b, ronfirming that lilt patitnt goals and OIJI(omes haY!' rod
5rf TiIbIt 114 turo rIIe;t r.mingopp/il:ionsopp/y.
13.10 Clinical Applications
of Anticholinergics
Agents that block the action of acetylcholine are known by
a number of names, including anticholinergics, cholinergic
blockers, muscarinic antagonists, and parasympatholytics
(Table 13.5). Although the term anticholinergic is most
monly used, the most accurate term for this class of drugs is
muscarinic antagonists, because at therapeutic doses, these
drugs are selective for Am muscarinic receptors, and thus
have little Effect on Ach nicotinic receptors.
Anticholinergics act by competing with acetylcholine
for binding muscarinic receptors. When anticholinergics
occupy these receptors, no response is generated at the
neuroeffectororgans. Suppressing the effects of Ach causes
symptoms of sympathetic nervous system activation to
predominate. Most therapeutic uses of the anticholiner-
gics are predictable extensions of their parasympathetic-
blocking actions: dilation of the pupils, increase in heart
rate, drying of secretions, and relaxation of the bronchi.
Note that these are also symptoms of sympathetic activa-
tion (fight or flight ).
Historically, anticholi nergics have beE"n widely used for
many different disorders. References to these agents, which
are extracted from the deadly nightshade plant, Atropa
ladonna, date to the ancient Hindus, the Roman Empire,
and the Middle Ages. Because of plant's extremetoxicity,ex-
tracts of belladonna were sometimes used for intentional
poisoning, including suicide, as well as in religious and
beautification rituals. The name belladonna is Latin for
Kpretty woman." Roman women applied extracts of bel-
ladonna to the face to create the preferred female attributes
of the time--pink cheeks and dilated, doelike eyes.
Therapeutic uses of anticholinergics include the following:
GI disorders: These agents decrease the secretion of
gastric acid in peptic ulcer disease (chapter 4()00).
They also slow intestinal motility and may be useful for
reducing the cramping and diarrhea associated with
bowel syndrome (chapter 4100).
TABLE 13.S Cholinergic-Blocking Agents (Anticholinergics)
",,'
atropilH' (Atro-PftI, AlrOpiIir,Airopilolj

cydoptnlolatt (Cydogyl)
diqdomilH' (Btotyl, othtn)
(Roblm.! )
ipratropiJm
mtlhKOpOlalli1H' (PamilH'j
oxybulyrin (Ditropan,Oxylrol)
pIOpiInthdint (Pro- 8anthilH'l
!(opoiamilH' (IIyoOOnt, TrJflldmn.Srop)
liolropium (Spiriva)
toItenxilH' (D""oI)
uihtlypheridyl (AnilH', otherl)
tropiumide (Mydiraql, Tropic.lql)
Primary Use
Poisoningwilh 10 in(fUll' ilun pl4i1l
dilUlt, nfllroitptk side
pl4lill
bowd syndfOllH'
To prodlKr J I1tkI prb' 10 ilH'llllesli, ptplk ukm
..
,""olion IidlH'll,ukm
IncootilH'lKt
bowd
,""olion syndromt,adjIM to anestllflia
..
OvtraaiYl' bladder with IYIIlptoms d !qI' uinary inconlilH'll{t, urgene): and Ir!qutnq
Partimoffi dilUlt
'"")Ui.ilis ind qdoplt9a for diq.oltic pnKfdJres
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I
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144 Unlll TteNe<v"",.Synem
Ophthalmic procedure5: Anticholinergics may be used to
anISe mydriasis or cycloplegia during eye procedures
(chapter 49C'O}.
Oirdiac rhrlll/n abnormalities: Anticholinergics can be
used to accelerate the heart rate in patients experiencing
bradycardia (chapter 2600).
Preane5thesia: Combined with other agents,
anticholinergics can decrease excessive respiratory
secretions and reverse the bradycardia caused by
anesthetics (chapter 1900).
Asthma: A ft'W agents, ouch ao ipratropium (Atrovent),
are useful in treating asthma, because of their ability to
dilate the bronchi (chapter 3900).
The prototype drug, atropine, is used for several addi-
tional medical conditions owing to its effective muscarinic
receptor blockade. These applications include reversal of
adverse muscarinic effects and treatment of cholinergic
agent poisoning, including that caused by overdose of
bethanechol (Urecholine), cholinesterase inhibitors, or ac-
cidental ingestion of certain types of mushrooms or
organophosphate pesticides.
SPECIAL CONSIDERATIONS
Impact of Anticholinergics
on Male Sexual Function
A iundioning autonomic: fIl'fY(M 'ystl'lll is for norml malt
hNlth. The parasympathetic ntrvom \)'Stem is rte(essal"j for eredions,
wherw the sym Pilthetic: djyilion is respon.ible for the pnxes; of ejarulation.
Antic:holinergic: drugl block trammilsion of parasympathetic: impulles and
may inwfere with normal i ntagonist! (.-J intmere with
the IIOOOth-mU\derontliKtiolll in the II'minal esidts and ptOis,lt"IUlting in
iln illibility 10 ejac:ulate.
For malt patient! lI'(eiying ilutonomi( medimiolll, the rurll' should in-
dude questions about 19ual activity during the a>ses.ment pnxm. for pa-
tient! who all' not II'xuall, these lide tffern may be unimponanl
For patients who all' lI'XUally oowe"ltr, drug-indu{td dys iun{-
tion mily be i miljor of nOMompliin(t. Tht patienl should he in-
formed to expt<I sum side tffe(ts iIId to II'pon them to the htillth (all'
provider immtdiate/y.ln most mes. medic:ations are available
that do not atle 19ual function. Inform the patitnt thillt.pponil'l' {oun-
is available.
Ii't- Prototype Drug I Atropine (Atro-Pen,Atropal"AtropISol)
Therapeutic (lass: Antidote for anticholinerase poisoning Pharma(ologic (lass: Muscarinic cholinergic receptor antagonist
ACTIONS AND USES
8)' O({upying munarinic: atropilll' bIoc:ks the parillympathetic: ac:tions
of Al:h and indlKtI .ymptoms of the fight-or-flight respoOlt. Most promintnt
ilre a led hea-t rate, broMhodiiation, a led motility in the GI trac:t, my-
drg Iis"nd led from gland . At therapeutic: doses, atropint has
no effea on nic:otinic: It(eptors in ginglia or on .ktlttJ I mus<lt.
Although atrqlilll' hiS bttn used for a variety of purposes. its
use has dt<lined in decades because of the 01 "Ifr and
mOIl' III'diutiolll. Atropilll' rna, be UII'd 10 treilt dis-
of the GI tOO IlKh is irriublt Wftl syndrollll', to .uppress I('(lI'Iions
during pIO{tdUII'I, to inm'iIII' the heart rate in with bradl'{iIf-
dii,and to dilate the pupil during t umillillions. OlKe widely UIfd to {.lYSe
broMhodilation il patients with iIIthma, atropine is na.v rall'ly ptfl(ribed for
this disorder. Atropine ther,py is Ull'iul for the tll'''mtOt of refltxie brad)'o::ar-
dia in inflms lndinfilntilt hypertrophic: pyloric: stenosis (lHPS).
ADMtNISTRATlON ALERTS
Hevtr administtriM.
Oral and doII'!ilre IIOl intt'l"{hangNblt.
Monitor prtSIUII', and respiration. befOIl' adminiltration ilnd
for at Itm 1 lour afil'l IUbrutilneous idminisuation.
Pre<JDaDq UIfgOry e
PHARMACOKINETICS
Om<1: 30 min PO; 5- 15 min IUbrutan...,.,,1y
Peak: 60-9(1 min PO; lS- JO min 30 min 1M, 2-4 min IV
Halflift:. h PO; 120 min suiKuuneously
Duration: 6 h PO; 4 h subc:utantously
ADVERSE EFFECTS
The side tllem of iltropint limit in therapeutic: Ull'iulnffi ilnd ire plI'dictablt
trtensions of its autonomic: ac:tions. Expecttd side effeus indu:lt dry mouth,
ronstipation, urinary II'Ifntion, and an inuuled hNn r"e.lnitial eNS mitt-
mtm may progren to delirium ,nd e\'eO (Ollla.
Contraindirnions: Atropine is ulually {oomindiuttd in patimts with glau-
rollla, beUU\I' the drug may iMlI'iIII' preslUre within the Alropilll' Ylould
not be administered to patients with of tilt GI iii{\, para-
lytic ilM, bladder neck obstruction, benign prostatK hypenroplly, mya.!heng
grais,urdia( insuffio:ielK)',or arute htmorrhage.
INTERACTIONS
I)ug-l)ug: Drug inteOOions with iUopne ilduM an irKrNsN , lied
antihistamine\, triqdK antidepressants, quinidine, and jro(jilliOlide. Atropinlo
dioo:l!NlfllKII oflHOOopa.
Lab Unmown
IkorbaVFooo: lJsf with {.Iution with htrbat SIKh is ,10f, IMIna rfP811
b"ilwpikMUol,buOOIIorn,and a\GIIiI
b,d in Sparish I, whim may iooUlol' atropilti with [hronk Ulf of
--.
Treatment of Al:cidtntal poisoning has O(rurrtd in dlildll'O who till
the uliorM purple berrie. of the de,dly nightshade, misuking them for (her-
ries. Symptoms of poisoning those 01 inlfnll' parillym pathetic: stimulation.
may {.lUll' eNS stimulation or deprel5ion. A .oon-,(\ng harbituratt
or diazepam (Valium) may be to (ontroi Physosug-
mint is iln antidott for "ropine poisoning tlut quic:kly II"/efIes roO"la uu.ed
by large doll'! 01 nropilll'.
Rtm III MytmJnqKl tot a MnInq I'roctll Foots sp/II( IlIIM <tug.
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Some of the anticholinergics are used for their effects on
the CNS, rather than their autonomic actions. Scopolamine
( Hyoscine, Transderm-Scop) is used to produce sedation
and prevent motion sickness (chapter 4100); benztropine
(Cogentin) is prescribed to reduce the muscular tremor and
rigidity associated with Parkinson's disease; and donepeLiI
(Aricept) has a slight memory enhancement effect in pa-
tients with Alzheimer's disease (chapter 2()O1O).
Anticholinergics exhibit a relatively high incidence of side
effects. Important adverse effects that limit their usefulness in-
clude tachycardia, CNS stimulation, and the tendency to cause
urinary retention in men with prostate disorders. Adverse ef-
feets such as dry mouth and dry occur due to block3de of
muscarinic receptors on salivary glands and lacrimal glands,
respectively. Blockadeof muscarinic receptors on sweat glands
can inhibit swwting, which rmly lead to hyperthermia. Photo-
phobia canoccurbecausethe pupil is unable to constrict in re-
sponse to bright light. Symptoms of owrdose (anticholinergic
crisis) include fever, visual changes, difficulty swallowing, psy-
chomotor agitation, and/or hallucinations. (Use this simile to
IlIop1flll DnIg< Affl'CllngtN> Autooomk fIlE, ... ,,,, synMl 145
remanber the signs of anticholinergic crisis: "Hot as hades,
blind as a bat, dry as a bone, mad as a hatter.") The develop-
mem of safer and more effective drugs has greatly decreased
the current use of anticholinergics. An example is ipratropiIDll
(Atrovent), a relatively new anticholinergic used for patients
withCOPD. Because it is delivered via aerosol spray, this agent
produces more localized action with fewer systemic side ef-
fects than atropine.
HOME & COMMUNITY CONSIDERATIONS
Promoting Safety with Medications
That Affect the ANS
Mell"latiom affecting tilt autonomK nmoJlJS systm 1ft' oflrn adminimft'll
in thr homaft' srtting. h is important that the jlatirnt Ind family unde,-
SLl nd not only tilt ft'llOn for tilt roo:Jiution but i ko tilt im pomnc:e of imllll'-
diatrly ft'JIOrting tffr>rts 10 tilt hNlth me provmt
meditation (omplianceto tilt patirnt and family. Stlffi hoIIII' saffty, bel:aust
many 01 thell' d rugs may prorb:r side tffKts that rould put tilt jlatirrl II risk
fo, lills or other injuries in tilt home rnvironmen1.
NURSING PROCESS FOCUS PATIENTS RECEIVING ANTICHOLINERGIC THERAPY
Assessment
BIIHlinr assrssment pnorto administration:
o UndenLlnd the INson the drug has been pJl'Suibed in orde, to UIffi fo,

o Obtain I complete lItaldJ history ino:klding
respiratory for irule (narrow-aogle) giaIKoma.Obtain i drug
hislOry induding preso:ription ind OlC drugs,and herbal
preparatiom. Br a Ie n to po!$ible drug intrractions.
['I<Iluall' appropriate findings sIKh,H IItPltK or ft'nallUnc:tion
lIudirs.
o Obtain b.1lt1ine viLli outpul,bowek IOUnds,and (;j,dioK rhythm
if Ipproprilte.
o Asses. the jlatient's abil"t)' to ft'CeiW' and undentand instnK1ion.ln(kide thr
family and cartgmn
Assessmrnt throughout idministration:
o A" ... fo, de!ilM thm",utK rfho<tI doptndMt on tile fNSOn fo, tho drug
(r.g.,inc:relsed Nse oHrrnhing,cardial rhythm 'Llble,BP within normal
range).
o Continue and 1olft'1U1 monitoring olviLlI and urinary output
and urdioK monitoring .JS appropriate.
o A.sess for and promptly ft'port IdW'nt efftru:umymdia, hypertension,
dysrhythmwl, trentOll, diuillf\.S, headac:he, or demased urinary output.
StizUJl'S tKhywdii may signal drugloxic:ity and should he
immediately reported.
Potentilll Nursing Dillgnoses
o Decl!asrd GJrdial Output (dysrhythmial)
o Uriniry Retention
o Constipition
Risk for Imjlaift'll Body Tempernuft'
Rille for Imjlaired Oral MlKous Mffitbrille"S
Risk for Injury (relattd to ofdrug tlltrapy)
DrfKirnt KnowIedgr (drug therar,o)
Planning: Plltient Goals lind Expected Outcomes
The pitirm will:
o Experience tlitrapMil: tfferu dependent on the ft'aIOII tilt drug is being gil'!'ll in(lNsrd rail' 01 blNthing,delft'asrd GI motiliry Ind mmping).
o from, or minimal. riferu.
o In undentandng olthe drug's 1M, idvrne effeds,ind Il'quift'd prruutions.
o Demonstrate proper ItIf-idministration 01 tilt mtdiution (e-9.,dosr, timing, whtn to no:ify provider) ind proper U\f of the inhaler.
(Continued)


,


"
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146 Until "TheNelvoo,Sy'tem
NURSING PROCESS FOCUS PATIENTS RECEIVING ANTICHOLINERGIC THERAPY ICOnrlnutd)
Implementation
Interventi ons and (Rati onales) Patient and Family Education
Ensuring therapeutic effects:

CominUl' !ITItnts as denribt.:i fa rlitr for thtrapfUtK tIfects

Tf.l(h tilt family,or carrgrm- how to monitor pulsf and blood
dtptndent on tilt realOn tlltrapy blood pressure. Ensure the plOprr USt i nd functioning of 'Il)' hOIIII' tquipment
,nd rt-lpiratol)' ratt should be within oornwllimits or within parameten Sd obt,intd.
by tilt lItalth (, re providef.GiltrK motili\)' and cramping have dowfdJ

Providt supportive nUl"! inq mta lUres; f.II-, proper positioninq for dylpnN; Ke

InstnKt tilt patient that sips of ffiips.oral rinses of
chips, fluids, or hard undyfordry mooth,t!c.(Nur1ing !U(h II hard undies nwy eaS!' mouth drylH'ss (akohol-hall'd will dl)' the
raising htad of the btod during ely!;pllN will supplement thtraptUtic: drug mooth funher).
effKlI , nd optimize outWIIII'J

Follow appropriate administration technilJJes for inhalant orophthalmil:

InstllKt the patient in proper administration te<hniques, followed bV ft'lUm-
dasH. chapter 3, Priociplts of Drug for tKhniquePO J dtmonstration.
Minimizing ildft l"!f efffits:

Monitor for ligns of ANS stimulation sIKh as drowsilH'Sl,blurred

InstnKt tilt patifot to repon palpitllionl, shonlltnof blt'ath, diuilltlS,
t.Kh)urdia,dl)' roouth, urinal)' lItsitancy, and <lKre,sed s'M'ating. dysph,gia, or syncopt immediately to heakh ure provider.
(Side efftcts are dUl' to the biockadt of mUl(arinic: reuptol"!.Anticholilltrgia
are (ontraindicated in p,tients with .l(ulffrurrow-angle gialKOIIIiI beuuS!'
mydriasis will inc:reall' intraocular pll'Isure.)

Notify the hukh ure proYicItr blood prtlSureor pulsf e:ueed

To allay possible anxiety, ttach the patitot aboot rationale for all
est,bliWd paramt tt l"!. CominUl' cardiac monitoring as appropriatt tquipllll'llt used and the lH'ed for frequtllt monitoring a\ applic:able.
(f.g.,ECG} ind urilH' outpu1.(Bmusuntic:hoIilH'''lic: drugs stimulate lItan
ratt and iocrea se tilt chan Cf for ely!; rftyth mias. tllty must be closely
monitored to iIYOid ,d-;elW' dem. htemal monitoring devicf! will dettct
taffy signs of ad\'el"!e riftm a I well i I monitoring for tlltra ptutic:.)

Monitor tilt lliIitot for i bdomioal distention and ausrultm for bo'M'l Te.l(h tilt patitnt ,bout the imponaocf ofdrinking 811a fluids and
sounds. Palpatt for bladdt r a nd monitor output. (Anticholinttgia ioclNsing fiber inuR.lnstruct tilt patient to ootify tilt heakh tare provider
may decrease tollt and motility ofimtstinal i nd bladdtr !mooth rrusdtJ if with urination occurs or if constipation II'I'I're.

Minimizf flposure to lItat and strenuous rltltM.(Aoticholilltl9ia can

InstnKt the patifot to awid proior.ge<l or slrttluous i cti'lity in wa rm or hot
inhibit S'M' at gla nd stclt'tiOOl. Sweating OKtIS' IY for patitmlto cool mviroomenB on humid days. hila-hot sho'M'rs and hot tubs
down,lO tilt drug un inclNse their risk for heat uhaustion and heat StroR.) should also be avoided. DizzilH'lI,chall9l' in lIII'IIul stitus, pale Ikin. musdt
uamping. and oauS!'a are signs of an impending heat exhaustion or stlOR
and should be reported

PlO'Iide fore)'l'comfort IlKh a\ darkened room,so/t doth 0'ItI e)'l'l,ind

InstnKt patittn thai photOlfnsitivity IIIiIY occur and may be
sunglasm.(Anticholinttgic drugSUUSf mydrialis and photosensitM\)' to I"ftdtd in bright light or for outside ilCtivitits. Caution should be ukeo with
light) driving until drug efFtcts are known.
Patimt understanding of drug thrrap-,:

lIS!' opponunitits during administration of mtdiutiJns and cbing

nw, patienT, bmiy,or cngi'ltl shJuld btoablelO state the ft'i lOll brtlltdrug;
alSl'IIml'01S to dis(l/lS r.nionale for drug therapy, dfsired theraprutic: llJI(omes, appropriate doll' and S(heOji1g; what a:l1'l'fW to obsem fur and wlBl
most commonly obseritd illMrS!' efFtcts, paraml'tro for when to tall tilt to ft'port; tljUi:Jrntm netdN as appropriate and row to Ult that i nd
hukh ure and any OKeIWIY moritoring or precautions. (Using timl' tilt reqlired imgth of tnl'diation tlwrapy netdN with all)' instructions
cbing cart helps to optimil'l' ind ft' inbKe lfilChing alNsJ I!9iIrdiflj ft'oewilg or contiruing prtsaiption as appropriate.
Patimt selfadministration of drug therapy:
When the instruct tilt or caregiver

InstnKt p.atient in proptr tKhniqUl'l, followed by ft'lUm-
in proper of an inh, leror ophthalmic drops.(Utilizing demonstration.
time ruring .xlministrJlion of thelcdf1191 hdps to

Th" ""lim!. f.", ily, or '"""'Ii..,r ., ble kI di>l." "" dtniny .od
administmion needs.
Evaluation of Outcome Criteria
(Y, IUilf tilt of drug thtrapy by confirming that lliIient goals and fllpKted ootcomes hom mt! (Iff "Planning").
"" TIIbIt illffdfl!!Il rowlOChrlll'lt gp/iY.
LibraryPirate
OIop1fl U ONg<Affealngthe Autooomk:Ne,v"", Sylll'm 147
'\
Chapter REVIEW
KEY CONCEPTS
The numkred kry coneepM provide a of the important points from the corresponding numbered ""clion
within the chapter. If any of these points are not dear, refer to the numbered section within the chapter for rt'View.
B.l The periphE1<lI nervous system is divided imo a somatic
portion, which is under voluntary control, and an auto-
nomic portion, which isin"oluntaryand comrols smooth
muscle, cardiac musde, and glandular Sl'(;retions.
1 J.2 Stimul.1tion of the sympathetic division of the autonomic
nervous system causes symptoms of the ftght -or flight re--
sponse, wherrus stimulation of the parasympathetic
branch induces rest -and-digest responses.
B .) Drugs can affect nt'fVOUS transmission across a synapse
by prewnting the synthesis., storage, or release of the
neurotransmitter; by preventing the destruction of the
neurotransmitter; or by binding neurotransmittt'fs to
the receptors.
BA Norepinephrine is the primary neurotransmitter released
at adrent'fgic re<:eptors, which are divided into alpha and
beta subtypes. Acetylcholine is the other primary neuro-
transmitter of the autonomic nt'l"Vous system.
H .5 Acetylcholine is the primary neurotransmitter released
cholinergic receptors (nicotinic and muscarinic) in
both the sympathetic and parasympathetic nervous sys.--
terns. It is also the neurotransmitter at nicotinic recep-
tors in skeletal muscle.
NCLEX-RN" REVIEW QUESTIONS
D Following administration of an adrenergic {sympatho-
mimetic} drug, the nllnt' ",mid assess fo r which adwrse
drug effects?
t. Insomnia, nt'l"Vousness, and hypertension
2. Na\lSt'3, vomiting, and hypotension
3. Nervousness, drowsiness,and dyspnea
4. Bronchial dil1tion, hypotension, and bradycardia
o Therapeutic uses fo r anticholinergics include: {Select all
that apply.}
1. peptic ulcer disease.
2. bradycardia.
3. decreased sexual function
4. irritable bowel syndrolllt'.
5. urine retention.
o Adrenergic-blocking (antagonist) drugs include all of the
following adwrse reactions except:
1. bronchodil1tion.
2. tachycardia
3. edema.
4. heart failure.
B.6 Autonomic drugs are classified by the receptors they
stimulate or block: Sympathomimetics stimulate target
tissue innervated by sympathetic nerves, and parasym-
pathomimetics stinlulate target tissue innervated by
parasymp..1thetic nerws; adrenergic antagonists inhibit
functionality of the symp.1thetic division, whereas anti-
cholinergics inhibit functionality of the parasympathetic
branch.
1 U Sympathomimetics act by directly activating adrenergic re-
ceptors, or indirectly by increasing the release of norepi-
nephrine from nerve terminals. They are used primarily for
their effects on the heart, bronchial tree,and nasal passages.
I)A Adrenergic antagonists are used primarily for hyperten-
sion and are the most widely prescribed class of auto-
nomic drugs.
B .9 Parasympathomimetics act dire<:tly by stimulating
cholint'fgk receptors or indire<:tly by inhibiting acetyl-
cholinasterooo. They have f"", u..,,; because
of their nu merous side effects.
B.l0 Anticholin ergics act hy blocking the effects of acetyl-
choline at muscarinic receptors, and are used to dry se-
cretions, treat asthma, and prevent motion sickness.
o Elderly patients taking bethanechol (Urecholine) need to
be assessed more frequently because of which of the fol -
lowing side effects?
1. Dl1phoresis
2. Hypertension
3. Dizziness
4. Urinary retention
D The patient taking benztropine (Cogentin) should be as.--
sessed for:
1. heartburn.
2. constipation.
3.
4. increased gastric motility.
o The patient taking tacrine (Cognex) should be observant
for which of the foUowing aclvt'fst' effects that may signal
a possible overdose has occurred!
I . Excessive sweating, salivmion, and drooling
2. Extreme constipation
3. Hypertension and tachycardia
4. Excessively dry eyes and reddened sclern
LibraryPirate
148 Unlll TheNelv"""Sy'lem
CRITICAL THINKING QUESTIONS
1. A 24-yt'3r-old patient {gravida 3, para I} is admitted to the
labor and delivery unit and states that she is having con-
tractions. She is at 32 weeks gestation. The obstetrician ini -
tially begins tocolysis with magnesium sulfate and then
switches the patient to terbutaline (Brethine), 5 mg PO
ewry 4 hours around the dock. The nurse recognizes
terbutaline as a beta,-adrenergic agent. What nursing as-
sessmems should be made with a patient receiving terbu-
taline therapy?What education does the patient require in
relation to terbutaline thernpy1 How wiU the nurse evalu-
ate the medication's effectiveness?
2. A 74-year-old female patient underwent a retropubic ure-
thral suspension. She required a Foley catheter for 4 days
postoperatively and was still unable to void. She was re-
catheterized, and a bladder rehabilitation program was be-
gun that included bethanechol {Urecholine}. What
nursing diagnosis should be considered as a part of this
patient's plan of care given this new drug regimen?
3. A 42-year-old male patient was dl1gnosed with Par kin-
son's disease 4 years ago. He is being treated with a regimen
of amantadine {Symmetrel}, an indirect-acting dopamin-
ergic agent, and benztropine mesylate (Cogentin). The
nurse recognizes Cogentin as an anticholinergic agent.
What should the nurse assess this p.1tient for? Discuss the
potential side effects of benz tropine that the nurse should
assess for in this patient.
Su Appendix D for answers and mtionales for all activities.
EXPLORE
'")'00' 0"" stop lor ""II"" <llaIller fnI ... matenai, "rIC
reWUfOllS. PHil_lIe lor SLQ;ess with additlOllal practi ce
Questioos, InIerllctil' e and adilties. wetl litks. animlrtioflS
arid videos. and metel
J\eglSlel yow CMe lrom me front 01 yrn.o- bQ()k at
WWIII.JII'jn .. sing kilclIfII .
LibraryPirate
DRUGS AT A GLANCE
ANTIDEPRESSANTS JI(IgI! 154
o QlQlore (l.txopro) pu;t 156
BENZOOIAZEPINES {IIY/t 157
o brOMpOm (Allvon) ptJI}t 1511
BARBrruRATES JXl}t l58
NON BENZODIAZEPIN E, NONBARBITURATE CNS
DEPRESSANTS ,.' 59
o zo/pIdffn (Amb/tll) JIIlgt 160
Antiseizll't Mtdication {llXJt160
Beta 810mB /Xl}t 160
KEYTERMS
antidtprtsSilflts JXI}t 154
an.iety 1D1, 150
anxiolytia {X1IJt /5}
(EEG) {XJ}t I5J
generaliztd lInxietydisonler ((;AD) pq 150
hypnotic pogr 154
insomnia pagt/5]
limbiuystelll pajt 150
Drugs for Anxiety
and Insomnia
LEARNING OUTCOMES
After reading this chapter; the student should be able rex
1. Identify the major types of anxiety disorders.
2 . Discu5s fKtors contributing to ",oxiely and e)(plain some
nonpharmacologic therapies used to cope with this disorder.
3. Identify the f!!'glans of the brain assodated with anxiety, sleep, and
wakefuilless.
4. Identify the three classes of medications used to treat anxiety lind sleep

5. Explain the pharmacologic management of anxiety and insomnia.
6. DeKribe the nurse'$ role In the pharTTklcologic management of anxiety
and insomnia.
7. Identify normal sleep patterns and explain hOY/these might be affected
by anxiety and stren.
8. Categorize drugs used for anxiety and insomnia based on their
classlflcatlon and mechanism of aalon.
9. For each of the dasses listed in Drugs at a Glance,know representative
drugs and explain thelr mechanisms of action. primary actions, and
Important adverse effects.
10. Use the nursing process to care for patients receiving drug therapy for
anxiety and Insomnia.
1000g\erm pagt 152
obleli.e-{olIlpuilnot disorder (OCD) fJ09t ISO
POWlK di1ordt" IXJt 150
phobial pG}t 150
polltraumatK It rmdisonler(PTSD) (XJgt 150
rtbound itKOIIIni.J ,.153
REM pJIJt 151
rttiruiar actimingsystem{RAS) pagt 150
rttKular !ormation Pl9t /SO
sedatif! fJ09t lSI
sedatifr-h)'JIIlOIK {III]t 154
shOfttermor insorni. Pl9t 15]
situ.Jtionai OWl_iet, /XlJtI50
slrrp drbt pagt 151
sodal anxiety ptl}t ISO
tranquilizer (IIJIJt 154
LibraryPirate
150 Unlll Thl'Ne<voo,Synem
P
atients experience nervousness and tension more often
than any other symptoms. Seeking relief from these
symptoms, they often turn to a variety of pharmacologic and
alternative therapies. Most health care providers agree that
even though drugs do not cure the underlying problem,
they can provide temporary help to calm patients who are
experiencing acute anxiety, or who have simple sleep disor-
ders. This chapter deals with drugs that treat anxiety, cause
sedation, or help patients sleep.
ANXIETY DISORDERS
Acoording to the International Classification of Diseases,
10th edition (ICD-IO), anxiety is a state of "apprehension,
tension, or uneasiness that stems from the anticipation of
danger, the source of which is largely unknown or unrecog-
nized." Anxious individuals can often identify at least some
factors that bringon their symptoms. Most peoplestate that
their feelings of anxiety are disproportionate to any factual
dangers.
14.1 Types of Anxiety Disorders
The anxiety experienced by people faced with a stressful en-
vironment is called situational anxirty. To a degree, situational
anxiety i.< beneficial be,,;ause it motivate, people to
plish tasks in a prompt manner- iffor no other reason than
to eliminate the source of nervousness. Situational stress
may be intense, though patients often Learn coping mecha-
nisms to deal with the stress without seeking conventional
medical intervention.
Generalired anxiety disorder (GAD) i.< a difficult-to-control, ex-
cessive anxiety that lasts 6 months or more. It focuses on a
variety of life events or activities, and interferes with normal
day-to-day fWlctions. It is by far the most common type of
stress disorder, and the one most frequentlyencoWltered by
the nurse. Symptoms include restlessness, fatigue, muscle
tension, nervousness, inability to focus or concentrate, an
overwhelming sense of dread, and sleep disturbances. Auto-
nomic sigru; of sympathetic nervous system activation that
accompany anxiety include blood pressure elevation, heart
palpitations, varying dt'Srees of respiratory change, and dry
mouth. Parasympathetic responses may consist of abdomi-
nal cramping, diarrhea, fatigue, and urinary urgency.
Women are slightly more likely to experience GAD than
men, and its prevalence is highest in the 20-3S age group.
A second category of anxiety, called panic disorder, is charac-
terized by intense feelings of inunediate apprehension, fear-
fulness' terror, or impending doom, accompanied by
increased autonomic nervous system activity. Although
panic attacks usually last less than 10 minutes, patients may
describe them as seemingly endless. Up to 5% of the popu-
lation will experience one or more panic attacks during
their lifetime, with women being affected aboUitwice as of-
ten as men.
Other categories of anxiety disorders include phobias, ob-
sessive-<:ompuLsive disorder, and post-trawnatic stress disor-
der. Phobias are fearful feelings attached to situatioru; or
objects. ConmlOn phobias include fear of snakes, spiders,
crowds, or heights. A fear of crowds is termed social anxiety. Per-
formers may experience feelings of dread, nervousness, or ap-
prehension termed performance anxiety. Some anxiety is
normal when a person faces a crowd or performs for a crowd,
but extreme feartothe point of phobia is not normal. Phobias
compel a patient to avoid the fearful stimulus entirely to the
point that his or her behavior is nnnatural. Another unnatu-
ral behavior is obsmiw-<am]lJtsivedisordrr(OCD). It involves recur-
rent, intrusive thoughts or repetitive behaviors that interfere
with normal activities or relationships. Common examples
include fear of exposure to germs and repetitive hand wash-
ing. Post-traumaticstressdisordrr(PTSD) is a type of situational anx-
iety that develops in response to re-experiencing a previous
life event Traumatic life events such as war, physical or sexual
abU'le, natural disasters, or murder may lead to a seru;e of
helplessness and re-experiencing of the traumatic event Hur-
ricane Katrina,as weU as theterrori.<t attack on September] I,
2oot,are examples of situations that may trigger PTSD. Pea-
plewho experience these types of traumatic life events are at
risk for developingsigru; and symptoms of PTSD.
14.2 Specific Regions of the Brain
Responsible for Anxiety
and Wakefulness
Neural systems in the bra in associated with anxiety and rest-
1essness include the limbic system and the reticular activat -
ing system. These are illustrated in Pharmacotherapy
Illustrated 14.1.
The limbic is an area in the middle of the brain re-
sponsible for emotional expression, learning, and memory.
Signals routed through the limbic system ultimately con-
nect with the hypothalamus. Emotional states associated
with this connection include anxiety, fear, anger, aggression,
remorse, depression, sexual drive, and euphoria .
The hypothalamus is an important center responsible for
unconscioU'l responses to ooreme stress such as high blood
pressure, eiewted respiratory rate, and dilated pupils. These
are responses associated with the fight-or-flight resporu;e of the
autonomic nervoU'l system, as presented in chapter t )OO.
The many endocrine functions of the hypothalamus are dis-
cussed in chapter 4300.
The hypothalamus connects with the rrticular formation, a
network of neurons found along the entire length of the
brainstem, as shown in Pharmacotherapy Illustrated 14.1.
Stimulation of the reticular formation causes heightened
alertness and arousal; inhibition causes general drowsiness
and the induction of sleep.
The larger area in which the reticular formation is fOWld
is called the rrlicularadivatingsystem(RAS). This structure proj-
ects from the brainstem to the thalamus. The RAS is re-
sponsible for sleeping and wakefulness and performs an
alerting function for the entire cerebral cortex. It helps a
LibraryPirate
IlIopur 1( Drug. 10< Anxlety.nd Insomnia 15 1
PHARMACOTHERAPY ILLUSTRATED
---
14.1 The Reticular Activating System and Related Regions in the Brain Are Important
Areas of Focus for Drugs Used to Treat Anxiety and Anxiety-Related Symptoms
Unlavomb le II")'fTptome related to anxiety:
, ,,t09ue. ,eslle...,,_. inabiily to ....... P.
learlull_linga, feelings 01 dread. difficulty
<><><>eentr"ting.
Thalamus
Two regione oitlle brain am
strongly BMOC;"lad with anxiety,
expression 01 """,tiro., and a
..... Hess .Iale: (a) the limbic
system; and (b) the reticular
lormatio n (" nucleus whln
n ........... s;gnals IO!ICend to hip
cent"", 01 the brain).
person focus attention on individual tasks by transmitting
information to higher brain centers.
If signals are prevented from passing through the RAS, no
emotion-related signals are sent to the bruin, resulting in a
reduction in general brain activity. If signals coming from
the hypothalamus .reallowed to proceed, then those signals
PHARMFACTS
Anxiety Disorders
About 19 million Amt riuns uediagnostd with anxitty )'I'ar.
Other iIIotsm that ronist with aOlitty iodude rlepreswo,
ratiog disorders, aod rubll.Jnu <1 m.
top {lUll'! of aOQtty (1Ililled io order) o{{ur betweeo
of18and54:
1. Phobia
2.
3.
4. fffiiogs
5. Panic:
Cotpoo coIloaum
Antidepressant.: (5"" chapter 16 lor speeific
mechaniems)
Tricyclic amideprMsants(TCAo)
Monoamine <.idaH inhibitora (MAOls)
Selective HftItonin ""'plake inhibitora (SSRls)
Atypical .,l:idep<Maante including serotonin
inhibilora (SNRla)
e NS Depr.sanl.: (See chapte r 1510< speejf",
mechanismo)
BIInzodiazepi"""
Barbituml ...
. --
are further routed through the RAS and on to higher brain
centers. This is the neural mechanism thought to be respon-
sible for feelings such as anxiety and fear. It is also the mech-
anism associated with restlessness and an interrupted
sleeping pattern.
14.3 Anxiety Management
Through Pharmacologic and
Nonpharmacologic Strategies
Although stress itself may be incapacitating, it is often only
a symptom of an Wlderlying disorder. It is considered more
productive to uncover and address the cause of the anxiety
ruther than to merely treat the symptoms with medications.
Patients should be encouraged to e."lplore and develop non-
pharmacologic coping strategies to deal with the underlying
causes. Such strategies may include oognitive-behavioral
therapy, counseling. biofeedback te.:hniques, meditation,
and other oomplementary therapies. One model for stress
management is shown in .. Figure 14.1.
LibraryPirate
Aruliety and
IJYmPI0rr-0. on
longer besil
.. Figure , ... , A model of In whiCh events
or a changing mental condition un produce unfavorable
symptoms, some of which may be controlled by mediCatiOn
When anxiety becomes severe enough to significantly
interfere with daily activities of life. pharmacotherapy is
indicated. In most types of stress. or drugs hav-
ins thlO ability to relieve anxilOlY, arlO quite cifect iylO. These
include medications found within a number of thenpeu-
tic categories: centnl nervous system (eNS) asentssuch as
antidepressants and CNS depressants; drugs for seizures
(chapter 1500): emot ional and mood disorder drugs
(chapter It;QIe : antihypertensive agents (chapter 2)00):
and antidysrhythmics (chapt er 2t;Q1e . Anxiolyli cs pro-
vide treatment for all the conditions mentioned in
14.1: phobias, post- traumatic stress disorder, generalized
anxiety, obsessiw-eompulsive disorder. and panic attock.
INSOMNIA
Insoooia is a amdition chancterized by a patient's inability
to fall asleep or remain asleep. Ph.armacot herapy may be in-
dicated if the sleeplessness interferes with normal daily ac-
tivities.
14.4 Insomnia and Its link to Anxiety
Why is it that we need sleep? During an average lifetime,
about 33% of the time is spent sleeping. or trying to sleep.
Although it is well established that sleep is essential for well-
ness, scientists are unsure of its function or how much is
needed. Following are some theories:
Inactivity during sleep gives Ihe body time to repair
itself.
Slet']' is a function that evolved as a protective
med!.anism. Throughout history, night -time was the
safest time of day .
Sleep deals with "electrical
M
charging and discharging of
the bnin. The bnin needs time for proctSsing and filing
new infocmation collected throughout the day. When
this is done without interference from the outs ide
environment, these vast amounts of can be
retrieved through memory.
The acts of 51reping and waking are synchronized 10
many different bodily functions. Body lemperature, blood
pressure, hocmone levels, and respiration all fluctuate on a
cyclic basis throughout the 24-hour day. Whm this cycle be-
comes impaired, pharmacologic or other interventions may
be needed to readjust it. Increased levels of the neurot rans-
mitter serotonin help initiate the various processes of sleep.
Insomnia, or sleeplessness. is a disorder somelimes asso-
ciated with anxiety. There are several major types of insom-
nia. Shortterm orb.ha.ioral imomnia may be 10 stress
caused by a hectic lifestyle or the inabihty to resolVe day-to-
day conflicts within the home environment or the work-
pJa,e. Worrit'S about work, marriage, childrtn, and health
are common reasons for loss of sleep. When
stress interrupts normal sleeping patterns, patients cannot
sleep because their minds are too active.
Foods or beverages containing stimulants such as caffeine
may interrupt sleep. Patients may also find that the use of
tobacco products makes them restl ess and edgy. Alcohol. al-
though often enabling a jlI'l'$On to fall aslp. may produce
vivid dreams and rnquent awakening that prevent restful
sleep. Ingestion of a large meal, espedally one high in pro-
tei n and fat , oonsumed clO$C to bedlime can inlerfere with
sleep, due to the increased metabolic rate needed 10 digest
the food. Certain medications caUS(' CNS stimulation. and
these should not be taken immediately before bedtime.
Stressful condi tions such as too much light. uncomfortable
room tempenllire (especially om' that is too warm). snor-
ing. sleep apnea, and recurring nighlmares also interfere
with sleep. longtfllll ftsomiIii is often caused by depression,
manic disorders, and chronic paIn.
COMPLEMENTARY ANO A LTERNATIVE T HERAPIES
Valerian for Anxiety and Insomnia
y,ltriin (Vdfflaoo oflimdif) is iI pI.lnt grown in EUlOpt, Asi.!, ilnd
North AmerKa.y,ltriin has snwaJlUbllilll(ts in iu I00I1 t!wt 'ff1 thteNS;
tht wet has yfl to bt i<ltmififd. Yalerian!ws bftn used 10
ntrYOUSntI5, ,ro:idy, and insomni.! for thouundl of yurs and is OM of
tht most Tht drugappNl'I to Mie efftt
similar to b/,nzodi.!l'tpinl's, sum u (Valium) AtaUah, &
2(06). Tht IIU joni<lt eIMn of Villtri," iI re "tens ions of its tht"peu-
tic rifrm: dl'OWlinrss and dtcrmrd ,ltnnrss. y,ltrian should not be (011\-
binrd with akohol or othl r dr1J91 that (,11M or drowsintl5. Nott thlt
SOIIII' ptopIt , "paradoxiul with iI, they 11
nrrvous or jintrJ. A/thouqh tlIis is no! iI sidt tffKt. it bt ft-
ponrdllwllu!th(,lN' prom.,l
LibraryPirate
PHA.RMFACTS
Insomnia
Or.t mid ohhewoMspopoUlion hu uoubIf, slHpmg dImg


p.wnu okIef dlin6S IIeoep Ie! tlwnanyothtr. group.
Dilly ibout of peo,ltwith imomnw f'ftf thi! problem to their
hraltb PlUYiders.
P<"Oplt buy orc sltfp mediutions .lIId (ombination drugs with sItep
often INn an, oIlierdrug Examples oltrade-
name PIOlb:Uirt Mltin PM..Emllrin PM.. NytoLOuitr: World. Sltep-EtL
Sommer. PM ... d UniSOIll.
Al a lIIIIJIal solution Io! _ patie!J1:! comidrf meYlOIIin or hrItiI
I!mfdies sud! ts nltrWnGf km 1100).
Nonpharmaoologic means should N allempted prior 10
initiating drug ther.l py for sleep disorders. LOllg- term use of
sleep medin tions is likely to worsen insomnia and may
cause physical or psychologic dependence. Some
experience a phe nomenon referred to as lt'boundinsomnia. This
condition occurs when sedative drug is di scontinued
abruptl y or after it hu been taken for along time; sleepless-
ness and sympto ms of anxiety then become markedl y worst.
Older pati ents art more likely 10 experience medication-
related sleep problems. Drugs may seem to help the insom-
nia of an elderly patient for a night or lWO, only to produce
general ized brain d)Sfunction as the medication accumu-
lates in the s)Stem. The agitated patient may then bt- mistak-
enly overdosed with further medication. Nurses, tspedally
those who work in geriatric settings, are res ponsible for
making a"urate observatioru; and reporting pati ent re-
sporues to drugs so the health care provider can de ter mine
the lowest effea ive maintenance d05e. When PRN medin-
tion is required (or sleep, the nurse needs to conducl an in-
dividualized assessment of the individual, as well
follow_up l'\'alUalion and documentation of the
tion's effect on the p,tient .
PHARMFACTS
Insomnia linked to Insulin Resistance
ChrooiI; sItep mi, people IIIOR' proot type 2
dilbtle5,or non-wulil-dtpmdent mftIiM (NIOOM).
Chronic *tpun prOide thr imptM for bod, 10 dI:'Ielop a
Itnskivity to
In ooe study, heikh, Icl.rk! who IYeraged little m/ft Ihin 5 hours 01
sIHp jl(f night over 8 c)R1eaIIift 51*. mort insulin thin
thoIt who _aged 81K1urs ofslHp jl(f nightfortlle QIIlf ptriod.ThoIt
whowflliess wtrt 40\4 1m smVtM to insul .. tIIan tItOIf whogot mort
....
SIHop deprjwnion (6.5 houn w leI ptI' rigM.hnaynpliin why type 2
iI be<oming Win pm-HrI..
0Iapt1' DrugsIofA"""'ty.odr""'m..... 15)
COMPLEMENTARY ANO A LTERNATIVE THERA.PIES
Ka"
... {PIrrIllftfJy5rinln) SoudI Pm Minck.K.m h'l
iKIiw ill h lOOtS thilt iffe<t 1M OIS, ind .. ii hqumtly t.std b
t hr ftoJIlM_ of.nDtty iIId insomnia.lleurrt h_ shown tNt boa
may not br rIf1iw kif insomnil, IIIIt this rtsuh: IlIiY br dow,
5choley, condJr.trd on
b .. has plIMn its intianXitty rifI 20(6). !hi! hMI iI aYailille II i
t inc1U1I' (akohol miJrurt) or tu. or in (lplUle fonn. Km mi, in(rttse the
efltcu 01 boiIrbiturilts and may interact with i broad range oIdrugs,
indu:ling boil rbirurales, brnwdim-pines,lnd .n1ipoaoomoo ism agenls.
14.5 Use of the
Electroencephalogram to Diagnose
Sleep and Seizure Disorders
The is 1001 for diagnosing sleep dis-
orders, seizure activity, depressio n, and dementia. Four
types of brain waves-alpha, beta, delta, and theta-are
identified by their shape, freq uencies, and height on a graph.
Brain waves give the health ca re provider an idea of how
br ain activity changes during various stages of sleep and
consciousness. For example, alpha waves indicate an awake
but drowsy p;.Itient. Beta waves indicate an alert patient
whose mind is act ive.
T\<Qdistincl types of sleep can be identified with an EEG:
noruapid I')'l' movement (NREM) sleep and rapid eye
movement ( REM) sleep. There are four progressive stages
that .idvance inlO REM sleep. The stages of sleep are shown
ill Table 14.1. After NREM sleep has gone through tbe four
stages, the sequence goes into reverse. Under normal cir_
cunutances,after returnitlg from the deptruofstage IV back
to stage I of NREM, a person will still not awaken. Sleep
quality begins to change; il is not as deep, and hormone lev_
eu and body temperature begin to rise. At that point , REM
ileep occurs. REM slup is often caUed paradoxical sll'f'p, be-
cause the brain wave pattern of thi s slagI' is similar to that I
when persons are drowsy but aWllke. This is the stage during ".'
whid! dreaming occurs. People with normal sleep pallerns
mOVf from NREM to REM sleep about every 90 minules. !
Patients who are depri\'l'd of stage IV NREM slfep expe-
rielKe depression and a feeling of apathy and fatigue. Stage
IV NREM sleep appears to linked to repair and restora_
I
changes in the environment. The body requires the dream !!
state associated with REM sleep to keep the psyche function_ j
ing normally. When test subjects are deprived of REM sleep, _
they experience a 11Ufl debt and become frightened, irrita_
ble, paranoid, and even emotionallydisturbed.ludgment is ii
impoired, and reaction time is slowed. It is speculaud that :I
to make up for thei r b ck of dreaming, these persoru expe_ i'
rienee far more daydreaming and fantasizing throughout I
the cay.
LibraryPirate
154 Unlll lheNetv"",.Synem
TABLE 14 1 Stag"5 of SI""p
NREM llagt2

"REM stJgt4
DescrIption
At tilt of tilt a of
IttIwsintSs for abouJ: 110 7 minutfi. timr, tilt
patimt can Nsify lasll for abouJ:

TIlt paliffil un llill mily awaktntd. JJis
CMSiiMes lilt 01'101.11 .Iup [ilM, m-:,
1055%.
TIlt patiffitlNy IIIIM imo orOUI of a Hun
ratt and blood pIHlUfI' fal ; giSlrointrllinal activity lilts.
JJis Iaru for abOUl4% 10 6% oftotJl sIefp timt .
TIlt dtrpo!lI stJgt of thilllagt laIIS i litdt 10/H}tI"
lhan 1 or 1 10 15%.
lIagc wring wtidJ nightmares omr in dikttn.
i common for
Hun rite and blood pR"ISlR Jl'lllain iow;ljisutintestinal
remains high.
JJis lIige maliKltriztd by t)'I' IlIO\'ffilmt and a los! of
mUlde torIt. rrIO'mIItnl O((lI"! in bulllS of aairily.
Druming lakes ploKt in thi! stJgt.1ht mind iClivt
and restmblts i nonnal wal::i1g stJll'.
CENTRAL NERVOUS SYSTEM AGENTS
eNS agents are drugs that produce profound activity in the
brain and spinal cord. eNS depressants are that slow
neuronal activity in the brain. Patients experiencing aru.iety
or sleep disorders benefit from four general classes of med-
ications: antidepressan ts, benwdiazepines, oorbiturates,
and nonbenzodiazepine/nonbarbiturate eNS depressants.
Additional drug classes have anxiolytic activity and prevent
stressful reactions in the body.
14.6 Treating Anxiety and Insomnia
with eNS Agents
Antidepressants are frequently used to treat symptoms of
anxiety. Thesedrugs an ability to reduce anxiety symp-
toms by altering levels of two important neurotransmitters
in the brain, norepinephrine and serotonin. Restoration of
neurotransmitter imbalances may reduce symptoms associ-
ated with depression, panic, obsessive-compulsive behav-
ior, and phobia. Typical antidepressants include tricyclic
antidepressants (TCAs), selective serotonin reuptake in-
hibitors (SSRIsj, and monoamine oxidase inhibitors
(MAO Is}. Atypical antidepressants are more diverse. More
detailed treatment of these drugs and their important
mechanisms of action are covered in chapter 1600.
CNS depressants used for anxiety and sleep disorders are
categorized into two major classes, the benzodiazepines and
barbiturates. A third class consists of miscellaneous drugs
that are chemically unrelated to the benwdiazepines or bar-
biturates but have similar therapeutic uses. Other eNS de-
pressants that have a calming effect in the body include the
opioids (chapter 1aoo) and ethyl alcohol {chapter 1200}.
eNS depression should be viewed as a continuum rang-
ing from relaxation, to sedation, to the induction of sleep
and anesthesia. Coma and death are the end stages of eNS
depression. Some drug classes are capable of producing the
full range of eNS depression from calming to anesthesia,
whee","s others les. efficacious. depress
the eNS are sometimes called sfdati-m because of their abil-
ityto sedate or relax a patient. At higher doses, some of these
drugs are called hypnotics because of their ability to induce
sleep. Thus, the term is often used to de-
scribe a drug with the ability to produce a calming effect at
lower doses and the ability to induce sleep at higher doses.
Tranquilizer is an older term, sometimes used to describe a
drug that produces a calm or tranquil feeling.
Many eNS depressants can cause physical and psycho-
logic dependence, as discussed in chapter 1200. The with-
drawal syndrome for some eNS depressants can cause
life-threatening neurologic reactions, including fever, psy-
chosis, and seizures. Other withdrawal symptoms include
increased heart rate and lowered blood pressure; loss of ap-
petite; muscle cramps; impairment of memory, wncentra-
tion, and orientation; abnormal sounds in the ears and
blurred vision; and insomnia, agitation, an.'ciety, and panic.
Obvious withdrawal symptoms typically last 2 to 4 weeks.
Subtle ones can last months.
Antidepressants
Starting in the 19605, antideprmanlS were used mainly to treat
depression or depression that accompanied anxiety. Today,
antidepressants are used not only to treat major depression
(chapter 1(00), but also to treat anxiety conditions includ-
ing general anxiety disorder, obsessive--compulsive disorder,
panic, social phobia, and post-traumatic stress disorder.
Given the effectiveness of antidepressants for these condi-
tions, many believe that in the future, anxiolytics and anti-
depressants will no longer be treated as separate drug
classes.
14.7 Antidepressants for Symptoms
of Panic and Anxiety
For most patients., panic symptoms wme in two stages. The
first stage is termed anticipatory anxiety, in which the patient
begins to think about an upcoming challenge and starts to ex-
perience feelings of dread . The second stage is when physical
symptoms such as shortness of breath, accelerated heart rate,
and muscle tension start to emerge. Many of the stressful
symptoms are associated with of the autonomic
nervous system. For panic attacks, the most useful therapy is
to help the patient become motivated to face his or her fear
and to suppress symptoms in one or more of these stages. If
drugs can reduce the negative thoughts associated with the
anticipatory component of panic, then there is less likelihood
that the patient will feel stressed. Drugs also reduce neuronal
activity and actually suppress the autonomic nervous systenl,
helping the patient to remain calm. The patient can then use
self-help skills to control his or her behavior.
LibraryPirate
IlIapttr I( Drug. 10< Anxk>ty.nd In'iOmna. 155
TABLE 1,( 2 Antidepressants for Treatment of Anxiety Symptoms
On"
Route and Adult Dose (max dose where Indicated) Adverse Effects
TRICYCUC ANTIDEPRESSANT'S (TCAs)
IElavil) PO; 75- 100 may gOOlia11'1 10 150- 300 mgfday
(Ult Iowtr in norhoIpitalilfd patimts) rtymoorh,mn5lipaD"on, urm rmnrioo, weigh! #11,
dom",amine PO; 75-300 mglday in dividfd
f1m1Of, bWfd rifion, JIgIr! m)'JriofiJ
dcsipliminr (tIoIpf.1mil, PO; mglday.l or in lividcl:l maygr.dually
AIl.nuOCV!Ws.!!2!! maTOW
Prnoffine.OIhe-s) inuult 10 150-300 mglda, (lISt 100000doie in oIdft ad'*:
hNrt blod, "'I a!'!lJiotdema offalt toogue or
patiffiu)
"""""
doJ:epin (Sintqwn or Adapin) PO; 30-150 mglda, at bedtimeor in limN dole; may gradually
inuult 10 300 mglday (lISt Iowrr dostl in oIdtr adult patients)
imipraminelTo/tanil) (Sf!' page 187 PO; 7S- 100 mglday (max:lOO mgfday) in lingitor divided dole
for tilt Drug box 00)
"'lInrlor) PO; 2S mg or ioor.1rd to l00- 1SO mg/day
uimipramine {StI"montilj PO; 7S- 100 mglday (max 300 mgfday) in divided 00Its
MONOAMINE OXIDASE INHIBITORS (MAOls)
p/lftlflzint(tjartll) PO; IS mg rapidy toat INII60 mgldar, may net<:!!4l Orlllmir h)'JIoleruion, cm:sriplllion, rty 1IIOIIfh, MlMtI
to90m9Idi)'

trin)kypromine I Polmate) PO; 30 mglday in 2 dividtd dostl(1O mg in am., 10 rng in p.m.);
may ilKl!lII' IJj' 10 mg/di)' al J-wk irltmts (max:60 mg/di)')
/taro ilKkitt ammon admsIo ilKkitts loffious adYerll' effKls.
The primary medications used to reduce symptoll15 of
panic and anxiety have been the TCAs, MAOIs, and SSRIs.
The medications with the longest track record for treating
anxiety symptoms are summarized in Table 14.2. The newer
firstIine SSRIs treat not only panic symptoms but also
symptoms of obsessive-compulsive disorder and phobias
(Table 14.3). Popular SSRIs available for treatment of anxi-
ety symptoms and depression include citalopram (Celexa),
TABLE 1,( 31 Antidepressants for Anxiety Symptoms, Restlessness, and Depression
On"
Route and Adult Dose (max dose where Indicated) Adverse Effects
SELECTIVE SEROTONIN REUPTAKE INHIBITDRS(SSRls)
dtalopram ICdw) PO;Yotl1 at 20 mglday; may ilouse 10 40 rng/day Hnrtdrd Mw>t41OO1iring. dry moom, imcmnkl,5OmfX)/trrt,
Q !:Idtalopram oolale (lnipro) PO; 10 mgldar, may inurlll' 1010 mglday W 1 wk
I1todocM, GI mJl!UOOocO'1.
ftuoxetint (Prom) PO; 10 mglday in a.m.;1IIi)' iOO1'alt IJj' 20 rJl9/di)' it
JmJd dylfuocrioo, Dgirkll. dizzir.ru, fafigw
inl ......... l ..... :80 "'II/doy);whm "",bio: may ,wil<h 10 _ 9CJ..mg
StM!!! Joh!l\!l!!
tapll.it (mD:90 mgIwk)
INoyibypomooja oDd 5ljdd
o
ljty (np!'dally iD
(1Jriox1 PO; !liIt wilh SO mg/day;may inuull' !lowly up to300 mglday
,bildlml oIl1norrnol
cli!turbam:e. jnmbirtr with
giftn al bedtine ordividtd bid
po$siblt rapid /luawlions of vital !ian\:, snm
l!'.til) PO; rng/day mOl'"jn svnOOuDP
!tf1ralinr (ldoft) PO; begin with 50 mg/day;graoilall'1 iOO!all' fflf'! fewwms
iCtordilg to rtspOnll' (range: 50-100 rng)
ATYPICAL ANTIDEPRESSANTS
miniLlpinr (Remeron) PO; 1 S mglday in a singe doIr il bedtime; may inatall' MIJ' fmIIic htarl rot! arid I!IC1C1d prtS5I!ff,
1- 1wk (max: 4S mg/di)') hyporemion,drymMll. dilZillflJ,f<lI!n<WfKt,
tr.zodonr IDrlyrtll PO; mglday in dividN may iooelll' by mg/d.ty am
MlfIlitilg..wto6111]
3- 4 days (max: 4OO-liOO mg/di)') 5Mre min!!)' iml1!!lIi'Ii\)',men!<!! mlgl d!i!!ml thjJ
YeIllafaxile (fffemr) is po; !tarl with 37.S mg/di)' sustained rrlelll' and iOO1'.lIl' 10
include mrrme atilation p!!l!RIsina t9 dtliiLnl and
an Sf!' mapter 1600) 75- US mglday 5U11ained mUll'
(oma
I[aro ilKkite a:mmon admsIo loffiousadYelSl' efltru.
LibraryPirate
156 Unlll Tte Netvoo, Sy<lem
escitalopram oxalate ( Lexapro), fluoxetine (Prozac), parox
etine (Paul), and sertraline (2oloft). Escitalopram oxalate
( Lexapro) is futured as a prototype drug primarily used for
treating generalized anxiety disorder.
Atypical antidepressants are drugs that do not fall conve-
niently into tht other categories. Mirtazapine ntay be useful
in managing disturbances or agitation. Adverse effects
for mirtazapine involve weight gain, constipation, and dry
mouth. Trawdone is often used along with an SSRI to help
with restlessness and insomnia. Blurred vision, headache,
and nausea are among the adverse effects expected with
these drugs. Further discussion of atypical antidepressants
is found in chapter ]CSOO.
Because of adverse reactions, some patients might find
antidepressant treatntent unacceptable. In 2004, the Food
and Drug Administration issued an advisory warning
pointing out the potential warning signs of suicide in adults
and children at the beginning of antidepressant treatment
and when doses are changed. In addition,manysigns, which
are the focus oi anxiety therapy, might be expected with the
use of antidepressants, for example, irritability, panic at-
tacks, agitation, insomnia, and hostility. See chapter ]600
for i of
pressant drugs in general.
Following is a brief swnmary of additional important
considerations for each class of antidepressant:
TC.As--Not recommended in patients with a history of
heart attack,heart block,or arrhythmia; patients often
Prototype Drug I Escltalopram Oxalate (Lexapro)
have annoying anticholinergic effects such asdry mouth,
blurred vision, urine retention, and hypertension
(chapter ]300); most TCAs are pregnancycategoryC or
D; concurrent use with alcohol or other CNSdepressants
should be avoided; pat ients with asthma, gastrointestinal
disorders, alcoholism, schizophrenia, or bipolar disorder
should take TCAs with e)ltrerne caution.
SSRIs--Safer than other classes of antidepressants; less
common sympathomimetic effects (increased heart rate
and hypertension) and fewer anticholinergic effects;
SSRIs can cause weight gain and sexual dysfi.mction; an
overdose of this medication can cause confusion,
anxiety, restlessness, hypertension, tremors, sweating,
fever, and lack of muscle coordination.
Atypical antidepressants including
serotonin-norepinephrine reuptake inhibitors
(SNRIs )- A nwnber of adverse effects might be
observed including abnormal dreams, sweating,
constipation, dry mouth, loss of appetite" weight loss,
tremor, abnormal vision, headaches, tl.1usea and
vomiting, dizziness, and loss of sexual desire.
MAOI&-Patients should strictly avoid foods containing
tyramine, a form of the amino acid tyrosine, to avoid a
hypertensive crisis and should refrain from caffeine
intake; MAOIs potentiate the effects of insulin and other
diabetic drugs; common adverse effects include
orthostatic hypotension, headache, and diarrhea; rarely
used because of the potential for serious adverse effects.
Therapeutic (lass: Antidepressant; anxioiytic Pharmacologic (lass: Selective serotonin reuptake inhibitor (SSRI)
ACTIONS AND USES
h(itliopram is a seitdi .... W' rotonin rtlJptakf inhibitor (SSRI) thu inuNsH the
av, ilabiliry of u spt(ific: pGSUynaptic rrct"ptor sitHloottd within the
CNS. Sritcti .... inlibilion of W'IOlonin reupt,kf I!"IUIts in, ntidepnoss.J nl ,ctiYity
withoot produnion of sym ploms of sympathomimetic or antic:holilll'rgic: miv-
This medic:.uion is indic' ltd for conditions of gtooaliztd anmly and
prHsion.Unlabeltd U!H include thr uutment of panic disorden.
ADMINISTRATION ALERTS
This medicaticn 5hou1d not br started until 14 days ,fler dis-
(ontinuing ' "I MAOI
I n mn of IftIOI or hepatic im poi""""l or in oIdtr adults, rtductd d ...... ift
"""'"
DoW' incftmelU should br stpar,ted by 'Iitan] Wl'rk.
Pl!gnallQ t
PHARMACOKINETICS
Onset: Wnh OIKHlail)' doIinllsttad)o-Stltr plasrru (oncmmtiom
can br INCIiN within] wk
Peak: 5h
Halflifr: 25- 35 h
Duration: V, ri.Jblt
ADVERSE EFFECTS
Srrious includr naum, ifllOmn;" IOmnoitrmr,ronlulion,
,nd seizure if laken in OY!'rdoI!'.
Contraindications: This drug should not br used in p,tienu who aft brusl-
feeding or within 14 of MAOI thr"py.
INTERACTIONS
1Wg- 1)ug: MAOfs IhoIMI bIo iI'IOidfd U to Irf

"'-Wfs aUrI mr:in IwfmMMoisis,
tpthHmi',MId .... ooorricinsubilily.
bdlil/oplam wil 0.:.-pI.Mw 1eftI. or meloproIoI.od <inetidi ... "","'. , ... !
U\f or aIaIhoI MId
palifru shcUd.woid akohol whfn tJkiIg this drug.
Lab Tests: Unknolrm
IkorbaVFoorl: lisf<1Ulionwith htrbaI IIKh ill St lohn\"IlO!l, wtich
rna, YU5I' serotonin s)"lldronwo DI inul'dll' 1M of!5dtJlopool
Tmtmrnt of O"ferdOSf: Theft is no Iptcifrc: IftUmtnt far!ll'l'ldol!'. TINt
symptams, as indicated, including diuinrss, (onfusion, naUlt ', 'IOmitinll
tremor, sWNting,lachyu!d;',and W'izufts.
IWrr III MyIUslniJKl for g MIsJnq Procell Foon <;pf!{/It: IIIIM It!!g.
SttGKf!M 14{1Qge 191, fIJI MnhjI'rlmlF00/5:/'QrItMRtfelwffJ,l "' rklI'JIItIIIIM
T/ltfll/lf OO .
LibraryPirate
Benzodiazepines
The benzodiazepines are one of the most widely pre-
scribed drug classes. The root word benZ() refers to an aro-
matic compound. Characteristic of an aromatic is its
carbon ring structure, which may be attached to another
carbon ring or to a dilferenl grouping 01 atoms. "jwo nitro-
gen atoms incorporated into the basic chemical structure
of the compound account for the diazepine name (di
two; aupine = nitrogen).
14.8 Treating Anxiety and Insomnia
with Benzodiazepines
The benzodiazepines are drugs of choice for various anxiety
disorders and for insomnia (ree Table 14.4). Since the intro-
duction of the first benzodiazepines-----chlordiaz.epoxide
(Librium) and diazepam (Valium}-in the 19605, the class
has become one of the most widely prescribed in medicine.
Although about 15 benzodiazepines are available, all have
the same actions and adverse effects, and differ primarily in
their onset and duration of action. Although used for other
therapies, some, such as midazolam (Versed), have a rapid
onset time of 15 to 30 minutes; others, such as halazepam
(Paxipam), take 1 to 3 hours to reach peak serum lewis. The
benwdiazepines are categorized as Schedule IV drugs, al-
though they produce considerably less physical dependence
and result in less tolerance than the barbiturates.
Cllaplfl t( Drug.1o< ,.""lety.OO In<omn" 1 57
Benwdiaz.epines act by binding to the gamma-aminobutyric
acid (GABA) receptor--chloride channel molecule. These
drugs intensify the effect of GABA, which is a natural in-
hibitory neurotransmitter fOWld throughout the brain.
Most are metabolized in the liver to active metabolites and
are excreted primarily in urine. One major advantage of the
benzodiazepines is that they do not produce life-threatening
respiratory depression or coma if taken in excessive
amoWlts. Death is unlikely, unless the benwdiazepines are
taken in large quantities in combination with other CNSde-
pressants, or if the patient suffers from sleep apnea.
Most benzodiazepines are given orally. Those that can be
given parenterally, such as diazepam (Valium) and 10-
razepam (Ativan), should be monitored carefully due to
their rapid onset of CNS effects, and potential respiratory
depression with adjunctive therapies.
The benzodiazepines are drugs of choice for the short-term
treatment of insomnia caused by anxiety, and have replaced
the barbiturates because of their greater margin of safety. Ben-
wdiazepines shorten the length of time it takes to fall asleep
and reduce the frequency of interrupted sleep.Although most
benzodiazepines increase total sleep time, some reduce stage
IV sl&>p, and some affect REM sleep. In general, the benwdi-
azepines used to treat short-term insomnia aredifferem from
those used to treat generalized anxiety disorder.
Benzodiazepines have a number of other important indi-
cations. Diazepam (Valium) is featured as a prototype drug
in chapter 1500 for its use in treating seizure disorders.
TABLE 14.4 1 Benzodiazepines for Anxiety and Insomnia
"n"
Route and Adult Dose (max dose where Indicated) Adverse Effects
ANXIETYTHERAPY
alprazolam (Xanax) f anxiay: PO;Ol5-0.5 mg tid (mn:. mglda,)
f panic PO; 1- 2 mg tid (max: 8 mg/day) haloonat"ont i!l{[ultd
cHordiaztpOlIid!, (librill!l) Mild JOg tidar !jd;1M.IIV; SO- 1oo JOg 1 h
inl!!!irmmt, roroomiQl !t1t1
mfdKal
ampng W()IIlrn wboare preg[),JDI rewUWy
imp.JillMnl due to hrpmilwjllioo. rtSpirjllO!l
anxiety: PO; 2O-1S JOg lid or qid; IMIIV; 50- 100 mg foIOW!'d
pslion,lmnaO\wm,cardoyasruar tollapse
by2HOmgtidorqid
doniztpam (l<1000pinJ PO; 1-2 mg./day in dMdtddoSfS (mal:. mgld.,)
dorazrpate (T PO; 15 mgld., at btdtime (mal:60 III9Id., in dvidtd MS)
dimpam(Valum) (Itt j)igt 174 PO;HOmgbid
for t(w, PrototYIH' Drug boJ: 00)
IMIIV; 2- 10 mg:rrprat ffnffiled in 3-. h
o ioraupam (Ativin) PO;H mg./day in dMdtddows (mal: 10 mlJ/da)')
oxaupam (Strax) PO; 10-30 mgtid or qid
INSOMNIA THERAPY
ffiazolam(Prosom) PO; 1 mgat btdtime; may iIKIM!' to 2 JOg ff nMSsar}
ftlNazrpam (D.Jlmalll'j PO;15- 30mgll t btdtimt AIJiDUIOM{tIj! <pIN
qlWl'pam (Doral) PO; 7.5- 15 mgu
(Rl"lloriIJ PO; 7.5- 30 mgat
triarolim (Hikion} PO;O. 125-11.25 mgu (nw::05 mglda,)
IrQ/ia ammon id'Imt tffem; underlining inoote sffiousad>imt
LibraryPirate
158 Until Thl'Ne<voo,Sy'tem
Il'r Prototype Drug I Lorazepam (AtlVan)
T her a pi! ut ic (lass: SedatiYt'-hypn otic; anxi olytic a nesthet ic adju net
ACTIONS AND USES
loruepam is a brnzodiazepint thataru b)' potmtiating thetIfKts ofGABA,an
inhibitory IIt\Jrouan,miner, in tilt thalamic, hypothalamic, and limbic: Itl'ffi of
the CNS.1t is Ont of the most ha, an Htended haN-
of 1 0 to 20 houl5, whim allow! for onu- or I"';u-,t.rby oral do,ing.ln addi-
tion to bring UIed '" an Iorall'j)im is '" .J tnanestheoc
to providt managMlffi t of ,taM
ADMINISTRATION ALERTS
administt ring IV, monitor rtspiratiom el'l'lY 5 to IS
airway and acu-IIiblt.
Pl!goanq category D
PHARMACOKINETICS
1At5l!t: 1- 5min 1V;15-30min 1M
Peak: 2 h PO;90minlM
111-20 h
Duration: Van;.blt
l
Other uses include treatment of alcohol withdrawal
symptoms (chapter 1200). central muscle relaxation
(chapter 2100). and as induction agents in general anes-
thesia (chapter 19CO).
Barbiturates
Barbiturates are drugs derived from barbituric They
are powerful eNS depressants prescribed for their sedative,
hypnotic. and antiseizure effects that have been used in
pharmacotherapy since the early 1900s.
14.9 Use of Barbiturates
as Sedatives
Until the discovery of the benzodiazepines, barbiturates
were the drugs of choice for treating anxiety and insomnia
(see Table 14.5).A1though barbiturates are still indicated for
several conditions, they are rarely, if ever, prescribed for
treating anxiety or insomnia because of significant adverse
effects and the of more effective medications.
The risk of psychologic and phr-;ical dependence is high-
several are Schedule II drugs. The syndrome
from barbiturates is extremely severe and can befatal. Over-
dose results in profoWld respiratory depression, hypoten-
Pharmacologic (lass: BenzOOiazepine;GABA. -receptor a!jonist
ADVERSE EFFECTS
The moll common .J<M1Sf eflect. of Imzepam af! drowsiness .J nd sedation,
which may demall' with Whtn in higher d=s or t:, the IV
roof! ,fftf! may br IlKh J I W1'iknffi, disoriffita-
lion, atnia, blood pre'Uf! blurml vision, double i-
sion,I"OIUIN,.nd I'Omiting.
Conlrai nd ications: This drug should not br UII'd in j)ititnu with acute 1"01 now-
i nglt glauc:omJ, primary d!"preliYe disordtn, or p,ychOlis, and .hould br
.Jl'Oidtd for mal"Olgrment of 1I'\'eC"! uCKomrol1fd j)iin.
INTERACTIONS
1Wg-1Wg: willl tKolmple,(OIKlJrrent 1M
iJ:Wng m iKmsesthe
rill; of rfljliritory arKI d&J\h.lorazepam CIIiI1 contribute !odigolil
toIici!)' '" inc:lNIing the II'fCIII rigmin thoJlIg@\,
nausN, "IOOIf!i!g.diuill5l,arKI confusion.
loraupam roayrItmR ihl'ilIlujOO:iIIorism m
--
lab Tfltl: Untnown
IIorbaVhcxl: ... i!h herlwt aample,wd.I!ion
IIfIbs SCKh ill 00, valerian, dlacmmilf, or hops ma, haole in
efffCt with ml'dif.Jtion. Stimulant hairs sum oil CJOIU kola and rna huang may ffdlKe
elfectil'enesI.
of !mrdo,e: IfoMrdoll' (Romuiconl..J spe<ific:
brnzodiazepint IffeIItor un br to IlWI5I! CNS

Rtftr IrI My/mIrrgKl for Q Mnbrg /'rOCef.l foon spt(1fc IrIIM /tug.
L tFESPAN CONStDERATtONS
Fall Risk in Older Adults and Benzodiazepines
For ptrsons oMf thr of 6S, f,lk &rr onr of thr Ie&ding of injury-
f!lated mit! mukipll'risk fJetol5llKh .J . vi-
sual inc:ominmu, and physic.illimitations JII
to an iCKf! J 51! in fall ri,1e, druglllKh '" the btnmdialt'pilll' group 11m the po-
If1Itial for this ri,k.
All patitnu preuibrd a drug should br yutioned about
tilt imj)iirm mobiliry, which mayoc-
cur eYffi at oorroal doms. This is espffi.Jlly for the oldu patitnt who is
PIOn.! to Tht nurlt sllould also tvawte the safm-of thr homt rnviron-
otlltr risk fJetOl5 rontributing to in,omnia (t.g., diurffic lU), and H-
pIof! oondlllCj options that ma, br useful in treating the patient'. underlying
insomnia oc amiety suc:h <IS ,hort naps to ddrt" or
going to brei u same timH.Kh night.WlItnever possiblt, tilt
of a for shonest amount of ,hould bt ull'd.
sion, and shock. Barbiturates have been used to commit sui-
cide, and death due to overdose is not uncommon.
are capable of depressing CNS function at all
levels. Like benzodiazepines, barbiturates act by binding to
GABA re.:eptor- chloride channel mole.:ules, intensifying
the effect of GABA throughout the brain. At low doses they
LibraryPirate
IlIapttr It Drug' lot AnxKoty.nd In'iOmnla I S9
TABLE 14 S I Barbiturates for Sedation and Insomnia
On"
Route and Adult Dose (mn dose where Indicated) Adverse Effects
SHORT ACTING
ptntobarbital sodiu m (Nerrbutal) mg bid orqid
Hypnotic PO;I20-lOOmg;IM.I50-200mg
100-100 mgld.ly iI thrn diYidN
I/ypnolkPOIIM; 100- 200 mIj
INTERMEDIATE ACTING
amobarbital (Amytal)
aprobirbital (Ah.ntt )
mg bid orlid
HypnolicPO/IM;6,- 200 mIj (madOO mg)

IIddwI stdIlion
Sleyenr Johnm
lYndrome rnPiratorrdeprn!ion (ituialOfY
roUapsr ,JQD!'.! Luyn!IP\I)j'1ll
buuba!bilil sodium (Butilol )
LONG ACTING
Hypnotil:PO; 40- 160 mg
15- 10 mg t id or qid
HypnoticPO; SO- I00 mg oil btdlime
mtphobarbital (MebaralJ
phenobarbital (Luminal) 171
for Prototype Drug box 00)
mg tid or qid
mgfd.ly;IV!1M,100-100 Ill9fday

100 ftlDiratro dwrnioo,
reduce anxiety and cause drowsiness. At moderate doses
they inhibit seizure activity (chapter 1500) and promote
sleep, preswnably by inhibiting brain impuls<'S traveling
through the limbic system and the reticular activating sys-
tem. At higher doses, some barbiturates can induce anesthe-
Si.1 (chapter 1900).
When taken for prolonged periods, barbiturates stimu-
late the microsomal enzymes in the liver that metabolize
medications. Thus, barbiturates can stimulate their own
metabolism, as weU as that of hWldreds of other drugs that
use these em:ymes for their breakdown. With repeated use,
tolerance develops to the sedative effects of the drug; this in-
cludes cross-tolerance to other eNS depressants such as the
opioids. Tolerance does not develop, however, to the respi-
ratory depressant effects. (See chapter 1500, page 177, for
Nursing Process Focus: Patients ReceivingAntiseizure Drug
Therapy. )
Nonbenzodiazepine, Nonbarbiturate
CNS Depressants
These drugs reduce anxiety symptoms but are chemically
different from the other anxiolytic drug classes.
14.10 OtherCNS Depressants
for Anxiety and Sleep Disorders
The final group of CNS depressants used for anxiety and
sleep disorders consists of miscel.laneous agents that are
chemically unrelated to either benzo;:liazepines or barbitu-
rates (see Table 14.6). In addition to nonbenzodiazepine,
St(Wj1 JohlllOll
(fiR) CHSderuuion roma dwb
nonbarbiturate eNS depressants, other drugs used mainly
for tre<ltment of social anxiety symptoms include the ""ti
seizure medi,ation valproate (Depakote), and the beta
blockers propranolol (Inderal) and atenolol (Tenormin).
Drugs used mainly for insomnia therapy include the newest
of all nonbenwdiazepine eNS depressants, zaleplon
(Sonata), eswpiclone (Lunesta), and the relatively new drug
wlpidem (Ambien). Older eNS depressants such as par-
aldehyde (Paracetaldehyde), chloral hydrate ( Noctec),
meprobamate (Equanil), and glutethimide (Doriglute) have
only historical interest , because they are so rarely pres<:ribed
owing to their potential for serious adverse effects. Bus-
pirone (BuSpar) and wlpidem (Ambien) are commonly
pres<:ribed for their anxiolytic effects. Zolpidem (Ambien)
and eswpiclone (LWlesta) are used for their hypnotic effects.
The mechanism of action for buspirone (BuSpar) is Wl-
dear but appears to be related to D, dopamine receptors in
the brain. The drug has agonist effects on presynaptic
dopamine receptors and a high affinity for serotonin rep-
tors. Buspirone is less likely than benwdiazepines to afft
cognitive and motor performance and rarely interacts with
other eNS depressants. Common adverse effects include
dizz.iness, headache, and drowsiness. Dependence and with-
drawal problems are less of a concern with buspirone. Ther-
apy may take several weeks to achieve optimal results.
Zolpidem (Ambien) is a &hedule IV controUed sub-
stance limited to the short-term treatment of insonmia.lt is
highly specific to the GABA receptor (chapter 1500) and
produces muscle rela.Ultion and anticonvulsant effects only
at doses much higher than the hypnotic dose. As with other
eNS depressants, it should be used cautiously in patients
LibraryPirate
160 Unlll TteNetvoo,Synem
..,. Prototype Drug I Zolpldem (Ambren)
Therapeutic (lass: Sedative- hypnotic
AalONS AND USES
P hanna co logic ( lass: fl onbenzod iazepine GA BA" receptor agonist; nonbenzodiazepint,
nonbarbiturate CNS depressant
ADVERSE EFFECTS
Although it is a <1 m in a limilar fashion to facili -
titf eNS dtprrslion io tht limbic. thalamic,and hypothalamic:
prem. H stagnln and IV of sftpand halooly on REM
Sftp."Theonlyindicationforzolpidemisforshort-urminsomniaman<l gl'OII' ot
(7to l 0diys).

wn, Oiulfa.<lnd wmiting.
Contraindications: lactating womm should nottae this drug.
INTERACTIONS
ADMINISTRATION ALERTS
BeulMof rapid onSfl, 7- 27 immediate/)' btfore btdtiOll'.
1Wg- 1Wg: Drug inteOOionswith zdpidem irKrNIfin!edatioo whfn
UIfd (ooo.mntlywilh Phfncr.hiaziMS


PHARMACOKINETICS
On",t: 7 27 nin
O.5--Bh
1.7- 2.5h
Duration: H h
Lab TfIIs: Unknown
HfrbaVFood: tJUn with food, absorptioo !iIowfd s9lilKarttJ and the
(1\\1'{ ofiKlion lOIybe delayed
T .... of GfMI. liHd ."mptomatic: support;" OII'.1Wln
should be applied with imOll'diatf gastric: Ia\\lgl' whtrt appropOatf.IV Auids
should be administered as rffied. Ulf of flumaml il (Rom.uic:onJ <II a benzodi-
<l zepine aotaogonist may be htlpful.
Rtr'tr IrIMyMnbrgnfrxa MlslrlqPrwI!l"l FoMsp/It IrIrMltrJ9.
TABLE 14.6 Miscellaneous Drugs for Anxiety and Insomnia
Orug Route and Adult Dose (max dosewhere Indicated)
NONBENZODIAZEPI NE. NON BARBITURATE eNS DEPRESSANTS
buspiront (Bl6pir)
reOII'ItronjRomm)
liI/fplon (Sonata)
Q lOIpidem (Ambito)
ANTISEIZURE MEDICATION
vai proic:idd(DrpatrM) 176
for ttw, PrOlOiypr [hog boxOO)
BETA BLDCKERS
(Tenonnil) (Ite pq m for
tilt ProtOlype IlrugboxOO)
propranolol (Inderll) (Ite 164 for
tilt ProiOlype Ilrugbox 00)
Sedativr:PO;7.S- 15 mg i1 d'lidtd i )(rml' t.,
S mglda'"tr"f 2- 3 if OI'rdtd (1OI1:6OIJI9Iday)
ioadilg dosr I m{9l\g owr10 min; maintl'llarut
dw 0.2- 0.7 m(gIkgJtr
H)1IOOtic:: PO; 2 mg at btdtime; dependi" 9 on t/if dinic:.J1
and toltrilKe of ttw, doll' may be IOWMd to
lmgPO
SedatiYr:PO;200 mg bid ortid
H)1IOOtic::PO; SOO mg- I gil
H)1IOOtk:PO;3 mg al btddOll'
H)1IOOtic:: PO; 10 mg at bedtiOll' (mad l) rngIday)
H)1IOOtic::PO;5- 10 mg it bedtimt
Sodal alUlitty symptoms: PO; 250 m 9 tid (1011: 60 mglkgfday)
Sodal alUlitty symptoms: PO; 25- 100 mglday
Sodal anUtl, s,mptoms:PO; 40 mg bid :max:l20
Adverse Effects
l>illinru, IrfOOodIe, 1WlltI, (orip,
Qr<ll'iq. fOIOirn;, bilftf mffallk 10Ile, dry mruth,
diorrIrtD, hypoltmion

IookSl"l'IIS- Jotmon syn!tpm!: lOiphYiaxil,
Il'pratpry faj!! roma W!klro dNlb
WotiOfl, 1IQIj1tll, Imlirir4 proioogtd
bImInga11If'
OcnJ torna wilh ovcr<Jo\t liver
prolonged blmiOQ s!!W!lsion
Brod)fQrdio, hyporrmiOfl, ronlilli<w1, IQrigw,
drowinru
ADiplribq k mmiOD! Stmm JqbD\9D !mdmml'
tui( ffidermt l fINO/YIis. erloiiatM
LibraryPirate
with respiratory impairment, in older adults, and when
used concurrently with other CNS depressams. Lower
dosages may be necessary. Also, because of the rapid onset
of this drug (7 to 27 minutes), it should be taken just prior
to expected sleep. Because wlpidem is metabolized in the
liver and excreted by the kidneys. impaired liver or kidney
function can increase serum drug levels. Zolpidem is in
pregnancy category B. Zolpidem is used with caution in in-
dividuals with a high risk of suicide, because there is a po-
tential for intentional overdose. Adverse reactions are
usually minimal (mild nausea, dizziness, diarrhea, daytime
drowsiness), but rebOlmd insomnia may occur when the
drug is discontinued. Other adverse effects are amnesia and
somnambulism (sleepwalking) or other activities that may
be performed during sleep (e.g., sleepdriving).
Although st ructurally unrelated to other drugs used to
treat insomnia,eswpiclone (Lunesta) has properties similar
to those ofwlpidem (Ambien). The effectiveness of eswpi-
clone has been shown in outpatient and sleep Inb studies,
but the drug has not directly been compared withzolpidem
or other hypnotics. However, eswpidone's longer elimina-
tion half-life, about twice as long as that of wlpidem, may
give it an advantage in maintaining sleep and decreasing
Cllaplflt( Drug. 100 .,,,,lety.00 In!iOmn" 161
early-morning awakening. On the other hand, eswpiclone
is more likely to cause daytime sedation.
Zaleplon (Sonata) may be useful for people who fall asleep
but awake early in the morning, for e."lample, 2:00 a.m. or 3:00
a.m. It is sometimes used for travel purposes and has been ad-
vertised by phamlaceutical companies for this purpose.
In 2005, re:melteon (Rozerem) was approved by the fDA in
a single IJ...mg dose. Remelteon is a melatonin receptor agonist,
which has been shown to mainly improve sleep induction. It
has a relatively short onset of action (30 minutes), and its du-
ration is comparable to the non-e:rtended-release form of
wlpidem. The FDA indications for remelteon or wlpidem are
not limited to short-tenn use, because they do not appear to
produce dependence or tolerance to the dose.
Drugs not listed in Table 14.6 include diphenhydramine (Be-
nadryl) and hydroxyzine (Vistaril). These: are antihistamines
that produce drowsiness and may be beneficial in calming pa-
tients. They offer the advantage of not causing dependence, al-
though. their use is often lintited by anticholinergic adverse
effects. Diphenhydramine is a cotmnon component of OTC
sleep aids,such as Nytol and Somina (chapter 3SOO). Doxy-
lamine (Unisom) is another antihistamine medication com-
monlyused as a night-time OTC sleep aid.
NURSING PROCESS FOCUS PATIENTS RECEIVING DRUGS FOR ANXIETY DISORDERS
Assessment
Baselin! assrssmtnt priorto administration:
Undtfltmd tht drug has prtKribtd in order to me s for
thtrapwtic: fffects.
Obmin a (omplttt htakh histOf)' ilKluding htPitic,
cardiornarlaror ntUroIogic: rntntal status, narrow-anglt glaucoma,
and prrgnaocy or a drug hil10ry including alll'''lie,
(urrent plt'\{ription and OK and (ifltinr and
akohol ulI'.Bt altn to drug
IIrI'SI and roping (t.g.,l"lIisting or
(oping mtdlanilrmor
Obmin a !Ieep histo!)' and oilleep.
lrequmt or apnea, remtditl ustd lor
appropri.ltt laboralo!)' findings (t.g., or Ilunction
studia).
Obmin vital signs and the patitnt's risk for lills.
AslI'Ss tht patient's ability to and undtflund instllluion.llKlude thr
la mily and carf<jiYrfl as I"ftdtd.
Asst lSmtnt throughout il dministration:
AslI'Ss for thrrapeutK rfletn (! .g.,I1i1rmntl of in
to (.i ll)' out AOCs. and iftp patterns
Continue periodic: monitoring ofli!'r and rrnal funnion l1udie.
AslI'Ss vital signs and Wl'ight periodically or ijsymptoml warrant.
AllI'Ss for and promptly report
drowsi III'ss,light-htadtdnrss, (onfusion, agitatio n, palpitation !aC:hlUidia,
diuines or and
Potential Nursing Diagnoses
Anl itty
Disturbtd Slet p Pattern
Fatigue
Coping
ktjyity to loss of sltrp Of ddytimt *tpines)
KnowIedgt (drug thtrapy)
Risk for lnju!)', Risk for Falls to adYmt of drug thtrapy)
(conrlrwed)
LibraryPirate
162 Unltl TheNetvOll'Sy""'"
NURSING PROCESS FOCUS PATIENTS RECEIVING DRUGS FOR ANXIETY DISORDERS (Continued)
Planning: Patient Go.ls and Expected Outcomes
Thr patimt wit:
rlIef .... tic tfffm 01\ tilt _ the drug is kin9 gjYen {t.g..dem.Sfd ,nxitty, impJOfd sIetp
k lite from"Of millimal,.1Mrw tlfKb.
LJIIdemardng of the drug, 1M. advent tfftm,.nd r!q.md
Demonltr.lt proper seIf ... inistr.don ohhe mtdic.tion (t.g.dOlt, timing, whtto to notify plOi6tf).
Implemtntation
Inte-rvtntloM and (Rationales) Palit nt and family Education
h 'lring tMr.ptutic
CoMinut .ssmmtnts as d&ribed tarlit!" Iof thmptVtic tfft.:1!. (If tilt tht INbtnl in dtvtloping htalthy(oping and sIttp habits
drug is gjYen for .nxiety, tilt pabtnt repom dtm-nd imprlM'd wittJ kI hukh cart as
sletpand rating {Oping,.nd abilitylo (;IllY out ADls
thf pUnt to 1r.fqI. sIttp diMyofbedtimt, tilt timt inYoIYtd
IOithout anxitty.1f lilt drug is giwn for slttp, tht palitllt re,orts lilt .bility
trying to fill quantity oIs1etAdaytimtsltotpintSs,tk.
10 fan and diytimt wikeulnmJ
Minirnldn91dftlSt fffKb:
Continur to I!IOII vital sigm. mmt.1 shM, and lOOIIf IIItian .nd bIIancr 1Ndr tilt patitntto mt m IJing or sitting kllt.nding to .void
k paniculally CMious with oIcItr .duM wbo.m 011 inaN!I:d diuintssorfds.
risk for fil lh.{1lnI9s uSfd for .mciety ilrId IIttp m.yausttruSsivt
druwsiness,tnd diuinm, inm'iling thf riskoffalb and
Ensurt patitnt j,Jftty, tspt<iill, in oIdtr -'uk!.. CltMM forlight- Ostruct the patient to uiliof ... !islinct prior to getting out fA btd 01
Monitor Imbularion until tht tfft<ts of drug lit itttmpring IOwal ilont,Mtd to i'IOid dfiving OIothtr iKtMtits rtq.jring
known. {Dizzintss.nd dlOWlintss for a plDblged pmod oflilll!' rnayoour; mtntal or physical (oordin, tioo unti of tilt
011 tilt drug's h.f-ift. D.Jytimt drowsintSs mi)' impair WIIbIg ......
tht abrlity to carry OOJI USUil AOIJ.)
lslffi kIr diMlQts in Irvd of (OIlICiousnm,disoritnlilion or(onfusion,Of

Dwuct the patiml or to im!1lldiattl, rousing Ittlww,
{Ntutologic changes may indiuae O'itrrntdiutioft orfl'lt<u fA disofitntation. confusian, dIinges in bth.wior Of moor!, sIurr!d spm:h, Of
IIttpdeprinrionJ oltma.
lslffi i)r diMlgn in blrrrtdYision, 1os:s of ptl"ip/ltral vision, Ostruct the patiml to irnrntliatdy report ,tIIJYisu.1 dwngts or t"Yt pa ....
Itting rainbow halo.lround f)Ie pain.or.ny
symptorm K<ompanitd by RoMI' nd lOIlIiling and
patitnu with gl. lJ(OlIW m.!,
ouur in patiml! taking btnmdiilfpints..!
Monitor al'lt<t.nd emotion.!1 SI.IDS. lIWy incrfill:' risl of mmul Instruct the patient to report signifium moodchangts,tspt<ially
in with suicicIaIltndt!lCies.Conwrrtlll 1M of nd to .void ikoboI.nd othfl" CNS dtprtssalltS wt.ilt
akohol and othfl" eNS drprtSwnts in_ thtel'lt<ts and tht riskJ .......
Enmur'l]f appr!)pri.l(! IhstyIt <h.lngts:1owmd inlike including [n(our'ge 1M pititm to I ht.hhy of 01
ore that (OIluinufftirlt, inataSfd tRI{M during th.! da, but abslirlf!ICt from uiftirlt,nKotW, ind a1cI>hol;.lrId irK/US!
not befm bedtimt.limittd or no akohol in"k.nd srnokillO
Advise the poo...t to disc .... ..n OlC m.dirniom with the h .. W. ar.
lifetyW challgtS will IUppln and minmin th.1ftd for
pIDI'idtr to etSUn' affrine c. .kohol is no! indudtd in me formulation..
drug thtr'JIIluffeint.rId nimtint rrvy demiSe tht ohM
drug. AkdJol and otlltr CHS IIIi)' incr.iSe tht tffem of
thtdnICJS.)
Altoid. brupl dilCominualion of thtrapy. (Wibdrawil symptoms, induding Ostruct tilt patient to I.iR tht drug txaetIr prI'ICribed .nd to not Slop ;;
.nmry and possillit with abrupt discontinuation .bruptly.
.ftt.r Iong-ltrm 1M.)
lslffi of IMIiutions.1Id idmtify risks for K1icm. OstnKt tilt- patient th.lt thtst drugs should no! be krpl" tht btdsiOt to
(1hmIosagt mar oc(Ur if the patitm likl's addition.ldosts when or ..m:I liking dosts wlltn drowsy.
disoritnMd m mtdiutionrifl'ctsJ
LibraryPirate
Cllaplfll( Drug'lo< ,.""lety.oo In<omn" 163
NURSING PROCESS FOCUS PATIENTS RECEIVING DRUGS FOR ANXIETY DISORDERS (COllffllUtd)
Implementation
IntelVenti ons and (Rati onales)
A'les prior melhods of IIIflS II'dlKtion or slttp h)'gitnl'. Rtinfor(t
ustd ,nd teac:h ntw (oping .kills. (Drug
tiltr' py is ustd for tht , rooum of tim!' possible. other
(oping skilk or improl'ed sleep hygitnr ieslfn the rwd for drug
tiltr,py.)
Patirnt underst anding of drug thrrapy:
U", opponunit;.. during odminimillion of during
<lIwtnts to dis(U15 the for drug theraPl', desill'd therlpMK
most {ommoniy !),r,mtlel> forwhr n
to (illl the health GIli' Ill)' nKtl!.lIY monitoring or
prtuUliolll.(Using timr ruring rursing Urt helps to optimizt ,nd rtinfortr
ke)' teaching areasJ
Patirnt Rlfadministrilt io n of drug thrril PY:
When administrring thr mrdKation, inmu(\ patiom.
in proper stK--administration of drug. r.g., taking only amount pll'l(ribed.
(Utilizing tim. during of thesr drucp helps to
1I'ac:hing.)
Pati ent and Family Educati on
Trach thr !)'titnt mtlhods for II'lief ,nd for
implO'/td sleep h)OJimr.Rfier to heakh GIli' providers or
IUppon groups as IIffdtd
Th. potiom ,hould bubl. 1<1 ""I< tilt 11'1>01\ for th. drug;oppropn.l<
dose and IChfduling;what ,mrlt rffects to for and when to
II'port; and the length of mtdKation therapy.
patitm is ablt to appropriate dosing and administration needs.
Evaluation of Outcome Criterii!l
thr ofdrug ihtr,py by confinning that !)'tirnt np1l'd hl'lf been m!'t .
. Chapter REVIEW
KEY CONCEPTS
The numbered key concepts provide a succinct summary of the important points from the corresponding numbered section
within the chapter. If anyof these points are not clear, refer to the numbered section within the chapter for review.
14.1 Generalized anxiety disorder is the most common type
of anxiety; phobias.. obsessivtl-(;ompulsive disorder,
panic attacks, and post-traumatic stress disorders are
other important catq;;ories.
14.2 The limbic system and the reticular activating system are
specific regions of the brain responsible for anxiety and
wakefulness.
14.) Anxiety can be managed through pharmacologic and
nonpharmacologic strategies.
14.4 Insomnia is a sleep disorder that may be caused by anx-
iety. Nonpharmacologic means should be attempted
prior to initiating pharmacotherapy.
14.5 The electroencephalogram rewrds brain waH'!S and is
used to diagnose sleep and seizure disorders.
14.6 CNS agents, including anxiolytics, sedatives, and hyp-
notics, are used to treat anxiety and insomnia..
14.7 When taken properly, antidepressants can reduce symp-
toms of panic and anxiety. First-line medications in-
clude the selective serotonin reuptake inhibitors (SSRls)
and other antidepressants; tricyclic antidepressants
(TCAs) and monoamine oxidase inhibitors (MAOIs)
are older drug groups.
14.1 Benzodiazepines are drugs of choice for the manage-
ment of anxiety disorders and insonmia.
14.9 Because of their adverse effects and high potential for de-
pendency, barbiturates are rarely used to treat insomnia..
14.10 Some commonly prescribed agents and CNS depres-
sants not related to the benzodiazepines or barbiturates
are used for the treatment of anxiety and sleeplessness.
LibraryPirate
164 Until Thl'Ne<voo,Synem
NCLEX-RN" REVIEW QUESTIONS
D Tht' nurse should assessa patit'nt who is taking lorazepam
{At ivan} for the development of which of these adverse
efl"ts?
1. Thchypnea
2. Astigmatism
3. Ataxia
4. Euphoria
D A patient is rt'Ceiving temazepam (Restoril). Which of
these responses should a nurse expect the patient to have
if the medication is achieving the' desired afft?
1. The' patit"nt sleeps in 3-hour intervals, awakes for a short
tinre, and then fulls b.1ck to sleep.
2. The patit"nt reports feeling les anxiety during activities
of daily living.
3. Thepatient rqx>rts having f ...... erepi5odesof panic
attacks when stressed.
4. Thepatient rqx>rts sleeping 7 hours without awakening.
D A 32-Ye'ar-old female patient has lJe.en taking lorazepam
(Ativan) for her anxiety and is brought into the emer-
gency department after taking )0 days' worth at one time.
The antagonist used in some cases of benwdiazepine
owrdosage is:
1. epinephrine.
2. atropine.
3. tlumarenil.
4. n:tio:<lme.
D A patient hasheengiwn instructionsaboUi the newly pre-
scribed medication alprazolam (Xanax). Which of these
statements, if made by the' patient, would indicatt'that the
patient nreds furtht'r instruction!
CRITICAL THINKING QUESTIONS
1. A 58-year-old male patient underwent an emergency
coronary artery bypass graft. He suffered complications
while in the cardiac intensive care unit and spent 3 days on
a ventilator. He is still experiencing a high degree of pain
and also states that he cannot fall asleep. The patient has
been ordered S&obarbital (Seconal) at night for sleep and
also has a prescribed opioid analgesic. As tht' nurse, ex-
plain to the student nurse why both medications should be
administered.
2. A 42-year-old female patient with ovarian canU'r suf-
ft'red profound nausea and vomiting aftt'r her first round
of chemotht'rapy. The oncologist has added lom:repam
(Ativan) 2 mg pe'r N piggyback with ondansetron
(Zofran) as part of th .. prech .. mother3py regimen. Con-
sult a drug handbook and discuss the purpost' for adding
this oonzodi"upine.
1. "I wiu stop smoking by Wldt>rJ!oing hypnosis."
2. "[ wiu notdri, ... immediately after I takethis
medication."
3. "I wiu 6101' the medication when I feel less anxious."
4. "[ wiu take my medication with food if my 610mach
feels
D A patit'nt has been taking diarepam (Valium) for 3
months. Which of these statt'me'nts by the patient would
indicate that the'outcomeofmt'dication therapy has been
succe.ssful?
1. "I win need to take this medication for the rest of
mylife'."
2. "I feellikt' 1 am able to ropewith routine 61ft'SS at
my job."
3. "lUke this medication Ilmow that I needed it to treat
my anxiety, which is /lOW betlt'r, but I think it just makes
me feel good,so I am planning to stayon it for quite
awhilt'."
4. "I thought this medication vrould make me think
clrurly. but I don't ft'el. any chang<> in my feelings."
II Education giwn to patit'nts about tht' use of benzodi -
aupines should include' an e'mphasis on what important
issue!
1. TheywiU be required lifelong toachit,'e lasting effects.
2. They requirt' frequent blood COWlts to amid adverse
.-
3. If the drug is not effective within the first 2 months, it
will be stopped immediatt'ly.
4. The use of counseling or behavioralthniques in
addition to the drug wiu assist in addressing the
underlying disorder.
3. An 82-year-old femalt' patient complains that she "just
can't get good rest anymort'.She says that she has come to
her doctor to get somt'thing to ht'lp ht'r sleep. What infor-
mation can tht' nurse offt'r this patit'nt regarding the nor-
mal changes in sleep pattt'rns associated with aging! What
would you recommend for this patient?
Sec Appendix D forans",,,rs and rationale, for all activitie .
EXPLORE
M)'NuI"$i1g1Q1 is ywr COle SIOjl1or ol1ine CIlIlPW r1!vIo!w materi&ls and
reliWrQls. I'lllll<ire for IiUGCIlSS with alfdilional NCLEX""s!j\e practice
Que5tloo5. Interactllie 9grvnent'l and actlliltles. web 11n<s. mtlMllDns
and videos. Inc! mille!
Rl!(JisW your aceess roM from 1M Iron! ot )'OUr 000Ic at
www.myn .. *.tkil c .....
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DRUGS AT A GLANCE
DRUGS THAT POTENTIATE GABA ACTION pa;t 1i\1
Barbiturates fJt1j 1 III
O phenolJoroJfol/Lurnt'la/J pogt III
Benzodiaztpines (K1IJt III
I4I diozepam (\otll/um) (K1IJt 174
Newer GADA-Relat ed Drugs f#Jf 171
H'fDANTOIN AND NEWER DRUGS (fJ9t III
Q p/lenytoln(D/bnlln) pilrJtllS
C V<'J .,role n,/d l""pnkPnp, r>PplJknr,.)
"",,,
NewerDrugs rwtllJ
SU((INIMIDES /it 174
Q elhowxlmk1e (Zoront ... ) (XJfJt 116
KEY TERMS
abstn(!seizurl' (XJfJt m
atonies/jzure paqt 168
convullions pogt 1M
rdampsia (IQIJt 167
epilepsy patll'166
Drugs for Seizures
LEARNING OUTCOMES
After readinfJ this chapter, the student should be able to:
1. Compare and cont rast the terms selzures,convu/s/onJ. and tp/kpsy.
2. Recognize possible causes of seizures.
3. Relate signs and symptoms to specific types of seizures.
4. Describe the nur$E"s role In the pharmacologic management of sel:nJres
of an acute nature and epilepsy.
S. the Importance of patient drug compliance In the
pharmacotherapy of epilepsy and seizures.
6. For each of the drug classes list ed in Drugs at a Glance, know
representative drug examples and explain their mechanism of drug
action, primary act lons,and Important adverse effects.
7. Cate-gorlze drugs used in the treatment of seizures based on their
dassification and mechani sm of action.
8 . Use the nursing process to care for patients receiving drug ther<!lpyfor
epilepsy and seizures.
S!' izull' fO'!t 166
gamma-aminobutyri,a,id IGABA)
gt nt ralizfdS!' izull'
myoclonic: stillm: JUjI m
partiallfocal) sfizull' pu;t I.,
stirurr pu;t 166
status tpiltptirus f'!'!t 171
tonic-donicseizull' pl9t168
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166 U"IIJ 1heNe<vooISyltem
A
s the most common neurologic disease, epilepsy af-
fects more than 2 million Americans. By definition,
epilepsy is any disorder characterized by recurrent seizures.
Symptoms of epilepsy depend on the type of seizure and
may include bladc.ou!. falntlog spells, 5enSOfy disturbances,
jerking body movements. and te<npor"f)' lou of memory.
This chapter examines the phan1l1K()(OOapy ustd to treat
epilepsy and different kinds of
SEIZURES
A wizIR or dinially dt'le(Ubie sign of tpilfpsy is a disturbance
of electrical activity in the brain that may affKt ConscioUli-
ness,motor activity, andsens:ltion. Seizures are aused byab-
normal or uncontrolled discharges. Uncontrolled
charges may remain in one focus or prop3gate to other areas
of the brain. Ju. a valuable tool in measuring uncontrolled
neuronal activity, the ele(:tfoencephalograrn (EG) is useful
in diagnosing seizure disorders. Figure IS.l compares nor-
mal and abnormal neuronal tracings.
The terms seizl.re and colIl'lO/sio., are not synonymous.
(onvulyons specifically refer to involuntary, violent spasms of
the large skeletal muscles of the face, nock, arms, and legs.Al-
though some typeS of seizures involve convulsions, other
seizures do not Thus, it may bestated that all convulsions are
.seizures, but not all seizures are convulsions. Because of this
difference, drug'> described in this chapter willgeneraJ.ly be re-
ferred to as anristizure drugs rather than a"ricoru'loonN. Rec-
ognizing also that antiseiwre drug'> are commonly called
antWpil .. pric drugs (AEDs), dle term anristizure in thi!; chap-
ter applies to the treatment of all symptoms
indudingsigns of epilepsy.
15. 1 Causes of Seizures
Aseizure is really considered symptomatic of an
disorder, rather than disease ilSelf. Triggers ex-
posure to stroDe or flkkering lighlS or tht of
small fluid and electrolyte imbalances. Patients to
tonic-dorOc MillIN
have a lower tolerance to environmental triggers, and
seizures may occur when patienlS are sleep deprived.
There are many different etiologies of seizure activity. In
some cases, the etiology of seizure maybe clear but not in aU
situatioos. Seizures represent the most common serious
neurologic problem affecting children, with an overaU ioci-
dence approaching 2% for febrile seizures and 1% for idio-
p3thic epilepsy. Cenain medications for mood disorders,
p5}'1:hoses, and local anesthesia whtn givtn in high doses
may cause seizures, possibly because of increased levels of
stimulatory neurotransmiuers or toxicity. Seizures may also
occur from drug abuse, as with COCl.ine, or during with-
drawal from alcohol or sedati\'e-hypnotic drug'>.
Seizures may present as an acute situation, or they may
occur on a chronic basis. Seizures that result from an acute
complication generally do not recur after the situation has
been resolved. On the other hand,if a brain abnormality ex-
i!;ts following an acute compliation, recurrent seizures are
likely. The following are known causes of seizures:
Infectious diseases: Acute infections such as meningitis
and encephalitis can cause inflammation in the brain.
Trauma: Physical trauma such as direct blows to the
skull rna)' increase intracranial pressure; chemical
trauma such as the presence of toxic substances or the
ingestion of poiSOn<; may cause brain injury.
Metabolic disorders: Changes in fluid and electrolytes
such as hypoglycemia, hyponatremia, and w.Jler
intoxication maycause .seizures by altering electrl al
impulse traru;mission at the cellular level.
Vascular disemes: Changes in oxygenation such as those
caused by respiratory hypoxia and arbon monoxide
poisoning, and changes in pl'l'fusion such as those
caused by hypotension, Cl'I'ebrai vascular accidenlS,
shock, and cardiac dysrhythmias may be causes.
Pediatric disorders: Rapid increase in body temperature
may result in a Itbrilueiz ....
Neoplasricdiseasr. Tumors, espeo::ially npidly growing
ones, may occupy space, increase illlracranial pressure,
and damage brain tissue by disrupting blood flow.
Figure 15. I EEG rl!<Ofdlngs showing tne dffferencfs IM!tween normal,absence setzurf',aod tonlc-dook: sqjaJf1! trKlngs
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An important topic when discussing epilepsy and seizure
treatntent is pregnancy. Because several antiseizure drugs
decrease the effectiveness of oral contraceptives, additional
barrier methods of birth control should be practiced to
avoid lUlintended pregnancy. Prior to pregnancy and con-
sidering the serious nature of seizures, patients should con-
sult with their health care provider to determine the most
appropriate plan of action for seizure control. \Vhen pa-
tients become pregnant, extreme caution is necessary. Most
antiseizure drugs are pregnancy category D. Some anti-
seizure drugs may cause folate deficiency, a condition corre-
lated with fetal neural tube defects. Vitamin supplements
may be necessary. Edlmpsia is a severe hypertensive disorder
of pregnancy, characterized by seizures, coma, and perinatal
mortality. Eclampsia is likely to occur from around the 20th
week of gestation until at least I week after delivery of the
baby. Roughly one fourth of patients with eclampsia e.""l:peri-
ence seizures within 72 hours postpartum.
Seizures can have a significant impact on the quality of
life. They may cause serious injury if they occur while a per-
son is driving a vehicle or performing a dangerous activity.
Almost all states will not grant,orwill take away, a driver's li-
cen ... ami r"'l"ire a period hefoTe gmnting
license. Without successful pharmacotherapy, epilepsy can
severely limit participation in school, employment, and so-
cial activities and can affect self-esteem. Chronic depression
may accompany poorly controlled seizures. Important con-
siderations in nursing care include identifying patients at
risk for seizures, docwnenting the pallern and type of
seizure activity, and implementing safety precautions. In
collaboration with the patient, the health care provider,
pharmacist, and nurse are instnunental in achieving positive
therapeutic outoomes. Through a combination of pharma-
cotherapy, patient- family support, and education, effective
seizure control can achieved in a majority of patients.
15.2 Types of Seizures
The differing presentation of seizures relates to their signs
and symptoms. Symptoms may range from sudden, violent
shaking and totallos5 of consciousness to muscle twitching
or slight tremor of a limb. Staring into space, altered vision,
L tFESPAN CONStDERATtONS
Seizure Etiologies Based on Genetics
and Age-Related Factors
Tht tliologie thi! triggtrtht dmlopmtnt of childhood fary
oKcocding to agt.
Coogtnital ofthr CNS, ptrinml brain injury, aocl metabolic
im balance UlWIIy to ictiYity in lH'ooate, info! nts, i ocI
..,"'.
Inherited t piitpsie,(NS inftaiool,aocl ntlJroIogic dtgtneratil'l'
dilordm linkrd to smUItS that h.wt thtir oostl in latrr childhood.
Ct rm-al ntoplastic
II'pretm the most frec;Utnt of in theaduk population.
''''''If.t5 Drug<forSelzult'1 167
and difficulty speaking are other behaviors a person may ex-
hibit during a seizure. Determining the cause of recurrent
seizures is important for planning appropriate drug selec-
tion and treatment options. Proper diagnosis therefore, is
essential.
M('!hods of classifying epilepsy have changed over time.
For example, the terms grand mal and petit mal epilepsy
have, for the most part, been replaced by more descriptive
and detailed categorization. Epilepsies are typically identi-
fied using the International Classification of Epileptic
Seizllres nomenclature, as partial (focal), generalizl, and
special epileptic syndromes (see Table 15.1). Types of partial
(fOCllll or generalized may be recognized based onsymp-
toms observed during a seizure episode. Some symptoms
are subtle and reflect the specific nature of neuronal misfir-
ing; others are more comple."I:.
15.3 General Concepts
of Antiseizure Pharmacotherapy
The choice of drug for antiseizure pharmacotherapy de-
peoel . on sign. presenloo hythe patient, Ihe pMi enT" previ_
ous medical history, and associated pathologies. Once a
medication is selected, the patient is placed on a low initial
dose. The amount is gradually increased lUltil seizure con-
trol is achieved, or until drug side effects prevent additional
increases in dose. Serwn drug levels may be obtained to as-
sist th.e health care provider in determining the most effec-
tive drug concentration. If seizure activity continues, a
di fferent medication is added in small-dose increments
while the dose of the first drug is slowly reduced. Eecause
seizures are likely to occur if antiseizure drugs are abruptly
withdrawn, the medication is usually discontinued over a
period of 6 to 12 weeks.
Traditional and newer antiseizure drugs with indications
are shown in Table 15.2. The newer antiseizure drugs offer
advantages over the older traditional drugs, mainly because
of troublesome side effects. Due to the limited induction of
dr ug-metabolizing enzymes, the pharmacokinetic promes
of the newer antiseizure drugs are less oomplicated.ln addi-
tion, the newer antiseizure drugs are generally better toler-
ated and pose less of a health risk in pregnancy.
One issue of antiseizure drug therapy relates to recent
warnings issued by the Food and Drug Administration. In
2008, Ihe FDA analyzed reports from clinical studies in-
volving patients taking a variety of antiseizure medica-
tions, mostly newer nontraditional drugs. Patients with
epilepsy, bipolar disorder, psychoses, migraines, and neu-
ropathic pain were among the disorders included in the
study. Compared to placebo trials, II popular antiseizure
examples were found to almost double the risk of suicidal
behavior and ideation among patients. In a warning is-
sued by the FDA, health care professionals were admon-
ished to carefully balance clinical need for antiseizun drugs
with risk for suicide. Patients and caregivers were encour-
aged to pay dose attention to changes in mood and not to
make chanRes in antiseiz ure r/'Rimen without
5

,

"
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TABLE 15. 11 Classification of Seizures and Symptoms
Classification
"""
Symptoms
Partiil
Ilfactory.iuditory.i'Khiswl halkKinations
mlO!ions

Complu panial (ps)'diomo!or)
Awol (preading)
Britf ptriod of (onfusion or afit!Wiro with no mrnlOll of s.rizLno Iposri!/QI roofug'm)
Of aUtmplilg to dolhing
No to 'lffilil (ommandl
0;;;.,

lanilg a few Ittonds
mn most oftm in mildlm (mild rum inlo!paC!. 11M not mpond tovrlllillstimwtion.milY
fuuffing Of jrrkingl
MisdiaogllOlt(j often (6pt(iiliy in as ADO
Atonic (drop iruOO) Falling Of stumbling for no fl'ason
lanilg a few Ittonds
Tonic-doni( (lJind mill)
Atl'a (preading)
ItIIIdr (onuaction (tonic: foIlowIod II)' akemating (onuactim and rriaLition of musdrs

Cl)ing at IJr9n"ngmi, Iral'fllungs; loss (ont,oI; shallow oo-atling with ptriods 01
ipMa;U5Uiliy lining 1- 1 miMe
Disorientation ind dtfp ifitl sftllll'
SptWlsyndrome Ftbrilt lfilll'r lonic:- donic: inil'itylming 1- 1 minute
Rapid to aHlsciousnes
Ikon il mildrrn UlUilly brtWffil J months and yms 01 olCJI'
Myodonic: srizu,r
lalljl'jrJII:ing II'oIMIIIen!lof a miljormusdr 9'ooP, wdJ.H an aim
Falling 110m a sitting positim 01 Itopping what is IIdd
SUlUSrpiltptiws

Comiooouslfil!ll' whidJ un to(OIIIi
with Iheir health care provider. The sum of this review in-
dicated that although the older antiseizure drugs have se-
rious clinical drawbacks, so do the newer antiseizure
drugs.
PHARMFACTS
Epilepsy
Thf word tpilrpsy is f,om the Gfl'rk word tpiIqnKJ, muning"to
IiIkr hold of Of

One of f'YI' ry 100 h.il rpilrpsy.
Of the U.S. populnion, 10% will hoiVI' seizurH within thrir Iiletillll'.
Most PfOplewith seizurH an')OOngtI' than 4S of alit.
-'
Many of the newer antiseizure medications are used in
adjlUlctive therapy. Some drugs are being evaluated for their
potential use in monotherapy. In most cases, effective
seizure management can be obtained using only a single
drug. For some patients, two antiseizure medications may
be needed, although unwanted side effects may appear.
Some antiseizure drug combinations may actually increase
the incidence of seizures. The nurse should consult with
current drug guides regarding drug use in monotherapy and
compatibility before a second antiseizure drug is added to
the regimen.
Contrary 10 populu btlitt il is impossiblt to 1W!llow the tongue during a
ltU:uR.and ont mould lorn' an objf(1 into the mouth of someone
who is having a
How Antiseizure Pharmacotherapy Works
The goal of antiseizure pharmacotherapy is to suppress neu-
ronal activity just enough to prevent abnormal or repetitive
Epiltpsy is nOlI menlill iIInt55; mildfl'n with h.ivr 10 I<Om
equivalent to wilhout the disordtr.
prople who had rpilepsy inc:ludt .kJlius Almnder the
Napolron, van of An, matn,
Aqatha Christit, Truman Capote,and Richa,d Bunon.
Among iduk akoholics IrNtment fo, haN will
still"e within 6 hours upon aniving for ut'.Hmtni.
LibraryPirate
("'Plfr 15 Drug<; for Selzure. 169
Abwnce Tonlc-Clonlc Myoclonic
DRUGS THAT POTENTIATE GABA

, , ,
gabapmtin (Nell'onIin)
,

,
phtnobarbital(lumilal )
, ,
pregabali'l (l,nu)
,
primidont(MySOiM)
, ,
tiagabi!H' (Gabitri)
,
lOpiramate (lopamax)
, ,
HYDANTOIN AND NEWEll DIlUGS
urbam.J!!pint (ltgrtlol)
, ,
Iall'lOU'i9nt(limimn
, ,
Inetir.Kelam (Krppri)
,
ouarburpi!H'
, ,
(Ililantil)
, ,

, , , ,
lOOisamide (ZOntgran)
, , , ,
SUCCINIMIDES
t\h&IUximide (ZaroJltinj
,
df1191 forUll inadjll'Ktiw 1htrapyor mark! potmtial UIlSas wellasappwml indiutions.
firing. To this end, there are three general mechanisms by
which antiseizure drugs act:
Stimulating an influx of chloride ions, an effect
associated with the neurotransmitter gamma-
aminobutyrk acid (GABA)
Delaying an influx of sodium
Delaying an influx of calcium
Antiseizure pharmacotherapy is directed at conlrolling Ihe
movement of electrolytes across neuronal membranes or af-
fecting neurotraIl'lmitter balance. In a resting state, neurons are
normally surroWlded by a higher concentration of sodiwn,
cakiwn, and chloride ioIl'l. Potassiwn levels are higher inside
the cell. An influx of sodium or calciwn into the neuron
enhances neuronal activity, whereas an influx of chloride ions
or an efflux ofpolassiwn ions suppresses neuronal activity.
Some drugs act by more than one mechanism. This has
prompted drug researchers to try to understand more
clearly various drug mechanisms and to develop newer bet-
ler conlrolled drugs. Recenlly, a fourth mechanism has been
proposed and studied, anlagonism of the primary excita-
lOry neurotrall5mil1er glutamate. Glutamate works in con-
cert with the cell's Na ... K ... ATPase pump, which helps 10
restore ion balances across neuronal membranes after fir-
COMPLEMENTARY AND A LTERNATIVE T HERAPIES
The Ketogenic Diet for Epilepsy
Tht ketogtnic: diet is used when (.)nnot bf (ontrolled through
or when tllm are ul\a((eptabk' id"irl1l' diem to mtdic:.l-
tions. Bdofl' antitpiltoptic: drugs well' deYrIoptd, this ditt Wi! i primal)'
tfl'Ument
The ktlogenic: dift is a (ikulated ditt that is high in fat and low
in urboh)llrates ,lIld protein. It limits watfr intaklo to avoid kIoto!H'diknion
a nd (ifl'fUli)' (ontrots (iloric: inta kr. Eim mfal has tht samf ketogtnic: ratio of
g offat to 1 g of protein and wboh)llratdxlri fat is usuali)' giwn in tilt
fonn of (ft'am.
Rest.Jn:h wggests the diet prodlKes high 51KU'SS rate fur (enain p.l-
titnu (Crw, 2009). About 0111' third of thf (hildrfllllling it bfooml' sub"in-
tially sfizurt frrf whilto one third their seizures fl'dlKtd by SO% (It"I'Y &.
Cooptr,200lj. Tht diet apptm to be equally for nff)' sfizufl' I)'pr.
Tilt most II'pOntd adYef"Sf eifll in(kidt vomiting, fatigUl',
pition, diarrhea, and hungtr.Kid!H')' stones,addosis, and sIowrr growth ratts
aft' possiblto risks. T"- intmstrd in trying tilt ditt must (OIlIUk with their
hNkh Llfl' prwidtr;this is nota do-it-)'OurwKdietand may bf hannfUl if oot
urefuliy monitOll'd by sl::illtd poossionals.
ing. Anydrug that blocks glutamate activity prevents an in-
flux of positive ions into the ceU, so this is consistent with
the last two mechanisms.
LibraryPirate
170 Unltl TheNe<vomSy'tem
PHARMACOTHERAPY ILLUSTRATED
15.1 Model of the GABA Receptor- Chloride Channel Molecules in Relationship
to Antiseizure Pharmacotherapy
Seizure Ktivity: EpHp'-'
Unc>c>nIroIled neuronal discharge
Drugs that pot..,liale GABA &etions:

Barbituralea
Hydantoins and """"' ... "!1"nts
SuccinrnidM
Strn"'I11;'9 infllDl 01 a -
Delaying infl"" 01 Na+ and Cs?-*
Anlagonism 01 Glutamate
NOITTIIII EEG record;,g
DRUGS THAT POTENTIATE GABA ACTION
Several important antiseizure drugs act by changing the ac-
tion of gamma-aminobutyri( acid (GABA), the primary inhibitory
neurotransmitter in the brain. These drugs mimic the ef-
fects of GABA by stimulating an influx of chloride ions that
interact with the GABA receptor---chloride channel mole-
cule. A model of this receptor is shown in Pharmacotherapy
Illustrated 15.1. When the receptor is stimulated, chloride
ions move into the cell, and suppress the firing of neurons.
2 Unc:ontroled ............ chcn.rv-
A number of drugs have GABA-related potentiation. Drugs
may bind directly to the GABA receptor through specific
binding sites. Well-characterized sites have been designated
as GABA
A
and GABA
B
Drugs may enhance GABA release,
or drugs may block the reuptake of GABA into nerve cells
and glia. Newer drugs are agents that inhibit GABA degrad-
ing enzymes. Barbiturates, benzodiazepines, and several
newer drugs reduce seizure activity by intensifying GABA
action. The predominate effect of GABA potentiation is
eNS depression. These drugs are listed in Table 15.3.
LibraryPirate
''''''lfr 15 Drug< for Selzu"" 171
TABLE 15.3 1 Antis"izure Drugs That Potentiate GABA Action
On"
BARBITURATES
amobarbitallAmytin
mtphob.Jrbitall Mtbiral)
o p/IffiobarbiIaHwmina')
prirridont 1 Mysoillt)
BENZODIAZEPINES
doniztpam (KIooopinJ

o diazl'pam (Valium)
Iormpam (Ite pa.;t 158 for
"'" Pmlotypo'Dn"l hnJOO)
NEWER GABA-RELATED DRUGS
gabilpmtin (Nl'\IIOnlinJ
pll'gabillil (l)Tica)
liagabilH' [GabitriJ
lOpiramatt (Topamax)
Barbiturates
Route and Adult Dose (max dose where Indicated)
1V;6HOOmg(mil:1 g)
PO:400-600 mglday
For partialand gmaliztd srizll'ts:PO.lOO-1OO IJI9/tIay:IVm,l,
rng !4l10 20
For status I'piIrpliru\.: IV; 15- 181119ibJ il ordMdtd dolts
(mn:20rngIkg)
PO:lSO iooMed by 2SO rngIwk!4l1O max rl2 9 in I'M)
10 foor dividtd dolts
po; 15 rngIday in lhrt!' dvidtd dolts, ilaustd by 0.;- 1.0 mg
MIY] day, IftMtsill' controled
PO; 75 rng lid
1M1IV;5- IO rng (rtptala1 nffiltd il10--15 mil !4l10
30 mg; rl'ptiligainal IH'fIItdMIY 2- 4 hI
IV pum; iltnilist mul!ion 011 5 ffi9lmin
IV; 4 rng il ;e,ntd ill mg/mil; if inadtquau ff!pornt ifl
10 min.moy fl'JH'ir ""'.
For PO, llart with 300 mg 00 day 1:300 rng
bid 00 day 2:300 mg tid on 10 iKrNS! a.'I'Il wi;
tool 011,200 mglday (400 rngtid);moy ioot'iltto
1,&X1- 1,400 rngIda,
PO;!lart with 150 mglda,:may tit ioor.astd up to]OO mgiday
wilhil 0IIt W!'rto: (max:600 rngIday)
PO;!lart with 4 rngIda,;may ilKll'ilt by 4-8 m9ldayMIY wffi:.
!4l to 56 mglday in two 10 fOll' li'Iidtd 00sts
PO:!lart with 50 rngIday,inuustd by 50 mg/Wk
(mil: 1,600 rngIda,)
Adverse Effects
Ag@DuloMO\jiSuwrn_Ig/DlQIlwD!tpme ,JOOioo!erN
Y!)'!IQOSWIlll, dwrnion,CtlSd!:prrnion.
coma dNlh
Jed!riw1, I'IrTigol;
coofuliOll, asrlrfnio, IrtododIe, III'nII7, fll'nOO>'It1\.
mffOOf)' cfflfcrlry, cfflfcrlly IOOO'nrnnillQ, pi)'dIomom
!IowiIg.ll)'S!agmIJ1. naMG, rmrrxiIl
5rrio1J5 dj5fogurjng,Joe! debjlj!atDg @W Wddro
IIleJ:Dlaintd dmh il tpim (5(JDEP1;withdrimllrizll'n
00 of drug
Barbiturates are organic compounds derived from barbi-
turic acid. All derivatives intensify the effect of GAB A in the
brain and generally depress the firing of CNS neurons.
incidence of adverse effects. \Vhen the drug is given orally,
several weeks may be necessary to achieve optimwn effects.
Phenobarbital is a drug of choice in the pharmacotherapyof

On>rall barbiturates are effective against all major seizure
types except absence seizures. Other than phenobarbital,
mephobarbital is occasionally used for epilepsy treatment.
Mephobarbital (Mebaral) is converted to phenobarbital in
tbe liver, and offers no significant advantages over pheno-
barbital. Primidone (Mysoline) has a phannaoologic profile
similar to phenobarbital and is among the drugs used effec-
tivelr to potentiate GABA action.
15.4 Treating Seizures
with Barbiturates
The antiseizure properties of phenobarbital were discovered
in 1912. and this drug is still commonly prescribed for
seizures. As a class, barbiturates generally have a low margin
for safety, a high potential for dependence, and they cause
profound eNS depression. Phenobarbital, however, is able
to suppress abnorrrul neuronal discharges without causing
sedation. It is inexpensive, long acting, and produces a low
Amobarbital (Amy tal) is an intermediate-acting barbitu-
rate given 1M or IV to terminate Unlike phe-
nobarbital. which is a Schedule IV drug, amobarbital is a
Schedule II drug and has a higher risk fordependenct.As an
antiseizure medication, amobarbital is not given orally.


,
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2
,
a
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"


LibraryPirate
172 Unlll TheNe<v"",.Sy.tem
.... Prototype Drug I PhenobarbItal (Luminal)
Therapeutic (lass: Antiseizure drug;sedative Pharmacologic (lass: Barbiturate; GABA" receptor agonist
ACTIONS AND USES
is a long-acting barbirurate usrd for tilt management of a vari-
el)' of seizurrs. k is also und to promote Phen obarbitalshould not wd
for pain .... 1;.(", it ma, i!l<rNIU to poin.
Phtnobarbitt I am biochtmicaliy by tnhallCing the xtion of tht GABA neu-
rotransmitter, which is rrsponsible for suppressing abOO/mal neuronal dis-
charges that can caUll'
ADMINISTRATION ALERTS
Parenteral phenobarbital is .! !oit-tillueirritanllM injffiions ma,prodJcr
a local infbmmatol)' ",action. IV administration is ra .... 1y Ull'd,btcause u-
tra'/illation rna, producr tissut nrcrosis.
(onlrolled substa!l<f:Schtdult IV
P"'9nancy categol)' D
PHARMACOKINETICS
(),sel: 20-60 min PO; S min IV
Peak: 8- 12 h PO; 30 min IV

Duration:6- 10 h PD;4- 10 h IV
Benzodiazepines
Like barbiturates, b,mzodiazepines intensify the effect of
GABA in the brain. The benzodiazepines bind directlytothe
GABA receptor, suppressing abnormal neuronal foci.
15.5 Treating Seizures
with Benzodiazepines
Benzodiazepines used in treating epilepsy include clon-
azepam (Klonopin), clorazepate (Tranxene), lorazepam
(Ativan), and diazepam (Valium). Indications include
absente seizures and myoclonic seizures. Parenteral diazepam is
used to terminate status epilepticus. Because tolerance
may begin to develop after only a few months of therapy
with benzodiazepines, seizures may recur unless the dose
is periodically adjusted. These drugs are generally not used
alone in seizure pharmacotherapy, but instead serve as ad-
jum.ts tu utl",r uru!\'> fur shurl-t"r", ,,,iotu,,,
control.
The benzodiazepines are one of the most widely pre-
scribed dasses of drugs, used not only to control seizures
but also for anxiety, skeletal muscle spasms, and alcohol
withdrawal symptoms.
ADVERSE EFFECTS
Plltnobarbital is. Schedule IV drug thit m" talU drptndencd ommon side
rifls indudt drowsinffi, vitamin drr"iffiOts (vitamin D; Of II,; and
Bu) . nd laryngo<pa<m<. With ownIo .... phmoborbiul m. , cause .. ""Pi_
I1tory depreSlion, (NS deprtlSion, coma, death.
Contraindications: Mminimation of phtnobarbit,1 is inadvil:able in me of
to b,rbiturates, uncontrolled pain, prHxisiting (NS de-
prrslion, disease with dyspnta or obstruction,
and glaucoma or prostatic hypertrophy.
INTERACTIONS
I)ug- l)ug: PIKonobarIitaI inreraru with mony otIPr for !LJmplf.
no! II! 1M with akohol If other (1fS dioprflSann. The!t substance! pottrtiate
barbiunte action, ino&l\iIg til! rill: of ift-thr&llHlilg dep"fISion or
ooIiac arr& PhPnobarbitai iOONlfS til! rnetilbotilm of many other r!'diKing

Lab Tests: BarbilUra!l'! mayaffmlrom!ul)toalein test! and
......,.
IlerbaVForxl: K.No! arK! villerian I!Ia1 potmtiale rdalion.
Trtatment of INtrdole: Thert is no spuific trutmtnl for owrdost. Drug rt-
mo\\ll may momplished b, g'lIric IaIll9t or U\e of .!aivated diartoaL He-
modialysis may effective in facilitating ",moval of from the
body. T",urntnt is ,nd oonsists mainl, of intubation
li nd rnrchinical ventilation. T .... atllll'm of br.dyu!dia and hypotension may bt
IH't6"",
__ 111 MyMnlngKl ,.. MIsIniJ 1'r/x155 fIJ< >pt<1IIr. 1II1M druf.
DRUGS THAT SUPPRESS SODIUM INflUX
Several drugs dampen eNS activity bydeL1ying an influx of
sodium ions across neuronal membranes. Hrdantoins and
related antiseizure drugs act by this mechanism.
Hydantoin and Newer Drugs
Sodium channels guide the movement of sodium ions
across neuronal membranes into the intracellular space.
Sodium ion movement is the major factor that determines
whether a neuron will undergo an action potential. If these
chafUlels are temporarily inactivated, neuronal activity will
be suppressed. \'-.'ith hydantoin and phenytoin-like drugs,
sodium channels are not blocked; they are just desensitized.
If channels are blocked, neuronal activity completely stops,
as occurs with local anesthetic drugs. Several drugs in this
group may not desensitize sodium channels directly, but
tl,,,y lIlay aIT""t 11"",I,ulu uf ""urunal liri,,!\, ur th"y may
interfere with transduction of the excitatory neurotransmit-
ter glutamate. These actions are slightly removed from the
actual suppression of sodium influx; however, the result
(delayed depolarization of the neuron) is the same. These
drugs are listed in Table 15.4.
LibraryPirate
("",10,15 Drug<fo,Selzu,e. 173
TABLE 15.4 1 Hydantoins and Related Drugs
""9
HYDANTOINS
ROUle and Adull Dose (max dose wh>re Indlca1ed) Effects
fosphtnytoin (u"dIyx) IV; inijia! dosr 15- 10 IIIIj P[lkg all00- 150 mg PElmin by
H mg PfJtgIday
dirzjfltlj, 9i/l9ival

Q trJ)'Ioin (Dilanlin) PO; lS- 18 mgillg or l-g inilial dosr;lhtn 300 mglday ill - 3 dividtd
dosrt; may bf gOOuil1y iOONsrd 100 f1l9,I'wffk
Agranu!ocytMaplilli!: allmlias;bu!!M,ufolialivto!
purpuric ktlnlOll !'!IIdr9mt;IO*
tpidrnnal arm!
PHENYTOINL1KE DRUGS
PO;lOO mg bid,lJadUiIIy iOOl'aitd 10800-1,200 mglday 10
fOIl' rhidfd dosr!
lWirltlS, MIDiIl,lOmoomr:t, Mtidht, blurred
/lQ"JimI indiqeUiro. rlliJim, Ifukopmio, proIongfd blMling

LrnOOX--YSliIUl \)'Ildromr: PO;stJn ailS ffi9/kglday in m!RlofOll'
rhidtd dosrs; may wasr 15 nJ9/kgal inlmais 10 malof
45 mWt9lday
Agranul[!()WiI; iplank iot!!!W; buRoul.
dermaJj[jrS!mm lohDloo 5vodromcgiccojder!M
marrow II"ffl"IallUI(:
paOOl'ilijirhml blod:rnpira!p!'f depmsioo
lamolriljilr (LJrniaal)
Partial srUlftS;PO;SLlnwilh 1)00 in 10 four rhidtd
dosri; may ilUl'aII' by 600 "'9iday mry 2 wk (max; 1,600 mglday)
PO;SO for 2 wk, 1IIffi SO IIIIj bid for 2wk; may ilKrusr 9radlil1y
!4l10 lOO-SOO in 2 dividtd dosr! (mal;700 mglday)
PO;SOO mglWKr daily (mal;l,OOO mg lOlal ptr day) lMIi,aulam (Krppfa)
orurIIazrpiM (Triirplal) PO;initialion of monol00ip)',300 IIIIj lwicr daly,iOOl'asr 100 mglday
thld day UplO 1,200 nl9lday


POIIV; 15 mglkglday il rividtd dost! whffi Itw 101.11 dosr i \
IJNlr1 1han 2SO mg; irKJUsr 5- 1 0 ffi9/kg/day wk until srUlftS
irr oontrdltd (madO m9Iday)
PO; 100400 mglday
OPE = phtnytoil
" I):hrr fonnWlion I of valproir: add inckJdt ill valprMr, and rhalprotx sodium.
Irdia ildialr oommon idvrrsr rflrm;.IIlId!:diniog. indialrs srriws admsr
15.6 Treating Seizures
with Hydantoins and Related Drugs
The oldest and most commonly prescribed antiseizure
medication is phenytoin (Dilantin). Approved in the 1930s,
phenytoin is a broad-speclrum hydamoin drug, useful in
treating all types of epilepsy except absence seizures. It pro-
vides effective seizure suppression, withoul the abuse po-
tential or eNS depression associated with barbiturates.
Patients vary significantly in their ability to metabolize
phenytoin; therefore, dosages are highly individualized. Be-
cause of the very narrow range between a therapeulic dose
and a loric dose, patients must be carefully monilored.
PhenylOin and fosphenytoin are first-line drugs in Ihe treat-
ment of status epilepticus.
Phenytoin-related d rugs are used less frequently. Several
widely used drugs share a mechanism of action similar 10
lhat of the hydantoins, including carbamazepine (Tegre-
tol), oxcarbazepine (Trileptal), and valproic acid (Depa-
kene, Depakote), which is also available as valproate and
divalproex sodium. Because carbamazepine produces
-
fewer adverse effects than phenytoin or phenobarbital, it is
a drug of choice for tonic- clonic and partial seizures. Ox-
carbazepine is a derivative of carbamazepine, so its teeM
ment profile is similar. Oxcarbazepine is slightly betler
tolerated than carbamazepine although serious skin and
organ hypersensilivily reactions have been noted. Valproic
acid is a drug of choice for absence seizures and is used in
combination with other drugs for partial seizures. Both
carbamazepine and valproic acid are also used for bipolar
disorder (chapter \600).
Newer antiseizure drugs show promise in lreatment fora
range of disorders including absence seizures, partial
seizures, myoclonic seizures, generalized tonic-clonic
seizures, and mood disorders. The most common adverse
effects of the newer antiseizure drugs are somnolence,
drowsiness, dizziness, and blurred vision. Lamotrigine
(Lamictal ) has a broad spectrum of antiseizure activity, and
is FDA-approved for longer-Ierm maintenance of bipolar
disorder. This drug's duration of action is greatly affected
by other drugs that inhibil or enhance hepatic metaboliz-
ing enzymes. Levetiracetam (Keppra) and zonisamide
LibraryPirate
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I
". Prototype Drug I Diazepam (Valium)
Therapeutic (lass: Antiseizure drug Pharmam\og i< ( lall: BflllOdiuepile; GABA. rtctp(or agonist
ACTIONS AND USES
binds 10 the GABA rKe plGl'-<hloridtchinneh throughout the (NS.1t
prodtKfS itI tflfm by Iivity in tIw, mbic: inc!
impulsts tim might be tlimmitttd 10 the rtticuLn . ctiwitill!l s)'!-
Iml. EffKb of thi5 drug supprelion of ibnonnal neuroroal fori t!wt INJ
CMe seizures. c.lmirIg withN: SIIong std<Ition. ilIId sktlrt.! mUlde
When iMdorally.m.WlIIJm iheripMX riKb nwytJkt from I to 2-.-b.Tot.
IIWII' detlop after ibolrt 4 Wftlr:s. When IV, ell"ects 0(0. in min
Ult!. inc! its intic:omuIsant Nfects loISt . bout 20 minUits.
ADMINISTRATION ALERTS
Whtn .dministering 1'1; lIIOIIitor Jt5jIiIatiom Mry 5 10 15 min<.m. HiM
airway ilIId JtIIII(itltM!@IIuipmtNI((HSibit.
PrtgIIilIIC)' Ulf'IJOf)" 0
PHARMACOKINETICS
(Mset: 10-60 mill PO; 15-30 min IV
PNII:: l-lhl'l);Hmin1M;1-5mi11 IV
Halflilr: lo-SOh
Dmtion: 2-1hl'l); l HiO min IV
(Zonegram) are approved for adjunaive therapy of partial
seizures in adul ts. Among the newer antiseizure drugs, lev
etincetam is generally less reactive and has Itss adverse ef
fec ts than the other antiseizure medicati ons. Conversely,
1.Onisamide is a sulfonamide and can trigger hypersensitiv+
ity reactions in some patients. Felbamate (Felbatol) can
also cause potentially fatal rt'actioru in patients indudi ng
aplastic anemia and liver failure.
DRUGS THAT SUPPRESS CALCIUM INFLUX
Neurotransmitters, hormones, and some medications bind
to nt'uronal membranes, stimulating the entry of calcium.
TABLE 15.S Succinimides
ADVERSE EFFECTS
Beause 01 toielllnce.nc! ust of is JtSMled for s/Iort.
ttrm seizuJt Of fof status rpptio:us. When gimJ IY, h)'llOtensioo, 1I"l/!'
ruLu we. knHS. tJClr/wdi., anc! repir.!O/y deprKIion ire common.
Conuai ndiciJlions: Whm adnWJinertd in injecuble form, this mrdiutixl
should be.1'Oided undef the foIowing conditions: s/tock,com..depresed vitl l
W!nl"obstellnl paDml!" iOO infinb Ins min 30 dqs of q.ln t.biet form,
the mediution slloukillOl beJdrninisteJtd 10 "lallG less months 01 q,
to ".titnll with OIOJte rIIm7 ..-.ngIe gl.lllWlllil or lII'IlINtfli opl'lhlngle glau
mllll,or within 14 cI.lysof MAD! theli P1.
INTERACTIONS

bKAIII' of mrrI:ftd sediIian rll"fCts. OM Q-u:j illlfriCIi OIl! irWif Iinfidinf, IRI


phfnytOOiliM rnqalllf KIi!iIJ.
lair Itstl: u.a-
IU!I''' incrNIed ffl"Kl
TrNlI1Ient 01 If.n Mrdose ocwrs,admmter HumutniliRomizi
mn),i spteft bmzocimpint Jt(ep1or oI nugonistto OIS
SCIIrfIfr 14, pII}t 16100. NuI1iIfI'loms lfo4.pgt!ftWI RtMItIJW;Sflft

...
Without calci um influx. neuron:ll transmission would not
be possi ble. Succinimides delay entr y of calcium into neu
rons by blO(king low_threshold c:llcium channels, ill(:reas
ing the elearicalt hreshold of the neuron and reduci ng the
likelihood that an action potential wi ll be generated . By
l1Iising the seizure threshold, succi nimides keep neurons
from firing too quickly, thus suppressing abnormal foc.i.
Su(ci nimides
Sucdnimides are medications that suppress seizures by de
cakium inflwt into neurons. They are generally only
effective agairut absence seizures. The succinimides are
listed in Table 15.5.
Dru<j
ethosuJirnide (Z.arominl
rMhllmrnide (CrIontiIII
p/IntlulinicSe (MiIonOOI
Route and Adult Dose (max dow when! 1ndlcated)
PO;2SO IIIg bid,ioomtd !nly4- 7 diy!(mil: IS IJfdqI
PO;lOO .yUy;!IIi'f iKrrN rmy 4- 7days (m.u: 11 g/diJ)
PO;O.> i.Ogbidortid
Advel5l! Effects

_.rominIJ
LibraryPirate
("'Plfr II Drug<; for Selzure. 175
II, Prototype Drug I Phenytoin (Dl/antm)
CI als: Antiseizure drug; antidysrhythmk Pharmacologic Cia II: Hydantoin;sodium intlux-supprelsing drug
ACTIONS AND USES
Phenytoin im by wdium channels in lilt, (NS for
neuronal prn ents Ihr sprr id of disruptivt M.:tri-
(.II (hiR)6 in the blilin that is riffctiYf igainst most typrs
of seizures txetpt !tizur6. Phtnytoin has antidysrhythmic activity
similar to that of lidocaine kim 18). An unlabeltd 1M is for digiulis-imb:rd
dysrhythmias.
ADMINISTRATION ALERTS
When idministering IV, mill with salinr only, and infusr at thr lllilximum
ratt of 50 mg/min. Mixing with other mrdi(.ltions or dtlllr= solutions
prod!K6
Always primr or flush IV lin6 with S.Jline brfoft' hanging phrnyloin as a
pigg)"back. ,ilKr tram of dffirosr IOknion in an rxisting main IV or pig-
9)'bo<:k Ii .. (In taU" mi(lol(opK formltion. whim bt<ornt
rmboli ij irrhM<l.1.M an IV line with fihrr when infusing this drug.
Phenytoin is a soft-tiSSUl' irritantthat(.llMS 001 tissue dam-
agr following utrivamion. To rmlKr the risk of soit-riSWl' dalNgr,do
oot gi!' IM;injm into i WR)l' \'tin orm a (entral Vl'oouscatherer.
fwoid using hand mns 10 prnrM !triM Ioul \\IlO(onlUicliVl' rrsponll'
(purp1t gloft syndromr).
PregnalK)' Ulf90ry 0
PHARMACOKINETICS
Onset : Slowly and variably absorbrd PO
Peak: h prompt h sUitainrd
Halflife:21h
Duration: 15days
15.7 Treating Seizures
with Succinimides
Ethosuximide (Zarontin) is the most commonly prescribed
drug in this class. It remains a drug of choice for absence
seizures, although valproic acid is also effective for these
ADVERSE EFFECTS
Phenytoin rruy (.IUS!' dysrhythmi.l .. su:h is brid-prcia or mnri:ular fibrillation,
snm hypotension. and byptrgiycmlia. SrYM' (NS rrKtions irdJcko 1Iradachr,
nystagmus. ataxia, mnfUsion and sUlTI'd paliOOxiul
twitching. and insomni.l.Peripht ral mayoccurwith Iong.ttrm 1111'.
Phenytoin (an Wilt multiplr blood induding agranulocytosis and
aplastic: anemia.
This mrdiution ilia)' caUir skin rra(uons, sum is IiIshrs, including
exfoliatiYf dtrmatitis, and S_ns- Johnson syndromt. tillue ft'ac-
tions in{kKir lupus rrythematOSUI, hyprnri:hosis, hirsutilm, gingival hy-
ptrtrophy.
(ontraindi (.llions: Patirnu with h)'ptBensitivit)o to hydimoin prodKts
should bt (.Iutioos. Rish, S!'izurts due to hypoglycrmia,sinus bridyurdia,
hean block arr
INTERACTIONS
PhI'n)1oin iltflilGwim 1llilrf0lher drujs.iddng
.. iMlfrruliI ",folk
D.kifl"4OOtlltellioc/of drugsmas!io;itolin,
dox)tydnf,hn:Iernide,l!IIrogens.n:louroaG'pli'RS,.n:I
(00lbMI m.wrsfina-I'S.
l.i b TI5IS: Hydantoins may pffdu Iowfr h.JlOllU "IiIufs for duarlM' !basont or
metylipolll' tests. PIlmytoilmay iMJ&ISI' IeVl'Is of gllK(M, IrornsWphalein,
iodilM'aOO urilliry
SIfIoid ,", Is.
Herba VFood: (bu::tthom. USGlr.I Ifnllilmay irKRalf
tIw therolpflllic: of pherryroin.
l INi ment of Overdosr: "lhrrr is no sprcifll trritllll'M lor 0Y0."rd0S!'. Drug rr-
IIIO'/i l may bt momplislied by gastric: iavagr, uS!' of oKtivattd (hil{Oal or lax-
.IIi!'. Trratment is supportivt and (onsisu miinly of maintlining the airway
and brt.ilhing. monitoring phenytoin blood ,nd trriting
adversr symptoms.
It!ftr Ie M}M!rl/ngK1l for Q Nurlifllj Prru1s foals spKlk Ie rlrls
types of seizures. Some of the newer antiseizure drugs, such
as lamotrigine (Lamictal ) and wnisamide (Zonegran), are
being investigated for their roles in treating absence
seizures. Lamotrigine has also been found to be effective in
patients with partial seizures, usually in combination with
other antiseizure medications.
LibraryPirate


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176 Unlll TteNetvoo,Synem
..... Prototype Drug I Valprolc ACId (Depakene, Depakote)
Therapeutic Class: Antisfizure drug Phannacolog ic Class: Val prOdte
ACTIONS AND USES
Tilt IJIe(hani<m d action of valproic: acid i< !wI th!' Iolmt i ction
as that of phenytoin, although tffrill on GABA and ykium (h anntls allo make
this drug to btruodiazepine "Id ",ainimidf5. k i< !M1U1 for. MIle
rangt of Itizull' ilKlOOing ableoc:t and mixrd types of stizurrs.
Otlltr UIfS indurr pR'Vemion of migraiO!' hNdac:hts and ofbipola,
disordtr.
ADMINISTRATION ALERTS
Valproic acid a GI initam.AdviIt patitnll oot to mfW nteodtd-rtleast
ublru mouth \l3l1'Offi will (Kwr.
Do not mil v.lproic i(id I)'IIJP with bt<aUst they
will triggtr II'ltast of drug. which UUsti \e'l'l'1I' mouth and
throat initation.
Open Ypluitl and Iprinklt on !oft foods if tht patitm yooot Iwallow
tlltm.
Plf<lnaocy 0
PHARMACOKINETICS
()Jstt: ab!orbed from GI tract
Peak: 1--4h
S- lJ h
Duration: Variablt
.... Prototype Drug I EthOSUXimide (Zarontm)
ADVERSE EFFECTS
Side ellras iKkm !fdation,drowsms,GI upstI.and prolonged bletding bill!'.
Other NItm iKkm dilrulbalKn,lIIUidt tll'mtr; Pl){homotor
igitltion, boot nYmlW IUpprmion, 'Might gain, abOJmilal oa mp!, rash, alopr-
0" photo5t05itivity, mukifOllO!', and fatal
Contraindication!: Hypmeositivity may oc:rur. medication Ihould not be
to patitml with di!ult, bletding dysfunctiol,
ind (ongtnital mmbolic di<ordtn..
INTERACTIONS
l)ug-l)ug: YaiproiI: arid inlerarts wiIIl many dlll9l. f in,
00IWdine, <Norprornaz_, fI)'/hrorny<in, and ffIIamate may i"KruIio 1l!Ipr<t add
tmid/)'. Coocomirant wil'farin, alpi'in, or akd"d l1li' ran (iJU\f It'Il'II' 1H;>diDg.
AIutIoI, and othtr OIS IIfpm.sam pciPlltialf CHS
iKIicn lIIf of dooazfpam (OIKUIl!fltly with uproil:add may ilduaiNoo
If'illl@l.lIaIproiI: add and p/lfoyroil
larnoiri9irw. IowflVaiproil: add
Lab 11'115: Unknown
Ili!rbaVFoo:1: Unknown
TlNtment of Owordose: Theil' i< no Ipe(ifK tll'anneot for OftdOle. Drug 11'-
mo\\ll may lit ac(omplishtd by gastric: usr of activated dwrroal, or
ilin. TlI'almtm and (onsim mainly of maiOtlinlig tht airway
ind bll'ilhiog. monitoring plltrr;toin Ievek,ind appropriately tl1'ating adl'l'llt
l)'IlIptolnS.
RM lIIMyMnlngKlfo( MnIlIgl'rof.t5.IFooII'ijI/It IIIMItrJg.
Therapeutic CIaS!: Antiseizure drug Phannacolog ic Cia!!: Succinimide
AalONS AND USES
Ethowu midt i< adrug of for (petit maO Itizull'!. k depll'SIt! the
activity of IltUI'OIlS in tilt motor mnn by elmting tilt IltUlOIIil thrr4lold.1t is
intffNtil!' igainn ps)'(homotor or tonic-donic Itizurrs; it
may lit ginn in mmbinarion with othtr mtdicarioM thit littler treat tlltlt
{onditions. k "'ililablt in ubiet and flawlI'd-syrup formulation!.
ADMINISTRATION ALERTS
Do not abruptly withdraw !hi< mtdilabon bt<ausr doing 10 may indKr
tonic-tlonic v.izulI's.
PlI'9oancy cattgory (
PHARMACOKINETICS
()Jstt: ab!orbed from thr GI tract
Peak: 4 h
30 hin (hildll'O;60 h in adull!
Duration: Variablt
ADVERSE EFFECTS
Etho!urimidt nYyimpairmentaland mood
swirqs, inWding depl!'!Sion with a'rt ",icidal intent, un 0ffiI". Behavioral
ill' more promilent in Ilalitnts with I history of psyrhi.mc: ilM!. (m-
tral OI'I'IOIIS S)'SItm efferu indJde he.Klac:ht, lethargy,
Iftppattemdisturbaras,atttnliondiflkuity,andhimJpI.Bontmarrowsupprts-
<ion.nd blood dyKruia, ... p05Siblo, ... ;' <y<1rmic: ...
Otlltr lI'actions ilKlude gingiva I h)'pertroph)' and tongut sWflling. Common
Iide all' abdominal Wfight los!.
Contraindications: may (KW'. Do oot ulr this medication in
mrs of !rftre lin, or kidney diINlt. Safety in (hildll'n YOUOgtl!hi n 3 of
agt !ws not tstablishtd.
INTERACTIONS
I)ug-l)ug: inoNsts p/l@nyroinIoKOOI,",,!.'hJproiI:a:idraws
f1IIo!UDnidf IflIIm lewis to and IIKIMfJ.
Lab 115Is: lktoown
Ili!rbaVFoo:1: GinlGjo may rf<i1Kf tIIf thflapeutic: fffK1iwom 0( MhoiIIIimidf.
TlNlment of OwordOS!: i< no Ipe(ifK trurmmt for OftdOlr. Drug 11'-
mo\\ll nYy indoor rmesi< unltss the patitnt i< or TlI'ar-
IO!'nt may be mompii!hed by gillric: Imgt, usr of activattd (haKoal or
m!wniu,ind supponiW' mu",rrs. Htmodialysi< may be eIflMo in
fariliutingll'lIIO\\Il of t rhosuximide from tht bod)'.
RM 1II MyMnlngKlfo( MnIlIgPrl!Ct5.IFooII!pK1/I: 1II1M1trJg.
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("'Plfr 15 Drug<; for Selzure. 177
NURSING PROCESS FOCUS PATIENTS RECEIVINGANTlSEIZUR' DRUG TH'RAPY
Assessment
Baselinr assessment priort o admini stration:
UndtrsLlnd INson drug has bn presc:ribtd in onlmo uses for
t ...... p.uti< .ffu.
Obtain 1 compltt. lItahh history induding IItpatic,
nrurologic \titus; naflow...Jnglt gliU(omi;and pregni lK)'
or brmt-feeding.Obtain a drug histor, ilKluding all.rgiM,culTI'nt
presc:ription and OTe drugs,and altrno
drug interactions.
Obtain IsNuft' histor, (r.g. physical symptoms,
prodromal warn Irngth of po5tim I ptriod).
Obtain viLli weighl"nd in ptdiatril: patirnU.heighl
Obtain 1 histor, in ptdiatril: patitnts OOSTll lml of
growth and dfeiopmtftl,Khool
Evaluate approp riat. laboratory ( . g., eBe, hfpatic or
r. nallUnnion \tudits).
Ailes abilit)- to ,nd undtrmnd
tilt family and 011 ne!'dtd.
Assess ment thro ughout Idministrati on:
Allel for dtsired (r.g., diminilhfd or ablffiCt of .. izurr
activit)o).
Conti .. ", pniodic monitoring of(O(,.nd lim- and ", .. I function Iwdits.
Asses ViLli signs and Wl'ight or ij symptoms warrant.ksel
and Wl'ight in all ptdiatril: PltitntS.
ASIeI for Ind promptly rrport dill.iness,
dlllWlinm,light hudtdlll'Sl, confulion, agitation, palpiLltionl,
tich)l:ardia, burrt'd or doublt vision, continuotJl .. izurr activit)-, skin
broiling or biffiling. i bdominal pain, changt in {olor of
Itool,flank
Potential Nursing Diagnoses
low (situational orchroni<; ft'IaIN to effrcts)
Soc:iIIllnteraction (rrlatfd todil. ase, l.!ck of srizuft'control)
Drticitnt KnowIedgt (drug thtra py)
Rille for Injury(ft'littd to !eiZUrM or adVPISI' drug tffr<ts)
Planning: Patient Goals and Outcomes
Ih. patitnt wiu:
U:ptntlKt tlitraptUlic effrcts dtptndtnt on r. ilOn th. drug is being given ( . or abl!' nt I!' izull.'adjyit)-j.
from,or tlptntlKt
an undtrstanding Ofthtdrug'I!IIt, .ffts,and rrquiml
Demonltra!. proper oftht medication timing. wh. n to notif)o provider).
Implementation
Interventi ons and (Rati onales)
Ensuring therilpeutk efffits:
Continue messments on described .Irlicr for theraptUlic efffS.
IAntill'izurr drugs may not rompirtrly symptoms but Irrquenq
and of shoold bt diminishtd.)
Minimizing adft ne effects:
Continue to monitor
periodicalI}'. E nlu ft' patirnt monitor ambulation until the effects of
tilt drug i ft' known. pinirulart; UUtioul with older adults whoar. at
in{lNlfd risk for falls. (Antisrizull.'drugs may caUl!' ,rod
diuilll'Sl, hypoteo\ion, or im pairro flll'ntal and physic.i I abilitits, inc:"'iI
lilt risk offalk.nd injJr,J
Pati ent and Family Educati on
Tmlt tht family,or {llt9ier to kt rp a Mit diaryof frt<;(uenq,
protiromalsymptoml,and partictal period.
Tnch th. j)ititnt to riIt from lying or lilting to nanding slowly to mid
dill.inen or falk.
patirM to call for prior to gening oot ofbtd or
attempting to walkaloll!', and to aYoid driYing or atlltr 1tqUiring
mtftLlI altnness or physical coordination until tffNIs of th. drug a",
k_.
(conrlrruefi)
LibraryPirate
NURSING PROCESS FOCUS PATIENTS RECEIVINGANTISEIZURE DRUG THERAPY (Conrlnued)
Implementation
Interventi ons and (Rati onales) Pati ent and Family Education

Cominue to monitor in pMiatril: Tt.Kh tht patitnt's familyorcart gmr to s<ileduled
poatitms.ln tht s<hooI-11jt (hild,I!I;m s<hooI appointments with tht htalth ('11' pltlider and rt porl any de''lopmentll
tffn of antileirurt drugs or unll'SOlved may hinder normal IigSOl{on(eflls.
growth and devflopmfm.)

Cominue to monitor drug It:Yrb, C8(,rroa) and liepalit

)nmuu thr p.llient on thr IIC' rdto return periodkaUy for lab wort.
poalKlI'aiic (AntMzure drugs requill' periodic drug Intis to

IlIIIruct poatitnt to UIIY a walltt identification utd or Wl'ar medical
romlitr It:\'eI with symptoms.AntMzure drugs may UIM
idmifution it'M'11' ildiming a smtJredilorder and antisMR medKation.
hrpato\O);icity a nd '/iIlproic I(id may ta!M poalKlI'atitis isan ad"/mt

T_ h thf patitnt to promptly rt port any abdomini llHlin,poanKuiarly in
rfffft.)
upptr in slool (oIor;)'fllowing of sdera or skin;or
dlluoed urinr.

Aslffi klr (hinges in the of (on sciousness, disoritntation or (onfusion,

InstnKt family, or cart9m r to immediatrly II'port inc:lI'iIsing
or agitation. (Nr Utologit du nqes may indiutf or ad''rIt !fthargy, disorientation, {OfIfiKio n, (hangl's in brhavior or mood, durre:l
drugrffn.) Ipffih,or mxil.

Aslffi klr manges in visual acuity, blumd vision, 1m of peripheral vision,

InstnKt patienl to immediately report any visual (hange or pain.
rainbow halosaround rye poain,or any of
symptoms I(rompanied by naum and wmiting and II'pOIt
(llKreased intraoptic presSUIl' in poatitnts with narrow-anglr glauooma may
o((ur in patients taking btnzodill'pinrsJ

Aslffi tlr bruising.. blmling,or signs ofinftion.(Antistirure drugs may

Ttadl thf patitnl to promptly report any signs ofinc:reasro bruising,
blood dj'SUHYS ind ilKrused (halKrs of blerding or inkrtion.) blreding..or inftions (e.g.,1OII' throat and fIow,skin ruh).

Monitor allfit and motional stilus. (Antistizull' drugs IIU)' in(lI'asr

InstllKt family, or cart9mr to II'port significant mood (h angrs,
risk of mental deprrssion and suicide.Conc:umm of akohol or other rspe<ially deprrssion, and to 110 id akohol a nd other eNS deprma nts whitt
eNS deprrss.Jnts risk.) taking thf drug.

Aslffi the rondition ofgums and oral hl'lienr i nd

InslnKt patienl to rrwimain m:ellent oral hl'lient and rtgUlarl)o
phenytoin-like druqs may calllt gingival hyperplasia, inuming the risk of I{heduled dent!) nts.
oral

En{QIJriljt appropriatf lifrstytt dittiry (hanges: inaNsed intakeof

ErKouraljt tht patitnt to deerea or bslain from caffeinr, nicotinr, and
vitimin K. D, folil: vitamin B-ric:h ioods:loWI'red "ffeillC' intake of folic: .Kid,and vitamins B, K- ric:h foods.
inc:luding OK medications that {ontain Uffein!';i nd limited or no akohol

./dvisf poatient to discuss all Ole medications with health care
(Caffein!' and nic:otin!' mi y thf riftivenrss of tIM-
provider to ensull' that caflein!' or akohol is not inc:luded in tht
btnzodinepinrs. Barbituratrs, drugs with GABA oKtion, and hyda n toins and
formulation.
phenytoin-)il? druqs afftct thr absorption of vitirnins K. D, fo)it a{ id, and B
vitimins. Akohol and other e NS dfprrsunts may inc:re a Ihf itIYrof
rffn of the amistizull' drugs.)

Monitor (hildren for pariooxiull\'SjlOmt to (HyptrKlivit)o

InstnKt the family,orcar!gmr to notify health ure provider if
mayocwr.) tht patitnt rxhibits hyptrKti,, b!'hnior.

Aslffi women 0 f (hild-btaring IIjt for thf possibility of prt9nanC)', pian s

DisCU\5 PlI'9nanq and family planning with wornrn of (hild-buring q.
for pregnanq, brmt -fetding, and rontr.Kfp live (Antiseizure Explain thr tfft of medicltions on pregnane-; breast-fmling Ind thf
medications are tilrgory D in deell'ilsr nred to disc:uss any PlI'9fUnq plans with the hrlkh (all' pltlider.OisMs
riftivenm of oral (ontliKrptives a nd additional forms of (ontrueption tht nml for forms of (ontroKeption, ilKluding barril'r m!'thods,
should be used.) with patients tlking for!Nure romrol.

Avoid abrupt dis.:ontinuuion ofthffilpy.(Status epiltplirus rrwy Q(ur with

InstnKt patient to the drug eX.Ktly u presc:ribed and to not stop it
ibrupt discontinuation.) abruptly.

Aslffi hom!' slar"9l' of meditations and identify risks for rorrlive "tion.

InstnKt patient that drugs should not bt ktpt at the bedside and
(DYerdos.JgI' O{cur if the p.ttitnt tikrs<ldditioni) dam when drowsy toavoid taking additiona)!lasn whrn drowsy.
or disoritmed from mrdic:.ilion rfftm.DYerdo!.agt with barbituratrs
pKM'latal.)

PlO'Iide MIOtioBillsupport and appropriatt II'fmals u nreded. (T

Tt.Kh tht family,or wegiver about support groups and
with antileirurt drugs may require using (ombinations of drugs and seizure appropriate II'ffrrals II nmled.
I(uvity may diminish but may not bt II'soiffiLSoc:i.JI isolition i nd low self-
may occur with (ontinued disorder.)
LibraryPirate
(lIIplfr 15 Drug<; for 179
NURSING PROCESS FOCUS PATIENTS RECEIVINGANTISEIZURE DRUG THERAPY (COOllnued)
Implementation
Interventions and (Rationales)
monilOr lilt IV infusion using IV drugs.AIIIV
drips should via infusion pump.
irritltinglO lht vrin.BlafKhing and pain U lilt IV
indiutors of mr,mution <lnd the IV infusion should be immediatl'ly
nopped and the provider ronloKtt<l for funhtr treum!'nt InfUsion
pumps will allow pletisr dosing of the mrdKatioo J
Patint understanding of drug tht rapJ:
1M opponunilil's during administration of mt<lKatioosand during
as ItSlIIIl'Ot> to discl& the for drug theraPl', tlitraptUlic
Ol/I(omrs,most commonly obsrrvtd parameters forwhen
to call the health we and afT1 nf5sary monitoring or
ple(autiom.(lkingtimr ruring ri ming carr helps to and
by INChing
Patint stlfadministrilt io n of drug therilPY:
Wlltn administering thr mrdication,imtOKt tht palil'm. family,or
in propl'l" srlf--adminismtion of drug. r.<j, takt the drug as
prrscribtd and do notlUbstilUle b"nds.(Utilizing tim!' during nUI1e"-
administration of thl'Sl' drugs hPips to reinfof(e tM:hing.)
Patient and Famil y Education
Te<lm tht patient to imOll'diately report pain or buming at the IV in
atremity with IV.
The patitm should R to Stitt the for tht drug; appropriate doW'
and lCheduling; willi! toollW'rYf for <l nd when to rrpon; <l nd
tht imicipatt<l length of mrdicition therapy.
Team tht patil'm 10 takt the mt<lication as foiIoM:
Exactly as ordert<l and thes.Jm!' manufacturrr's brand tach time tht
prrsaiption is filled. (Switthing brands may rt'Wk in
phi rmoKokinetiu and ikerations in seizure (ontrol.)
Td:r iI missed dose IIsoon as it is notKtd but do not tlU doublt or utra
doW'slOutthup. "
Tau with food 10 dtcrriW' GI upset
Do oot abruptly dil(ootinlK' the mrdiution.
Evaluation of Outcome Criteria
E'lilluate the rffe!:tiYelll'SI of drug tllrrapy by confirming that p,1tirm goakand npKtM outcomes hn'l' 11\I't (W'tPlanning1.
rrItIIH, IH,QOO IUfor 1M ridflllllfl1fr"hj(h mtst IWingf'rol.mFOMUli* milr<flm 14ilfrmDlDlreIomilfl
J
. Chapter REVIEW
KEY CONCEPTS
The numbered kt-y concepts provide a succinct summary of the important points from the corresponding numbered section
within the chapter. If any of these points are not clear, refer to the numbered section within the chapter for review.
15. 1 Seizures are symptomatic of an underlying disorder and
are associatoo with many causes, including head trauma,
brain infection, fluid and electrolyte imbalance, hypoxia,
stroke, brain tumors, and high fever in children. Preg-
nancy and quality of life are importam issues to consider
when discussing epilepsy and seizure management.
15.2 The three broad ,ategori.-s of seizUI.-s are partial
seizures, generalized seizures, and special epileptic syn-
dromes. Each seizure type has a characteristic set of
signs. Comrol of seizures requires proper diagnosis and
drug selection.
15.1 Both traditional and newer antiseizure drugs are indi-
catoo for seizures. Both drug classes have serious draw-
backs. Anti.seizure drug therapy works by suppressing
repetitive and abnormal neuronal firing. Distinct mecha-
nisms include GABA potemiation, delaying an influx of
sodium or calcium ions into neurons, and antagonism of
the neurotran5JIJ.itter glutamate. Pharmacotherapy may
continue for many years, and antiseizure drugs must be
withdrawn gradually to prevent seirure recurrence.
15A GABA-potemiating barbiturates, mainly phenobarbital
and primidone, are effective against all kinds of seizures
except for absence seizures. Phenobarbital is the drug of
choice for neonatal st'izures.
15.5 Benwdiazepines reduce seizure activity by potentiating
GABA action. Their use is lintitoo to short-term therapy
LibraryPirate
180 Until TheNelv"",.Sy.tem
for absence seizures, myoclonic seizures, and to terminate
status epilepticus.
15.6 Hydantoin and related drugs act by delaying sodium in-
flux into neurons. Phenytoin, carbamazepine, and oxcar-
bazepine are broad-spectrum drugs used for aU types of
epilepsy except absence seizures. Valproic acid and lam-
NCLEX-RN" REVIEW QUESTIONS
D The nurse evaluates patient teaching related to causes of
seizures. Further teaching is needed if the patient makes
which of the following statemen1li!
1. "Seizures can becmsed by inllammation of the brain."
2. '"Seizures can be caused by low blood sugar."
3. relatiVl' had seizures l>ecauseof a large tumor
growing in his musdes."
4. "Seizures may ou;ur after a head injury."
D The nursing student asks the nurse to explain the action
of the anti.seizure medication, phenytoin. The nurse ex-
plains the mechanism of action as:
I . suppression of the influx of chloride into the neuron.
2. stimulation of the influx of cakiWll into the neuron.
3. suppression of the influx of sodium into the neuron.
4. stimulation of cakiWll and sodium needed to Sllppress
seizure activity.
D The nurse re;:ognizes that several chemicals inhibit neuro-
transmiller function in the brain. The primary inhibitory
transmiller in the brain is:
1. sodium.
2. GABA.
3. chloride.
4. calcium.
CRITICAL THINKING QUESTIONS
1. The nurse practitioner reviews the laboratory results of a
16-year-old patient who presents to the dinic with fatigue
and pallor. The patient's hematocrit is 26%, and the nurse
notes multiple small petechiae and bruises owr the arms
and legs. This patient has a generalized tonic- donic
seizure disorder that has heen managed well on carba-
mazepine {Tegretol}. Relate the drug regimen to this pa-
tient's presentation.
2. A 24-year-old woman is brought to the emergency depart -
ment by her husband. He tells the triage nurse that hiswife
has bern treated for seizure disorder secondary to a head
injury she received in an automobile accident. She takes
phenytoin {Dilantin} 100 mg every 8 hours. He relates a
history of increasing drowsiness and lethargy in his wife
owrthe past 24 hours. A phenytoin level is performed, and
the nurse notes that the results are 24 mcgldL. Relate the
drug regimen to this patient's presentation.
3. The nurse is admitting a 17-year-old female patient with a
history of seizure disorder. The patient has broken her leg
otrigine treat all major types of seizures. Several d rugs
in this class act by more than one mechanism.
15.7 Succinimides act by delaying calcium influx into neurons.
Ethosuximide {Zarontin} is a drug of choice for absence
seizures.
o The patient, age 8, is prescribed valproic acid {Depakene}
for treatment of a seizure disorder. The nurse should
monitor the patient closely for:
1. hyperthermia.
2. vitamin B deficiency.
3. restlessness and agitation.
4. respiratory distress.
D Discharge teaching for a patient receiving carbamazepine
{Thgretol} should indude:
I . monitoring blood glucose and reporting decreased
levels.
2. expecting a discoloration of oontact lenses.
3. immediately reponing unusual bleed.ingor bruises t o
the health care provider.
4. expecting a green discoloration of urine.
II Which of the following medications may be used to treat
partial seizures! (Select all that apply. )
1. Phenytoin {Dilantinj
2. Valproic acid {Depakene}
3. Diazepanl (Valium)
4. Carbamaz.epine {Tegretol}
5. Ethosuximide {Zarontin}
in a car accident, in which she was the driver. The patient
states that she hates having to take phenytoin {Dilantin},
and that she stopped the drug bt>cause she could not drive
and it was making her angry. Instead of reassuring the pa-
tient, the nurse first considers the possible side effects of
long-term phenytoin therapy. Explain possible long-term
effects of phen)'toin therapy and their impact on patient
compliance.
See Appendix D /oransWf'rs and rationales for all activities.
EXPLORE
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reWUIOI .. Pnlll<lla fur suoxass
Questions. Imerarle 8SSIglll1ents and actMlies. wetl linka, an lmatioos
and videos. and mClIOl
Flegi!JIer)'DIX accegs CO!II! rmm me front a/ \'OUI bor:t lit
www.mwn ...... gkitcom.
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DRUGS AT A GLANCE
ANTIDEPRESSANTS JIalII8J
T ricydicAntidepressants (TCAs) (JY/t 184
Q Im/pram!n!' (Torronl/) {IQIJt 187
Serotonin Reuptake Inhibitors
(SSRls) {IQIJt 164
Q 5f'rtroUne {Zolofl} {IQIJt 188
AtypicalAntidepressants {lQlJt 188
Serotonin- Norepinephrine Reuptake
Inhibitors(SNRls) pagtl88
MAO Inhibitors(MAOls) pllJl l89
Q phenelllne (Nardll) f'jt If()
DRUGS FOR BIPOLAR DISORDER fII1'J'191
Q /lrhlum {Eskalllh} {IQIJt 194
Antiseizure Drugs {IQIJt 193
Atypical Antipsychotic Drugs fI<XIl' 191
DRUGS FORAmNTION DEFICIT - HYPERACTIVITY
DISORDER(ADHD) fDlt197
eNS Stimulants JVjIlOO
O melhylphenldare (Ritalin) {IQIJt Ill!
Nonstimulant Drugs forADHD {lQlJt200
KEY TERMS
attention deficit-hyper.ctivity (ADHD)
Ill"" 191
bipolar disorder (ilIIjt 189
depression ftlf/l'l ll.'
dysthymicdisordrr {lJ9t181
rlectroronvulsi'ft' thuapy (ECT) (IQIJt 183
major depressivr ftlf/l' Ill.'
Drugs for Emotional
and Mood Disorders
LEARNING OUTCOMES
After reading mis chapler, the student should be able to:
1. Identify the two major categorie s of mood disorders and their
symptoms.
2. Identify the . ymptom. of .. ttentio n deficit-hyperactivity di . order.
3. Explain the eti ology of major depressive disorde r.
4. Discuss the nurse's role In the pharmacologic management of patients
with depression, bipolar di sorder, or attentio n deficit-hyperactivity
di sorder.
S. For each of the drug classes listed in Drugs at a Glance, recognize
representative drug examples, explain their me chani sm of action,
primary actions, and important adve rse effect s.
6. Categorize drugs used for mood and emotional disorde rs based o n
the ir classification and drug acti on.
7. Use the nursing process to care for patients receiving drug therapy for
mood and emotional di sorders.
mania patjtl'lJ
monoaminfoxidase inhibitor (MAOI) pagt189
mood disorder {!all 181
moodstabilim (!alI19J
postpartum depresion paqt 181
psychotic depression pagt 181
seasonal affective disorder (SAD) pi!9f 181
selectiYe serotonin reuptake inhibitor (SSRI)
,.,,"
serotonin - norepinephrine reuptakt inhibitor
(SNRI) pl'lt IIlB
serotonin syndrome (S[S) fII.Tjt lS7
tri(Ylli( antidepressant neA) {UJll S4
tyramine {!all 189
LibraryPirate
182 UnllJ TheNe"""ISSystem
I
nappropriate or unusually Intense emotions are among the
leading causes of mental health disorders. Although mood
changes are a normal part oflife,when those changes become
severe i!Ild result In Imp.IIlred funalonlng within the family,
work environmmt,or Interpersonal relatlonshlps, an Individ-
ual may be diagnosed as havi ng a mood ciuwdu. The two
major categories of mood disorders aTe depression and
bipolar disorder. A third emotional dlsorder,altention defidt-
hyperactivity disorder, is . Iso Included In this chapter.
DEPRESSION
DrpmWn is disorder dUr.lcterized by 11 or despondent
mood. Many symptoms art associ3tW with deprl$Sion, in-
cluding lack of energy, sleep disturbances, abnonnal eating
patterns, and flings of despair, guilt, or hopelessness. De-
pression is the most common mental health disorder of el-
derlyadults, encompassing a variety of physical, emotional,
cognitive, and soci al considerations.
, 6, 1 Characteristics and Forms
of Depression
Among the most common forms of menul illness, majordf,-
disorder is estimated to affect 5% to 10% of adults in
the United States. The Amerinn Psychiatric Association's
Diagnostic and SIIl/;slieai Manual of Mental DislJrders. 4th
edition (DSM- IV), describes the following criteria for diag-
nosis of a major depre:s.<;ive disorder: a deprE'SSli'd affrct plus
at least fi ve of the following symptoms lauing for a mini-
mwn of 2 weeks:
_ Difficulty sleeping o r sleeping too much
- Extremely tired; without energy
_ Abnormal eating patterns (e;) ting too much or not
enough)
- Vague physical symptoms (GI pain,
or headacha)
- Inability to coneentnte or make ded sions
- Feelings of despair, guilt, and misery; lack of self_worth
Obsessed with deilth (expressing wish to di e or to
commit suicide)
_ Avoiding psychosocial and interpersonal inter:actions
_ Lack of interest in personal appearance or $(')(
- Delusions or hallucinations
The majority of depressed patients are not found in psy-
chiatric hospitals but i n society. For proper di -
agnosis and treatment to occur, recognition of depll'ssion is
often a ooUaborative effort a mong health nIl' providers. For
example, it might be the ph.armacisl who recognius that a
customer is depressed when he or she buys N tuT31 or over-
the-counter (arc) remedies to cont rol anxiety symptoms
or to induce sleep. o,sth,lfli< cfjOfdH is cruHa(leriud by less Se-
veIl' depressive symptoms that may prevenl a person from
feeling well or functioning normally. Because depressed pa-
tients may be found in multiple settings, every nurSE' should
be proficient in the assl$Sment of patients affiicted wilh this
condition.
Some women experiellCe intense mood shifts associated
with hormoNI changes duri ng the menstrual cycle, preg-
nancy, childbirth, and menopause. Up to 80% o(women ex-
perience pMtparl\n dtpmsion during the first several weeks
after birth of their baby. About 10% of new mothers experi-
ence a major deprl$Sive episode within 6 months related to
the dnmatic hormonal shith th:lt occur during pouddivery.
Along wi th the hormonal ch:l nges, additional situational
stresses such as responsibi litieli at home or work. single par_
enthood, and caring for children or for aging p;).fents, may
contribute to tbeonset of symptoms. If mood is severely de-
pressed and persists long enough, many women wiUlikely
benefit from medical treatment, including those with pre-
menstrua] dysphoric di sorder, depression during pregnancy,
postpartum mood disorders, or menopausal distress.
Because of the possible consequences of perinDlal mood
disorders, some state agencies mandate that all new mothers
after giving birth receive information aboul mood shifts
prior to their discharge. Health care providers in obstetri -
cian's offices, pediatric outpatient settings,and family med_
icine centers are encouraged to condu(l rouline screening
for symptoms of perinatal mood disorders.
During the dark winter months, some patients experience
INsonaI.tfedm disordtrlSADI. This type of depression is associ-
ated with enhanced release of the brain neurohormone
melatonin due to lower Light levels. Exposing patients on a
regular basis to specific light therapy may relieve SAD de_
pression and prevent future episodes.
T REATING THE D IVERSE PATIENT
Cultural Influences and the Trutment
of Depression
To W,1IlderllaOd ;mypatimtYl41a

l ind othn" ihul is ohen ignofed in "' .. ",.,
{ommtlnitin of!he tmnmdou! .mount of stigm.1ttKhed toil
Emomm aft' IIrgrir pititftll ttf1d to (QII"It to tilt
mmtion of mmuI hulth wortm in IfIe (OUMof theirJlntII,.nd
often IIlw ftfiing of hopelelintli.1t should be ..ottd thn kiul
African Ammnl metibolizt mOlt slowl1li11n
othn" ioitWi dom lhould be r!dtxtd to 'Oid drug
toxicity.
Alterrlltift thmpifs Mh 011 often UItd to tru t emotiofl/ll
iIIntlses within lOme Hilp.lnic groups;thus, mtdiul
001 lit IOlIght for of dePr!ISion. Tlltrt is often.
attachrd to mental probleml.long with tilt btlief that religious
plilctiUS wililOlvr ment.1 he.Jlth probiffi"ls.Hispanics meubolilt
about tilt lolme.1 othtr IUbgroups,.khough
r!po!lS of to anticholiM!gic ffft<U.
SaM ofEuropun origin den, tNt fMntiI mnm Wits oil
thfMorf beIine!!wt deprmion wiI subside on its OWII.HigMftiolfl 01
iIItidepltllolllll itt often .. tfd in this IUbgroup.
LibraryPirate
Psychotic: deprrssion is char,Jcterized by the expression of in-
tense mood shifts and unusual Depressive signs
and loss of with re.tiity, delusiom,
and disorganized spee<:h patterns are the behaviors ob-
served. For psychotic patients and for patients with extreme
mood swings, severe behaviors are often treatable wi th an-
ther,Jpy. se<:tion ]6.8 of this chapter and
dlapter 1700.
16.2 Assessment and Treatment
of Depression
The fint step in implementing appropriate treatment for
depression is complete health e.uminat ion. drugs.
such glucocorticoids, levodopa, and oral contr,Jceptives,
can cause the same symptoms as depression, and the health
care provider should rule out this possibi lity. Depression
may be mimicked by a variety of medICal and ne urologic
disorders, ranging flom B-vitlmin deficiencies to thyroid
gland problems to earl y Alzheimer's disease. If physical
causes for the depression are ruled out, a psychologic evalu-
ation is often performed to confirm the diagnosi s.
During initial health inquiries should be
made about alcohol drug use, and any thoughts about
death or suicide. Thi. exam should indude questions about
any family histol)' of depressive illness. If other family mem-
bers have been treated, the nuTS(' should document what
therapies they may have reived which were efftive
or helpful.
To detennine a OOIlTS(' of treatment, health care providers
and nurses assess for ""'eIl-a"epted symptoms of depres-
sion. In general, seYtI"e depressive illness. particularly that
which is recurrent, will TJuire both medication and psy-
dlotherapy to adliew the best response. Counsel ing thera
pies hel p patients gain insight into and resolve their
problems through "a-bal interaction with the therapis t. Be
havioral therapies hllp patients learn how to obtain more
satisfaction and rewards through their own and how
to unlearn the behavioral patterns that cont r ibute to or re-
sult from mood shifts.
Helpful short_term psychotherapies for some forms of
depression are illlerpt'1'SCllal and rogn;r;l'6-behavioraJ rhera-
pies. Interpt'rsonal ttll'rapies focus on the patient's disturbed
personal relalionships Ihat both ClUse and e.ucerbate the
depression. Cognilil'e-behavior3\ therapies help patients
change the negati ve Sl yles of thought and behavior often as-
sociated with their depression.
Psychodynamic Illfrapies focus on resolving the patient's
internal conflicts. Tru-se thenpies a re often postponed until
the depressive symptoms a re significantly improved.
In patients unresponsive to pharmacotherapy and with
serious and life_lhrenening mood disorders,
(ECT) oontinues to be useful treatment. Although
ECT is found to besaie, deaths (I in 10,000 pa-
tients). Other seriom related to seizure
ity and may be by ECT (Janiak, 2002).
Rent studies that repetitive tranSCfanial magnetic
stimulation (rTMS) is an tffe<:tive somatic treat ment for
o..plfll6 Drug' for Mood Disooden 183
maj or depressive disorder (O'Reardon, 2007). Thil trut-
ment requires surgical implant of the device. In contrast to
ECf, rTMS produces minimal effts on memol)', do-es not
require gener.ti anesthesia, and is helpful without the overt
risk of generalized seizures.
Ewn with me best pmfession.ti care, the patient wi th de-
pr=ion may take a long t ime to recover. Many individuals
with major depression have multiple bouts of the il lnESS over
thecouTS('of a lifetime. This can t:l.ke its toll on the patien!"s
family, friends, and olher caregivers who may sometimes feel
burned out , frustrated, or even depressed themselves. They
may experience episodes of anger toward the depressed
loved one, only to subsequendy suffer reactions of guilt over
bein8 angl)'. Although such feelings are common, they ClIO
be distress ing, and the caregiver may not know where to t um
for help. It is often the nurse who is best to assist the
family members of a person suffering from depression. Fam-
ily members may need counseling themselves.
ANTIDEPRESSANTS
Drugs used to treat depression are categorized as antidepres-
sants. Antidepress.ants treat depression by enh.anci ng mood.
Over the years, mood has rome to represent a broader term,
encompassing feelings of phobia, obsessive-compulsive be-
havior, panic, and anxiety. Thus, are often
prescribed for these disorders as well. Rent studies link de-
pression and anxiety to similar neurotransmitter dysfunc-
tion, and both .\.eem 10 respond to treatment with
medications (chapter] 40'=1) Antidepressants
are also benefici.ti in treating psydloJogic and physical signs
of pain (dl apter I sex , especi.tily in patients without major
depressive disorder, lOr example, ",nen mood problems are
assoc:iated with debilitating a)ndilions such as tibromylagia
or InlSCle spastici[}" (chapter 2100).
There is one important warning antidepresSints; In
2004, the U.S. Food and DrugAdministration issued an ad-
box warning" to be included at the beginni ng
of drug package inserts and drug informat ion sheE1s. The
advisory was iss ued to patients, families, and heahh profes-
sionals to closely monilor adults and children taking l nt ide-
pres..<ants for warning signs of suicide, espe<:ially at the
beginning of treatment and when doses are The
PHARMFACTS
Patients with Depressive Symptoms
manic: deprr,sion, and situnional depltSsion artsorne
Dltlle mo5I (ammon mental hulth challrngrs worldwide.
Oinic:al depmsion affrru mort than 19 miHion Amerons uch rur.
r-r-- than IwKolthowsufferill9 from deprtSsiOll seek
UUlmrnt.
Nosl pitirnl'l (OIIsidft"dtpltSsion I weakntss an inne-ss.
not", is 00 rommon .. mnic: II(IOf deprrssion-it
unl\awrlr IOill)'Ollr.
i
"
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,

;


184 Until The /IIe<v",,, Sy'tem
FDA further advised IIlat certain signs might be expected
among certain patients including anxiety, panic attacks, ag-
itation, irritability, insomnia, impulsivity, hostility, and ma-
nia. These warnings apply especially to children, who are at
a greater risk for suicidal ideation.
16.3 Mechanism of Action
of Antidepressants
Depression is associated with dysfunction of neurotrans-
mitters in regioru; of the brain connected with focused cog-
nition and emotion. Although medication does not
completely restore chemical imbalances, it may help reduce
depressive symptoms while the patient develops effective
means of coping.
shown in Pharmacology Illustrated 16.1, antidepres-
sants are theorized to exert effects through actioru; on specific
neurotransmitters in the brain, including norepinephrine,
serotonin, and dopamine. The two basic mechanisms of drug
action are slowing the reuptake of serotonin and norepi-
nephrine and blocking the enzymatic breakdown of norepi-
nephrine. Within centrally located synaptic terminals,
monoamine oxidase (MAO) enzymes normally break
down catecholamines and recycle them for further use
(chapter 1300). Making catecholamines more available
by either inhibiting MAO elllymes or inhibiting neuro-
transmitter uptake, enhances activation of adrenergic re-
ceptors. The primary classes of antidepressant drugs, listed
in Table 16.1, are as follows:
Tricyclic antidepressants (TCAs)
Selective serotonin reuptake inhibitors (SSRIs)
Atypical antidepressants including the
serotonin- norepinephine reuptake inhibitors (SNRls)
Monoamine oxidase inhibitors (MAOls)
Trlcy(li( Antidepressants
Named for their three-ring chemical structure,
(TCAs) were the mainstay of depression pharma -
cotherapy from the early 1960s lUltil the 19805, and are still
used today.
16.4 Treating Depression
with Tricyclic Antidepressants
Tricyclic antidepressants act by inhibiting the presynaptic re-
uptake of both norepinephrine and serotonin. TCAs are used
predominately for major depression and occasionally for
milder situational depression. Clomipramine (Anafranil ) is
approved for treatment of obsessive-compulsive disorder,
and other TCAs are sometimes used as unlabeled treatments
for panic attacks. One atypical use for TCAs, not related to
psychopharmacology, is for the treatment of childhood
enuresis (bed-wetting).
Shortly after their approval as antidepressants in the 19505,
itwas found that the tricyclic antidepressants produced fewer
side effects and were leM dangerous than MAO inhibitors.
However, TCAscontinued to have some unpleasant and seri-
ous side effects. The most common side effect is orthostatic
hypotension, due to alpha, blockade on blood vessels. The
most serious adverse effect occurs when TCAs accrunulate in
cardiac tissue. Although rare, cardiac dysrhythmias can occur.
Sedation is a frequently reported complaint at the initia-
tion of therapy, though patients may become tolerant to this
effect after several weeks of treatment. Most drugs have a
long half-life, which increases the risk of side effects, espe-
cially for patients with excretion. Anticholinergic ef-
fects, such as dry mouth, coru;tipation, urinary retention,
e.lcessive perspiration, blurred vision, and tachycardia, are
common. These effects are less severe if the drug is gradu"
ally increased to the therapeutic dose over 2 to 3 weeks. Sig-
nificant drug interactions can occur with CNS depressants,
sympathomimetks, anticholinergics, and MAO inhibitors .
Since the advent of newer antidepressants with fewer side
effects, TCAs are less frequently used as first-line drugs in
the treatment of depression andlor anxiety.
Selective Serotonin Reuptake Inhibitors
Drugs that slow the reuptake of serotonin into presyn.1ptiC
nerve terminals are called s srroton in inhibitors (SSRls).
ThE"}' have become drugs of choice in the treatment of depres-
sion because of their more fuvorableside-effect profIle.
16.S Treating Depression with SSRls
Serotonin is a natural indolamine neurotransmitter in the
CNS, found in high concentrations within neuroru; of the hy-
pothalamus, limbic system, medulla, and spinal cord. It is im-
portant to several booy functions, including cycling between
NREM and REM sleep, pain perception, and emotional
states. Lack of adequate serotonin in the CNS can lead to de-
pression_ Serotonin is metabolized to a less active substance
by the enzyme monoamine oxidase (MAO). Serotonin is also
known by its chemical name, S-hydroxytryptamine (S-HT).
In the 1970s, it became increasingly dear that serotonin
had a more substantial role in depression than once
thought. Cliniciaru; knew that the tricyclic antidepressants
altered the sensitivity of serotonin to populations of recep-
tors in the brain, but thE"}' did not know how this change was
connected with depression. Ongoing efforts to find antide-
pressants with fewer side effects led to the of
A VOI DING M EDICATI ON ERRORS
A 2J..yw-old man WI! Ihis moming following a suicidt Jttt mpt
when his girlfriend broke up with him. Wht n tilt nurse his room with
his medications, is ulking on tilt ttltphont with his girlfriend. Ht
t yecoMaa with Jnd motions for iIII' IlUrst 10 lu l'l' his IIIfIIk.uions on tilt
tablt 10 lit (an take bttr.Tht nurst,oot wantinglO inltrrupt his(onl'l'r-
s.ltion, pun tht mtdiutionsontMublt,ltavrs iIII' room,anddlam tlltmed-
kations. Wh.u did nUBf (ommit and what is tilt appropri.J1e nu
intmentionl
LibraryPirate
PHARMACOTHERAPY ILLUSTRATED
16.1 Antidepressant Therapy Is Directed Toward the Amelioration
of Depressive Symptoms
No.maIy.
No ... 'p'n .. ph ...... (NE) ____
Of ____ PcetsynapIIC
HfOton,n (S-HT) _. ""
o 5 HT if; ..... sed.
e 5HTbinds to its
rec.pt0l'
:. NE or 5-HT
o 5HT binds to its
p'"Y"l'P4ic reoeptor.
'.' .' . I.
Tncydic anlid&pnossantll V
o Step ",suits in Jen
5 HT being
",1'WbiI r.. uptake of
NE and !rHT intc the
P!5Y""I'tOc: terminal; .....
elfe.cIs .. ""'"' drrtm8l ic.
TeA. productl the.n.a. by
Inhibiling !he of
neuro!mrwnitl .. inlo
Pf'M)"I4ptic nerve tmI!\Qt..
The affected
neurot ... nemitt .. In
norepinephrine lind MfOlonin..
SNR!. ha .... a llirrilar
mechanilm. Their dMmicel
IIructI.Iu ... d iffen!l'1l from
"'04
Tyroeine

'-do<>'
+
....

), .
o "","\0
0"-...'"
/fi'
l
MAOM MAO .-.zyme
IICIMty iMide preaynaptic
_I"'"' .......
enzyme IICIMty.
, 101 opio' epho io.. and oIIwr
neurotranamitt ......
degraded. MAOI. have an
ell.,;! of ..,t.nc:.d
catecholamine reIe&ae.
em,-
lhett ......... ta
Ihoo action of
rooreplnephrine
o " .. rotonin uptake
ill bIocksd, ITION &-HT
wi' be available in
!he synapIic apace.
SSRI, bIodIlhe
reuptaka of ..otcrin
into preaynaptic .......
t.-min8le. Incfeaeed
Ie....,. 01 aerotonin
indut;:e
cNro!tM in prw)'Mplic
and
........on. of !he bf1lin.
Pno.ynIlf)tX: receptorI
t..come '-,..,.;tive
and pomynaplic
"""'P1ors become ""'"'
....a; .....
MAO MonoM'Iine ollid ...
COMT" Catechol anme
O-melhyllrwwleraae
o NE ;. ... leased.
e NE binds wiIh
ilS.-"tOf.
o II MAO I'lnhibited, NE
ia net btokon down as
quiddy ,00 prodUON
" """"' d,,,,,,,,!ic elllICt.
e The..:lion of NE
ia tenninal&d by
MAO and COMT.
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TABLE 16 1 Antidepressants
0""
Routt ilnd Adult Dose doS& where Indicated) .\dYerSt Effects
TRICYCLIC ANTIDEPRESSANTS (TeAs)
(Elm) Adik: PO; 75-100 1ll9lda)' (fIIol'j'!Jidllilly inoNlI'to lSO-lOO Mlrmotic /Ifpoftmn,
GtMric PO: lG-25 mgJl btdIine (may glfiWIJ ilKJtfll' 10 25-150 RlflSlipt!rbt,. wiMfYA'lemior1, /lMtrdtiliM,
OJI""
IIf1dMJif, II'IIUd 1I/icidQ11dNtit:rn m
!All'ndil) AIkIIl: PO;br9n wittJ 100 mg/dIf (IIYY ncrull'lII day 110 lOO 1ll9lda)');
_Olin f1'I4l!mt
GtMric PO: 2S mg It btd:imt:1U)' ino:tNlI' )-7 dqs IG SG-150
IllIlr!2! m!i!!!! hUll
I'IIgfday (max:. mglday)
bind; M! lOO""'tm> "(We rmlt til T""i"i''''
(Arlatrri) PO; 75-300 mgfu,iI diwidrd do!I's
<Ie!Ipmrine (Horpramift) PO; 15-100 mgflWy;INY InoNlI' 10 150-300 mglday
doIfIIn ISinrquan) PO; 30-150 mgfu, JI limoiii' 10 300 mglday
I;) imipAmlne Ho(tri) PO; 15-100 1'I9'u, (max: 300 "9'da)')
R\ilprvlih (llKimIi) Miklto modftaIe dtprelion: PO; start at JSlIJ}fdIr.gr,dUily mull'
ttfJ 2 'lit 10 150Il9ldi'/:5nm 100-150
I'IIgfdar. mull' IG 300 mglda)'
noruiplyIne (A'mI1yI, 1'arneIor) PO; 25 mg ti:! 01' qid;may iOO9ll' 10 100-150 mg/day
prolllplJline ('/M(III PO; lHO mgfu,1n 10 11M doIn(molX:60 mgIday)
trinipminr.' (Surmonli) PO; 15-100 mgfu, (max: 300 rncYdi'/)

SELECTlVE SEROTONIN REUPTAKE INHIBfT()qS (SSRls)
"
J
cilaiopmll (C!lw) PO;$I! at 2Omgfu, (max:40 mg/dayj
Q nduIopilm PO; 10 mglday:mI1 ilatall'tG 1(1 mg 1 'II1II;
GI rlistrJfNllln,tlniMSl,

ffrlgw, Jiddd

,"-,


lkroRtint(Pro!ac) PO; 2G mgfday II tilt a.m.lIY)'lImall' by 2GlIM}'day nwtHlJintft'/als
(IIIU: 80 mglda)'k wilen stable !NY 10 I 9(l.mg mlirwd-alUll'
5fm:!J!-!qhmm <rre1!Jl!1lt
E
i
otI(f -u, (m.:911 mg/'IIt)

PO; $I! with 50 I119fday (max: 300 fr9Iday)

p.lttMeIine (PiXi) Dtprusion:PO; 10-50 fr9IdaJ' (flloIX:BO

ci!ordB: PO: J(I-f,(I mg/day: Pft .. ttaW: PO:40 rrglda,

Art.IIt: PO; sun wilh 50 incrtlll' evtf)' ftw IIIftb to I
!
of SO-1OO mg; CieNtrlcltalt with 2S mgldaJ
t

ATYPICAl ANTIDEPRESSANTS
PO; 15-100 mg ticI(grtiltf tllln 450 mg/ilayiMlull'l rIsIt 101 flti_ 1/IIIIISftt.d!y comtipotfo1lnota!td
"i
lI'actions)
<IrA.-tine (SHIll) PO;40-60 rrgldaJln lIIe 01' I .... doIn
IWNIiIl9- ..".lMJrrtdriliM,/rfodh( , __

rrmid/li

(RmIftOI'I) PO; 15 mg/day iI. !ingko doll'iI! brdI.iM;fIIol'j' inoNlI' MIJ \- l wk
b)Jll1lfMiorr._ldysUlcDorlIlJiddd idtiIIIr rnJ
..
>
(11111: 45 mgldao)')
1I'fO(0Iin syndrrmI
.. .- PO; 50- 100 mg bld;may II'IataII' upto rig/day
5tr
lTO
)-lghpm 5'!!l!!mmr


trarocli:lnt (Deyrfl) 1'0; ISO mg/dq: ruy matall' bJ SO mgldar Mf)' 3-4 to

-mol'"
E

nnlafaxint (Efftmf) (9IRI) PO;25-125mgtid

MAO INHIBITORS (MAO Is)
>

iIoOOcIwid (Ma-pIin) PO; 10-30 mgfdaJ(lNx:1O 1IlI)'day)
Q Jilmdzine (Mardil) PO; 15 mg ti:! (nwx:90 mgldiJ)
1i!.i:IIr, ___ mmtipation, _txil,dry_rh,urillllry
i
Iftfntion, II'IIHI suicidol idMi1II tnd
tranplcrprooline (Pamatr) PO; 10 mg/diJ 20 mg in a.'ul'd 10 1119 iI p.m.); mar irKrHII' by 10 syndrrmI

mglda, at3-wlo: intmrak up 10 60 mglday
BtUtiWllad Wll1iI1Qll
""""
II'rioIr;HYtfIl'
LibraryPirate
1lI>p1tl16 Drug'1o< Emollon.11 arod Mood D11ord ... , 187
;Or Prototype Drug I Imipramine (Toframl)
Therapeutic (I ass: Anlidepressant;treatrnent of nocturnal enuresis (bed-wetting) in children Pharmacologic (lass: Tricydic antidepressant
ACTIONS AND USES
Imipramiot bloc:b thIo I\'IIptakt of in and phriot imo ter
mina k.1t is USfd mainly major depres,ion, although il is 0((.1 Iiona II)' u led for
thIo treatment of I1O(tumal enuresis in children. The may find irnipramiot
prescribtd lor a oomber of lMS including intr.utablt pain,miety
disorders, and wilhd IiIwals)'IldromtS from akohol and cO(aiot. TIler apeutK d
fKliYfnm may oot O(tur for 2 or more werks.
ADMINISTRATION ALERTS
Parada.ital diaphoresis (.In be a side tffta ofTCAs;therefore,diaphoresis
may oot be a reliable indicator of other disNIt StitH SIKh is hypo-
glycemia.
Imipramine cau<es .lnticholinerqie tffKts.md may potentiate eIftcts of
antidJoIinergic: drugs administered during surgery.
Do not discontinUl' abruptly, because mound dysphorY, irritability, or
may O(tur.
Plf9nanqcategoryC
PHARMACOKINETICS
Onsrt: 1 h
Peak: 1- 2 hPO;30min 1M
Half life:8-16h
Variilble
an additional category of medications, the selective sero-
tonin reuptake inhibitors (SSRIs).
Whereas the tricyclic: class inhibits the reuptake of both
norepinephrine and serotonin into presynaptic nerve ter-
minals, the SSRIs selectively target serotonin. Increased lev-
els of serotonin in the synaptic gap induce complex
neurotransmitter changes in presynaptic and postsynaptic
neurons. Presynaptic receptors become less sensitive, and
postsynaptic re.:eptors become more st'nsitive. This mecha-
nism is illustrated in Pharmacology IIIwilrated 16.1.
Today, SSRIs have approximately the same efficacy at re-
li""'ing depression as the MAO inhibitors and the tri-
'yclics. The major advantage of the SSRIs, and the one Ihat
makes them drugs of choice, is their greater safety.
Sympathomimetic effects (increased heart rate and hyper-
tension) and anticholinergic tffects (dry mouth, blurred
vision, urinary retention, and constipation) are less com-
mon with this drug class. Sedation is also experienced less
frequently, and cardiotoxicity is not observed. All drugs in
the SSRI class have equal efficacy and similar side effects.
ADVERSE EFFECTS
Side efftm incUdl' sedation, dlOW! illl'Ss, bkJITl'd filion, dry mouth, J nd cardia-
mrular symptoms sum '" lINn blod, and 9tlfllle hyprrtell-
sion. that mimie the action of norepinephrilll' or serotonin should be
aYOidtel imipramint inhibits tMir metabolism and may tOllie
it)'. Some patients rna, elptril'nce photosensilivity Jnd hypersensitivity to tn.
cydicdrugs.
(ontraindi (.ltions: This drug should not be used in of iKU1l' recovery af
1l'r Ml dtf1S in bundle-branch conduction, glaucoma, and
Wit ft'nJI or hepatic impairment Pnitnn should not !lSI' this drug within 14
days of dilrominuing
INTERACTIONS
DrurDrug: (IIIumnt U!f of othfr 0fS d@p"flWllu, ildlllingakDhot,IIW1(jlllf
lfIia!ioo. (inftitiM (Tigamftl may inhlJit !be IMlabohm of imiprarnilll', 0Ii1g
to ilamfd5flUm iNl'k alld possilH< mayrM'Bf!lM>
dooidillfalld of oral
COOllOKfPtil'fl may mu or ma,OI to
dttiliumand "gam IIIiI1 p-oduu>
Pheno!hialine; ilamfd iIIlkhotifm9ic: and SfdaIiw HlKl>.
SympillllomiMOO; may rrur: n a diac lOlidty. or dmetidilll' may
HlKnofillipramMld CiUII' toxidty.f'hfnytoi1 is IN fflKIMwhi>n
!.1loPn wim imipramiw JMOk may Il!'iuk in OOIro1fptic \)'IlItorIII'.
Li b IfSlS: IMIodgu:O'if tr%. ENion ofserum
atlritliol'
Helba VFood: H5ba1suppk>mmn SIKh iI pri nrOlf oil or gi1k1jO. may 101m
!1M> '>fizu"! mlWdd. >t. John \ wort USfd (OIKII"rmtl)' may (jU5f Sfrotonn
.,....,..
Treat ment of O"ft'Jdose: Theft' is 00 SpecifIC treumtnt for _rdose. General
supportive mmurH are recommended. Ensuft' an adequa1l'
tion,and Vl'milation.Monitor cardiac rhythm and vitalsigns.Gutric may
be indiuted.Acti"latf<1 {haKoolshould be
It!ftr Ie M}M!rl/ngK1l for Q Nurlifllj Prru1s foals spKlk Ie rlrls
In general, SSRIs t'licit a therapeutic response more
quickly than TCAs.
One of tht' most conunon side effects ofSSRIs relates to 5e)l-
uai dysfunction. Up to 70% of both men and women experi
enee decreased libido and lack of ability to reach orgasm. In
men, delayed ejaculation and impotence may occur. For pa-
tients who are sexually actM>, these side effects may result in
noncompliance with pharmacotherapy. Other conunon side
effects of SSRIs include tl.1llSea, headache, wt'ight gain, arujety,
and insomnia. Weight gain mayalso lead 10 noncompliance.
Serotonin syndrome(SES) may occur when the patient is taking
another medication that affects the metabolism, synthesis, or
reuptake of serotonin, causing serotonin to aCClUlluiate in
tht' body. Symptoms can begin as early as 2 hours after tak-
ing the first dose or as late as sevt'rai weeks after the initial
ing pharmacotherapy. SES can be produced by the
concurrent administr:ltion of an SSRI with a MAOI, a tri-
cyclic antidepressant, lithirun,or a numbt'rof other medica-
tions. Symptoms of SES include mt'ntal status changes
(confusion, aru::iety, restlessness), hypertension, trt'mors,
LibraryPirate
188 Until Thl'Ne<voo,Synem
sweating, hyperpyrexia, or ataxia. Conservative treatment is
to discontinue the SSRI and provide supportive care. In se
vere cases, mechanical ventilation and muscle relaxants may
be necessary. If left Wltreated, death may occur.
Atypical Antidepressants
In terms of classification, the atypical antidepressants do
not fit conveniently into the other antidepressant drug
classes. Thus, in this case really refers to the
unique chemical structures represented in the group. These
drugs are briefly dealt with here.
Duloxetine (Cymbalta) and venlafaxine ( Effexor ), some
times considered to be in their own subgroup, are the
serotonin-norrpinephrillf reuptakt inhibitors (SNRls). They specifically
inhibit the reabsorption of serotonin and norepinephrine
and elevate mood by increasing the levels of these agents in
the central nervous system. In many cases, levels of dopamine
are also affected with the SNRIs. In addition to being ap
proved in 2004 by the Food and Drug Administration for the
treatment of major depression, duloxet ine (Cymbalta) was
approved for the treatment of neuropathic pain. Venlafaxine
( Effexor), more recently used to relieve depressive symptoms,
is available in an intennediaterelease form that requires two
or three doses a day and an extendedrelease form that allows
the patient to take the medication just once a day.
Bupropion (Wellbutrin) not only inltibits the reuptake of
serotonin but may also affect the activity of norepinephrine
.... Prototype Drug I Sertraltne (Zoloft)
COMPLEMENTARY AND A LTERNATIVE T HERAPIES
St. John's Wort for Dllprllssion
0"" of ,"""I pupuLII h. rb> in Unilrd Sloll">, SL)uhn', WIIrl (H1I' 11iuu"
ptffoffllum) is found growiog throughout Asi.J, [urope,and Nonh AmtrK.!.lu
modl'm = is as an antmpressant.1t gets its from a legend that mI
spots DlKt afIPNrrd Dn its Ita15 on tht of the behudiog Df 5t
John the Baptist. The word \\Oft is >I British term fDr ' plant"
The primry .KtiYt ingrederru kuld i1 StJohn 'I worUrr hypericin ,md hyptr
Iorin. Evidtnu "'WIts thn theSf IUblUlKfS stlKtiwIy inhibit serotonin rel4l.
!aU in (main brain IltUrom..A runbtrof d nic.J1 studits wggtSt that St.klhn's
wort is an efFectift trratrnmt for mild 10 modem:e depression,and that it may
bt jU! 1\ t ffectift 1\ tricydic: and SSIIs & Itlltr,
2006). Rt ctnl analyles also IlJ9geSIlhat !he herb may be l"ffuctiYe for major cit
and that it (,JUleS aMllt t l'lKts than uaditilnal drugs (Lindt.
& Kriston, 2008).StJohn'l wort may imtrKl with many rnteimions, in
cUding onl warfam,di1ci1,and C){bspori"ot. k mould not bt
!aUn mlKUm>nllywith mtdit.nilOl.
St.lohn's wort is 'Milloitrated, produdng mild adI'tTSf fffKts SIKh as 61
distrrss, fatigut. and allergic: skin runion The hero (Onlains compounds that
tht skin;thlll, patitrlllshouid be advised 10 apply IUnS([ftn or
to 'Mar proltctil't doth iog when outdocn
and dopamine. It should be used with caution in patients
with seizure disorders because it lowers the seizure thresh
old. WeUbutrin is marketed as Zyban for use in cessation of
smoking. Mirtazapine (Remeron) is used for depression
and blocks presynaptic serotonin and norepinephrine reo
Therapeutic (lass: Antidepressant Phannacologic (lass: Selective serotonin reuptake inhibitor (SSRI)
AalONS AND USES
Semalint is used fDr tht UUlment of deprt 5SiDn, >luiely,
(Dm pu Isive disorder, >I nd panic:. The antideprrn.l nt and >I nxiolytic: proptrtits of
Ihis drug (an be attributed to its ability to inhibit the I!IJptlU of Sfrolonin in tht
brain. Other uses ilKlude dysphoric:disorder,posHrllJmatK stress
and social anxitty disordet iKtilns include ffihalKtllll'm
of mood and implO'/t llll'm of alft with maximum fffects obstrnd aher sn
ml Wffks.
ADMINISTRATION ALERTS
k is recommt oded thaI be giYeo in !he morning or
When >l dministeriog strmlilll' 1\ an oralliquid,mill with wattl,giogtr alt,
ltrnonllillll' sod.i, ltrnonadt, or orangt juic:t. Follow manufacturer's in
IIT11ctions.
Do not gil't conrurrtrltly with a MAO inhibitor or within 14 days of diso:on
tinuing MAOI mtdiution.
wf90ry C
PHARMACOKINETICS
2 ..... wk
Unknown

Duration: Variablt (atensiYe bindiog with ItrIIm proleinl)
ADVERSE EFFECTS
MvtrSf eiff(ts ilKludt >l gi!ation, insomnia, headhe, dimntlS, SomnoitlKt,
and Tau prruutionl in p.ititnts with wdiac: disuSf, hepatic:
impaillTl!'nl, stizurr d isordtrs, su icid.il mation, mania, or hypom i nia.
Contr.l indications: MAOis orprimoride is not
advistd.Amabuse should lit >l wided lIt(a= of!he akohol content of lhe drug
OOlKt nllille.
INTERACTIONS
Drug-Drug: Hijily jnIH1 bcMIId lIIldicOllionsllKhmigoxil and warfarin shook!
bt iMIicIfd owing ID lilt of tOIidly and inaNlfd blood (OIKmmions INding 10
inaNlfd bItKWlg. MAOk In.J)'G!tI\f rnalignanIS),"hoolf,fltrflllf
SfroIn n syndromt,dlalamriled
Ilizzi"Im. /MI.!U:rhN. sWNling. iIId shil'l'I"iog. lkt GltliauIIy with oihfr (Mtrally
iKlilgd1MJ! to avoidadl'l'll>! OIS
Lab Tests; Sl'l"triilll' restm il al"/lllptornalic: fIffiIed Iiv fIIKtion tem iIId a sigIl!
dMNst il uriuoo k<wIs.
HerbilUFood: Pai:ieflll s.hoold use prrooIion ff laking St. WDn or Itryp! .......
lOavoid 1fI00onin
T rratment of Overdost: TheR' is no IptCm{ treatment for OY!'rdosr. [mergency
IIII'diul ntention and gtntral IUpportil't mtuurts may be Symp
10m I of OII t rdost ilKludt [\jUSfil, vomiting, agiution,
hyptractjyity, rnydria tac:hlUrdi.J, and coma.
MmhjftocmForu!!pf'dt IOlhll rtII!/'
LibraryPirate
ceptors, thereby enhancing release of these neurotransmit-
ters. Nefazodone (available in generic form only) is similar
to Remeron. It was originally designed to treat depression,
and causes minimal cardiovascular effects, fewer anticholin-
ergic effects, less sed.1lion, and less sexual dysfunction than
the other antidepressants. Trazodone ( Desyrel) is most fre-
quentlyused as a sleep aid, rather than as an antidepressant.
The high levels of trawdone needed for the amelioration of
depression cause excessive sedation in many patients.
Monoamine Oxidase Inhibitors (MAOl s)
The group of drugs called monoaminf oxidase inhibitors (MAOls] in-
hibits monoamine oxidase, the enzyme that terminates the
actions of neurotransmitters such as dopamine, norepi-
nephrine, epinephrine, and serotonin. Because of their low
safety margin, these drugs are reserved for patients who
have not responded to TCAs or SSRls.
16.6 Treating Depression
with MAO Inhibitors
As discussed, the action of norepinephrine at adrenergic
synapses is terminated through two means: (1) reuptake into
the presynaptic nerve and (2) enzymatic destruction by the en-
zyme monoamine oxidase (MAO). By decreasing the effecti\e-
ness of the enzyme monoamine oxidase, the MAOIs limit the
breakdown of norepinephrine, dopamine, and ..,rotonin in the
CNS. TIlis creates higher levels of these neurotraJl5milters in
the brain to facilitate neurotransmission and alleviate the
symptoms of depression.Asshown in Phannaootherapy Illus-
trated 16.1, MAO is located within presynaptic nerve tenninals.
In the 19505, the monoamine oxidase inhibitors were the
first drugs approved to treat depression. They are just as ef-
fective as TCAs and SSRIs in treating depression. However,
because of drug-drug and food-drug interactions, hepato-
toxicity, and the development of safer antidepressants,
MAOIsare now reserved for patients who are not responsive
to other antidepressant classes.
TABLE 16.2 1 Foods Containing Tyramine
Frutts Datry Products
_ .... ,
Cl"ftst(O!tagf cMef
..

.,.,
induding mut tendmms
(anned/igl
Vegetables Sauces
Podsoflrold beanl(/ava bNns) So)' WlKf
IlIopltl16 Drug. lor Emot"""'t ar.d Mood Olsome" 189
CollUllon side effects of the MAOIs include orthostatic
hypotension, headache, insomnia, and diarrhea. A primary
ooncem is that these agents interact with a large number of
foods and other medications, sometimes with serious effects.
A hypertensive crisis can occur when a MAOI is used con-
currently with other antidepressants or sympathomimetic
drugs. Combining an MAOI with an SSRI can produce sero-
tonin syndrome. If MAOIs are given with antihypertensives,
the patient can experience severe hypotension. MAOis also
potentiate the hypoglycemic effects of insulin and oral an-
tidiabetic drugs. Hyperpyrexia (elevation of body tempera-
ture) is known to occur in patients taking MAOIs with
meperidine (Demerol), dextromethorphan (Pedia Care and
others), and TCAs.
A hypertensive crisis can also result from an interaction
between MAOIs and foods containingtyriminf, a form of the
amino acid tyrosine. Tyramine is usually degraded by MAO
in the intestines. If a patient takes MAOIs however, tyramine
enters the bloodstream in high concentrations and displaces
norepinephrine within presynaptic nerve terminals. The re-
sult is a sudden release of norepinephrine, causing acute hy-
pertension. Symptoms usually occur within minutes of
ingesting the food and include occipitalheadache,stiffneci:,
flushing, palpitations, diaphoresis, and nausea. Myocardial
infarctions and cerebral vascular accidents, though rare, are
possible consequences. Calcium channel blockers may be
given as an antidote. Because of their serious side effects
when taken with food and drugs, MAOIsare rarelymed and
are limited to with thai are r""istan! to
more traditional therapies and to patients who are more
likely to comply with food restrictions. Examples of foods
containing tyramine are listed in Table 16.2.
BIPOLAR DISORDER
Once known as manic depression, bipdar dilorder is character-
ized by extreme and opposite moods, episodes of depression
that alternate with episodes of mania. Although patients usu-
ally experience extreme episodes, periods may shift between
Akohol

"",
SMOfdimn i'lff
WiMl (fSJIfdilly rfd wine)

Pidled or kiwmd liming
Prppfrooi
Salami
""""
BobJI.ilhot dogs;
Yeast Other Foods to Avotd
T ,I,llymtOf)'ust9!1Kll Chocolate
LibraryPirate
.... Prototype Drug I Phenelzine (Nardll)
Therapeutic (lass: Antidepressant Pharmacologic (lass: Monoamine oxidase inhibitor (MAOI)
ACTIONS AND USES
of moooimintooolll';
it inte05 iIies Ni"Kls of in adreo!'J9ic synipll"S. k is
to m,nigt symptoms of dtlftlSion not to othtr typtS of phir-
ml(olhffilp)', ,00 is med lor p,nK disordtr. Drug may per-
sist for 2 to 1 WffIu .lIter theripy is disrominUl'd
ADMINISTRATION ALERTS
WI>lIOUI of 2 to) I .. J<quired bolo .. imrodueing orhor
drugs.
Abrupt disrontillJition of this drug rna)' .. brond hypffit' nsion.
Pr<goanq category (
PHARMACOKINETICS
()Jsrt: 2 Wftks
Pei k: V,riablt

Duration:48-96h
extremes, or there may be prolonged times when mood is nor-
mal. Depressed symptoms and slightly depressed or dysphori'
symptoms are the same collection of signs as are referred to
earlier in this chapter. Mania is characterized byex>:essive
e NS stimulation that results in symptoms listed in Sec-
tion 16.7. To be diagnosed with bipolar disorder, manic
symptoms must be present for at least 1 week. Hypomania is
characterized by the same symptoms, but they are less severe.
Mania and hypomania may result from abnormal function-
ing of neurotransmitters or receptors in the brain. Hypoma-
nia may involve an excess of excitatory neurotransmitters
(such as norepinephrine or glutamate) or a deficiency of in-
hibitory neurotransmitters such as gamma-aminobutyric
acid (GABA) ('hapter 1500). It is important to distinguish
mania from the effects of drug use or abuse and also from
schiwphrenia (ch.1pter 1700).
16.7 Characteristics
of Bipolar Disorder
During the depressive stages of bipolar disorder, patients
exhibit the symptoms of major depression described ear-
ADVERSE EFFECTS
Common side t1Fts rollltipation,dry mouth,orthostatic in-
somnia, naUIN, and Iosl of may illUNlI' hei n and neural activ-
ity,ltadiog to dtlirium, mania, InriHjo, and roovuisions. hypenemion
may occur when ingtStiog foods containing \ylimine. Srizurt'l, rtSpiratory
(oIlapll'"nd com, may occur in calrl of
(ontrai nd ications: Patitnts with cardiovalrular or (ert bmra !(uiar distall',
pili< 0/ JPIl,1 phParhmmorytnnu ", .. ,Id not '''''Ihi< dnHJ.
INTERACTIONS
1Wg-1Wg: MiIIrf othHdrugsiflKt thriKlicrl 01 01
tritydI: ilntidfpmsants ind SSRk IhoUd be iI'IOidiod bKNIe the (ootilation un
<aII1f tl'mpffatln mwtm.()piates.ind:.ting IlK'pfridiDf,!ihcUd be
iMlidfd due to iMINIfd riIIr oIl!IpiIiII(fY (f hyptmlWf uiIiI.
SympatbonimHklmay IIypfnHIIMailk. (alleilll' may II!ItIk in

tab 11511: I'IIIoHziIt un ptOIiKe i \Iio1ldY false inuN'iIo iI \eI\IIO biinDn. Si n
plaleitt tan "" iIIfc:tI'd, iI1I'flion IhcU:I "" dMitfd to (Be ifill\.
IkorbaVFoo:l: Conrufll'lli Ulfolgilseng may t.lUIf trtmor\,mania,
inmnia, ifritability,m rt.uaI haIIudnatioos. ((III(UfIl'IIl till' 0I1IIiI huao:Jt
(f StJolln\ wonmayte\Ut in, IIypKll'OIi'lfuM.
TlNtmml ofOftrdose: 10te05iYl' symptomatic indlUpporlr;r t!Ntmem may
be of mM or galtri: tavig!' with instilation of c:harroal
slurry may helpful. Siglll and symptoml d (NS Ilmulation, iodudiog Il'izUIfS,
Ihould t!Nltd with IV "'"Y Hypertemion Ihould
t .. attd with ukium (hanotl bloc:km. Hypotension and mruiar
rolapSl' should truttd with IV fItids i nd. if nKelilry, blood titration
with an IV infulion of I prtS5OI' i9fOt Body temperilUrt shouk] be moni-
tored dosely, ,nd should supported Mih appropriate measures.
_ III MyMIsIngClfDf. MnlngPtrxI!5!i fUIspKJ/I{ to 1M druiJ.
lier in this chapter (section 16.1). Patients with bipolar dis-
order also display signs of mania, an emotional state ,har-
acterized by high psychomotor activity and irritability.
Symptoms of mania, as described in the following list, are
generally the opposite of depressive symptoms:
- Inflated self-esteem or grandiosity
- Decreased need for sleep (e.g., feels rested after only
3 hours of sleep)
- Increased talkativeness or pressure to keep talking
- Flight of ideas or subjective feeling that thoughts are
racing
- Distractibility (i.e., attention too easily drawn to
Wlimportant or irrelevant external stimuli)
_ Increased goal-directed activity (either socially, at
wurk ur ,druul, ur .... ually) ur
agitation
_ Excessive involvement in pleasurable activities that have
a high potential for painful consequences (e.g.,
unrestrained buying sp rees, sexual indiscretions, or
foolish business investments)
LibraryPirate
l' Drugs lor [molloNI MOd Mood DboJdm 191
NURSING PROCESS fOCUS PATIENTS RECEIVING ANTIDEPRESSANTTHERAPY
Assessment
.suslllltnl prio,lOadminisuMion:
Undtntll'ld 1M Imoo drug hi preaibed in orOO 10 .IIftS for
thmptUlicelru.
Oblain. com plett ht.kh hislClr)' in<kIding hep.tic, ItNlurologic,
mtnl.lsUlm,Nrrovr.ngIIo
brtt-f(tdiIl9-Obuin . drug hhtDry in<iudilg
.&etgies._1 prtl(riplion IIId ore dru;s,.nd he!bII
aIffi: 10 drug inlffi<tion\..
Oblain. history of deprtUion 01 mood diIonIer,incUdilg. histOf)'
of Wmt.rId SoMrity.lbe lools wbtI1 possible (t.g.,
8td Innnlorr or r.fflatric: SuIe). 1f symptoms
w .rr.nt, iIso ronsider of tIw Mini Ikfttal Stilt Exam for demtnlil
soeening.
Obtain b.rsnnniul signund Wl'ight.
Evalualt applOpri;!tt Libcntol)' findings (t.g., (8(, ele<trolytn,
hep.IK.nd furl(tion studiH).
Assrss the pibmt"s abrlity to m:tift .nd undtnu nd instruction. I ndudI'
W bmily and Cl$1IffiIed.
AssHsmrnt throlghllUllckninislration:
AlWSs fordnim:! tlifllpMic tHem (t.g., rot. sed mood, Insenilg
dtpIession, inueastd '(Iimy 1e\oeI, retum to norm.1 ADiJ.'l'Ptlilt .nd
swp patteml;if IIII'd for oIMrlMl,t.g., llfllropathic pain, .sms for
awropri.ln
Conlinut periodic monitoril'lg hepatic .nd
ruwl function studiH.
AslfSs vital $iI;11l'J .nd WI'igbt periodicily 01 as sympt_ wanant.
AlSfIs for.nd promptly rtport .dvtnt rifms:diaintss OIlighl-
hudt<! 1ItU, drowsiness,. confusion, ac;utiln, suicicLJl
pilpilations,. U(ltyardj,,1H.md or double "fis ion, skin ll'lbes, bruising or
bleeding. .bdomiN I pain, jllII1dice, d\allgt in color 0111001, flank pain. mel
hrm.turia.
lneflmift CGping

ArtJiety
Potential Nursing Diagnoses
Jhought i'nxHIfS
Sleep p.Utm Oisnrmrl(e

o Imb.rlan<td Ibrition, Morf or lHs Than Body
Dysfunc: liorwl Grining
Sociillsolation,lmpairfd SoOaIlmer.lI(tion
Aktrtd Flmil,
UrNI)' Rtttntion (reIatf<l to .ntkholintrgic me tift(B oIdnrg therapy)
Noncompl"lolnce (INted to drug t l'lKu oIdt(fl'ol\fd Sell1i1lli1do
illldlorwtightr;.i11

Risk for Violence, Risk for Risk b Suicide, Risk
lor kt,iJ1)'
Pl anning; Patient Goals and Expected Outcomes
TIlt p.ititm wit
bperitn<t wf'pMic eKtS dtptndtnt on lilt ltiSOll tht drug is being (e.g., inaeast<! mood,lnsened dtp!eSsion).
lie !Itt frorn,orUptMnct t trll.
o iln .... dtrmnding oIlIItdrug's lise, IdYtnt eKecu. and prtCautions_
plTlper se/f-ildmiMlli1tion 01 tIw medication (e.g.,dolt, liming, wht n 10 notify proMf).
Implementat ion
Interventions and (Rationales)
Ensuring thel'ilpHtk effects:
Continut .mfSSmtnts as dewibtd t . rlitr lor tIwr. ptUtir t trls. (Drugs
us.td fordtpmsion IIIiI)" take 2 to 8Wftks fuR
Use objKtit mtalUrH,t.g., IIKk Dfprtlsion whm possiblt to
htl p qua rIify tlwrlptUtic: reults. For outpitient thmpr; JRl(riplions
lit limitf<l to 1 &ys' worth ofmtdiwion. HaI't tht patitllt sign a"No
HarmlHo SUcicIt" contrKt uappropriatt. When ustd lor iIIIxittyor
insomnia, nonpharm. mIogiI: mt.mlrtllllilJ be netdtd until lilt drug
rmhes fuI rifms.)
Patient and Family Education
o 1NdJ tht patiennhat lull rifms not IKrurfor a prolongtd ptriod of
bne but thil t imprvmntnt v-.oukl be .her beginning
.....
Enc:ourlgt 1M p.i6tm to Io:ftp .applintmtnrs with the thtllpist.nd III
dilruss 01190 iIg symptoms of deprtlsion,!epOfIing any sUOcM I ideatiom
immtdiatt ly_
(Cootlnued)
LibraryPirate
192 U,*l The Ne!\lousSyuem
NURSING PROCESS FOCUS PATIENTS RECEIVING ANTIDEPRESSANT THERAPY (Conllnutd)
Implemtn1l11ion
InterV1! ntions and (Rati onales) Pati t nt and Fami ly Eduuotion
Minilllizill9 .dftnt tffedS:
Cominut 10 lIIOIIilor vital IIIfIltal suM, and cOOldfiltion and INCh tilt, pailiffl: II rin from lying or lining 10 nanding dowIr 10 avoid
periodiully, Enwrt pimm loI'"r.mooitor . mbulation umil the oizzinessor f&
fffu of ItIe drug aft known.!It partiaAlrt, cautiM witt! older adults
Instruct the patimt to cd for prior k! gt'lting out of bed or
ill: inmo.-l risk fOr falk. l1li)'
towal .. avoid drimg or other actiritin ftqJDIg
dIowsiness Qdizzintu, bypo\fnsion,or troeIIQI . nd plrJsial
mtnQI.ltrtness or ph)'!iul coordination lind rifNb of the drug II!
abililits,irKftuing tilt, risk off4llt and irfJIJ'J
.... ".
Cominut to <BC,eItwoIytn, and hep.ificfunction. Instruct the pitient on the k! retum periodically for bob WOIk.
(Antidtpmwnt drugs m.y ta\M U in efft<t.)
TNCh tilt, pailifnl k! promptly rtpMt any .Jbdominal pain, partiarbrly in tilt
upprI' quaclrinu,dJinge1 in stool 01 Idm orstin,or

klr dlingrs in mI ofconl(iouInm,disoritntalion orconiusion, Of mtruct the P'timt. fi mily,OI' rtpOrt
{Nrua?Iogic chall9tS may indiu., oodtr or avmordication, lrtIIifgy, d"liOritnotion, {ooMion, th. 1Igt'S in bmavior or mood, agiulion or
tucerbatiolt of other PI)'Chinric iIInts!, 01' tftMuJ OIggrt uion, stmd speh, 01' iUri! ,
Ic!!e\ in viIlwI iKlIity,bkJrml 'Iision,1OIS d pffiphmIvi!ion.5fti1g Instnxt the pititnt 10 dw.'1grs pain.
r;Wrbow lYbsarotnd iIlh6,1OM eye br
_a ind\lCll'l'iil:ingi nd prtS!UIt in
_ .... gllOOlIIIa rrwy OWIrin tatilJl Tllil
SQIIA. (Llrly signs of SESand "rptrtt nSM crisis Instruct the patitftllO I!port _
with MA(J thmpy incl.* IlIpid in blood JRSSlft and puM. poIin. MIM' or
diaphoresis, 01' t-[
k>r bruising, blmflnq.OI' Vgm of inttion.(JU.s may blood TNCh tht pailiffl: II promptly any signs of incl!-.I bruising.
6y$cri$ils ;lIId of or infwioft.) blmf"mg,or throat $kin 1lI!II).
klr dry mouth,bllIIRd I'ision,OOnary and Tth tht paitirnt 1M itt dJips, frtqumt sipsofw.ttr, 01" cMwing glm or
drsfunction. (AnticholiMfgic tffrm .nd dysfunction, induIing bard candy to dry mouth and to noid lIkohol-bistd mouthWilWs,
loss of libido i nd common i nticltprtss.alll adYtnt tffffu. which miY inot.l:!e dryness.
Toleranct to .JrnhaliM!gictffKl! UIUi.,6MIops in 2to 4 Wftks,)
cI!cps.nd mUng f)'e5 ptOO:fruly l1li)' to dKl9K dry
rJ! TNCh tht ,..tienllO report ,IllY fmirJgs 01
pail immedi.ntly.
Instruct the pititnt to promptly diflirulty with urination, hrsitarqOf
.,....
I ncoulllgt tilt pilient to diswss COllctrns ilbout !eX\IiI1 function ing and
mel k! hNlth pI"O'fiOO if COrKtms.tffft mrditOllion compliolrn.
Encoulllgt and dietllry changtS to rtd:n tht
of Might QliIt:iMrmtd irltakt offruilslnd \lt9tUblts, M 'se<!
and 9I!rtM !rw,b is dejRUion from akohol,.nd n oiding
meals brfoI! btdtime.
For patimu uking USUlI dirt..,. intaR and proYide mInK! the pititm, family,or indittlry.nd mrdiGtion
instruction on Ioock. (foods and PID'ride wrinm .nd Yl'tb.II imtruaion.
brotmgrs{ocuining tyIlImiM. akohcA,OO stimulants and
Instruct the pitimc 10 _
drugs,IIiKDtin,.nd othtr CNSdepr6Sints may {aIM significant adw-rw
p.llpitatiom, t.Jchrca rdil, {he!: polin. MIM. or 'fOI'Iliting.
tffKu including crisis or profound
diaphoresis, or ft'O'r[
.\!laid . brupt diIlontinu.nion of IhffiIpy. (Profound dtprmf:.rJ, or Instruct the pititm 10 taR thtdnrg mct!y ill pltSCribtd and to not stotJ it
withdrawal symptoms ma,. ocrur with .brupt d ilcontinuation.) abruptly.
LibraryPirate
0I0p1fll' Drugs lot Emotlo .... 1 ar.d Mood Oloord.... 193
NURSING PROCESS FOCUS PATIENTS RECEIVING ANTIDEPRESSANT THERAPY ((OfIIInUlldJ
Implementation
Interve ntionJ and (Rationales)
Patint undtnundilg of dng tMI.r:
1M oppo!1Irlities during adrririmllDiw nmmions alld !bing asse.smenIS
to disa& IItioni\e foI ckug the-apy,dMed thtrapMil: IlIkDrntI, most

prmutirn..(lkingtimt<k.ring
nmilg to optinizt alld Ir)'
Palirnt of dNg t herapr:
When idministtling the mecIiution,imtlU(t thr patient, famii);or
in seW-idminismlioo of take 1M dNg itS
pmuibtd alld do 1101 wbltitutr bwm .. jlltilizing timedllring /\Wit-
administration 01 tt-drugs htlps kI rrillortt l00.ing.)
Patie nt a nd Family EduUltion
Ihr patitnt sholAd be to Ililt the rrilSoOll b tilt druIj;awropn.tr dIM
and Khrd:d"mg;alld wllill to obwrw to. alld when to
....
the palitnt to the itS fQlIows:
TakeUKtIy.n ordmod.1Id \lie the IIW mMlufa(1IftI's brilld 9Ch time
the pttKripIion is filled. (nhing InAdsllU'f IfIlIII in differing
p/wmKllkindD ar.! Wf,tlons" tffrrt.)
taR a misHd dme.n _ as iI is IIOticfd but do IIOItaR doubIforfl1R
dosfs toutdl up..
Takf wid! load to dtmast Cal upItt.
If IMfKatioo YUSn drowIinns.1aI:e at bedmot.
Do not abruptly diKonlinut mediulion.
Evaluation of Outcome Cri teria
'I<Iluatr rfft<Uytl'ltlS of drug theraPl' by (onfifTning Ihat patient goals.nd elpKtfd outtomn hm IIfrn met brr1'lIInnin().
SNWIt " 1 kI' 1st(i/tu!1l towlidl rbet
DRUGS FOR BIPOLAR DISORDER
Drugs for bipobr disordel'" are CllIed mood JtoJbiliHl"s. b3uu
they have the abililY 10 moderate e.xt r eme shifts in emo-
tions between m3nia and depre:s.sion. Antiseizure drugs
and atypical antipsychotic drugs are also used for mood
stabiliution in bipolar patients.
16.8 Pharmacotherapy
of Bipolar Disorder
For years, the traditklOaitreatment of bipolar disorder has
been. Lithium ( Eskalilh), as monotherapy or in oombin.alion
with other drugs. Ulhium wasapprmed in the United Sl2tts
in 1970. Today, in addilion 10 lithium, antiseizure drogs,
have emel'"ged as very effective agents employed for mood
stabilization (chapter 1500). For example, valproic acid
(Depakene) and carbamazepine (Tegretol ) are the anti.
seizure drugs most often used in the treatment of mania or
for rapidly cycling and mixed states of bipolar disease.
Lithium remains effective for states of purely mani c or
purely depressive episodes. For purely depressive episodes
however, the newer anliseizure drugs, for example, lamo-
trigine (Lamictal), may be even more effective than lithium.
Lamotrigine is parlicularly helpful for patients who haveeJI.-
perienced chronic depression and have not reived eff-
tive treatment with Ihe other mood stabilizers. Table 16.3
lists selected drugs used to treat bipolar disorder. In addition
to the listed agents,gaoopentin (Neurontin), Ol{
Clrbazepine ("Irileptal ), lopiramate ("Lopamax), and ron
isamide (Zonegran) all have beneficial effects for mood sta
bilization (chapler 1500).
Atypical anti psychotics have been. effeCIive mood stabiliz-
ers especially for the treatment of acute mania.. Clozapine
(Ciozaril) was the first atypical antipsychotic but carries an
increased risk of agronulocytosis. Newer agents with less of
risk for agranulocytosis induding aripiprazole (Abil ify),
olanzapine (Zyprexa). quetiapine (Seroquel), risperidone
(Risperdal), and liprasidone (Zeldox), have replaced Clo-
razil in bipolar treatment. Longer.term stabilization of
mood and behavior with atypical antipsycllotics is discussed
in mnre det3il in c""pler t ?ClO.
Given that Lithium is sliII in use. it is necessary to profile
this drug. Lithium has a narrow therapeutic index and is
monitored via st'l"um levels ewry I to 3 days .... hen begin-
ning therapy, and every 2 10 3 months thereafter. To ensure
therapeutic aclion, concenlrations of lithium in the blood
remain within the range of 0.6 to I.S mEq/ L Close
monitoring encourages compliance and helps prevent toxi-
city. Lithium acts like sodium in the body, so conditions in
which sodium is lost (e.g., excessive sweating or dehydra-
tion) can cause lithium toxicity and serwn sodium levels
will be monitored along with lithium levels. Lithium over-
dose may be treated with hemodialysis and supportive care.
Baseline studies of renal, cardiac, and thyroid status are in-
diCiled, as well as baseline eltclrolyt e studies.
It is not unusual for olher drugs 10 be used in combina-
tion with lithium for the control of bipolar disordt'l". Dur-
ing a patient's depressed Slag<', tricyclic antidepressants or
bupropion (Wellbutrin) may be necessary. Duri ng the
LibraryPirate
194 Unlll Thl'Ne<voo,Sy'tem
TABLE 16 31 Drugs for Bipolar Disord"r
Dru, Routeand Adult Dose (max dose where IndIcated) Adverse Effects
ithum (Esulith)
1
PO; mg tid;maintenanu:3oo mgtid (max:H glda,) 1 HtodiJdIf, Itrhilrgy, (OOgIJf,ll'I:tnl mtmCt)'1om rnmtG, ImrjliQi
aooraio,obdJmind pdn,ditnhfo, dry mulde lII'atnru,hand
frtmOf'l, rfffrJible /tOOxyIalis, i1t'p/1rogfflk dQbt/t! i"sipiduI
fltrjphtr;ll drndatro (ollapsr
ANTISEIZURE DRUGS
PO; 200 mg bid, gradual, 10 800-1,200 mglday in
to fOIl' dividtddo\e
hfrldIdie naMII,dipiopio. bIlJrmI
mlilriI1II, dlll'llflirltlI, fWIi'G, pr%fIgfd bIMIirlg tiff!('
HNft b!o<l aplastic aOOllia rr!piratOlY detmli9l1, exloHtin
Stmm Johoson Mrrmal on:roIy5is,
elm> (with O'wdosrlliver liiluft' panqratitil
lamouiginr (LAmmi) PO; 50 mglday for 2 'IIftk>, tIIffi 50 mg bid for
ilKJUle lJadualy '" to lOO- SOO mglday in two diIoidtd dolts
(max:7oomglday)
valproit i(id (Ilrpaktnr)

Prototy,", Drug bcJxOO)
PO;l5O mg tid (max:60 mglkglday)
ATYPICAL ANTIPSYCHOTIC DRUGS
PO; 10-15 mg/day (max: 30 mglday) (Abitily)
oIanzapinr (1)'III'W) Adult: PO; stan with 5- 1 0 mglday; may il'ltfmt by 25- 5 mg
M!Y wffic (ralH}P 11)-15 mgidol)';max:20 mglday).Gffiauic
Tildrjcorriia, /folUitnl (eM!!; iWlrion, IINdlKht, lighr-
frtadedflru, lOfIlOOItlKt, OflOOy, ntrl'OIIIIltIS, Msriiry, inIOmfiQ,
I'Omirilg, rorurip<Ili9l1, okorMio
Alnnuocy!Olit nwro!fPlK rnaiooam (wei PO; lIart with 5 mglday


PO; lIart with 15 mg bid; mol)' Masr to a tal9tt 01
300400 mglday in divided dolts
PO; mg bid;ilaeasr by 1 mg daily 10 in initial tal9fl of
6mglday
(Gtodon) PO; 20 mg bid (mad) mg bid)

-
Prototype Drug I Lithium (Eskallth)
Therapeutic (lass: Mood stabilizing drug;bipo(ar affective disorder drug
ACTtONS AND USES
Ahhough mechanism of lion is oct ithilm has been thought to
alter ionK activity and tilt activitifS of nrulOOS rontairing dopImiDl', norrpinrph-
riOI', and Sl'rotonin b)o inftuenc:ing their ft'1NS!', synthm,and !tI4llau.MOfI' I!'-
(mtuudifS!IJ9I}tII thnlithium may inhibittht anionofgwmate;.JnootalOl)'
neurotransmitter in tht syn.I jISI'. Other promililg infonnation indKatfi that Sl'ro-
tonin it the may bloded and thaI syntIIaSI' beta
may be inhibittd within liMo nruron.TheSI' ani:msl!nd 10 stabiiIr a widtr
of (elkJlar tlllnsc1ucti>n pathways. ihtraptUlK KIions aft' of mood
durilg periods of mania, and amideplt'SQ nt duriIg periolk of depll'Ssion.
LithiJrn has nrither antimanit nor amidtpres.ant propertifS i1 indivWals who do
not bipoiardisordtr.Afur taking lithium for 110 3 __ shooJd be
abl!o to bener arod function in
ADMINISTRATION ALERTS
lithium has.J narrowtherapeutidlou.: ratio; the risle of toxicity is high.
Acute o'mdosaqe m.JY be UNiN by
Prrgnancy categPl)' 0
PHARMACOKINETICS
IAlset:S-7da)'l

Peak: 10-21 days
Duration:
Pha rmaco(ogic ((ass: G(utamate inhibitor;serotonin receptor
antagonist
ADVERSE EFFECTS
Lithium mily aul(' filtig!Je,sIlon-trrm m!'mory urina-
tion, naUS!'a, wmiting,loss of abdominal diarthN, dl)' mouth,
lIlJS(uiarweakDl'ls, ind tft'mm.Patifrru should not haY!' i s.alt-flffdiet
when tlking this drug. beuUS!' it rtdlKfS lithum O{ft'09l1.
Contraindications: This drug is {omraindkatN in dtbilitatN and Pol-
tifnl5 with Sl'Y!'fI' (ardio\\lsrular disNSI', dehydration, or ft'nal distasr, and in
um of SI"IeI1' sodium deplttion.
INTERACTIONS
l)ug-Drug: Solllf 00Jgs iIoNIe thf IOO! oJ! wIith tht on,s eo:M' IiIhUn from!ll>
tbcIsUYn, dW!ics, IOIi!Jn biIartIOOatf,R/ pclassiIfn dlOO!. 0!hI'r 00rgs,
mastni'!h)tiopa
inaN\.!thf t6rofithl.m

ilNn,ma,GlUSI'afllldQlemergerqNrold<anpdl'llliiltfdrugarnn
Lab Tflts: Unlnolrm
IIfrbaVFood: Unknown
Treatment of Oerdose: is no spr<ific: [ft'almenl for
is supportil'l', illduding gastric lalllqt, ulrll'ttion of Auid a nd imbal-
a and rrgulation of rtnalfunction iog. Hernodial)'sis is an Nl'KliI'l' and rapid
means of fI'IIIoving ion from lOu.: patient howeYer, rt<0YerY
time may be prolonged.
LibraryPirate
IlI>pltlt6 Drug' lor Emol 1onol arod Mood D""rd ... , 195
NURSING PROCESS FOCUS PATIENTS RECEIVING THERAPY FOR BIPOLAR DI SORDER " SKAlITH)
Assessment
Bllselinr a,srssmrnt priorto administration:
o Undtr>tind Il'ason the drug has prec:ribfd in ol'lltr 10 mes for
lhtraptUtic:
o Obtain I (omplue history induding IItpalK,
nturologic Obtain I drug history induding
prec:ription and ore drugs,and herbal preparalions.Br alm 10
drug imeraaions.
o Obtain a history oIdeplfi-Sion or mood dilordtr, ilKUding <I family history
of \fW'm,. UI!' SUHning tools when possiblt (r.g.,
Otpll'lYon lIT/emory).
o Obtain vitil signs and W!'ight
o ['/<Iluateappropnate laboratory (e.g., MctrolytH (esptCially
wciiumj,CB(, hepalic and Il' nalfulKtion studies).
o AllI'Ss the ability to and undtrmnd instllKtion.llKkidt
lht family and {all'9iYl'lS al llffdtd.
Assessment throughout iI dministration:
o Asses for dHill'd therapMic t A'em (r.g., slabiliztd mood,les5ol'lling
nannalill'd a{tivit)' ltYeIs,apptlitl', and SftP
o Continue periodic monitoring of rlt(trolytes,(BC,and hep.atk and ll'I1al
fUnction srudies. Orug will monitOll'd IrtqUl'lltly or as sympl01111
warram.
o Continue to monitor vital signs and W!'"ighl
for Ind promptly Il'pon diuintU,drowsifl6\ lighl-
hNdfd III'SS, fatigUl', muse: It W!'iIkritss, slight tremor>, thirst. nalllN,
moulh, ilKll'n<i urinary outpul, shon-temJ
Ioss,and
Potentilll Nursing Dillgnoses
o Anmt)'
o DislurbtdThought Proc:e stS
o SftpPatlemOisturban(f
DerKient Self.{all'
o ImbilalKrd flutril ion,More or Than Body Rtquilt'flll'flll (rspeciall-;
!Odium)
o SocialilOlation, Socia llnleraction
o Akell'd Family Proc:HStl
o OtrKient KnowIedgt (drug therapy)
o R isle for Ri!le for Stlf-MUlilalion, Risk for Suicidt, Risk
Iorlnjury
Plllnning: Patient GOllls and Expected Outcomes
The paritmwill:
o UptrielKf lheri pMic e1fts dtptndtnt on the 1l'<l lOn the drug is bting gra,n (t.g., impf"{lft() and stibiliztd mood, itssentd depression).
o Be!ll't' from, or elptrielKt tffem.
o Vtrbalize an undtr>landing ofthedrug's USf, ad-ifill' effects, and Pll'Cautions.
DtmOmlrate plllptr Irlf-il dministration 01 tht mtdication (e.g.,doIe, timing. wht n to notify provider).
Implementation
Interventions and (Ratiol\llles)
Ensuring thrrilpeutic effects:
o Continue aslflwmB as describfd ea rlier for lhmptUlic tffeas.{Lithium
may take 210 3 W!' t kl btioll' full t flto:uart Il' lliztd UI!' objectivr
mwull'l, t.g., BNk Dt pll'lsion when possible 10 htl p qwmily
lhelipMic sign a "No IIarmfNo Suicidt" (onma
auppropriale.)
Minimizing adftlSe efflfCts:
o Continue to monitor druglfl'fls, MctrolytH (ept(ially sodium), CBC,and
I!IIiII and hepatic function .Maintiin a Auid balalKt. (Lithilm is an
sail and the body will (OnSfI'll' or lithium Il'laled 10 the
sodium 1evtI. Serum sodium should br drolWn wilh mh d1ll9lntl.
Dehydration or O'II'rhydration will ll'Suh in Iossorgain of lithium.)
Plltient and Fll mily Education
o TNCh the thu full tffNII flIiIy not O{(Ur for Sf'll'fal Wffkl bul thu
10m!' imp("{I'Hm!'nt should notictable aitt r beginning
o [1l(ourage tht patient 10 keep ill "ppoinlmenu wilh the and 10
disrusl ongoing symploms oIdtpll'Ssion and mania,and immtdiattly
Il'pOI1 any suiciclal idtations.
o InslnKt lht piliem on lht nrtd to rdum ptriodically br lab work.
o InllMt lilt paliem to flIiIinlain a nannll salt Ind fkJ id intakt, withoul
unusual or dramatic in(ll'astS ordeCll'iIfI in oonnal ditto
o TNCh the that (onditions SIKh as dehydration may fl'SUk in
drug IfI'fIs and to immfdiately Il'pOn any symptollll SIKh as
th diuiness, {(InMion, or musde weakness and 10 (IUlious with
mortising or on hot lW!'aling may Iud 10 Auid
!Odium Rtpon U(HSm lhir>t or urination promptly.
(Conr/ooed)
LibraryPirate
196 Until Thl'Ne<voo,Sy'tem
NURSING PROCESS FOCUS PATIENTS RECEIVING THERAPY FOR BIPOLAR DISORDER (ESKAUTH) (Confillui)
Implementation
Interventi ons and (Rati onales)
Weigh the patitnt diily and <I Might g<lin or IoSI of 1 kg
(appro:.:imately 21b) or more in a 24-hour ptriod. imakt and
output in tho hospitoliN<! potion!. _ight is on >u"t. of
Huid staM aM takel into aount intaite,OUIput,and mltS.
Diuresis is indicat.d by output lignirlUndygrt'atrr than intallt.)
Pati ent and Family Education
Hoi!, the patient _igh self diily, ideally at the Ia"'. ti",. of diy, and If(ord
'Might HiM' tho patitm It'pOn a Wl'ight 101\ or g<lin of mort than 1 kg
(.pp..,.iorw.1y lib) in. l .... hour pMod.
Advise the p.uient to rominur to liqJids to
adequately, but not o'mly, hydrated. Drinking when thil'lty, avoiding
akoholic .. gfl and ufleine. and .lIIUring adequate but not elUSsi!'
l.ih intallt will mist in maintaining <I oormal Auid and drug balalK' .
.'.sstS5lor changts in 1tv.1 of ulnsc:iou!nfl',diloritntation or(oniulion,or Insuu(\ tho to immtdiately 1t'p00 ilKlN.ing
agitation. (Neurologic: (hanges may indic:.Jte unlltr -or ol'ffrnrdication, lethargy, disorientation, <onMion, change< in bthavior or mood, agitation
wctrbation of other ply<:hiatric iIInfll,or tfftrnJ or aggression, surred Ipffih,or mxia.
--+---=--
Monitor status, acid, and urinaiysis.(Lithium IlIIlnKt tho patient to promptly rt'port dt<1N d hematuria,
may Wilt dtgtntrativr <hangfl in the kidney, whic:h in<lN.fI drug or urine Itdimtm; IoWt'r abdomin.ll tendemm or funk pain; naUlti;or
tOllic:ity.) diarrhea to the heakh <are provicll'r.
Cominur to roonitor <.Irdj,JalQJlar ItatUl ilKluding vitll sign. and apic:.J1 IlIItnKt tht patient to imrnrdiatrly It'pOn palpitationl,<lIest prrSlUrt',or
pullt. !lithium toric:it)- may rflUk in <ardiacdysrltythmia< or angina. 1M pain,esprcially if i(rompanied by dNiO.a;ordiaphorosis.
with <aulion in patienll with i history of (OronaI)' iOtl)' diSl'alt or heart

Patimt IInd'lStanding of drug thrrapy:
lMoppor1IIliOOduring idmimtratm d rnrdiationlandduing
assf\!OlI'nI\lO discusl rationale for dlUl thtr.!PJ dtsirrd thtr.!peutJ: 0I/00JII"0e!,
moll ob!eMd ad!'Il!' eifI'ds, pararnetrl5 for whrn to (all tilt
hNhh 10ft any IIffi'Slal)' monitorilg or plt'COllJli:m. (Usilg tin!'
ruring rul5ing Ull'heipl to Il'iIw U)o trac:hilg atM.)
Patimt solfadministration of drug tht rapJ:
When administering the mtdic:ation, illltnKt the patient, fami!y, or
c,lt'9iYl'r in the proptr Itlf-administration of drug. . g., takt the drug 011
PIfICribtd and do oot substiMe brands. (Utilizing time during
adminil1ration of tilesr drugs help< to mnfon:. tmhing.)
The patient should bt able to state tht IN.on for tho drug;'ppropriate dOl.
and IChtduling; ,nd what adYers. effr(l\ to ob\eI"W for and when to rt'port
,t.m.
Tea<h the j).J titntto thr rnrdication 011 follows:
Taktl'J:iKt!y 011 orderod and UII' tho lame roanufactult'l's brand eoch
the prtICription is filled. (Swit<hing brands may rt'.ult in diffffing
ph,nniKokintliu and akffation. in thffapl'lltic: rffKl).
Takt a miM.d dolt 011100II <II it is notic:td but do not uktdouble or utra
dc11t1lO(,)\chup.
Taktwith food todemalt GI Uplll
Do oot ,b ruptly dileontinur IIH'dic:.Jtion.
Immtdi,tely rt'port any ilKrt'alt in diue urine,diarrbN,
inmobilit)o.
Drink plenty offlurn to <lvoid dmjdration.
PriKtic:e rt'liable (ontraception and notif)o your health <.III' plOl'ider if
pregnancy is plannrd orsu'PfCttd.
Evaluation of Outcome Criteria
Evaluite eflecti'lentll of drug therapy by (onfinn ing that patient goa lsand I'J:pKltd out(omfl been rntt (Sf!' Planning1.
manic phases, a benzodiazepine will moderate manic
symptoms. In cases of extreme agitation, delusions, or hal-
lucinations, an antipsychotic agent may be indicated.
Continued patient compliance is essential to achieving
successful pharmacotherapy, because some patients do
not perceive their condition as abnormal. To prevent re-
lapse, psychologic therapies and sleep management are
considered e.'l:tremely critical components of bipolar dis-
order thera py.
PHARMFACTS
Attention Deficit- Hyperactivity Dborder
ADHD is iheroajorlNsoo(hildlt'O art' rt'ftrnd brment.J1 IINhh trNtrnent.
Abrut haH art' 01110 ciagnoltd with oppoIitilrwl defiant or <OnCiJCt dilonler.
About onefounh art' <1110 diagoo.td with anxittydilOrdtr.
About one allo diagOOSfd with dtpnollion.
one fifth ,110 a leaming dis.ibilit)o.
LibraryPirate
ATTENTION DEFICIT-
HYPERACTIVITY DISORDER
A condition characterized by poor attention span, behavior
COCIlrol issues, and/or hyperactivity is called ,Ilmtion
dtool-ll)'pffactilitJ disonlef (AllHD). Although the condition is
nonnaUydiagnosed in chiJdhood,symptomsof ADHD may
enend into adulthood.
16.9 Characteristics of ADHD
In reality, ADHO is neither an emO(ional disorder nor a
mood disorder. II is r:l.lher a behavioral disorder thai affects
as many as S%of all children. Most chi ldren diagnosed with
this condition are De!ween the ages of J and 7 and
boys are 4 to g limes more likety 10 be dJ.agnosed than girls.
ADHO is charxteriud by de\'dopmentnlly ill3ppropriate
behaviors involving difficulty in paying attention or focusing
on tasks. ADHO may be diagn0600 when the child's hyperac-
tive behaviors significantly interfere wilh normal pJay,sleep,or
learning activities. Hyperactivechildren usuaUy have increased
motor activity that is manifested by a tendency to be fidgety
and impulsive, and to interrupt and talk excessively during
their developmental years, therefore, they may not be able to
interact with othen appropriately at home, school, or on the
playground. In boys, the activity levels are usually more overt.
Girls show less aggression and impulsiveness but more an:tiety,
mood swings. social withdrawal, and cognitive and language
delays. Girls also tl'nd to be older at the time of diagnos.i!>, so
problems and set:backs rdated to the disorder exist for a longer
time before lreatment interventions afe undertaken. Symp-
toms of ADHD art'described in the following list;
_ Easydi.'illxtibility
- Failure to receivt' or follow instructions properly
- Inability to focus on one wk at a time and jumping
from one activity to another
_ Difficulty remembering
- FrequentloM or misplacement of personal items
- Excessive talking and inten"upting other children in a group
- Inability to sit st iU when asked to do so repeatedly
- Impulsiveness
Sleep disturbance
Most children with ADHD have associated challenges.
Many find it difficult to concentrate on tasks assigned in
school. Even if children are gifted, their grades may suffer
because they have difficulty following a conventional rou-
tine; discipline may abo be.1 problem. Teachers are often the
first to suggest that a child be examined for ADHD and reo
ceive medication when behaviors in the cbssroom escalate
to the point of interfering with learning.A diagnOSis is based
on psychologic and medical evaluations.
The etiology of ADHD is oot dear. For many years, scien
tists described this disorder as menul brain dysfunction and
hyperkinetic syndrome, focusing on abool1Tl:ll brain functiOll
and overactivity. A variety of physical and neurologic disor
1lI>p1tl16 Drug. for Emotlonilt and Mood OfsoJde.s 197
ders have been implicated; onlya mtall percentage of those af
fected have a known cause. Causes include oonbct with high
levels of lead in childhood ;md prCfl.ltaJ exposure to alcohol
and drugs. Genetic factors may also pby a role, althoUgh a sin-
gle gene has oot been isolated and a sj'OOfic mechanism of ge-
netic transmission is nOi known. The interplayof genetics;md
envirOllment may be a contributi ng dynamic. Recent evi-
dence suggests thai hyperactivi ty may be related to a defICi t or
d)"sfunctiOll of dopamine, oorepinephrine, or serotonin in
the reticular activating system of the brain. Although OlIce
thought to be the culprirs, sugars, dlocoIale, high-carbohy-
drate foods and beverages, and O;'!"tain food additives have
been refuted as causative or aggravating fxtors for ADHD.
The nurse is often inrolved in the screening and the mental
health assessment of children with suspected ADHD. Whena
chikl i.. refe""" fnr """ing, i, i.< impnr'an' In l"f'T1"lfn1hf.r
both the child and family must be assessed. The family is
screened with, or prior to, the ,hild's evaluation. [t is the
nurse's responsibility to oollect ,omprehensive data about the
character and extent of the child's physical, psycoologic, and
developmental health situation, to formulate the nursing di-
agnoses, and to create an individuahed plan of care. A rele-
vant nursing care pbn be created only if it is based on
appropriate communication that fosters r.1pport and trust.
Once ADHD is diagnosed, the nurse is irutrumental in ed-
ucating the family regarding behavioral strategies that might
be used to manage the demands of a child woo is hyper:.ctive.
For the school-age child, the nurse often selVes as the liaison
10 parents, tea,hers, and school administrators. The parents
and (hikI need to understand the importance of appropriate
expectations and behavioral amsequences. The ,hiid, from
an early age and based on his or hI'\'" devdopmenbllevd, must
beeducaled about thedisordl'\'" and undtfStand that t1lereart'
wnsequences to inappropriatebduvior.Sdf-esteem must be
fostered in the child so that strengths In self-"'"Orth can de-
veIop.1t is important for the child to develop a trusting rela-
tionship with health care providers and learn the importance
ofmedication management and compliance.
One third to OlIe half of children diagnOSl with ADHD
also experience symptoms of attention dysfunction in their
adult years. Symptoms of attention deficit disorder (ADD)
in adults appear similar to mood disorders. Symptoms in-
clude anxiety, mania, restlessness, and depression, which
can cause difficulties in interpersonal relationships. Some
patients have difficulty holding jobs and may have an in-
creased risk for aloohol and drug abuse. Untreated ADD or
ADHD has been linked to low self-esteem, diminished so-
cial success, and criminal or violent behaviors.
DRUGS FOR ATTENTION
DEFICIT-HYPERACTIVITY DISORDER
The traditional drugs used to treat ADHD in children holve
been the CNSstimulants. These drugs stimul3te sptOtic
of the central nerwus system that heightm alertness and in-
crease focus. Recently, a IlOI1CNS stimulant was 3ppt"O\lcd to
treat ADHo. Agents for treatingADHD are listed in Table 16.4.
LibraryPirate
I
198 Unlll /IIe<v"",. System
TABLE 16 4 Drugs for Attention Deficit- Hyperactivity Disorder
DN'
eNS STIMULANTS
I>-- and I amphetJnint rownic:
minurt (,I.ddtIa1l) ial!O avaiablt a.

(DiRx)
dexmmyiphtrida:t (Foolin)
(Duedrintj

Dmdrint Spm'*,)
i ldwmftlilmintl'o'ylall!o!)
methamphetJmilf {Dffix)"Il)
Roull' and Adult Oose (max dose where Indlcatedl
6 ),!al'l oId:PO;5 mg one orlWOtinel/day;1N)' iOONIo! by 5 mg at wtftIy
intmak {max:40 mglday). 3- 5 ),!al'l old: PO;25 mg to tWD timffiday;
may iooNlo! 15 mg at 'IMkIy inter'lib
PO:b-SO mgl-l ptrday {max: 150 rrg/day)
Child oIderthan 6yeal'l:PO:15 mg bid may iroNlo! by 25- 5 rng/wfH
(mal: 20 5 mglday 9tM d may illUl'aII' by. mg/wffk
mg bid; may ilmalo! 2.5- 5 ng/day at WffUy ilttr'"k
(mal:20 mglday)
l - 51!iJl'lold:PO; 2.5 mg 0fH' or two ilmalo! 25 mg at
Wffkly intt Mk
6 ),!il'lold:PO:5 mg OIl!' orlWO tineslday:irmalo! by 5 mg at wtftIy
intmal. (max:40 mglday)
PO:30 mg 0IICl' daily in am. {max: 70 mglday)
6 ),!al'l oId:PO;2.S- 5 mg 0fH' or two inuealo! 5 mg at
WffkIy intt Mk (max: 20- 25 mglday)
PO; 5- 10 mg brukfall and lund!, withlJadwl iOOl'alo! of . - 10
mg/'IIftIral IIffiItd (max:60 mg/day)
Effects
Imrabiiry, III'flOOW'1I, inlOllllW,
t!JPhorio, PQ/pirkru
Sudden duth lreDO!lfd in mldrtn
5\IUCIln i urdia( dn:wtory
coIlapsr. 9 foiati"lt trmat"tis. anrnia.livt r
-
NONSTIMULANT FOR ADD/ADHD
,... Prototype Drug I Methylphentdate (Rltalm)
Therapeutic (las.: Anention defidt-hypelllcti..;ty disorder drug
AatONS AND USES
Mtthylphenidateacti"lates reticular adi'l<lling systt m,(.lusing ht ightt ntd
alertntl! in yaricu! regiom of brain, panirularly (enters a\5ociated
with focus and <lItention.Acti"lation is panglly by of 1ItU-
rotrammimol'l su:h al noll'pintphrine and dopamilll'.lmpulsiftntll, hyptrac-
twitpnd bthayior are usually rM.oc:td within <I few vmoln. Thts.e
(hanges intt r.J{\iom and acadenlic: perfor-
mallCt. A mmritrmal,mencitd mu ll' form ofmethyphenidatt wasapproYed
in 2006 (!laytrarw).
ADMINISTRATION ALERTS
Susuinedffltall' ub!ru must btswallowtd wholt. Breaking orclUshing
SR u blets (.lu;es immtdiate II'INII' of tilt entiR' dost.
Controlltd suhtallCt": Schedule II drug
PlI'9l1inq UIf90ry C
PHARMACOKINETICS
lm trun 60min
Pl!ak: 2 h;3-li IUltaintd II'INSt
2 ..... h
Duration: 3-6 h;8 h su.uintd reluse;8-12 h mtndtd
Pharmacologic Class: Central nervollS system (CNS) stimula"
ADVERSE EFFECTS
In a nonADHD (austl nt l'lOUlntl. Ind insomnia.
All patit nll art at rilk for ilT!' guLu high blood and liver
toxicity. methylphenidate isa xhtdult II drug, it has the potentia I for
(.l using dtpenrimt u!o!d for 6tendtd periods. Pt riodic drugflN
"holidays' are rKOmllll'ndtd to redUCt drug dtpendt n(t and to 01 111'1. the
patient"s (ondition.
Contraindication!: Patitm. with a history of marktd anlitt)o, Igitation, p!)I-
(hosis.suicidal idMion, glaucoma, motor tin, or TouR'ne. dileill' should not
UII' this drug.
INTERACTIONS
I)ug- l)ug: illHittl with manydnJ9l.FIX" may

(roc"-""t thfr...., wih doniclirof IIIiII' illUUlf oiIW_ ffftru.Anlil)"pfrtfllli'm 01
odIfI OIS stimWnll could poIfIItialf 1M _onstrictift action of
hWHIMli'll' crM.
Lab TI5ts: Uninown
IkorballFoo:I: Adminiltration \into! r8.itiw to mNk and mNI compo:Ition IN)'
rwd
Treatment of OverdOlf: There is 00 ,perific trmment for Ot'rdost .Sigm and
l)'IIlptOIlll of arutt R'lUk principally from Ot'I'ltimulation eNS
<I nd from 6Ci'\ Ii!' Iympathornimetic elferu. Emergency mian and
gt ntralsupportivt lIII'alUlI'I may he lIKessary.
LibraryPirate
OIiptflt6 Drugs for EmotloNl ar.d Mood DliOrd..-s 1"
NURSING PROCESS FOCUS PATIENTS RECEIVING TREATMENT FOR ADHD, ADD
Assessment
Baselinr ISHssment priorlo IIdminislralioo:
Und!'nund lhr INson the drug has pmcribtd in orDtr to mes for
thmptUlic: t1FfCts.
Obtain. compitte i1Nhh history including hepilic:,
naualogi< dilNlr, including Obtain. drug history including
allergies,eurmlt plfl(ription Ol( drugs, and hflbal
alert to drug intemtionl
Obtain I IO(gl and bthivioral S(lttning tools when
polSible.
Obtain. nutritional history.nd HIfIS norm. 1 paltrrns.
Obtain vital sigm,.nd heighund weight.
appropri.nr l.iboratory findinqs (e.g., (BC hepatic:
and mlil function studies).
AslrSs the patitnt"s ability to re<tiYt.nd undtrsUnd inltnKtion.lncludt
the family .nd as nerdrd.
ASSfls mtnllhroughoul iI dminisltation:
AslrSs for theriptUlic: e fie<u (e.g., incrt' sed ability to
normiliud Ieels with lesltned impulsivity, maintfllantt of
norm.1 i ppetitr .nd paltrms).
Continur periodic: monitoring of rittlroiytes;, (BC"md hepatic: and I\'nal
truditl
(ondnur to monitor vital sigm, .nd height and wright wttkly.
Assess for.nd promptly I\'porI idftntffie<b:dizzinrlS, light-
phySic:.tIICtivity, t.drfurog,
inclI'asrd blood h)'ptrtrlllion,.nd palpitations.
Potentllli Nursing 01llgnos.5
Imbal.incrd Nutrition, lrss Than Body RrqJiR'mrms
Disturbed Sletp Pattrm
Altered Family Proo:tSItS
Koowledgr
Risk for DeI.J,rd Growth and Dr-Irlopmrm (relatrd to (oodition or to
Idvmr dlll!J diem)
Risk for Soci.llsoI.uion, Risk for ImpaiR'd Soo:iillntrri ction
Planning: Patient Goals and Expected Outcomes
Tht p.titm will:
uptrienct effts dtptndfm on the rmon th r drug is bting givrn (t.g. improl'rd ability to pyKhomotor symptoms).
1It'!Ift from, or tlptntnce minimll rfffCts.
Vrrb,aliu.n underst.nding ohhedrug's eff!s"nd R'qJil!d preuutions.
Demonstratt proptr seIf-ildministration of the medication (e.g.,dolt, timing. when to notify providrr).
Implementation
Interventions and (Rati o nales) Plltient lind Fllmily Educlltion
--+--
Ensuring ther. peutlc effects:
Continur asltllments.s decribrd u rlitr for theril ptutic: effts.
(Thmpeuo{ includr the ability to iotlft and
impulsiYity,ind improved IO(g I imtriltliomJ
(ontinur to monitor the PUM Ind blood plI'SlUR'on hrakh caR' visits.
(lachyurog,in{R'm blood p1rSIlJR', or hyptnrnsion may occur if lhr
d= is el{fSsWe.)
Wrigh thr wtt'kly .nd obtain the patitnt's height.lleport .ny
weight loss orfailuR' to ga.in weight during thr txpKIrd growth ptriods.
Assess nutrition ind 1M of other slimul.iting prooiKts (t.g:rlH'!9Y
drinln, (.ffrinatrd be'l"rrages). (Diminishrd appetitr or ;r norma from
stimulating effts of the drug, or 1M of othrr sli rrul.inn, may impair thr
normal nutrition nredrd for growth and dtvriopmrnt)
the p.titnl, family,or to keep;r \O(gVbehal'iorill
InwM- !Chaol f.eult)' and (r.g., .ftrr""lchooi YII').
TriKh the pltiem, family,or wegivrr totae thr puMalong wilh Wttkly
hright;rnd Wfight or all)' time symptoms warrant (t.g. child (ompl.iim of
chest disromfort or pa Ipit.nioltl). Almt the patient. family, or (aR'givrr to
fi nd PUM Ioc:ation mOlt Mil)' frk and hm the family, or wegil'tr
pullt taking beioll'going homr.
TriKh the pltiem, family,or wegivrr toobtain hright;rnd weight weekly
and to rrport all)' loll of wright or l.ick of tlprard growth. EnSUR' thr
!Mand functioning of.1l)' home rquipmrnt!/ltd (e.g., electronic:
scale).
Disru!! thr rwrd to iVoid or eliminate ;rllloocls,beYtraget,or Of( drugs that
{oot.in uffrilH'orothrr stimul.iou.
(Conrmued)
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t

200 Unlll Thi'Ne<vDI"Sy'tem
NURSING PROCESS FOCUS PATIENTS RECEIVING TREATMENT FOR ADHD, ADD (COt!lInuw)
Implementation
Interventions and (Rati onales)
Cominut to monitOl\leep patt!'lllS. (Stimulatort efied,of dfIIQ IIIIIV ,flKt
oormal ,ftpirogpattern,and may dOIagt.l
Patient and Family Education
o Instruct tilt patient family.or Cill1'oim to inform thl- providerof dimrption
to ,leep, incrmed rurirog the day effea from lackof
,leep).OIH<ffiil'l' rurirog tilt rIa)o.
o H,Ye the patjtnt talce the d=ear/y in the day and beloll' 4:00 p.m. to help
alleviate insomoia unless 9tenried-lI'tea,e Ionnulation is!Md. rake
___ +--, "'::::''''''= .fe1e,1I' formul,tion, in the momirog.
kll'U for 9CtS,il'!' stimulatory efl'eru:.Jgitation,aggll'ssion. tremoB, or 0 Instruct tilt patient family.or {all'gil'l'r to immediately II'pon tlflllOl' or
ll'izures and Il'port (NS stimulation II1II)' (aUII' ,eizure-! to the health "II' providet
ll'izures uan ,dvelll' efl'ed)
kl('S, the Iftd for rominuous medK.-ttion or I'ftd ilr dIU] holidays with th e
f, mil)o. and health we PlU'fid!'l baled on the
lO{iaVbeh.J'Iior,1 diart findirtg!.(Dtpendent on tlltdtg""' drug
holidays 0I'!'f oon---smool days or VoKiltion periods may he IffimmendedJ
kll'U the oome !'II'Iironllll'ntfor medication \ilfMy and the I'ftd for
intl'M'lltion Mvile the fam on II'StrKtion, about
prescription lI'IWWal.(Methyiphenidate is a Scherule II drug ,nd lIIIIy oot
bt UII'd by all)' other peoon than the patient mediution in the
oome to pll'Vfllt ovenlolagl'.)
Patirot understanding of drug thrrapy:
lktopponunitiesduingidrriri,trationofrnedicationsaooduinga,l('SSmertU
to diIruss the rationa Ie for drug ther,Pl'. desied therapeuti: ou/IIIIfS, molt
obsmoed advl'lll'etre.:15, parallll'ltfS b when to cal the heahh
IlII1' and all)' IIK!1s.J1)' monitoring orprtuutiom..(lkirog time
!bing nulling helps tooptimilr and rffifolU' kr)' teaching alNsJ
Patimt self-administration of drug therapy:
When administe rirog the mediution. instllKt the or
in the propersrH-idministration of drug. f.g . take the drug as
and do oot sullstiMe brand,. (Utilizing time durirog nur5e-
admini,tration of these drugs helps to tmhing.)
o Te,ch the f,mii)<,orurt9i1'1'r about the of drug holidays.Jnd
expIolI' option,.lf tilt drug dole is" the upper dOSl',considef
taperirog tilt doll' prior to beginnirog the drug holid,y to ,void rebound
hyperactivit)' or agitation.
o Instruct tilt patient family,or call'givrr in proper medication storagt and
the I'ftd lor the drug to be used II)' the patient only.
o Teach the oruregil'l'r about renewal r!1trictions ij.f.,
new prncription each tilll!',oo refills, pltKription may oot becalled in) and
expIolI' Khool polkits lf9,rding use (e.g_. 'irogle.dose \I'Ilt eam
do)o. oun:d bii"or piKk =d ij multidoscs "'01).
o The patient family. or ulI'giver ,hoold bt ,ble to stile the for the
drug;approprilltt doll' and Kheduling;.Jnd WMt ildYl'lll' efferu to obII'lI'I'
for ,nd when to when to II'pon them.
o Teach the pilil'llt to take the mediution al follows:
o Take exactly as ordrrrd and in the momirog to insomnia.
o Do oot takedouble or Utr, doles to focus or to plI"I'!'nt
lleepines,. The drug will not achiel'l' th!5f effects but will the
adoi!lII'erre.:u ofthedrug.
o Do oot ablllptlydiKominut the mediution without cOlllUkirog the
he,khweprovider.
Evaluation of Outcome Criteria
16.10 Pharmacotherapy of ADHD
The main treatment for ADHD are CNS stimulants. Stimu-
lants reverse many of the symptoms, helping patients focus
on tasks. Drugs prescribed for ADHD include D- and l-am-
phetamine racemic mixture (Adderall), benzphetamine
(Didrex), de.:'l:methylphenidate (Focalin), dextroampheta-
mine (Dexedrine), lisdexamfetamine (Vyvanse), metham-
phetamine (Desoxyn) and methylphenidate (Ritalin).
Intennediate- and longer- release forms of methylphenidate,
marketed as Concerta, Metadate, and Methylin, are avail -
able. For greater flexibility in dosing, a methylphenidate
patch marketed as Daytrana was approved by the FDA in
2006.
Patients taking CNS stimulants must be carefully moni-
tored. CNS stimulants used to tr""t ADHD may crute pu_
adoxical hyperactivity. Adverse reactions include insonmia,
nervousness, anorexia, and weight loss. Occasionally, a pa-
tient may suffer from dizziness, depression, irritability, nau-
sea, or abdominal pain. CNS stimulants are Schedule II
controlled substances and labeled as pregnancy altegory C.
Methylphenidate abuse has been increasing, especially
among teens who take the drug to stay awake or as an ap-
petite suppressant to lose weight.
Non-CNS stimulants have been tried for ADHD; how-
ever, they exhibit less efficacy. Clonidine (Catapres) issome-
times prescribed when patients are extremely aggressive,
acth"e, or have difficulty faUing asleep. Atypical antidepres-
LibraryPirate
Li fESPAN C ONSIDERATIONS
Methylphenidate Use In Older Aduhs
\Ir'IIR (RjQIin1 his bn IIWg lIN
dlilcftn.m 1M iI tbr use of odwf DIS Itindilm. is
hu IIttft s'-" l!I.IintMnw.Rfuinm,MId ..

IJfRrd ifill Akll.,lplw:nldnr drouse bI 1M by RpooritIg llenllm, IIId
.., 1IIriIII. lilt Iltiu.tnil of lwmintoglKl diso!dtr.1IM
pltimb 9-_"* of Ihr wbwl field.
IItouIt lilia stindIting rftKt!.1IIt of ulttl"lpIitlliclne.
sliouId dt!eIJ _1Oftd. Frtq,ItnI ..... signs, HjIKiIIy Wood PftS-
-' MId lilt
.. nualionshauld Iho .... itcftd.And 1MI00IIgtili dIt
CIIIIiJsion 01' IgiuIion.stIauId pmmpdr 1tpOfIfd.
KEY CONCEPTS
unls such as bupropion (Wellbutrin) and trkydics such as
desipramine (Norpramine) and imiprnmine (Tofranil) are
considered s.erond-choice drugs, when eNS stimulants fail
10 .... ork or are contraindicated.
Arecentaddition k,) ihelrmtmmlof ADHD inchiklren and
adults has bM\ alolllOlttioe (Slrattera). Although its GOICI
mechani!;m is no! known, it isclassifitd as a norepinephrine re--
uptake inhibitor. P-Jtients tWl1(I atortlC\.U'llne show improved
ability 10 focus on wits and reduced hyperactivity. EfflCaC}'ar-
pears b be equivalenl to methylphenidate (Riulin). although
the drug is too nrw for Iong. term a.>mp;arisons. Common side
dfects include headKht. insomnia, uppl'f abdominal pain. de.
creased appmte. and rough. Unlike methylphmicbte. it is not
aJChedultd drug, thus. Jments wnoart Iwsitant to place thei r
dUId on stimula nts now have a reasonable alternative. An dill
dren tre:ltoo with should be monitored dosdy for
increased risk ofsuidde ideation.
The numbered k.-y concepts provide a succinct summary of tile Important polnls frolll the corre5pQndlng numbered section
within tile chapter. If any of these points all' not de:.u. Il'fer 10 numbered section witllin the chapter for revM'w.
16, 1 Everynurwshoukl bf, proflcltntln Iheassessment of pa-
titnu with signs of depreaion. Dep.-eWon has many
forms and chal1iiCleristlcs.. and 115 identification and eti-
ology areessenllallOr propel'" Ill'atment.
1'-2 Approaches to treatment of major depression inwlw a
proper htaltll I.'DITllnatlon. medIcations. p5ycoothent-
peutic thnlquet.lnd e\tfO)nvulsiw or rTMS ther
apy. Thtre is an important warning from 1M FDA about
anl idfPll'5Unts.
163 Anlldtpressanu act by corrtlng neuro!l1iiosmltter im-
balance in tile brain. The two bnk JTle(haf\isms of action
are blocking the I:fIJ;ymalk breakdown of norepinephrine
and slowing the reuptalce of serotonin. The primary
da_ of antidepr_nts the TeAs. SSRIs, 31ypicalan
lidepressmlS, and MAOls.llIe serotonin-noreplnephrine
reuptake inllibiton (SNRI5) all' a subgroup of atypical
amidepressants rec.ently approved for the relief of depres-
sive symptoms.
16.4 Tricydic anlidepressmts all' older mediatlons used
mainly lOr the treatUlellt of major depll'SSion. obIes.Yve--
disorders. and panic attacks. They llave un
pleasant and serious side effects.
16.5 SSRls act by selectiVely blocking the reuptake of 51'ro-
tonin in nerve tennlnals. Ilec:aUSf of fewer side effects,
SSRI5 are drugs of choice In the pharmaCOl.herapyof de-
pression. Serotonin syndronlt 1$ a $erlous concern lOr
SSRls and forother antIdepressant drug d.as.ses.
16..6 MAOI5 aft' uwally prescribed In cases wilen otller anll
depresAnls haw not been 5UCSW.ll. They haVl.' more se-
rious sidt' effects tJu.n other antidepressants.
16.7 PatlenU with bipolar disorder display not only signs of
depression but also mania, I state charxterlud by ex-
pressive psychomotor activity and Irritability.
l U lithium (Esblith). antlSl'Qure drugs. and atypical an
tipsychotic drugs are ustd to treat bipolar dUorder.
Lithium i!; purely manic or purely depressiVe
stages. Anl lsel.zure drugs are more effective In tile treat
ment ofmania or for cydingand mixed SUtts ofbipoLtr
disorder. Atypical anlipsycholics are more effective lOr
the treatment of KIlle mania and for tile longerterm
treatment of pyschotic depll'SSlon.
16.9 Attention defidt-hypernClivity disorder (ADHO) Is a
common behavioral condition occurring prlmarlly in
cllildren and is diuacleriztd by difficulty atten
tion, hyperactivity, and impulsiveness.
16.10 The IJ106I efficacious drugs for symptoms of ADHO are
the CNS stimulants suell as methylpllenldate ( Ritalin). A
newer, nonstimulant drug, atomoxetlne (Str.lttera). has
shown promise in patienU with ADHO.
LibraryPirate
202 Until The /IIeIv"",, Sy'tem
NCLEX-RN" REVIEW QUESTIONS
D Anticholinergic effects are common adverst' effects of an-
tidepressants such as imipramine (Tofranil). These effeds
may include:
I . psychomOiorsymptoms.
2. tachycardia, hypertension,and increase in respiratory
rate.
3. tardive dyskinesia&.
4. blurred vision, dry mouth, and constipation.
D The parents of a patient receiving methylphenidate (Ri -
talin) express concern that the heal th care provider has
suggested the child have a "holidayn from the drug. The
nurse explains that the drug-free holiday is designed to:
1. reduce the risk of drug toxicity.
2. allow the child's "normal" behavior to return.
3. dl'Cf"f' ....... dn,gdep .. ndenceand ... ",,,,<st.h ...
4. prevent hypenensivecrisis.
D Which of the foUowing symptoms would indicate to the
nurst' that a patient is experiencing lithium toxicity? (Se-
lect all that apply.)
1. Diarrhea and ataw
2. Hypotension and edema
3. Hypenension and dehydration
4. Increased appetite, increased energy, and memory loss
5. Slurred speech and muscle weakness
CRITICAL THINKING QUESTIONS
1. A l2-year-old girl has been diagnosed with ADHD. Her
parents have been reluctant to agree with the pediatrician's
recommendation for pharmacologic management; how-
ever, the child's performance in school has deteriorated. A
school nurse notes that the child has been placed on am-
phetamine (Adderall), not methyl phenidate {Ritalin}.
Disruss the developmental considerations that might sup-
port the use of amphetamine.
2. A 56-year-old female pattent has been dtagnosed wtth
clinical depression following the death of her husband.
She says that she has not been able to sleep for weeks and
that she is drinking a lot of coffee. She is also smoking
quite a bit. The health care provider prescribes fluoxetine
(Prozac ). The patient seeks reassurance from the nurst' re-
garding when she should begin feeling "more like myself."
How should the nurse respond!
D A 17-yror-old male hasstarted valproic acid {Depakene}
for treatment of bipolar disorder. While he is taking this
drug, he should be carefully monitored for:
I . UnllS\lal abdominal pain, especially in the upper
quadrant areas
2. An increased susceptibility to infections
3. Lethargy or confusion
4. Unusual bleeding or bruising
D Which of the following would be a priority component of
the teaching plan for a patient prescribed phenelzine
(Nardil) for treatment of depression?
1. Headache may ocrur.
2. Hyperglycemia may ocrur.
3. Read bbels offood and over-the-counter drugs.
4. Mnnitnrhlnnd p'l'S"<nl"f' for hypnten.<inn.
D A patient experiencing moderate depression is placed on
st'nraline (Zoloft). The nurse should counsel the patient
to expect full effects from the drug in:
1. 2- 3 days.
2. 1 wt't'k.
3. a month or longer.
4. within 24 hours after staning thedrug.
3. A 26-year-old mother of three children comes to the pre-
natal clinic suspecting a fourth pregnancy. She tells the
nurse that she got "real low" after her third baby and that
she was prescribed sertraline (Zoloft ). She tells the nurse
that she is really afraid of "going crazy if she has to stop
taking the drug because of this pregnancy. What concerns
should the nurse have!
See Appendix D for answers arid rationales for all activities.
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resources. I'rejla(e Ioc suCQ!;S Wllh addjlimal
(JIeslloos, as'l91mcnts and web links, arimatons
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DRUGS AT A GLANCE
CONVENTIONALANTIPSYCHOTICS pagt.ni
Phenothiazines 1lUJtlO5
Q chlofpromal1nehydrochkNlde
(Thofazlrw) fXXJl ](JJ
Nonphenothiazines plJlJOllJ
Q haJopmdoi (Holda/) plI}t }(M
ATYPICALANTI PSYCHOTICS pl9t}(18
o r/spefIdone (RJsperdaJ) {II1Jt m
Dopamine System Stabilizers (DSSs) plI}t 1I6
KEY TERMS
akathi5ia puJl105
delusions page](J4
dopaminr type 2 10,1 rueptor pi1tjt}(H
dystonia flljl 106
utrapyramidal sidr f'ffects (EPS) (X1IJt lO5
hallucinations {llXJt lO4
Drugs for Psychoses
LEARNING OUTCOMES
After reading this chapter, rhe student should be able to:
1. Explain theories for the etiology of schizophrenia.
2. Compare and contrast the positive and negative symptoms of
schizophrenia.
3. Discuss the rationale for selecting a specific antipsychotic drug for the
treatment of schizophrenia.
4. Explain the importance of patient drug compliance in the
pharmacotherapy of schizophrenia.
S. Describe the nurse's role in the pharmacologic management of
schizophrenia.
6. Explain the symptoms associated with extrapyramidal side effects of
antipsychotic drugs.
7. For each of the drug classes listed in Drugs at a Glance, know
representative drug examples,explain their mechanism of action,
primary actions,and important adverse effects.
8. Categorize drugs used for psychoses based on their dassification and
drug action.
9. Use the nursing process to care for patients receiving drug therapy for
psychoses.
illusions fllKlt lfJ4
nfgative symptoms JXT;' lfJ4
neuroleptic { I I J t ~
nruroleptit malignant syndrome (NMS) pot}f
paranoia pot}f 104
parkinsonism fllKlt l1J6
positive symptoms {II1JtlfJ4
schizoaffrctivr disorder fIIKIt 105
sthilOphrr nia paqt 104
tardiYr dyskinrsia {II1Jt )()5
LibraryPirate
204 Unlll The /IIeIv"",, System
S
evere mental illness can be incapacitating forthe patient
and intensely frustrating for family members and those
dealing with the patient on a regular basis. Before the 1950s,
patients with acute mental dysfunction were institutional
ized, often for their enti re lives. With the introduction of
chlorpromazine (Thorazine) in the 1950s,and the develop-
ment of newer drugs, antipsychotic drugs have revolution
ized the treatment of mental illness.
'7.' The Nature of Psychoses
A psychosis is a mental health condition characterized by
delusions (firm ideas and beliefs not founded in reality),
hallucinations (seeing, hearing, or feeling something that is not
there), illusions (distorted perceptions of actual sensory stim-
uli ), disorganized behavior, and a difficulty relating to oth-
ers. Behavior may range from total inactivity to extreme
agitation and combativener.s. In addition, some patients
with psychoses exhibit paranoi., an Htreme suspicion and
delusion that they are being followed, or that others are try-
ing to harm them. Because these patients are Wlable to dis-
tinguish what is real from what is illusion, they are often
viewed as medically and legally incompetent.
Psychoses may be classified as acute or chronic. Acute psy-
chotic episodes occur over hours or days, whereas chronic
psychoses dewlop over months or years. Sometimes a cause
may be attributed to the psychosis, such as brain damage,
overdoses of certain medications, extreme depression,
chronic alcoholism, and drug addiction. Gt>netic factors are
known to playa role in some psychoses. UnfortWlately, the
vast majority of psychoses have no identifiable cause.
People with psychosis are usually Wlable to function nor-
mally in society without long-term drug therapy. Patients
must see their health care provider periodically, and med-
ication must be taken for life. Family members and social
support groups are important 50urceS of help for patients
who cannot function without continuous drug therapy.
SCHIZOPHRENIA
Sdtizophrf nia is a type of psychosis characterized byabnormal
thoughts and thought processes, disordered commWlica-
tion, withdrawal from other people and the outside envi-
ronment, and a high risk for suicide. Several subtypes of
schiwphrenic disorders are based on clinical presentation.
, 7.2 Signs and Symptoms
of Schizophrenia
Schiwphrenia is the most common psychotic disorder, af-
fecting 1% to 2% of the population. Symptoms generally
begin to appear in early adulthood, with a peak incidence in
men 15 to 24 years of age, and women 25 to 34 years of age.
Patients potentially experience a variety of symptoms that
may change over time. The following symptoms may appear
quickly or take several months or years to develop.
PHARMFACTS
Psychoses
Sjrmptoms of psychosis .reoftm moc:iatfd with othtr ment.1 hNlth
problems indJding subll.nc:t .bust,depmsion, .nd dtln!'ntia.
disorotrsare .mong tilt moll misundtmood mtntal htalth
disordeB in North Amerita.
Approximattly 3 million AflII'riufIS havt !(himphrenia.
Patients with devtlop symptoms brtween theages of 11
.nd tht Nrly lOs.
As many as SO'Ibofhomeles peoplt in Amtriu h'Yeschizophreni .
The prob.;obilityof dtYOlopi!ll) I<hizophruia 1 in 100 for tht <Jl'llffill
population, 1 in 10 if one p.llent has the disorder,.nd 1 in 4 if both
partnts h.M I<himphrenia.
Hallucinations, delusions, or paranoia
Strange behavior, such as communicating in rambling
statements or made-up words
Rapid alternation between extreme hyperactivity and
stupor
Attitude of indifference or detachment toward life
activities
Strange or irrational actions
Deterioration of personal hygiene, and job or academic
performance
Marked withdrawal from social interactions and
interpersonal relationships
'Vhen observing patients with schiwphrenia, nurses
should look for both positive and negative symptoms. Posit iYt
symptoms are those that add on to normal behavior. These in-
clude hallucinations, delusions, and a disorganized thought
or spee.:h pattern. Negat iYe symptoms are those that subtract
from normal behavior. These symptoms include a lack of in-
terest' motivation, responsiveness, or pleasure in daily activ-
ities. Negative symptoms are characteristic of the indifferent
personality exhibited by many people with schizophrenia.
Proper diagnosis of positive and negatiw symptoms is im-
portant for selection of the antipsychotic drug.
The cause of schizophreni.1 has not been detemlined, al-
though several theories have been proposed. Thereappears to
be a genetic component to schizophrenia, since many patients
suffering from schizophrenia have family members who have
been afflicted with the same disorder. Another theorysuggests
the disorder is caused by imbalances in neurotransmitters in
specific brain areas. This theory suggests the possibility of
overactive dopaminergic pathways in the basal nuclei, an area
of the brain that controls motor activity. The basal ganglia
with associated nuclei, as shown in Figure 17.1, are respon-
sible for starting and stopping synchronized motor activity,
such as leg and arm motions during walking.
Symptoms of schizophrenia seem to be associated with
the dopaminetype2(D,jrNeptc.". The basal nuclei are particularly
rich in D, receptors, whereas the cerebrum contains very
few. All antipsychotic drugs act by entering dopaminergic
LibraryPirate

.ad .. ta
.....
Figure 17. 1 Basalganglia:overstlmulallon of dopamine
receptors may be responsible for schizophrenia
synapses and competing with dopamine. By blocking a ma-
jority of the D, receptors, antipsychotic drugs reduce the
symptoms of schizophrenia. ,.. Figure 17.2 illustrates an-
tipsyt:hotic drug action a\ the dopaminergic receptor.
Sc: hizoaffl!Ctivedisordtl is a condition in which the patient ex-
hibitssymptoms of1:oth schizophrenia and mood disorder.
For example, an acute schizoaffective reaction may include
distorted perceptiotl'l, hallucinatiotl'i, and delusions, fol-
lowed by e:rtreme depression. Over time, both positive and
negative psychotic symptoms will appear.
Many conditions can cause bizarre behavior, and these
should be distinguished from schiwphrenia. Chronic use of
amphetamines or cocaine can crealI' a paranoid syndrome.
Certain complex partial seizures (chapter 15010 ) can cause
unusual symptoms that are sometimes mistaken fo r psy-
choses. Brain neoplasms, infections, or hemorrhage can also
caufoE.' bizarre, psychotic-like symptoms.
17.3 Pharmacologic Management
of Psychoses
Management of severe mental illness is difficult. Many pa-
tients do not see their behavior as abnormal, and haY\' ditti-
TREATING THE DIVERSE PATIENT
Cultural Views and Treatments of Mental Illness
hil'fVl'rydiflorem on IhfQlM of and trratmtnt for
mental d manyoftlwstmenul hfahhtrrnntnts ir.olYrs
heali-og rwthods.Arntrilan
lIlInit)o1raditionarmtdmman, whomaytlratmtnUll)'lllptomswithas'M'l!
and he!bs.Afric.anAmeOOm maygotoa traditional \OOdoo priestorOOief
!tram t.ty frtquentIy = hrm to tmll memall)'lllptorm.
Hispanics sm ,",atl1lfflt fmn a Iol a rurmdm:I;and they may =
htrbs su:h as (himomit, swett basil for mental (onditions.Mm!-
beB 01_ rultures may 1M andets, or manm that oft worn on .J Itmg or
diail, to prott" the WNrrffrom ml lpirits that beIiMd to (,lUll' mental ill-
11m. BKalIW' brlieB can vary within rultures tlrmltlYrs,a tIIoroo.qJ rut-
tunl autI!menI d ftli1qs and beIitfs about health and 'M' lntSl will assist the
!tralth QIl' in proYi:Iilg the IIIOIt appropriatt !air possilk-.
CNplfr17 ON9'/orPsycho ... , 205
Dopamine
\ : .
0
Dopamine (0,)

Postsynaptic

,.. Figurf 17.2 Mechanism of action of antipsychotic drLgI:
(a) O'owproductlon of dopamlne;(b) antipsychotic medication
occupies D, receptors, preventing dopamine from stlmulltlng
the postsynaptic neuron
culty understanding the need for medication. \'/hen that
medication produces undesirable side effects, such as severe
twitdtingor loss of sexual function, compliance diminishes
and patiems exhibit symptoms of their pretreatment illness.
Agitation, distrust, and extreme frustration are common, as
patimtscannot comprehend why others are unable to think
and see the same as them.
The primary goal for patients with schiwphrenia i5 to re-
duce psychotic symptoms to a level that allows the patient
to maintain normal social relationships, including self-care
and interacting with other people. From a pharmacologic
perspective, ther:lpy has both a positive and a side.
Although many symptoms of psychosis can be controlled
with current drugs, adverse effects are common and often
sevele. The antipsychotic drugs do not cure mental illness,
and .ymptoms remain in remission only as long as the pa-
tient chooses to take the drug. The relapse rate for patients
who discontinue their medication is 60% to 80%.
In terms of efficacy, there is little difference among the
various antipsychotic drugs; there is no single drug of
choice for schizophrenia. Selection of a specific drug is
based on clinician experience, the occurrence of adverse ef-
fects, and needs of the patient. For example, patients with


,


"
z



>
i


LibraryPirate
206 Until TheNelv"",,Sy.rem
psychoses as well as Parkinson's disease nero an antipsy-
chotic with minimal extrapyramidal sid e effects. Those who
operate machinery need a drug that does not cause seda-
tion. Men and women who are sexually active may want a
drug without negative effects on sexual interaction. The ex-
perience and skills of the physician and memal health nurse
are particularly valuable in achieving successful psychiatric
pharmacotherapy.
CONVENTIONAL ANTIPSYCHOTIC DRUGS
Because of neurologic side effects, antipsychotic drugs are
sometimes referred to as neurdeptiu. The two basic categories
of antipsychotic drugs are conventional antipsychotics and
antipsychotics. The conventional drugs for ps),(hoses
indude the phenothiazines and phenothiazine-like drugs.
Phenothiazines
The phenothiazines are most effective at treating the posi-
tive signs of schizophrenia, such as hallucinations and delu-
sions, and have been the treatment of choice for psychoses
for 50 years.
17.4 Treating Psychoses
with Phenothiazines
The conventional antipsychotics, sometimes called flrst-
generation ortypical antipsychotics, include the phenothiazine
and phenothiazine-like drugs listed in Table 17.1. Within ea(h
category, drugs are named by their chemical structure.
Theflrsteffective drug used to treat schiwphrenia was the
low-potency phenothiazine chlorpromazine (Thorazine),
approved by the FDA for this use in 1954. A number of phe-
nothiazine:s are now available to treat mental illness. All
block the excitement associated with the positive symptoms
of .chizophr .. nia, although diff .. r in potency and .ide-
effect proftles. Hallucinations and delusions often begin to
diminish within days. Other symptoms, however, may re-
quire as long as 7 to 8 weeks of pharmacotherapy to im-
prove. Because of the high rate of recurrence of psychotic
episodes, pharmacothernpy should be considered long
term, often for the life of the patient. Phenothiazines are
thought to act by preventing dopamine and serotonin from
occupyingcriti(a1 neurologic receptor sites. For the conven-
tional antipsychotics, dopamine has higher affinity for the
receptor. This mechanism is illustrated in Figure 17.2.
Although phenothiazines revolutionized the treatment of
severe mental illness, they exhibit numerous adverse effects
that can limit phannacotherapy. Theseare listed in Table 172.
Anticholinergic effects such as dry mouth, postural hy-
potension, and urinary retention are common. Ejaculation
disorders occur in a high percentage of patients taking phe-
nothiazines; delay in achieving orgasm (in both men and
women) is a common cause for noncompliance and menstrual
disorders are conunon. High fever, confusion, and other signs
of nrurol.ptic malilJlant <yndrrm. (Nt,f;) may nITtlf. P.:w::h phenothi_
azine has a slightly different side-eff"ect spectrum. Forexample,
perphenazine (Phenazine, Trilafon) hasa low incidence of an-
ticholinergic effects, whereas chlorpromazine (1borazine) has
a high incidence of anticholinergic effects.lhioridazine (Mel-
briO frequently.:auses sedation, whereas this side effect is less
conunon with trifluopt>razine hydrochloride (Stelazine).
Unlike many other drugs whose primary a(tion is on the
e NS (e.g., amphetamines, barbiturates, anxiolytics, alco-
hol), antipsychotic drugs do not cause physical or psycho-
logic dependence. They also have a wide safety margin
a therapeutic and a lethal dose; deaths due to over-
doses of antipsychotic drugs are uncommon.
Extrapyramidal effects are a particulMly serious set of ad-
verse rea(tioru; to antipsychotic drugs. Extrapyramidal dfl.'ds
(EPS) include acute dystonia, akathisia, parkinsonism, and tar-
dive dyskinesia. Acute dystonias occur early in the course of
phannacotherapy, and involve severe muscle spasms, partic-
ularly of the back, neck, tongue, and face. Akathisia, the most
common EPS, is an inability to rest or relax. The patient
paces, has trouble sitting or remaining still, and has difficulty
sleeping. Symptoms of phenothiazine-induced porkin",ni. m in-
clude tremor, mtls<:le rigidity, stooped posture, and a shuf-
fiinggait. Long-term useof phenothiazines maylead to tardiw
dyskinrsiil, whkh is charaderized by unusual tongue and face
movements such as lip smacking and wonnlike motions of
TABLE 17. 1 Conventional Antipsychotic Drugs: Phenothiazines
"n"
Route and Adult Dose(maxdosewhere Indicated) Adverse effects
o ddpromazine Ha (lhorazile)
PO;15- 100 mg tid orqid (nw:: 1,000 mg/d.y) UIIOpyranidoi J)'mplGm\.
lM/lY;15- 50 rng (nw::600 rng r'lrty h)
romtipalion, pIror05t1lJiriYiry, orl/KmQrk h"",rtmio'l.
urtJaryrmntion
ftuphrnuil r IKI Prohin) PO;O.5- 10 mglda1 (max:1O mgiday)
Apu09Wis, pa!!C)'!pprniil.ilnaphy\agoid
ptIjI/Irnazinr (Phrnazilr, Triafon) PO; 4-16 mg bid toqid (nw::64 rngIda,)
Indin !XIIiblllf
proddprrilzinr (CompalinrJ PO:O.5- 10 mglda1 (max:1O mgid.y)
hyootbrrmy mmk ilew Wq!m unr!!!!lolinrd dNth
thioridazile IKI (Mrliarin PO;50- 100 mg lid (mal:800 mgid.yJ
Ha l0ri9naliy markrlrd PO; 1-1 mg bid; (mill: 10 rngIda,J
as Strlizilr)
1M; 1-1 mg "rr"l4-6 h (mill0 rngIda,J
IIOIi<> indG>10 <OIIImon .mrs< S<riou> odvt ....
LibraryPirate
CNplfr17 Oru9,lorJ>,ydl<''''' 207
TABLE 17 2 Adverse Effects of Conventional Antipsychotic Drugs
Effect
A(U\! dyltonia
AkaltilU
AntidlolintrgK dftcts

SIo\'m1pl1llll, b.Kk ladil mum; mol'l'mtlts
Consunt pi(i1g wilh (ompoJ siv! rnov!IMnll
ilrllllOllh,l.myGlrdia, bhmd vision
IIN'oItplk
Parkinsonism
\oMIl' whl'fl!he mows q.i<kly Irom rtlurtlbeot 10 ill upright
High ft'Itr; (onfusion, rrusdt hig/lltlurtl uwil! kir.aI!;G1n faul
shuffling
Usually dininishts wilh (ootinued thn'ap)'
mpoWKt and dimirished libido SIoml dysfunaion
1Irtift dyskintSia BizaITl' lOII9J!' and loa mlWl'fIIenllsum " lip smading ind 'IIOIIIIlike moIioos 01 tilt puffing 01 dims. unrontrolltd
dltwing mO'ffllln'l1l
.... Prototype Drug I Chlorpromazine Hydrochloride (Thorazme)
drllCJ
ACTIONS AND USES
Chlorpromuillt plVt'ides symptomatic: R'lief of positive Iymptoms of s(hizo-
phlfnia and controls manic symptoms in piUenIl with schizoollftcti'fl' disordtr.
Man, pilients mUlt ukt chiorpromazilll' for 7 or 8 weeks bfflllt'
t nct improl'l'mt nl Extmnt 'gitation may IrNttd with 1M or IV injKtions,
whkh to mwithin mirutts.(hlorpromazine can also (ontrol nau-
SN and Of11iting.
ADMINISTRATION ALERTS
Do not crush or open lUIuined-relNl! forms.
When administert<l 1M, dtfp IM,only in quadrant of
tilt bullOCks; the pilitnt should lfIIIi in supilll' for 30 to 60 minultl afr:t r
injtction,and then sIowl,.
Tilt drug must gradwlly withdrawn 01'1'1" 1 to 1 weeks. and
IIfmOn,or dyskilll'lia may ocrur.
IV forms should lnt d only during surgtf)' or lor Stfflf hkrup!.
Pregni ncyUltgory(
PHARMACOKINETICS
On..t; min
2-.4 hPO; 15-lOmin IMIIV
Halflife; 6 h
Duration: 30 h
l
the tongue. If extrapyramidal effects are reported early and
the drug is withdrawn or the dosage is reduced. the side effects
can be reversible. With higher doses given for prolonged pe-
riods, the extrapyramidal symptoms may become perma-
nent. The nurse must be vigilant in observing and reporting
EPS, as prevention is the best treatment.
With the conventional antipsychotics. it is not always
possible to control the disabling symptoms of schizophre-
Pharmamlll9ic D, dopamilll' Il'cpptor antagonist;p/1pnothia1inp
ADVERSE EFFECTS
Strong blockade of alphNdR'ncrgic: Jt<eptm and weak bloxbdt of dlOliocr-
gk upliin somt of dllorpromazinf'l ad'fI'M efrecu. Common ,d-
tfftm 'If diuinm. drowsintll, and orthostatk hypotension.
ulUapyrl midallide tfftru (EPS) occur fIIIR (ommonly in tldtrly, female,
and pediatric p.atitnu who alf dthydrated. Neuroleptic malignant syndromt
(NMS) may also ocrur. Palitnu taking chiorprom'zilll' who alf 10
warmtr lt mperatulfsshould monitortd more (J,uly symptoms ofNMS.
Contraindi (itions; U,t is 001 advised during akohol withdrawal or wlltn tilt
p.atitnt is in a (omatost slate.uution should bt lntd with other conditions, in-
duding ,ubc:onic.J1 brain damagt, bolll' marrow dtPlfllion, and IIt)ot'S 1)11-
drornt. (hiorprornazilll' is conlr<lindk,ted in 1.Kution.
INTERACTIONS
DIIII}-DIIJ!I; wi!lllfWlai
UII' wi!ll IfdaliH m"imions IIKh as p/IfrII:t.rbitJI shcU:I bf iMlided.latilg
chklrtromazilf wi!ll uiqck Intidfpresam uo elmu bbod prl"llUIf. (1IKIIIfffl
UII' of (hlolpromazioc with illlistizlfllM:li:ation uolo\m" lilt wuu tImhokI.
li b Tesll; mil')' ilKlNl! <lphaIin ftoccul.nion and O!h@r
lim function Ifill. Fall!-jHIIiliw Il'IUhs may om. for anyIast,
iCf!ic: add, urobiRlgfn,and ..... bilirWin. FoJM..posilil'l' ...
faI .... !If9OtM Pf"9'IOIK)" !tm may ,..ut.
Hm VFood; (.wa i nd StJohn\ won may OO&I!I' lMrist and lfWIilyoldystonia.
TrNt ment of OftrdOS! ; Tlltlf is 00 speciJi< trt atllll'ni for OIItn:l=; patients
aR' tR"!N symptomatitally. [PS may bt: tR',tN with antipartinlonism dllJljI,
or diplltnhydramilll' (8enadryl). AYOid producing Ifspiralory cit-
plffiion with thtl!' trNlmt nts.
9tftr /() M)NUIlIngm for Q MmlrJ} I'n:lasI fooJl Jjlt(1t /() rIrIs df!!9.
nia without producing some degree of extrapyramidal ef-
fects. In these paTients, drll8 therapy may be warranted to
treat EPS symptoms. Concurrent pharmacotherapy with
an anticholinergic drll8 may prevent some of the ex-
trapyramidal signs (chapter l JOO). For acute dystonia,
benztropine (Cogentin) may be given parenterally. Lev-
odopa (Dopar, Larodopa) is usually avoided, since its abil-
ityto increase dopamine function antagonizes the action of
LibraryPirate
the phenothiazines. Beta-adrenergic blockers and benzodi-
azepines are sometimes given 10 reduce signs of alcathisia.
Nonphenothiazine,
The nonphenothiarine antipsychotic medications have
equal efficacy as the phenothiazines. Although the inciderKe
of sedation and anticholinergic adverse effects is less, t;[-
trapyramidal effects may be COOlmon, p3rticularly in older
adults.
17.5 Treating Psychoses with
Conventional Nonphenothiazine
Antipsychotics
The conventional nonphenothiazi[lt' antipsychotic cla!;!; oon-
sists of drugs whose chemical structures are dissimilar to the
phenothiazines (Table 17.3).lntroduced shortly after the phe-
nothiazines, the nonphenothiarines were initially expected to
produce fewer side effects. Unfortunately, this appears to not
bt the c:ase.1be spectrum of adverse effects for the nonphe-
Prototype Drug I Halopertdol (Ha/dol)
TherapMic Class: CollWfllionaiantipsydlotK;sdmlphrenia<tug
ACTIONS AND USES
is dlSlilitd chtrnically u but)'lOflhtMM.1u primary lISt is fOi lilt
mlf1i9t1llfll1 of Inc! chronic: psydJotic: dilonltli. II may bt ustd to IJN(
patienu wilh TClUltttt's syndtomt thildmt with st'ftlt beha'tiof problems
well uunplll'lORd IggrHSMntlS MIIItJPlosiw hypm:xcit.lbility.h iuppnlll-
imilte/y SO times _ potttllthan thlolpromazine but l\utqual in
lieving symptorm of schizoptmia. HaidolLA is pRp.lrltion that
lam lor Ipproximalely 1 Wftb following 1M 01
This is pal1kulolrly btnefKilllO! Pftitnts who 01 unablt to
uu n mrdicatioos.
ADMINISTRATION ALERTS
Do lICK ilbrupdJ lWonmue,OI_ aMB!' maYO(rtII".
TIlt INtitntllMt tau 1M rTIfIiution IS CHdtml fOf IIItrapMX IHIIIS
IODtOIr.
If 1M patient dots not (limply with or.1 thrrapy, attnded-
RluSf haloperidol shlDcl bt
Prf9IIiIKY Ulf90ry (
PHARMACOKINETICS
!met 3O-lSmin
Puk: PO;lO-20 min 1M
HalHiM: 12- 37 h PO;lO-19h 1Y;17- 1S hIM
Duration: VoIrwbit
nothiazines is identical with that for the phenothiazines, al-
though the degree to which a p3rticuLareffect occurs depends
on the specific drug. In general, the nonphenothiaziIll.'drugs
cause less sedation and fewer anticholinergic adverse effects
than chlorpromazine (Thorazine) but exhibit an equal or
even greater incidence of extrapyramKbJ signs. Concurrent
therapy with other CNS dt>prl.'SSants must be carefully moni-
tored, because of the potential additive effects.
Drugs in the nonphenothiazine class ha,e the same ther-
apeutic effects and efficacy as the phenothiazines. They are
also believed to act by the same mechanism a5 the pheno-
thiazine!. that is, by blotking postsynaptic D2 dopamine re-
ceptors. As a class, they offer no significant advantages over
the phenothiazines in the treatment of schiwphrenia.
ATYPICAL ANTIPSYCHOTIC DRUGS
Atypical antipsychotics treat both positive and negative
symptoms of schizophrenia. They have beoome drugs of
choice for treating psychoses.
PIYIIMCologi( ClaSI: Dzdopamint rmpIOI' antagonist; nonp/lenothiAline
ADVERSE EFFECTS
Haloptridol p!OChICH Itss and h)'pOtension than (hiolJllOmuint, but
thi! inc:idtncr of EPS is high. 0Idfr aduln IrI' mOIl' IirIy to O"pmmc:t
tftects .nd oftrn art pttSCribtd hilf tilt icLiIr clost until tilt rifu of
thenpy (In bt dtttnnintd.Although thi! inc:idenlr of NMS is r.lrI', it can occur.
ContraindKations: IIOIIphtftothiazinrs is not.dristd if
ttw, patient is mtdication for illl)' of the loIowing <onditiom.: Partin-
lOll'S disult, seizurt disofdm,.oholism,and _ menu! dt9itssion.
INTERACTIONS
CN;I-ttug: IWIope!idoIMract5 ..;ra1Oi"otugs.

(l)fQnilg ifUCids, \rIo6opi (., dlill<fS 111 ItlOdopa 1OIicty), itmn
tilaNledlloo! 111 a_r (.,
iIIaNsts m.e of p/ItQJtoin tolid!Jl, rf .... .-.d bt\.J iIuNSf
tIIood lewis 111 I\aIopf!idoI.lhus INtifI9 to podIII! lOIm,lllalo9tridol inhibits 1hf

... leu: Unknown
lIe!UlIFoocI: lm ilaNIoI' 1hf rlfKt ofllalopioriOOl..
T !NUDent of OYerdow. In gtnmI, tlHo S)'IIIptoms of 0'I0mI0Sf .It <In 0"aI}9tI"-
.rion of kncwn phal!l\i{oIogio;: dftcts.nd 1NdioM, tilt most plDmi-
_ of which would be st'ftlt 6IraPJRlnidal rl'Mtions, h,-po\tlllion, or
5edation. W"Jth [liS, .nliparl:illSOllism rntGcation should bt ministtm!. Hy-
po1msion sIIouId bt UIUIItmatd wilh IV plasma,or Ulll<tmrattd aIbu-
min,or drucJs.
II!lI>r a MyItlJlnijKl ffII. MnJnq frf'f5 Fo:I!I!pf(/II( a 1M d"u9-
LibraryPirate
RoIpI.,11 OtugsforPsychows 209
TABU 17.3 Conventional Antipsychotic Drugs: Nonphenothiazines
"'''''
Adverse Effects
cHo!pothixmr (brawn)
(Kaldol)
Routeancl Adult Dose (max dose where Indicated)
PO; 150 mg/day (maX:600 rntj/day)
bid or tid
dfOldlltl1 tltff1J{1frllmidd flt'mll l
Ofthostlltt IIyptmiaI

PO;uart with 10 mgfd.ly and rapidly inmast to
100 mg/d.iy In diYiMd dolls (mal:150 mgJday)
HCI (Mabin) in four dMdfd dost!; ma, irKRast
to 100 m!JId.iy in 3-4 d.iJ1 (mar:lli 119'day)
pinozide (Orap) PO; in dMdfd dnst!; ,adualy ilKn!ast ntry
othtr day to 16 mg/day (mar: 10 mglday)
thiothilene HO {Haoantj PO; 2 mg tid: may irmast up to 15 mg/diy (mar:60 mg/1Iay)
common adtrsc dfts; lIlIIk!iDiDi lnllcatts scriovsadmst t fftru.
NURSING PROCESS FOCUS PATIENTS RECEIVING CONVENTIONAL ANTIPSYCHOTICTHERAPY
Assessment
Baseline anessmtnt prior to administration:
Unikrs"nd tht IWCfI tile drug has bttn prtSCribe<i in ordtt 10 isstiS fur
thmpeutic effe<ts.
Obtain a hrakh history id..ding hepitic. renal. urologic.
neumlogic.disNst (tspMilly Parlilson's
distast Of mtnt.llstatus, pltgn.uq Of brwtfl!oeding. Obuin
a dIU\! history incWng aDtrgies,amnt pMption and an: dlU\!s, akohol
use,smoUIg.and he!bal prqwrations. Bt alert to possible: drug intcrKlions.
Obtain, history of deprmion or memal disorden, including a family
hiSioryofsamtand
Asstls for disturbalKts in thought pen:tplion, wtrbal
communiUlion,afftct, interptl"sonal n!Litionsilips, and self-Un!.
1M obje<tiYe screening tools per tht health otgPllcy.
Obtain yital signs and M"ighl
EvaluaU! appropri.llf Liboralory findings eiKtrolytes,glucOSf,
hepatic and n!1Ia1 function swdits, drug IUttning).
Asstls the patient's ability to!"tUm: and understand instnKtion.lnducle
the family and as needed..
Asst Siffitnt throlghout administration:
Assess for desired thmpwtic tfft<ts (t.!J" normalizing thought proctSSts,
lessening cItIusions, hanocinations" impfIl'Itmtm in positiYf or ntgativt
Iymptoms" ability to rKum to normal ADls, imptOtllltnt in appttilt and
sittp patttmS; if lISe<! for othtlustl, t.!J" hiccups, asstU for
appropriatt ihtrapetJtic tfftcts).
Continlll! periodic monitoring of {BC, electrolytes,. htp.ltic and
n!nal 'metion studies, and thtraptUtic: drug Inti!.
Asses litiI orthosmr.: bbod IWigh ptriocicaty.
Assess ilr and promptly ffPOn iKMr5t effKlS:dizziYss Of li)ht-btDdness,
ideations, hypotension, t.rn,urola, il"l(l!lW' in
Itmptutult, bk.rntd or cIoubit vision. skin rashes,. br\isiIrg Of
abdominal pail\)aurdct, (!lange in color of stool, flank pain, II nd hematuria.
AsStls for and prompdt n!port6IIapyramid.i1 (EPSI inckKfing
pstudoparkinsonism, dystonia!, akathisia,and dy1tilltSias
(Stt "Minimizing advtr5t effts"in tilt following se<tionl.
Immediately report signs and of neuroleptic: II1ilignanl
Iyndromt (HMS):unstabie blood Pn!ssure, titvattd ttmpera\un!,
diap/rorM-,dyspnta, musdt rigidity, and incontintMt.
Potential NursIng Diagnoses
Disturbed Thought
Disrurbed Sensory Perreprion (auditory, visuaO
DisturbN PersOf1al kientity

Impaired Vt rbal Communication
Impaired Soc:ial lnlmction
IntffKtiwo Heilkh Mainterlanct
Impaired Home Mainttllanct
NoncomplwlKt
Deficient KnoIlMdge (drug tWPY)
Risk ilrV"IOIeMt (stlf-<liltCted, diltCte<! it othtrs)
Risk ill St/f-Murilation
Risk ilr Disturbed FamWt Proctsses, Caregiwl Role Suain
(ConrfooPd)
LibraryPirate
210 Unlll /lle<vOI" Sy'tem
NURSING PROCESS FOCUS PATIENTS RECEIVING CONVENTIONAL ANTIPSYCHOTIC THERAPY (ConrlnuMj
Planning: Patient GOllls and Expected Outcomes
Thr patimt wiH:
Experitnc:. therapeuti< . fftru dtpendent on thr It'aIOII the drug i, lIting giI'M (f.g.,1t!1eIWd positiveand lII'g;ltivt paraooia,
hallucinations).
8. mt from, or experienct minimal. "IYefSt tlfKh.
an undemanding of the drug's UI!', adorot tlftru, j nd rrquifl'd prK.!uUons.
of tht medication (t.g.,deM, timing. when to notify plO'/idtrJ when pouible.
Implementation
Interventi ons and (Rilti onll les)
Ensuring thfrilpeutic tfffCts:
CominUl' illStnmtmS iI,decribtd tarlit"! lor thtraptUtic tlftcn. (DIII9'
lMd for p')"hO<t< .nd I<hizophffnio do not (Uff tho undtrlying di,,,",,,,
but implO'/t pcnitiv. ilnd 'ymptom, of the disorder. Gradual
improlm\ent Sf"Ieral wtt'H to month, may lit oot.d)
Monitor patient complianct with thr drug P'tsenCt of Sf"Itlt'
mental dison:lers may It'IUk in oonc:omplianct with
ClInsistent dosing is to ClImcting tht undtrlying disorOO.
the dlll9' do not QJIt' tilt undtrlying if It'gular adminisuation i,
dilruptN,symptom, return abrupti)o.lmramunular depot
may nttd to lIt(onsidtlt'd if thronic oonc:omplianct continUfS.j
Minimizing ildYflSf effts:
CominUl'to monitor vital sign, periodicali)o, tspe.:ially orthoslittK blood
prtSSUfl'. Kt tp patiem IUpilll' for 30 mirutes to 1 hoo, afl.rgiving
pilfI'nltral mediutiolll and fl'(hKk blood prtSlUlt' rntollUfI'mtmS mry 15
to 30 minlllts. Emuit' patient ;alety; monitor ambulation until tht tffKn
olthf drug aff koowlL particularly cautious with oidt, adult, who art at
an mil 10, falls.lAntipsythoticdlll9' may calM hypotl'llsion,
the risk offalk and injuryJ
ContinUl'to monitor motor activil'l,(oordination and for EPS
symptoms, inc:kJding:
I'W'udoparkiMOllism: mlH(lt ri4Jidity. ,tooptd puturt',
brad)'l;:intSio blow to llitn "nd shuffling. slow gait}
Akathisia:inabiliry to It'St and rt'Iax,often with pacing
Acute ciystoni as: ItYI'rf mlH(lt lpiI,m, of bet, t0n4Jlf, ne<k, or back
Tardi'lf moYt"",nn wch is lip !IIIicking.
wormlikt mowmenuofthl' tongut,unrontrolltd chewing. and
grimacing (EPS mil)' be an unawidablt .ffeet of drug therapy
but the drug doW' wili bt tmtd or ltopptd,or tilt mtdication dJange<!
when possible.)
E""" t . rJ.qwte nuuilian.nd nuid inl."" il ""dift d,w .......... rt
thorroathrtoid tongue rtIO'/emtm may significantly
hinder or plt'Yent ildtqJatt nutrition.)
EnlUrf patimt safety if pW'IJeIoparkinsonism alfed, gait or akathisia is
preem.kult' dyllonio, rna)' rtquirt' tlNtment with other medications to
hak !palms. (8rildykinflias, !Iow-to-Ilan ambulation ind slow, shuffling
g;lit,m.lY plt'dispose the patient to f.llls.Akathisia with pidng m.ly
impiir the patitmiabiliry to It'St and slttp.Additionill
medications may lit I!qJirt'd to tl!at Antitholint"lic, or other drugs may
lit I!qJilt'd to ,top lpiI,m,.)
Pllt ient lind Family Educati on
Tt,uh thr famii)o,orurt<;liver that lull tlftru rna)' not occur
immtdiotoly but th.t "'''''' imprcw"",nt,hould lit notic blt.1ter
btginning therapy.
SupportiYt, inpatitnt cal! rna)' be during ilGlIt, farly period of
therapy.
IIIYOIvt the famii)o and (al!giver to the flIent in l'IIwring tilt
patitm I!mains on rt'9Ular mtdirnion rootiOfS.
EIl\UI! that the patitnttakl'S tht mtdication as prescribtdlkm
mtdication, at the btd,idt.
Quetion tht oonc:omplianct original ,ymptoms or
tflKn inclNM' in ifl'quenq or ,tytriry.
Ha'lf the patitnt riM' from lying or sining to ,tanding to il wid
diuineuor falk.
Instruct the to Glillor mimnct prior to getting OUI of btd 0/
anent pting to walk il ion . For patient> on at -homtloutpatitm mtdication,
awid driving or other requiring mental "ltnOfS,or ph)"lical
coordination umil tlfKh of the drug "It' known.
In,truct the cal!givtr to immtdiattly rtpOrt EPS
symptom, for additional tlt'atmem.
LibraryPirate
a.." .. 17 OruglforPsychoses 211
NURSING PROCESS FOCUS PATIENTS RECEIVING CONVENTIONAL ANTIPSYCHOTIC THERAPY (ConrJnuM)
Implementation
Pati ent and Fami ly Edualltion
ligns ,nd l)'II1ptoml ofNMS:Im - .- .C,-+.-:- ,_ C-...
the
p.ltRnI, 'ny minge
Interventions and (Rationales)
blood tt!nptf.lrutl',diaphomis,rIy5jxw, mUl(ir riljdily, .. '"'" of SWNting,!l'mI'
iltd in<OIIbnern.(NMS is, r'f!! but fatallrndlome thac IIlUIt mIIIdt _leiled m,ifniOlllor lhortntsl ofbreilh,or
be le<ogniM ,rd tleatnl inmtdiollel):) ioomtinmlf.
Continue to monitor (BC,tIfwolytes. ,nd hepitil; Nncrion nd
tMr'pMK drug ltoiel1. (Antips)J(hotK dru!P m'1 C'lM bone m,mIW
and Mp.lloloxiri!y n ad'lmt rffrm.)
iltooolinfrgil: elFu. irdJding dry moU1h.dfOWlinm.
bllllred l'iIion,romtipation,ind Urillil)' letention. Pmide Iymptomllic
trMmem 10 effb.. (AntidJoli IIfrgK sym ptorm ,re l1li mon ..t.ome
,ntiplydiotk to 'ntidlolinergic rifcts \/lUI'"
dMIoPI Oft! time.)
Of df19S c.M
phOllenWlCy.)
Moho! and iIIegiI drug lM. Clked con<lIIft'IIti); these ause in
irroeilsed etft or In o:acerbation in

Monitorafftine (list ofClffeine-<OIIt.1irring subsunce may M90IIt
tM rfftruof antip)'Chotia..)
IIIIWCI the on the to II'tum periodicilly for lib WQlk.
lNdr the palitit 10 promptly any ibdominal pain, particubrly in the
IIPP" quadr.Jnu, <h, in stool )'fIIowing of I(m or m n, darkrflfd
urine,lkin Iow-grildt 1M!'\, gtIItrillllfliM or in bfhlvior
or K\;"ily lMI,or rednffi or -cling ,nMId ICH of in;ury.
nr:OIIrage lip! of (hips, hard und);or thewingl}Ulll to
IIOUth mout"-HIlH. 'tAlKh III' drying to lilt
IfIU(OI,) Ind PIOOrt m,ydrink.
IIItlffit ditty fibef and adequalt IUd
Rtport Urilliry relefttion to tM health ClI! pm& promptt,.
tilt p,titflc, to ilPpiJsunsal'fll (SPf 15 or abow)
priorto IIIn txposllft or enwrt ptOIKti...e clothing is worn. Plomptiy ItpOrt
illlJllbum to heakh UfI' prwiIer.
IIIIWCI the to aYoid ,Icohol ,nd illtg,ldrug 1M." tilt patient 10
community IUpport groups sud! ill M or HAiIIlppropri.tr..
kid! tilt pllitrc, toa'lOid Clifeine-<OIIuining
Iooch,and OT( mediutionl.,nd .. 1Nd food Iibm when in
cIoob of whetlwrlllt produtt corQilll
IoIIIOking. (lIf..,-smoking nYYcltutirlt the met.lboiilmof Jllltnxt the p.ltRn\ to IlopOf ImolQng. Refer tile to
IOmI' ,ntiP!YdIOtiO IlKh ;tI IIiIoperidol, leading to dtaN!td rifiucJl) IIIlOking {eloJlion progriflll" l ndiuted.
---"---+---'
htint umlent.,.dln9 of dnr9 thefiIPY:
tM opportlllliie! during adminiltration of mfdiutio'll and during
to cflSMl fltionlle fordrug theripeulil;
O!.IIcom6,ftmt obsmtd idwtrse e!fecu, fOfwhtn
10 ull hNlth Ind 111)" I\MSlary monitoring or
brid t Jplinatiolll during tWntI of deIuIionl or
hilKilloltiom.{Uling time during nunir\g (ile helps tooptimizt ,nd
reinlon:l' upbnltionl iII\ilt to
inttrrupt dflulion.il ptriodI.)
Plllient stlfad .. lnistr.tion of drug tlteflPY;
When administmng!he mrdic.ation,inltnxtthl' Piltirftl, bmiiy,or
Uffgiftr in proptr lell-adminimuion of drug,e.g., lite tile drug a\
prrscribtd ,ndda not IUbstiMe branck.. (Utilizing timeduring nurw-
adminillfltion drug! htJj)! to tNching.)
The fimit:or should ibIe tonate thr fI'iIIOII for the
d!urJ;ilPPIOpriiltl' and sdwdrling;and whit ildYerseefftl tOOWM
for iltd when 10 thtm.
leith the family.or co the rnedimiOllIS follow!.:
e.uctly is ordered ilnd 1M' the l.ime milnufactufl'f"l blind N{h bne
tM PII'l(ription is filled. (Swildling blind! may IflUk in differing
ph,rmacokinetiG and ,hmtion! in therapMic tfffd)..
EIllUI! thai" is euatywhen and ;tI ordefrd.tMof iI
ulend.Jr co mdr dOSH fIIiI"1 be helpful
lithe tiI!MIdruwmell.!aRiit brdtime. Taltnn<e to
ilnticholinergK effrru IlKh is drowlillflS _r time.
Do not IbruprlJdilcOlltillUl! the rnediution.
Evaluation of Outcome Criteria
kiluate the tftitiJene!1 of drug ther,py byamfinning that goil! iltd txpted goal! have mtl (leI'i'lanning1.
5tt WlIeIII.' RIll J kf isD
LibraryPirate
212 Until /lle<vOI" Sy'tem
17.6 Treating Psychoses
with Atypical Antipsychotics
approval of (Clozaril ), first atypical an-
tipsychotic, marked the first major advance in the pharma-
cotherapy of psychoses since the discovery of
chlorpromazine decades Oozapine, and other
drugs in this class, called second or atypical,
because they have a broader spectrum of action than the con-
wntional antipsychotics, controlling both the positive and
SYJllptoms of schizophrenia (Table 17.4). Further-
more, at therapeutic doses they exhibit their antipsychotic ac-
tions without producing the EPS effects of the conventional
drugs. Some drugs, such as dozapine, are especially useful for
patients in whom other drugs have proved Wlsuccessful.
The mechanism of action of the atypical drugs is largely
llilknown, but they are thought to act by blocking several dif-
ferent receptor types in the brain. Like the phenothiazines, the
atypical drugs block dopamine D, receptors. However, the
atypicals also block serotonin (5-Hfj and alpha-adrenergic
receptors, which is thought to acooWlt for soJlle oftheir prop-
Prototype Drug I Rtspendone (Rtsperda/)
Therapeutic (lass: Atypkal antipsymotic; schizophrenia drug
ACTIONS AND USES
of rispfridOOl' inckJde prevl'Iltion of Ilhizo.
phmlia and HpltSsion of bipolu milnia RisperidOOl' also
tR'an of irritability in autistK (hildml. upIed R'sulu aR' a R'dlK-
tion of Hritmtnl, paranoia, or nrgatiW' IIthavioB as5O(iated with pysdiosis. Ef
o((ur primilrily from blockade of dopamilll' type 2, ItfOwnin 1)'111' 2,and
alphl, admlelljil located within CHS. For a full range of
ness, the drug is sometillll'S (ombilH'd with lithium (Esblith,lithobid) or val-
pro.1!e (Depakene, DepHon). Risperidone is a long-acting whilh
following 1M adm inistration, only a small amount After a ]-wk 1iIg.
the ItSt of the drug rele.JSI"S and IiIsts for \I'I'ks. PO pR'pa-
ratiom sooner hlW' Ons!'t of oKtion.
ADMINISTRAT10N ALERTS
SeW'ral weeks aR' rtqUired for thmpMK eifl<IINelll'S5.
When switching from other antiplymotics, dillontinut to
avoid umlap.
Plf9nancy category (
PHARMACOKINETICS
IAtSl'I:
Peak:

Duration: 6wk
J
erties. Because the atypical drugs are only loosely bound to Dl
receptors, theyproduce extrapyramidal side effects than
the oonventional anti psychotics.
Although there are fewer side effects with atypical an-
tipsychotics, adverse effects are still significant, and pa-
tients must be carefully monitored. The ust' of atypical
anti psychotics have recently been differentially associated
with an increased risk of weight gain, diabetes, and hyper-
triglyceridemia. In addition, they have been associated
with a possible increased risk of cerebrovascular events
and higher mortality rates. Although most antipsychotics
cause weight gain, the atypical drugs are specifically asso-
ciated with obesity and its risk factors. Risperidone
(risperdal) and some of the other antipsychotic drugs in-
crease prolactin levels, which can lead to mt'nstrual disor-
ders, decreased libido, and osteoporosis in women. In
men, high prolactin levels can cause lack of libido and im-
potence. There is also concern that somt' atypical drugs
alter glucose metabolism, attributing to the onset of typt'
2 diabetes.
P ha r macol 0 g i c (lass: Dl dopamine receptor antagooist (weaker affinity fcf
D
j
replors); serotonin (5-HTj reptor antagonist
ADVERSE EFFECTS
Common efftlts aR' Htrapyrimidtl R'aions (involunury shaking of
the lH'Ck,andanm),hypmcril'ity, fatigut,naulu,diuinm, viswldirtur-
banc6, orthosUlil hypotension. Risperidolll' mil)' (1= Wl'ight gain
and hyptrgl)l:fmia, thus wolltlling gllKoSl' comm in diabetic patients.
Contraindications: If older adults with dementia'R'liIted are giW'll
risperidone, they aR' at an increased risk for failure, pneumonia, or sudden
death. Patients with undtrlying Iol rdiov;J sru1ar mil)' lit fljltCially prone
to dym)1hmial and hypolension. RilperidOlll' should lit lroided in pllieml
with a history of Sl'izurrs,SoUilidtl idutions,or kidlH"/lIivrrdist aSl'.
INTERACTIONS
PoJl i@nutaking rispmIorII' sum IS
akltool, anllh'ltMlUnrs, INaWH"oypnoro. or 0JI0icI analgeln I /l!"S.! can IIImolSf
100M' of the IJdI'l'l>! of rilpfrid OM. 0... to itjbitirn of il'H fIll)'1Iti, O!htr
trugI that inm.u adwr;e of rilpfridolH' indOOf SSRh SIKh as parolElilf
lPaliO,l1ralinl' UDIofIJ, and IkIol1linf lPro/Xl and antifoogal drug! sum il
IkIooazoIf mfllKan}, itroKlWlaZOlf l5p<fanoxJ, and u llKOllaZdt
en.., ittrhn withflimiwlion by the KlwriO,
whidl a1O ifl(r&lIeI the risk of advtrw
Lab leIS: RiIpfridoIH' en.., (oJIIII' iOO"UIfd II'IIIIl prolactin It"Il'Ii and ifl(JMfd AU
aminotranftrNl<fI andAST lalpilrtate illlinotrmerNl fti'I Ml)'lllf
IMII. Othtr poIMtiai Lib (IlangtS art iftIria, thrombor:)loptrlia,1M1K)'IOIis. and
koIi(ffllia.
fk.rbaVFood: lktwithuution with htrbaI IS bYi, ' ilffian,or
dlamomilf, whidl mayifl(JI'U d@p"fIliwtIfK1I.
TrNtmt nt of Overdose: ktivatN char(oal, whilh may lit used with sorbitol,
may lit u or more t fltive than tmesis or gastric: Livage. and should lit (onsid-
ered in tR'ating oven:los.Jge. Est,blish and mainu in ana irway; tnsuR' ldeqwte
oxygenation a nd W'Iltiliition. Maintain carGtovaI<U1ar function.
LibraryPirate
TABLE 17.4 Atypical Antipsychotic Drugs
0""
aripiplalOlt (ADlify)
donpnt lClouri)
oIanzapilll' [Zyprm)
paliptridolll' (lfMgi)
quetiapilll' fumarate (S6oqueI)
(.) riIpftidoIII' (Rilptldal)
lipfilidont (Gtodon)
Route and Adult Dose (max dose where Indicated)
PO; 11>-15 ""llday (mal;lO
PO; run at 15- 50 mgldoIy and to a tal9tl oil Sl>-4,O mglday
in 1 dol)'\; furthe- (max;900 mglday)
Ad!lt; PO;run with , -10 mgldar. may ilKll'aII' by 1.5- 5 wtd!
(range 11>-15 mglday;madO mglday).GffiatricPO;lt.lnwith S mg/day
PO;6mg1day (max; 11 mglday)
25 mg bid;may tool targtl dolt 0( lOO-400mglday in
dvidtd doItI(mil; &XI mglday)
PO; 14""l bid; illR'aII' by 1""l daily toan target dolt 016
PO;10""l bid (max;OO mg bid)
1M; 10 mg 1 h (mal;40 Ill9iday)
Adverse Effects
IOChyradio,. dininru,

IrJJriiry, rn!U>t4 Kllllirirrg,
cmsriplllioll.lK'limonilm, okmlrilio"

Ag!i\DulocyKtl j;.rreyrPIeptic maljooant
!'t"!Id!9rM
NURSING PROCESS FOCUS PATIENTS RECEIVING ATYPICAL ANTIPSYCHOTIC THERAPY
Assessment
Baselinr assmmf nt prio rto administration;
Undtrmnd thr the drug hal presc:ribN in ordtr to mel for

Obtain a htahh hiro:q indu:lilg hepatic, 1flIi1, uroIo.jc,
repiratOl)\OI ParDnlOO'l
or IMtre),rul1!lll mental blNst-fN,;Iing.ObIainadrug
hiliO!y indu:lilg ahlirs,rul1!lll indOK dlll9l,akohollU,
IDlOkinq. an:! he!b.J1 prrparatiJns.ik iltn to PJISibit drug mtflKti:m.
Obtain a history oIdeprmion or rntntal disordm, induding a family
history of!.lme and I!'YeriI)'.
AslI'Ss for diliuroalKr! in thought procell'S, ptlttption, mbal
(ommun ic:.noo, affed, interpftlOnal and \elf
UI!' took ptr health (aft' agtnq.
Obtain vitll signsand Wl'ight
appropriate labor<llory findilJ9l (t.g., C &, M(\roiytrs, 91uc:CM,
htpatic and II'nallulKtion lipid Klffning).
AllI'Ss the patient's ability to m:tivt and undtrltlnd
the family and "ft'9iI'l'lS as needtd.
ASSfssmrnt throughout Idministration:
AllI'Ss for dtsirtd thtraptlllic: t flem (r.g., oonnalizing thought procr!lI'S,
Irs \riling driusions, halluc:iDilion in or
to return to normal ADIJ, imprwemrm in appetitr and
slttp patterns).
ContinUl' periodic: monitoring of CBC, rirdrolytes, glurol!', htpatic a nd
furxtion studits, lipid Itvtls, and thtraprutic drug Itl'eis.
AII!'!.s vital signs, rljlKially onholtltK bkiod prrlSlR, and WI'i91
Alsm brand promptly rtport or light-htMnrss,
(onfusion, agitation, sum. 1 ideations, hypotenlion, tac:hyr:ardia, ilKft'a Ir in
itmperatute; burrtd or doubit vision, \kin rallies, bnising or bftdinq.
alKbmiial pain, jaundic:r, (hangr il (obr of stool, flank pain, and hematuria.
AslI'Ss for and tJtrapyramidal ([PS) symptoml in(kiding
pswdoparkin IOnism, ac:utr d)'ltonias, i!lath ilia, an:! dyskinrsia I
(set' Minimizing following Ir(tion).
Immtdi<llt}y ft'port signs a nd symptoms of NMS; Lllltibit blood pII'IllR,
t lmttd IffilperallR,riaphcum,dy\pIll'a, IIIUIdt rigi:lity,and
Potential Nursing Diagnoses
DisturbedThought Promse
Disturbed PtKtption (auditory,vilu.Jl)
Disturbed Personalldffitity
Anxitty (snrft', panic:)
ImpairtdVerbal Communic:ation
ImpairN Sociallnteranoo
Intffmivt
ImpairN HolDI' Maimt narxr
NOlKompliarxr
DeflCirnt KnowiNgi' (drug therarf)
Risk for Violtrxt (stlf-dirlfd,dill'(\I1d at othtrs)
Risk for SeIf-lMilation
Risk for Disturbed Family Caft'9iver Rolt Smin
(COnrlrwed)
LibraryPirate
214 Until TheNe<voo.Sy.tem
NURSING PROCESS FOCUS PATIENTS RECEIVING ATYPICAL ANTIPSYCHOTIC THERAPY (Conflnued)
Planning: Patient GOlll s and Expected Outcomes
Tilt patimt wiH:
Experitnc:t therapeuti< tfftru dtpendent on tilt It'aIOII the drug il lIting giI'M (f.g.,1t!1eIWd positiveand lII'g;ltive paraooia,
hallucinations).
Bt fret from, or exptrien(r minimal. idYerst tfftcts.
an undemanding of the drug's UI!', adoror dfrru, j nd rrquilt'd p!.!uUons.
properselhdministrition of tht mediution (r.Q.,d(M, timing. when to notify plO'/idtrJ when pouible.
tmplementation
tnterventi ons and (Rilti onll les)
En. uring therilpeutk tfffCh:
Cominue i ssmmrm. i lde(riiltd tarlier for tfit(u. (Drug.
UIed for p,yc:horn and do oot (urt tht uoclerlying d isordtr
but implO'/t positivt and otgatiVt S)'lllptoms of the di>ordef.Gradual
impro\'elllent 01'1'1" >t'Ifnl Wffh to roonth, moly lit oottd)
Monitor patient compli.tlKt with tilt drug It<jimen.(Tht prtSelKt 01 >t'Il'1t'
mental disordm moly It'IUk in oonc:ompli.tlKt with
(onsislmt doling is e>l'llti.tl to (ometing tht underlying di,ordtr. BtuIM
tilt drug. do nol <II.., lilt undtrlying if "'9uiar .dministration i.
di>rupttd. symptom, miy return abrupdy.)
Minimizing ildftlSf effKts:
Cominue to roonitor vital pfflodiully, t,peciallyortho,tatK blood
and for tachymdi.t. Enwlt' patimt salety; monitor am bulation
until the tifeds 01 the drug ilt' kna.vn.Bt panic:ulariy uutioo.H with older
IdllIS who a.., at an ilKlt'oIlf<i risk forlaUs. (Amipsycholic: dfll9! may (aIM
itypottnsion,ioclt'iling the risk of faUs and injuIYJ
Pllti ent lind Fll mily Educlltion
Tej(h the patienl,family,or caregil'ef that full tffeds may OOIOC(Ur
immtdiatt ly but that sorne imJllO'lfflll'flt Ihooid lit notimble after
beginning tht l<lpy.
Su pportivr, inpatient Ult' may be rtquired during thl' i rutt, eilrly period of
therapy.
In\'Dlvt the family aoel GlltgiYl'r to tilt Hlmt pouibit in tnwring the
paliem rtmain,on It'lJIlir mtdiution routints.
thil thr patient take the mtdic:ation ilS plt'l(ribed.Hmr itJYI'
mtdic:ation, iI tilt bedside.
I).Jtstion tilt pouibilit)o of oolKomplianc:t iloriginil symptoms or
tfft<1I suddenly in(lt'aIt in frequency or >t'Il'rity.
Hm thr patient 1M from lying or sitting to ltanding slowly to avoid
diuinrss or lalls.
InmuG the patient to u II for as s.istanc:r prior to gelting 0lII of bed or
itttmpting to walk ilont. For patimts on at -homrf ootpatimt mtdiution,
oI \'Did driving orother oIctiYitit1lt'quiring mtmal alertnrss or
roordimion umil the tiff(/S of the drug ilt' known.

Monitor for Jnd immtdiiltly It'port and symptolll! of NMS: unstable
blood pteSure,mattd rigidit):
loel inrontintnc:t. (NMS is a rare but potenti.tlly fml syndromt that must
rt(ognized and uuted immediately.)
Cominue 10 monitor rootor Jdivit)o,coordination and balanc:e,iloel for EPS
symptolll!,inc:kJding:
mUl(Ie rigidity, stooped POSIUIt',
br<ldykilll'Sia {Ilow to niln i nd shuffling. slow gaitj
Akathisi.t:inabilit)o to ret aoel It'lax,often with pacing
Arute is: Itl'It mUl(Ie spasms of bc:t, roOlJlt, neck, or back
lardil'!' !lKh is lip !II!<lding.
wormlike mOYmll'llu 01 thr tongue, unromrolltd chewing. aoel
grimolcing (EPS is len (ornmon with atypic:al antipsyc:hotic mtdiutions
butmayoc<llr.)
adtquatt nutrition aoel AuK! intake iltardive dyWlII'1ias art
pretm.(Stvtlt' chorroathl'toid tongut movtmtm milY
hinder or plt'l'Mt nutrition.)
Ensurt patient saftly if alftru gail or if akuhisia
pretm.Acute dystonias may requilt' tINtment with othrr mtdiutions to
hak IpilSIII!. (BradykinMs, sIow-to-,tln ambulation aoel slow,shuffling
g;lit milY prtdilpost tilt parient to loIlk.Akathisia with pa.c:ing milY
significantly impair the patitm'labilit)o to rei aoel sletp.Addilional
mtdic:ations may lit It'qJi..,d to t..,atAntic:holint19Ks orother drugs milY
lit It'qJi.ro to ItOP spoasms.)
Instrua thr lam ily, or urtgil'l to immtdiollt ly It'port all)' changt1
in IevtI of cOnsOouSlltu, eltvattd
mu!<le rigidit)o, inc:reiStd rrspirations or !honnrss of brtilh. or
inc:ontinenc:t .
Instrua thr poatienl, lam ily, or urtgiYl'r to immtdiattly It'port EPS
symptOIll! for i dditional ueatmtnl
LibraryPirate
Choplfr 17 0"'9' lor J>sy<:ho",. 21 5
NURSING PROCESS FOCUS PATIENTS RECEIVING ATYPICAL ANTIPSYCHOTIC THERAPY (Continued)
Implementation
Interventions and (Rati onales)
Continue to monitor CBC, rmal and hepatic: fuMtion,
lipid levtls, and thtrapMio: drug IeYels.(Arypiul antipsythoti( drugs w.:h
as risptridone lila)' uuse <10 in gluc:OII' dOlapine !IIi)'
uusr bonr marrow deprffiion.Somi' ofthi' atypiul antiPlythotin may
cause an ilKf"NlI' in lipid lew-Is or hyperlipidemia. Hepatic: lOI:ic:it)o is an
adY!'1II' Hfffi with all of the antipsythotic: drugs.)
Monitorfor antidlolinergic: t ffffiS iMkJding dry mouth,drowsilll's.,bulTI'd
vision,oonstipation, and urinlry Pmridt S)Tl1ptOlliitic: tll'itment
to e_effem.(Antitholintrgic: symptoms all'(ommon adY!'rll' of
antipl)'lhotit drugs. Toltrantt 10 anlitholintr<jit tfftcts usualI)' dewlops

Monitorfor weight gain, g)'nKomastia (bINS! tt ndemtss in
gender),and (hanges in 5eX\IiI1 (e.g.,
amenonhei ,impoterut ). (Arypiul antipsytootit drugs may tallll' 'Might
gain <lnd haY!' pituitary tfj"Kts.lmpotente and weight gain may be
signifK.l m for oooc:ompliaMe.)
Pati ent and Family Educati on
InstllKt the patient on the need to return periodiuli)' for lab woll
Teath the patitnt to report any abdominal pain, panirularl)' in the
upper qJidra nts; (hi ngt1 in 1100 I (oIor; yt llowing of Kie ra or ,kin; da rI:ened
urine; skin rashes; Iow..gradt or (hanges in
or leYrI;or If<illtll orswelling aroond sill5 ofinjury.
TNdJ wdiabetic: monitorthe bbxllUCJoIr
frequentl)' and II'pOII (onsillent elMtion, to w hNkh tall' prafider.
[Moorage ,ips of water, ic:t (hips. hard (andy, or (hewing gum to filS!'
mouth drynffi. AYoid akoholb.Jsed mouthwashes, whic:h drying to the
mlXOla and whic:h the !)Mitnt drink.
Ioc:reu e dietary fiber imakeand adeqJate fluid intake.
Report urinary II'tention to health (ire provider prompti)'.
Tmh the patitm, mt<)i'lmo 'Migh tht patitnl daii)' I
signiliunt 'Might gain (afer 2 kg. 4 to S pounds to the htalth

[Moorage, heakhy ditt fruin and I'e9!'tables, <l deqJate
prott in intlkt, and
AddrelS IHIIiII oooc:ellll in a mut t roffaa lllinntl <l nd as <lppropriate
to the he<lkh proYider.
--+--
Monitorfor akohol and illegal drug LIII'. [Used oooc:ulTl'lldy, these c.J!III' an
intll'ilstd CNS depress.Jnt eflett or an UiKerbation in psythotic:

Monitoruffeioe LIII'. (U,t of caffeilll'"<ontaining nv; neqate
the Mfff1I of antipl)'lhotia.)
Monitorfor smoking.(HtiIYy smoking mol)' dKreJS!' metabolism of
antipsythotiu leading t fliu(,.)
Patirnt understanding of drug therapy:
US!' opponunitiloslklring administration of medic:ationsand Iklring
assesSmi'nts todisCUIS rationale fordrug therapy,tiesilt'd therapeutic:
Ol/I(OOlel, most (om roonl)' obll'rwd amlll' efletts, p.l ramtlt rs for when
to ull htalth UII' and any ntttlary monitoring or
prtulllions.UII' brief explalliltion,lklring timts of dtiusionsor
halkKinations. (Using nursing UII' helps to and
reinfon:t key reathing Britf,(onsistent nplannionsalsist 10
interrupt delusional periods.)
Patint selfadm inbtution of drug thrrilPY:
When administering the medic:ation, instnKt the patitm, famil"or
(irf9mr in proper ,tlf..oJdminismtion 01 drug, t .g., take the drug as
prtI(ribtd ind do not substitute br.llllds. (Utilizing time during nufll'"-
administration of thell' drugs helps to teiKhing.).
InstllKt the patitm to avoid Ikohol and illtgil drug Reftrthe patitm to
(OOlmunity support groups w.:h <l sAAor NA 1\ appropriatt.
Teath the p.nitm, famii)', or mf<)i'ltrto awid (affeilll'"<ontaining
btwrages, ioods,and ore medkations,and to food labels when in
doubt of whethtr tht product rontain,
InstllKt the patilom to ,top or the patitnt to
.rooking (tIation l1li, if indic:ated.
The patitm, lamii)',ormf9mr ,hould be <lblt to .tate the forthe
drug; awoprWte dosr and s(heduling; what ad'lmr effl'cts to observe
for and when to them.
Tt.J(h the fJmily,or (art<:Ji'lerto take the medic:ation as follows:
TJkeemtl)' as ordered and !III' the manufa(turef. brand tilth time
the pIflIription is fillt<I.(SwitdJing brands may result in differing
phanniKokinttiu and akeration, in therapeutic: tfft<t}.
that all the medic:ation is taken when ,nd as ordered.US!'
of a "lendar to trac:k doSl'l may be helpful.
If medic:nion WJSI'S drowsintsl, take at bedtime. TOOtrantt to
antic:holinergic: effffi> ,1Kh a. d rowsilltl, usuali)' develop, O'/er time.
Do oot abrupti)' distontinuetht meditation.
EVllluation of Outcome Criterill
E"I<Iluatt the elfettiY!'lltls 01 drug therapy by oonfinning that patitm goalsand t xp!'(ted Olll{OOle, haY!' bttn met (see Planning1.
5tf TIIbIt IHforQ htlfihlJl rowlidr rIIet rurlirrl) 0II00m
LibraryPirate
216 Until The /lle<v01" System
17.7 Treating Psychoses
with Dopamine System Stabilizers
Due to side effects caused by conventional and atypical an-
tipsychotic medications, a more recent drug class was devel -
oped to better meet the needs of patients with psycltoses
(Bailey, 2(03). The newer class is called dopamine sysrem Sfa-
bili:rers (DSSs) or dopamine partial agonists. Aripiprawle
(Ability) received FDA approval in 2002 for the treatment of
schiwphrenia and schiwaffective disorder. Because ari -
Chapter REVIEW
KEY CONCEPTS
piprazole controls both the positive and negative symptoms
of schizophrenia, it is grouped in Table 17.4 with tlte atypi-
cal antipsycltotic drugs.
Aripiprawle-Ireated patients appear to exh.ibit fewer EPS
than patients treated witlt haloperidol (Haldol). Anticholin-
ergic adverse effects are virtually nonexistent. In fact, the in-
cidence of adverse effects generally wmpared to the other
atypical antipsycltotic drugs is very low. Notableside effects,
however, include headache, nausea/vomiting, fever, wnsti-
pation, and anxiety.
The numbered key concepts provide a succinct summary of the important points from the corresponding numbered section
within the chapter. If any of these points are not clear, refer to the nWllbered section within the chapter for review.
17.1 Psychoses are severe mental and behavioral disorders
characterized by disorganized mental ClIp.'\City and an in-
abilityto recognize reality.
17.2 Schizophrenia is a type of psychosis characterized by ab-
normal thoughts and thought processes,disordffed com-
mWlication. withdrawal from other people and the
environment, and a high risk for suicide.
17J Pharmaoologic Jrulnagemenl of psy,hoses is diffkult be-
cauS<' the adverse effects of the drugs may be severe, and
p.1tients often do not understand the need for mediClltion.
17A The phenothiazines have beoen effectively uS<'d for the
treatment of psychoses for more than SO years; howewr,
they have a high incidence of adverS<' effects. Extrapyra-
NCLEX-RN" REVIEW QUESTIONS
D The patient states that he has not taken his antipsychotk
drug for the past 2 weeks becauS<' it was causing sexual
dysfunction. The name antiplychotic explains that wntin-
uing the medication as prescribed is important beCllUS<':
I. hypertensi\"e crisis may occur with abrupt withdrawal
2. muscle twitching mayoccur.
3. parkinson-like symptoms will occur.
4. symptoms of psychosis are likely to return.
D Prior to discharge, the nurse provides tea,hing related to
side effects of phenothiazines to the patient, family, or
caregiver. Whkh of the following should be included?
I. The patient may experien,e withdrawal and slowed
activity.
2. Severe muscle spasms may occur early in therapy.
3. ThrdiVl' dyskinesia is likely early in therapy.
4. MediClltiollSshould betaken as prescribed to prevent
side effects.
midal side l'ffects (EP5) and neuroleptic malignant syn-
drome (NMS) are two particularly S<'rious conditions.
17.5 Thl' nonphenothiazine conventional antipsychotics hav,,"
the sam,," thernprutic appl ications and adverS<' effects as
the phenothiazines.
17.6 Atypical antipsychotics are often preferred becauS<' they
address both positive and negative symptoms of schizo-
phrenia, and produre less drama Ii, side effects.
17.7 Dopamine system stabilizers are the newest antipsychotic
class. II is hoped Ihatthis new class will have the same ef-
ficacy as other antipsychotic classes, with fewer serious
side effects.
D A 20-year-old man is admitted to the in-patient psychi -
atrk unit for treatment of acute schizophrenia and is
started on risperidone (Risperdal). Therapeutic outwmes
of this drug will include:
I. restful sleep, elevated mood, and wping abilities.
2. decreased dl'lusionaJ thinking and lesst'ned
auditorylvisual haUu,inatiollS.
3. orthostatk hypotension, reflex tachy,ardia, and
sedation.
4. relief of anxiety and improved sleep and dietary habits.
o Nursing implications of the administration of haloperi -
dol {Haldol} to a patient exhibiting psychotk behavior in-
clude which of the following! (Select all that apply.)
I. Take I hour before or 2 hoorsafi:er antacids.
2. The incidenceofEPS ishigh.
3. It is therapeutic if ordered on a pm basis.
4. Haldol iscontraindiCllted in Parkinson's disease, seiZllre
disorders, alcoholism, and S<'vere mental depression.
5. Con,'" fOrm for ""-<ier
LibraryPirate
o Which of the following data collected by the nurse during
the history and physkal isa oontraindication for a patient
to receive fluphenaZIne (Permltil, ProlixlnJ!
I. mellitus
2. Age older than 70
3. Bone marrow depressIon
4. Hypertension
CRITICAL THINKING QUESTIONS
1. A 22-year-()ld male patient has been on haloperidol (Hal-
dollA) for 2 weeks for the treatment of schizophrenia.
During a follow-up the nurse notices that the
patient rubbing his neck and is wmplaining of neck
spasms. What Is the nurse's Initial actIon? What is the po-
tential cause of the sore neck and what would be the po-
tential treatment ? What teaching is appropriate for this
patient?
2. A 68-year-Old patient has been put on olanzapine
(Zyprexa) for treatment of acute psychoses. is a pri-
ority of care for thLs patient? What teaching is important
for this patient?
3. A 20-rear-oId, newly diagnosed patient with sdIizophre-
nia has been on chlorpromazine (Thorazine) and is doing
217
o A female, age 39, has been on haloperidol (Haldol) for 3
months for severe psychosis. The nurse is monitoring the
patient for the development of acute dystonlas with
haloperidol, and will monitor for:
I . dry mouth, constipation. and blum.'d vision.
2. pacing, squlnning. ordiffirulty with galt such as
bndykinesia.
3. So:'\'eTe spasms of the muscles of the tongue, face, neck,
or back.
4. tremors, wormlike tongue lJIO'o'ements,and involuntary
lip puckering.
well. Today the nurse notices that the patient appears more
anxious and Is demonstrating increased paranoia. What is
the nurse's initial action? What is the potential problem?
What patient teKhing is important?
Su Appendix D for answers alrd rarionaln for al/Ilctivities.
EXPlORE
Is ywr one $IOj) 'Of CWIIine d1aptff review mater1als aI'ld
tt'SWrCfi. Prepare 5iJC(;6S5 with additional trux"'-5IyIe
QlIeSIlDr\s, ItllenICIM and a&II\Jldes., web linIc!! ,
and and tl\{)l"e!
R8QilICef your access code tmm the Iroot 01 I'OJr Imk at
wnM.mynU"lingkit com.
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DRUGS AT A GLANCE
OPIOIDANALGESICS {IIIltllD
OpioidAgonists f'Jt}fll/
Q morphine (AsrramOlp/l Pf, DUfOmorph,
puJf llJ
OpioidAntagonists pil9tl.'J
Q naloxone (NaKon) pogt'126
Opioidswith Mixed Agonist-Antagonist
Activity [X1IJ! 2ll
NONOPIOIDANALGESICS poge ll7
Nonsteroidal Anti-Inflammatory Drugs
(NSAlDs) (X1IJtm
Asplrtl and Other SaNcykltes (X1IJt m
" aspirin (o(eryls4l1cy/1c ocl4 ASA) patIf l j(J
Ibuprofen and Reklred Cfugs (IIlJt 118
COX-1/nhlblrol'5 pagt m
Acetaminophen paiJt ll9
Cent rally Acting Drugs p!XJt il9
ANTIMIGRAINE DRUGS fi'Xllll3
ErgotAlkaloids
Triptans pogelJ3
Q IUmIlrrlplanOmltrex) n 234
Additional Drugs f'J'II'lJJ
KEY TERMS
AOfibrrs (X1IJt l}/j
nalgesi< pagt lX!
aura {IIIltHJ
(fibers p!J}t m
cydooxygenase fiUJllll
endogenous opioids page ]X!
kappa re(rplOr {IIIlt 111
Drugs for the Control of Pain
LEARNING OUTCOMES
After reading this chapler, me student should be able to:
1. Relate the importance of pain assessment to effective
pharmacotherapy.
2. Explain the neural mechanisms at the level of the spinal cord
responsible for pain.
3. Explain how pain can be controlled by inhibiting the release of spinal
neurotransmitters.
4. Describe the role of non pharmacologic therapies in pain management.
S. Compare and contrast the types of opioid receptors and their
importance in effective management of pain.
6. Explain the role of opioid antagonists in the diagnosis and treatment of
acute opioid toxidty.
7. Describe the long-term treatment ofopioid dependence.
S. Compare the pharmacotherapeutic approaches of preventinq
migraines with those of aborting migraines.
9. Describe the nurse's role in the pharmacologic management of patients
receiving analgesics and antimigraine drugs.
10. For each of the drug classes listed in Drugs at a Glance, know
representative drug examples, and explain the mechanisms of drug
action, primary actions, and important adverse effects.
11. Categorize drugs used in the treatment of pain based on their
classification and mechanism of action.
12. Use the nursing process to care for patients receiving drug therapy
for pain.
mainttnan(e pqjl1l7
pi1tjI' i 1O
mu pqjl ll1
narcotic paqt m
neuropathic pain paqt 1I9
nocKfptiwpain {!QIJt l19
nocic:eptor pYJe m
opiatt paqt m
opioid {XIgt;;o
patient(ontrolled analgesia (PCA) {!QIJt ili
substance P pYJe no
tension htadarne {!QIJt i 10
LibraryPirate
P
llin 15 lin experience characterized by unpleasant feel-
ings, usually asscxJated with traurnll or dlsea1oe. Since we
all experience tissue trauma, pain Is a universal experience.
At a simplistic level, pain may be viewed as II defen4!! mech-
anism that helps us t o .woid potentially o;Wn.a.glng $Ituations
and mcourages us t o seek medical help. Although the neu-
ral and chemiul me<hanlsms'Of PlIln ate f!llrly stralghtfor-
ward,many psyt:hoIoglc a nd emotional processes ate II pan
of this Anxiety, fatigue, aocl can in-
crease the perception of paln;posltlve ,,"ltudes lind support
from yregivers may reduce the perception of pain. For ex-
ample, OI1lt patients tolerate their PlIIn better If they know
the OUI'Ct of trauma and the medic.I cour5e$ ;,val1able to
treat their discomfort. There 11ft many options for pain as-
sessment and the treatment of plIln-lIssoc\aled dlloOl'ders.
18.1 Assessment and Classification
of Pain
The psychologic reaction to pain is subje"ive. During phys"
ical assessment, the same degree and typeof pain that would
be described as excruciating or unbt:lrabJe by one patient,
may not even be mentioned by another patient. Several nu-
meric scales and survey instruments are available to help
health care providen standardize the patient's conveyance
of pain and subsequently measure the progress of drug ther-
apies. Successful pain management depends not only on an
accurate a.ssessment of how the patient feds but an under-
standing of the undulying disorder causing the suffering.
Selection of appropriate therapy is dependent o n both the
nature and characteristi c of pain.
Pain may be classified as either aCUle or dlronic. :' CUU'
paill is an intense pai:"Locclirringover a brief period of t ime,
usually from injury tG reco\ery. Chronic pain persisls over a
longer time. Six months is considered the standard. Quonic
pain interfe-res continuously with daily activi ties, and usu-
aUy results in feelings of helplessness and hopelessness for
Ihe patient.
Pain may alO be dassified according to illi Ource.lnjury
to produces IIlCKrptilt pilin. This type of pain may be
described as wmarit pai" (Ilrarp, localized $eIl$ations) or
visceml pain (generalized dull, throbbing, or ochi"g sensa-
tions). In contrast, results from injury 10 ,Ill:
lIerves and is typically described by patients as bumillg,
mooring, or 1111mb pain. Whereas nociceptive pain responds
wdl (u paiu-II:lid ".,uru-
pathic pain is more difficult to manage.
, 8.2 Nonpharmacologic Techniques
for Pain Management
Although for most patient s,drugsare qui teeifective at reliev-
ing pain, many ha,e significant side effects. For example, at
high doses, aspirin causes gastrointestinal (GI ) binding. Opi-
OIop1flli Drugs fa< the ConT,oI of Plrn 2 t 9
oids have the potential for dependence and can ,ause . ignifi-
cant drowsiness. To assist patients in obtaining:wcquate pain
relief, nonpharmacologic techniques may be used :l.lone or as
an adjunct to pharmacotherapy. When used ,oncurrently
with medications, nonpharmaoologic techniques ma-( :l.UOW
for lower doses and po:IIiibly fewer drug-related advn-5e ef-
fects.Some techniques used for reducing pain :l.re as follows:
Acupuncture
Biofeedback therapy
r.hssage
Heat or cold packs
or prayer
Rdaxation therapy
Art or music therapy
Imagery
Chiropractic manipulation
Hypnosis
Therapeutic or physical touch
Transcutaneous electrical nerve stimulation (TENS)
Energy therapies such as Reiki and Qi gong
Patients with intractable cancer pain sometimes require
mOl? invasive techniques as rapidly growing tumors press
011 vital tissues and nerves. Chemotherapy :l.nd surgical
treatments for cancer can cause severe pain. Radiation ther-
apy may provide pain relief by shrinking solid lumon lhal
may be pressing on nerves. Surgery may be used to rOOu"
pain by removing the tumor. Then, there is the issue of pain
subs.equent to the s urger y. The of canc,r pain
usuaUy inwlves opioids o ther adjuvant d rugs. Opioid
drugs used to relieve cancer pain may require higlur than
expe::ted doses but given the gool of relieving suffering :l.nd
improving quality of life, tDere is no set ma.."timum <bse for
the amount of drug used in these circumstances.
In:ection of alcohol or other neurotoxic subsurw::es di-
rectlv into neuronal tissue is occasionally performed to pro-
duce" nerve blocks. In many iJlSunces, nerve blocks
irreversibly stop impulse transmission and have the poten_
tial to provide total pain relief.
PHARMFACT5
Pain
Pain il a (ammon l)'fIlptom, rule<ttd by the following statistics:
E",ry)ON' in Amm<.,.ppltllliJllilld'l' 16 million (hroni<

ilia!! than 11 million ,l(lult! 11m 1!pOrttd low b.Kk pain, while 19 million
have on' lIIOft(hronit bisis.
It leollt SO million luflyor parNlty djs,bltd due til paio.
t.Ior! than 509Ii of aclulb IIU!de pain Hth )'rilt.
UJ 10 4O%0f people with una.- modtr"t to 5e'ItI'f paio wih




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220 Unlll Tte """"D." Synem
T REATING THE D IVERSE PATIENT
Cultural Influences on Pain Expression
and Perception
Howa per;on repcmklO p.lin ,ndchoc= thtl)'ped p.lil manqrrrntmayilt
an.,11y dell'llllirrd. Establishing ,n optII therapMil: with tht p.l-
titm it of UImOII The shoUd repra th!o p.ltimt's uitm and
nerds ClNKemilg tisor htr p.li'l,olI wtli as dioKfof tll'atrnenlAssess-
ing tht patitnt' S ,nd rustoms by istfllilg. II'Spf<I, and ,lbNing
tht p.ltirnt to ,,_ th!o 'pproprim p.lin 1INImtn!, is the bet ,ppltlKh.
Wlltn aslNing p.lin, tilt nUM VKUd II'OleIIIber that patitnlS may
OpMy I'XpII'SS 1htf fetliIgs ,bout p.lin ,nd thtir ntfd b p.lin 'o'Ihtrras oth-
mrTl')' bdieYr tha ofp.lil symptoms, wch olIopenI)o worrying or
(rylrllj, is, sicJl d IftakllN. Pail mani9fOlfnt (oning 10 rukulal
,nd lI'IigiJus bdief.Tlllditilnal p.lin mtdi:atiJns may or may oot lit pmrrJl'db
p.lil (OI1\roi.Asiam,nd Native Amtmm may to
!lKh as herbs, therroal thtr.lprs, rna!SI9t, ,nd mflitatlJn. Prol)'l'l"
pYys ,n importam rolf within AfrKiln Amffiun ,nd Hisp.loK ruitull'S.
18.3 The Neural Mechanisms of Pain
The process of pain transmission be-gins when pain recep-
tors are stimulated. These receptors, called noc:i(tptors, are free
nerve endings located throughout the body. The nerve im-
pulse signaling pain is sent to the spinal cord byway of two
types of sensory neurons, called Ali and C fibers. AIi!ibm are
thinly wrapped in myelin, a lipid substance that speeds
nerve transmi>sion. ( !ibm are unmyelinated; thus, they
carry information more slowly to the brain. Scientists and
clinicians believe that AI) fibers signal sharp, well-defined
pain, whereas the C fibers conduct dull, poorly localized
pain.
Once pain impulses reach thespinal cord,neurotransmit -
ters are respomible for transmitting the message along to
the next set of neurons. A neurotransmitter called substance P
is thought to be responsible for continuing the pain mes-
sage, although other neurotransmitter candidates have been
proposed. Spinal neurotransmitters are critical because they
control whether pain signals continue to the brain. The ac-
tivity of substance P may be affected by other neurotrans-
mitters released from neurons located within the CNS. One
group of neurotransmitters called involves
endorphins, dynorphins, and enkephalins. ,. Figure 18.1
shows one point of contact where endogenous opioids
modify spinal sensory information. If p.lin impulses reach
the brain, a person may respond to the sensation with many
possible actions, ranging from signaling the skeletal muscles
to jerk away from a sharp object, to mental depression,
which involves higher brain functioning, e.g., suffering and
debilitating thoughts about the pain experience.
The fact that the pain signals begin at nociceptors located
within peripheral tissues and proceed throughout the CNS,
allows several targets for the pharmacologic intervention.
In general, two main classes of pain medications are em-
ployed to manage pain, and they act at different locations:
The opioids act within the CNS, whereas the nonsteroidal
Sub5tanoe P

Receplor fo, Receplor fo,
.... bslance P opioids, serolonin,
ot norepioophrine
Opioids ot
.... rolonin (5-HT) or
nomp;nepIorine
The .... inhibit the
'e"'a .... oI .... bs1anoe P
Descending inhibitory
endogenous opioidI
lse''''orOn.norBpinephme
","u""," (corning
down from the b,ain)
,"0 r
lrensmission
-"' F ................. &ndings
(nociceptor)
"" fIgure lB. I Neural pathways for pain
anti-inflammatory drugs ( NSAIDs) act at the peripheral
tissue level.
OPIOID ANALGESICS
By definition, il nalgfsia are medications used to relieve pain.
The two basic cate-gories of analgesics are the opioids and
the nonopioids. An opioid analgesic is a natural or synthetic
morphine-like substance responsible for reducing moderate
to severe pain. Opioids are narcotic substances, meaning that
they produce numbness or stupor-like symptoms.
18.4 Classification of Opioids
Terminology of the narcotic analgesic medications may be
confusing. Several of these drugs are obtained from opium,
a milky extract from the unripe seeds of the poppy plant,
which contains more than 20 different chemicals having
pharmacologic activity. Opium consists of 9% to 14% mor-
phine and 0.8% to 2.5% codeine. These natur:J.i substances
are called opiatfs. In a search for safer analgesics, chemists
have created several dozen synthetic drugs withactivity sim-
ilar to that of the opiates. For example, morphine is a natu-
ral narcotic; meperidine is a synthetic narcotic. is a
general term referring to any of these substances, natural or
synthetic, and is often used interchangeably with the term
opiate.
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Narcotic is a general term often used to describe opioid
drugs that produce analgesia and CNS depression. In com-
mon usage, a narcotic analgesic is the same as an opioid, and
the terms are often used interchangeably. In the context of
drug enforct'ment however, the term narrotic describes a
much broader range of abused illegal drugs such as hallu-
cinogens, heroin, amphetamines, and marijuana. So this is
an important fact to remember when relating use of opioids
with mt'mbers of law enforct'ment.
Opioids exert their actions by interacting with at least six
differt'nt types of receptors: mu (types one and two), kappa.,
sigma, delta, and epsilon. From the perspective of pain man-
agement, the mu and kapp. are the most important.
Drugs that stimulate a particular opioid receptor are called
opioid agonists; those that block an opioid receptor are called
opioid antagonists. Responses produced byactivation of mu
and kappa receptors are listed in Table 18.1.
Some opioid agonists, such as morphine, activate both mu
and kappa receptors. Other opioids, such as pentazocine hy-
drochloride (Talwin), exert mixed opioid agonist-antagonist
effects by activating the kappa receptors but blocking the mu
receptors. Opioid blockers such as naloxone (Narcan) in-
hibit both the mu and kappa receptors. This is the body's
way of providing for a diverse set of body responses from
one substance . .. Figure 18.2 illustrates actions resulting
from stimulation of mu and kappa receptors.
Opioid Agonists
Narcotic opioid agonists bind to opioid receptors and pro-
duce multiple responses throughout the body. Morphine is
the prototype drug used to treat severe pain. It is considered
the standard by which the effectiveness of other opioids are
compared.
'8.5 Pharmacotherapy with Opioids
Opioids are the first line of 'hoice for moderate to severe
pain (discomfort thM carmot be controlled with other
classes of analgesics). More th.an 20 different opi-
oids are available as medications, which may be classified by
similarities in their chemical structures, by their mecha-
nisms of action, or by their effectiveness (Table 18.2). The
IlYplflll Drug; 10< tho> Comrol of Poln 221
Pureopioid
agonis1
Morphine

clln f<1C11J11ors
Pent azocine
8utotphelnol
Mu: Analges",
DIIcrHsII<I GI motil;ty
Respiratory depression
Sedation
Physical depeo<loonce
T Kappa:
Analges",
DllcrM.5ll<l GI mo1il;ty
Sedation
.. Flgur! 18.2 Oplold receptors
PurQ opioid
anla.gonsl
NalOllone
most clinically useful classification method is by effective-
ness, which places opiates into categories of strong or mod-

Opiates produce many important effects other than anal-
gesia . They are t'ffectivt' at suppressing the cough reflex and
at slowing the motility of the GI tract for cases of severe di-
arrhea. M powerful CNS depressants, opioids can cause se-
dation, which may either be therapeutic or dett'rmined a
side effect, depending on the patient's disease state. Some
patients experience euphoria and intense relaxation, which
are reasons why opiates are sometimes abused. There are
many adverse effects, including respiratory depression, se-
dation, nausea, and vomiting.
All of the narcotic analgesics have the potential to cause
physical and psychologic dependence, as discussed in
chapter 1100. Over the years, health care providers and
nurses haw hesitated to administer tht' proper amount of
opioid analgesics for fear of causing patient dependence or
of producing serious adverse effects such as sedation or res-
piratory depression. Because of this tendency, some patients
have not received complete pain relief.
TABLE 18.1 I Responses Produced by Activation of Specific Oplold Receptors
Response Mu Receptor Kappa Receptor

Analge5i.J .' .'
Dtumfll Gl motiity .' .'
Euphori'
.'
-
.'
.'
iIt!pimory dtpmsion .'
.'
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222 Unlll Thi'Ne<vDI"Sy'tem
TABLE 18.2 Opioids for Pain Manag"m"nt
Drug Route and Adult Do5e (max do5ewhere Indicated)
OPIOIO AGONIST'S WITH HIGH EFFECTIVENESS
Ir,'dromorphone
l\J'w.ilromoran)
mrptridillf hydrochloride l[lrmrrol)
methadon!, hydrochlorid!, (Dolophillf)
o morphinr IUlfatr (Miramorph PF,


PO; tid- qid pm
PO; 5O-1SO IIIIj 3--4 h pm
10 IIIIj r'll'I)']--4 h pm
PO; 10--30 IIIIj r'll'l)' 4 h pm
OPIOIO AGONIST'S WITH MODERATE EFFECTIVENESS
-.
Ir,'dllKodonr (I/ydIn)
hydrodlloridr (Ox)'Contin); IIXJ(OIbIr
(Pt-rUKtI-S, Roxictl,
propox)'lWnt hydrochloride (0.I'l00)
propox)'lWnt (IMrwn-tl)
OPIOIO ANTAGONIST'S
hydrodlloridr (RMI)
nal!reJ:OIII' IrfdrodJloride [Trwn.
PO;IS--i.Olllljrjd
PO; 10 IIIIj 4-6 h pm (max: 15 mg/doIr)
PO; 10 IIIIj rjd pm
PO; 6S IIIIj (HCI form) or 100 IIIIj form) "try 4 h
PRN (mal:l90 mglday HCI; mal:600 mglday na/ll)'latt )
SuIKwIM'OlJl./lMllY;lHf 1 mg/ml (OIKmtralion
Nmopoid dependent:05 mgl70 kg
OpioiddepMdent:O.l
rng;may "" MIY min upto 10 mg ij
IIt(tslil)'
PO; 25 mg IoIIowtd by amiller 2S mg in 1 h ij mwithdrawal
(max:&Xi mg/da,)
OPIOIOS WITH MIXED EFFECTS
buprrnorphilM' hydrochloride
butorphinol (Stidd)
dtzocillf (Oalgan)
nabuplilM' hyrtodllorjdr, (Hubain)
pmUlOOIIf hyd rodJloride (Talwin)
1M/1Y;0.31111j f'll'l)' 6 h (mal:O.61111j"fIY 4 h)
1M; 1--4 mg fVff1l --4 h pm (mal: 4
10 IIIIj (UlUiIIy 5 mg)"try 2--4 h
lOmg)f'II'I)' Hh
SubrulaIM'OlJl./lMllY; mg MIY l--i.h pm jmn: 160 mglday)
PO;50-100 IIIIj 3--4 h jmal:600 mg/day)
-c-cc--c-'-- ' -""' --c-- MIlY;]O mg MI)' 3--. h (1IIiI:360 mglda,)
lldicr indKite romroon advmt tffMs; lIII1flIiliDg. indKitts strious tlhru.
Adverse Effects

drrlWlinm, dilziflm
Anaphy!a<!oid .flts!,
!tI'm reWtOlY depmsjon or allffi
(onl'Jlsions
MU5lO, (omliPQIion, dizziflm
HtNtOioxisitY. !tSt!iIa!p!'f dtpmsion.
drru,l1O!Y ooIlaDg
Mwltorrdjom"am, diffirulty Jlttting,


HtNtOioxidty
1ig/rfOO!dtftlru,
MU5lO, (IIImmy Iii",
wrnIipotion
RopjrAJOa drw1'iion shod
\'/hen used according to accepted medical practice, pa-
tients can, and indeed should, receive the pain relief they
need without fear of addiction or adverse effects. One
method available is patient(ontrolled analgesia (PeA). In this in-
stance, patients are allowed to self-medicate with opiate
medication by the pressing of a button. Safe levels of sched-
uled pain medication are delivered with an infusion pwnp.
In the pharmaoologic management of pain, it is oommon
practice to oombine opioids and nonnarootic analgesics into
a single tablet or capsule. The two dasses of analgesics work
synergistically to relieV\' pain, and dose of the opioid atn be
kept small to avoid dependence and narootic-related side ef-
feets. With growing ooncern over the risk of hepatic toxicity
related to large doses of acetaminophen, it should be noted
that additional doses of combination products may raise Ihe
dose of acetaminophen or adjuvant drug to unacceptable
levels. Additional doses of the oombination product should
not be used unless the doseofthe nonnarcotic analgesic does
nol exceed the recommended dose. A5 examples, oombina-
tion analgesics are as follows:
Vicodin (hydrocooone, 5 mg; acetaminophen, 500 mg)
Peroocet (oxyoodone hydrodJloride, 7.5 mg;
acetaminophen, 325 mg)
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Percodan (oxycodone hydrochloride, 4.5 mg; oxycooone
terephthalate, 0.38 mg; aspirin, 325 mg)
Darvocet-N 50 (plOpoxyphene napsylate, 50 mg;
acetaminophen, 325 rug)
Empirin with Codeine No.2 (cooeine phosphate, 15 mg;
aspirin, 325 mg)
Tylenol with Codeine (single dose may contain from 15
to 60 mg of codeine phosphate and from 300 to 1,000
mg of acetaminophen)
Some opioids are used primarily for conditions other
than general complaints of pain. For example, alfentanil
(Alfenta), fentanyl (Sublimare), remifentanil (Ultiva), and
sufentanil (Sufenta) are used for general anesthesia; these
are discussed further in chapter 1900. Codeine is most of-
ten prescribed as a cough suppressant and is covered in
chapter 3SOO. Opioids used in treating diarrhea are pre-
sented in chapter 4100.
Opioid Antagonists
Opioid antagonists are substances that prevent the effects of
opioid agonists. Many druJ!;S are considered competitive an-
tagonists because they compete with opioids for access to
the opioid receptor.
IlIaplfl tl Drug< fo< the Control 01 p.ln 223
LtFESPAN CONStDERATt ONS
Tha Influenca of Aga on Pain Expression
and Perception
Pain control in both children and olcltr idults (an be challenging. Knowledge
of dMlopmtntal tht iging behavioral (ue, subtif of
discomfort,and Vl'rb<ll and oorrmbal responses to pain <lie <I must..-hen it
to tffrttiVl' pain OIdtf patients may haVl' a tif.:rNsN
pereption of pain or may !imply ignOll' pain is i "natural" colllfqlltllCl' of ag-
ing. thelt patients go uodenntdiuttd, i thorough assess-
mtlR is I"ftded.As with i dults, in 5elf-1!pOI1 when oIIltlSing forpain in
<hilCren is imporu nt pain-rating tools all' mil-
.lbleaocl should be usN on <I consistent b.ilis. Comfort measull's shOlId also

...... t n idministering opioids for pa in Il'litt .!ways monitor patients do5el,.
Smalifr dosts all' l/SUiIlly iocliuted, and sitk tffKts may be Ill'ighteOl'd
(Ioltly monitor demasN rtlpimions, lO(,and Take body Wl'ight
prior to starting opioid administration and (akulatt dOlfS i(mrding'y. Ktt-p
bed and crib rails raised aocl till' bed in low position at all times to prf"ll'llt in-
jury from f.lls. Somt opioick, sum 011 mtptridiOl' (DemeroO, should R usN
uutiously in childll'n. Mill)' oIdtf .lduks u ke multiplt drugs (polyphnnaq),
so itis important to obliin i complete list of all mtdic.ilions taRn anl (lII'<k
for iateractions.
for Prototype Drug I Morphine (Astramorph PF, Duramorph, others)
Therapeutic (lass: analgesic Pharmacologic ( lass: Opioid receptor agonist
ACTIONS AND USES
Morphine biocls with boill mu aocl kappa fl'{tptor !ites to profound
.JOalge!i.I.lt uuses flJpoori.l,{oostriction of the pupils, ind lIimul.ilion of Cit-
diac mUKif. k is !Md for symptomatic ll'Iief of acute and (hronic piin
iittf oonnarcolk .na igesn haYf fa iltd, is medication, to Il'lil'-Ye
shorlnts5 ofbrNth i>SOtatedwith hein failureand for
,mile {liest pain mnnemd with MI.
ADMINISTRATION ALERTS
TbeorallOlution gWen sublinlJlilly.
The oral sokllion (orne! in multiplt stll'llgths; carefulI)' drug or-
dmand libels
Morphine (iuses Yilsodilition, which lfiuhs in orthostatic
h)opotension.
Pll'gnillQ uttgOl)' 810 in Iong-tl'llll 1M or with high dom)
PHARMACOKINETlCS
Onset: liss than 60 m'n
PNk: 60 min PO: 2O-tiO min fl'(ully; so-9O min subcutaneously;
10-1 min 1M; 20 min IV
Halflife: 2-3 h
Duration: Up to 7 h
ADVERSE EFFECTS
Morphill' may dtpression, and anxiety), halb:ioa-
tio OlUIt i, con stipation,diuioeu, aocl .J n itching sen >ation.1lYfrdosf m y Il'-
suit in itVtfI' mpiatory depression or wdia( alll'll ToieriOO' dtYmps to the
SfdatiYf, naulti-producing. and fIJphoric ffItcts of tilt thIcj. Cross-toleran:t ilso
devrIops lll'iwffn morphilr and other opioids IlKh is heroin, mtthidort, aocl
meperi:lilt. Physiul aocl psychologic deptndmtr devrloJn wlltn high dosfi a Il'
taken fur prolongtd pffloih.
Contraindi utions: Morphine may inten or misk the pain of gallblacldtr dis-
dJf to biliary tract spasms. Morphinf should iM tit <lvoided in um of
acute or ItYfll' uthm., Gl obstnKtion,.ocI seYl'Il' hepatic or renal im pailllltfll
INTERACTIONS
DrurOIlJ!l: Morphint with WIl'I"iII m.gs. for txamplt, <llOOIIfI1t Uf of

antidtp'fSldllts luch ai tMO itoibilm aIKI triqdic:5 potrruiat@!thtactiooof
tht rill: of!f'll'lf rrspiralory dft:lMooaodOOih.
LlbTl5l1: Unknown
Herba \'OOimIH!, kiwa kiwa, vaIHiao, and St. .Iolm i wort may potentiatt tw
Ii
Treatment of O"ferdme: IV .ldministruion of nalolOOI' is the spe<iIic trrat-
ment Other IINtments iawated a lixauY!', aocl a (ounteract-
iog narcotic antigonist.Multipifdoses may be ntfded
lit fer I!J M)MmlrrqK!/ for Q NurslfIIJ Pnxm form!pt(1k ro rIr/<i dr!!g.
I
;
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224 Unltl Thl'NetvO'"S)/lt'''''
NURSING PROCESS FOCUS PATIENTS RECEIVING OPIOIDTHERAPY
Assessment
Billellne assessment prior to administration:
Understand the rtuon the drug bttn prescribed in Older to assess 101
the!apeutic ./feds.
Obt,in a complete heakh histor)' including wdiO'<i!cular.lltllroIogic,
titOr)'. htpatic, rt'nal. 9illibladdtr or urologic di 1M.; IR9nancy;
01 JfCent surqeriesor injuries. Obtain drug histor)'
including ililelgies. cuJlent prts<ription and orc herNl
prt'pilratiom.B. ller! to po\l;iblt drug intmdions.
AsSffi the leftl 01 pain. Use lCrt'rning tools when ( . g..
HAC( [llCe,limbs,anm. cr)'. conso!abiliryl for infants or Yfry young chiklrt n.
WOll9"S,ktr FACES sulr for (hildren, numeriul riling S(11e for fClultsl.
Assns history 01 pain ilnd whit has worktd or not for the
patient in the Plst
Obt,in viul signs Ind weight.
E'/IlllIte Ippropriate laborillor)' findings (e.g.,CB(, hepatic Ind renal
luncrion studies),
Assns the patient's ilbility to If(ei'o't and umtand instruction.lndudt the
family and (IIrt'gim IS ne.ded.
Assessment throughout administration:
AsSffi i:lr lhe!apeulic dfu (e.g., abltnt diminished
pain, to fJlO'<e mort easily without pain. carr)' out
me). Continue to use I pain-rating scalr to quantify the It'Iel 01
imprOYfllltrll
Continue periodic monitoriog ofCBC,and hep,tic and JI'IIiIllunction studies.
AsSffi ,;tll blood pressure, PUM, and respirillOlY rllt.
o Assns i:lr ilnd Jtport fCl.erse effts:w:elSivt
confusion, hypol.mion. brfClypnu, Ind pinpoint
pupils.
Potential Nursing Diagnoses
Acute or Chronic Pilin (Iflated to inju!),. disult,orlUlgical pnxedurt)
Brtathiog P,tt.rn (rtIat.dto pain ordrug
whrn in the prtSl'nce olothe! CNS deprt'\l;, nts SIKh as anesthetics
postoptlatiYfIy)
(rtlilttd to iltlvtrsedrug efflS)
Dtfi<ient Knowlrdgt (rtlilted to drug therJpy)
Risk forlnj,Jr)',Risk for Falls (rtlated to drug effects)
Planning: Patient Goals lind Expected Outcomes
The patient will:
Experience therapeutic tffts dependent 00 the rtilSOl1 the drug is being (e.g., absent or de<rt'ilstd pain,Nst in JIIO'Ifment and postoperltivt Cilrt).
8. ne from, or nperiencr minimal, IdYtrse tfftru.
Verbaliu an undemanding 01 the drug's tffws,Jnd Jtquirtd pttuUlions.
o Dtmonllrillt proper IfII-administr"ion 01 the medic"ion (e.g.,dose, timing, whtn to notify pJOYidtr),
Implementlltion
Interventi ons and (Rati o nales)
Ensuring thtrJpeutlc ,ffed s:
Continue I \l;fSSmeOU I s dfICribed earlitr for thtrapeutic effects. Gift drug
IItftnthe Stili 01 lcutt pain and .ncouragt rt'gularfy for
the lim 24 to 48 postopemiYfIy for adequate postoptrltivt pain
rtlief. Provide comfort IntiIsures to supplem.m drug therapy.
us. of I pain filling scale by ,II providers will help quantify the
01 pain rt'Iief Ind lead to beU.r p,in (ontrol. Wmh for subtle sigm 01
pain: he1iu ncy to IIIOYf, shallow brt'uhs to awid incrt' I g pain. grimac:ing
OIIl1'1O'1tr11enl Encouraoging thf p,rient to maintain regular dusduriog the
lcute postoperltil'f or Plin period lIIiIy provide bener rt'Iief thin giving
' pm" duson JtqUl'lt when pain has incrtilSfd to the point that medic, tion
isn.ededJ
Pati ent and Famil y Education
Teach the paitnt that p,in relitt rather than mtrI'ly (ootrol,is the (!NI of
therapy.
Encoutaljf the patient to tab thedrug during the ac:u!e
postoperatiVl' or proctdUrt period tith.rthan reqUf'Sting when p, in is

Explain the rltionale behiod the pain r,tiog suit (i.e., it allows consist.ncy
among ,II providers).
Encourlljf the p,tient, Ilmily,olUlI'9il'tr to
nonphannKoiogi( p,in rtlitf ttdlniquf'!, e.g.,dismaion with ttltvision or
music. bi<krubs,guided imaljfr)'.
LibraryPirate
NURSING PROCESS FOCUS PATIENTS RECEIVING OPIOIDTHERAPY (ConrlnuQ<;/)
Implement ation
Interventi ons and (Rati onales) Patient and Famil y Educati on
Minimizing ad'ftrlf rifKts:
o ContinU!' to monitor vital respirnionland is

[lI(ouraqe thr patil'nt totakr brNrhI in thr poltoperauY!' period.
ordrred, and in patienn with pain.For terminal WKtr

[lI(ouraqecomilleot pain mrdication usage to ill(ru!l' activity toler-m(t .
pain, obtain imtrunion I from thr onc:oiogist or providtr on any

[lI(ouraqe thr patient with terminal (anc:('I to thr doll' IOmisteotly
I!"Itrictionl. (Respiratol)' tieprrllion is thr mOlt (OOlmon with thr first do!l'
around dock with pm dole 011 tht family or
of an opioid and when gr..eo in tilt of othrr (NS deprrwnb, e.g.,
on the PlOllidefl in!!rudionl for adequate pain relief and to (onlan thr
postoperatiY!'1y when thr may still tfftru of
providtr if any pain
a OI'lthtIia. Cou nt rrspiratiom More giving the opioid drug a nd
(ontlo(\ the plOl'ider giving if the I!"Ipirationl are bdow 12 bft'athl
per minute , duk or 011 ordtft'd in (hild. ContinU!' to alll'li
thr respiratory tvrl)' 15 to 30 minutes for the first 4 hours. For terminal
tall(('I pain, the drug may not withheld oftht I!"Ipiratory 1<I\e,
dtprndtm on thr proYider.)
.
Monitorthr blood prffiUft' ind periodically or if 5)'mptoms warrant o Tea{h the jHltil'nt to 1M from lying or litting to standing llowly to avoid
En.ul\' pnil'n! .. /My, monitor ambulnion untiltht .ffttl:< ofdrug oil\' diuiOl''' or loll .
known.8t panicularly uutious with oIdtr i duks whoare at an inc:re,utd
o InstllKl the to (all for assislaro:r prior to gttting out of brd or atttmptilg
risk for foil Is. (Opioids may UUII' hypottn!ion as an adl'l'lSr tffr" and
to wa. and to aOi:l diving or other anjyitits rtqtimg mental alrrtOl'sl
thr risk offalls or injuril'sJ
or physical ooonioation ootil the effK6 of the drug all' known.
o ContinU!' to illl'Il lClJods.llI(ft'i!l' IUd intakr and dil'tal)' fibtrintlkr. o Tt ath tht jHltil'nt to inau!l' fluids to II prrday and to tht iotakr
(DKlUsro perisuu is,n effect ofopioiddrugs. Si/nifkantly of dil'til)' fibl'lSuc:h is fruit, whoII'
diminishedor abll'llt 1OU000are ft'portedto the hNlth careproYidef

patil'm to report!l'l'l'II' {onstipation to thr hNith tart
immediately. Mditional fkJ ids and fibtr may t a!l' (onstipation but
providtrfor additional idvkt on 1a1iltiY!'l or stool SOftfners.
medicatiom suc:h as MiralaxorCoiaa- may retPred.)
. Monitor for itthing or {00l pia inu of it(hing. (Opioids UUII' histamilll'

Tm h tht jHltil' nt to rt port it{hing to thr (are ij
it{hing or a II'fIS.Jtion of itthing.ln itthing is II'Ym or ioc:reuing.
may rrquift'd.kml br it{hing as an 9pKtrd sideeffett Y!'I>US signs

InstllJ{t thr paritm to immediately report all)' itthing asSO{iatrd with
and lymptOnu of tllll' in vi,,1 tsptdilly
diuiness or difIKulty blt'ath iog.. pa Ipiutions, or
hypoten!ion and tI{hyra rdia, d)'lplII'a, or unica ria J
significanthiY!'l.
o ASIl'lI for (llanges in IeY!'I of or {onfusion, o ImtllJ{t patient, family,oruregiver to immediately rt'pOrt in{reasing
agitllion, slugcj ish or pinpoint pupils, or (Nturoiogk leth a 19)', disoMntation, oonfusion, (lla nges in or mood, i4jitation
{lIangti may ovennrdiution, ill(lU5<rd imrmi nial pressure, or or ' ggrffiioo, IUrrrd Ipffih,itlJia, or
drug t lfeill.OIdft" .dJlu may risk for (onfusion and falls.)
o Ensure patient safety if disoritntltion is
o Asll'ls for urinary ft'teotion,tspfd.11y in thr postoperatiY!' prriod.{Opioids o [lI(ourage thr patient to IIIOYI' about in btrI and to start ambulation
may ('UII' urinal)' rt tt mion as an t/fr(l) as soon postoperatively.klist to i nolTllill voiding position if
unable to usr bathroom or

InstllJ{t patitm to report an inability to void, ill(lUsing
bladder PII'SSUIt',or p.in.
o Monitor pain relitf in patients on patieoH:ontrolled allillgtsia (PCA) pumps.

InstllJ{t patitnt, family,orurrgiver on tht Ull'of thr PCA pump.
If a basal is not givrn (ontinuousty, asll'ls that pain ft'l iI'fis [lI(ouraqe u II' on an b.sis .nd t mphasize the
and oonwt thr providtr if pain remains prt-ll'Ot Ttac:h and t ll(ourage thr limitations pft'ltnt to pro\e(t the patient (i.e.,oveniolt is not
patitot to U!l' {ontrol button whtntm pain is
in{lUliog,or brfoft' activities. (PO-administered pain (ontroi hugll'atly
impltl'{rd pain relil'ffor patients with lI'gular dosing but is only riftive
whtn takrn as Iftded. Rn<itw dosaoge histol)' and patil'm symptoms to
rnsul\' adtqwtt pa in relief. Contl(t thr plO'lidtr if dolt, irtqUtlK)', or ba sal
doll' inadequatr for !\'lief.)
Patirnt understanding of drug thfrapy:
o U!I' opponunitits during administration of during o Thr parii'm should able to lIatt thr It'alon for thr drug,appropriate
as Il'Imltntlto dis{\/!l the rationale for drug thrrap)', thmprutic doII'and sdlrduliog,and what efftru to obItIV!' for and whrn to
moll adve rsttffetn, paramettrs forwht n rt portthem.
to tall the hNlth ure providtr,and all)' nKtSSiry monitoring or
pm:autions.(lking rimt ooring riming tal\' hripi to optimizt and reinfon:r
ke)' tt athing arfasJ

LibraryPirate
226 Until "TheNelvoo. Sy.tem
NURSING PROCESS FOCUS PATIENTS R'CEIVING OPIOIDTH'RAPY (COO'",."
Implementilltion
Inter venti ons iII nd (Rillti onill les)
Patimt stlladministration of drug thtrapy:
When administering medic.Jlioo,iostllKl family, orcart<jM-r
in proptr islration of drug, e -9., take tht drug a I plI'!criWcl wlltn
I"ftdtd (Utilizing time during nunt-administration olthfse drugs helps 10
reinfoKt teac: hing.)
Pati ent iII nd Fill mily Educilltion
Teach the patimt to tau the medic.Jlion as follows:
Beforl.' tilt btcomtS sel'l'fl' , nd for cancer as coosislenti)' as
possible.
If a patient-rontrolltd i nalgesii (PO.) plJmp:use thr seIf-dosallt
button wllmtl'l'f begins to ilKruse or btfott activitie SIKh as
at tilt btdsidt.
Takt with food to dt<rmeGI upset.
Btf.luse opioids art sct-.edtRd drugs (rrost oftto (11 thlOlJ!t! IV),
nsale, nd used thednJ1 to the pmon
ltlrd-u;!
bt)OOCI the Mil rmikart notabYed
drugs). Do not sm wi h any other pmon ard do oot discard any 1IIUSl'd
dnJ1 doNn drarn, lIush doNn tht toitI. or pOO i1 tht garbagt. P.enm any
!ftIseddrug tOlhe pllarmoK)' orhNth call'
EVillluilltion 01 Outcome Criteriill
[valuall' effeuivtotSl of drug therapy II)' confirming that goa Is and 6 pt(\ed outcome haVl' been roo (SI'!' "Planniog1.
SH TQbIf' tlJ.lflU rcwhidHIrI'lt gpply.
18.6 Pharmacotherapy
with Opioid Antagonists
Opioid overdose can occur as a result of overly aggressive
pain therapy or as a result of substance abuse. Any opioid
.... Prototype Dr ug I Naloxone (Narcan)
may be abused for its psychoactive effects; however, mor-
phine, meperidine, and heroin are preferred beOluseoftheir
potency. Although heroin is currently available as a legal
analgesic in manyoountries, it is deemed too dangerous for
therapeutic use by the FDA and is a major drug of abuse.
Therapeutic (lass: for treatmenl of arute opioid OYerdose and Pharmacologic (lass: receptor antagonist
ACTIONS AND USES
Mamone is a opioid blocking bolh mu i nd ttceptoo. k
is UIed for complett or partial of opioid rifKls in ernerg!'1K)' situations
wlltn ac:UIl' opioid is susptued. Givrn it brgins 10 11"-
Vl'f\e opioidinitiiied (NS and respiratory dtpreslion within minute . k will im
mediill'ly cause opioid withdrawal symptoms in physically dtptndtm
on opioick. k is , ko used to Itt u postopfl"ative opioid dtpres lion. k is O{usion
ally given as i djunctM-ll1mpy to hypott nlion causfd II)' septic shock.
ADMINISTRATION ALERTS
Adminisll'ffor a respirator) rall'offfWfl"lhan 10 breaths/minute. Kttp 11"-
slJI(italive tqUipmeot aCCfssibit.
PrrgoalK)' category B
PHARMACOK1NET1CS
il1sel: 1- 1min lV;l- S min IM;1- 5minsubrutaflE'OUll)'
f'eik:S- 1Smin
ro-l00min
Duration: 4S min
ADVERSE EFFECTS
itself has minilllil of rifKls of opioick
llliy ttsult in rapid loss of analgeia, i(){rrased blood Ift'mors, hypl'l.
vemiiation, nauleil and I'Omiting, and drowsiOfls.
N. Inxa"" "'nuld Mt br u...d for ""pirat".., rIPprP"inn
caused II)' nonopioid medications.
INTERACTIONS
I)ug- l)ug: 1lru9 inteOOionl ildlHlf a It'VN of thf aoaIgrsic: . lfem of opioid
agonists iIOd mind..,m.: O:ugs.
Lab Unmown
IlerbaVFood: EdifIa(N m.J)' OOfilf thf rislrofhtpitotoJiOy.
Trtatmenl of Olerdose: Naloxone _rdie lI'qUire tilt use of OX)'9tn, IV flu
idl,alOpttsrors,and other supportiVl' mNSUII'I i l
llliy bt useful in combination drug OI'I'rdose (for example, pentalOCine with
rwloxont [lalwin NX)).
RI'Ii'r to MyNrfilngKt I'or MnIniJ 1'rixf'S.! Foo/5 spt(1/I( Ii1 rJrIlltr!g.
LibraryPirate
Once injected or inhaled, heroin rapidly crosses the
blood-brain barrier to enter the brain, where it is membo-
lized to morphine. Thus, the effects and symptomsofheroin
administration are actually caused by the activation of mu
and kappa receptors by morphine. The initial effect is an in-
tense euphoria, called a rush, followed by several hours of
deep relaxation.
Opioid antagonists are blockers of opioid activity. They
are often used to reverse the symptoms of opioid addic-
tion, toxicity, and overdose. Symptoms include sedation or
respiratory distress. Acute opioid intoxication is a medical
emersency, with respiratory depre .. ion beins the most
serious problem. Infusion with the opioid antagonist
naloxone ( Narcan) may be used to reverse respiratory de-
pression and other acute symptoms. In cases in which the
patient is unconscious or unclear which drug has been
taken, opioid antagonists may be given to diagnose the
overdose. If the opioid antagonist fails to quickly reverse
the acute symptoms, the overdose may be attributed to a
nonopioid substance.
Opioids with Mixed Agonist-Antagonist
A(tivity
Narcotic opioids that have mixed agonist-antagonist ac-
tivity stimulate the opioid receptor; thus, they cause anal-
gesia. However, the withdrawal symptoms or adverse
effects are not as intense due to partial activity of receptor
subtypes.
, 8.7 Treatment for Opioid
Dependence
Although effective at relieving pain, the opioids have a
greater risk for dependence than almost any other class of
medications. Tolerance develops relatively quickly to the eu-
phoric Effects of opioids, causing abusers to escalate their
doses and take the drugs more frequently. The higher and
more frequent doses rapidly cause physical dependence in
opioid abusers.
When physically dependent patients attempt to discon-
tinue drug use, they experience extremely Wlcomfortable
symptoms that convince many to continue theirdrug-taking
behavior to avoid the suffering. As long as the drug is contin-
ued, they feel and many can continue work or so-
cial activities. In cases when thedrug is abruptly discontinued,
the patient experiences about 7 days of withdrawal symptoms
before overcoming the physical dependence.
The intense craving characteristic of psychologic de-
pendence may occur for manymonths,and even years, fol-
lowing discontinuation of opioids. This often results in a
return to drug-seeking behavior unless significant support
groups are established.
One method of treating opioid dependence has been to
switch the patient from IV and inhalation forms of illegal
drugs to methadone (Dolophine). Although oral
methadone is an opioid, it does not cause the euphoria of
IlIoplflll Drug; Iont... Com,oI of Poln 227
the injectable opioids. Methadone also does not cure the
dependence, and the patient must continue taking the
drug to avoid withdrawal symptoms. This therapy, called
methadont maintfnan(f, may continue for many months or
years, until the patient decides to enter a total withdrawal
treatment program. Methadone maintenance allows pa-
tients to return to productive work and social relationships
without the physical, emotional, and criminal risks of ille-
gal drug use.
A newer treatment option is to administer buprenor-
phine (Subutex), a mixed opioid agonist-antagonist, by the
.ublinSual route. Buprenorphine i. used ""rty in opioid
abuse therapy to prevent opioid withdrawal symptoms. An-
other combination agent, Suboxone, contains both
buprenorphine and naloxone, and is used later in the main-
tenance of opioid addiction.
Health care providers should always be aware that when
administering opioids with mbred agonist-antagonist ac-
tivity, their pain-blocking properties are reduced when ad-
ministered in combination with opioid agonists. Thus,
there may be a tendency to overprescribe mixed opioids,
promoting drug misuse. This is true even though in most
cases, the potential for causing opioid addiction is lower
with mi-,:ed agonist- antagonists compared with pure opi-
oid agonists.
NONOPIOID ANALGESICS
The nonopioid analgesics include NSAIDs, acetaminophen,
and a few centrally acting drugs. The role of the NSAIDs in
the treatment of inflammation and fever is discussed more
thoroughly in chapter 3J01C> . Therefore, there is only brief
mention here. Table 18.3 highlights the more common
nonopioid analgesics.
Nonsteroidal Anti-Inflammatory
Drug'lNIAID'1
The NSAIDs act by inhibiting pain mediators at the noci-
ceptor lew!. When tissue is damaged, chemical mediators
are released locally, including histamine, potassium ion, hy-
drogen ion, bradykinin, and prostaglandins. Bradykinin is
associated with the sensory impulse of pain. Prostaglandins
can induce pain through the formation of free radicals.
'8.8 Pharmacotherapy with NSAIDs
Nonsteroidal anti -inflammatory drugs ( NSAIDs) inhibit
cydoOJlygenasr, an enzyme responsible for the formation of
prostaglandins. When cydooxygenase is inhibited, inflam-
mation and pain are reduced. NSAIDs are drugs of choice
for mild to moderate pain, especially for pain associated
with inflammation. These drugs have many advantages over
the opioids, in that the NSAIDs have antipyretic and anti-
inflammatory activity, as well as analgesic properties.
LibraryPirate
228 Unlll Tte Netvoo, System
TABLE 18. 3 Nonopioid Analgesics
Dru, RoulI' and Adult Dose (max dose where Indicated)
NSAIDs: ASPIRI"I AND OTHER SALICYLATES
Q iSpirin (_)'IQlkyliI: acid,.\SA)
dIoint wlicylatt (Arthropan)
wll.JLltt (llisakid)
PO;350-6,O mg f'ltr)' (h (max:. gfllay)
PO:(3)'-870 mg {2.'-' mL)Mry 4 h
PO;32>-3,OOO mglliay il divided glda,)
NSAIDs: IBUPROFEN AND RELATED DRUGS
(Ciulialn,
di'hllilal (Doload)
t\oOOIi( (lodint)
frnoprofffi ukilll1 (HaKon)
Ikubiprofffi ( ........ idj
bupro/ffi (Advil, Motrin)
i"IdoIntthHio (lndodo)
ketoprofffi (Aaron. Orudi,)
ketoroLK tJOOltthiinint (Toridol)

IOI'loxic:.Jm(Mobic:)
nalPurrlttont (Rdaltn)
naproen (NaprolnNaprrlan)
naproRll !OdiU1l
(AIel'!',
OliIpro.zin (Ilaypro)
piroxkam (ffldtntI
ruindH (Cjnorin
tolmttil (ToIKtinJ
NSAIDs: CDX-2 INHIBITORS
crIroIxib
ACETAMINOPHEN
po; 50 mg bid-.:tid (mal:lOO mgldqJ
PO; 1,000 mg followtd by 500 mg bid-tid
PO; 100-400 mg tid- qid
PO;lOO mg tid-ljd
PO; 50-100 mg tid- qid (miX:lOO mglda/)
PO;400 mg tid-ljd (max: 1,100 mgfday)
PO; 2),-50 mg bid-tid (miX:200 01 75 mg lustaiOl'd
rdNIot 001' to twotinnlday
PO: 11.5-50 mg lid- qid
PO; 10 mg pm (mal:40 mgfday)
PO; lIliding dolot: >00 tog; MiioltnalKt obit: 150 mg Mf'/ 6 h pm
PO; 75 mglda, (miX: I, mgfda,) 7.S- I'mg daly
PO; 1,000 mglda, (mal : 2.000 mglda,)
PO; 500 mg followtd by 100-2,0 I09Iid-qid (mn: 1,250 mglda,)
PO; 250->00 mg bid (miX: 1,000 mg/daynapronn)
PO;600-I,lOO mglilay (mn: 1.&X1 mglrII,)
PO; 10-20 mg _totwo timtsldq (mil: 20 mglday)
PO; 150-lOO mg bid (max:400 mgfday)
PO;400 mg tid (max:2IJ/dolY)
po; l00-lOO mg f'ltry6-8 h or 100 mgo;id
Q (TyitnOI) (It\' I PO;32)'-6>0 mg f'ltry (-6 h
... 472b"liIt PKtypf IlrIJl 001
010
)
CENTRALLY ACTING DRUGS
doridilt
trarnadoi (UlUim)
PO;O.1 mg bid-lid (max:O.8 mgfday)
PO; 50-100 mg f'ltry (-6 h pro (miX: 400 mglday);may stanwith
2S mlJ/day,ind iIKIWI' by 2, mg f'll'IY J dar.; !4l10 200 mgfdolY
louathtCill O.llII(gih via infusion, mily ilm'a\f by O.llII(gih
Mry 2-l days (mn:O.8 m(glh)
lidinindic:itt ronrnon actl'!'f"lt strious idl'!'rst tfltm.
Effects
Broocbqg!i)m apaph'llanic:!hod hemglytk iDmJia
WIIjfSTioo,IIfW4 ocrulrblood Icl\ QIII1R:li4
IrtixJodIe,dn:Iwfinru,dlzirHIJ5
Aplagi<arrem@ dOlQ:jnd!K!'!! peptiq la'r GI
lameal
NrnMprriDhrral f!Iema MUlt !l'nal
(onsti'l<nio!l. djarrOO
Abdomiool poin, dlzirHIJ5, lrHdIxilt,

CaUI"OUI Ulot dut to fDA rrnew
l
oraDdryinQIaJhoiCJ
l!epalotoxid\y l!epati( (oma I(U!e renal failure
I/ypoumktr, dry
II'rTiN
AnaphyOOkrtlion
Aspirin, Ibuprofen, and COX-2lnhibitors
ferent formulations, including those designed for children.
They are safe and produce adverse effects only at high doses.
Aspirin and ibuprofen are available OTC and are inexpensive.
Ibuprofen and related medications are available in many dif-
After tissue damage. prostaglandins are formed with the
help of two enzymes called cyclooxygenase type 1 (COX-')
LibraryPirate
L_" ., "'.0 to increase
body te<rpe.llture
Free"""""
endings
(nociceptor)
'.0 j
transmission
,. Figure J8J Mechanisms of pain at the nociceptor level
and cydooX}'genasetype 2 (COX-2).Aspirin and ibuprofen-
related drugs inhibit both COX-I and COX-2. Thus,
COX inhibition is the basis of NSAID therapy. Because the
COX-2 enzyme is more spedfil; for the synthesis of inflam-
matory prostaglandins, the selective COX-2 inhibitors pro-
vide more specific and peripheral pain relief. Celecoxib
(Celebre .. is the representative COX-2 inhibitor. Other
COX-2 inhibitors are available outside of the United States.
,. Figure 18.3 illustrates the mechanism of pain transmis-
sion at the nociceptor level.
Acetaminophen
Acetaminophen is featured as a prototype antipyretic on
page 472 in chapter 33010. Acetaminophen reduces fever
by direct action at the level of the hypothalamus and
causes dilation of peripheral blood vessels enabling
" ,
block ph. l ..... 1
..
o..pter 11 ClnJ9' lor tho> Cont.oI of Poln 229
cox '" Cydooxygena ....
PGs '" P",staglandina
",
pain and

Selectiw
COX-2 inhibito
o Celecoxi b
Non_ lectiw
COX inhibitor.
o Aspirin
olbuprolon
Tissued"""'98
sweating and dissipation of heat. It is the primary alterna-
tive to NSAIDs when patients cannot take aspirin or
ibuprofen. Acetaminophen does not produce GI bleeding
or ulcers, nor does it exhibit cardiotoxicity. Aspirin and
acetaminophen have similar efficacies in relieving pain
and reducing fever.
Centrally Acting Drugs
Qonidine (Catapres), tramadol (Ultram), and zioonotide
(Prialt) are centrally acting analgesics. Of the three drugs, tra-
madol is the most widely prescribed. Tramadol has weak opi-
oid activity, although it is not thought to relieve pain by this
mechanism. Its main action is to inhibit reuptake of norepi-
nephrine and serotonin in spinal neurons. Tramadol is well
tolerated, but conunon adverse effects are vertigo, dizzine!>S,
headache, nausea, vomiting,oonstipation, and lethargy.
LibraryPirate

i
o


I
,
1!
"
230 Un'll Thi'Ne<vol"Sy'tem
"', Prototype Drug I Asp,nn (Acetylsal'cyl,cAc,d,ASAJ
Therapeutic (lass: Nonopioid analgesic; nonsteroidal anti-inflammatory
drug (NSAID); antipyretic
ACTIONS AND USES
Aspirin inhibits pronaglaooin synthtsis in the Ie of in and in-
flammation and protium mild to rnocIfrite reliefof fewor. k has elfects
on blood nsooiLllioo aoo lWt'ating.Aspirin ha, sig-
nmnt intXoagulant i ctiYity,lOO this proptrty is rtSporIsibll' for its ability to
rroUCf tilt risk of monalil)' following Ml.iloo to It'du incidelUe
Aspirin has also foundto rroUCt rilkof (olorfaal the
bt' which it alforos this is unknown.
ADMINISTRATION ALERTS
PlateII'! aggregation inhibition (iIlMd by aspirin is Aspirin
should be disCDntinued IlWek prior totlectivt IUrgery.
Aspirin is t J(rttt!! in the uriIII' aoo alfects uriIII' tfiting for gllKOIe and
wch as vanili)olmandtl"K acid (VMA).
PregOilIKY utegory 0
PHARMACOKINETICS
()jset: 1 h
Peak: 2--4h
15- 20 min (aspirin);2- ] h Iwlicylateat low dolf); molt' than
20 h (salicyl.att ill high dose)
Duration: 2( h
TENSION HEADACHES AND MIGRAINES
Headaches are some of the most oommon complaints of pa-
tients. Living with headaches can interfere with ADLs, thus
causing greal di.tr.,. . The pain and inability to focuo and
concentrate result in work-related absences and difficulti es
caring for home and family. \'/hen the headaches are per-
sistent, or occur as migTllines, drug therapy is warranted.
18.9 Classification of Headaches
Of the several varieties of headaches, the most common type
is the tension hadache. This condition occurs when muscles of
the head and neck become very tight because of stress, caus-
ing a steady and lingering pain. Although quite painful, ten-
sion headaches are self-limiting and generally considered an
annoyance rather than a medical emergency. Tension
headaches can usually be effectively treated with OTC anal-
gesics such as aspirin, ibuprofen, or acetaminophen.
The most painful type of headache is the migrainf, which is
chaf3cterized by throbbing or pu\sa.ting pain, sometimes
preceded by an aUTll. Auras are sensory cues that let the pa-
Pharmacologic ( lass: Salicylate;cydooxygenase (COX! inhibitor
ADVERSE EFFECTS
At high dolts. such as used totrut IfW," inflammatol)' disorden,upirin
rruy utUIf gastric dil(omfon aoo bletding btutUll' of its efit(B.
ntm-<Oatt!! tablwand bulftrrd preparaborn aft' available for patient; who
6pfI"itIKt GI side effects.
Contraindications: aspirin ilKlt'lle bftding tillll',it should oot bt
9Mn to patitrm rr<eiving anticoagulant thtrapy wm as warlirin, htparin, and
plic.ully<in.
INTERACTIONS
I)ug-l)ug: OOrurreflt l1li' of phfnobartitaI, anOOdl, a nd 9WKottioim rruy
demai.! illpiin"s etIKt; . .l6pirin may potMWIf thf iKIion of oral h)1lOl#fmic
O:ugs. Ule(/; of tl>AlOi,lI"iroslU such as prrbfnKid, btta bIockm,
SJirordaamt, and IUIa Ikugs may bf Iif<mIfd whfn rombitIN wi h illpiril.
lollAin,lIIPIhotrmIf, phion)1oin. sUfonamid.>i. and PfOidlll may iooUlf
WhM;r;piin istal;M wfth orne! HS.IJOs,
thin iKlNII'd nlk for g;r;tric:!KH";.
lab Ii5Is: ASJino may taIIII' proIongfd jnIhrorIIbil by dfousilg
prothfWlbit production. A\piin may also IIl!riln with PJlVOOCY ttIU,.1Id
dl>t:1UIf fIOOIlfvellof chI:WmroI,potasWn. Itwl!
may taIIII' abnormalffit.! II I'll'!" IurKtion !fIB.
IWrbaVFoo:l: g.B. gill9fl,and ginkgo may i1aml' thf risk of blttding.
01 Overdose: TrNllllfllt may inWd!- tlltlollowing:artivatfd
gastric lavaqr, wau'',or drug theraPl' for Dl'!'rdolt symptorm wch as
drowsines,abdominal Ifilult's.
tient know that a migraine attack is coming soon. Examples
of seru;ory cues are jagged lines or flashing lights, or special
smeUs, tastes, or sounds. Most migraines are accompanied
by nausea and vomiting. Triggers for migraines include ni-
trates, monosodiwn glutamate (MSG}-folUld in many
Asian lOods, red wine, perfumes, lood additives, calfeine,
chocolate, and aspartame. By avoiding foods containing
these substances, some patients can prevent the onset of a
migraine attack.
PHARMFACTS
Headaches and Migraines
About 28 million AIIII'ric.Jns wfltr from hNdaclies ind migfiiOl'1.
Of all migraiOfi, 9S% ire (ontmlt!! by drug therapy and other mtilwrfi.
Befon! puberty,mOlt' hm milraillti than girk.
puberty. WOOlM have four to tight times more migraines thi n I11I'II.
migraiOfiipptitr monly among propIt in thtir 21>saoo 3I>s.
PeMOI with i family history oflltadarllt or migraine hal'l'a higher
disordtB.
LibraryPirate
NURSING PROCESS FOCUS PATIENTS RECEIVING N5AIDTHERAPY
Assessment Poltnt lal Nursing Diag noses
Bastline IISHlnWnl prior to adminillultion:
Undtnund tilt reasonthtdrughasbttnp!e(ribedinordHtom&kK F'HI IAcuteorOwonid
Wr<lpMK Rill! for Injury (n:llled to adwne drug effts)
(omplete history inWdillg htp,til:, n:rlll.fespirato/y,
0 r neurologic dU. It; pn:gna My. or b!Mt *Ning. OM
drug mooing .1Hgie, aJm:m pn:Kription ind OTC druqs, hfrbiI
and ak:ollollM.Bealert \(I drug
intefa<tions.
Obtain wstiM vitll signsind Might
hiluatt appop riltf bboroJlOl)' findiJIgI (f.g., CBC,(OigUIation
bleeding tirM, III rm.lfunction slm).
AMls tht pilimt's abllitylo imd UOOU'lt.lnd etrunion.lndudI'
W bmil)' as needed.
lssHs mrnt thID' ghout .ckninisIJltion:
AlWSs for dtsir!d thtrapMi( rifeo:ts (f.g.. pa;n is or absrrw,
signs and symptomsofinllammation wdI H redness orswrlling In:
deurased).
Continur periodic monitoring ofCBC,(I)IgWtion studies, bletding tVnr,
Md hepatic ind n:rlll fun<tioIt Itudits.
AMls vital signs ptriodiuly.
AlWSs for and promptly rtport adYrrst efieas:symptOJlll of GI bIding
(& rt Of 'tarry" s tools. Of mffM-.ground _is, blood in tilt
slooO, abdominal ",in, stftre light-
fUphorii ordrprHSion,pilpitatioM,
uch)o:arlii, inoNled respfltHy ratt and drpth, pulmorllry
congestion, and rdrma.
Planning: P,tl e nt GOll s and Expected Outcomes
TIlt pitifm wiI:
Exptrirn<e wr.pMic effects or abstnt piin, signs Ind srmplOms ofinillmmltion).
fmon,orv:prrimcr acImw rlfts.
an undrrmncling of tbtdrug's list, adYe'W rlJe<ts. and prteaUtionI.
Otmonstmt proper seIi-fdministratiott of tilt mediClibon (f.g.,doIt, timing, wilt" 10 notif! providtr).
Impl ementation
Interventions and (Rationales) Pati ent and Family Education
Ensuring t Mupeutic effKls:
Continur Msesments IS dtscribed tlrlirr forthtnprutic effeas.
{Dim inMed piin, III signs and i)'IllptOlJlS of infll mrnatiln (ontributing II
IWin should br1jin altrr takioIg first and continur to Tht
proI'idrr should be notified ifw polin inm:ase.)
ltadl the 10 drug nonpNfmiCologic
{e.g. rNxation trdJ niquf!. d iYMiorwy SlJ(h is
telmsion or fIMi<J and to n:port inclf.l sing pain unn:1iMd by drug.
Minimizi t g ad'ftrsr effects.:
Continur to monitor ptriodit lab and Ifllll imaion ttru"
(I(,<lnd stlJdirs Of biffiling time. (Aspirin and wli<ylatfS
affKt plateleuggn:gatiott.lnd should monitored ifUlotd Ioog term or if
bftding or bruMlg is ooted. ,l,maminopilrrl YII be htp,notoxi<
in Ia"lf doses or if taken w4len htpatio:: d,simdion is pretnlJ
Il\SllII(t the p,nitnl on tht Iftd to If tum prriodiully for lab work if on the
drugs long tmII.
ltad! thf ",tirnlto abstiin from alcohol whit taking acflilminophtn.Men
who twoakoholic bnmges prf &y Of womrn who
(onsumr JllCRwn Ont akoholic prr &y should mm.uh tbN
..... Ith pMidrr btf .. tHing .<rt.minophm.
---'---
{Conrlnued}
LibraryPirate
232 Unlll TheNe<vol"Sy'lem
NURSING PROCESS FOCUS PATIENTS RECEIVING NSAIDTHERAPY (Contln(Jed)
Implementation
Interventi ons and (Rationales)
Monitor for .Jbdominal painJIbc:k or t,flY nook. blood in till' nool.
III'maleme1isor emnis, diuinffi.light.he,dtdntlli .J nd
h)'potemion, with tam)'{ardia.(NSIdOs (.JIU
Glblffilir.g.)
Monitor for tinnittn,diffiruity diffKUit)' with
rt'pOn promptly.(NSIdOs ,nd QIKyLttes may btototOJic and
(.JlU lII'aring loss.)
Monitor uri III' output .J nd rt'na I fulKtion studiel ptriodically. (NSId Os ,nd
salicylate, may lit rt'nal toxic: and j)atienllon long-term or high.oose
tOOap)' should monitor urineOUlput and ha\'e ptriodil: rt'llal fuoction
studits.)
Avoid the lUof aspirin or !.llicyLttn in (hildrt'n under 18 uplicitly
by tllf hNlth w e provider.(Mpirin has bet-n with an
ilKrt'altd risk ofReyts ,yndroml' in (hildren 18. p,nirularf)'
with tllf fkJ virus and wnlla iofto:tiom.)
Patimt understanding of drug thrrapy:
Use opportunities during administration of medKaiiom ,nd during
I,,, .. mtntl to diKu .. rationalt for drug llIfrll')'. th.rapwlK
ou/(omes. man (ommonly oblm'td efftm, tHIraml'tl'n forwlll'n
10 call tllf health "r. proYider.and any monitoring or
prfuutions.(Using timl' during nming (<In:' to optimilr and
n:'infortt keytu(hing
Patimt self-administ ration of drug thtrap1:
WIII'n administering tllf mtdiution, imtnKt tllf family. or
(<lA:'giY!'r in PflIP" seif-adminisuation of drug.e.g., with food or mill
(Utilizing tiIMduring of thf'St drugs helps to
n:<inforttleac:hing. me.J!uring SIKh as teaspoom
signifKantly in and ,moont and should not bt wd for ptdiatrio: or

Patient and Family Education
Innllltthepatiemto inrMdiatl'ly rrport any,q.sor ')'IIlptornsofGl blerding.
Teac:h till' patient to the drug with food or milk to irritation
and to ,wallow tabiru whoit without or breaking.
Akohol ule should bt 'l'Oidtd or
ImtnKl tllf patitot to i mmediateiy repon any signs or symptoms of ringing.
humming. buui ng in t m, diffKull)' with balalKf, diuinffi or venigo, or
nalUa.
ImtnKt tllf patient on NSAI05.Jnd "IKylatn to promptly It'port (hanges in
quamil)' of uriIII' output, darkening of urine, or edema.
Teac:h the patient on NSAl05 and ulicybtes to ilKrme fluid intake,
fSptd,11y if fewr is IR'tnt.
ImtnKt partnu to lU NSIdOs or ac:mmioopllfn in (hildren 18 for
ft-mor otht rvme ordmd by IIII'
Tt ac:h to rtad Ltbtlson all OTe medications.Jnd to avoid
formulatiom with alpirin or salicylate on lhe labtl.
Tilf should ill' abit to ltatellll' INIOn for IIII'
drug; l ppropriOltdo .. and Khedulir.g; whit Idvt"" d'km tooln<rw for
and when to report;and theanticip'led itngth of mMic<ltion theraII)'.
Tilf is abit to discuss appropriale doling ,nd
administration needs,ilKluding the following:
NSAI05 bt with food or milk to 61 upset.
liquid OMsof or NSAIDs should bt mt wrrd with the
elKiosfd dosage (UP, dropper, or spoon .If that measuring devKe is 00
miLtbit. do NOT lU a hou!ehold spoon but obl,in anotllfr
talibratl'd ml'alUring (UP or dropptt
Evaluation of Outcome Criteria
(y,luate till' of drug lheral')' by (onfirming that j)atitnl goals <lnd ouuomes hom bet-n m(l (_"Planning").
5tf TM!It III IilllidflllJl rcwhich rhm fllningaaim\
18.10 Drug Therapy
for Migraine Headaches
There are two primary goals for the pharmacologic therapy
of migraines (Table 18.4). The first is to stop migraines in
progress, and the second is to preVl'nt migraines from oc-
curring. For the most part, the drugs used to abort mi -
graines are different from those used for prophylaxis. Drug
therapy is most effective if begun before a migraine has
reached a severe level.
The two major drug c1aroses used as antimigraine drugs,
the triptans and the ergot alkaloids, are both serotonin
(5-HT) agonists. Serotonergic receptors are found through-
out the CNS, and in the cardiovascular and GI systems. At
least five receptor subtypes have bffn identified. In addition
to the triptaru;, other drugs acting at serotonergic receptors
include the popular antianxiety drugs fluoxetine (Prozac)
and buspironc (BuSpar)_
Pharmacotherapy of migraine termination generally be-
gins with acetaminophen or NSAIDs. If OTC analgesics are
lillable to abort the migraine, the drugs of choice are often
the triptans. The first of the triptans, sumatriptan (Imitrex),
was marketed in the United States in 1993. These drugs are
selective for the S-HT, -receptor subtype, and they are
thought to act by constricting certain intracranial vessels.
They are effective in aborting migraines with or without
auras. Although oral forms of the triptans are most conven-
ient, patients who experience nausea and vomiting during
the migraine rna)' require an alternative dosage form. In-
tranasal formulations and prefJlled of triptans He
LibraryPirate
II Drugs 100M Conlrol of Hl
TABLE 18 4 Ant.migraine Drugs
On"
Rout" and Adult 00sI! (mu do!il' wher" Indlcaled) Adverw Effects
ERGOT ALKALOIOS
dilydlOffgOlalrine (O.HHS, 1M; 1 mg;lNy be Hllnttrv,lstoa lotal on tog pth,pnfflM
MigI,nal)
(lNl:'ffi9.I'wk)
DtilillD iOlwniDml
tlgotnine I[rgoSUt) PO; 1-2mg followed by 1-2 mg"try 30 min ullil
...-
with Glfltine (Caftlgol, ErQtOlhm) Slops (nw::6 mg/d.lyor 10 O\9I'WkJ
TRIPTANS
aknouiptan (AIM} PO;615- 1l5 mg; may irptat in 1 h iffll!<e\.Sary (max:
2 tabs/d.ly) verli90
elMripun (Rtlpaxl PO; mg; may 2 h ifnmary (max:80 mgld.ly)
!!II
froutriptan(flM) PO; 25 mg; lNy Itpt'.t In 2 h W nKtssar:y 1m,.: 75 mg/day)
nar"riptln PO; 1- 25mg; may il4 h ifnmafJ (max: 5mg'd.ly)
rilatriptan lM.iult) PO; S-10 mg;may ill h iffIt{PIQry (max:lO mg/day);
5 mg with concwrtlll propnnolol (max: IS mgl<1ly)
o sumatrlptan (mitra) PO; 25 mg for I d.t (INt 100 mg)
IOImitriptan (Zomil!l PO;15-5mg; may il2 h ifnmafJ (max: 10 mg/d.ly)
ANTISEIZURE DRUGS
topiram.tt llopimax) PO; ltart ""'th SO mg/My,lname I1i 50 mgt.ek 10 /(QIISttI, wtOtnm
1.600 mg/day)
Ilm!:
Yilprok acid (OepiW, Dtpakott) PO; 250 mg bid (max: 100 mg/day)
BETAADRENERGIC BlOCKERS
.tenolol (Tenormln) lsee pi9I! 347 PO; 2HO mg/d.ly (mal: 100 m9l<11y) 8It!dycQrdQ, hyporrrrs/(JIt (/If, arnl\m drowsIr.m,
PtoIotypeDrugbo:w: OC '_IIIQ
PO; 50-100 mg one 10 twolimHld.ly (mil: (SO mgllby) BmndmNl!!I.o!iatM: Itrmati!il.mou!omnn
II Kllba!!!: iritation rash QI!!W;!m!
proprjoolol hyoi"ochloridt( hdtralJ (1ft PO; 00-2 40 mglday in diYiikd dales; lNy need
SIM!I!-Jo!rnm Syndrprm
364 Protot)'Pl! Drug boJ( 00) 1'0-240 mg/dly
PO; 10 mg bid;mllinawf 10 60 mg/dllin IWO divided doses
CALCtUM CHANNEL BLOCKERS
nifedipine (Proc.Jrth) lOS for the PO; 10-10 mg tid (max: 180 IIMJ/day) fOOd &islriJ9,lwr
PtoIOI)lK Drug boJc 00) sen!irirlry.C#QrrWperip/ltrlll tdem411todoche
nlmodplfH! (Nimolop) PO;6O mg ffflY 4 h for 21 days;SUrttilerapy within 96 hours

of !Ub,.,(hnoid htrnorrhagt MI ,w b!oct
Wtlipamil hydrodllorid/, 1Sf!' pagI' PO; 40-00 IIMJ lid IINI:l'O IIMJ/dayl
366 for Pl"o\OlYpt Drug boxOO)
TRICYCLIC ANTiOEPRESSANTS
hydioo:tjoridf [Eiavi) PO; 75- 100 mglday
imipramill (Tofranil) (1ft PO; 75- 100 IIIC)fday Imax:lOO IIMJlday)
mioo.Jghl
PtoIol)lK Drug bo:w: 00)
(omtiporioo
(V"l"Iactil) PO 15-40 mg/cliry illlul'e to fOIl" dvided dwllfllil:
MI mnoomosn
6Omg/day)
anqiofdtrnol bon rrnrrow !!rrmsion
MISCELLANEOUS ORUGS
meth)"WflJiIIt ($inStIl) PO; (-8 mg/dily in diYicied dole! /(1IlMQ, WfDknts.!.
riboliavillYitamin B,) M' !l.ppImtenl: PO;5- 1Omg/day
diW>lo,.rion cf iii", (M- ,;,.mi" 8 j. poinfu/ u,;",/i""
FordriidtlKy:PO; 5- 30 mg/da1 in diwided doses

IIQIia illCkatt Ullllmon id'Ime sffiousadwl'l"\e eflKu.
LibraryPirate
234 Until /lle<vOI" Sy'tem
for patients who are able to self-administer the
medication.
For patients who to triptans, the ergot
alkaloids may be used to abort migruines. The first purified
alkaloid, ergotamine (Ergostat ), was isolated from the ergot
fimgus in 1920, although actions of the ergot alkaloids
had been known for thousands of years. Ergotamine is an
inexpensive drug that is available in oral, sublingual, and
suppository forms. Modifications of the original molecule
have produced a number of other pharmacologically useful
drugs, such as dihydroergotamine mesylate (D.H.E. 45, Mi-
granal). Dihydroergotamine is parenterally and as a
nasal spruy. Because ergot alkaloids interact with adren-
ergic and dopaminergic receptors as well as serotonergic re-
ceptors, they produce multiple actions and side effects.
Many ergot alkaloids pregnancy category X drugs.
Drugs for migruine prophylaxis include various classes of
drugs that are discussed in other chapters of this textbook.
These include antiseizure drugs, beta-adrenergic blockers,
calcium channel blockers, and antideprt'5Sants. Because all
these drugs the potential to produce side effects, pro-
phylaxis is initiated only if the incidence of migraines is high
and the patient is unresponsive 10 Ihe drugs used to aborl
migraines. Of various drugs, the beta blocker proprn-
..,. Prototype Drug I Sumatnptan (Imltrex)
COMPLEMENTARY AND ALTERNATIVE THERAPIES
Evening Primrose Oil for Pain
primr= (Primui<l himJ) is a plant natM to North Ameriu. The oil
extracted from tilt of tilt pLtm (Olluins high amounts of g.Jmlllil
linoltnic acid, <In fatty acid thai is II)' the body for normal
growth ,nd
EYeIling primrosr oil hi. twn used for a Ltf9r numbtr ofdivern mnditions.
Ihr mongen KientifK is for tl"!ating Zt1llil,1l rondition (hariCIer-
ized II)' infbmed,itdJ, .kin.Somtdata hu Wl}9r1tfdlhalthe IItrblllily
p.,tin in patienll with brNll tendernf"l' ,nd rhfUmuoid anhritis (little &
Pmon!, 1(00). Although uled frtquently to tft'at the .ymptom. of prrmen-
lIrual')'Ildrolll!', I"!learch hi. not shown lhe IItrb to for this indi-
cation Ulog, 2(01). Other daimt<l u ItS indude diabttir: lII'uropathy,(holtllerol
Ifduction, mukiplt Illtrosis, oI nd plfVfntion of strokt; I(itntm.: !"Ii-
den(e is towppon thflfindiuUons.Evening primroleoil is YerY
Thetr is some that it IIIiIY Iowtr in parifnt!
with epileply.
nolol (Inderal) is one of the most commonly prescribed.
Amitriptyline (Elavil), an antidepressant, is preferred for
patients who may have a mood disorder or suffer from in-
somnia in addition to their migraines .
Therapeutit Class: Antimigraineagent Pharmacologic Class: Triptani S-HT (motonin) reptor agentivasoroffilrictor of intracranial
arteries
ACTIONS AND USES
Sumuriptan to a rtLttively III'Wer group of antimigraine drugs koown
.H tilt Thf triptans ac:t II)' cau.ing moronstriction of mnial anerirl;
this oIlOXOIIltriction is mocIt!lltely leltctiY!' oInd rIofI not usually affrn OYfIall
blood PI"!lIUft'. This mtdir:ation is oI '/i1ilable in oral, intranasal, ,nd wbcutalll'OUl
form . SubwwlOOIS adminiltr.nion terminatf! migraine anadG in 10 m 20
minutel;the dole may rtpeated60minutf"loliterthe filii injKtion,tooi max-
imum of tWO dose ptr day.lf taken o!lllly, IUllliluiptan .hould administe,ro
.H lOOn 01\ aitfr the migraine is 'UIpf(1ed or hal
ADMINtSTRATlON ALERTS
Sullliluiptan m,y prooiKt cardiac isclltmil in IUlaptiblt ptrwnl with no
prI"YioUI (ardia( Heakh cal"! pIIJidrl5 mol, opt m oIdminint'r thr
initi,1 doIfof IUllliluiptan in the he,kh Un' letting.
Sumauiptan'! 'ystfmic. '/aIOOlnstric.tor oIctiYity may Wllf hyperten.ion
and molY ft'IUk in dysrh)'lhmil. or IIf)'O(olrdial infa rnion. Krep relJIcilollive
tquipmeM oK(f"lliblt.
Sullliluiptan \electively ,ro!Kf"I wotid oIIterioil blood flow. Monitor
dian9l" in It-Ifl of and for 'fizulf!.
Plf9l1ancy categol)' (
PHARMACOKINETICS
1At5l!1: 15 min n,sal; 30 min PO; to min lUocutalll'OUl
Peak: 2 h PO; 12 min .ubrutalll'OUl,60- 90 min nasal
2 h
Duration: l ..... 48h
ADVERSE EFFECTS
Solii!' drow.ines!, or 01 warming IfIlsation may t lptl"itlKtd oIlter
taking .umatriptan; howeY!'r, thfslo efftru aft' not normally II"Yfft' enough to
warram discootinuation of therap)'.
Contraindications: BeuUIf of its moronllric.ting ac:tion, the drug .hould be
used (i1utiou!ly, if Ilt all, in patients with te<ml m}'lXolrdial infarnion, or with 11
hinol)' of oIngina hyprnenlion,or
INTERACTIONS
I)ug-l)ug: Sum.!tripUn ReroKll wth ilKlNlfd
ffl'fU may (]I" WMo t.en with moooamiM' OIida1t inhibitoo I MAOfs) and
IOlII ouur
whM tabn with PIgot alkaloid! and O!htr iI1>ln.
lab Tesll: Unlnown
Ik>rbaVFtIXI: Ginbjo. <;WfIItII9, edtilloKN, and >t. .101m"! won may OON ..
lOIir:ity.
Treatment of O"RrdO.f: Tl"!atment IIIiIY ilKludt dllHj theraPl' for the following
.ymptom.: weaimtu, loKk of (oordination, watel)' r)'f! oInd mooth, treman,
leizurel, or bl"Nthing probltm .
Rnfor III MytmIfIgKI (or a tmIniJ /'rIxts5 fooIlIpK/It: 10 1M <tI!q.
LibraryPirate
c..,1II'1' 1]5
NURSING PROCESS FOCUS PATIENTS RECEIVING TRIPTAN THERAPY
A.uenmerrt
prior to administr. ion:
UndeI5t1nd 1bt tilt cWg pm<ribtd in ordeIlO auns fof
therapMK
Obtain i health histOf} inWcling
htpllic..or it drug
history iIIdud ing illtrgit1. ontnt presaiption and ore drugs,
IRP'Iratioo!, ilmbollM.BeaRrt 10 drug
Obtain baseint vitll signs,ipal pulsf,ltI'tI of cOI\I(iousntll,and Iftigbl
Aswsslilt fttI of pain.1M objfdift SUftlling took wMn poIlibif (e.g..
WlIIg-8.tkn fA((S iQIf fordWdrtn, rating S<aIe for aWbl-
AlSeSs tilt hislOfy of the polin and wlwt 1115 worbd wcctSiful1y 01 not for
the patifnt in the
MlualtappropNte Liboralory findings {t-g., (BC,hepitic or renal bJniotr
stooitsl.

the family ancIulf1liYffS as netded.

or
absent).
ConlinUl' monitoringltftl of {OOKiou\nm.nd nrurobj:: symptoms (r..g.,

AlSeSs sigM, especiilJ, blood p_ and pulsf periodically.
ContinUl' pmocIit: monitritg MId rual furKtion studits.
Aswslstms i nd oopill9 p.itltms for po!5ib1e symptom <OOeIation (t.g.,
ecistill9 or pnttiYtd ibilion,copi"!l mKhanismsOf rttnfdie).
Mel for and promptly rtport pain ortightnKl,
p.llpitiltiom, lIypenertsion, diuintsl, lightheadednesl,
{onMion,ind flUmbnKI or tinglill9 in ntmnitits.
NI,I15in9 Diagno5u
Anat Pain
intfftil't fiNllh Mlinltl'oaOO! (rtlattd 10 mbilit, 10 mI"'9t of
eliiii'


Plillnning: Pilltlent GoiII I5 iII nd Expected Out(omu
TIlt wit:
Experitn<t iOOipMK tlfts dfprndtnl on the rtilson tlrt drug is or heada< piin,prtwfllirm of hueli{he p.lin
flam migf,. "uti:).
Be frtt from,OI"tlpt'Mnr:t ilMrwtfl"ts.
Ytrbalizt,n of the drug's 1M, ildI'trsr! tffects. ilnd prtuutions.
Oenonstillt proptr leIf-adminislr<1tion of the iMdi<arbon (r..g.,do!t,.tJning, whtn 10 notify p!O"fidtrJ.
Impl ementilltion
Inte rvention. Ind (Aat ionl l .. )
Ensuring lhe ... ffl'eds:
ContinUl' il6&ribN IortheraptUtir tfI"ts.Giw the
drugbtfotrthe mrt of aruit pain when prKwlt. (Coo5iSRnt US!' of a pain
rating suit by d providtrs wi helpquantify tire Ifftl of pain relirf ind
Iuds to limn pain (ontroLEnr:oorage the patient to sQrt IMdiution
brim W'fm' for bHttrrontrol.PMr ftf btgiM within
first ItftfiI m inutes afte- administratioll.)
Pati. nt and Family Education
lNdr the p.ltimnhat Plin rtWf; latht r than mmly is thegoal of
....,.
EnlDUrlgt tht patitm to tlktthe drug bdIre a hfarbc:he
and ronsisturtly ordroml.
Explain I1tionilt bthind t!rr pain raling Kilt (i.t.,iulO'M (onsistrfllJ
iIIIOII(I all p!O"fidtn).
Inmurlgt tht patitm to US!' additional, nonphannarologir: pain rtlitf
itdDqutS, t. g., quit!, dinzMl, tool room.
(Conrlnued)
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236 Unltl TheNe!\rouSSyslflTl
NURSING PROCESS FOCUS PATIENTS RECEIVING TRIPTANTHERAPY (COIlltlUfi1)
Implementation
Intervention$ and (Rati onale5)
___ +C" C'C"C"::. t and family Eduuot ion
Mini .. izill9ldftnt fft'ts:
Moni!l:lr the blood pl!SSIIIt IIld in palifftUIt
ris.\: for UtWgrmtd should be
the fiBI clost giIom. {lriplillli (,)USf
mO(Olrnriaion.POllmtllOpiIIIoIIWOIIIfl!,mtn O\If/.o, vnoio:tn,.nd
people willi othe! known CAD risk (aclM II1I'I be II the risl)
ch.1IgtI in Ofduration ofhudichf. (SudcIHJ
_ of"th\llldefd.lp qwlity c.n wbioollOid
th.1 difftl in and.1t ac(flll\plnied by such
IiIjnl u fnft, ruh,or Iliff ntd: II\a)' hmId mfflingilil.)
Continue to st.tus ptriodkally. ollight
hNdtdnm m., be !!111ft! to htadachf,MllcMBedlll!l tffffi,O/ m..,

Monitor Wt.I)" inllkf offoods thaI (OOliin Iyramillf, or
I narutt
(rmbting symptoms with Iood Of in Ifirving

Patiftll ulcltrttanding of eng thmpr.
list opportUrtitie doril\9.dminillrauOll of medkltiofts.nd during
UlffimtOU 10 diIlun t!r rItionait for drug mt/apy, thtraptlltic
1II,1\(0mes, lII0I1 commonlyobservtd rlin,.,.rilmtteB forwhen
to call the IItailfl (alf plO'l'iclef..nd an, nemsary monitoring or
PfNautions. {Iking limt d umg nurling CilR' htlps to optirrm and rftnfot
key teaching
Patiftlt of drug therlflJ:
When ,l!lmontring mtdK.ition,instnICt the or
urtgirl in the proptr stlf-Idminimatioft of dll4t.g, tab! tM dlll!l
pmtribtdwhm IItfdtd. (UtjlWng time !bing nUBe"-adminiltration of
tht5t drugs to rtinlou lI'achi"9-l
lnstnxt tht 11:1 Ifpolt .nydltst pBI. tightnflS, III pulslting .ctivity
1M iI st\'el'f III aHlunUts IoIIowiog dlll!l dosq.
Instruct lht pltRm to immtdintly Itporl thall\Jl5 in thalXtfl 01 duralion
ofhudiche Of I accomp.nied by .dditW SJIIlptomllUlh.s fever,rnh,
orltiff IIf(k.
lnstnxt Iht pilitm 11:1 immtcNlejy Itporl inatuill9 tIWintss, lighl-
hNMdntl5,1II bUrmI vision..
fntouragt thf pltifftl 10 kHp.1oad dwry ntDmwtt lymptOrns with
sptdit food! or bfo.<tragfS.lNch the patimt lD.void 0I1imir: foods
containing tyr'-'llKh.s pickled wint, ind aged chttSfl,
whid! alf rom mOIl triggtts for migraine..
The pllitntshoukl be able to StItt lilt I!ason forlht drug;.ppropriatt dost
IIld lChtduling;.nd wh.!tadYmt rlit<ll to br.mel wIItn 10 I!pOI1

TtoKh tht palirfll: ID uu the mtdK.ttion brloR the pain br<0II"IfS SrYm or
1\ tht fiBISymjl10rns of. migriint possille.
Tt.achlht patinJf tIM< proptI' Idrninillration of lIIiKuuntOlll mtdication,
Ming tht plbtn( or urtgWtllf!Um-OrIllOlllUiltr ItChniJlf.(Pain or
I!dness lllhe in;t<tion is CDmmOll but II!.UIlly disaPIIUII within i n
how alttr 1M clost iI takm)
lnstnxt the pltitm that an ' ppIOfIna!r inuan.asal dost ii_splay iota
ONE nostril unltsloth_ist by the hNlth c.1t p!Oidtr.
Evaluation of Outcome Criteria
&aIIr.tt t ffKtitnelof drug thmpy iI1 <onfirmill9 thlt pltifftlgGilll iItId Upt<tfdOlll(DmM hal\! been mtt {Sft"Planning1.
5ft iI/IIt 18.4 rnIt1'tipfQns'for dulfdfllJl II rmidr rhMllfllilll;ffIkInf QPJIIf.
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o..plfltl Onq;iont...ConuoIofp.ln 237
'\
Chapter REVIEW
KEY CONCEPTS
The numbered key concepts provide 3 succinct summary of the important points from the corresponding numbered section
within the chapter. If 3nyofthese points are not clear, refer to the numbered section within the chapter for review.
18.1 Pain is assessed and classified as acute or chronic, noci-
ceptor or neuropathic.
18.2 Nonpharmacologic techniques such as massage,
biofeedback therapy, and meditation are often impor-
tant adjuncts to effecti"e pain management.
18.3 Neural mechanisms include pain transmission via Ao or
C fibers and the release of substance P.
18.4 Opioids are natural or synthetic substances extracted
from the poppy plant that exert their effects through in-
teraction with mu and kappa receptors.
18.5 Opioids are the drugs of choice for severe pain. They also
haw other important therapeutic effects including
dampening of thecough reflex and slowing of the motil-
ityofthe Gl tract.
18.6 Opioidantagonists maybe used to reverse the symptoms
of opioid toxicity or owrdose. such as sedation and res
piratory depression.
NCLEX-RN" REVIEW QUESTIONS
D The nurse teaches the patient relaxation techniques and
guided imagery as an adjunclto medication for treatmet1t
of pain. The nurse explains that the major benefit of these
techniques is thai they:
t. are less costly.
2. allow lower doses of drugs with fewer side effects.
3. can be used at home.
4. do not requireself-injection.
D The nurse recognizes that opioid analgesics exert their ac-
tion by interacting with a variety of opioid receptors.
Drugs such as morphine act by:
t. activating kappa and blocking mu receptors.
2. inhibiting mu and kappa rq>tor .
3. activating mu and kappa receptors.
4. blocking sigma and delta receptors.
o A patient admitted with hepatitis B is prescribed Vicodin
2 tablets for pain. The appropriate nursing action is to:
I . administer the drug as ordered.
2. administer I tabkt only.
3. recheck the order with the health care provider.
4. hold the drug until the health care provider arrives.
D The nurse administers morphine sulfate 4 mg IV to a pa-
tient for trrutment of severe pain. Which of the following
18.7 Opioid withdrawal can result in severe symptoms, and
dependence is often treated with methadone mainte-
nance and newer drug combination therapies.
18.3 Nonopioid analgesics, such as aspirin, acetantinophen,
and the selective COX-2 inhibitors, are effective in treat-
ing mild to moderate pain and fever.
18.9 Headaches are classified as tension headaches or mi-
graines. Migraines maybe preceded by auras, and symp-
toms include nausea and 'omiting.
18.10 The goals of pharmacotherapy for migraine headaches
are to stop migraines in progress and to prevent them
from occurring. Trip/ans, ergot alkaloids, and a number
of drugs from other classes are used for migraines.
assessments require immediate nursing interventions?
(Select all that apply. )
t. The patient's blood pressure is 11O{70 mmHg.
2. The patient is drowsy.
3. The patient's pain is unrelieved in 15 minutes.
4. The patient's respiratory rate is 10 breaths pt'f minute.
S. The patient becomes unresponsive.
II Nursing interventions for a patient receiving opioid anal-
gesics over an extended period should include:
t. referring the p.11ient toa drug treatment center.
2. encouraging increased Iluids and fiber in the diet.
3. monitoring for GI bleeding.
4. teaching the patient to..,lf-......,.. blood PreMUfe.
1:1 The most appropriate method to ensure adequate pain re-
lief in the immediate postoperative period from an opioid
drug would be to:
L give the drug only when the family met1lbers report thai
the patient isoomplaining of pain.
2. give the drug {'I.ery time the patit'nt complains of aalle
pain.
3. give the drug as oonsistently as possible for the first 24 to
48 hours..
4. give the drug only when the nurse observes signs and
symptoms ofpain.
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CRITICAL THINKING QUESTIONS
1. A patient is on a analgesia (PCA)
pump to manage postoperative pain related to recent OT-
thopedic surgery. The PCA is set to deliver a basal rate of
morphine of 6 rug/h. The nurse discovers the patient to
be unresponsive with a respimtory rate of 8 breaths per
minute and oxygen saturalion of 84%. What is the
nurse's initial response? What are the nurse's subse<Juent
actions?
1. A 64-year-old patient has had a long_standing history of
migraine headaches as well as coronary artery disease, type
2 diabetes, and hypertension. On review of the medical
history, the nlll'Se notes that this patient has recently
started on sumatriptan (Imilrex), pre5(;ribed by the pa-
tient's new neurologist What intervention and teaching
should lx> dont' for this patient?
3. A 58-rear-old palient with a history of a recent MI is on
beta-blocker and antkoagubnt therapy. The patient also
has a history of arthritis. and during a renl be-
gan laking aspirin because it helped control pain in tlk>
past. What teaching or recommendation would the nurse
have for this patient!
Su Appendix D jor llnswtn" lind rationales for all activirieJ.
EXPLORE
Is )'''''' IIIII! sIllp I<Y _ cmpl ... "",lew rnateriDI!; am
mOlJfO!'S. l'Iepare for _tess 'Mill adGtIoolll prac!rCe
QI.!I!5\ic;ns.. inltlrlJdi,u and acti'litlelS. web Ii'b,
alll videos.
)'W' ;w;ess <;Ode from the IrvnI ot root' bod.; at

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DRUGS AT A GLANCE
lOCAL ANESTHETICS
Amides (IIt141
Q lidocaine (Kylocolne) pog04J
Esters (llJ}tW
GENERAL ANESTHETICS ".146
Inhalation Agents p!IIJtl#
&lses !ifl41
o {JIig/141
Itlkltlll!Uqulds (JfJIJt147
o ho/orhan. (F/uoIIIDMJ ,. ut
Intra'ltnousAgtnts pogtUJ
lIarbltumtt and BorbHurot1ct
plllltlSI
Q pogtlSl
0p/0ltJ$ ,..151
9fnzodlcwptlfS ptIIJtXI
ADJUHClSTOANESTHESIA ptIIJt1S1
Opioids ptJ9t lS1
Hewomu!(UlarBlodling Agents ptJIJ/15]
o wcdnyk/lOJlM (MIInf) /111ft 15J
KEY TERMS
amide (II19t241
balanced anethelia (JI19t 246
nil!!' fJIJIIt)j]
Drugs for Local
and General Anesthesia
LEARNING OUTCOMES
Aftef reading this ChClpltr, the studtn! should obk to:
1. Com part and contrast the five major cllnl clIl techniques for
administering local anesthetics.
2. Describe differences between the two maJor chemi cal classes of loclli
anesthetics.
3, Explain why epinephrine and sodium hydroxide are $Ometl mes
Included in local anesthetic cartridges.
4. Identify the actions of generaillnesthetics on the eNS.
S. Compare lind contru t the two prlrTUlry ways that general anesthesia
may be Induced
6. Identify-the four stages of generalanesthesiCl.
7. Foreach of the drug listed In Drugs at a Glance, know
represenultlve drug examplnand explain their mechanisms of action.
primM)' actions, and Important effects.
8. Categori ze drugs used k>r anesthesia based on their classification and
drug action.
9. Use the nursing process to care for patients who are reuMng
Inesthesla.
gfnerll anrsthfsia {X1gt 2W
local anuthfsil paqtl!
lIt'uro!f,ptanalgftil poqt 148
lIt'uromuS(ulu bloxkfr poqt 25J
lurgici l antSthtsia poqt 246
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240 Unlll /lle<vOI" System
A
nesthesia Is a medical procedure performed by admin-
Istering drugs that cause a loss of sensation. l ocil l
II nesthesili occurs when sensation is lost to a limited partof
the body without loss of consciousness. Generlll anesthesia
requires different dasses of drugs that cause loss of sensa-
tion to the entire body, usually resulting in a loss of con-
sciousness.This chapter examines drugs used for both local
and general anesthesia.
LOCAL ANESTHESIA
Local anesthesia is loss of sensation to a relatively small part
of the body without loss of consdousne.ss to the patient.
This procedure may be necessary when a relatively brief
or medicol procedure i. performed.
19.1 Regional Loss of Sensation
Using Local Anesthetics
Although local anesthesia often results in a loss of sensation
to a small, limited area, it sometimes affects relatively large
portions of the body, such as an entire limb. Thus, some lo-
cal anesthetic treatments are more accurately called surface
anesthesia or regional anesthesia, depending on now the
drugs are administered and their resulting effects.
The five major routes for applying local 3nesthetics 3re
shown in ,. Figure \9.1. The method employed is dependent
on the location and extent of the desired anesthesia. For ex-
ample, some local anesthetics are applied topically before a
needlestick or for minor skin surgery. Others are used to
block sensations to large areas such as a limb or the lower
abdomen. The different methods of local and regional anes-
thesia are summarized in Table \9.1.
Local Anesthetics
Local anesthetics are drugs that produce a rapid loss of sen-
sation to a limited part of the body. They produce their ther-
apeutic effect by blocking the entry of sodiwn ions into
neurons.
19.2 Mechanism of Action
of Local Anesthetics
The mechanism of action of local anesthetics is well
known. Recall that the concentJ"3tion of sodium ions is nor
mally higher on the outside of neurons than on Ihe inside.
A rapid influx of sodiwn ions into cells is necessary for
neurons to tire.
Local anesthetics act by blocking sodium challllels, as illus-
trated in Pharmacotherapy Illustrated 19.1. Because tlte
blocking of sodium channels is a nonselective process, both
sensory and motor impulses are affected. Thus, both sensa
(h)
(e) No"", block
- =
(d) Spinal
(e) EpiWral
,. Figure 111.1 Techniques tor applying local anenhMla:la) toplcal;lb) Inilltrallon;(c) nerve block;ld) splnal;and Ie) epidural
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TABLE 19 1 Methods of local Anesthetic Administration
Rout{'
[pid .... ll nnlhffio
hfikration (fitid bIodo:)
Formulatlon/M{'1:hod
Injtaion ;"toth. opiduRil lpKo oflll< spinll conI
Dna injl'Clion inlot iuUI' immtdiato to lilt IUlgiYl m.
Dna in;ction intot ilsUl' Ih.t may btdil1.nllrom tilt
Gpft"aliDn !it.
Injtaion illo tho (mbral5pinal ftuid (C5f)
Chop! 19 Drug, /0, lOGlI .nd "" ...... 1 Ar>e<sthes.la 241

Mon <ommonly.>O<I in ob!lrtrio dui"lliobor Ind doliv<1"/
[hJg dffulti inlO tisWl' toblodo:. 5pf(ific: i1 a
IlllaU alN 10 tilt IUrgiYl !it.
[hJg iflKtS Irmllg lilt SI.I1JitaI na;usrd 10 bIodo:
ItMation i1 i limb Of lalgl' 011., of iht fa<o
[hJg .fIKt'i large, lt9orulall'l lIKhas iht tow.r .bOJmm and
'"
10 mlKom mmlbralll'l induli"ll iht
llalil mtmbralll'S, and Itroal; 'm'! saito Unl t!il absorbrd
lion and musde activity will temporaril)'diminish in the area
treated with the local anesthetic. Because of their mechanism
of action, local anesthetics are called wdium chmmel blockers.
During a medical or surgical procedure, it is essential that
the action oftheanesthctic last longenough to complete the
procedure. Small amounts of epinephrine are sometimes
added to the anesthetic solution to constrict blood vessels in
the immediate area where the local anesthetic is applied.
lbis keeps the anesthetic in the area longer, thus extending
the duration of action of the drug. Theaddition of epineph-
rine to lidocaine (Xylocaine), for example, increases the du-
ration of its local anesthetic effect from 20 minutes to as
long as 60 minutes. This is important for dental or surgical
PHARMACOTHERAPY ILLUSTRATED
19.1 Mechanism of Action ofLocal Anesthetics
,"rye c:onduction;. Il0l"I11III.
Sodium channllls are open, allc.ing Na+ to ent ... the neuron.

2 L.oc: .....thetic i. edminie .... d.
Amide exa mpi"";
Udoc:aina (Xyloc:aine)-ehort ading
Bopivicaina (Marc:a;M)-\ong.er acting
Sodium c: ............. blocked.
N_ condJction ia
tllmporllnly 8U9pended
preventing pain ,.;gnat
Irom "",c:hing the e NS.

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242 Unlll TheNe<vol"Sy'tem
PHARMFACTS
Anesthesia and Anesthetics
20 million peoplt rMY!' grnt rJI JlIHthetia ta{h YNr in tilt
UnittdSw6.
About lulf of all gtneral administmd by a
anrsthetist.
Tlltfim mtdkal JPplUiions of Jnrsthetia were in 1842, using
amI. in lS46, using nitrouHIlid!.
Herbal prodKu may intetact with anesthetia;St.lohn's WOIllllily
or prolong lilt elfts of somtopioidsand alll'nhHia.
procedures Ihat take longer than 20 minutes; otherwise, a
second injection of the anesthetic would be necessary.
Soc\ium hydroxide is sometimes added to anesthetic solu-
tions to increase the effectiveness of the anesthetic in re-
gions that have extensive local infection or abscesses.
Bacteria tend to acidify an infected site, and local anesthet-
ics are less effective in this type of environment. Adding al-
kaline substances such as sodium hydroxide or sodium
bicarbonate neutralizes the region and createsa more favor-
able environment for the anesthetic.
, 9.3 Classification
of Local Anesthetics
Local anesthetia are classified by their chemical structures;
the two major classes are estfrs and amidrs (Table 19.2). A
small nwnber of miscellaneous agents are neither esters nor
amides. As illustrated in .. Figure 19.2, the terms ester and
amide refer to types of chemical linkages fOWld wi thin the
anesthetic molecules.
TABLE 19.21 Selected l ocal Anestheti cs
Chemical Classification Orug
.. '"
. ooil. (!.optodont)
bupiv.uilll' (Ma"YiIll')
dilHKiilll' (NuptrGJiIlf, NlpfItIi nal)
Q lidoCiIiIt (Xylocaile)
priocaile (CitantSlj
f--
ropWac.Jilll' (Naropio)
[slfrs lItnzooilll' (AmtriGlilt, Soiauailll', othtn)
d"joroprocailll' (Ht5IYilll' I
proGIilll' (tfu.oocaill
(Ponioailll')
MiKtilintOUs ilgftlil dydonilll' (Dydoritl
pramoxilll' (Tronotllalll'l
inli<att rommon iId<at .. striousadYl'I\I' ttItm.
COMPLEMEtHARY AND A LTERNATIVE T HERAPIES
CloVlls for Dental Pain
0111' naturalll'medy for tooth pain is oil of doYl'l, a
use date! bac:k thousands of )'l'ars in mtdkilil'. umatd from tht
{iOYe plant tllgtnol is tht actM {heniiGJl tlut prodlKrs a numbing
elfKl. k worb rspecia well 10 r dental wits (Ia'Iitiet).T1It htro is.t pplitd by
soaking a pit{f of {onon and pading it aroond tlltgums dost lOW alfttd
tooth. raommrnd it for temporary rtlit!" of a toothM:he
(AlqaIffl,Alyah)\l,& Arodt,rslOn, 20(6). CloY!' orl Ius oI n tift" tlut
hiS bttn rtpOntd to kill miuoorganilml.
Other Ulet of {iOYe oiltlut lac: k reliablt !{itmific rvidffic:f indudt treatment
of libido,and it-YI'r redlKtion.Ckrn oil is safe,
with r.Jsh Jnd GI upset being the most {ommon Clove oil may
inaNst tilt rilk for blttding and lhoold be lMd {autioUliy in taking
antiroagulantl.
Cocaine was the ftrst local anesthetic widely used for med-
ical procedures. Cocaine is a natural ester, fOWld in the leaves
of the plant Erythroxylol1 coca,native to the Andes Mountains
of Peru. A5 late as the IS80s, cocaine was routinely used for
eye surgery, nerve blocks, and spinal anesthesia. Although still
available for local anesthesia, cocaine is a Schedule II drug and
rarely used thel1lpeuticaUyin the United States. Theabuse po-
tential of cocaine is discussed in chapter 1100.
Another ester, procaine (Novocain), was the drug of choice
for dental procedures from the mid-l900s Wltil the 19605,
lUltil the development of the anlideanesthetics led to a signif-
icant decline in the use of the drug. Ont' ester, benzocaine
(Solarcaine, others) is used as a topical OTC agent for treat-
ing a large number of painful conditions, includingsunbum,
insect bites, hemorrhoids, sore throat, and minor wounds.
Gent'ral Adverst' Effects
Difficulll Of !!m"'ion ",d
annt {ar.'usKm anaphylactoid rurtion.buming,{ontKI
-
(J(5ikpmsim
Rt!i!:al!l!l.rrm <irarial!!!l fail!!! i!li1I1!!l!anoid !l:.KIion
Bl!ming. stinging. <II oppiratioo liIl'
Rt!i!:at!l!lomrd!Harrm
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"eo

o
"
R- C- O-A
o
"
Amidoo R- NH- C- R
CNptor l' Drug. /0. lOGlI 000 """",.1 Ar>e-;thel.la 243
Example
Procaine
Lidocaine
,.. Figure 19.2 Chemical struc!uresof ester and amide local anesthetics
Amide; haw largely replaced the esters because they pro"
duce fewer side effects and generally have a longer dur:alion of
action. Lidocaine (Xylocaine) is the most widely used amide
for short surgical procedures requiring local anesthesia.
Adverse effects oflocal anesthetics are uncorrunon. Allergy
is rare. \'lhen it does occur, it is often dul' 10 sU/fites, which
are added as preservatives 10 prolong the shelf life of the
anestht'tic, or to methylparnben, which may be added to re-
.... Prototype Drug I Lidocaine (Xylocame)
Therapeutic (lass: Anesthetic (locaVtopical); antidysrhythmic (dass IB)
ACTlONS AND USES
Lidouifll',the monfrftjutmly UIfd injmJblt local ilfII'SthetK, KIs by blocking
pain impulse. It miy injffird as iI ntrlf block for !pinal and
rpidural aneitliesi.l.1t am by blocking sodium dunfll'k looted within the
membranes of fll'lJrons.
lidouinr IIIiI)' giYtn IV,IM, or to treilt dysrftythmias, as
disc:uslfd in (haptef BOO. A topitill Ionn isallo
ADMINISTRATION ALERTS
Solutions of lidouilM! (onlilinillC) presmatiYft or tpintphrifll' are in-
trnded for 1001 afll'Stlrsi.l only, ind mun neY!'r pamltefaUy for
dysrftythmias.
Do nOi apply topitalliiouinr to IIIrgr areas or to brokrn or abraded
ilreas, bKaIM !oignifiunt absorption IIIiI)' cur. Do nOi allow it to (ome in
ClIn!Xl with ther)'H.
For spinal or epidural bIoc:k, u only preparations !pr(ifK.l II)' for IV
=.
PregninquttgoryB
PHARMACOKINETICS
Q,scot: 4Hl0 1V;5--1 S min lM;l- S min topical
fINk: Lmtllan 30 nin
Halflife: l.S-1 h
DJration: 10-20 millV;60-90 min 1M; min topical; more than
100 min injent<l for Inesthrsi.l
lard bacterial growth in anesthetic solutions. Early signs of
adverse effects oflocal anesthetics include symptoms of eNS
stimulation such as restlessness or anuety. Later effects, such
as drowsiness and unresponsiveness, are due to eNS depres-
sion. Cardiovascular effects. including hypotension and drs-
rhythmias, are possible. Patients with a history of
cardiovascular disease are often given forms of local anes-
thetics that contain no epinephrine to reduce the potential
Pha rmacologic (lass: Sodium channel blocker; amide
ADVERSE EFFECTS
Whrn 'idouinr is usrd for ineitlirsi.l, me effecu ilre uncommon. M ti r\Y
symptom of lOJitity is (NS leading to irritability and (onfusion. *
rious ildvmt rffKls ilKkidt convulsions, respiratory and urdi.lc i r-
rest. Iknil the effect of the antlthtlit diminishes, patitnts mily injure
themstlvrs by biting or dltWillC) illNS of the mooth that no
Iowingi dtmal proctdure.
(ontr.indi(ations: Lidocaifll' should avoided in UStl of sconsitimy to
amidttypt local ilfII'ItheOO. Applitillion or injKtion oflidocainr antllhtlit is
als 0 {Oltrainditattd in the prestlKt of seYtre muma or sepsis, blood dysaasi.l
silltll brildyutdia,ind of hean block.
INTERACTIONS
BarIil..-atPI may dKlNIt' the oKlility oIIOooR.11KINIfd iIIKI!i 01
Iidouilll' (II" ff (onruuntly with dmMidiw, ani btta bIodH".11
IMd on a rfgvlar basis,its wIwn IMdwilh
--
I..ibTi5ls: IncJN\fd(PK
Unknown
Treatmrnt of O"ft'rdosr: Emttgtnq mt<lital antmian is I"ftded beciIIM of
the miny ilSociillrd 5Ubslilmil't' s)'lllptoms IIKh as blNlhillC) dif'irulty,
swtllirg of tht tlirst pain, irrrlJ.llar heart niIMi, yomitiog, tllmon,
and sHureac:liYity.
Rl'1'e" Ie M)Nu1lJnqKJ/ All" Q NiJrlirll} Pn:ms fooJ5 Jjlt(1f{ Ie rills
I
if
,
LibraryPirate
244 Unlll "TheNelvoo.Sy.tem
NURSING PROCESS FOCUS PATIENTS .ECEIVING LOCAL ANESTHESIA
Assessment
BiStline assess mfnt pri or to administrat ion:
Understand the the drug his been prfnriilfd in order to for
therapMic: fiff,m.
Obtain a (Ompletf health hillory indudi ng (ardmascular, hepatic, rfnal,
or neurologi< disnIC; prtgn.ocy; or 1!rt<I-fre:iinlj. Obtain
drug hillory induding allergits,(urrent and OK
preparations,,,fffinr, nKotinr,Jnd akohollM.1f tilt patiem rtplru an
to' caint' drugs, no tt the spfCifK the patient t lPfriflKf<!.
St ."" to p<mib" drug int .. .aion .
llJ"in ritllsigns and weight.
AsSffi for of broken skin,abmions, burm,oroth .. wounds in to
bf In'iltfd with 1oc,1 inrsthetic:.
Enklatt laboratory findill9l .ppropri.tf to the If -9-, (Be,
tif(lrOiytes, he()atK or mul fun(tioo .rudies).
AsSffi the ()atiem'. ibility to rtiYl' and understand instrooion.lndudt tIM<
family and carf<jiYl'l'l" nrrrifd.
throughout administration:
AsSffi for dtsir! th .. apeutK rffB (r.g.,1oo1 or numbllfls).
Allffi YiI.1 cspc<it liy blood prtSsurt and pullC if rtgion.1 blod: is
UIed.Report a BP less thin 90160, puiSI' l00,or per ()aramrtf rsas
orderf<! by the plO'/ider.
AsSffi thr local or rf<jional ura blocked.Exp:t blan(hing in a Iooliz!
if the 1oc,1 inrsihetK (omaiotd rpinrphrint.lf, lI'9ional alN was blocktd,
periodically asSfiS thr ability to limbs dis,,1 to tIM< block.
AsSffi thf Itftl of (00 sciouSlH'ls if a largt Il' giona I bkKi Win giYl'O. Report
'0)' ilKlNsing drowsinfll, d iuinrss,lighi -headednffi, confusion, or
,gitation immrdiattly.
AsSffi for and promptly fffrds:brad){<lrdit or tac:h){<lKiia,
hypottnsion or hypellrnsion"nd dyspnt,.
Potenti al Nursing Diagnoses
Pain (Il'lated to undtrtying disem pnxm or condition,mllndary to IUrgtry

DrrKient Knowledge (drug tlM<r' py)
Risk for Aspiration
RisldorlnlKtion
Risldorlnjury
Planning: Pat ient Goa ls and Expect ed Outcomes
The ()atient will:
uPfriflKe therapeutK ttfrru (e.g., numbness in local or regional all").
8r!rtt from, or experience minimal. ,dYef!r tiftd .
Verbalin< an undemanding of tIM< drug's USl', adYef!r fiff,ru, J nd rrquill'd prtautions.
pIOPfr stlf-administration oftht mrdK.tion I r.g. dosr, timiog, when to notify plO'/ider).
Implementat ion
Interventi ons and (Rati onales)
En. uring effects:
Cominue i ISfSSlOfnlS .n drs(riilfd rarlier for thtrapeutic fiff,(15. As IfIS the
localized all'. for numblltSsand blalKhing ihhe 1oc,1 antstlM<tK included
tpinephriOf.Asms thr ability to Il101'1' limbs distal tothe Il'gioOilI
,ntnhetic. (Thf duration of InrstlM<tic: action will dtpend on the solution
UIed and whetlM<r 'piOf phrin. is i nduded in the solution .If a largt Il'gionJ I
is bIoc:kfd, r.g., the may rtgain samr motor ability
<l'Os,tion Il'tums ,nd tIM< Il'tum of IIIOtOf signals ritr:lNliog
imlsof ability 10 srotaliorll m.y
during ,lIfItilrsia and miy br ilanning to the ()atienl EpiOfphrinf
in the inrsthetK 5Okrtion will (oostrict kKaliz! blood mitis and r=k in
bLl,RI,i"9 uf tht '""'.)
Pat ient and Famil y Educati on
Trach the ()a tient that tIlr UN m.y br numb for hoursaft.r the
pnxf<!UIl' is (ompletf<!.
T_h the p,>titnt that it is norm.1 thaI. !light PIl'.rul'l' ns.nion m.y Il' .... in
during (r.g.,.tnsation of"luggio( during suturing) but that no
()ain should tIM< patient ,ifn tIlr he.kh proI'idu if
than a .Iight pIl'SSUIl' <l'Osation or.ny ()ain is notic:td ruriog ,nmhesia.
Trach the ()atiem that it is normal to 5010f ability to mO'ff limbs (e.g.,
alter tpidur.ll ' IIfItheiic) ,nd mOYl'lOent may Il'tum brlort thr abilil)o to led
thf IIIOYl'IOrm.
LibraryPirate
Chop' .. t' Drug, /0, lout.odGe ..... t Ane<the<.I.o 245
NURSING PROCESS FOCUS PATIENTS RECEIVING lOCAL ANESTHESIA (Continued)
Impl ementation
Interventi ons and (Rati onales)
Minimizing ad'ftrse effed:s:
(o,ninue 10 monilO' vit.lsign<,npeci.J11-, blood IR,sull'.nd pul<e 10,
paDenU gmn Il'poIl a BP below 90160 or
pa,amettll as arde,td by tbe hti kh call' proYicle" tac:h)U,dia or
bradycardia, <hanges in level of canKiouslII'lI, or dysplII'a in
,tspi,atol)' 'ilt. (Advelle tifls ofOOlantltlll'w all' ,a't. Rtgional
bIoc:ks may caUSt hypotension with till' possibility of ,.fieJ uchyurdii.
B,adyurdii, hypotension, IeYeI of consciousnesl,de<ll'istd
Il'spi,alOl)' ,att, and dy!opnea may signal that till' ant-lthesii has ente,td
till' systemic ci,tulation and is acting as a gelll'ral illl'S!hetic:.)
uution the patient 001 10 t at,dww gum, or drink until the IIIOU1h
hasll'lU,ntd ifklcal (dental) ororaVthroatantlthesia has been
usodlf throot ane.tIl ..... Wtl u <I, a, sn. tilt gag rtfltx t:.c-for., .ating.
(loci I antltlll'tics all' for up 10 3 hooll or mOIl'. Biting injuries to
oral mucous mt mbrantl may ocrurwhile lis= is numb.Aspi,ation of food
or liquids is possible swallowing !m.Jtion and gag ,tilt. Il'lums.)
[nsull' patient safety; monitor motor coordilllltion i ndfa, ambulation
post- region.J1 bklck until {enain mOlOr mMIIK'1I1 is unaffected. g.,
partiruLtrl)o cautious with older aduks who all' ilan incll'astd risk for lalls.
(tlJmbnffi or tfFIs on motor ability post- ll'9ional illl'llhetic may impair
inaease the risk allall< or inju,iesJ
ASlesalNS of ab,asion,bums, or open wounds ij a 001 anesthetic was
applied to the all'a.(Luge open 0' dtnudtd ill'lSIlll)'
of drug absorption into the ci,ulation.lkr !terile tKhnique to
appl-, drug to open all'a!.)
!!rId (artfUlly using pall'ntml IOlutions. (Solution<
(ornaining mUll fIWfr be ustd IV orlo, oot.nesthesii in
all'lI of de<ll'astd ciltulat ion ! fingertips, tOl'S, rulobrs J to
\\IIOCOnlllKtNr t!fern.)
Monitor pain Il'litf in Pilienl! polt- Il'gionil block (e.g., r piciJral). (Pain
will a! tilt ll'9ional block afF.Additional pain ll'Iief
may br Il'quill'<l.)
Patint understanding of drug therapy:
1M oppoMunitit. during of m. dimion. Ind during
IIItS!mtflts to dim/U the rationalt 10, drug theraPl', desill'd therapeutic
moll (ommoni>' obsmtd pa,amt tell forwhf n
10 call tilt health CilIl' and any nKeSsal)' monitoring or
prro:aUlionl.(Using timf during 'Iming ca,t helps to and
key teaching a,ras.)
Patirnt self.administntion of drug thf ripy;
When tht mtdication,in<truct tht patient, lamily,or
<.1ll'9m, in p"'p<'I .. of tilt drug.. . g., uk. Ih.drug is
prescribed whrn 1II'KItd. (Utilizing tifnl' dun ng nurse-adm inimation of
ht lp! to ll'infOKf tea(hing.)
I
Patient and Family Educati on
Instruct the patient to Il'port any in(fl'lIing nalllN, drowsiness. dizzintll,
light-headtdlltlS,confusion, or .ro:ie1)o
Instruct the patient 10 Il'frain from eating or drinking for 1 houror moll'
postanesthesii or umilstlllition has Il'lUmed 10 tilt oral cayity
orthroat
Instruct the patient to call 10, misun<r prio, 10 getting out of bed or
anempting 10 walk .Ione post- epwr. I block,. nd to avoid drNing or other
actjyitits Il'qui,ing physiul coordination (t.g., ll'9ional uppt, limb block)
umit the ,t-sidual tifem aftIII' drug all' known.
tnllruct the patient to inaN!td Il'dnm, 1Wt'1Iing, 0' from
open ifN! under lIl'illmrm.
Proyidt an explanation of dIoli,td rffemof the local illl'Slhetic i nd the
III'rd for postproctrull' monitoring.
TNCh patient to Il'port any discomfort or pain i! the anesthesii wt'III
ofI.
The pat;'nt .hould bt Iblt 10 ,!.Ito the " .. on for tilt drug, .nticipltod
sensation I, a nd effects to obsmoe lor a nd when to Il'port them.
TNCh till' patient to uRoral medication (e.g.,lidocaint iscous) by
.wi<hing.nd ,pirting if USfd 10, 0,.1 cavity a, i>19i'9linll< .nd do not
Iwallow unle-s5 dill'cted by the heakh Call' prwidtr.Appiy topical
medication in a thin Lt)'!" 10 tilt skin afN II dilf(ttd.
Evaluati on of Outcome Crite ria
haluatr thr eirectiYene!s of drug the,aPl' by oonfirmingthat patientgNisand opKItd outcomrs been fnl't
5u r.bIt 19.1forQ htDfItrJ'I' ",w/Wdr rIr6t ""';"'1""'" om
LibraryPirate
246 Unlll The /IIe<v",,, Sy'tem
t'ffects of this sympathomimetic on the heart and blood
pressure. CNS and cardiovascular side effects are not ex-
pected unless the local anesthetic is absorbed rapidl),orisac-
cidentally injected directl), into a blood vessel.
GENERAL ANESTHESIA
Gt'neral anesthesia is a loss of sensation throughout the en-
tire boo)" accompanied b), a loss of consciousness. Gt'neral
anesthetics are applied when it is necessary for patients to
remain still and without pain for a longer time than could
bt' achieved with local anesthetics.
19.4 Characteristics
of General Anesthesia
The goal of general anesthesia is to provide a rapid and com-
plete loss of sensation. Signs of general anesthesia include
total analgesia and loss of consciousness, memory, and boo)'
movement. Although these signs are similar to those of
sleeping, general anesthesia and slet'p are not exactl), tht'
same. Gent'ral anesthet ics depress most nervous activity in
the brain, whereas sleeping depresses only vt'r)' specific ar-
eas. In fact, some brain activity actually increases during
sleep, as described in chapter 1400.
General anesthesia is rarel), achieved with a singlt' drug.
Instead, multiple medications are used to rapidly induct'
lUlconsciousness, cause muscle ft'laxation, and maintain
deep anesthesia. This approach, called anesthrsia, al-
lows a lower dose of inhalation anesthetic, thus making tht'
procedure safer for the patient.
General anesthesia is a progressive process that occurs in
distinct phases. Tht' most efficacious medications can
quickly induce alt four stages, whereas others are able to in
duCt' onl)' stagt' I. Stage J is where most major surgery oc-
curs; thus it is called surgical anrsthesia. \'lhen seeking surgical
anesthesia, it is desirable to progress through stage 2 as rap-
idl), as possible, as this stllge proouces distressing symptoms.
These stages are listed in Tablt' 19.3.
TABLE 19.4
Inhaled General Anesthetics
"'" """ Go. Q oxide
liqtid dtsfhrrant (Sup_)
rfIfturaot (E!brant)
Q halothane (Roothane)
isofhrrant
meThoxyllurant (Pmthraot)
(Ultantl
TABLE 19.3 Stages of General Anesthesia
'UO'
1
CharacterIstics
tmot pain:Thr IoII>s but may
awau.This stagr thl' patiffit lose (oosdousnm.
Exdtemrru and Ir,' Thr patiffit may dtiirious
try to Hurt ratt and bruThing may IIrcorM
irrt<jUlar and blood prrISUfl' (,]0 oJ9rII!I art
admiri!l8M Ilffl, to aim patiffit.
Sunj<alaM:llhl'sia:SktlmI musdts btiomt fl'Imdand
driri!lll stabii=CardiovallWr and bfuThing auivitirs
skM and IhI' patimT btiomes still.
Sull}tl)' bt90s hffl' and rrrnaiosllltillhl' proadul! mils.
mrrlula fl'9ion io!be brain fof
(ootroling If'ipiratory wdio'mruiar Klivily):lfbfuThing or
thl' hun stop!,duth {wkl mUI. Thk IIilgC k ulWlIy
d."iIlOj ynll'ldld""'ll.rn..
General Anesthetics
General anesthetics are drugs that rapidly product' lUlcon-
sciousness and total analgesia. These drugs are usually ad-
ministered by tht' IV or inhalation roUles. To supplement
the effects of a gt'neral anesthetic, adjunct drugs are
before, during, and after surgery.
19.5 Pharmacotherapy with Inhaled
General Anesthetics
There are TWO primary methods of inducing general anes-
thesia. Intravenous agents are usually administered first be-
cause They act within a few seconds. After the patient loses
consciousness, inhaled agentl are used TO maintain the anes-
thesia. During short surgical procedures or those requiring
lower stages of anesthesia, the IV agents may bt' used alone.
Inhaled general anesthetics, listed in Tablt' 19.4, may be
gases or volatile liquids. These agents produce tht'ir effects
by preventing the flow of sodium into neurons in The
CNS, thus delaying nerve impulses and producing a dra-
G>neral Adverse Effects

hypffillwnia apnea, MIlOS;'
OrOW5inm, I'Omirilg
dep!ession rnarkrrl hl1!!l:lenS!2!! Il!I!mooao:
Irdi<> ir.dkoto <om1llOR odv<:"" <fforu;cndaiioiM ir.dkot<5 sc:rious olltm.
LibraryPirate
Prototype Drug I Nitrous OXide
Class: General anesthetic Pharmacolog ic Class: Inhalation gaseous agent
ACTIONS AND USES
Tilt main oKtion 01 nitrous oxidlo is analqcia uultd by of pain
mtChanilll'l! in tilt CNS. This h.n <I low potency and doe not procItn <I
complttr 1015 of conKiou!lIeS! 01 profound maxation of skelttal mUldr. Br-
uuse n ilrous co:id .. doe! not IUrgi{al ar.etthesiJ (stage 1), it is commonly
combintd with other nesthetic Nitrous olidlo is idea I for denul
pnxrdJlI'! btuuse tilt p-atitnt remain! colI\{iou! and un follow inruucticrn
wh ilt tlptnencinglull analgtYa.
ADMINISTRATION ALERT
IV ifolll' i! not alll'adyin pl.icr in use ernergtlK)' mt<:liulion!
aft'nttded.
PHARMACOKINETICS
Onset: 2- S min
Iflk: ll-suhan IOmin
Halllift: Variable
Duration: Patitnn II'mvtr lrom rapidly alter nitrous oxide is
----"'
matic reduction in neural activity. The e.uct mechanism
is not exactly known, although it is likely that ganuna-
aminobutyric acid (GABA) receptors in the brain are ac-
tivated. It is not the same mechanism as is known for local
anesthetics. There is some inconclusive evidence suggest -
ing that the mechanism may be rt'lated to that of some an-
tiseizure drugs. There is no specific receptor that binds to
general anesthetics, and they do not seem to affect neuro-
transmitter release.
Gaseous General Anesthetics
The only gas used routinely for anesthesia is nitrous oxide,
commonly called laughing gas. Nitrous oxide is used for
dental procedures and for brief obstetric and surgical pro-
cedures. It may also be used in conjunction with other gen-
e!";ll anesthetics, making it possible to decrease their dosages
with greater effectiveness.
Nitrous oxide should be used cautiously in myastheni.1
gravis, as it may cause respiratory depression and prolonged
hypnotic effects. Patients with cardiovascular disease, espe-
cially those with increased intracranial pressure, should be
ADVERSE EFFECTS
Whr n usrd in low to moderollt dolts, nitrou! OJide produc:es lew tf-
Inn.At higlltr doles, p-atitnn tlh ibit Klint adYMr sign! 01 stq 2 antllhtsia
wc:h <I ! anlitty, aUtrml'nt. and lO'ftring tht inhaled dolt win
quickly rtVtlse 'Mise As n ilrous omr is tilt patitnt may
temporarily KImi' dilfkulty bft'athing at the md 01 a pnxrOJII'. NaUIN
and vomiting following the proredurr aft' moll' common with nitrous oxidlo
than with other inhalation ' lII'sthetiu.
Somt alll'!thetic:s inlreqllerltly prodln li!'r Nitrous oxidlo
has thr potential to lit abustd by Ulm (lOIIlttimrs medical personntl) who t n-
joy thr statt that tilt drug producrs.
Contraindi cations: Thi! dlll9 is cootraindiuttd in patitnn with an impolift'd
injury, inability tocomp/)' with
pr!"!!ion (nitrogtn naltosis, <l ir r mboiism, air mnsport), undi.lgooltd
abdominoll p-ain or marktd distt mion, bowel obstruction, hypotension, Ylock,
chronk obstructi!' pulmonary C)'anolis, or chell trauma with plll'll-
mothOiail.
INTERAalONS
Drug-Drug: Sympathomilllflirs 0100
d)'llh)1hm.
li bTl5Is: Unknown
HerlIaVFood: Miktmtlt Ii ..... bfiOll' oI oo alter rna)' kI_tfwo potellial
risI: ot' her damage.lk>rbil p!lnlets! urn iIIginger liioi)' also proWH tfworolprulic
_ ..
Trm mr nt ol Overdose: Mttodopramidr molY help rmr the symptoms of
nau!ta and wmiting mociattd with inhilation 01 nitrous oxidlo.
1II!{pf III M)M!1l1ngm (of Q Nulling I'rIKlu FDaIIlpt(1k III rhls
monitored carefully, because the hypnotic effects of the
drug may be prolonged or potentiated.
Volatile liquid General Anesthetics
The volatile anesthetics <lre liquid at room temperature but
are converted into a vapor and inhaled to produce their
anesthetic effects. ConmlOnly administered volatile agents
are halothane (Fluothane), enfiurane (Ethrane), and isoflu-
rane (Forane). The most polent of these is halothane
(Fluothane). Some general anesthetics enhance the sensitiv-
ity of the heart to drugs such as epinephrine, norepineph-
rine, dopamine, and serotonin. Most volatile liquids depress
cardiovascular and respiratory function. Because it has less
effect on the heart and does not damage the liver, isofiurane
(Forane) has beoome the most widely used inhalation anes-
thetic. The volatile liquids are excreted almost entirely by
the lungs, through exhalation.
IV Ane,thetics
IV anesthetics are used either alone, for short procedures, or
in combination with inhalation anesthetics.
LibraryPirate
248 Unlll The /IIeIv"",, Sy'tem
.... Prototype Drug I Halothane (Fluorhane)
Therapeutic (lass: Generalanesthetic Pharmacologic (lass: Inhalation volatile liquid
ACTIONS AND USES
proolKes a Inel of wrgi!ill that is rapid in Ollld.
Akhough halothant does not prodOO' as mlKh rnusde or
analgesia as othtr wlatilt anesthoo. Thtreforr, haloth.Jne is UIfd
with other antsthetK agents inckJding mUI& and Nitrous
oxm is somdimes (ombined with halothane.
PHARMACOKINETICS
()tset: 2- 5 min
Peak: Les than 10 min; the minimum alvtolar (onmltration (MAC) is
0.1591i.MI( is rut<! in older adulK
Variablt
Duration: Halothane's du rilion of action is '/aria bit dot to iulipid solubil-
ity. Patifnu !Ol'tl" from .J nesthesii halothane is dis-
(ominuN lvariablt among diflerrm q groups; oldtr adults tJkt longer
to rfWIt r).
HOME & COMMUNtTY CONStDERATtONS
--
Postanesthesia Follow-Up Care
Patiems ue upt in the or outpatient hospital or dink IflIing until
the tffects of an anesthesia mol , rtlUm 10 the hoIIII' ro-
vironmt nt following 'min and diagnostic pro-
(MUrH using con sdOllS sMoi tiGn bl'fort the effects of worn
of[ Patiems requirt<! to Mt with them for 2( hoUB to monitor
and a Sl;ist their lIffiIs.lkually, a toUOW-iJP aslffimem by phone is (om pltttd
b)' tht nuBl' or othtr {.)re providtr within 24 iIouB. Providing writt{'fl
imtllKtionsof all hoIIII' caft' rl'qJirtd is beilrl' discharge bKiull' vi-
tal information may bl' forgotten the patitnt mnaim groggy.
19.6 Pharmacotherapy
with IV Anesthetics
Intravenous anesthetics, listed in Table 19.5, are important
supplements to general anesthesia. Although occasionally
ADVERSE EFFECTS
Halothane rnodtrately srnsitim tht hean IIIJKIt to epinephrine: thtft'fort'.
dysrhythmia! a mncfm. This qnt Iowt rs blood pft'SSUrl' and the respil1l-
tion 11111'. k also _nol1lI'S rI'fI9 that kttp the
of tht stomilm from tnttrill9 tht !!aUS! of potenrial iltpalOtoxicity, tht
UII' of halothane has dedined.
Malignant hypertht nnia is a rift' but fatal aciY!'BI' tffea trig-
gertd t:,r all inhaloltion anesthetics. k caUll'\ mUlde rigidity and trntpl'l"-
oI tuft' Mation (up to 4l'C). This rilk is gft'atest whtn halothane is lISt<! with
IIKdnykholine.
Iotha ne dilates the '/a\QJlaturt and may, in (Main (onditions, in-
intrauanial
Contraindications: is contraindicated in with a of
signiliunt or m.Jlignam hyPfnhennii pR'Yious halothane
should beusM with (olution in poltienn with hepatic: function dys-
rhythmia!, head injury, myallhenii gravis, or ph_hromoc:)'/Om.J.
INTERACTIONS
I)ug-l)ug: EmsWf h)llOtmsion m.I, (I(QI" wIll'fl hillItI"oiftis<ornbiIfd with
HaIotIIn pomniatrstlw a<tionofnoodfpoloViling
blocking igHlB.
t.IDn UWK\mIlIy ilIrNIHtIw It'IPIof tIw(HS, and
sbould bf diKOOtirud 6 to 8 hom b@fore itdmilliltraticn
SboIrut muIdt WMknHs,rHpiroitory apaN may IKUl' if
lIiIIothoIIle is iOOIi"istfl!'d (OOOIrirotly with iMomy!in,OI
amioogly;olida
Lab l eu: Unmown
il@rbaVFoa:I: Untncwn
TrRtment of OmdoS!': No spKiIK is oI '/ailable; patienu art trl'atfd
symptomatically.
RtI\'r 1lI MyMIsIniJR {Ix Q MIsIniJ 1'roce\S FoM lpK/II( IIII1r1! <tug.
used alone, they are often administered with inhaled gen-
eral anesthetics. Concurrent administration of IV and in-
haled anesthetics allows the dose of the inhaled agent to be
reduced, thus lowering the potential for serious side ef-
fects. Furthermore, when IV and inhaled anesthetics are
combined, they provide greater analgesia and muscle re-
laxation than could be provided by the inhaled anesthetic
\\fhen IV are they
are generally reserved for medical procedures that take less
than 15 minutes.
Drugs employed as IV anesthetics include barbiturates,
opioids, and benzodiazepines. Opioids offer the advantage
of supt'rior analgesia. Combining the opioid fentanyl (Sub-
limaze) with the antipsychotic agent droperidol (Inapsine)
produces a state known as neuroleptanalgesia. In this state, pa
tients are conscious, though insensitive to pain and Wloon-
nected with surrowtdings. The prernbred combination of
these two agents is marketed as Innovar. A similar oonscious,
dissociated state is produced with ketamine (Ketalar) .
LibraryPirate
CNptor l' Drug. /0, lOGlI .00 "" ..... 1 Ar>e-;thel.la 249
NURSING PROCESS FOCUS PATIENTS RECEIVING GENERAL ANESTHESIA
Assessment
&selinr assrssment priorto admini stration:
Undtrstlnd mr IN.on drug has IRS',ibtd in ol'lltr to IIIfSS lor
tllt,apwlic: effls.
Obtain a lIt.hh history ilKklding lfIPir.tor"
htp.tic, ren.I, or neurologic: P't9ru ncr. or br"Nltfeeding. Obtain.
drug history ilKklding . 11t"lifl,wlTI'm IRS'riplion ind OK dnH}l, htrhal
prepamions, (alleinr, nirotine, and .kohol USt. Be alert to pol siblt drug
intrrauiom.
A!!fI' for. PrrYKM hillory of antslht!oia and Mtt iny 'ignioonl
rmtionl.Obtain. fami')' histor, of allt1thflii panic:ularfy
to USt of ntlromusw Ia r blodm (t .g., or any
unUIWI 1Nttd to suf9tlY.
Obtain vitll weight.Hott tht diy/hour tht
patitrlt Lm. tt or drink.
Evaluall' iabo,.tory findings appropriatt to (t .g., CBC,
or .rudifl, MRI or CT !Un rtlUltsl.
Obtain p.aptrwork (e.g., informtd
(ompleltd history and
Adminil1tr any p1fOptritivt .djulKti"ledrug. (r.g.,stdati!',aruigesic:) as
,,"'''''
A'!fI' Ie!'! of anxier:y,ind any rolKrm. or qutstionltllt
family, 0' mf9 i"ltr may ha!'. ReinloKe prtoptrativt tt.m iog. induding
detp f.mily with infomlition
on tilt anticip.ttd lenglh of proc:t<kJ1(, w.iting room tl'Itphont
and t iling availabilil)'.
Wlltn working with preiitrK pdtients, allow parrnts orthr (,1't9i!'r to
Ita)' with il Iotg is agelKy policy ptrmits to dt(ft'alt p.atitnt
anxitl)'. Providt Ilplanations of appropriate for tilt

Wlltn working with oIdtr i\l;istivt dtvim (t.g .. gia.Sft,
htilring aids) and 1\'IIl00f only when nt(tswr,.Gi"lt to f.mily,
or provide lor lifeketping. En lU,e molt devic:fS ava ila bit in
the pol1optrilivt ptriod.
Inili.te an intl"<lffllOU! mm !itt lor tilt
A'!fI' p.atitrlt's ability to and undtrstlnd instllKlion.lndudt
the family and (ilf9i!'1! 011 nttdtd.
AsselSm!nt throughout ildmini.tration:
AsSfS.lor tlitraptUlic: eflem or loss of
(olllciousntsl).
A.SfSS vital ligns, t.ptdilUy blood pullt,
BP itsl than 90/60, pulleabovt 100,or per paramtltrs as ordem:l irI the
htilhh provider.
M.iint.lin operati!' Ill'riil)'lhroughout proc:tdu,r.
A'!fI! ItYeI of ron.Oousntll in ponoptl.ti!' ptriod.Continue
frtqutllt monitoring ofYitil sign. and pulst oximetry.
.nd promptly report .dvtlS!' elfem: bradyu rdii or tI(ityu rdia,
h)'pOtension or rapidly in(JNsing
Potential Nursing Diagnoses
AIllie1)' (rNttd to IUI9ic:al
Impaitd Gil Enhangt
lnef'm:ti"lt BJNthing Pattern
Cardii{ Output
DisruJbt<i Sensor,
N.USN (1Nttd to aa.tlS!' drug tlfem)
Dtfi<iPnt Knowltdgt (drug tMr. p)')
Risk for Injur" Risk for Infection
Plllnning: Patient Goals lind Expected Outcomes
Tht palitm will:
ExptritrKt therapwlic: tfi"Is ruring
frorn,or tl ptritlKt idvtlS!' effls.
undtm.neing inttndtd !U,adYffit effls,and plf(iUliolll.
(Continued)
c.
o

"
>
,
I
LibraryPirate
250 Unlll /lle<vOI" Sy'tem
NURSING PROCESS FOCUS PATIENTS RECEIVING GENERAL ANESTHESIA (Conllnutd)
Impl ementati on
Intervent ions and (Rati onales) Patient and Family Educat ion
Ensuring theril peutk t fl"trts:
Cominut i lSffiments i sdecribtd t arlier for eifr(l5. Pmride

Provide a quiet environment postoperatmly and Imjuently orient tilt
for patient wfet)o during tilt pll'Optratm and optritive period and iS1E"S1 patient to tilt pollopet"atil'l' ret:OYtry unit.
tilt ItI'I'I of vit.J1 signl,ind mum of molor ilnd
sensation poIlOperatm Iy. (The duration of alletllttic action will deptnd
00 tlltdllJ9l UIed and or I"mI1<lI agents usN.)

AsselS for shil'l'ring in tilt poslOptratm period and additionil Continut 10 orient tilt patient in the poIIoptratm ptriod and alia)'
bla nRts or wamtth a\ rftded. (General anesthetics tht CNS ,md ilnxiety ilbout Ihmring.
5OlI\taulOnomic: activil1.As ilutOnomic: "tivil1 rec:urlll,shil'l'ring is
(ommon.Wann blankets pmridecombn during this ptriodJ
Minimizing il dftrse effKts:
ContilUl' to monitor vital BP Providt an 9planation for all pnxerufl's and monitoring 10 the patiem.
bmw 9Q/60 or pI'I" palilrnetM ill ordertd by the health we p!O'Iider. Continut 10 fl'orient tilt patient to tht surroundings frequently in
or signifiunt any iKrNlI' i1 period.
tl'll"9fl"illUfI' inrrxdiattly. (CNS drpll'!!ion wil UUll' dtcfl'aSI'S in i ll ritilli9:ls
butli9:lifiynt br.ad)'Cardia,hypotmion,draNsN repililtor;
shook! lit rrported promptly.Malignant "pfflhtrmia iISlOOated with

tfrrptrillUfI'aboYethtpreoptliltil'l' IIt reponed inmmatelyJ

PlVlide adequatf pain reliefin tilt immediate postopet"aul'l' ptriod. Providt i rationille for pain fl'iief pll'OpI'I"illivtly and elKouril9t tilt
do not IIt(ffiarily provide ilnalgrlia, drpending on patient to requet pain medication a\ ablt. Assufl' the family,or
tilt illjen1.!.deqUiltt pain reliefbt<jins ideilliy in tilt pll'Operiitive pl'riod. cartgmr that pain will befrequently monitOffd.
AsII'IS for nooverlJal signs of pain SIKh u restit-1S1IrIS orgrilllilCing as tilt
patient regains (OOICiousntsS.)

En(OlJragt the patifm to take dtep bfl'illhs il nd IIIO'/e tilt Iu.I'I'r

Teilch the patient dtep bfl'athing run:ises in the prroptratm period and
ertrt'lllitifs ffl'qufmly in the postoptratm pt riod. (Gftlerill illtSthetia that t-arly mol'l'ment oflegs will lit flKouraged in the wiy postopet"aul'l'
given by inhalation art viii tilt lungs. Detp breathing mists in period,unless othtrwill'ordtfl'd by the PlVlider.
tht A'maining antsthetic.Early rangr-of-motion may
IItlp prtWnt thrombosis and complic:ationsJ

Ensufl' patient saftl)' in tilt poIlOptratm period. orient tht
patient to tht surroondinljl,day and time, and maintain a saft
erMronll\tnl (During tilt pr-riod of alltSthesia,colI\(iousnf"lS is lost along
with tht ability to orient to day, time,and ptlWn. Confusion fl'lated to
thtSl' effK15 in tilt poslOptfillil'l' period is common. USI' of liliet)<
mNSUfl'S IlJ(h is side rails and 50ft restraints lit III'CfSlilry until the
patient regains (OOICiousntsS.)

For patifnts fl'(tiving kwamint and othtr drugs uusing

uplain tilt full procedufl' ind pollplIXedural UfI' to tilt
IIfIJroIeptallillgtosia, pmride, quiet, (aim postproc:MUfl'. family, or tht family or ufI'gil'l'f that visiting may lit
kioid ol'l'nlimulating tht patient ruring rital ligns,using a lOft tooc:h And rt-nOOed during the immediate period in order" to minimii'l'
txplalliltions of ill proc:t<iuresdollf".(During fl'(0I'I'f)' from Sl'MOI)' stimulation.
IIfIJro!eptallillgtosia drugl,confusion and milintflpfl'tltion ofSl'llsol)'
stimulation mily uuse otfl'me ilUiety, INr, or paranoia. Ktep all stimuli 10
a minilllJm until patient lf9ains full consdousnffi.)
Patimt understanding of drug thf ra p)':

Use opportunities during tht pll'Optratm period 10 discuss tilt rillionalt The pillifm shook! lit able to lIatt tht f1'asoo for drug(s),inticipated
fordrug therapy,desired thmpwtic outcomr-s, moSI commonly obmvtd II'nsations, ,nd efftru 10 obll'fl'l' for and wlltn to f1'port them.
elftru,and alTj nKrlsal)' monitoring or prwutions. (Using till\t
ruring ri ming cart helps to optimizt and rtinforte key leaching artils.)
Evalui!l ti on of Outcome Criteri a
haluale tht of drug therapy by (oofinning thill patient goals and t xpected OUICOIllrl mfl (_ "Planninc().
5tf TGbIts rU<1!Id 19.Hxli5ls .trhljl rcwhttr rht!t
LibraryPirate
TABLE 19 5 I Intravenous Anesthetics
Chemical Classlftcatlon Drug G@neraIAdverSf' Effects
Barbit .. alts arod b.J aqmll (Amidaltj (ooMio'l.lIr/5IPQdi)m
mdlohexiial sodum (BlnilaIJ
IJallblllll ll[(tllliWlllllifRlI:lliIO 1iD:[IgI;IIl!iIl m >II1iRb:d.ub
prop<IoI
Btnzodiul'pintl dmpam(ValiLmJ dtcNostd dirli!ished !ma1IfTQoon
Ioraztpim (AlMn) roUapg:.laryngosoasm
midarolim hydrodlkfjdf,
-
h)'drodlloride (AHmta) NaIJSffJ, GI dimJrooocn
fmunyl tiUall' (Sublimm,oIhn-sj CNS depmsion
l'I'rIIifmtaril hydflKNoride (Ukin)
sufmtanil ciuatr lSufmta)
MisctililltOUS I reallifW [jlJOliorion, int!tll mllIIood PIPl54!ff' mil plJM Wllfusion, ndwnml
Ilolkl idvI'fSI' tfIloru;.lllllkl:liniuinoot6 I'fiKU
.... Prototype Drug I Thiopental (Pentothaf)
Therapeutic (I ass: General anesthetic Pharmacolog ic (lass: Intravenous induction agent;short -.acting barbiturate
ACTIONS AND USES
is tlltoldest IV i IH'Sthtiic:.1t is ultd for medical
to inm ulKOO\{iouW1S prior to administefing inhiltd ant'Sthttic:s.1t
is (bssifil'd is an uhrashon-xting barbiturate, ha-ting an onset titni' of kosi
than 10 nd a dumion of only 10 to 30 m inut6. Un likt IOml' antsthttic:
!gtnts, it his low analgesic propel'Ms.
ADMINISTRATION ALERT
PlI'9nancymegoryC
PHARMACOKINETICS
30--60
10- 30 min
Half-life: 12 min
Duration: 20-10 min
19.7 Nona nesthetic Drugs
as Adjuncts to Surgery
A number of drugs are used either to complement the ef-
fects of general anesthetics orto treat anticipated side effects
of the anesthesia. These agents, listed in Table 19.6, are
ADVERSE EFFECTS
otht r barbirurates. can product repirnory depresion
when ultd in high doles. k is UIfd with caution in poatimll with cln:iiO'mcular
distill' beulIIl' of its ability 10 deprl'SS the arod cause dysrhyth-
min. Patients may dtlirium This (!!M1
confusion, and t J<iubility.
Contraindi Cli tions: should not lit administefl'd to poatimts with hy-
to baroiturat!'! or wi th eins unsuil! bllo for IV idministrarion. Var-
iegatt porphyria or !rutl' porphyria mmraindications.ln
thiopl'mal or oihl' r barbitural!'S can ClIUse IH'I'II' c1tmyl'lination a nd CHS
lesions, whic:h may !tad to pain, paralysis.
INTERAalONS
DrurDrug: Thiopental inm!(!S with mooy 0!lIft' 00Jgs. For uilmplt, 1M with OIS
dtpressaIlll rllPr_tory arod OIS dtp"Mon. PhMotlia!iIt1 OOf!1f lilt
rM ofhypotemion.
li b lets: Unknown
HtIba VFood: (ava and \\I1Prian may potential! SI'dalion.
Treat mf nt of Btuust tilt of thiopental is vtl)' brid; Ut'tr-
dose is managrd in tilt surgical by dilcontinuing tilt drug ind u-
sisting Y!'nlilalion untilrepiritionl [ftum to normal.
called adjuncts to anesthesia. They may be given prior to,
during, or after surgery.
The preoperatiw drugs given to relieve anxiety and to
provide mild sedation include barbiturates or benzodi-
azepines. Opioids such as morphine may be given to coun-
teract pain that the patient will experience after surgery.
LibraryPirate
2S2 U.,U n,., HefYo,,,, <;ynem
TABLI19' 1
SelQcted Adjuncts to AnQsthesla
Cheml<ill ClasslfkatlOl'1
"""
General
AltithoilWfgk atropine

Ildrllillulii 1W>Mr kID RIY!!lllilii
BtruocIi.utpint midwMn{\estd) JjJrrrd spt/I, tmnor
Rtlllilllilla Ikmr:iiilo
<hoIilWf9:< btchiOKhoi dlIoridt (Duvoid, IIItd101m)

lYiliml Iluo IIIRdi
Dop.!minr Ihke' dllllni/llll, r.IIIIPJfDmNfd J.)IIIpImn,.
hyportm.b.\ IIKhyrilrth
I.Jfmaoso.lsm
mivurium IMhoooo)
o JUinyIctIoIint (Mtint) Rc!pi!3!oa !lwftnign m"ign.M !rtprrtbmnia !!!IN
IltlOCurarine

Opioim alfmlinil hydrochDidt (Alfmt.l) lftIQI1II1. norU!&
Irrunyl dtntr
WlIY!!![! !kml:a2!! WIlH!; irrm mRiw!!!lIk ..... Wn !!I

im!!l !!I!W<NSdnrnWn
rtmiftnlilni h)O'odlIoride (lItN.)
suff!uanil dtlate (5ufeou)
prorr.tIh.Ilint (PMrwhl', Utmd1l5ilM,ttymouth
hales iocIcate CIIIllOlOll adftr5t Itrioos
Anticholinergic.s such as atropine may De administered 10
dry secretions and to suppress the bradycardia caused by
some anesthetics.
During surgery, the primary adjuncts are the naJromulO.llar
(chapter 2QOO). 1l is ne.::essary to administer drugs
that cause skeletal muscles to totally relax in order to carry
out surgical procedures safely. Administration of these
drugs also aUows the amount of anesthetic to De reduced.
Neuromuscular blocking agents are classified as
depolarizing blockers or Ilolldepolarizing blockers. The only
depolarizing blocker is succinylcholine (Anectine), which
works by binding to acetykhol.ine receptors at neuromus-
cular junctions to cause total skeletal muscle relaxation.
Succinylcholine is used in surgery for ease of tracheal intu-
bation. Mivacurium (Mivacron) is the shortest acting of the

nondepobrizing blockers, where.1s tubocurarine is a
longer-acting neuromuscular blocking agent. The nonde-
polarizing blockers c;lUse muscle paralysis by competing
with acetykholine for ,hoJinergic receptors at nellromus-
,ular junctions. Once attached to the re<:eptor, the nonpo-
larizins blockers prevent muscle cont raction.
Postoperative drugs include analgesics for pain and
antiemetics such as promethazine (Phenergan, others) for
the nausea and vomi ti ng that sometimes occllr during re-
covery from the anesthetic. Occ.asionaUy a parasymjXItho-
mimetic such as bethane.::hol (Urecholine) is administered
to stimulate the urinary tract and smooth muscle of the
bowel to begin pt'l"istaisis following surgery. Bethanechol is
featured as a prototype drug in chapter 1300.
LibraryPirate
Chopt .. 19 Drug, /0, lOGOI . od Gi> ...... ol Ar>e<thesla 253
Prototype Drug I Succrnylchoirne (Anectme)
Therapeutic (lass: Skeletal muscle paralytic agent; neuromusrular blocker Pha rmacolo gic (lass: Depolarizing blocker; acetyldtoline
re<:eplor blodc:ing agent
ACTIONS AND USES
Like the naturollll'llrom nsmiller suuinykhol illt acts on cholin-
ergK recrptor lite <II nfliromusruLII junuions. AI. fir;1, OC{Ur;.
I nd sulltal mUKIts ronlracl.Aftt r ,epu tro tilt IIII'm-
brIll!' is unabit to II'poIarilr.n long II the drug lIays to rt<eptor.
[ffms all' fim ooted as mus{lt Wl'aml and spasml.
paralysis o(UI"I. Succinykholine is r.lpidly broken down by tht
the IV infusion is \lopped. tht duration of mion is only <I
flow minull5.lM of IIKcinykholill!' the amount of gelltral anethtlK
needed for procrdult'S.Danlroitll!' sodium (D<l ntrium) is a drug used pll'Opera-
tiYfly or poItoptraliY!'ly to tht signs of malignam hypmhennia in sus-
(tptible patitnu.
ADMINISTRATION ALERT
Pregn<l lK)' Ulf90ry (
PHARMACOKINETICS
OnS("\ : O.s- 1 min 1V;1- 1 miniM
PNk: Unknown
Halflife: Unknown
Duration: 2- 3 min 1V; IO- 30min 1M
KEY CONCEPTS
ADVERSE EFFECTS
Succinykholillt can complete paralysis of the diaphragm <l nd inten:OItal
thus, IIII'{hanK11 Vl'milation is during wrgery. Bradycardia
and II'spiralory dtpll'SSion all' txpled <l oMlSe eflfch.1f dole all' high. tilt
gangli.l all' affecttd, Llusing U(hycardia. hypotension. <I nd urinary II'ttmion.
P<IIitnn with {t nain gtntlK dtff(l\ may tilpMmc:t <I rapid onle! of til-
tll'll\ely high ieY!'r with mu5dt rigidil)'--.l strious (ondition known as malig-
nant
Succinykholill!' should bt t mployed with caution in patitnn with fracture
or musdt initial musdt f<lIlKulationsm.ty additional
trauma. Nturomusrular bloc:kade may bt prolonged in palitml with try-
pokaltmia. hypocalct mia.or low plasma ltvtls.
Contraindi {alions: Su{(inykholi lit should bt used with atll'lIII' (,JUlion i n pa-
titnu with 1t'IM' bulTll or traum<l . nelJtomUI(IJlar disNsfS, or glaucoma. Suc-
cinylcholint is (onmindicated in palitnts with a history of malignant
hyptrthennia or {onditions of pulmonary. 1I'I\a1. (ardiO'm(utar. IIII'labolic. or
hepati( dysfulKlion.
INTERACTIONS
D"'!t"Drug: MdiOO ,bltulllllldo bIo<bdo wil lKtU"if "",rlnykboli .. ;'9;""
{ooumn!lywith flnsnirle, ithUn, quiridi ... or
lidocai ... 1lII' eIfl>ct of SlK<i1yk:hoIillt may tit ilaU\fd ij giwn (OOOI"ffItly with
phtnothialilltl.oxytoon.prmwirlf, taoi ... orthiaz ..... iu.1lII' of
.. droNsfd Wgiwn with dazrpim.
If !hi! drug is gil'en (l)I)()JIIfII!ly with haiolJlant or ritrouI oDdf, an incrr.M:! risk
ofbOOycMda, dysrhyllnias,siMamst,apne.!,and
If !U(OOjkholi .. is 9ivPn {(.OOJffllily with Uo1Iiac 91y<Dsidt>1,!Mrf incrr.M:! risk
of dysrhythmias.1f nartotics giwn (OIl()JffI"jjy with '>lKtin)tholirlf, ihfII'

LlbTfSls: Unknown
HOIbaVFood: Unkoown
lINIment ofOverd_: lINiment may involY!'drug forthefoliowing
symptotnl:WI'akness.l.t(k of rooldination. watery a nd mouth, tmnors. and
ProbIeml with bruthing requill' t mergtlK)' medital mtalUlI's.
I+t ftt [0 M)Nu1l1frglJ/ for Q NullifJ9 I'Ioct1! focus lpt(1k [01Ir/s
The numbered key concepts provide a succinct swnmary of the important points from the corresponding numbered section
within the chapter. If any of these points are not dear, refer to the numbered section within the chapter for review.
19.1 Regiona]]ossofsensation is achieved by administering lo-
cal anesthetics topically or through the infiltration. nerve
block. spinal, or epidural routes.
19.2 Local anesthetics act by blocking sodium channels in neu-
rons. Epinephrine is sometimes added to prolong the du-
ration of anesthetic action.
19J Ux:al anesthetics are do1ssified o1S o1mides or esters. The
amides. such as lidocaine (Xylocainel . have generally re-
placed the esters due to their greater safety.
19A General anesthesia produces a complete loss of Sl.'rtsation
accompanied by loss of consdousness. This state is usually
achieved thr ough the use of multiple medications.
LibraryPirate
19.5 [nhaled general anesthetics are used to maintaIn surgical
anl'$lhl'$ia. $ome,such as nilrouso:{ide, have low efficaq;
whereas others, such as halothane ( Ruothane), can In-
duce deep anesthesia.
NClEX-RN REVIEW QUESTIONS
o The[XItienl received lidocaine viscous bt-fore a gastroscopy
was performed. Priority nurslngassessmenllncludes:
1. return of gag reflex.
2. abUJtYlOurlnatt.
3. abdominal pain.
4. abUitYlOstand.
o The nurse observes a co.-orker preparing to administer a
501ullon of Intra\-enol\li [idocalne and epInephrine to a
[XItient with multiple premature ventricular contractions.
The appropriate action by the nurse [s to:
1. docummt administration oftbedrug..
2. notify the nursing supervisor of me error.
3. do nothing; the drug choice i5 correct.
4. prevent theadministnllion and discuss the need for a
solution of[ldocalne without epinephrine in thb
situation.
o The nurse recognizes that the main action of nitrous ox-
ide is to:
L. provide total relaxation of sIreIetaI musdes.
2. induce loss of
3. cause analgesia by suppressing the pain mechanism In
theCNS.
4. induce stage3 anesthesia.
CRITICAL THINKING QUESTIONS
1. An eklerly patient requIres local anesthesia for a 3-cm lx-
eration to the distal fourth metacarpal of the Ief't hand.
The health care provider requests lidocaIne (Xylocaine)
1% with epinephrine. What is the nurse's response?
2. A patient who has a history of heart failure is on digoxin
(!.anoxin) :and has a hi5tory of mild renal failure. The
health care ptovider asks the nurse to prepare succinyl-
choliIlt' (Anectine) IV as an anestht'lic for this patient
who is having an outp3tient procedure. What is the
nurse's response?
1. The nurse is reviewing the chart of a patient who has re-
cently had aIxIominai surgery. The patient is 67 years old,
has been on digoxin ( Lanolin). ibuprofen, St. John's won,
and Maalw: daily. Which of the information would indi-
19.6 [V anesthetics ue used either alone, (or short procedures,
or in combination with inhalation anesthetics.
19.1 NumI.'JOus medications, including opioids,
antianxiety agents. barbiturates, and neuromuscular bkxk-
ers, are administered as adjuncts to 5Urgery.
o The nurse should ass-ess the patient for which of the fol-
lowing side elfecl5lf succInylcholine (Antellne) Is used as
an adjWld to anesthesia? (Select aU that apply.)
I . Bradycardia
2.
J. Hypertension
4. Respiratory depression
5. Urin.1ry frequency
o A [XItient is admitted to the postanesthesia recovery unit
(PACU) after receiving keumlne (Ketalar ) after his minor
orthopedic surgery. In the recovery period, the patient
should be:
I . frequently oriented to time, place, and penon.
2. kept in a bright environlllt'f1t so there is\ess drowsiness.
J. assessed IOrsensorydepriY3tion.
4. placed in 3 quit'!: place with low lights and away from
noisy or equlplllt'f1t.
cate that this patient may require closer monitoring (and
why)? Which is a priority!
Sa Appendix D foransWfrs and rationales for all aCflvifies.
EXPLORE
ycMII' one stop tor online CI'oa/ll er re"f,fW mat!r.als .n:I
rwJlues, h. success Mth additiOll3l pradDI
questms, 111IeIl!I:Iive 8S.'IijJlment5 IDI 8CliWil':!. wen 1i'Jks, 8/EIatiom
and 1iOeos. and m!le!
ReglMer you- ecdo! from 1M trmI: II! you- boak a1
_ ... gkitcam.
LibraryPirate
DRUGS AT A GLANCE
DRUGS FOR PARKINSON'S DISEASE JII1ltI51
OopaminergicAgtnts (ill/t157
" Ievodopa (Larodopo) pilrJt lJ
Anticholintrgics p:1IJt1S9
Q benmoplne (Cogenrln) 16J
DRUGS FOR ALlHEIMER'S DISEASE fflgt}64
Acttylcholintsterase Inhibitors fJII}t164
Q donflpt>l1/ (JIorlcept) fXJI}t 166
DRUGS FOR MULTIPLE SCLEROSIS MI}!!
Immunomodulators pagt167
Immunosupprtssants (Jt1jt 267
KEY TERMS
acrtylcholineteraSf (AchE) IllIJt 164
Alzheimer's disNS! (AD) ,..163
amyloid plaqun p<!'11'163
bradykinrsia (II1JtiS6
corpusstriatum {X1;I151
Drugs for
Degenerative Diseases
of the Nervous System
LEARNING OUTCOMES
Afrer readinfJ this chapter, the student should be able to:
1. Identify the most common degenerative diseases ofthe centl,,1 nervous
system (eNS).
2. Describe symptoms of Parkinson's disease.
3. Explain the neurochemical basis for Parkinson's disease, foc;uslng on the
roles of dopamine lind IIcetykholine In the brain.
4. Describe the nurse's role In the pharmacologic management of
Parklnson'li dlseaul and Alzheimer'li disease.
S. Describe symptoms of Alzheimer's disease and explain theories about
why these symptoms develop.
6. Explain the goals of pharmacotherapy for Alzheimer's disease and the
efficacy of existing medications.
7. Describe the signs and basis for development of multiple sclerosis
symptoms.
8. Categorize drugs used In the treatment of Alzheimer's disease.
Parkinson's dlsease,and multiple sclerOSis based on their claSSification
and mechanism of action.
9. For each of the drug classes listed In Drugs at a Glance, know
representative drug examples, and explain their mech8nlsms of action,
primary actlon,and Importllnt adverse effects.
10. Use the nursing process to care for patients receiving drug therapy for
degenerative diseases of the CNS.
163
hippoGlmpus pu;t 164
multiplrsderosis (MS) paqt166
Jl!qt263
paricinlOnism pu;t lS6
primary- progtessin MS 267
progressive-relapsing MS pq;e 267
relaps!-f!mitting MS pq;e 167
sKondary-progtessin MS 167
substantia nigra pq;e i57
LibraryPirate
256 Until /lle<vOI" Sy'tem
D
egenerative diseases of the eNS are often difficult to
deal with pharmacologically. Medications are unable to
stop or reverse the progressive nature ofthese diseases;they
can offer only symptomatic relief. Three common debilitat
ing and progressive conditions-Parkinson's disease,
Alzheimer's disease, and multiple sclerosis-are the focus of
this chapter.
20.1 Degenerative Diseases
of the Central Nervous System
Degenerative diseases of the CNS include a diverse set of
disorders that differ in their causes and outcomes. Some,
such as Huntington's disease, are quite rore, affect )IO=ger
patients, and are caused by chromosomal defects. Others,
such as Alzheimer's disease, affect millions of people
(mostly older adults) and have a devastating economic and
social impact. Table 20.1 lists the major degenerative disor-
ders of the CNS.
The etiology of most neurologic degenerative diseases is
lillknown. Most progress from very subtle signs and symp-
toms early in the course of the disease, to profolUld neuro-
logic, cognitive, or sensory and motor deficits. In their early
stages, these disorders may be quite difficult to diagnose.
\Vith the exception of Parkinson's disease, pharmacother-
apy provides only minimal benefit. Currently, medication is
unable to cure any of the degenerotive diseases of the CNS.
PARKINSON'S DISEASE
Parkinson's disease is a degenerative disorder of the CNS
caused by death of neurons that produce the brain neuro-
transmitter dopamine. It is the seoond most common de-
generotive disease of the nervous system, affecting more
than 1.5 million Americans. Pharmacotherapy is often suc-
cessful at reducing some of the distressing symptoms of this
disease.
20.2 Characteristics of Parkinson's
Disease
Parkinson's disease affects primarily patients older than 50
years of age; however, even teenagers can develop the disor-
der. Men are affected slightly more than women. Thedisease
is progressive, with the expression of full symptoms often
taking many years. The symptoms of Parkinson's disease, or
parkinsonisrt\ are swnmarized as follows:
Tremors: The hands and head develop a palsy-like
motion or shakiness when at rest; "pill rolling" is a
common behavior in progressive states, in which
patients rub the thumb and forefinger together as if a
pill were between them.
Muscle rigidity: Stiffness may resemble symptoms of
arthritis; patients often have difficulty bending over or
moving limbs. These symptoms may be less noticeable at
first, but progress to become more obvious in later years.
Bradykinesia: The most noticeable of all symptoms,
bradykine ii is marked by difficulty chewing, swallowing,
or speaking. Patients with Parkinson's disease have
difficulties initiating movement and cont rolling fine
muscle movements. Walking often becomes difficult.
Patients shuffle their feet without taking normal strides.
Postllmi instability: Patients may be humped over
slightly and easily lose their balance. Stumbling results
in frequent falls with associated injuries.
PHARMFACTS
Degenerative Diseases
of the Central Nervous System
Men thn 1.5 million Partinloo's
Most patifnts with Parkinson's oIdtr than i9l' so.
Morr than SO% of Parkinson's patienll who hm diffirulty with voluntary
lIIO'Iement all' than 60.
Morr men than women de-YeIop Parkinson's
Morr than 4 million Ameriu ns haft Alzheimer's dM.m.
Alzheimer's mainly afftru patients older thin age 6S.
Of all parif,nIl dmtentia,Wl'. to 11m Alzheimer's dise_.
Morr than 49,000 Ameritans die anrually of
OYef 2.5 million peopIeworidwide hi\\' mukiple sdew.
Morr than 400,000 AmerKaln hoM mukiple sderosis.
Morr women than men de-YeIop mukiple sderosis.
Multiple sclerosis is fil' times mOIl' pIl'Vilent in temperate climates than
in tropical dimatn.
TABLE 20. 11 Degenerative Diseases of the Central Nervous System
DtS<'asc
Aizhrilrler's dilNlt
Am)'O!mrdlk Iltml sdtJOSk
Huntington's
D<><e. tptton
ProJtsVvt lossol brain function dlaoomml by dmmItia
Pmgrtsliw WNW!I and WI!tiJ14 01 mUldts by demucti6/1 01 motfl/ I\t!fOIK
Autosomal--domiiantgeOl'tic: dison:ler ll'Iiliilg in dementia i nd inl'OkmYiy, sp.lsmo<i( rtIO''menu of limb and fidal
m."'"
Oemyrinatioo of IIN'OOS in the Wlual nervous systml (eNS), ll'Iiliilg in WNknm, Yisual disturbaoc:ts, mood akmtioos,
and '091itift driKits
1011 in the CNS (,lUling lIflIIor,mm rigidly,and ibnorrnal momnenll i nd pollUIl'
LibraryPirate
- Affective flanuring: Patients often have a masked face"
WOOl.' there is littlt f:acial expression o r blinking of the

Although Parkinson's disease is a progressive neurologic
disorder primarily affecting musde movement, other health
problems often devebp in these patients, including anxiety,
depression, sleep disturbances. dementia, and disturbances
of the autonomic nervous sysltm such as dilflCulty urinat -
ing and performing sexually. Several theories have been pro-
posed to explain the devd opment of parkinsonism. Because
some patienlS with Parkinson's symptoms have a family his.-
tory of this disorder, a genetic link is highly probable. Nu
merous environmenraltoxins also have been suggested as a
cause, but resul ts tu'-e been inconclusive. Pot entially turm-
ful agents include a rbon mono.lide, cyanide, manganese,
chlorine, and pesticides. Viral infections, head t rauma, and
stroke have also been proposed as n uses of parkinsonism.
Symptoms of parkinsonism develop because of degener-
ation and destruction of dopamine-producing neurons
found within an of the brain known as the ni-
gra. Under normal ci rcumstances, neurons in the substantia
nigra supply dopamine to the (orpus striatum, a region of the
brain that controls unconsclous muscle movement.
Balance, posture, muscle tone, and involuntary muscle
movement depend on the proper balance of the neurotrans-
mitters dopamine (inhibitory) and acetylcholine (stimula-
tory) in the corpll5 striatum. If dOP'lmine is absent,
acetyl.choline has a more dramatic stimulato ry effect in this
area. For this reason, drug therapy for parkinsonism focu5eli
not onlyon tenorins dop.:lmine fu nction but al so on block-
ing the effect of aCelykhol ine within the corpus str iatum.
Thus, .... 1Ien the brain experiences a loss of dopamine within
the substantia nigra o r an overactive cholineTglc influence
in the corpus striatum, parkinsonism results.
Exlrapyramidal side effects (EPS) develop for the
neurochemical reasons as Par kinson's disease. Recall from
L IFESPAN CONStDERATIONS
living with Alzheimet 's
and Parkinson's Disaas8s
80th AIzh!imrf's ilnd PMIinson'slis!ilWI l it ptOgrmiw dtgellffllile lIN-
rologiClMortim. WMfUS l.IzIItimtr' sleids to irmtnts in mmlDfJ, th ink-
ing,and ItlSoning, PaRirwI's gn 0:110 the inability 10 hold ImaR
bo .. "", of tftmon n.idity.1t iJ brcil\lSt of progns ..... s1mptoms
thit patitnts IItfd all the Wip ilnd wpport tllat urtgiven (iln give. Although
nonpllillmac:oloqic wr;h ill proYiding iI Iilft trMronmenl un
ht lp, mrdic.Jtionl iIIt il'lilublt to dow tilt prog,euion ilnd symp-
toms. (ilmji .... n will nttd to providt assistanct ADu, in<k.oding milking
Wit that thtsl p,iltitntl It(!i .... thfir mediutions.
Tht sidt tfft(( of somt drugs iMd to control dtmtntil in patitnts with
Allhtimrr's ran disrupt many ptopIt with dtmtnriil oftm
sulkr sftpilj)nu.Nt:wltiUrchwggtSu that in ilddition 10 providing iI roo-
tint ,md SlfUC(urtd mvinnmtnt ill ilS iI itw hours 01 Mght
wily in 1M tIfrrling, II\a)' Itlp peoplt IMfI9 witll Abhtirntr's maintain I IIOr-
INI slt!ping paM1\. Pitimrs who It(fflrd Iio/It therilPJ in tIr! eI'IIlng 1M

'hlplfl20 Drug< for oft'" NeIYOOI System 257
mapler 17010 that antipsychotic drugs act through bl ock-
ade of dopamine receptors. Treatment with certain antipsy-
motic drugs may induce parkinsonism-like symptoms, or
EJ>S, by interfering with the same neura.l and fune-
tiorn affected by Ihe lack of dop:!mine.
EPS may occur suddenly and become a media d emer-
gency. Wi th aCUle EP5, patients' muscles may spasm o r be-
wmt Ftver and confusion are o ther signs and
symptoms of lhi s reaction. If amlt EPS occ urs in a health
care facility, short- term medical treatment can be provided
by administering parenteral diphenhydramine ( Benadryl).
If EPS is recognized oUlSide the health care sett ing, the pa-
tient should immediately be taken to the emergency room,
because untreated aCUle episodes of EPS can be fatal .
Parkinsonism Drugs
Antiparkinsonism agents are given to r/.'S tore the ballnee of
dopamine and acetylcholine in specific regions of tht brain.
These drugs indude dop.aminergic drugs and anticholiner-
gics (cholinergic blockers). Dopaminergic drugs art listed
in Table 20.2.
Oopaminerg/cs
These drugs either restore dopamine functio n o r stimulat t
dopamine receptors located within the brain. Recent t fforts
have focused on the use of dopamine agoni sts fo r the initial
treatment of Parkinson's disease.
20.3 Treating Parkinsonism
with Dopaminergic Drugs
llletoaJ of pharmacotherapy lOr Parkinson's disease is to in-
crease the abilityof the patienlto perform normal daily activ-
ities of living (ADu) such as ealing, walking, dressing. and
oothIng. Although pharmacolherapydoes not cure this disor-
der,symptoms maybe dramatically reduced in some patients.
Drug therapy aUempts 10 rl'$to re the funct io nal balance
of doparnineand acef)'lcholine in lhe corpusslrialum of the
brain. Dopaminergic drugs are used to increase dopamine
leveh in this region. The drug of choke for parkinsonism is
levodopa (Larodop.a), a dopaminergk drug that has been
used more extensively than any other medication for this
disorder. Asshown in Pharm.acotherapy Illust rated 20.1 (see
page 259), levodopa is a precursor of dopamine synth/.'S is.
Supplying il di rectl y I" ads 10 in"CG-sW biosynthesis of
dopamine within the nerve terminals. Whereas leYOdopa
can cross the blood-brain barrier, do pamine cannot; thus,
dopamine itself is not useful for thenpy. The effectiveness
of levodopa can be Kboosted" by combining it with ear-
bidopa. lbis combination, marketed as Sinernet, makts
mOR levodopa available to enter the e NS.
Several additional approaches to enhanci ng dopamine
are used in treating parkinsonism. Tolcapone (Tas mu), en-
tacapone (Comtan), and selegiline (Carbex, EJdepr)i ) in-
hibit enzymes that normall y destroy levodopl and
dopamine. Selegiline is a monamine oxidase (MAO) in-
hibitor. Apomorphine (Apokyn), bromocr iptine ( Pa. lode]),
!
I
LibraryPirate
258 Until /lle<vOI" Sy'tem
TABLE 20.2 1 Oopamin"rgic Drugs Us"d for Parkinsonism
Drug
amantadine (Syrrmeutl)
apomorpline
Route and Adult Dose (max dost> where Indicated)
PO; 100 mg 1- 1TiRll'!/da)'
Adwrse Effects
dilliwlry n:lnfrIIlini

fIgw. rDMG, I'OI11i!irJi orlhos!oril:
hyporellJion, rhorfiform
fflOl'I'mmt\, dyJiOliD, djJRIIfliD
SC;l mg forTIlt frSi ftwdays,dolfl m.y lit inaultd
by I RIg (mil1:6 mg); nmm than 1 wm plSIfI 1It1Wtffi dosr!,
titration should lit II' stamd at 2 mg
brornouine (Parkdtl)
(Sinernet)
PO; 115-25 mglday up TO 100 mg/day in dMdtddolfl
m MI short neuroleptic ma1jgMD[lyMKIIIle
jprillr.ilpcywjj drPlfI'ipowitb SlDeW!
imdmdn. EP$ IUminin! liwlaikJrt,smrt
PO; 1 ti bltt rontlinilg 10 mg taJbidopaf100mg It'IOdopa or
15 mg G1rbidop;tflOO mg if, 'IOdop.J Tid (mill; 6 ubi/day)
ffitaYpOne (Corntan)
Q In odopa (l.{)opa.lirodopa)
PO; 200 mg givtn with le'/odopHlrbidop;t upTO
PO; SOO mg- I gld.y;may lit ilKll'Nd by 100-750 mg
1- 7da)'5
IItINTOCI' luarinpm
dih)'ltodlloridt (Miraptl) PO;StJrt with o.m mg tid for 1 wk;doublt thisdosr for tllt nelt
W'k; (ontinue to iOOl'.l SI' b1 O.1S fll9/dose !'Vl'IY Wl'ek 10 a
target dosr of 15 mg tid
ropini'ole Irfdrodlloridt PO;Soo with O.1S mg tid; may illll'aII' by 0.25 mgfdosr Tid
WffI: to i doseof 1 mg Tid
!tIt9line hydrodllorid/,
"""'"
PO; 5 mgldosr bid;dwi greaTtr th.tn 10 mgfday are potenTially

tokapone (filmar) PO; 100 mg (milx:600 mgfday)
pramipexoJe (Mirapex), and ropiniroJe (Requip) dire,tly
activate the receptor and are called dopamine ag-
onists. Amantadine (Symmetrel ), an antiviral agent, causes
The release of dopamine from nerve terminals. All these
drugs are oonsidered adjWlcts to the pharmacoTherapy of
parkinsonism because they are not as effective as levodopa.
Recent guidelines have focused on dopamine agonists as
the iniTial line of treatmenT for Parkinson's disease. For ex-
some sTUdies have purported ropinirole (Requip) to
be more than Twice as effective in conTrolling d)l5kinesia. Pa-
tients taking ropinirole alone may also experience less pro-
gressive dyskinesia symptoms. However, in terms of
activities of daily living (ADLi), some have repor ted thaT
L-dopa may still better control motor sympToms. Others have
suggested that L-dopa taken alone may produce no greater
long-term ther:apeutic advantage than dopamine agonists.
Pramipexole (Mirapex) and ropinirole (Requip) have proven
TO be safe and effective for the initial sole therapy an d when
combined with L-dopa. The side effects of pramipexole and
ropinirole are intense and may include nausea and oonstipa
tion. headache, orthostatic hypotension, nasal congestion,
sudden sleep attacks,and hallucinations.
dIUgs rUf L-dupa ill -
clude the transferase (COMT) in
hibitors. Like L-dopa, these agents increase concentrations
of existing dopamine in the brain and improve motor fluc-
tuations relating to The wearing-off effect. Examples of this
drug class are entacapone (Comtan) and tolcapone {Tas-
mar ). Side effe,ts of COMT inhibitors include mental con-
fusion and hallucinations, nausea and vomiting, cramps,
headache, diarrhea, and possible liver damage.
COMPLEMENTARY AND ALTERNATIVE THERAPIES
Ginkgo Biloba for Dementia
Iht swls ,lIId luYel 01 ginkgo bilobi haYe betn used in traditional
for Thousands of Tiff is plinTed throughout world, in-
duding tilt United SI<lt6. ln Western medicine. til!' forus has betn on tll'iting
depression dnd memory loss. In Germiny, i n fXUact 01 gink90 bilobi is ap-
forTIlt trutment of dtmentia.
Ginkgo h.ts beI'n shown to impltlVl' mt ntal functioning and stabilize
Alzhtillll"l's The IIII'(lianism of action setms 10 br II' litfd 10 inam-
ing Tilt blood to tht brain b)' dilating t!I!' vis-
cosity oftllt blood,and modifying the Ol'Urotransminer system (Birks, 1007).
Studits conckidtd that cognitive pl'rformanU' and bthavior stabiliztd or im-
for a tillll' pfflod of 6TO 12 months in patitna with
Alzhtillll'l"s dMoN. Othtr srudits II<l'It shown no improYeIlll'nT in t!I!' 5)'01P-
toms or progll'lS of (DtKosky. Williamson, fiupauick,
Kronmal. Sanon t t al.,2008l.Ginkgo is COMidtred salt; hOWe'/e!; i! may
inause the risk 01 bleeding i n patitntstaking antico.agulints. Or:1Ier potl'nul
um for ginkgo thati ll' bting inmtigilled sc:ltrosis,
interminfnt claudication, smJ.1 dysfulKtion 10 antmplffiints, i nd in-
sulin
LibraryPirate
''''PIf, 20 Drug<; fo, Dlsea ..... oft"" fIie,,,,,,,. 5)'-aem 259
PHARMACOTHERAPY ILLUSTRATED
20.1 Antiparkinson Drugs Focus on Restoring Dopamine Function and Blocking
Cholinergic Activity in the Nigrostriatal Pathway
Dopami ...... conl .. nng lIeU""'" "'" " specially damaged.
Corpu triatum
striped body'"
8 ...... llJIIngl ..
Inlemal capeule

10ITT"0S" slripe.
Dopaminergic ag" nt. :
BIIo.aI ganglia:
PlOICUraors 10 dopamine:
eg: Levodopa (L-Dopa)
Dopamine receplo, "9""18:
eg: Ropinimle, Pmrnipllllole
Chol inergic-blocking drug. :
8enztropine
Anrichofinergics
Anticholinergics inhibit the action of acetylcholine in the
brain. They are used early in the course of therapy for
Parkinsonism disease.
20.4 Treating Parkinsonism
with Anticholinergics
A second approach to changing the balance between
dopamine and acetylcholine in the brain is to give choliner-
gic blockers, or anticholinergics. By blocking the effect of
acetylcholine, anticholinergics inhibit the overactivity of
Drooping
"yelids, open
mouth, drooling
Progressive
deg-eneration 01
neurone in the
rign>!llriatal
palhw"'lcan
-" l:J
Aniipeydlotic
dopamine-
blocking
"",. -
ptOduc,,:
(1
Symptoms 01 Pa rkin.",'. Disea.,,:
Trem<>nl (IMting tremors)
Rigid body alructu",
SIown_ 01 movemenl
(bradyki.--is)
LOSII 01 balanc"
Copa mi ne
this neurotransmitter in the corpus striatum of the brain.
These agents are listed in Table 20.3.
Anticholinergics such as atropine were the first agents
used to treat parkinsonism. The large number of peripheral
side effects has limited the uses of this drug dar.s. The anti-
cholinergics now used for parkinsonism are centrally acting
and produce fewer side effect<;. Although anticholinergics
act on the eNS, autonomic effects such as dry mouth,
blurred vision, tachycardia, urine retention, and constipa-
tion are still troublesome. The centrally acting anticholiner-
gics are not as effective as le-vodopa at relie-ving the se-vere
symptoms of parkinsonism. They are used early in the course
of the disease when symptoms are less severe, in patients who
LibraryPirate
260 Until lheNetv"",,Synem
fIT Prototype Drug I Levodopa (Larodopa)
Therapeutic (lass: Antiparkinson agent Pharmacologic (lass: Dopamine precursor; dopaminergic drug
ACTIONS AND USES
ll'DIIopa I!'StOlft tilt IlfUrolran5l11inu dojlamint in mraP'l'ramidal aru s of
tilt brain. thus ft'lieving some Parl:iruon's symptoms. To inc:lNSt its effen, ltv-
oOOJlol is often (ombined with otht r medications,!lKh as Llrbidopa,whic:h pre-
I'MI its t lll)'matic: brukdown. Up to 6 months may lit ntfdtd 10 ac:hiew
mn imum tooapl'lllic: tfftru.
ADMINISTRATION ALERTS
Tht Jloltitm may lit unablt to I!' If-administer mtdication arod II\a)' nffil
assisuntt.
Administer tuctiy as ord.:ft'd.
Abrupt withdrawal of the drug Lln ft'sult in Jlolrkinsonism (risis or 1Itu-
ro\eplic: malign,m syndrome (NMS).
Plfgnanc:yLlltgOry C
PHARMACOKINETICS
IAlset: L.m than 30 min
Peak: 1- 3h
1 h
Duration: Variablt
ADVERSE EFFECTS
Sidt t1feds of Irodopa in(kIdt unc:ontrolled a rod purpost1tss sum
a s tIItffi ding the fingm arod shrugging the shoulders. involuntary IIIO'/t mtnts,
loss of appetitt. nausea. a rod vomiting.Il'uS(1I' twitming arod !palmodic: win king
aft'tarly sigru of toxicity. Orthostatic hypott nsion is (ommon in SOmt palitntl.
TIlt drug shoold lit dilwntinued graduall): bKaust abrupt withdrawal Ll n pro-
diu oKUtt Jlolrkinsonism.
Contraindicilti ons: L.evoOOJlol is (ontraindicated in tilt tft'atmtnt of narrow-
ang1l' glalKOOIa. panic: ularly in patiffits with suspic:ious pigmt med lI'sions or iI
history of mt lanomi . This mtdicalion should lit a"loided in of lrutt ply-
(hoII's and I!'YtfI' psydlonturosis within 2 wtth oftht rapy with MAOI.
INTERACTIONS
I)ug- l)ug: If'iOOOpa inoom with many
of1mldopa. OONIf polin h)"poImsion.and m.l1
inuNlf !)fl1pathetit with h)'pl'I"lfnIioo and WM tachycafd.i. lmOOpa
GlOoot bt used if i MAOI Will t.Jkffi wit hin 14 to 18 da)\ OOIIIMt Ulf
IMf "pKlMli"ll! aM. HaIopfridoI taken {OOOIfreotly IMf aoligCllill'
tfuo thtriIp@UtKtlff(\! MethylOOp.! m.ly inc:rNIf lOJ!idty.
Antih)"pfllmlim may (iIlIIf oomfd "poIHIIWf AnTitoo'o'lNrn may
th. thtropMil: offo.mofIHodopo.AntaOd.'onOO"'l.....,...,; ....
00110.01 !odilrn bic;!o:booalf may irKlUif abIorptiln. whi:h (OWd
to ilnliparkiolOOilmfflKts ofk>vorlopa.
lab Tl5Is: AbnomwIilifi in lab l15li filii')' fIf"/iltioos 01 li'ffllunc:tion lf511
sum 011 .ka1ir1f pho:!pholilf, i!p<lrtate aminorrifllferR lAS n. alilnirlf
aminouml'l"olII' (.un.1oKti<: deh)'drogeoR.and AboormaIffits in blood
lfN nilro9l'O iIOd pc!Iitivf Coombslf!( 11M i!Iso lK>fn fI'POIIOO.
Ik>rbaI!JFoo:I: K.lurruyWQMltlll' I;'IIIpIOm! ofl'olrttrlon!.
TrNtment of Overdose: mtasul!'S should hi' uktn , long
with immediatt gamic J,vagt.lml"ilftnollS fluids .hould lit administered judi-
ciOUliy arod an adequatt airway maintJined.
TABL.E 20.3 1 Anticholinergic Drugs and Drugs with Anticholinergic Activity Used for Parkinsonism
Drug
o (Cogentinl
biptriden hydrodlloridt (,i, kiotlonl
diphtnhydramirH' hydrod"jorid.: (Btnadryl)
mlorl,"", ProIotyptDrug IHD: OO)
proqdidot hydrochloride (Kmlidrin)
lri,"", xyphffiidyl hydrochloridf (Amot)
Routeand Adult Dole Imax dose where Indl(ated)
PO;05-1 mgld.y;grmlly inuull' as (m.l1:6 mglday)
PO; 2 mg Oot IO loor limffid.y
PO; 2HO mg tid- qid (max: 300
po; 25 mg lid,/ln' mull; may III' iKrull'd 10' mg tid ifldtratfil.
wiTh i n additional, mg al btrItimt (m.ll: 4, - 60 mg/day)
PO; 1 mg on day 1;1 mg on day 1; thtr1 iOCR'al!' by 1 mgffl!Y
3- , d.yl up 10 6-10 (m.lI: I, mgld.y)
..
Adverse Effects

moolfl. b/lJrrrd li.<.i1n,dl!1Wlmt5l,
rhyrQrdkl. hyporemioll,
--
=-
FIX lirf(.ltooflirlgplO(tsJ wNriflirlg Procm FooIs:Pariennlktimg Amidloliotrgk rhfrop%pogt 145 n d!op/tI 1]0/0.
LibraryPirate
NURSING PROCESS FOCUS PATIENTS RECEIVING lEVODOPA (lARODOPA) OR UVODOPA
WITH CARBIDOPA (SINEMET)
Assessme nt
Baseline Ilmwnent prior to adminiltral ion:
UndenLlnd tIIf
thtr,pMit: flfKa.
Obldin, (omplett hrikh history incUling
gLJumma. Obtiin, drug history inck.odi!19 *'gies,runml
p!tKriptioo...d OlC hrm,1 aIM!O poslille
drug imtrKtionl.
Obtain' hi!tory ohht ument aMu...d symptom\fititming
(ond"ttions, ,nd to CMT)' out ADU, pirtKularly mobil)' and NtinrJ.
haluatt laboralo,., findirlgS well II htpnic or /ttI.1 furKtion
studies.
Obtain llisdilt vital Ygn!. bowel wunck.urir.ary oupu1, mUKit
Md mtnul SIaM M ipp!Clp!iilt.
AtS1 tile 1Y1imt'1 i1b1litylO UllCifnund iRmurtion.lndudI' tht

lsHllmtnllhroighoulldminillration:
Aistil for dnirtd thr"pMic riIeo:ndfpmdtm on tht rUlOn for thtdrug
dKrtMtd trtmon, rigaty).
Continue ptriodK monitoring of viI.1 sigm,lIlI'mal stJrus,.nd motor
blctiolL
AtSs for ,nd promptly tfport ,dvtrstefftru:trypottfllioo, incrt.sing
tmnm,diczzinm, dJ.ngtI in menul
lIillI!, including .gitatioo orcoofll!ion..
Potential Nursing Diagnoses
Impaoirtd Ph,n Mobilil)'
knpaiml Swalowi!19
Impaoiml Communiation (It,wl)
Comtip.tioo
StI.utl' DtfKit hygltnt,
DtfKitnt KnowltOgt (drug tfItfapy)
RiIlfor In;..y, Rill for Falb (maltd 10 dM_ or adYtrw tffmsof drug
thtr3PY)
Planning: Pltle nt Goals and Expected Outcomes
TIlt pilitm wiI::
bptritrKt rlImptUlic tfferts dtptndtllt on tilt rt.1On the drug is bting (t.g. imp-oytd pi!,n mobility ,nc! coord"tnation,dKrtMtd
bradykinHia,.nd inclt.5ld .bilil)' in Iflf--un: oKtivitiesj.
ftom.or minimll efftL
tm,lizun Ul'llienlincing ohllt drug's 1M, ,a.trst tIfKts, ilnd precautions.
Dtrnonmatf proptr lI'If-idmiMuation of w mtdiGation (tog.,doIf. timing. Whfn., notify proWler).
Impl f me nu "Ion
Interventions and (Rat ionales) Patient li nd Fomily Education
--+--
Ensuring IMr.peutl( efftm:
Continue i111f%1t1m1l ill dtsaibtd utlitr for mmptUlic: tfferts.
Orug thfUpy like IMriII wtffi Ot months to 1Iat , full fffKt.
Support th.: in Ifli-<.lllt .ctivities ill nfmsary until impfOlmllel\t is
oblm'td.{TIIt. bilityto urryout AIls graduilly if1ljlfO'ltS with roMisttnt
IIIoigf. Continued tltmotl, rigicfrly,or otlotr symptOnt'l1!liY rtqUirt dosIgt
adjunmfnl)
Minimizing adftnt effeds.:
Emult p,nitm saiety; moo lOt motor roonfll\ation ,ndlor .mbulation,
ming. or othtr fllfntiallllOlOf partirul.riJuutious oldtr
adults who m il.n i!KlNStd risk for f. Ik.{(;radwl impromtlfflt in
symptoms mil)" notictd O'/e" time but !lot drug dots not rult tilt
undtrlying diIOnItr ,nd symptoms mil)"waxand want om tIIf (OOOf of
tilt drug with .mbuLrtion is .1
bradykinHia Ind rigidity mil)" inc:1t.1f tilt tilt 01 f,lb. )
lNdo lilt moplllYft11tnt IIW)" bf gr.ukwl..
Tht patittu sIoouId rtpOrt inousing symp\Ont'l thn .ftsmL1r to tholf
nottd bdortdrugthflllPYwas inmatN.
Imtruu tilt patimt to GaU for i11lislanct prior to gtlli!19 out of bfd or
,ufmptill9!owalk .Ionf riIjcIity,or tltlllO/\.1t
""nirularlylfftlt.
Assffi tilt uttgim'uolity to tiItfJ out ADlUl
homt.nd tilt for additional ht.1th Galt rtfmIls. [v,kiilf
homt lftl)' rwdi.
(Conrtnued)
LibraryPirate
NURSING PROCESS FOCUS PATIENTS RECEIVING lEVODOPA IlARODOPA) OR lEVOOOPA
WITH CARBIDOPA (SINEMET) (CollIlnuld)
Implementation
Interventi on, and (Rali onales) Patient and Family Eduu,ti on
Continur to monlOi vital WJns. TXt blood prmull' IyWog,sitting. ilnd Tfh tIM- piltitm 111 from IyWog 10 Iitmg 01 SQnding slowly to;woid
SIi1nding todtlea orthosUtK hypotension. Be pilrtKuIaIIy (ilUlU wkh dizzinm orlalls.
okItr wfooall' al an inc:JNSfd risk for byJxJtfmion. Notify 1M hulth
{ill! ptO't'idff if blood PIl'SS\.IIt beyond par;Jflletffi or
ifhypotmsion is. KCOmPilnitd by u{hrurdia. {OrtbcnIatir:
hypoifnsion isil common dfta ilnd mily iD(fNSf Ihf of fills or
injllr1.}
Moroitorfor bellavior (hilf"geS.(Drug IMfilPY nil)' illClt.st tilt risk of Tftch tilt piltitm, Umily,Of Ulegiver IOwiluh found Il'!IGfI in1JIlt<iiItly
igitation, confusion, dtpression, 01 wicidal thoughts ind may UIM othfl" ill!)' signs of manges in behilriofOi moocIllJ(h II inm,I5N 01
mood dinurbillQS IlJ(h lIS tggressivt bthmorJ ((IIfusiDn..Provide additiooallotilhh (f Il'ierr* ilS requirtd for wppon
gfOUp,munstling, Ofrespitf 1m.
CiI!Niy evaillatt and tepOft do!Hel4ttd symptoms such ilS iMl!ilStd Instruct the Piltitnl. filmily,OI to be ilWiII! of ntwly occurring
tll'mon and rigidity 1M next dose is due orgll'illlJ intn'iISfd mUl(It twitdoing,indJding (in rru!des of
sympl1mS unttl.ted 10 die timing of the dow.(T1lt Il'Il,IIn ofgflduil Duusing trtmors, rigidity, \WNIing,orothtr S)mptOOlS iIOd to Il'!IGfI
of ymplOlOI as tIM- nHt COOlrS dUl' m" signil l iI"Maring thtm il!UllfdiiltfiJ.
off"timt .nd m" need III !of illCll'IsfII, tht inltr'lill of dosq
EncOllrq patienl to mMouin iI S)'IIIp1OOl diiry if
ild;..sttd,or an Idjunctiw drug addtd.A signifiant and suddtrl in
tffKts SHm to cfmWnisIJ ilS tIIf next dose is dllt. Revitw dial) witt1 tht
symp1DlM nil)' sign.1 an OI'frdow OI"on-oll"" phtnommoo
tid! htalthCilIl'I'isH.
sympl1mS dri m.ata Ily inclt.lst.1I spmptoms ilit signifiCilnt, hospiu liution
nil)' lfIIuirtd to iSIm for tht miooillt behind
Enbltf rutrition.1 intake.(AblOrptiOll 01 If"fodo[)il deuuses with high Tftch
PJIlttm muls or high {OIIlUIIlption of food! 01 "titamins that (onu in vilMnin taking tqthtr with a higl!-prol:ein muLAYoid consumption of
B., lPrridOJCiM].Symptoms mily drollflalKait,o if .bsorption is wiumin B.-rich foods weh i s such asINMIIiII, whtat gtrm.lortififd
impaim:l as dcM does no( adtqUillfly bSOlb during die timt fJIIfCIfd.) (fll'ais,gfHII vrgttabIes, mNT.. and and noid muIlMtamins that
((IItilin vitilmin s..
MotUtor htp.!ic .nd Il'NI MIction Ifl!s ptriodiully. {A D thest Tetch [)iItitm, f.mily,Of uregiver ilbout tht import.lICt of Jl!tuming
lunctions II\IJ slaw the IMabolism ilrId ellrttian of tht drug,possibly forfollcw-up Ifb stucliH.
Itiding ID 0'tIfrd0ll' Of IDIXityJ
MonitDrfOi other (haoges.(Thr drug II\IJ UUIf urine and Ac!vist 1M piltitnt tfIat UriM 01 swt'at m.y darRo and uodtnhirl5 01 dress
ptlSflifation todalttn in colorJ shitkk mily help 1O...aid IUining of clothing.
Palilmt Uldtrltanding of thuapy:
USt opportUnities durillg .dminiltsatioo 01 mtdications.nd during The piltitfll, filmily,or CilrtgMr shoule! be ilblt to state thf Il'jSOfI for
iSStII/IIfOU to dilcun die miollillt for drug mtr.l[l1, drsill'd thnaprutic cWg;appropriiltf dow .nd Khed.rling;.nd wfoill 10
OIIK_, most (ommotllyobsmtd adtlSt rife<:ts,parimttm forwhtn oto_ for iI1d whrn \Q Il'port.
to GIl die heilth (irf prwidtr,ilOO MY ne<fUiry monitoring 01
pll'CMions. {Using timt during nursing calf hrIps to optimizt,."d mnfoll:t
kty lNdoing MNSJ
Patilmt H"If'administfalion of dlllg therapy:
Whtn .dministering thr mtdiCiItionl" instruct die 01 Instruct die Piltitnt in pJllpl'f administsation guidelines.EncOllfil9l' die
CilrtgiYrf in tht proprr \tlladministration ofckugs."d die Ilffii for paOOolfamiy, or 10 "",inuin a log, noting
(omistrnt doling. {Utilizing timt during nurw-adm inistmion of these symplDms or .dmwderu .Ioog witto tbt dOlI' and timing of
drugs hrIps to reinfof{f tOOingJ mfIIications.
Evaluation of Outcome Criteria
LibraryPirate
cannot tolt'ratt' levodopa, and in combination tht'rapy with
otht'r antiparkinsonism drugs.
ALZHEIMER'S DISEASE
Alzht'imt'r's dist'ast' is a dt'Vastating, progressivt', degt'nera-
tivt' disease that generally begins aftt'r age 60. By age 85, as
many as 50% of the population may be affected. Phanna-
cotherapy has limited success in improving the cognitive
function of patients with A1zht'imer's disease.
20.5 Characteristics
of Alzheimer's Disease
Alzht imt r's disrilsr (ADI i. responsible for 70% of all dt'mentia.
Demrntia is a degener:ltive disorder characterized by progres-
sive memory loss, confusion, and an inability to think or
commlUlicate effectively. Consciousness and perception are
usually unaffected. Known causes of dementia include mul-
tiple cerebral infarcts, sevt're infections, and toxins. Al-
though the cause of most demt'ntia is unknown, it is usually
associated with cerebral atrophy or otht'r structural changes
within the brain. The patient generally lives 5 to lOyears fol-
lowing diagnosis; AD is the fourth leading cause of death.
Despitt' extensive. ongoing research, the etiology of
Alzheimer's disease remains unknown. The early-onset fa-
Prototype Drug I Benztroptne (Cogentm)
HOME & COMMUNtTY CONSIDERATIONS
Caring for Loved Ones with Alzheimer's Disease
Tht diagoom of diINM' is dt-asming 10 lilt patienl and family
Inl'fIbers Family mtmbm mun dral with many unexptutd clanges.
Tht of Iht patient with Alzheimds diINSf slowly (hangrs and
llla)'indudt pa r.J naia. and frustrillion. Many bmilits i11lf"f11p1 to [art for
t heir Ioffil one ill for as long as possibif. A of
Alzh imds M' is tilt ttllllenq for IItt palifnllO WI ndtr lNIlfi. Thr palifnl
t.J bomrs lost aitfr ifaYing thf familiarity of tltt homt This
ttndtlK)' 10 wander is lItlitwd 10 lit linktd 10 anxiti"; on lilt pan oftht AD
patitm who pa(rs or Wlndtrs 10 ft'lif'Ie tilt Ifmion. Wandrring pun tilt pa-
t ifnnt a high mHor StYere trauma or dtalh, and it is imporlam for family
Uft'gWen to ft'<Ognizto Ihis symptom and ask for misunu promptly.
milial form of this disorder, accoWlting for about 10% of
case!, is associated with gene defects on chromosom? I, 14,
or 21. Chronic inflammation and excess free radicals may
caust neuronal damage. Envirorunental, immunologic, and
nutritional factors, as well as viruses, are considered possi-
ble sources of brain damage.
Although the cause may be unknown, structural damage
in the brain of Alzheimt'r's patit'nts has been well docu-
mented. Amyloid plaqufs and nf urofi briHarytangle, found within
the brain at autopsy, are present in nearly all patients with
AD. It is suspected that these structural changes are caused
Therapeuti c ( lass: Anliparkinson agent Pha rmacologi( ( lass: Ctntrallyacting dtolinergic receptor antagonist
ACTIONS AND USES
lklllllUpi"" ... 1> by bluc.lil"J ... ..,. ,limul.oliun uf ""."un, in
(orpul miatum.k isulf<! for ft'litfof parkilllOllivn s,mptoms and tilt IIut-
mrnt of EPS brought on by amipsycoolir: pha!T11Koliltrapy. This IMdiution
WPPft'l Sf! but rIot>s not afftcl dyskinrsia.
ADMINISTRATION ALERTS
Tilt patitnl rna)' bf ullbif 10 mtdiution and nY, netd
assisun(f.
Btnrtropine may bft,ken in dividtd dolts, two 10 four limf1a dlfI. or tht
days cIosf rna)' tot taktn at btdtimr.
lfmUICifwt'.Jmrsso!IuB, tht dostshould bf ft'd1Ktd.
PlI'9nalK)' uttgOl")' C
PHARMACOKINETICS
Onwt: IS minlMI1V;1 h PO
Pfak: 1-2 h
Halflife: 2-3 h

ADVERSE EFFECTS
"" rlp!"llc"ll [,"111 it> .ul"IIOm;" liun, bnlllrupin" ,.n uu .. typiul
(holinergK side rfrecu IIKh as d!)' mouth, conniparion, and tam)n!lh. Ad-
Ymf ffltch indudr Sfdition, diuinflS,
iniubiily. insomnia.
Contr.indi u tions: Contraindiutions i!l(lude narrow-.Jnglt glaIKoma, myas-.
theni<! nd diINlrs of tht gen nOUfina!), and Gl mID.
INTERACTtONS
Drug-Orug: SI>nztropft n_1I with drugs.For
IhcUd HI bf takton with akohol, triqtic. 1olAOk, phtnothia1infl,
p"(I(ainamidf, or q.-nidill!' bfatM of I1IIIbini'd sedati'll' elfKiI. orc (old medililts
and IbhoI IDoUd bf .J"IOided.OthKdrugs thai rMROI"
oKINltiIn of thf dopamine fKepto! !IW)' produa additi'll' elfKiI. HaIoptridoI
dt<ruIo!I elfKti"lf!ll%
.l.ntii:lIMlliws,phfnothialints,
nY, ilKlM!' antidlolinHgil: tflKlI,and antidiafll"lNb may oiKrtH oIb\o!ption.
La b Ii5IS: l.Intnown
Unhown
Treat mt m ofDlfrone: Physostigmine salKylatt.110 2 mg wbrutlntoJslyor
IV, will lt' \'erst symplOtnI of anlidlolin. rgir: intoumion. A !oKond injt(ticn tna)'
bt 9N!n aittr 2 hours, n ft'I[uift'll. OtherwiM', UNlm. nl is symplomali!: and
supportivr.
RPM rc M}M!rl/ngIJ1 fr1f Q Nlmifll} Pnxm FOOIIlpKl/{ rc drui}
>
"

l
."

i
LibraryPirate
264 Unlll Thl'Ne<voo,Synem
by chronic inflammatory or oxidative cellular damage to the
surrolUlding neurons. There is a loss in both the number
and function of neurons.
Alzheimer's patients experience a dramatic loss of ability
to perform tasks that require acetylcholine as the neuro-
transntitter. Because acetylcholine is a major neurotrans-
mitter within the hipJXlcampul. an area of the brain
responsible for learning and memory, and other parts of the
cerebral cortex, neuronal fimctioning within these brain ar-
eas is especially affected. Thus, an inability to remember and
to recall information is among the early symptoms of AD.
Symptoms of this disease are as follows:
_ Impaired memory and judgment
_ Confusion or disorientation
- Inability to recognize family or friends
_ Aggressive behavior
- Depression
- Psychoses, including paranoia and delusions
_Anxiety
Drugs for Alzheimer's Disease
Drugs are used to slow memory loss and other progressive
symptoms of dementia. Some drugs are given to treat associ-
ated symptoms such as depression, amiety, or psychoses. The
acetylcholinesterase inhibitors are the most widely used class
of drugs for treating AD. Representative agents are listed in
Table 20.4. In 2003,memantine (Namenda), the first of a new
class of drugs called g1utamatergic inhibitors, was approved.
Other agents purported to prevent or help slow the onset of
AD progression include nonsteroidal anti -inflammatory
drugs (NSAIDs), vitamin E,and selegiline ( MAO inhibitor).
Acetylcholinesterase Inhibitors
(Parasympathomimetics)
The FDA has approved only a few drugs for AD. The most
effective of these medications act by intensifying the effect
of acetylcholine at the cholinergic receptor, as shown in
Pharmacotherapy Illustrated 20.2.
20.6 Treating Alzheimer's Disease
with Acetylcholinesterase Inhibitors
Acetylcholine is naturally degraded in the synapse by the en-
zyme iI(etylrnoli neteIllSl'(Ac:hE). When AchE is inhibited, acetyl-
choline levels beoome elevated and produce a more profound
effect on the receptor. As described in chapter 1300, the
AchE inhibitors are indirect"acting parasympathomimetics.
The goal of pharmacotherapy in the treatment of AD is to
improve function in three domains: ADLs, behavior, and
cognition. Although the AchE inhibitors improve all three
domains, their efficacy is modest,at best. These agents do not
cure AD--they only slow its progression. Therapy is begun
as soon as the diagnosis of AD is established. These agents are
ineffective in treating the severestagesofthis disorder, prob-
ably because so many neurons have died; increasing the level
of acetylcholine is effective only if there are functioning neu-
rons present. Often, as the disease progresses, the AchE in-
hibitors are discontinued; their therapeutic benefit does not
outweigh their expense or the risks of side effects.
AU acetylcholinesterase inhibitors used to treat AD have
equal efficacy. Side effects are those expected of drugs that en-
hance the parasympathetic nervous systl'lll (cbapter 1300).
The GI system is most affected, with nausea, vomiting, and di-
arrhea being reported. Of the agents available for AD, tacrine
(Cognex) isassociated with hepatotoxicity. Rivastigmine (Ex-
elon) is associated with weight loss, a potentially serious side
effect in some older adults. \'/hen therapy is discontinued,
doses of the AchE inhibitors should be lowered gradually.
In 2003, memantine ( Namenda) was approved by the
Food and Drug Administration (FDA) for treatment of
moderate to severe AD. Its mechanism of action differs from
that of the cholinesterase inhibitors. Unlikt> cholinesterase
inhibitors that address the cholinergic defect in the brains of
AD patients, memantine reduces the abnonnally high levels
of glutamate. Glutamate exerts its neural effects through in-
teraction with the N"methyl-D-aspartate ( NMDA) re.::ep-
tor. \'/hen bound to the receptor, glutamate causes calcium
to enter neurons, producing an excitatory effect. Too much
glutamate in the brain may be responsible for brain cell
death. Memantine may haw a protective fimction in reduc-
ing nt'uronal calcium overload.
TABLE 20 41 Acetylcholinesterase Inhibitors Used for Alzheimer's Disease
Drug Route and Adult Dose (max do' where IndIcated)
Q hydrodlloridf lAri:tpt) PO; 5- 10 mg ,t
gaiant,milt (Rmdynt, Remin)'l) PO; Initiall' with mg bid for i11lmt 4 wi!; ntolermd, may
illU!iII' b)' 4 mg bid Mry 4 wk toa t,rgttdoltol12 mg tid
(max:8- 16mgbid)
rivallilJnint tJrtrate (ERIon) PO;Stut with I.!i mg bid with food;molY iOOl'illt by I.!i mg bid
Ml}2wk iftoitr'tfd;tlfgtt doll' 3- 6 mg bid (max: 12 mg bid)
PO; 10 mg qid; iOOl'illt in 40 mglday iJKmrlffiI! oot 500IItf th,n
Mf"I6 wk (max: 160 mgfda,)
Adverse Effects
immmi4 romiring,
mIIlCk aroraio, Qlldomiool poi"
HepatolCJ:idty
LibraryPirate
''''Plfr 20 Drug<; for Dlsea ..... oft"" Ner""". 5)'-aem 265
PHARMACOTHERAPY ILLUSTRATED
20.2 Alzheimer's Drugs Work by Intensifying the Effect of Acetylcholine
at the Receptor
Characturizad by RbnDlTTloOl 5truc1ulas in tho bnOn:
.
ThII brain ohrinu .
Mumory is lorst
2 Drug thenpy foc u ... on _ t oring or e """""ina
-Wlc:ho .......... in the bnoin.
Cholinest"' .... inhibitor:!
'"9: donapuzi
Cholinergic: nuuron- _
Normally:
o Ach is .", ... "ad.
3 Fac10re reaponeible for brIIi n coi l d..n
include ... iV8ln1n..,,_on of gk.aa mate .
o Ach binds with
its .cup/or. Normal rde 01
--no
Drug th .... py:
E) Thu action 01
in a v ... t array
N-methyl-D-espartate (NMDA) receptor agents
memrrntino
Combination drug the. apy:
donapuzi and "",""",tiM
Because memantine and cho!inesterase inhibitors act by
different mechanisms, they may be taken in combination.
Donepez.il and memantine are approved for the treatment
of progressive AD and are marketed Wlder the brand name
Aricept. When taken together, these drugs do not interfere
with each other's absorption, distribution, metabolism, or
Ach is terminatad
by AchE.
o H AchE is
inhibited. Ach is
notbroken down
as quickly and
producea a. mON
dramatic: ellec1.
ChoIine.gic .eceptor
ofbrain
functioN,
incUding the
ability to
speak, """"'.
.... think,end
.......
elimination. There is evidence that memantine may be ef-
fective in the treamlent of vascular dementia.
Although acetylcholinesterase inhibitors have been the
mainstay in the treatment of AD dementia, several other
agents are being investigated fortheir possible benefit in de-
laying the progression of AD. Because at least some of the
LibraryPirate
266 Until The /IIeIv"",, System
.... Prototype Drug I Donepeztl (AT/apt)
Therapeutic (lass: Alzheimer's disease agent Pharmacologic ( lass: inhibitor
ACTIONS AND USES
is AchE inhibitor that improyes IIII'mory in (.1m of mild to mod-
erate Alzheimers demtntia by tnhandng tilt effect; of etykholilll' in nt\I-
rons in th!o cmbl'ill corti'll th" haYe not)'e1 btm damaged. should
rKtivt for n itall 6 month! priorto ;H!eSling maximum
benefit; of drug therap)'.lmpl'O\Oemtnt in IIIl'IIIOI)' may lit obmved as early as
1 to. Wffb following mtdintion. Th!o therapeutic: elferu of donepezil <I II' of-
ttn Ihort lil'd,and is moOOl,at oot.An ad'/<l ntage
of donepezillM'r other druqs in ilidau is that its long half-life pennill it to lit
given once daily.
ADMINISTRATION ALERTS
Gift mtdiution prior 10 btdtilll!'.
Mediution is molt effeai!' wherl on a I\'9ULtr sdltdule.
PII'9I1aIK)' <alf901)' C
PHARMACOKINETICS
Q-/set: Less than 20 min
Pt,ak:Hh
70h
Duration: Variable
neuronal changes in AD are caused by oxidative cellular
damage, antioxidants such as vitamin E are being examined
for their effects in AD patients. Other agents currently being
examined are anti-inflammatory agents, such as the COX-2
inhibitors, estrogen, and ginkgo biloba.
Agitation occurs in the majority of patients with AD. This
may be accompanied by delusions, paranoia, hallucinations,
or other psychotic symptoms. Atypical antipsychotic agents
such as risperidone (Risperdal) and olanzapine (Zyprexa)
may be used to comrol these episodes. Conventional an-
tipsychotics such as haloperidol ( Haldol) are occasionally
prescribed, though extrapyramidal side effects often limit
their use. The phanllacotherapy of p,yclto,is is proented in
chapter 1700.
Anxiety and depression, although not as common as agi-
tation, may occur in AD patients. Anxiolytics such as bus-
pirone (BuSpar) or some of the benwdiazepines are used to
control unease and excessive apprehension (chapter 1400).
Mood stabilizers such as sertraline (Zoloft), citalopram
(Celexa), or fluoxetine ( Prozac) are given when major de-
pression interferes with daily activities (chapter 1600).
For the complete nursing process applied tv anticholinesterase
therapy, see Nursing Process Focus: Patients Receiving Pam-
sympathomimetic Therapy, paxe /41 in chapter / JOO.
ADVERSE EFFECTS
Common side tffNII of dolll'ptzil all' vomitioo. diarrhea. and urine.
CNSside eflecli include insomnia,syncope, deplI'Ssion, headKhe, and initabil-
ity. MlJI(uloili leta I side efleo:t; inckKie mUl(Ie cramp!, arthritis, a nd bolll' hc-
Nit!. effects includt iabgut, cileIt p.lin, inCII'.lIM
libido,hot 1Lt!hts, urinary incontilll'lKe, dehydl'iltion,and bkmM vision.
Unlikt with tmilil', htpatotOlic:ity has not been OOsmed Patients with
brad)uldia, h)'potension, asthma, h)'perth)'roidism, or "'ti!' peptic: uker dis-
ease Ihould lit monitoll'd carefulI)'.
Contraindications: DolII'p!'zil is contl'ilindic:a!ed in p-atienll with 61 bftding
<l ndjaunditr.
INTERACTIONS
[)ug-[)ug: Oonfpelil wi GltI\f intidlolinfrl,tG to IN< It2; eIIectM.
in!eram with \f\'erilllllhfr dllllJS. F(f !Llmple, bmanedlol (itMI a

HnWr:KIn of OOnrp!zi. (f bllKOnarol! may mlt.Jbolilm of
OOnfpezil 8Kil111' am by incrtaling dIOIinII9ic: mily,1WII
WUd not beadminimrI'dCOlKlllJl'fldJ.
Lab Tets: Unl:nolw1
Ik>rbaVFood: Unknown
TINlment of O"ft' rdose: Anticholinergic! sudr as atropine m.ty be used as an
<l ntidote for donePfiil oMldOSilge.lntravenous atropine sulfate titrated to ef-
fen is 1I'(0mmtnded: an initial dOle of 1 to 2 mg IV with sub!l'l1utnt doln
based on dinicalll'SporI!e.
Rfftf ll) MyIlrnJngn (llf NrnhIq I'rI!Il" Foo/5 'ipt(/II( IrIIM ItrJ9.
MULTIPLE SClEROSIS
Multiple sclerosis is a chronic, inflammatory, autoimmune
disorder found most prevalent among young adults. Sen-
sory and motor deficits become progressively worse as the
patient grows older. If treatments are started early, the fre-
quency of disease symptoms can be slowed and permanent
neurologic damage can be delayed .
20.7 Characteristics
of Multiple Sclerosis
Multipl! sclerosis (MS) is a disorder characterized by damaged
myelin located with the CNS. Antibodies slowly target and
destroy oligodendrocytes, myelin, and axonal membranes.
As axons are destroyed, this impairs the ability of nerves to
conduct electrical impulses. Inflammation accompanies
damaged tissue, and multiple filamentous plaques called
scleroses are formed. During the early stages of MS, some ax-
ons recover due to partial myelination and the development
of alternative circuitry, but as antibodies continue to attack
neural tissue, further damage and infianullation lead to
neuronal death. Patients often bave recurrent episodes of
which at a fairlyrnpid rate.
LibraryPirate
(""'If I 20 Drug< fOI D""a ..... of ,"" Nervoo. SY;lem 267
TABLE 10 S I Disease-Modifying Drugs Used for Multiple Sclerosis
On"
IMMUNOMODULATORS
Rouu>and Adult Dow (max dose where Indicated) Adwrse Effects
(Copaxont,
mpoIymtrIJ
intffifron 1Imf) IM;30f1l(g (IfIWffk
SC;44 f1l(g thrtt
SC;2S0f1l(gMIYOIlltfda,
IV; 300 mg infwd ()ftf 1 h MIY month
hwIocht\. Wfaknru,ronillli<l1. Qntry,
mtmd rDMII,
KlmitirJ;,ronJripOOon,diorrlIto,I6l!Q/dyifrJnrOOIi,
mmsrrua/ dilordm,.lIMIOfHrio,.
ar IIw injKoon w
SMm,inap/rllam,hmalotoximy!p!U!'tOusilgJim
intffifron bttI 1b (BetaltrOllj
(T)'Iabn1
IMMUNOSUPPRESSANTS
mitoxantront (Ncwantront) IV; 12 mgim' MIY 1 months (iletiM max: 140 mg/m'J 1iiwlfQ, fMr,mou/hsom,dQrrhto,. hllirlul5,.
oflf11lio, irvtam/5lMfI!tibiUty ro infrrrim
IJrdiot!1);Ki!y'dys!!rtthmY shorioessolbrtith
The etiology of multiple sclerosis is unknown. Many cli-
nicians and scientists suspect genetic or microbial factors
due to reports that in most cases, MS occurs in regions of
colder climate. One thooryproposes acquired immwlOlogi-
cal resistance against pathogenic factors in warmer climates.
Microscopic pathogens such as viruses have been sU88ested,
though there is not slrong evidence for this theory.
Signs and symptoms associated with axonal injury in-
dude fatigue, heat sensitivity, neuropathic pain, spasticity,
impaired cognitive ability, disruption of balance and coor-
dination, bowel and bladder symptoms, sexual dysfWlction,
dizziness, vertigo, visual impairment, and slurred speech.
The course of MS is unpredictable, and each patient experi-
ences a variety of symptoms depending on the extenl and
localization of delll}'\'lination.
Drugs for Multiple Sclerosis
There is no cure for MS. Drugs mainly provide relief for pa-
tients with recurring symptoms. This is the case for patients
diagnosed with MS and l!'(ondary-progrrlliwMS.
Drugs slow progression of the disease and modify associated
symptoms. Immunomodulators are the main approach for
therapy. These drugs reduce the severity and frequency of
symptoms.
If drugs are not successful, as with progfl'Ssive-relap1ing MS,
the intrawnous immunosuppressant mitoxantrone may be
considered. Other immunosuppressants (chapter JZOO)
may be successful, although these drugs are mainly used for
primary-progrrlliw MS. V'lith this subtype of MS, symptoms
continue to worsen throughout the course of the disease.
Disease-modifying drugs used in the treatment of MS are
listed in Table 205,
20.8 Treating Multiple Sclerosis
with DiseaseModifying Drugs
Currently used for the treatment of relapse-remitting MS
and wcondary-progressive MS, immune-modulating drugs
are found in two categories: interferon beta (Avonex, Rebif,
Betaseron) and gbtiramer acetate (Copaxone). lnterferon
beta is available in two forms, interferon beta la and
interferon beta lb. These products are slightly different and
are available as 1M medication (Avonex) or SC medication
(Rebif and Betaseron). Both formulations reduce the sever-
ity of MS symptoms and decrease the number of lesions de-
tected with magnetic resonance imaging (MRI). Although
generally well tolerated, the interferons have unfavorable
side effects including fIulike symptoms (e.g., headaches,
fever, chills, muscle aches), anxiety, discomfort experienced
at the injection site, and liver toxicity. Due to toxicity con-
cerns and additive effects, caution should be exercised when
taking these drugs in combination with chemotherapeutic
agents or bone marrow-suppressing drugs.
Glatiramer acetate (Copaxone), formerly known as
copolymer-I, is a synthetic protein that simulates Ill}'\'lin ba-
sic protein, an essential part of the nerw's myelin coating.
Since giatiramer acetate resembles myelin, it is thought to
curb the body's attack of the myelin covering and reduce the
creation of new brain lesions. Copaxone is available in pre-
filled syrinses can be stored al room for
several days. As with the interferons, patients complain of
self-injection side effects: redness, pain, swelling, itching, or
a lump at the site of injection. Rushing, chest pain, weak-
ness, infection, pain, nausea,joint pain, anxiety, and muscle
stiffness are common effects experienced with the im-
munomoduiatofS.
For progressive-relapsing MS, mitoxantrone (Novantrone)
is the FDA drug approved for MS patients who have not
responded to interferon or giatiramer acetate therapy. Pri-
marilya chemotherapeutic drug, mitoxantrone is substan-
tially more toxic than the immWle-modulating drugs.
Toxicity is a concern due to irreversible cardiac injury and
potential harm to the fetus. Notable adverse side effects are
reversible hair loss, GI discomfort (nausea and vomiting),
and allergic symptoms (pruritus, rash, hypotension).
Some patients experience a harmless blue-green tint to
their urine.
LibraryPirate
268 Until The /lle<vOI" Syslem
Chapter REVIEW
KEY CONCEPTS
The numbered key concepts provide a succinct summary of the important points from the corresponding numbered section
within the (hapter. If any of these points are not dear, refer to the numbered se<:lion within the (hJpter for review.
20.1 Degenerative diseases of the nervous system such as
Parkinson's disease and Alzheimer's disease cause a pro-
gressive loss of neuron function.
20.1 Parkinson's diseaSl' is characterized by symptoms of
tremors, muscle rigidity, and postural instability and am-
bulation caused by the destruction of dopamine-producing
neurons found within thecorpusstriarum. The underlying
biochemical problem is lack of dop.1mine activity and a re-
lated overactivity of acetylcholine.
20J The most commonly used medications for parkinsonism
attempt to restore levels of dopamine in the corpus stria-
tum of the bl1l in. l.evodo]Xl (Larodopa) is the drug of
choice for Parkinson's disease.
2004 Centrally acting anticholinergic drugs are sometimes
used to relieve symptoms of parkinsonism, although they
are less effective than levodopa (Larodopa).
NCLEX-RN REVIEW QUESTIONS
D The family member caring for a patient with Parkinson's
disease at home notifies the nurse that the patient is
demonstrating a dramatic increase in extrapyramidal
symptoms. The nurse should instruct the caregiver to:
1. giwdiphenhydramint> (Benadryl) 25 mgPO.
2. transpon the patient to the emergency department.
3. increase the dosage of antiparkinsonism
4. make an appointment with the health care provider for
evaluation.
D The patient asks what can be expecred from drug therapy
for treatment of parkinsonism. What is the best response
by the nurse?
1. A cure can be expected within 6 months.
2. Symptoms can be reduced and the ability to perform
ADu can be improved.
3. Dis<'ascprogrcssion will bcstoppcd.
4. EPS will be pW'ented.
D Levodopa (Larodopa) is prescribed for a patient with
Parkinson's disease. At discharge, which of the following
teaching poi nts should the nurse implement?
1. Monitor blood pressure every2 hours forthe first 2

2. Expect the urine color to beorange.
3. Report the dt-I-elopment of diarrhea.
4. Keep scheduled lab appointments for liver and renal
function tests.
20.5 Alzheimer's disease is a progressive, degenerative disease
of older adults. Primary symptoms include disorienta-
tion, confusion, and memory loss.
20.6 Acetylcholinesterase inhibitors are used to slow the pro-
gression of Alzheimer's disease symptoms. These agents
have minimal efficacy, and do not cure the dementia.
20.7 MS patients often have recurrent episodes of neurologic
dysfunction, which progress at a Iilirly rapid rate. Symp-
toms depend on the extent and location of central de
myelination.
20.8 Disease-modifying drugs slow the progression of MS and
modify associated symptoms. There is no cure for MS.
o The nurse discussed the disease process of multiple scle-
rosis with the patient and caregiver. What does the nurse
explain is the cause of
1. The cause is unknown. Amyloid plaques and
neurofibrillary tangles have been found in the brain
autopsy.
2. The cause is unknown. Manyscarslocated throughout
the brain have been foulld 011 MRI scans.
3. Loss of circulation to the brain has been found on MRI

4. Loss of dopamine receptors is thought to occur asa part
of the process.
II All overdose of drugs to treat AD may occur if they are
taken improperly or if decreased liver or renal function
occurs. The nurse assesses the patient for signs of over-
dose, which indud<,: (Select alt that appty.)
I . bradycardia and muscle weakness.
2. tachycardia and hyperteJ1sion.
3. nausea and mmiting.
4. emotional withdrawal aIJd tachypnea.
s. hypotension and incrt'llSed muscle strength.
o An early sign(s} of levodopa toxicity is {are} which of the
following?
l. Orthostatic hypotension
2. Drooling
3. Spasmodic eyewinking and muscle twitching
4. Nausea, mmiting, and d l1rrhea
LibraryPirate
CRITICAL THINKING QUESTIONS
1. A 58-rear-old ?Irkinson's patient is placed on levodop;1
{Larodopa}. In obtaining her health history, the nu['l;e
notes that the patient takes Mylanla on 3 regular basis for
mUd lndlgeslloll, and also takes multivitamins dally (vIta-
mins A, B" D, and El. She also has a history of diabetes
mellitus type 2. What the nurse include in teaching
for this p;!tient!
2. A p;ltil'nl Is on Ie-ooopa and benztropine (Cogentin).
During a regubr office fOl low-up, the p;1tienl teUs the
nurse that she is going to Arizona in July 10 visit hergrand_
children. What teaching is important for this patient?
3. A 67-yeu-old Alzheimer's patient is on donepezil (Arl-
cepl ) and has a history of oongeslive heart failure, diabetes
mellitus type 2, and hypertension. The patient's wife asks
the nurse if this new medicine is appropriate for her hus-
band to take. How should the nurse respond?Whal teach-
ing should be donl'?
Su Ap[nndjJC D for II nSWaJ lind rariou<lltl for ali llcriY;litJ.


M)NImllngKllIli \'OUr one SIIJII !er anllfII! c!laptlf lB'fiew mmeriols and
ruourcet. Prepare lor wim aaditional practice
irrhr.lctilltlllSlOgm>IIIis lnI ao;ti'lities. WIIb anDil\i0n5
and vicIoos, and mae!
lIeQ.tSter '1W' rode from lhf ffor<t 01 your boot. at

LibraryPirate
DRUGS AT A GLANCE
CENTRALLY ACTING MUSCLE RELAXANTS rx.1n
o {cycoflu. Fiexerfl}
pqJtll1
DI RECT-ACTI NGAHTI SPASMODICS fX1IJtm
o danuol4'n. sodium (DrmrtlumJ IU}t 115
Nondtpolarizing81ocktrs ,.]78
PfIfItm
KEY TERMS
doniupmn paqt m
dystonia {lDgt 171
Drugs for Neuromuscular
Disorders
LEARNING OUTCOMES
Aher reading this the jtudmt should oble to:
1. Identify the different body systems cont ributing t o mUSoCIe movement .
2. Discuss nonphllrmacologi c therapies used to treat muscle spasms lind
spasticity.
3 . Explain the goals of phafmIKotherlipy with skelelal muscle relaxants.
4 . Describe the nurse's role in the pharmacologic management of muscle
spnm$.
5. Compare and contrllst the roles of the following drug clltegories In
treating muscle spasms and 5past idty:centrally acting skelet al muscle
reillunts, direct-acting antispasmodics, Md skeleul muscle rellixants
for short medi(a! procedures.
6 . For each of the drug classes listed in Drugs at II Glance, know
representlltlve drugs,and their mechanisms of action, primary
actlons, and adverse effect s.
7 . Use the nursing process to care for patients who are receivi"lg drug
therapy for muscle spasms.
lIIU5dupUmi p:IIJt 1lI
nturOlllU5CUlar bIcKlim paiJt lIS
LibraryPirate
D
isorders associated with movement are some of the
most difficult conditions to treat because their underly-
ing mechanisms span other important systems in the body:
the nervous, muscular, endocrine, and skeletal systems.
Proper body movement depends not only on intact neural
pathways but also on proper functioning of muscles,bones,
and joints (chapter 4700), which in tum depend on the lev-
els of minerals such as sodium, potassium,and calcium in the
bloodstream (chapters 31 and 4700). This chapter focuses
on the pharmacotherapy of muscular disorders associated
with muscle spasms. spasticity, and t reatments involving the
neuromuscular junction. Many of t he drugs used to treat
muscle spasms are distinct from those used for spasticity.
MUSClE SPASMS
MUlde spasms are involWltary contractions of a muscle or
groups of muscles. The muscles become tightened and de-
velop a fIxed pattern of resistance, resulting in a diminished
level of functioning.
21.1 Causes of Muscle Spasms
Muscle spasJTl.'i are a common condition usually associated
with excer.sive use of and local injury to the skeletal muscle.
Other causes of muscle spasms include ovennedication
with antipsychotic drugs (chapler 17(0), epilepsy,
hypocalcemia, pain, and debilitating neurologic disorders.
Patients with muscle spasms may experience inflammation,
edema, and pain at the affected muscle, loss of coordination,
and reduced mobility. When a muscle goes into spasm, it
locks in a contracted state. A single, prolonged cont raction
is a tonic spilsm, whereas multiple, rapidly repeated contrac-
tions are doninpasms. Treatment of muscle spasms involves
both nonpharmacologic and pharmacologic therapies.
21.2 PhlllrmlllcologiclIInd
Nonpharmacologic Treatment
of Muscle Spasms
Treating a patient with complaints of mus.:le spasms requires
a careful history and physical exam to determine the etiology.
After a determination has been made, nonpharmacologic
therapies are normally used in conjunction with medications.
Nonpharmacologic measures may include immobilization of
the affected muscle,application of heat or cold, hydrotherapy,
ultrasound,supervised exercises, massage, and manipulation.
Pharmacotherapy for mU5Cle spasm may include combi-
nations of analgesics, anti-inflammatory agents, and cen-
trally acting skeletal mU5Cle relaxants. Most skeletal muscle
relaxants relieve symptoms of muscular stiffness and rigid-
ity resulting from muscular injury. They help improve mo-
bility in cases in which patients have restricted movements.
The therapeutic goals are to minimize pain and discomfort,
o..plfll1 DrugsfOfNI'U.omusrularOlsor<ier, 271
PHARMFACTS
Muscle Spasms
Moll' than 12 million PfopIIo worldwide hal'!' musc:1e 'p,nm,.
MUl(le!palms Il"'Il' t llOU9h for drug oftt n found in
piltitnts who othtr dtbilitating SIKh II mokt, inju!)',
or pillS)'.
is i!5O(iattd with n'ffill that O(cur btfort or
dJring birth, but miy lit acquired during tht ftw months or )'Nnof
life II the ofhtid trauma or inftion.
Dystonia iffKts iboot 250,000 JlNple in the Unittd StattS; it is the thild
most mmmon moY!'ment following esltmial tll'mor ,nd
Parkinson'ldisem.
ft'(ogniZl'd mukiple fonmofinheritable dystonia ,nd
idtntified at lem 10 getlHor(hromosom,llo!atioll! Il'sponsible for tht
mioul
range of motion, and improve patient', ability
to function independently.
Centrally Acting Skeletal Muscle Relaxants
Many muscle relaxants generate their effects by inhibiting
motor neurons within the brain andlor spinal cord. Thus, the
origin of drug action is within the central nervous system.
21.3 Treating Muscle Spasms at the
Level of the Central Nervous System
Skeletal muscle relaxants act at various levels of the central
nervous system (CNS). Although thei r exact mechanisms
are not fully understood, it is believed that they generate
their effects within the brain andlor spinal cord by inhibit-
ing upper motor neuron activity, causing CNS depressant
effects, or altering simple spinal reflexes.
Antispasmodic drugs are used to treat local spasms result-
ing from muscular injury and may be prescribed alone or in
combination with other medications to reduce pain and in-
crease range 01 motion. Commonly used centrally acting
medications include badofen (Lioresal), cyclobenzaprine
(Cyroflex, Rexeril), tizanidine (Zanaflex), and benwdi-
azepines such as diazepam (Valium), clonazepam
(K1onopin), and lorazepam (Ativan), 3S summarized in
Table 21.1. All the centrally acting agents have the potential
to cause sedation.
Badofen (Lioresal), structurally similar to the inhibitory
neurotransmitter gamma-aminobutyric acid (GABA), pro-
duces its effect bya mechanism that is not fully known. It in-
hibits neuronal activity within the brain and possibly the
spinal cord, although there is some question as to whether
the spinal effects ofbaclofen are ar.sociated with GABA. Ba-
dofen maybe used to reduce muscle spasms in patients with
multiple sclerosis, cerebral palsy, or spinal cord injury.
Common side effects of baclofen are drowsiness, dizziness,
weakness, and fatigue. Baclofen is popular due to its wide
safety margin.
LibraryPirate
272 Unlll Thi'Ne<vDI"Sy'tem
TABLE 11. 11 Centrally Acting Skeletal Muscle Relaxants
Dru,
IOOoI'ffi (Lioman
cariIoprodoi (SofN)

(P.uaftu. Parafon
donmpam(Klooopin)
Q dobtnzaprilll' hydnxllloridt (Cycollu.
FIo.rol)
diazrpam (Valium) (1ft' palJl' m for
tilt ProiOlypt' Ilruij box 00)
Ior.izrpam (A/ivan) ISS for
tilt ProiOlypt' Ilruij boxOC
1III'IaXi/ont
(Robaxin)
0Iphtnadri1ll'
M)'oIin,Norllu)
lizanidilll' (bnaflex)
Route and Adult Dose (max dose where Indicated)
PO; S mg lid (max:80 IJI9/day)
PO;lSOmgtid
PO; 800 mg tid dfMiw'; rt'duu to 400 mg qid orlm
PO; 150- 500 RIg tid-"d (mn:] glday)
PO; 1.5 mg tid, may ill' in irmnltnts of 0.5- 1.0 mg

PO; 10- 20 RIg (max:60 mglday)
PO; 4-10 RIg
lMIlV; 1- 10 mg. Jtpt'it if ill-4 h
IV pump:mililttl mulion 011 5 mglmin
PO; 1-1 RIg (mal:
PO; 800 mg (max: 10 mg/dayl
PO; 1.'i 9 qidfor 1-1 days;thtn rmn 10 1 9 qid
PO; 100 mg bid
I
Adverse Effects
_.\ mIotiOfl,illIDiQ, i g/lr-
urioory IrrirQncy Qf rmnrion, hypowllilfI,
bradta!rdQ
[dtrna of 10m. anaphylagi< rt'a(!ipn, rrspiratO!Y
deomsjoo.(oma /aryngo>Mm.wdmw/ar(o!!apse
Prototype Drug I Cyclobenzaprlne ((ycof/&, Flexenl)
Therapeutic ( lass: Centrally acting skeletal musde relaxant Pharmatologit ( lass: Catecholamine reuptal:e inhibitor
ACTIONS AND USES
C){lobtrJzaprifH' spilmsolloul origin withoutinlerfloring with
mUlde funnion. Th is drug am by .Rprt'lling motor activity primarily in
IIw ttfem abo ouur in spioal toro.C){lobfnzaprine in-
cirrulating 01 bloc:king prt'Synaptic: uptau.1ts
mro.anilm 01 anion is similar 10 thai 01 tri(){lic: antidtprrslllnu (chapler
1600 I.TIIt drug {ium mUl(ito rt'lHation in of acute mustito Spi\tic:ity,
but it is not in pall)'or oltlw brain ind spioal
(oro. This rntdiution is fllNnl to providt 2 !o 1 Wffks.
ADMINISTRATION ALERTS
drug not rt'(Ofllmtnded lor ptdimic: 1M.
Mn imum effKh may tau 1 to 2 weeks.
PrrgoallQ talf90lY B
PHARMACOKINETICS
()}stt 1 h

HalHiflo: l - ldays
Duration: 12- 14h
ADVERSE EFFECTS
rrauions to indude drowsinffi, blurred vision, dizzi-
III'SI, df)' mouth, rash, and tathycardi.l. 0111' ikhough rarf, is swelling of
thetongUl'.
Contraindiutions: CydobtnLlprilll' should bf used with mnion in palitnu
with MI,
INTERACTIONS
Akohol, ..... oothiaziws,and oIhPr 0iS 1IW11aU\f iIiIii"ll'
nutIII' IMd within lWHk:i ofamonoamiltollidN
iMililll" (lMClI thtrapy III'Yus.! "II5P'1"fNk (risis and torII'Ulions may oml".
Lab Tests: Unl:nom
IWrbaVFoo:l: Unknown
01 OYl' rdose: TIw administration of 1 10 1 mg 01
is to of poisoning by drugs
with antitholilll'rgic: .Jdivity. Physostigmilll' may bf in the 01

Ro>Ii'r Ie MyMIsJni}D MNlgI'rOCt5.1FlxlllspK/II( /M1t!!g.
LibraryPirate
Tizanidine (Zanaflu) is a centrally acting alpha,-adrenergic
agonist that inhibits motor neurons mainly at the spinal
cord level. Patients receiving high doses report drowsiness;
thus, it also affects some neural activity within the brain.
Though uncommon, one adverse effect oftizanidine is hal-
lucinations. The most frequent side effects are dry mouth,
fatigue, dizziness, and sleepiness. Tizanidine is as efficacious
as badofen and preferred by some health care providers.
As discussed in chapter 1400, benzodiazepines inhibit
both sensory and motor neuron activity by enhancing the
effects of GABA. Common adV\'r.ie side effects indude
drowsiness and ataxia (loss of coordination). Benzodi-
azepines are usually prescribed for musde rela.ution when
badofen and tizanidine fail to produce adequate relief.
SPASTICITY
Spasti city is a condition in which certain muscle groups re-
main in a continuoui state of contraction, usually resulting
from damage to the CNS. The contracted muscles become
stiff with increased muscle tone. Other signs and symptoms
include mild to seVtre pain, exaggerated deep tendon re-
fiexes, muscle spasms, scissoring (involuntary crossing of
the legs), and joints.
21 .4 Causes and Treatment
of Spasticity
Spasticity usually results from damage to the motor area of
the cerebral cortex that controls muscle movement. Etiolo-
gies most commonly associated with this condition include
neurologic disorders such as cerebral palsy, severe head in-
jury, spinal cord injury or lesions, and stroke. D)'5tonia, a
chronic neurologic disorder, is characterized by involun-
tary muscle contraction that forces body parts into abnor-
mal, occasionally painful movements or postures. It affects
the muscle tone of the arms, legs, trunk, neck, eyelids, face,
or vocal cords. Spasticity can be distressing and greatly af-
fect an individual's quality of life, whether the condition is
short or long term. In addition to causing pain, impaired
physical mobility influences the ability to perform activities
of daily living (ADL; ) and diminishes the patient's sense of
independence.
Effective treatment for spasticity includes both physical
therapy and medications. Medications alone are not ade-
quate in reducing the complications of spasticity. Regular
and consistent physical therapy exercises have been shown
to decrease the severity of symptoms. Types of treatment in-
clude muscle stretching to help prevent oontractures, muscle-
group strengthening exercises, and repetitive-motion
exercises for improvement of accuracy. In extreme cases,
surgery to release tendons or to sever the nerve-muscle
pathway has occasionally been used. Drugs effective in the
treatment of spasticity include several dassifications of an-
tispasmodics that act at the level of the CNS, neuromuscu-
lar junction,or muscle tissue.
COMPLEMENTARY AND A LTERNATIVE T HERAPIES
(ayenn; for Muscular Pain and Tension
u)'!'lInr al50 known as chili paprika,or red
has bffil as a II'medjo for minor musdt pain or trnsion. Caps.! ici II,thr II( -
ingll'ditm in diminisilts thl- chtmical thit Ir;r;ei
t hlOU9h ntMS, thtrrb)o dt[ll'asing thl- Sl'II sation of pa in
Rag;:n, khiyaml,& Iwamoto. 2(04). Capsaicin (lI'am (0.025%100.075%)
may bIo applitd dill'niy to tht up to bur times a dajo.1ts elem(-
(\JmJIatH tilllt, 50 (lI'ams containing (aps.!icin netd to bIo oIpplitd II'gU-
la rtyto bt Although no known mediul (ondition Hists that would
prmot u20f (oI)'etlnt, it should nrm lit oI pplied Ol'rl" brokrn
nal of full-stll'ngth (a)'l'nnt should bIo limited to no Il1011' than 2 days be-
it mol, (oIlM skin inflammation, blistm, and ukm.1t also I"ftds to bt
boplaway from and 1lIK0IJI oI'1Oid bums. Hands nUit bt
wasllrd thoroughly usr.
lIIoIy 01110 btyken
nessfor this indication is Iacking.1t isal'ailablt in upsults, 30 10 120 mg,tair.tn
lime.dlily,or I. lIN by Idding 11410 1Ill>pof powder tOI
ingwolter.
Direct -Ading Antispasmodics
A few centrally acting drugs effective in the treatment of
general muscles spasms have already been covered: badofen
(LiOJesal) and diazepam (Valium). These and other skeletal
musde relaxants are effective in treating spasticity as well. As
shown in Pharmacotherapy Illustrated 21.1, d,1ntrolene
(Dantriwn) is a direct-acting drug. The direct-acting drugs
produce an antispasmodic effect at the level of the neuro-
muscular jWlction and skeletal muscle.
21.5 Treating Muscle Spasms
Directly at the Muscle Tissue
Dantrolene relieves spasticity by interfering with the release
of calcium ions in skeletal muscle. Remember from
anatomy and physiology that calcium released from the sar-
coplasmic reticulum is necessary for skeletal muscle con-
traction. If the release of calcium is blocked, muscle tension
will be reduced. Other direct-acting drugs indude botu-
li nwn toxin type A (Botox, Dysport ) and botulinwn toxin
type B ( Myobloc), used to offer significant relief of symp-
toms to people with dystonia. Direct-acting drugs are swn-
marized in Table 21.2.
Botulinwn toxin is an unusual drug because, in higher
quantities, it acts as a poison. Clostridium bOll/linum is the
bactuium responsible for food poisoning or botulism. At
lower doses, however, this drug is safe and effective asa mus-
cle relaxant for patients with dystonia. It produces its effect
by blocking the release of acetylcholine from cholinergic
nerve terminals (chapter 1300). Acetylcholine is the natu-
ral neurotransmitter necessary for the voluntary contrac-
tion of skeletal muscles.
Because of the extreme weakness associated with botu-
linum, therapies may be needed to improve muscle
strength. To circumvent major problems with mobility or
LibraryPirate
274 Unltl TheNe<vomSy,lem
PHARMACOTHERAPY ILLUSTRATED
21.1 Mechanism of Action of Direct-Acting Antispasmodics
Spaeticity. s..., ......... oontncting
Dependent on calcium release
Symptoms:
2 Admirielnltion of . ntiapurnodic.
Botulinum toxin AlB (Botox:
MyobIoc) blocks reI_ of Ach.
Myofibrilo
\
Pain
InvnobOlity
lnabiity to perform ADl..e
(myosin)
n"o f>lamenla
(actin)
R89Ult of druI:Ilhempy;
Reducad pain
Mobility
Greater ... nge of muscle activity
Relaxed muac:l ...
TABLE 21 .2 1 Direct Acting Antispasmodic Drugs
Drug
NEUROMUSCULAR JUNCTlON
botulinum tOIin t)"\I!' A (Botox, 0yIp0rt)
botulinum tOIin t)"\I!' B (M)'ObI)
SKELETAL MUSCLE
Q \Odium (Oantrium)
Roull' and Adult Dose (max dose where Indicated)
25 injectfd dirKtly into muldf (max: 3O-day 00Ie
Ihould oot 9fd lOOunitl)
2,500-5,000 uri61doll' injtaftl dirffil)' into mUldt;
stOOd lit musdt 1JOUp!
I
PO; 25 mgldar. inul'aII' to 25 mg iooull' fflf"I
4- 7 dayl up to 100019 bid- tid
Irdies wmmoo ad'IffII' II'rioui illmll'
Dantrol _ (Dantrum) bIocke
calcium rei ........ within muscle.
Initiation of new
impul ....
Adwr,e Effects
IIeodQcN, fouirmlllle
poi", rnuJdf rm1emru
Anapbylaxh dnp/ygja dNfb
I
MUIdt diorrhtG
HrMk ncrut;
LibraryPirate
LI FESPAN CONSIDERATIONS
The New Fountain of Youth?
M .n new foonuin of)OOlh, botulinum ttI. in I)'pt A (801011 Cosmetic)
injKtioM Mft' approYfd II)' FDA for Irmporary improl'flllt nt in tht
of moder.ltf 10 stftft' frown lilli's (vMicallilll's btiWffll tht
brows) in iduh patimts aoged 6S or It works 10 r5u frown mus
des blocki ng 00'/11' that triqger wrinklt-<.iusing mlJl(ie [ootra(
tions. (lNting a ID!ooth 'ppearaIKt bttWffIl brows. Administmd in .I
fM tiny injruions of purified protein, this minimall)' inv.nm is
simple and quid:, and dramatic ft'IUlts with minimal discomfort Rt
IUIts un be In as NrI}' u 24 to 48 hours injKtion,and tht efftn
up 10 4 mooths.lnjtctions shoold not be It'pNttd 1IIOft' thn oo(e I'I'II'f)' 3
mooths. Side efftns nausu, flulikt symptoms, tt mporary
eyelid drooping. mild pain, erythema at the injKtion sitt, and mus[1e WNk
n6S.Ar:[ording to Amtrican Socitty for ksthetic: Plastic: SuIlJfI)' (ASAPS),
BotOJ: injtrtions .1 ft' the f3l6t growing cosmetic: proc:tdlJrt in the inrustry.
Plastic: 1Utgl'f)' known as BoIOX parties- as wt'li as stminars, t'lt nings,
and 10(;'''- ''' Ittn 10 be I k.y<l ...... nlofOoto. markting in rrAKh of the
Unittd StatfS.
posture, botulinum toxin is often applied to small muscle
groups. Sometimes this drug is administered with centrally
acting oral medications to increase functional use of a range
of muscle groups.
Drawbacks to botulinum therapy are its delayed and lim-
ited effects. The treatment is mostly effective within 6 weeks
and lasts for only 3 to 6 months. Another drawback is pain;
botulinum is injected directly into the muscle. Pain associ-
ated with injections 1<; usually blocked by a local anesthetic.
Prototype Drug I Dantrolene Sodium (Dantnum)
H OME & COMMUNITY CONSIDERATI ONS
Muscle Relaxant Therapy in the Home Setting
MUI(Ie sp.nms and !pa!tic:ity aft' ronditions that rna)' .Jlftct patients ttrough-
out thtir life span. In tocIay'swciety, many of the patients who in t'le past
rtIidtd in nursing hollll'land institutions aff now being urtd lor at h:rnr by
famiy members and horn!' heath aogeoc:it1.AIso, the nrurologic: disulI'I that
alftrt young arults aft' bti ng in the horn!'{(ommu nity sfning. Thus, all
igf groups aff able to be with thtir famil)' mtmbel'S and as nollllli a life
as possiblt. main factor to ffmember is that fdKation and for
u regil'll'rs is t rtlt' me/y important to that patitnts a ft' (ompii.-!t with
t htir therapy and that u regiven aff (om pttfm 10 admin isler the
21.6 Blocking the Effect
of Acetylcholine at the Receptor
Neuromusrular blodcers bind to nicotinic receptors located on
the surface of skeletal muscle fiben;. For pharmacotherapy,
nicotinic blocking agents interfere with the binding of acetyl-
choline, thereby prewnting voluntary muscle contraction.
Nicotinic blocking agents are cholillergic (chapter 1300).
Neuromuscular blocking agents are classified into two
major categories: nondepolarizing blockers and depolariz-
ing blocken;. Nondepolarizing blockers compete with acetyl-
choline for the receptor. As long as agents interfere with the
binding of acetylcholine, muscles remain relaxed. Bya re-
lated mechanism, depolarizing blockers bind to the acetyl-
choline receptor and produce a state of continuous
depolarization. This action first results in small
Therapeutic (lass: Steletal musde relaxant Pharmacologic (lass: Dire<:t-a(ting antispasmodic; calcium release blocker
ACTIONS AND USES
D<antrolene is often used for spasticity, for spasms of the hrad and
III'dt It reinf1 musde spasms by with thf of (alciu m
ions from I10fq affas imide skeletal mUl(Ie (fils. It dot-s not afiret (ardi.l{ or
,",ooth mu!Cl<. O. mrolen< ;. u..tirllor 'POID!' wI>< n Il><y 0<-
wr after spinal (ord injury or strokl and in ta\f"I of (frm-al palsy or mukiple
trtaDntm ofmusc:1e pain
k is ilso used tffalmtm of malignant hypMhennia.
ADMINISTRATION ALERTS
oral within days btU!M it dot-s not ronuin a

IV solution has i high pH and theftfoft' initating to tislUl'.
Pregn.JlK)' utt90ry C
PHARMACOKINETICS
Onsrt: h

Halflife: 4- 8 h 1V;8--9 h PO
Duration: Variable
ADVERSE EFFECTS
Advern tlftm ifl(k.odt mUl(It dry mouth,
naust a, dianhta, tac:hlUrdi.J, enatic: blood prfllUrt, photosensitivity, aid uri-
nar)' ft'Iention.
Contraindi u tions: Patitnts with impairtcl wdia{ Of pulmonary /ufl(lion or
hepatic disNst 5hou1d not ukl thisdrug.
INTERACTIONS
Drug-Orug: ImIr<Wfle n\m[\S with many O!hef drugs. For moukilKll
bf tal:et withOT( lWgh andantiJistJninei,akohol,Of OIher OiS
dtpres5.ln1l. Verapamil and other ukiOOl dIanneI bbders liter. with
inuNII the riIk ofYflltriruiaffibrilalioo iIIld
libTi5Is: I..Inkncwn
Unknown
Treat mf m of O"ft' rdosr: For awtr amONgf, gentral IUpportm mHlUr6
should be ustcl.
III'I'fr Ii1 MjNUrllngm kif Q Nlmlfll} I'rIKn.! fool! J{lKIk Ii1 rIr/s dnii}


,


"







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276 Unlll "TheNelvoo.Sy.tem
NURSING PROCESS FOCUS PATIENTS R,eElVING DRUGS FOR MUSCl' SPASMS OR SPASTICITY
Assessment
BiSfline azessmfnt pri or to administrat ion:
Understand the the drug his been prenriilfd in order to for
therapMil fiff,ds.
Obtain a complete health hillory indudi ng cardmascular, !\'Spiratory,
IIepati<, or muscuioskeltt.ll dile.Jm.Obtain <I drug hiltory inckiding
allelllies,QJlTI'm p=ription and OlC drugs,and herbal lit'
alen to poSlible drug inttractions.
Obtain a hiltory of the currt m (ondition and symptol1ll,tli!ceroning
ronditions,and ability to any out A(ls, particularly to mobility.
II illI'IS the iei'd al scrning tools whtn
possible kg., Fl.l(C lor inlams or ftry
young Wong--Biker F.I(ES ",Ie for children, numtriul rating
scale lor iduks)J.slI'Is tlMo history 01 piin modattd with mUl(Ie spasms
ind what has worted or nat worIctd lorthe pititnl in tht pall
E-Ialwte appropriate laboratory finding! SIKh as hepatH: or renal fUnction
studits.
Obtain ball'line vital signs, rruscle tht plI'Stnc:e of mUicle
Sp.lsms Jnd typI' honic,dooic, milltd).
AsII' \! the pititnt's i bility to and understand instructioo.lndudt
the family or uregilm U
Assfssment throughout administration:
AsSffi for therapeutil tfitllS dtpl'lldtnt on tht for tht
drug kg.,dtCft'astd muscle spasm, rigidity,dti:ft'astd pain).
ContinUl' ptriodil rronitoring of vital signs and motor fuMtion.
AsItS! for and promptly
dry mouth, orthosutil: hypotension, tKh)ocartia, s\Yl'ling of
tongue or fact,diplopia, ui nary lianbea, or (onmpation.
Potenti al Nursing Di agnoses
Pain (arultkhrooic,! to rruscle sj)wl1s)
Phy1K:al Mobility irel.ntd to arutt /rnronil piin)
SrI! Dti"Kit bathing. hygitne, toileting) (relattd to muscle
Sp.lsrtU,piin)
IMturbtd Body Image todisability)
Fat9Je
Dl'lKitm Koowledgt (drug thtrapy )
Rilkfor (ft'lattd to distill' tfftrn)
Planning: Pat ient Goa ls and Expected Outcomes
The pitient will:
Exptril-nc:e therapeutK tfmts on the the drug iI being given (f.g.,dti:rmtd mUl(lespasm Jnd pain,improvtd rrobility and
coordination, and inc:rtJstd ability in activities).
Bt flrt from, or txperierue minimal. ,dmst tfftru.
an uoderstandin 9 01 tilt drug's UII', adYent tfftds, a nd p!ff.lutions.
Dtmon strate proptr !ell-administration of tht milation (e.g., dOlI', timing. when to notify provider).
Implementat ion
Interventi ons and (Rati onales)
Ensuring therapeutic dfeds:
CominUl' asmsmtnts as decriilfd earlitr for thtrapeutil fiff,ns. Drug
therapy m.y !ake II'"Itral days to haY!' the fUll fiff,ct with iesltrling pain
and iMrulf<i ran9f 01 motion,and an iMft'astd ability to
romplttt A(ll nottd.Support the pititnt in 1I'If.(oJft' activitits as
IIt(tsury until improYl'ment iI obstrvrd. (An abili/)' to carry oot ADu
implO'fts with consiltent USi9f.)
Minimizing adftrse el"ffCts:
En !Ure patitnt salt ty; monitor motor (oordination andlor am bulation, or
other t1ltrltial motor activities. lit' pi rtirula rly (;IutOOs with oIdtr adults
whoare at an inc:rustd risk for lalls.(Gradual improYtrlltrlt in symptorm
may be notKtd O'It rll'Yl'ral weeks but pain or Sp.lSI1ll filii)' aflrct motor
skills. with ambulation iI as piin,Sp.lsms,or
rigidity may the risk of lalls.}
Patient and Family Educat ion
Teach the patitnt thit improYl'mtnt may gradually be nottd O'Itr II'YI'ral
days' time. Nonpiwrm.(oiogil OINSUII'S filii)' be IIffiIfd until the full
mediation tfftd iI noted.
Instruct the patient to (oJ II lor as sistanc:t prior to getting out 01 btd or
atttmpting to walk alont if piin, rigidity ,ft' panicularly II"Ifrt.
As= the familis,or outADLs at horntand
tJ:pIoft' nttdfor additional htalth Ifierrolls rrqUR long.
tmn physical thtrapy (e.g., cmbral palsy). Evauate horne safe/)' nttds.
InstllKt the patient to i wid driving or other actiyities requiring men!al
,Ion_, or ph)'lial <oordin"ion tilt ri"Kts of tho drug Ire known.
LibraryPirate
NURSING PROCESS FOCUS PATIENTS RECEIVING DRUGS FOR MUSCLE SPASMS OR SPASTICITY IC_
Implementation
Int erventions and (Rational es)
(onlilut III monifDr vOl sic}ns, pirticularly blood PfmUIt. TiR blood
pttUUIt IyiIg, stMllling fD deiKt orthost.tic Be
partiwl.lrIy c.wtious with 0& adults wfto if! i11.n risl for
HoI:ify tile hNIth Un! pmider if thf blood pl!SWIt
dtmlStS btyond tsUbIiWd or lhypotemionis
a(OIIIp.lnied by refttx LlChyurdii. (Orthosutic hypottnsion iu poIsibir
dlKt Ind in Iddilion fD I!Mdn SP'5llls, polin. Of rjrJdry, ml)'
inamt tM risk of t.1s or injury.)
MonitoI' IIlIM1t 10IIt, range of motion, 1M dtglft of muld!
(Imp_m be Otf dlt first wttt or!WO of thmpy.
Incrtuing ilbility of dKrustd muscle ttndtmm .nII rigid"rry
htlps 10 lIttftmine rffedM:JltSS of drug thffipy.)
Patient and Family Education
tht p.u itftt to rise from lying 10 Of !landing !lowly to ft'Oid
IiuftsSOf his if sight h,poffmlon noI:td.
"-lilt pitimt rtpOrt dizziness,
pilpiutions, Of 1)1ICOpf.
le.ch 1M pitienl bow 10 ptlfoflll gentil! 1i.-of-mo6on
exflriling on!yto the point of mild phJlial chcomfort but IIMr pain,
duougboutthed.,.
Pnwidt i1dditiollal piin mitf ITImUffS w.:h II pmitiollil support,qe:mit TeiCh me pititm compltmtnury Piin inttfYtntions such is positioning.
muugf. ind moist or ice plCb.(Supponi'le ooning melSUre may gcfItIt .ppliu6oc1 arht" or cold 10 11M! p,linfuI illtil.distrattion
pilin Itld Ind supplement drug melap)'.) .,----,,---,---+-c"c'=h:,,=,,",,, :':'::::"cm : usK.or guided
(onlinllt to monitom nal and I!tpatic function ptriodiully if thf' pitM!flI is In5lllKt the JNlitnt on tilt need 10 return ptriodiully forlilb work.
on IoIl9-tffm 1M of dIug.(IMdt rtl.lxants and dllJ,ll mjf
"'USt hepatotoxicit, is in ildYtlW tftt<t)
bowel periodiQIIy if (onstipition ord'linMa is problerNtic.
Incltue l\Jid inlilke uod dietary fibfr waR 10 ptntnl GI tfftcts and 113
NSf dry mouth efft<u. (MII$(Ie d:nI.p 1M)' dltile peri!1iI1sis II
an .MM elJt. SigNlicandy dininished Of ibstnt bowm!GU1Id!
imrnf'Cia,tdy Itpolled to the hti/tll Oft AdditioMll\Jidi and
Iibtr may est conltiprition and PfMIII diIrrht. but.dcIitionaI
mtdiutiofls sudllS Mnlar OfCcllce m.I, 1M! if !he constip.tion
isWlm.l
Anas fortof9JtOlt.cill swtling.(Ynliit ma,
CiIIM swing of tht tongut or t.t.nd should 1M! ItpOfttd immedi.ltdy.,l
Al'Oid the 1M of othtr(16 c\tprHwllll.idJding alcol!ol ind lilt willi
CiIIrtion CDI'ICUntIllIy with antihrptrttnsiY! dtpreswnts
ind akohol ma, inomt the propmiH olthedrug.
Antihypmmw mtditalions 1liiY inumt risk ofhypotmsion.)
Mstssforurinaryltl!ntion ptriodOIIy.(MusdtItLiunts and
antispasmodics may (Mf: urinary rtttl'ltion as In adVMt
Patlnt undtrstlllding of dl1lgtlltripY:
Ikt opJIOrtunitits I1lring administration of mtdic.ltlons 1M during
aSleSsJTltllU todiscuss the rltion.lt for drug thtrapy,dtsirtd tiltraptUlic
O\II(omn, moSI advtrle elfKt!, pmmtltB for when
10 un 1M htalth Ult pl'OYidtf.i1nd any nKf5wry monit:Ofing or
preuutions.(Using timt during lIJISillg cafe htIps 10 aptimizt.nd
Itinfortt kty ttaching altitS.)
Pllitlt setfiKllllinistr.lion of dNg thmpy:
Whtflmmtffing lilt 1I'lfdiCiItion, inSlruct the pitie,., family, or
UItgWtI .. 1ht proper self.-ninistration of drug.e.g., taR the drug IS
pmaibtd whtn fIftCkG. (Utiizing tintdunng of
tlwstdrugs htlps 10 ftinfon:t Itiding.)
Tt,ch tht p.ltient to iIaNst lluick to 2 L ptf d.y ind inut'le the inlilR of
d'.wry fibtr such IS fruits. Y!9tUbIes,.nd whoIt 9'ains.
InstlllU tilt patitnt 10 Itport W\Itrt COllStip.ltion to the health Cillt plOYidef
for Miditiollfl td'fia: on iliUM Of stool sof1tnm.
InstrucllM pa" 10 Itport.ny swding of Ior9JIr. fa<t. Of Itwo.!
immrdNttly.
1M jlihenl to Mid or tliniNte *01101 whileon the If othrr
Of antibypefttnsim ordert<l.lIaft the pitirnl consull with the
hNIth COIIt prtJiOOer abovt dow and stqI.Itrrilg.lmnwciilt:dy !'!port any
d'1ZZinm, pilpitations, or l)'lICopt.
InlUuct 1M patitnt 10 immediattly Ifport .n inability to Oid. and incrtasillg
bIiddtr presSUrt or pain.
Tht Piltitnt slloukl be ilble to stitt the ltiiSM fonflt dose
and schedulin!l .nd whit id'l'trst tflt<lS 10 obstM for ind whtn 10 report
thom,
T. Instruct tht prititnt in plOPtf idmiMtrarion guiddinn. Tht dow should 1M!
I takefl consineflcly i1nd not pm for best unIes othtfwist onItl!d.
(1ICIlUIaC}t 1M lIiIitnt to mMtMn .1I'IediCMiOn log. naIing symptoms.1ong
with dostlnd timilg ofmtdic.arions.nd bring lilt lag louch hullh
mit
EVAluation of Outcome Criteria
kahYIt tht of drug thtr.py b,. confirmilg "'" piUrftt 90111 a,nd outtOlllH haw t-I mrt (Ite "Planning").
Sfto lII*lJI.I n 11.J"1st!: dhfS /Ow/WidtetllWli,..m-qpIJ.
LibraryPirate
278 UnltJ
or brief repeated muscle movements, followed by relallation
of muscle fibers . Relaxation is short lived wl1il charges across
the muscle membrane are restored (repolarization). Impor-
tantly, patients treated with neuromuscular blockers areabl e
to fed pain. Thus, for surgical procedures, concomitant use
of anesthetic agents is essential (chapter 190"0).
An important fact to mention is that neuromuscular
blocking agents are different from gallglionic blocking agems
that target the autonomic nervous system. In this instance,
acetylcholine does indeed bind to nicotinic receptors, but
the resulting actions are involuntary and do not invol ve
skeletal muscle contraction (chapter 1300) . Ganglioni c
blockers dampen parasympatheti c tone and produce effects
like increased heart rate, dry mouth, uri nary retenti on, and
reduced gastrointest inal activit y. They also dampen sympa-
theti c tone, resulting in reduced sweating and less norepi-
nephrine being released from postsynaptic nerve terminals.
A5 an example. mecamylamine (Inversine) is a ganglionic
blocker primarily used to treat patients with essential hyper-
tension (chapter 2JOC .
The classic example of a nondepoJarizing blocker is
tubocurarine. Tubocurarine and related blocking agents are
used to rela.'\: the muscles of patients being prepared for
TABU 21 .3. Neuromuscular Blocking Agents
Drug
NON DEPOLARtZtNG BLOCKERS
itOOIilll1 (TrolUiwn)
dwtracurilll1 (JrimbeJ)
rIIN.KIIi1ll1 (Mifauon)
panatfOllilm (P,vulon)
pipMRllilll1 (Arduan)
rorurooium IZmllIOO)

vocwonilll'l (Momnn)
DEPOLARlZtNG BlOCKERS
dllarklt II pq m for thf Pm1(lYP'

longer surgical (Table 2J.3). Although not pre-
ferred for mechanical ventilation or endotracheal intubat ion,
small doses of these agents may be used for intermediate sur-
gical procedures (chapter 1900). Concerns of tubocurarine-
like tre;atment are over-rdaxation of muscles. As examples,
normal breathing activity (involving the diaphragm, and
glottic and intercostal muscles) and swaUowing act ivity (in-
volving the neck and certain esophageal muscles) require
contraction of skeletal muscle.
Depolarizing agents aJe used primarily to rela.'\: the mus-
cles of patients receiving electroconvulsive therapy (ECf)
(chapter 1500) and for shorter surgical prQCedures, for eJ\-
ample, mechanical ventilation and endotrocheal intubation
(chapter 190"0). Succinylcholine (Anectine. Quelicin) is
the prototype example of a depolarizing blocker. Adverse
effe-cts include persistent in some patients, ele-
vated blood levels of potassium. malignant hyperthermia,
and postopt'tative muscle pain. A5 a specifK antidote for
persistent paralysis, patients are often given cholinesterase
inhibitors. Cholinesterase inhibitors also represent a form
of theropy fo r diagnosis or treatment of myasthenia gravis
(chapt er 1300) and for the treatment of Alzheimer's dis-
ease (chapter 2()OO) and glaucoma (chapter 490'= .
Duration and Admtnlstratlon ROIlte
Long dll"ion; IV
Long dll"ion; IV
Shorttr IiJfation;lV
Long dll"ion; IV
dll'tion; IV
Long dll"ion; IV
dll,ti(:n;oIde1t of the nontkpolilrirlng il9"ltl;milktmdlV iIIId 1M
Long dllilion; IV
LibraryPirate
CIIopltlll Drug. fo< NI'O,omuo;rula, Dlsord<'" 279
. Chapter REVIEW
KEY CONCEPTS
The numbered kt-y concepts provide a succinct swnmary of the important points from the corresponding numbered section
within the chapter. If any of these points are not dear, refer to the numbered section within the chapter for review.
21.1 Muscle spasms, which are involuntary contractions of a
musde or group of musdes, most commonly occur be-
cause of localized traUJrul to the skeletal mU'ide.
21 .2 Musclespasmscan be treated through nonpharmacologic
and pharmacologic therapies.
213 Many mU'icle relaxants treat muscle spasms at the level of
the CNS by generating their effect within the brain and/or
spinal cord, U'iuaUy by inhibiting upper motor neuron ac
tivity, causing sedation, or altering simple reflexes.
21.4 Spasticity, a condition in which selected musdes are con-
tinuoU'ilycontracted, results from damage to the CNS. Ef-
NCLEX-RN" REVIEW QUESTIONS
D Cydobenzaprine{Cycoflex, Flexeril) is prescribed for a pa-
tient with muscle spasms of the lower back. Appropriate
nursing intervention would include: (Select all that apply.)
I. assessing the heart rute for tachycardia.
2. providing for patient safety.
3. encouraging frequent ambulatiO/l.
4. providing oral suction for excessive oral secretions.
S. assessing for rash.
D The patient is scheduled to receive botulinum toxin type
B (Myobloc) for treatment of muscle spasticity. Patient
education needed to prepare the patient for the injections
includes that:
I. relief of muscle spasms should ocrur within sewral days.
2. drowsiness may occur.
3. a rapid return of ene'l':Y is to beexpected.
4. local anesthesia will be given to decrease the pain of the
injections.
D Prior to administration of cyclobenzaprine {Cycoflex,
Flexerilj, the nurse notes that the patient's liver enz.ymes
are elevated. The appropriate action would be to:
i . hold the medication and report the ele>'ation to the
health care provider.
2. give the medication as ordered..
3. placethe lab report on the medical record and await
instructions from the health care provider.
4. give the medication asordered, then coUe<:t a blood
sample for liver enzymes in 6 hours.
o A patient who was prescribed cydobenzaprine {Cy-
cofle:!:, Flexerilj reports taking propranolol {Inderal} for
fective treatment for spasticity includes both physical
therapy and medications.
21.5 Some antispasmodic drugs used for spasticity act directly
on muscle t issue, relieving spasticity by interfering with
the release of calcium ions.
21.6 Neuromuscular blocking agents 3fe classified as nonde-
polarizing blockers and depolarizing blockers. Both
agenl5 bind to the acetylcholine nicotinic receptor, relax-
ing mU'ides by slightly different mechanisms and dura-
tion of action.
blood pressure control. nursing interven
tions include:
l. monitoring neurologic status.
2. giving the drugs concurrently for best results.
3. monitoring closely for hypotension.
4. monitoring renal function.
II Which of the following statements made by the patient
prescribed dantrolene sodium (Dantrium) indicates an
understanding of the side effecl5 of the drug?
l. "I will be able to myself home from the
2. "I will not beconcerned if] cannot t'ITlpty mybladder;
it's probably my prostate."
3. "I will beabletodo my regularworkas soon as 1 get
home."
4. "I will report frequent changes in myblood pressure to
my doctor."
o A patient who has been prescribed badofen (Lioresal) re-
turns to the health care provider after a weekof drug ther-
apy, ,omplaining of continued muS(;le spasms of the
lower back. The nurse would assess for :
i . whether the patient has been taking the medication
consistently or only when the pain is severe.
2. whether the patient has been cOflSWlling alcohol during
this time.
3. whether the patient has increased the dosage without
consulting the health care provider.
4. whether the patient's log of symptoms indicates the
patient is telling the truth.
LibraryPirate
280 Unlll Thl'Ne<v"""Syn "",
CRITICAL THINKING QUESTIONS
1. A 46-year-old male quadriplegic patient has been experi-
encing severe spastkity in the lower extremities, making it
difficult for him to maintain position in his eleclri, wheel-
'hair. Prior to the episodes of spastldty. the
to maintain a sl U Ing posture. The risks a nd benefits of
thernpy with dantrolene {Dantrium} haw been explained
to him, and he has decided that the benefits outweigh the
risks. What assessment s should the nurse (mile to deter-
mine whet her the treatment Is beneAda1?
2. A 52-)"f.'ar-old breast canU'r survivor is taking tamoxifen
(Nolvadex) and has experienced leg and foot CTamps "al -
most nightly." She states that these cramps have markedly
de.::reased the quality of her sleep and that she is ready to
"just stoptakingn the tamoxifen to end the legcramps. The
nu.= is aware that tamoxifen is considered important in
the chemoprevention of breast cancer. What variety of
tre;ltment modalities can be offered this patient to pro-
mote her comfort and dE'(;rease the chance that she will
stop therapy?
1. A 32-year-old coUon farmer injured his lower back while
unloading a truck at a farm cooperntiYe. His health care
provider started him on cydobenzaprine (Flexeril ) 10 mg
tid for 7 days and referred him to outpatient physlcalther-
apy. After 4 days, the patient reports to the office
nurse that he is consliJXIted and having trouble emptying
his bladdt'T. Discuss the cause of these sideeffects.
See Appendix D forll/l5 wers lind rill/Oil/des for (llllle/ivi/lff.
EXPLORE
is )001 tile stDp 101 online enapte, review materialS aM
resource&. I'fl\ll<lfe to, success with addibonal NCLEX"-style practice
questions, I", .... dille BS9igMlenlS >n:t ectivitil':!!. web links. animatioos
and videos. and m()O"e!
f\egisle, YOII' OCCllSS axle rrGm me /rorJI of)'OOf book al
www.myn ..... gkitcom.
LibraryPirate
CHAPTER 12
CHAPTER 23
CHAPTER 24
CHAPTER 25
CHAPTER 26
CHAPTER 27
CHAPTER 28
CHAPTER 19
CHAPTER 30
CHAPTER 31
Drugs for lipid Disorders
Drugs for Hypertension
Drugs for Heart Failure
U NIT 4
The
Cardiovascular
and Urinary
Systems
Drugs for Angina Pectoris and Myocardial Infarction
Drugs for Oysrhythrnias
Drugs for Coagulation Disorders
Drugs for Hematopoietic Disorders
Drugs for Shock
Diuretic Therapy and Drugs for Renal Failure
Drugs for Fluid Balance, Electrolyte, and Acid-Base Disorders
LibraryPirate

DRUGS AT A GLANCE
HMGCoA REDUCTASE INHIBITORSISTATINS
.. "
Q QIOfVQ5/orJn (Upllor) ptJIJt NJ
BILE ACID RESINS
Q cholesryramklp (OUes/ran) p:xJt 291
NICOTINIC ACID (NIACIN) pxjtNJ
FIBRICACIDAGENTS pI1JI'l91
o gemflbrozl/ (Lopldj {XIgt 192
CHOLESTEROL ABSORPTION INHIBITORS pI1JI'l9I
KEY TERMS
ipoprouin (lQ9tl8J
.therosdtrosis tG'II'183
bilracidmin (!QtIt189
dyslipidemia pI1jl185
high-density lipoprotein (HDl) {OJ1183
HMG.CoA paqt 187
Chapter 22
Drugs for Lipid Disorders
LEARNING OUTCOMES
After reading this chapter, me student should be able to:
1. Summarize the link between high blood cholesterol,LDL levels,and
cardiovascular disease.
2. Compare and contrast the different types oflipids.
3 . Illustrate how lipids are transported through the blood.
4 . Compare and contrast the different types oflipoproteins.
5 . Give examples of howcholesterol and LDL levels can be controlled
through nonpharmacologic means.
6. For each of the drug classes listed in Drugs iIt a Glance, know
representative drug examples, and explain their mechanisms of action,
primary actions,and important adverse effects.
7. Explain the nurse's role in the pharmacologic management of lipid
disorders.
8. Use the nursinq process to care for piltients receivinq druq therapy for
lipid disorders.
hyperc holrstrrolemia paqt 185
hYPfrlipidemia paqt 185
lecithin f<1jt183
lipoprotein paqt18J
low density lipoprotein (LOU paqt l8J
phospholipid p:lge183
re"ftfSr cholesterol transport paqt'18J
rhabdom-,olysis paqt'183
strroid f<1jtl8J
sterol nudeul paqt]8]
triglyteridt paqt'l8J
mylowdensitylipoprotrin (VlDU (llTjlm
LibraryPirate
R
esearch during the 19605 and 1970s brought about II
nutritional revolution as new knowledge about lipids
and thei r relationshi p to obesity and cardiovascular disease
allowed people to make more intelligent lifestyle choices.
Sino, th.>n,advanc ... in the diagnosis of lipid disorders have
helped identify those patients at greatest risk for cardiovas-
cular disease and those most li kely to benefit from pharma-
cologic intervention. Research in pharmacology has led to
safe, effective drugs for lowering lipid levels, thus decreasing
the risk of cardiovascular-related diseases. As II result of this
knowledge and through advancements in pharmacology,
the incidence of death due to most cardiovascular diseases
has been declining, alt hough cardiovascular disease remains
the leading cause of death in t he United States.
22.1 Types of Lipids
The threetypesoflipids important to hwnansare illustrated
in Figure 22.1. The most common are the triglyc:eridn. or
neutral fats, which form a large family of different lipids all
having three fatty acids attached to a chemical backbone of
glycerol. Triglycerides are the major 610rage form of fat in
the body and the only type of lipid that serves as an impor-
tant energy source. They account for 90% of total lipids in
the body.
A second class, the is tbrmed when a phos-
phate group replaces one of the fatty acids in a triglyceride.
TIlls class of lipids is essential to building plasma mem-
branes. The best known phospholipids are lecit hins, which are
found in high concentration in egg yolks and soybeans.
Once promoted as a natural treatment for high cholesterol
levels, controlled studies have not shown lecithin to be of
any benefit for this disorder. Likewise, lecithin has been pro-
posed as a remedy for nervous system diseases such as
Alzheimer'sdiseaseand bipolar disorder, but there is no def-
inite evidence to support these claims.
The third class of lipids is the steroids, a diverse group of
substances having a common chemical structure called the
sterol nudeus, or ring structure. Cholesterol is the most widely
known ofthesteroids,and its role in promotingath!rosderosis
has been clearly demonstrated. Cholesterol is a nalural and
vital component of plasma membranes. Unlike the triglyc-
erides that provide fuel for the body during times of energy
need, cholesterol serves as the building block for a number
of essential biochemicals, including vitamin D, bile acids,
cortisol, estrogen, and testosterone. Although cholesterol is
clearly essential for life, the body needs only minute
amounts of it. Moreover, the liver is able to synthesize ade-
quate amolUlts of cholesterol from other chemicals; it is not
necessary 10 provide additional cholesterol in the diet. Di-
etary cholesterol is obtained solely from animal products;
humans do not metabolize the sterols produced by plants.
The American Heart Association recommends intake of less
than 300 mg of dietary cholesterol per day.
Choptor 12 Drug, fo< Lipid Olsorde" 283
PHARMFACTS
High Blood Cholesterol
Tile of high blood dlOitslrrol inuUlr-s until age6S, al wlic:h
tiM it Ir-Ieis off.
IIIoIl' lhan 100 million Ameriuns all' estimued al risk f
dioItstrrollrYels (200 mgldL or abovr). This is4O% to SO% .duh
plp'.Jiation.
Moderate alcohol intake> does nOlll'lb:e LOL -<holtsterol,but it dots
itc:rwe HOL -<holtsterol.
Prior to menopalM, high blood choitstrrol CUI"! moll' fno"",miyin
Mn.Alter age SO,a higher pl'rcmlage ofwomen
dIOIeslerol.
To lower blood dim!)' cholesterol and fll!
II1II1 be Il'duud
hypeKholtstmiemia affrrn 1 in sao pI'Ople and isa g!"flrtic:
lUan that predisposes pI'Opit 10 high dJoltsterolitvtls.
22.2 Lipoproteins
Because lipid molecules are not soluble in plasma, they must
be specially packaged for transport through the blood. To ac-
complish this transport, the body fornlS complexes called
which consist of various amoWlts of cholesterol,
trigl)"cerides,and phospholipids, along with a protein carrier.
The protein component is caUed an (apo- means
from or derived fromW).
The three most common lipoproteins are classilied accord-
ing to thei r composition,size,and weight orden6ity, which is
due primarily to the amount of apoprotein present in the
complex. Each type varies in lipid and apoprotein makeup
and serves a different function in transporting lipids from
sites of synthesis and absorption to sites of utilization. For ex-
ample, high-density (HDL) contains the most apopro-
tein, up to 50% byweighl. The highest amolUlt of cholesterol
is carried Figure 22.2 illustrates
the three basic lipoproteins and their compositio,lS.
To understand the pharmacotherapy of lipid disorders, it
is important to learn the functions of the major lipoproteins
and their roles in transporting cholesterol. LDL transports
cholesterol from the liver to the tissues and organs, where it
is to build plasma membranes or to synthesize other
steroids. Once in the tissues, cholesterol can also be stored for
later use. Storage of cholesterol in the lining of blood ressels,
however, is not desirable because it contributes to plaque
buildup and atherosclerosis. LDL is often caUed abad
w
cho-
lesterol, because this lipoprotein contributes signilicmtly to
plaque deposits and coronary artery disease. Very low-density
(VLOL) is the prim3ry carrier of triglyceride:s in the
blood. Through a series of steps, VLDL is reduced in 6ize to
become LDL Lowering LDL levels in the blood has been
shown to decrease the incidence of coronary artery disease.
HDL is manufactured in the liver and small intestine and
assists in the transport of cholesterol away from body
tissues and back to the liver in a process Cllled moles
ttroltransport. The cholesterol component of the HDL is then
LibraryPirate
284 UnII4 Tho C.rdkIY. ",u lor .00 Url",,'Y Syl1efm
H
H- O-CH
I
,
H-O-CH

HO - C - CH,-CH2-CH,a-CH,-CH"-CH,-CH,-CHrrCH,, -CH,-CH,,- ele.
I
H- O- CH
H
Fatly , eid.
1

beckbooe (Hydrophobic)
(b) Phospholipid.
,H,
HC - CHl
I
CH,
I
,H,
CH,
I
HC - CH,
CH,
CholestefOl
(e) Steroid.
,.. Flgure22. 1 Cheml calmucture of lipids
Testostomne
LibraryPirate
_ Triglyaorida
Phospholipid
_ P",tein
Cholestorol
Figurell.l Composition of lipoprolelns:(a) HOL; (b) LOL;
(c)VLDL
broken down to lUlite with bile that is subsequently excreted
in the feces. Excretion via bile is the only route the body uses
to remove cholesterol. Because HOL transports cholesterol
for destruction and removes it from the body, it is consid-
ered "good" cholesterol.
Several terms are used to describe lipid disorders.
Hyperlipidemia, the general term meaning "high levels of lipids
in the is a major risk factor for cardiovascular dis-
ease. Elevated blood cholesterol, or hypl.'rmolu tl.'rolrmiil, is the
type of hyperlipidemia that is most familiar to the general
public. Dysli pidemia is the term that refers to abnormal (ex-
cess or deficient) levels of lipoproteins. Most patients with
these disorders are asymptomatic and do not seek medical
intervention until cardiovascular disease produces symp-
toms such as chest pain or signs of hypertension. Statistics
suggest that more than half the adult population in the
United States have total cholesterol levels above 200 mgldL
and that two thirds of these patients are unaware of their
hyperlipidemia.
The etiology of hyperlipidemia may be inherited or ac-
quired. Certainly, diets high in saturated fats and lack of ex-
ercise contribute greatly to hyperlipidemia and resulting
cardiovascular diseases. However, genetics determines one's
ability to metabolize lipids and contributes to high lipid lev-
els in substantial numbers of patients. For most patients,
dyslipidemias are the result of a combination of genetic and
environmental (lifestyle) factors.
22.3 LDL and Cardiovascular Disease
Although high serum cholesterol is associ.1ted with cudio-
vascular disease, it is not adequate to simply measure total
cholesterol in the blood. Because some cholesterol is being
transported for destruction, a more accurate profile is ob-
tained by measuring LOL and HOL. The goal in maintain-
ing normal cholesterol levels is to maximize the HOL and
minimize the WL This goal is sometimes stated as a ratio
of LOL to HOL.lf the ratio is greater than 5.0 (five times
more LOL than HOL), the male patient is considered at risk
for cardiovascular dis<!ase. The normal ratio in women is
slightly lower, at 4.5.
Scientists haV\' further divided LOL into subclasses of
lipoproteins. For example, one variety found in WL, called
lipoprotein (a), has been strongly associated with plaque
fomlation and heart disease. It is likely that further research
will discover other varieties, with the expectation that drugs
will be designed to be more selective toward the "bad"
lipoproteins. Table 22.1 gives the optimal, borderline, and
high laboratory values for each of the major lipids and
lipoprotein .
Establishing treatment guidelines for dyslipidemia has
been difficult because the condition has no symptoms, and
the progression to cardiovascular disease may take decades.
Based on ongoing research, the National Cholesterol Educa-
tion Program (NCEP), an expert panel of the National
Heart , Lung, and Blood Institute, periodically revises the
recommended treatment guidelines for dyslipidemia. The
current guidelines are based on accumulated evidence that
reducing high cholesterol levels can result in
fewer heart attacks and fewer deaths. Optimal levels of LOL
cholesterol have been lowered from 130 mgldL to 100 mgldL
HOL cholesterol should now be at least 40 mgldL, com-
pared with the previous 35 mgldL. In addition, the NCEP
guidelines recommend that high cholesterol levels be
treated more aggressively in people with diabetes, and that
hormone replacement therapy not be considered as an alter-
nathe to cholesterol-lowering medications.
LibraryPirate
286 UnII4 .. and Url""ry Syne<",
TABLE 21 .1 1 Standard laboratory Lipid Profilti!s
LaboratoryValue
lYpeofUpld (mgldL) Standard
<'00
l1-m high risk
>219
HiIj1ri51::
I <100
100-129 Ne.uorabow optimal
1l1>-159 high risk
160--189 HiIj1ri51::
>100
\lHyhighrisk
HOLdloitsttrol I low
<>"
high risk
>W

TrigIy(ffidel <IW
.... ,
1>0-199 high risk
'COH"
High ri51::
<100
\lHyhighrisk
LIFESPAN CONSIDERATIONS
- -
Pediatric Dyslipidemias
Molt ptop\t Conlider d)'llipidemia a condition thai (l{{UrI with .d-wKing
Igt.Dyslipidemw,h_,.It'.ko.conCffn forsomeptdiatric: p.tientSi nd
It'IeiIn:h studie haYe demonltmfd that tilt Nrf)o stage of atlltro
!(ierosis begin I in childhood. Childll'n who.1t' most at risk indude those with
I flmily history of pIl'lIIiIlUlt' coronary Inery dileasr or dyslipidemia,.nd
thoW' who hyptrtension, diabetn, or 'Il' ItYels in
childll'n and to be highef in girls. Nutritional intffi'!'ntiln,Il'!Jllar physi.
{II .ctivity, and risk fiKtor milWljl'IIItIIt ilt' warrantfd when tilt LDlleYel
ll'iKhe 110 to 129 mgldL Moll' dietary thrliP\' and phlrma-
rommP\' miy be wirrlmfd in pediarric: pititms with lDlltYeis.hew 110
mgldL Thr 10'"1" tmn eII"ts of lipid-loYming dlll95 in childll'll hal'!' not been
(It.rfyetablishtd;thmfoll',drug therapy is oot UIlUIIy below
10 of agt.The !latin d.ssofdrugs for Iowmng lipid in
9'lined FDA approval, but the COll(Ml OI'I"r rhabdomyo/ysis has led to.
to PIl'S(ribe thrm in .11 but pethiPS Htreme {I1f!.
(1).H,ItIin) .nd coltstipol (Cole5tid) also hal'!' FDA i PPIOIIII for hyJll'Kholts-
in childrm, bur side IOmetimtll"!lUlt in poor
Until molt' lmiICh into It'{ommenditionl for pediatric d)'llipi-
demia UN1mtnt is (ompleted, dietary change .Iong with inaNSfd nen:iII'
Itl'tls It'IIIiIin viabit option to ht lp ptdiatric: paril'nnde(fl'lW' lipid Irffls.
22.4 Controlling Lipid Levels
Through Lifestyle Changes
Lifestyle changes should always be included in any treatment
plan for reducing blood lipid levels. Many patients with bor-
derline laboratory values can controltl"leir dyslipidemia en-
tirely through nonpharmacologic means. It is important to
note that all the lifestyle factors for reducing blood lipid lev-
els also apply to cardiovascular disease in general. Because
many patients taking lipid-lowering drugs also have under-
lying cardiovascular disease, these lifestyle changes are par-
ticularly important. To emphasize the importance of
lifestyle changes, patients should be taught that all drugs
used for hyperlipidemia have side effects and, to the extent
possible, that maintaining normal lipid values witham phar-
macotherapyshould be a therapeutic goal. FoUowingarethe
JIlusl lipid-c"d li["",l rlt< inl"cv,,"tiuJls,
- Monitor blood lipid levels regularly, as recommended by
the health care provider.
- Maintain weight at an optimum level.
- Implement a medically supervised e:rercise plan.
_ Reduce dietary saturated fats and cholesterol.
Increase soluble fiber in the diet, sum as that found in
oat bran, apples, beans, and broccoli.
Reduce or eliminate tobacco use.
Nutritionists recommend that the intake of dietary fat be
less than 30% of the total caloric intake. Cholesterol in-
take should be reduced as much as possible and not exceed
300 mglday. It is interesting to note that restriction of di-
etary cholesterol alone will not result in a significant reduc-
tion in blood cholesterol levels. This is because the liver
reacts to a low-cholesterol diet by making more cholesterol
and by inhibiting its excretion when saturated fats are pres-
ent. Thus, the patient must reduce saturated fat in the diet,
as well as cholesterol, to control the amOlUH made by the
liver and to ultimately lower blood cholesterol levels.
The use of plant sterols and stanols is now recommended
by the NCEP to reduce blood cholesterol levels. These plant
lipids have a similar structure to cholesterol and therefore
compete with that substance for absorption in the digestive
tract. When the body absorbs the plant sterols, cholesterol is
acreted from the body. When less cholesterol is delivered to
the liver, LDL uptake increases, thereby decreasing serum
LDL (the Kbad" ,holesterol) level. Plant sterols and stanols
may be obtained from a variety of sources including wheat,
corn, rye,oots,and rice, as well as nuts and oJiveoil. Commer-
cially, stanols and sterols are available in products fortified
with Reducol, fOWld in margarines, salad dressings, certain
TREATING THE DIVERSE PATIENT
Cultural Dietary Habits
Whfn dflrrtnt rultu .. 1 groups prrpill' kIOd iI tilt W81 thty haYe been taught by
their okler bmiy lIIfIIIbm.ir can be diffiruk to mlll9t dietlry dIoIettroi imalr.
For uiHitional H ilp.lnic rooking may iKUde the UII' of lard for pIt'p.! .. -
lion offrijoles.m biscochitos,and for frying tonilas.ln :Iition.liJods JIIl'PIIt'd
in trmirional iI the soothrm and south mltr.1 Unittd State dten indldt
b"l" ImrI,n!<; of h.m .... m oiL fumpIM i"" ..... frird ok", n-rlralfi<h,.nrI
didcl'll.fried StNItTO toolIJragL' patil'ntlto lIIiIimail healttr, habits whilt
mjoying their it is inportamto dler ideas for plt'p.lr-
ing uiHitional foods .. thrr than Il'IIrictilg such foods .Itognhrr. Many new fth-
nic adcbooks now milabit with It'{Pe that ol'lo!r Iow-bt aktmatiYes to
tmlirionallllOkiIg methods ind plVt'idt talry akernatim thar htlp It'dn fNI!f-
al btimalr.
LibraryPirate
cere.ls, and some fruit juices. According to the AHA, the rec-
ommended daily intake of plant sterols or stanols is 2 to 3 g.
HMG-CoA REDUCTASE INHIBITORS/STATINS
The statin class of antihyperlipidemics interferes with a crit-
ical enzyme in the synthesis of cholesterol. These agents,
listed in Table 22.2, are first-line drugs in the treatment of
lipid disorders.
22.5 Pharmacotherapy with Statins
In the late 1970s, compowtds isolated from various species of
fungi were round to inhibit cholesterol production in hwnan
in the Thi.< d ... of koown the
sit/tins, has since revolutionized the treatment of lipid disor-
ders. Statins can produce a dramatic 20% to 40% reduction
in LDL-cholesterollevels. In addition to dropping the LDL-
cholesterol level in the blood, statins can also lower triglyc-
eride and VWL levels, and raise the level of HDL
cholesterol. These effocts have been shown to reduce the inci-
dence of serious cardiovascular related events by 25% to 30%.
TABLE 22.2 I Drugs for Dyslipidemias
Chopltl12 Drug' for Lipid O"",<le" 287
Cholesterol is manufactured in the liver by a series of
more than 25 metabolic steps, beginning with acetyl CoA,a
two-carbon llllitthat is produced in the breakdown of fatty
acids. Of the many enzymes involved in this complex path-
way, HMG(oA red uctase (3- hydroxy-3-methylglularyl coen-
zyme A reductase) serves as the primary regulatory .ite for
cholesterol biosynthesis. Under normal conditions, this en-
zyme is controlled through negative feedback: High levels of
LDL cholesterol in the blood will shut down production of
HMG-CoA reductase, thus turning offthecholeslerol path-
way. Figure 22.3 illustrales selected sleps in cholesterol
biosynthesis and the importance of HMG-CoA reductase.
The stalins acl by inhibiting HMG-CoA reductase, which
results in less cholesterol biosynthesis. As the liver makes
less cholesterol, it responds by making more LDL re.:eptors
on the of liver The treMer omnher of hepMic
LDLreceptors increases the removal ofLDL from the blood.
Blood levels of both LDL and choleslerol are reducOO. The
drop in lipid levels is not permanenl, however, so patients
need to remain on these drugs during the remainder of their
lives or until their hyperlipidemia can be conlrolled
through dietary or lifestyle changes. Statins have been
shown to slow the progression of coronary artery disease
Drug Routeand Adull Dose(max dose where IndIcated) Adverw Effects
HMG-CoA REDUCTASE INHIBITORS
Q itOl'/alliti1 ILipilor)
ftuViSLuin ILflll)
IUiiSLllin
piLlViSLllin ILNalo)
pramlllln IPriVadIot)
J05lNalliti1 (Cmtor)
]Zoo:or)
PO; 10- 80 mglda, (mal:80 "'9Iday)
PO;lO "'9Iday [max:80
PO; 1 0- 20 mg OII(t daily (mal: 80 m9f day immtdilHeiNIt;
60
PO; H mg OII(t daily lmal :. "'9Iday)
PO; 10 .... 0 mglda, (ma1:80mglday)
PO;S-40 mglda, [mal:80l119iday)
PO;S-40 mgldaylmal:80l119iday)
BILE ACID- BINDING }GENTS
Q dioItst)'ramilll' (Qu!oIDin) PO;4- 8 9 bid- rjdaund 011 btd!imt
mI=-'tlilm (WeidtoI) PO; 1.9 9 bid lmal:4.4 g/day)
lColtltid) PO;S-lO glda, in divided dosrs
FIBRIC ACID AGENTS
dofibralt
imofibrilt Oricor, others)
n,nofibrK add ITriplixl
Q gemfibroli ILopid)
OTHER AGENTS
mlimibelZtti.l)
PO;2 glday i12 to 4 divided rIosts
PO;S4l119iday lmax: 160
PO; 4S- m mg daily
PO;600 mg bid lmil: 1.soo mglda,)
Hypmpidmlia:PO; 10 mglday
I
Hypmpidmlia:PO; 1.S- 3.0 glday i1 di'lidtd doltS lmad y'day)
lIatindelidtnq:PO;l0 lOmglda,
mydrjo. rml or
pruriJJJl
smn: my9Iiti!
(omtiPQrioIi, 1lDUlf4
-.
til Iran obsl!lK!ion, viLlmin rlffilitndts rur, to DW
Abdi:rni!oI pan. rash. foIiqut,ftJlik! l)'OOromf,

Cholelithiasis.
fllligfJ, obd<:tnt!oI pm diarrirfo
t!o II'riou) Vdc dfrcll
fMMg.lICIU!f4pruriflJl,heododtt,bIoorirrg.diarrirfo
DrnIriIlvniu


,


"
z
"

I
;;
LibraryPirate
288 UnII4 TheCJrdkwasc:ubr.od Url",,'Y Syuem,
, .......
j
". Figure22J Cholesterol biosynthesis and excretion
and to reduce mortality from cardiovascular disease. The
mechanisms of action of the statins and other ~ for dys-
lipdidemia are illustrated in Pharmacotherapy Illustrated 22.1.
All the statim are given orally and are well tolerated by
most patients. Minor side effects include headache, f.1tigue,
muscle or joint pain, and heartburn. Severe myopathy and
rhabdomyolysis are rare but serious adven;e effects of the
statim. Rhabdomyolysis is a breakdown of muscletibers usually
due 10 muscle trauma or ischemia. During rhabdomyolysis,
contents of muscle ceUs spill into Ihe systemic circulation
causing potentially fatal acute renal failure. The mechanism
by which statins cause this disorder is wtknown. Macrolide
antibiotics such as erythromycin, awle antifungals, fibric
acid agems, and certain immunosuppressants should be
avoided during starin therapy, since these interf",re with
statin metabolism and increase the risk of severe myopathy.
Many statim should be adminislered in the evening be-
cause cholesterol biosynthesis in the bodyis higher at night.
Atorvastatin, pitavastatin, and rosuvastatin have longer
half-lives and are effective regardless of the time of day they
are taken.
Much research is ongoing to discover additional Ihera-
peutic uses of statins. For example, statim block the vaso-
constrictive I'ffect of the A-beta protein, a protein
associated with Alzheimer's disease. Cholesterol and A-beta
protein have similar effects on blood vessels, causing them
to constrict. Preliminary research suggests that the statins
may protect agaimt d",mentia by inhibiting the protein and
thus slowing dementia caused by blood vessel constriction.
Research also suggests that the statins may have the ability
to lower the incidence of colorectal cancer. Several at-
tempts have been made 10 move low doses of certain statim
to OTC status; however, the FDA has not approved these
applications.
BILE ACID RESINS
Bile acid resins bind bile acids, thus increasing the excretion
of cholesterol in the stool. They are sometimes used in com-
bination with the statim. Doses for these agents are listed in
Table 22.2.
LibraryPirate
ChoIU,12 Dwg' (or Lipid Disorder, 2B9
PHARMACOTHERAPY ILLUSTRATED
22.1 Mechanism of Action of lipid-lowering Drugs
Niacin
Dec""""", both VLDl
and LDlfe""fe
Bile acid ...
BOnd bile acids. thUII inc .. "wng
the excretion of choll!!lterol in
.....
22.6 Bile Acid Resins for Reducing
Cholesterol and LOL Levels
Prior to the diswveryof the statins, the primary means oflow-
ering blood cholesterol was through use of bile acid-binding
drugs. Thesedrugs, caUed li lracid rrsins orsequestranl5, bind bile
acids, which contain a high concentration of cholesteroL Be-
cause of their large size. resiru; are not absorbed from the small
intestine, and the bound bile acids and cholesterol are elimi-
nated in the feces. The liver responds to the loss of cholesterol
by making more LDL receptors, which removes more
cholesterol from the blood in a mechanism similar to that of
the statin drugs. The bile acid resins are capable of producing
a 20% drop in LOL cholesteroL Theyare no longerconsidered
St atin.
Interfere with HMG..coA
reductase, the aitical
enzyma in the bioe}<IthMis
01 choIeatOi
Ezetimi be
Bloc"" the abeorption
01 cl>oleslerollrom the
small inl""t ne
first-line drugs for dyslipidemias, although theyare sometinles
oombined with statins for patients who are unable to achieve
sufficient response from the statins alone.
The bile acid sequestrants cause more frequent adverse
effects than statins. Because they are not absorbed into the
systemic circulation, its effects are limited to the GI tract,
and include bloating and constipation. In addition to bind-
ing bile acids, these agents can bind other drugs, such as
digoxin and warfarin, thus increasing the potential for
drug--drug interactions.
The newest bile acid-binding agent, colesevelam (WeI-
chol ), has more bile capacity than the older
resins. It is formulated in smaller tablets that are easier to
swall ow, and fewer IlIblets are required per day.
LibraryPirate
2110 UnII4 TheC.,dklv.u:ub,.oo Urinary Synefm
'" Prototype Drug I Atorvastatln (Llpltor)
Therapeut ic (lass: Antihyperlipidemic Pha rmacologic (l ass: HMG-CoA reductase inhibitor,statin
ACTIONS AND USES
Tilt primal)' indiution for Itorvastlun is hyptn:hoItsteroiemil. The statins ad
by inhibiting HMG-CoA reductaS!' .As tilt li\'el" ma usltmholtswlll. it rtIpOnck
by mlking mlR LDL on tht surfatt of lim Tilt grtilter numhtr
ofUl rtCtptors in cells in incrnled rtmoval of LDl from tht blood.
Blood !Mis ofboth LDL Ind choltstt rolare red!Ked,ahhough at lust 2 Wffb
of thmpy is rrquired before thne t flfCn art realired. To enh.n(t tilt drug's
thmptutic riffCts, rtCeiYing atorYutatin should Ill' plated on iI
(hoitsterol-Iowtring dirt. Thr prim.1)' goal in atorYlltaTin tlltr.py is to I"t"-
duct tilt risk of MI.nd
ADMINISTRATION ALERTS
Administer with food to de<rtasr GI discomfort
M.y Ill' takrn at .n, tillll' of tht day.
PrtgnallQ calfgOl)' X
PHARMACOKINETICS
Onset: 2wk
Pblllu wllcl'nmtion, 1-2 h;(holl'stl'lOl reduaion,2-4 v.it
Hillf life: 14 h (20-10 h for aail'l' metJboiit61
DUl mon: Unknown
COMPLEMENTARY AND A LTERNATIVE T HERAPIES
Coenzyme Ql0for Heart Disease
(ornl)'1III' Ql0 (CoQIOj is I vitamin-liuwbstante found in mOil animal mls.
It is.n tl1tmial (omponent in tilt (rlrs mitoc:hondria for prockK:ing tfII'l9Y 01
ATP. ilausr the lItan high lel'l'ls of ATP. i sullkirnt ItI'I'l of(oQl0 is
l'IlI'fltial to that 019.n. Foods riclltst in this wbst.ntt art poR:. sardines, brtf
hta n. salmon, broc:(oIi, spinach, i nd nuts. E Idtrfy peopit .pptar to havt an in-
(1!'.1ed III'td for(oOl0.
of tht IlI'lII'fih of CoOl 0 for tINting heart dil!'i btgan to rmrrgr
in ch. rnid-196O>. Sub>."",nI '''1''''1' Iwv. d.j,,-..d CoQl0 "1<1)' bt bt".-
lic:ia I in angina ptCtoris, dysrhythmias, ptriodontal diseast, im IllJne disordtB,
neurologic disul!', obtsity, diahttts mrllitus, .nd (tnain UnttB. Consider-
abit !!"Swd! his httn (ondittl'd on this 'nlioxidlnl.
Inhibition of tilt rnzymt HM G-CoA rtdJru by rht statins dtclNStl CoO 1 0
Irnk. Many of tilt admS!' riffCtS of statins may lit due to tilt de(rtase in
CoQl0 Irnk, intluding mllKit wtamland rhabdomyolysis.Supplemrnta-
tion with CoQl0 may implO'/e symptoms (O'RionIan, 2OOSI. Likf,
most dirtal)' mntrolltd lIudirs art oftl'lliading and
gin (onAicting r=1ts. AI this tillll',nidentt to wpport tht lIS!' of (0010 in
trt.ting with lItin dist.1!', neurologic disordm,ol (inttl is wtak.
NICOTINIC ACID (NIACIN)
Nicotinic acid is a vitamin that is occasionally used to lower
lipid levels. It has a number of side effects that limit its use.
The dose for nicotinic acid is given in Table 22 .2.
ADVERSE EFFECTS
rfffCts of aTol'/aStatin IiIrt1y Iusr distominwtion of therapy.
HradldJr and GlllImpl.inu 9Jlh .s inttstinal mmping. diarrhea,.nd (onsti-
p.tion art (ommon dUling therapy.A sm.1I ptl{et"l\lgt of rlperirnuo
Irmdam.gt;rhus, fur.ction is monitoltd during tilt fim few monrhsof
therapy. Tht most srrious adYent tfir(t is rh.bdomyol)'iis.
Contraindications: (ontraindiutions intkKlt serious lim dise.1!', uno-
plaintd pmi!lt m elevations of st rum and prior
ity to tht drug.
INTERACTIONS
I)ug-l)ug: AtOf'/illlalin interact! with othrr drugs. f(If filii)'
iOONSf di;oxin b)' 2Im,as wtll as irImasllo!wl5 01 r.omIIinttonf ol/\d minyt
flUadioi (OBI {OOtntl'pti'mj. Ef)"thriJlll,on may intrNlt i tOMSlalin lewis 40%.
Rille 01 rtIabOOmyWy!.il iooUlfS with (OIKUlJeflt adminiltration of itorlillillin with
macroIidf antibiotics, f antiflJlgals, m niaci\. Ethanol WUd bf
iMIidN ruirlg thfrapy bffiJUIf 01 m VIm on hl'patic hMion.
Lab 115Is: lola, inoNIf IffIIm uansam iIaIf and tinN 1tvPII.
IIfrbaVFood: Gripffruit juitf 1M mflaboIiIm 01 lalins, allowing thtm to
coo IOlk Ievell.Rtd)'NII cU{OfIlililllIIIiII illlOlmB oinalUral statit:l and
inmu thf ffflom 01 atcni\lUlin. BKilIISI' uatim aIio dftrNIf 1M Irnthelil 01
(DffI1)'mtQl0 IN,beOOit mwn
M.nffllililnl 01 (oQl0 dffiOfocy iKlodP h9l blood prffllA', tongI5Iiw hMt
laim,.1Id
Treatment of Overdose: is 00 Spt(ifK tlNtment for OVl'rdose.
RI'I'fr III MytmJrtqKlr {Ix MnJng I'rtxell Fool! sptd/I( 10 1M Ikug.
22.7 Pharmacotherapy
with Nicotinic Acid
Nicotinic acid, or niacin, isa B-complex vitamin. Its abiJityto
lower lipid levels, however, is unrelated to its role as a vitamin
because much higher dose:sare needed to produce its antilipi-
demic effects. For lowering cholesterol, the usual dose of
niacin is 2 to 3 g/day. When taken as a vitamin, the dose isonly
25 mg/day. The primary effect of nicotinic acid is to decrease
VI .01. level., h"""n.e T.m. i. <ynthe<ized fTOm VI.oI. The
patient experiences a reduction in LOL levels. It has the
desintble effects of reducing triglycerides and increasing HOL
levels. As with other lipid-lowering drugs, maximum thera-
peutic effects may take a month or longer to achieve.
Although effective at reducing LOL levels by as much as
20%, nicotinic produces a higher incidence of adverse
effects than the statim. Rushing and hot flashes occur in al-
most every patient. In addition, a variety of lUlcomfortable
intestinal effects such as nausea, excess gas, and diarrhea are
commonly reported. More serious adveJW effects such as he-
patotoxicityand gout are possible. Niacin is not usually pre-
scribed for patients with diabetes mellitus, because the drug
can ntise fasting blood glucose levels. Because of these ad-
verse effects, nicotinic acid is most often used in lower doses
in combination with a stalin or bile acid-binding agent. Tak-
ing one aspirin tablet 30 minutes priorto niacin administnt-
tion can reduce lUlcomfortable flushing in many patients.
LibraryPirate
CIlo",0112 Drug' fcrUpld 0"",<1<'" 2111
Prototype Drug I Cholestyramlne (Ouestran)
Therapeuti c Cl ass: Antihyperlipidemic Pharmacologic Class: Bileacidresin
ACTIONS AND USES
Cholenyramine is a that is mixed with Auid befOIl' being "ken OllCf or
tv.Ke daily. It is oot ab!Qrbtd or metabolized onc:f it t nters the it
doe not proO:Ke any 'ystemic: tffKl>.1t may "kt 30days or Iongtr to prod!Kf
muimum Nfect. !luHlran bi ods with bilt, ac:ids (rontain ing choltslmll) i n an
insoluble rompln that is ellert-ted in the re.:es.Choltslmll du!' 10

ADMINISTRATION ALERTS
Mix thorooghly with liquid and hom the pam,m drink it to
aYOid potential irritation orobstruction in the GI trac:t.
GiW' other drugs mort than 2 hoors befOIl' or 4 hours aner the patitm
takes choil"ltyramine.
Pregn,IIICY Ultgory C
PHARMACOKINETICS
Onset: 24-48 h
I'Nk: 1- 3 wIc
Half fife: Unknown

J
Becawe niacin is available without a prescription, pa-
tients should be instrucled nOI to attempt self-medication
with this drug. One form of niacin available OTC as a vita-
min supplement called nicotinamide has no lipid-lowering
effects. Patients should be informed that if nicotinic acid is
to be used to lower cholesterol, it should be done under
medical supervision.
FIBRIC ACID AGENTS
Once widely used to lower lipid levels, the fibric acid agents
haW' been brgely replaced byth .. statins. Th1'yare 50metim ...
used in oombination with the statins. In addition thE")' re-
main drugs of choice for treating extremely high triglyceride
levels. The fibric acid agents are listed in Table 22.2.
22.8 Pharmacotherapy
with Fibric Acid Agents
The first fibric acid agent, clofibrate (Atromid-S), was
widely prescribed until a 1978 study determined that it did
nOI reduce mortality from cardiovascular disease. In fact,
clofibrale was found to increase overall mortality compared
with a control group. Although clofibrate is now rarely pre-
scribed, other fibric acid agents, fenofibrate (Tricor),
fenofibric acid (Triplix), and gemfibrozil (Lopid), are some-
times indicated for patients with excessive triglyceride and
VLDL levels. They are preferred drugs for treating severe hy-
pertriglyceridemia. Combining a fibri<: acid agent with a
slalin resulls in greater decreases in triglyceride levels than
ADVERSE EFFECTS
Although dlOlIosryramillt rall'ly produces worious sKIt effeds, poatitnts may ell-
bloating. ljaI"nd nauwoa thit limit its UW'.
Contraindi mions: Th is drug is cOllm indic:.Jted in patitnn with toLlI bilial)' ob-
struction and in th<M with prior hYpl'lII'nsitivity to the drug.
INTERACTIONS
Dru;rDrug: SKause dIOk>styramilll' GIn biId to other m-1IgI, wm.ll dgoxil,
pMidlins, th)"roiIlIomlcIne, iIId thiazidf dmtin, and in!l'Iftrl' with thM
ibIOIptioo, 'iIKUd not b.! Llkl!n at thf samf timf.ll tht5f othfr
ChoIfnyraminf may iOONlf thf efIKts of illicOigUan151rf dKrMiIg thf lewis of
"liUmin K il thf bod)'.
l.i b 11511: \.a00l aminot,iIlIffl"iISe (Am, phosphorus. (hloridf, and
illlalilll' phophalN (AlP) ItwIs may iKruse. SfnJn 00001, sotUn. and
potasliOOlIewls may dKJMe.
Herba VFood: Takilg dloIntynmilll' with food may in!l'If!JI' with 1M absorption of
thf foIowilllj nutrifnll:b.!tHarotfl"lf,takium,folK add,
'litamin 8", -Mamin D, riLlmil E, ftamil K. and rine. ManifNations of nutritn!
dtpIftioo may i1cklde WNkeIII'd rnmllllt \)'11m, ooiovOOlIar probImts. ioo
OIIeopolfWi.
l INI ment of Oerdosr: Theil' is no sptcilic tft'aimem for
IIrfl'l III M)NUIlInqm for Q NlmllJl} I'n:ms foaII Jjlf(1k III rIr/s
using eilher drug used alone. The mechanism of action of
the fibric acid agents is largely unknown.
CHOLESTEROL ABSORPTION INHIBITORS
In the early 2000:s, a new class of drugs was discovered that in-
hibits the absorption ofchol ... terol. There is only one drug in
this ciass,ezetim.ibe (Zelia), which is listed in Table 22.2.
22.9 Pharmacotherapy with
Cholesterol Absorption Inhibitors
Cholesterol is absorbed from the intestinal lumen by cells in
the jejlUlum of the small intesline. Ezetimibe blocks this ab-
sorption by as much as 50%, causing less cholesterol 10 en-
ler the blood. Unfortunately, the body responds by
synthesizing more cholesterol; thus, a statin may be admin-
istered concurrently.
AVOIDING MEDICATION ERRORS
Tht nUlle ,dministm tilt following 0,,1 medic:.Jtions orderrd for ,
old man: tetrac:ydine SOO mg bid, digoxin (l.iooxin) 0.25 mgfrby, and
(holl"ltyramine (1)JI"ltran). g bid" ,nd at bed time. At 8:00 '.m. befm
bll'akfan, W nulII' administflS tM"()'I:lillt SOO mg..digoxin 015 mg. and
choll"ltyramine 4 mg. 'Mlat shooklthe nulII' haW' dollt diffmntly?
StrAppmd/lDfIIIlht JlM]qeIItd_
LibraryPirate
292 UnII 4 TheCJrdkwasc:ubr ,nd Urinary Syuem,
..
Prototype Drug I Gemfibrozil (Loptd)
Therapeutic ( lass: Antihyperlipidemic Pharmacologic (lass: Rbricacidagent
ACTIONS AND USES
[ffKts of gtmfibrozil include up 10 a 50% in VLDl with an in
H DL The me<hanism of achieving this action i s unknown. It is Its. t fleo:tive than
the statins <II Io'ftring LDl; tIM, it i. not.J drug of first choict 101 lit
Iel'els.Gtmfibrolil is uken orally at 600 10 1,200 mg/!by.
ADMINISTRATION ALERTS

Administef with ml'ak to dKlI'iI!e GI
PrI'gnalK1 categolY B
PHARMACOKINETICS
DnSft: 1- 2 h
PNk: 1-2h
Halflife: I.S h
DUlation: l-4 months
When given as monotherapy, ezetimibe produces a mod-
est reduction in LDL of about 20%. Adding a statin to the
therapeutic regimen reduces LDL by an additional 15% to
20%. Vytorin is a oombination tablet containing fored-dose
ADVERSE EFFECTS
Gtmfibrozil produc6 fM Iffious etrfcts, but it may inul'iIse tht
hood ofgalillonesand mayomsionally . ffect Irmfull(tion.The moll rommon
.J<Mtweffemalt GI rI'lated:dyspepsia,diarThe., na!M.J, and cramping.
Contraindication!: GtmfibrOlil is conmindic.ittd in patienn with hepatic im-
It It llil dysfunaion, 01 plt-e. isting gallbladder dist.II', or thOl!'
with prior hypellfMitiYity to the drug.
INTERACTIONS
l)ug-DIII!I: ColKllllllt w 0( IjfII1fibroli with oral anticoago..tln6 may pOl!ntidte
bfawidl'd thiI
irmDs thtrilko( rrtJOPaIhyanl iIcrN'JIothtffflocG
Kmgoom.
Lab Tl5ts: Ma inoNIf li'IH QIIi m IfIIIn Iewls.May
dtocrI'aI.! hmIo9obin lllgll), hfmaIocrit I Hct), ani WI( (011)11.
lk>ibaVFood: fait)' food! may droNIe thf !Ificaq of 9fIll1ibr0liL
T rl'atment of Dn rdose: There is 00 SjlfCifK trl'atment 101
R#rt III MyIUIIngKl ror MIsIniJ 1'roce\S Footl 'ipt(/It: IrIIM d"!Jg.
combinations of ezetim.ibe and simvastatin. Because bile
acid sequestrants inhibit the absorption of ezetimibe, these
drugs should not be taken together.
NURSING PROCESS FOCUS PATIENTS RECEIVING LIPID-LOWERING THERAPY
Assessment
Bilst line aSHssment prior to administration:
Understand the It ilsan the dlug has betn Prl'lcribe<i in order 10 a!1f"SI for
therapeutic tifects.
Obtain a {omplete heakh histolY including
(prt-existing (onditions that might rl'lUk in musclt or joinl pain).
ga>lrointeslinal (peptic hMIonboids, inllammalOlY bowel
disNse, chronic constipation, dysphilgi. or tIOphageilmiclUltS), and the
prtgnalK1.0btain a drug histo!), including alltrgits,culR'm
.nd OTC drugs. heib.1 il kohol!M. alen to
drug intefactiom..
[nwte .ppropriate laboratolY fUnction studits
and lipid profilts.
patiem's ability tQ lciYe and ullwmand inltruclion.lndude
family and cartgiYeIS as nredtd.
Asstllment throughout administration:
fol desiltd therapeutic effu (r.g., total
in{lI'iIsed
CominUf periodic monitoring of lipid plOfiirs, liYef function lIudits, CPK
(UI'atine phosphol:illiSt), and uric acid ItYeis.
for advet1t tlftm: mUl(ulosktieul dist:omfort vomiling,
abdominal Clamping. diil rrhN. Se\'ffe muswloske\etal pa in. unexplained
muscle tendmiessaccompanied by to maintain activities of
diily liYing (ADls) die 10 musrulosktlttal wt'akness 01 pain, unaplained
numbnesl; or tingling of eXlrl'mities, yellowing of KItI.J or
constipation, or straining with passing of lIook 01 tarry stools shoold be
It'pOrted immediattly.
Potential Nursing Diagnoses
Imb.lanctd Nutrition: th.n Body ReqJil\'lllems (fat Imake)
lnefleo:tivr Health Maintenall(r (lndivicWl or family;diemY .J nd liftostylt
dungtS)
(hlOll ic Pain(itl.JiedlOdrugtflKts)
OefKiem Knowltdgt (dOl9thmpy,dieulY and lif6 ty\e milngtS)
LibraryPirate
(1101'1" 12 Drug. fo< lipid Disorder. 293
NURSING PROCESS FOCUS PATIENTS RECEIVING LIPID-LOWERING THERAPY (ConllnuMj
Planning: Patient Goals and Expected Outcomes
will:
o ExptritlKf flfects kg.,lowt-rtd total choottroU(l, illUNltd HDI.,
o from, or
o '0 uodtrst,nding 1M, fifb, aod prruutiom.
proper of the mediation kg.,doIt, timirog. to notif,o pmvidtr).
Implementation
Interventi ons and (Rati onales)
Ensuring therilptutic effects:
o Follow i ppropriate adm inistr,tion guideliotl. (Mill)' 01 lipid-Iowfling
drugs hoi!' spKific admini.tration lfqUill'l11fOU. For best rffiJl!s. the-,
,hould be taktn oil night when cholesterol bios)'lllhtsis is at iB higoot.}
Patient and Family Educati on
o Tfach the to drug following appropriate
101101'15:
o 5lQl;u: Tau with e\\'IIiog mNl;awid graPffruit ,nd graptfruit juic:e,
whic:h could inhibit metabolilm,luding to toxic
o Bile txidmim: Ti u beforr lIII'als with plenty 01 Huick,mixing powdtrs
thoroughly with liquid. medication. 1 hoor
befm,or. houl! biif acid rr.in is uun.
o Nitxin: rake with cold Wirer todKfNII' fMhing. Takeollf adult-
lIrength (325 mg) aspirin 30 befm oia.c:in doW'.
o Rift 0Ii1 agtM: rake with, lIII'al.
o ElKoorige ,ppropriatr chin9f.:IO'Mrtd lat intau, ilKrr,Itd --:---t-o,. - oo - ,,,, - th!o ,nd fimily to idopt, healthy oIlow-fat
I'nrtiW',limittd akohol iotake,and smoking PnMdt fordiMiIian food I'Rrrise,dtaeastd akoool cOOlumption,and
cORlUkation <IS nttdrd (Hulthy chaogrs will .uppon and ,rooking Cl'5mion.
need for dlll9 therap)'.) ElKoorq increased iotake ,nd COl'IIl)'IIII' Ql0-rich food,
(e.g.,r"h ruch" salmon and nuts,l!ltra-l'irgin oIi!' and ,,001,
bffi aM chic:un). miy be net'dtd; inllnKt
Minimizing adft nf effKts:
___ t-c"c"" = aclYice of a heakh c.Jfl' proYicIer befoll' wpplrotents 'II' taken.
o CootinUl' 10 monilOr ptriodic: li!'r iulKtion tests and CPI( (Abnormal
lil'tl" function or CPK may indicate drug-iodlKtd
ad!'11f eflem or myopathy ,nd should be rrported.)
o CootinUl' 10 as1f\S filr drug-rtlated which rna, indicate acfo.mr
diem ocwrnog. (Lipid-lowering drvg> ollen admnly a!fro the liver
but may also UUII' drug-spte:ifk aMB!' effects.)
o AsII'S' for oIiocrt'aW"d whtn I combination of
lipid-Iowfling i9fOB , rr ustd.(Lipid-lowering '9fOB may becombined for
but thi, ioc:re.W'S thf risk 01 ><I .... r .. ofj"K1S.)
If Iong-tenn is used, rRlUft' inukt 01 f,t-50luble vita min,
(A, D,E, K) ,nd folic: acid in thf di or consider wppiementation.(lipid-
Ioworing dllJ9l m, y depletion or dimioished .bso'Ptioo 01 IMIf
nutrients.}
ImtnKt p,titm on r.ttd to return periodic,11y for lib wall
o Tfach thf importan(folreponingYgn,or l)'IItptomS ft'lated
10 drug eifew al followl:
5lQl;u: unusual or uoupliintd muscif tfndemeu, ilKft'asing
mU\(if lHIio, or tingling 01 eff1S that hinder
nornul ADl actil'itiH.
l!ikood min<: .rwft' n.""", hunbum. {oOltipnion. or
maining with IHllSing stools.Any urry !1oolsor yellowing 01 sclera or
skin shoold ,150 lit rf porttd.
o Nitxin: Report slOmach j)ain, or yellowing of .ooa or
skin.
o Filwic Qdd ogerm: uou!W1 bletdiog or bruising. right upPfr
quadraot lHIio, muscif mmpiog.orchaoljl'l in color of thr stool.
o ukiog' combination oIlipid-loweriog drug! to
alert to l)'IItptom'lflattd to ,baff.
aod family about foods high io folic id and fat-
vitamins <lod ,bout r.ttd tocoRlUk with health "rf plO'fider
.bout poibio oord forviumin ,nd folic: I<id ,upplerntnmion while on
Ioog-term thffilpy.
(Conrlnued)
LibraryPirate
294 U,*4 The Cardlc;r,c:ubr and UrlNry Syst .....
NURSING PROCESS FOCUS PATIENTS RECEIVING LIPID-LOWERING THERAPY (Coollnuedl
Implementation
Interventions and (Rationales)
Patitllt ulclentandlng of thu,w.
1M duri", of medic:atiom.nd during
til diKUSI !<ItionaIt for dlUll wr.llY. dt!ftd thtraptUtir::
outtornn. mOil commo!llyobsffltd ildvme rlI"em,p.mettrs fOfwbeft
III call lhe hultfl Ort p!lJridtf,.nd an, IIHWI) rnonitoring or
pmautioru.(lking lilM during nurling (;R helps to and mnfotle
kt, tt.w:hing lIrm.)
Patient self-admi nistrllion of drug therap,:
When .dnWliitf ri", the rntdOtion.Wlltruct the fanWy"
p!Opff of 6Jring thtnrilg mNl.{UtibirIg
time Ming of drugs help! 10
ttichilMjlJ
Patient and Family Education
1M patient .ncVOf famil,!hooId be able 10 state thf _Io! drug;
apjlropriau rmr and rifem loolMrn for and
when to rtpOft;.nd the lll00p.lted length of mediation thmpy.
1M p.ltient Ind bmily able todilM! appropriatt dosn, and

Evaluation o f Outcome Crite ri a
Evaluate the of dn.w,j thtrapy bJ(onfirming thlt patifnt goiIls Ind tllpf(ltd out(/)"'" hatt btt n me{ (Sft1'LlnniIMjl1.
Str Ii/.IIt III frz. fit iii dru" II'IIt1I rlltst IIniI9 tdionI" m
. ;if: Chapter REVIEW
KEY CONCEPTS
The numbered key wllI:epts provide a 5ucdnct summary of the important points from Ihe corresponding numbered section
within the chapter. If any ofthO'S(' poinl$ are IlOl clear. refer 10 the numbered seaion within the chapter for review.
12.1 lipids can be classified into three type;. Insed on their
meminl structures.: triglycerides. phospholJpids, and
sterols. lTiglycerides and cholesterol are blood llpids that
can lead to atherosclerotic plaque.
222 Lipids are carried through the blood as lipoproteins:
VLDLand LDLarea.lliOcialed with an increased incidence
of cardiovascular di$ease, whereas HDL euTU a protective
effect.
u') Blood IIpk! protl1e!i are Imponam diagnostIc tools In
guiding the therapy of dyslipidt'mias. Theoptimum levels
of the different lipids are reviewed periodically and ad-
justed based on the results of current researcl! .
22A Before Marting pharmacotherapy for hyperlipidemia, pa-
tients shouJd seek to control the condi tion through
lifestyle changessudi as restriction of dietary saturated fats
and cholesterol. increased exercise, and smoking cessation.
US Statim; inhibit HMG-CoA reductase, a critical enzyme in
the biosynthesis of cholesterol These agents are safe and
for most patients and are drugs of choice in re-
ducing blood lipid levels.
22.6 The bile add resins bind bile and cholesterol and aa:eler-
ate Iheir eu:retion. These agents can reduce cholesterol
and IDL levels but are not drugs of choictdue to their fre-

22..1 Nicotinic add can be effective 3t]owering LDL cholesterol
""nen given in large amounts. It is not a drug of first
choIce, but 1$ sometimes combIned In smaller doses with
other lipid-lowering agents such as the statins.
U.8 Fibrk add agents kWier trigt)"U"ride levels but have little
effect on LDL They are not drugs of choice because of
their potential side effects.
22.9 A newer class of antilipidemic drugs includes ezetimibe,
""nich acts by inhibiting the absorption of cholesterol
across the small intestine. Its role in treating hyperlipi -
demia is in combinnion with statins to achieve an addi -
tive reduction in LDL cholesterol
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NCLEX-RN" REVIEW QUESTIONS
D Th .. nurse assesses the patient on a stalin drug (HMG-
CoA reductase inhibitor) for.
I. constipation.
2. musd{'or joint pain.
3. hemorrhoids.
4. flushing or "hot flash."
II When evaluating the efflivmes.s of lipid-lowering ther -
apy, the nurse would monitor for:
1. increased total cholesterol, LDL,and HDL te.-els.
2. increased LDL lew:lsand decll'ased HDL lewis.
3. decreased total cholesterol and LDL lewis, and increased
HDLlt'wls.
4. maintE'naoreof HDL,and LDL [{'WI&.
D The nurse is instructing a patient on home use of oioo-
link add and will indude important on how
to take the drug. The nurst' will teach the p.1tient to:
1. take the drug an hour before mm and with plenty of

2. mix th .. drug thoroughly in watt>r before taking.
3, lake other medio;ations 1 hour before or4 hours after
th .. nicotinic add.
4. take one aspirin (325 mg) 30 minutes before the
niCOlinic acid to reduce the incidence of flu.shing and
hot flashes.
CRITICAL THINKING QUESTIONS
1. Identify the plan of care for a patient with hyperlipidemia
who has been atorvastatin {Upitor}.
2. A patient is put on cholestyramine {Quest ran} for elevated
lipids. What teaching is important for this patient!
3. A male dtabettc pattent presents to the emergency depart -
ment with complaints of being flushed and having "hot
The patient admits to self-medicating with niacin
for el,,'V:lled lipids. What is the nu='s response!
See Appendix D forall5wers and r<JtiollaJes for all activities.
'lIop"< 12 Dfug' f ... Lipid OMId .. " 295
o The nu= teaches the patient with a diagnosis of hyper
lipidemia abontlipids in the body. The nurse informs the
patien t that the major storage form offat in the body is:
1. phospholipids.
2. steroids.
3. triglycerides.
4. ledthins.
II A patient has been on long-term lipid-lowering therapy.
Th prevent adverse effeds related to the length of therapy
and lack of nutrients, the following supplements may be
required: {Seled all that apply. }
1. Folic acid
2. VitaminsA, D, E, and K
3. Potassium, iodine, and chloride
4. Protein
1:1 A patient asks the nurse about healthy eating choices to
reduce lipid levels in addition to the prescribed lISt' of
statin drug therapy. The nu= will instruct the patient
that the following are good choices to include in a healthy
diet: (Select all that apply. )
1. Broccoli and carrots
2. Almonds and brazil nuts
3. Grapefruit and grapefruit juice
4. Salmon and sardines
EXPLORE
is yoor ooe SlOp for online CIl apler Il!'llew materialS 3f1d
reooorCOls. PlUl/are b IiUCCUSS IMtIl practice
Quesliln3, Interacti\'e 8S3ilJlVllenl'l Bnd al:lNitie3, web tirK'l . IIllrmtlons
and and mete!
Aegi!;ler roM from me tront of)'OO! IXlOIc at
_.myn .. smgkilc .....
LibraryPirate
DRUGS AT A GLANCE
DIURETICS pqJal
(0) hydrochlorothlOZidf (MIctozIde) ,.4
CALCIUM CHANNEL BLOCKERS p.1JtJ()7
CO) n!fed/plnf (A(/akll,ProcordIO,ot/lfrs)
....
DRUGS ,UFECrING THE
RENIN- ANGIOTENSIN- ALDOSTERONE SYSTEM
"",.,
.. ertiii 9 (AU)
Inhibitors ".NI
Q enalaprt/ (VaWl) {lQ)tJ!]
Angiotensin RenptOl' 810<ktr$ (illl}tJlI
ADRENERGKANTAGONISTS ptlgtJ14
Alpha,-Admlftgk BkKktrs (II1IJtJ!5
o doxarostl /CCIrduro) P'9t 316
Bet.,AdreMl9i(BkdtfS ptJIJtJU
Alph.rAdlftltfgkApists ptJtJtJI5
DIUCT VASODILATORS {iQ)t JII
(0) hydralallnt (ApmCIrIf) ptIIJt 119
KEY TERMS
.Idosterone !XJ!/f 110
ugiotenlin II rx;gtJIO
u giotfmiNOII'Itfting t nlynlf (ACl) (II1IJt J10
Inti diumichonnoe{ADH) (i09t199
llI rtnplon (II1IJtXA
GJkill'JdlanMlbIoxur{(CB) pogtXJl
Drugs for Hypertension
LEARNING OUTCOMES
Alrer reading this chapIn', the student should be ablt to:
1. Explain how hypertension is d an lfl ed.
2. Summarize the long-term consequences of untru ted hypertension.
3. Explain the effects of cardiac output, perl pheral resistance, and blood
volume on bl ood pre ure.
4. Discuss how the vasomot or center, baroreeeptors, chemoreceptors,
emotions, and hormones Influence blood pressure.
S. role l;fest",1e changes In the manag<ment of
hypertension.
6. Different iate between drug used forthe primary t reatment of
hypertension and t hose secondary IIgents reserved for persistent
hypertension.
7. Describe the nurse's role in the pharmacologic m.iII'"IlIg-ement of patients
receiving drugs for hypertension.
8. Foreach of the drug classes listed in Drugs lit II Glance, know
representative drug examples, and eKPIliin t heir mechllnisnu of drug
action, primary actions, and important MJverse effects.
9. Use the nursing process to care for patients re<elvlng
antihypertensive drugs.
mdiK output rogt NJ
, hrmorKrptors pu;t N8
diumic: pu;t]1;8
.. pq197
pl' riplwr. 1 ffVstancr pq l<;B
ffft u tamycudia
pq M
rgI199
strokt wkJ:nt ptJ//I198
yu0ll10l0f(tnltr pogt]!;8
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C
ardiovascular disease (CVO), which includes all condi-
tions affecting the heart and blood vessels, is the most
frequent cause of death in the United States. Hypertension,
or high blood pressure, is the most common of the cardio-
vascular diseases. According to the American Heart Associa-
tion, high blood pressure is associated with more than
150,OOOdeaths in the United States each year.A1though mild
hypertension (HTN) can often be controlled with lifestyle
modifications, moderate to severe HTN requires pharma-
cotherapy.
Because nurses encounter numerous patients with this
condition,having an understanding of the underlying princi-
ples of antihypertensive therapy is essential. By improving
public awareness of hypertension and teaching the impor-
tance of early intervention, the nurse can contribute signifi-
cantly to reducing cardiovascular mortality.
23.1 Definition and Classification
of Hypertension
(HTN) is defined as the consistent elevation of sys-
temic arterial blood pressure. The diagnosis of chronic
HTN is rarely made on a single blood pressure measure-
ment. A patient is said to have HTN if they present with a
sustained systolic blood pressure of greater than 140
or diastolic pressure of greater than 90 to 99 mmHg after
multiple measurements are made over several clinic visits.
Many attempts have been made to further defme HTN,
with the goal of developing guidelines for treatment. In
2003, the National High Blood Pressure Education Program
Coordinating Committee of the National Heart , LWIg, and
Blood Institute of the National Institutes of Health deter
mined the need for updated guidelines that addressed the
relationship between blood pressure and the risk of cardio-
vascular disease. This committee issued The Seventh Report
of the Joint National Committee on Prewntion, Detection,
Evaluation,and Treatment of High Blood Pressure ONC-7),
which has become the standard for treating HTN. The rec
OUplfr21 Oru9,/orHyP .. teo,kIn 297
ommendations from Committee Report }NC-7 are summa
rized in Table 23.1.
In addition to classifying HTN into three categories-
prehypertension, Stage 1, and Stage 2- the JNC.7 report is
sued remarkable data regarding the disease.
- The risk of cardiovascular disease beginning at
115{75 mmHg doubles with each additional increment
of 10110 mmHg.
- Individuals with a systolic blood pressure of 120 to
139 mmHg or a diastolic blood pressure of 80 to 89
mmHg should be considered as prehypertensive. These
patients should be strongly encouraged by health care
practitioners to adopt health-promoting lifestyle
modifications to prevent CVD.
- Patients with prehyper tension are at increased risk for
progression to HTN; those in the 130 to 139/80 to
89 mmHg blood pressure range are at twice the risk for
developing HTN as those with lower values.
Blood pressure changes throughout the life span, gradually
and continuously rising from childhood through adulthood.
What is considered normal blood pressure at one age may be
oonsidered abnonnal in someone older or younger. Hyper
tension has the greatest impact on elderly patients, affecting
approximately 30% of those older than 50 ymrs, 64% of men
older than age 65, and 75% of women older than age 75.
PHAIlMFACTS
Statistics of Hypertension
Prm1Pfl"tmsion (120-1391BO-89 mmHg) alfts .Jpproximately 22% of
till' adult population,or IJNrfy 4S million
High blood alfts thin n million U.S . .J<kJIu,o.-
approlimateiy 0111' in thrt'e Americans.
African American malts h.Je the highest rate (SI"') ofltyperterllion.
Among with HTN, mOrt' than 28% do not INlize IhI')o the
mndilion.
Hypertension is most common compliution of prt'9ni1ncy.
Approximately S4,000 of HTN per year, it isa contributing
facto.- in 300,000 additional duths yw.
TABLE 23 1 I Classification and Management of Hypertension in Adults
SystoltC/Dlastollc
tntllal Therapy
Blood Pressure Clas!olncatton Blood Pressure (mmHg)
WlIhoorCompelllng tndtcatton" With Compelling tndtcallon"
-,
119!79orlfll No inlihypentnsil'e indiuttd Hoantihypertrnsiw inlicattd
1ll}-B9ft11)-!I'}
I Hypertension l.fO-1591W-99 Thiazide diumic {for most patienB} Other as nffiled
5tagf 2 Hypenension 1600.- hi9:ler/100 or Two.aug [ombilation
(formost patients)
Souin': Halionitl H91 Blood EdlKation Hationaillein, l.ung& Blood &preIl:Thf Smnrh/Wpilrl rile mil NariiJooIfilmmirlet m
I'rPM1nD'on, Dtlfflion, fllWaion, liqh Blood I'rmIJrt. I oo-ine 1 hnp:/ /Www.nltlbiJlil.1jO'>'
"Compelilg indK.Jtions i1dude:hein fallft, post ....... youlllial infirnion, h9I rill:: for roronary diabflfl, dlrorK kid!le)' dst.t\e, ind Murrtnt stroiIl' P'"tnlion
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o
o
i
"





i
I!
"


!

23.2 Factors Responsible
for Blood Pressure
Although many bclors can influence blood pressure, t he
three factors rtSponsible for creating the pressure are car-
diacoutput, blood volume, and peripheral resistan(t. These
are shown in Figure 23.1. An understanding of thl'$(' fac-
tors is essential for relating the pathophysiology of HTN 10
its pharmacotherapy.
The volume of blood pumped per minute is the ardiilcoul-
put. The highe r the cardiac output, the higher the blood pres-
sure. Drdiac: output is determined by heart !'lite and ItroU
mullt, the amount of blood pumped by a ventricle in one
contraction. This is important to ph.armaoology, because
drugs thaI dmnge the cardiac out put, stroke volume, or heart
rate have the POlt'lll iallo influencea patient's blood presiure.
As blood f\()W$ al high speeds through the vascular sys-
tem, it exeru force agaill'll the walls of the vessels. Although
the inner Ja)'t'f of the blood vessel lining, the endothel ium,
is extremely smOOlh, friction reduces the velocity of the
blood. This friction in the arteries is called resislanCf.
Arteries have smooth muscle in their waUs that, when
drittNl. will Ihe nr Il1m!'n In
smaller, thus Heating more resistance and higher pressur e.
A large numbt>r of drugs affect vascular smooth muscle,
causi ng vessels 10 constrict, thus raising blood pressure.
Other drugs cause the smooth muscle to rela.:t, thereby
opening the l umenand lowering blood pressure. The role of
the autonomic nervous system in controlling puipheral re-
sistance is explai ned in chapler IJOO.
The third h elOr resporuible fOl' blood pressure is the to-
tal amount of blood in the vascular system, 01' blood vol-
ume. Although an average per.;on mainbins a relatively
const ant blood mlume of approximat ely 5 1., this value can
change due to many regulatory fadors, cert ai n disease
states, and pharmacotherapy. More blood in the vascular
system will e:xert additional pressure on the walls of the ar
teries and ralse blood pressure. Drugs are frequently used to
adjust blood volume. For e:xample, infusion of intravenous
fluids increases blood mlume and r aises blood pressure.
This factor is used to advantage when t reating hypotension
due to shock (chapter 2900). In contrast, substances
known as dilftlks can cause Tluid loss through urination,
thU'l decreasing blood volume and lowering blood pressure.
23.3 Physiologic Regulation
of Blood Pressure
It is critical for the body to trulintain a nomlal range of blood
pressure a nd to have the ability to safel y and rapidly change
pressure as it proceeds through daily activities ruch as sleep
and exercise. Hypot ensioll call causedi12inessand lack of ad-
equate urine fortrultion, whereas extreme Itypertension an
cause blood "esse!s 10 rupture,or restrict blood flow tocriti-
cal organs. Figure 23.2 iIIl15trates how the body maintains
oomeolitasis during periods of blood pressure change.
lbe centr.ll and autonomic nervous systems are intitrultely
inwlved in regulating blood pressure. On a minute-to-mi nute
basis, a dusteT of neurons in the medulla oblongata called the
vasormtoran\ft regulates blood pressure. Nerves travel from the
vasomotor center to the aneries, where the smooth muscle is
directed to t ither comtrict (ni ... blood pre"ur") or rel:u
(lower blood pressure). Sympathetic outflow from the vaso-
motor center st imulates alpha ,.adrener gic receptors on arteri-
oIes,ausing vasoconstrktion (chapter 1)00).
Receptors in the aorta and the inte rnal carotid artery act
as sensors to provide the vasomotor center with vital infor-
mation on conditions in the wscular system. B.wvmtpt0l'l
have the ability to sense pressure within blood vessels,
whereas dlftno'fI)tM Il"<::ognize levels of oxygen and carbon
dioxide, and the pH in the blood. The vasomotor center re-
ads to information from b:lmreceptors and dJemorecep-
tors by rai sing or lowering blood prasure accordingly. With
aging or certain disease states such as diabetes, the barore-
ceptor response may be diminished.
Emotions can also have a profound effect on blood pres-
sure. Anger and st ress can cause bLood pressure to rise,
whereas me ntal depression and lethargy may cause it to fall.
Peripheral resistanoIw'
diameI"r of .rterioles
Cwliac ouIpUI
AJid Ioao
Det.;<lration
AJid mlen1ion
Aldoote.one
' .<OH
Symplllhetic fl81'VOU11
'YI',. m activity
Rerin/angio1ansin II
t...,..IM in blood
""""";Iy
FlgurelJ.' Pflmary factofsaffecttng blood pressure
P""OIIo;!
eomractiity

-Heart ...
- SI"""'IheIic ..."....
.,..-

---.ya .....
.
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01",1<,23 DN9,forHYI"'nemlon 299
Blood pl9DUno
Vaoodlaaon
C<lmp"IISatory action by
r:ar<tkMIscuta'system
i
' Strc1<8 VDIUITII
,
Flgure23.2 Blood pressure homeostasis
Strong emotions, if present for a prolonged time period, may
become important contributors to chronic hypertension.
A number ofhomlOlles and other agents affect blood pres-
sure on a daily basis. \'lhen given as medications, some of these
agents may have a profOWld effect on blood pressure. For =-
ample, injection of epinephrine or norepinephrine will imme-
diately raise blood pres/iure. is a polent
vasoconstrictor thaI can also increase blood pressure by rais-
ing blood volume. ADH is available by parenlal administra-
tion as the drug vasopressin. The renin-angi:Jtensin-aloosteronr
system is particularly important in thepharmacotherapyofhy-
pertension and is discussed in section 23.9. A sununaryofthe
various nervous and honnonal factors influencing blood pres-
sure is shown in Figure 23.3.
23.4 Etiology and Pathogenesis
of Hypertension
Hypertension is a complex disease thaI is caused by a com-
bination of genetic and environmental factors. Forthe large
majority of hypertensive palients, no specific cause can be
identified. Hypertension having no identifiable cause is
called primary, idiopathic, or essential. and accounts for90%
of all cases.
In some cases, a specific cause of the HTN can be identi-
fied. This is called secondary hyprrtrnsion. Certain diseases--
such as Cushing's syndrome, hyperthyroidism, and chronic
romal l>]uuJ c.,rlaiu JruKS
are also associated with HTN, including corticosteroids,
oral contraceptives, and erythropoietin (Epoetin alfa). The
therapeutic goal for second1ry HTN is 10 Ireal or remove
the underlying condition Ihal is causing the blood pressure
eleva tion.ln many cases, correcting Ihe comorbid condition
will cure the associaled HTN.
. ...... '1 rata
,
Because chronic HTN may produce no identifiable symp-
toms, many people are not aware of their condition. Failure
to control this condition, however, can result in serious con-
sequences. Four target organs are most often affected by
prolonged or improperly controlled HTN: the heart, brain,
kidneys, and retina.
One of the most serious consequences of chronic HTN is
that the heart must work harder to pump blood to the or-
gans and tissues. The excessive cardiac workload can cause
the heart to fail and the llUlgs to fill with fluid, a condition
known as heart failure (HF). Drug therapy of HF is covered
in chapter 2400.
High blood pressure over a prolonged period adversely
affects the vascular system. Damage to the blood vessels sup-
plying blood and oxygen 10 the brain can result in transient
ischemic attacks and cerebral vascular accidents or strokes.
Chronic HTN damages arteries in the kidneys, leading to a
progressive loss of renal function. Vessels in the retina can
rupture or become occluded, resulling in visual impairmenl
and ewn blindness.
The importance of treating this disorder in its prehyper-
tensiw stage cannot be overstated. If the disease is allowed
to progress unchecked, the long-term damage to target or-
gans caused by HTN may be irrewrsible. This is especially
critical in patients with diabetes and those with chronic kid-
ney disease, as these patients are particularly susceptible to
the long-term consequences of HTN.
23.S Nonpharmacologic
Management of Hypertension
When a patient is first diagnosed with HrN, a comprehensive
medical history is necessary to determine whether the disease
can be controUed without the use of drugs. Therapeutic
LibraryPirate
;<


t

100 UnII4 Tte c.,dkIY.",ul., .nd Urinary Synem,
Va somotor cent",
in medul a
8aromceptors
'" Vasoconstriction
e '" Vasodilllion
Angiot&nsin II
Qung"J
\
Angiotensin I
Qi""'J
""
j
Chang .... in
~ i d vol ........
,. Flgure2J.J Hormonal and nervous factors Influencing blood pressure
lifestyle changes should be recommended for all patients with
prehypertension or hypertension. Of greatest importance is
maintaining optimum weight, since obesity is dosely associ
ated with dyslipidemia and hypertension. Even in obese pa-
tients, a 1(}" to 20-lb weight loss often produces a measurable
decrease in blood pressure. Combining a safe weight loss pro-
gram with proper nutrition can delay the progression from
prehypertension to hypertension.
In many cases, implementing positive lifestyle changes
may eliminate the need for pharmacotherapy altogether.
Even ifpharmaootherapy is required, it is important that the
patients continue their lifestyle modifications so that
dosages can be minimized. The nurse is key to educating pa-
tients how to control HfN. Because all blood pressure med-
ications have potential adverse effects, it is important that
patients attempt to control their disease through nonphar-
macologic means to the greatest extent possible. Important
nonpharmacologic methods for controlling hypertension
are as follows:
limit intake of alcohol.
Restrict sodium consumption.
Reduce intake of saturated fat and cholesterol and
increase conswnption of fresh fruits and vegetables.
Increase aerobic physical activity.
Discontinue usc of tobacco products.
Reduce sources of stress and learn to implement coping
strategies.
Maintain optimum weight.
23.6 Factors Affecting the Selection
of Antihypertensive Drugs
The goal of antihypertensive therapy is to reduu the morbid-
ity and mortality associated with chronic HTN. Research has
confirmed that maintaining blood pressure within normal
ranges reduces the risk of hypertension-related diseases such
LibraryPirate
as stroke and heart failure. Severnl stratt'gies that are used to
achieve this goal are summarized in Pharmaoothernpy Illus-
trated 23.1.
The pharmacologic management of hypertension is indi-
vidualized to the p.1tient's risk factors, comorbid medical
conditions, and degree of blood pressure elevation. Patient
responses to antihypertt'nsive medications vary widely
because of the many complex gt'netic and environmt'ntal
factors affecting blo<Xl pressure. A largt' number of anti-
hypertensive drugs are availablt', and choice of therapy is
often based on the experience of the clinician. Although
01 .. 11.,23 Oru9,lorHyperten,k>n 301
antihypertensivt' treatmt'nt varies, there are several princi-
ples that guide pharmacotherapy.
In mosl cases, low doses of the initial drug are prescribed
and the patient is re-evaluated, after an appropriate time in-
terval.lf necessary, dosage is adjusted to maintain optimum
blood pressure. The following drug classes art' considered
primary antihypertensive agents:
- Diuretics
Angiotensin-converting enzymt' (ACE) inhibitors
Angiotensin II rt'ceptor blockers
PHARMACOTHERAPY ILLUSTRATED
23,1 Mechanism of Action of Antihypertensive Drugs
DecreaH the heart
rate end myocardial

nodJc:ing cattliac

Oiurem.
Incnoase ume output..::l
doocnIau Huid voklme
Atpha
2
agoni
Oecreaae
impul ..... from the eNS 10
the heart and arteriole!!,
cllUaing vBsodilillion
Alphe, bloc ker.
Inhibit "Y"'p"thelic
activation in
Brteriot .... causing
vem lEllion
Diroot ...
.---.; .... -1. Acl on the omooth
......,.., of .Ieri""'.,
causng vaoodil9lion
Calcium channel
blocker.
Block calcu m ion
c han",,11 in arterial
smooth mU!ICle.
ca"';ng
vaoodilalion
Angiotenain
receptor bloc k ...
_ _ P,.....MI angiol ...... n
'1 II from reaching
receplors. causing
vaoodilation
ACE inhibilor.
Block fOlTTlll tion of angiote nsin II , causing
vasodilation and block aIdo5t"""",
lIIIC",tion. decreasing fll.icl voIu ....
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302 UnII4 Th<> .nd U'I .... ry Syne<",
Beta-adrenergic antagonists
Calcium channel blockers
The JNC-7 report recommends thiazide diuretics as the
initial drugs for mild to moderate HTN. Patients with a
compelling condition, however, may benefit from a second
drug, either in combi nation with the diuretic or in place of
the diuretic. The JNC-7 report lists the following com_
pelling conditions: heart failure, post- myocardial infarc-
tion, high risk for coronary artery disease, diabetes, chronic
kidney disease, and recurrent stroke prevention.
Prescribing two antihypertellSives concurrently results in
additive or synergistic blood pressure reduction, and is
common practice when managing resistant HTN. This is of-
ten necessary when the patient has not responded to the ini-
tial medication, has a compelling rondition, or has very
high, sustained blood pressure. The advantage of using two
drugs is that lower doses of each may be used, resulting in
fewer side effects and better patiem adherence to therapy.
TABLED.2 I Combination Drugs for Hypertension
Adrelll'rgic
TradeName Thiazide Diuretic Agent
Ao:rurtiK hyd rodKIrothiazidt
Aldactillidt hyd rodKIrothiazidt
AVoilidt hyd rodKIrothiazidt
""
BtniurHCT hydrodKlrothiazidt
"-
hydrodKlrothiazidt
"""'
bmdroll_liaridt
"-
hyd rodKIrothiazidt
Dyazid/, hyd rodKIrothiazidt
-
H .. , hyd riXtlorothiazidt
Indtridt hydrod"lorothiazidt
.-""
"D.

hydrod"lorothiazidt
... ,
lotftllin HCT hyd rodKIrothiazidt
"".
T ....
TeWIN IfCT hyd rod"Iorothiazidt oImilorid/,
....
.-
TemffilfCT hydrodKlrothiazidt
Iimolidt hyd rod"Iorothiazidt timolol
Uoi'tiK hyd rod"Iorothiazidt
VilItlffK hydrod"lorothiazidt
l!-!torttK hydrod"lorothiazidt
'"
hydrod"lorothiazidt
.......

hyd rodKIrothiazidt
'A'loliabllo if only
For con'A'nience, drug manufacturers sometimes combine
two drugs into a single pill or capsule. The majority of these
combinations include a thiazide diuretic, usually hy-
drochlorothiazide (Microzide). Selected combination anti-
hypertensives are listed in Table 23.2.
Certain antihypertensive classes cause more frequent or
serious adverse effects and are generally prescribed only
... firs(-li"" <.Iu llU( pru<.lu,""
sponse. The alternative antihypertensive drug classes in-
clude the following;
A1pha,-adrenergic antagonists
A1pha,-adrenergic agonists
Direct-acting vasodilaton;
Peripheral adrenergic antagonists
Convincing patients to change established lifestyle habits,
spend money on medication, and take drugs on a regular ba-
sis when therf .... 1 well is often a difficult task for the nurse. Pa-
PotassJum-spa ring ACE Inhibitor or
Diuretic Angiotensin II Blocker
m .. ,
qunapril
........
irbNrloln
oImlodipO!

(,Jptopril
IIIls.Jrlolo
uiolmltrtne
voIls.Jrloln oImlodipO!
IoIartoin
m!iolpril fmjpiO!
bmaztpril
btOilepriI oI mlodipO!
trolodobpril VrloI()oInil
_ru"
rnouipril
m!iolpril
Iililopril

LibraryPirate
COMPLEMENTARY AND A LTERNATIVE T HERAPIES
Grape Seed Extract for Hypertension
Grapes and gl'ilpe haw bffiJ UIfd for thousands of )'NB. Their primal}
use hu bffiJ for cardioYomuLII (oncIir:ioll! SIKh u hyptnension (HTN), hiqh
blood (hoiesterol,.uherosderosis"nd to improff dKulation.
(Llim thai grape omct improm wound lItaling, ,nd
towfrs tiMo risk for tiMo Iong-Ierm (onlequemt5 ofdiabeles.
The grape seem, ulually obtained from wintmaking, j re ,nd piKed
into rtquid forms. Typic,1 doses alt' SO to 100 mgllky.Grape
!fed omct has , ntioxidim properties. In amioUdanu improl'f
wound lit, ling ,nd lI'II'Iir (riluLl r in PI}. Prrliminal} fYmme suqgtSlS it may
W ben.fit in repairing bloorl ... >d thot could told to Ithu-
ol<t.rosis ,nd HTN. Comrolltd, Iong-Ifrm studifs on the rffKtl of grape
omm on HTN have not bffiJ (onducted. k has il'w adl'fBf efil'tts but (au-
tion should be UIfd ij laking anticoagulant drugs bt'I'iIUSI' inaNstd bleeding
may rl'IUIt. Owrall, tilt of grape Red I'JtraCl arf no dijfttml than
m<M of ,diet balalKed with narur,1 antioxidints (ind <In omsionalglm of
I!Clwine).
tients with limited incomes or those who do not have health
insurance are especiaUyat risk for adhE1"ence. The health care
provider should consider generic forms ofthest' drugs to re-
duce cost and increase adherence to the therapeutic regimen.
Further reducing compliance is the occurrence of undesir-
ablt' adverse Effects. Some of the antihypertensive drugs cause
TABLE 21.3 1 Diuretics for Hypertension
"' ... lfr 21 DN9' lor Hyperten,"'" 303
embarrassing side effects such as impotence, which may go
unreported. Others cause fatigue and generally make the pa-
tient feel sicker than they were before therapy was initiated.
The nurse should teach the patient the importance of treating
the disease to avoid serious long- term consequences. Further-
more, the nurse should teach patients to report adverse drug
effects promptly so that dosage can be adjusted, or the drug
changed, and treatment may continue without interruption.
23.7 Treating Hypertension
with Diuretics
Diuretics were the first widely prescribed drug class used to
treat hypertension in the 1950s. Despite many advances in
pharmacotht'rapy, diuretics are still considered first-line
drugs for this disease because they produce few adverse ef-
fects and are very effective at controUing mild to moderate
hypertension. In addition, clinical research has clearly
demonstrated that thiazide diuretics reduce HTN-related
morbidity and mortality. Although sometimes used alone,
they are frequently prescribed with drugs from olher antihy-
pertensive classes to enhance their effectiveness. Diuretics are
also used to treat heart failure {ch.1pter 2400} and kidney dis-
orders (chapter 3QOO) . Doses for these agents are listed in
Table 23.3.
Although JlIany different diuretics are available for
HTN, aU produce a similar outcome: the reduction of
Route and Adult Dose
",,'
(max dose wtH>re Indicated) Adverse Effects
POTASSIUM-SPARING DIURETICS
amiloridt 1 Midamofl PO:5- 10 mq/day (max: 20 mQlday) Minor hyPf'rtoIfmi4 hwlhe forigw.
tpitlt'llOllf(lnspr.l) 1'0; 25- 50 mg OIKf dailr (max: 1 00 mglday)
0Ilffi'1MfiII (spirmollKloot)
spNnoIactont (AIdaaOlll'j (Iff [II9f m for the PO;15- 100 mg 1-2 times/day (mn: KI
Qxldi:abmial 1m
ProIol)'pt Drug box 00)
hVDO!!jlrellia " am.iornosiund n blood

triamll'rfllf (o,rmium) 1'0;51>-100 mg (max: 300
THIAZIDE AND THIAZIDE-LI KE DIURETICS
dKIrothiazidt (Dini ) (lI' f page m PO:151>-5oo mglday Minorhyplll"dtrnio,. fotiglll'
for lilt Protol,Pf Drug box 00)
Sianifi@nlhypoblellia,*<trolmdepk!ion
dKinhalidont (H)'I)1Itonl PO; 51>-1 00 I119iday (max: 5(1 mg/da,) dehl:l!al!!m, maUmlia
Q IrfdrodKlrothialidt (Mirrozidt) PO:15- 100 I119iday (max: 50 mglday)
hyperdrumia roma blood dyxmia1
indapamidt (loroI) PO: I.lH I119iday (max: 5 mglday)
methydotliuide(Endnm) PO:2.S- S mg OII(f dailr (max: 5 mg/day)
metol.JlOIII' (Zarmolyn) PO:2.5- IO mg OII(f dailr (max:lO mg/da,)
LOOP/HIGH-CEILING DIURETICS
btmti,nidt (BlIIlfl) PO;O.5- 10mglday (max: 10 mg/day) Minor hypckdtrnio,. pIlSlrJrtI IYtpllltf!lim,
furostmidt (LasW (Iff page 110fortlit ProIotype PO: 10-80 moIday (max: 600 mQ/day)
rnlUl& farigue
Drugbox
OO
) SigniO@Djhypobleuja bkpod dyllliWl
toBtmidt (Dtmadtx) I'OI1V; 11>-20 (max:lOO
tkn!>'!m
dmllatOf1lJ!llapse
Ira/kJ indratf ammon id'ItrII' tfttm; undt!lining in riratflll'riOUS ad>imt ffitaS.
LibraryPirate
304 UnII 4 TheOrdkIY.",ul.r.nd Url .... ry Syne<",
blood volume through the urinary excretion of wa ter and
t'lectrolytes. Electrolytes are ions such as sodium
calcium (Ca
H
), chloride (CI - ), and potassium The
mechanisms by which diuretics reduce blood volume dif-
fer among the various classes of diuretics and are discussed
in chapter 3000. When a drug changes urint'composition
or output, t'lectrolyte deplE1ion and dehydration are pos-
sible; the specific electrolytt' lost is dependent on the
mechanism of action of the particular drug. Pot assium
loss (hypokalemia) is of particular concern for loop and
thiazide diurE1ics.
Thiazide and thiazide-like diuretics have been the main-
stay for the pharmacotherapy ofHrN for decades. The thi-
azide diuretics are ine.'l:pensive, and most are available in
generic formulations. They are safe drugs, with urinary
potassium loss being the primary adverse effect . The proto-
type drug in this class, hydrochlorothiazide, is highlighted
in this chapter.
Although the potassium-sparing diuretics produce only a
modest diuresis, their primary advantage is that they do not
cause potassium depletion. Thus, they are beneficial when
patients are at risk of developing hypokalemia due to their
medical condition or the use of thiazide or loop diuretics.
The primary concern when using potassium-sparing di-
uretics is the possibility of retaining too much potassium.
Taking potassium supplements with potassiwn-sparing di-
uretics may result in dangerously high potassium levels in
the blood (hyperkalemia) and lead to cardiac conduction
abnormalities. Concurrent use with an ACE inhibitor or
angiotensin II receptor blocker significantly increases the
potential for the development of hyperkalemia. Spirono-
lactont' (Aldactont') is featured as a prototype drug for this
class in chapter 3000.
Tht' loop diuretics cause greater diuresis, and thus a
greater reduction in blood pressure, than the thiazides or
potassium-sparing diuretics. Although this makes them
very effective at reducing blood pressure, they are not ideal
agents for HTN maintenance therapy. The risk of adverse ef-
fects such as hypokalemia and dehydration is greatt'r be-
cause of their ability to remove large amounts of fluid from
the body in a short time period. Loop diuretics are also oto-
toxic and may cause deafness. Because they have a higher
potential for toxicity, loop diuretics are often reserved for
more serious cases of HTN. Furosemide is the only loop di-
uretic in widespread use, and it is presented as a prototype
for heart failure in chapter 2400.
Prototype Drug I Hydrochlorothiazide (Mlcrozlde)
Therapeut ic ( lass: Drugforhypertension and edema Pharmacologic (lass: Thiazide diuretic
ACTtONS AND USES
It,dmchlomthiaridt tilt most pttsaibtd doo{ [0, HTN.likt null)'
urWa, it eflMsand probing, 10to
20 mmHg rtduailn in bbod P.tiffits with HTN Of. (ompelling
(ondition may rtqIlR the addition of. second dlll9 from , difll'rent (lass to con-
troltllt dilNlf. H)droc:hknuthiazidr tht most (ommon agffit bund in fixtd-
dOIf (ombilatiJn drugs klr HTN.lI)droddorothiazidto appruml to trW mite,
fdenu, heart HTN,.nd nephn:tK Syn:!rornt.IlJMS IOIne1iIllfS Ust HCU.s
an JiKmiMion for this drug; shoold lit awidrd btause it (,JUleS
(onf_ Iljdrochiortthiaridtwith Iljdrocortisone.
H)'drochlorothiazidr.m on tht kidnty IUbult to rtabsorption
of Na+. Normally, man' thin m of tht sodium Mtffing tht kidnl')' R'ab-
sorbtd by the body. When hydrochlorothi.uidt blocks rf.bsorption, IMft'
NJ + into tilt Wlltn sodium ml1m KJ"O\S tilt IUbult, water flows
with it; thus, blood Oiuml' dKR" !tS and blood PIffiUR' falls.TIIt oiullll' of
urinr produud is dirffif)o proportion,1 to the Jmount of sodum R'.bsorption
bkx:ked by tht diulMic:.
ADMINISTRATION ALERT
drug in day to pR'Yl'flt IIIXlUrW.
PR'9oancy rnegory 8
PHARMACOKINETICS
il'lset: l h

min
Dur.tion: 6- 12h
ADVERSE EFFECTS
I/ydnxhlorothiazide well tGierattd ftw seriotK MYerse effem.
TIlt most (ommon tifeds 'fl' potMtial dU!' to
Iossof K+ .nd Na .8t(aUSf hypokaltmia m.y (,JIM mdia( rondU(-
tion abnormalities, patienll usually inmuned to incre_ tlltir pot.ssium
int.kt as. pfl'uution.f/ydro<hlorothiazidr may prf<ipitatf gout .nac:ksdU!' to
its tfnderKy to (iIlU hyptlUn.:rm i .
Contraindiartions: Coomindiutionl irdJde .nuria .nd prior hypersflllitmt)'
to thiazidrs Of suifOfl,Jmoo. Thiazidrs . re (Olltraindirntd in prM<lJmpsia Of
otlltr prtgoancy-induc:td HTN.
INTERACTIONS
lng-Drug: v.t.fn giwn rooomntly, ot:M i111ih)"pen1'RSiw511iWf adoitil'e (f
ffIfru with hydrodllorothialide on IMIod pMllR. TIUzideI IN'f rmr thf
fffKtiW'llfSS of iIIlimigulann, !tMonylo..rni, iIId anIidiabetK dr\rgI inllfn
0I0Iesty..- ani d@cru;ethfaMptionofh)'drodlkfodiiaiidr.n:l

IMDl.Corti:OIIeroids BirKmIf pcOIWn tms_ giIomrih

todtJHydrodiIorothia dKruststhPmretionoflhilrn iIId(;ll\
-
Lab Tem: IIW)' ioofN o;mwn
Ykium IHm. Thedrug rna, dfcrrnrwnm 1MlneWn,
potmilm,.n:I Odium
1Ierb.:JVFood: GitgobiloboJ may prodOCf a par;l!kIIKiI1 iooNlf in blood prmtI"f.
I.ke with hawthorn (IUd ilJCiditiw
of (Mordosr: Dvrrooseis
tR'.tfd with infusionl of fluids containing of fluids will
Jiso prt'lmt dth)'dration and
Rtftf III MyMnJnqKl ror MnJnq /'ro(e\S fiKIIllpf(/II( III 1M iJ"rJg.
LibraryPirate
0I ... l<r23 DN9,forHYI"'nemlon 305
NURSING PROCESS FOCUS PATIENTS RECEIVING DlURETICTHERAPV
Assessment
Baselinr assrssmrnt priort o admini stration:
Undtr>und Il'asoo the drug has prec:ribfd in ol'lltr 10 mel for
theraptUtic:
Obtain I (omplUt history induding
diabete , PIfO]IIaIK)', or breast ffflling. Obu in a drug history ilKUding
allel9ies. wrlt'llt OlC drugs, IItrbal
akohol USI'.81' alen 10 drug
approp.utf laboratol) findings such u
(ompiell' blood (OUnl (CBO, hepatic: or Il'IIaI fulKtion studies.uric a{id
!ems,and lipid profiles.
Obtain yitalsigm blood pll'Slure [BPI arid
bll'ath sounds,lnd card"1<)( monitoring (f.g., ECG,wdy{ output) ij
approp.utf. lor location and (haroKter/amoum of rdtllY, if
prestn!. Asse I hearing a nd bawn(f.
Assell mrnt throughout iI dminiltration:
brdesil!d therapMic: effffil{f.g., S)'lloIic: and dYltoli BPJ.
Continue ptriadic: monitoring of CSC,Iipid profiles,
liYel function uric: oKid
AIII'SI for and report palpimionl,
diuinesl, mUKulolktletal or{lamping. llalnU, yomiting,
abdominal era mping, diarrhu, headamt. TinniN! or lItaring loll, Iosl of
halan{1' or inroordinuion, hypolmsion i((omflanitd II)' R'An
luhycardioK dysrhythmias, de<rea sed urine output. and 'ftight gain or
lois O!'r 1 kg (approlimateiy 21b) in a 2+hour period lhould be rt porttd

Potenti al Nursing Di agnoses
Dmcient FluidVoume
Fatigue
Dffit'ased CardioK Output (R'lattd to of diurflics)
Dtfitient Knowledge (drug thmp)')
Risk for Falls,Rilk for Injury (R'lattd to hypoltnsion,diuinesl allO(iall'd with
adw"SI'effb)
Risk for FulKtiona IllKOOlinl'lKr (R'lattd to diull'tic: USI')
Risk for NolKomplialKf (reI.itrd to effb of drug thtrap)')
Plll nning: Patient Goals li nd Expected Outcomes
patiem will:
llitrapMic: effb dl'Pffidtnt on the rt awn the drug is being giml (i.f.,de<R'aseci blood PIl'SIUIl').
fret from,or minimal, idw"Sl'
an undtr>,andiog ohhedrug'1 flfb, and R'qJired pll'lautions.
pflllll'l" :self-administration oftht medication timing, wht n to notil)' providtr).
Impl ementati on
Interventions and (Rati onales)
Ensuring thrrilpeut k effects:
Continue frequent iIIlffimerllS ill a boY!' for theraptUtic: tlfb: blood
presruR' ind puisI' are within norllYllimil>orwithin parametm 11'1 u,.
lilt lItakh {ilR' provider. (Systolic: and dystolic: should Il'tum gridually to
nomullimits without lilt p!I'IfIl{e of reflex tac:hlUrdia.)
Daily wtights should remain at or dOlI' to billl'linewtighl (An in
Wfight 1 kg pl'rday may indic:.Jtt fll(flSiYf fluid ljiIin.A of
Offr 1 kg perday may indicatf !j[(esi'll'diuresis and dthydration.)
ElKourol9f appropriate lift,style {hangtl.Proyidt for dittitian {onsulmion
as nfflIed. (Heahhy lifest)'1e (hanges will support and minimize the nfflI
for drug
dt"b:
Continue to monitor yitalligns.Takt blood pft'lSUR' lying, sitting,and
standing 10 ortholtatic: hypott nsion.8ecautious with thetlderf)o
who are at ilKR'lsed risk for hypotension.(Diull'lics rme drtuwting
blood Oiume,lt'IUhing in Io'ftl!d blood pR'ssure.Onholtatic
may the risk of falls and injury.)
Pllti ent li nd Fll mi ly Educllt ion
TeoKh lilt patient and/orfamily how to monitor puisi' and blood prffiUIl'.
Enrure pflllll'l" USl'and funaioning of an-; rquipment obtaintd.
Hm patitm weigh 11'11 daily and Ifford Wfight along with blood PR'ISUR'
and mearull'llltnll.
En(OUrage the patitm to adopt,. lItahhy lijest)'1e oflow-fat food dlOic:n,
redU{td Iodum intlu,in{rea\I'd akohol {Onlumption,
and smoking (esation.
Ttaoc:h tilt paDl'nt to risf 40wIy from lying or litting to standing to avoid
diuint lS or falls.
InstnK1the patient to stop taking the ijblood pR'lsure is
90/60 mmHg or btlow, or 11'1 II)' the hulth cart proYider,ind
ootil)' prwider
(ConrlnuefiJ
LibraryPirate
NURSING PROCESS FOCUS PATIENTS RECEIVING DIURETIC THERAPY (Conr/nuoo)
Implernentlltio n
Interventi ons and (Riltlonilles) Patient lind family Education
Cootinur 10 monitOl' tlrarolJles, profile, lim function mlnrtthe poatirnt on Ihtlftd III mum 10 inform
Ituditl,(Itatinillt,and urKlcid diuretics UUIt loss of
sodiJm a/ld potassium Ind may irKlHIt lipid,gb:ose,alld uric. iCid
the poatitftl to carry I Williet idtntifiution wd Of WNr mtdiul
lel'tls.)
iclentilication jNtIr)' indiciting diwetK the.ij)y.
Continur 10 monitor !wring Inc! balano::f,lfIIOrIIng pmislfl1l tinnllA 01'

IlI'ltruct 1M pllRnllII tinnitus,OI' baLl nc:f 01' roordilllllion
wrtiqo promptly. (0101_ 01 cranill_ VIU IN)' OIIr, HPKiaDy prnblfms immtdiattly.
with loop diuretia..)

EnWft palitftl IiIlrty,epf<i.lly for light-

lmtlllCl the .ssiltWt pror 10 9fIIilg out libtd 01'
hudtdnes Of dizzines. Monitor Imbulation until effemofdrug atttmptiIg IOwllk _Ind m woiddrivilg 01 adwr iCtMtiM
known. (Dizziness from orthomtK hypottll'lion m.ly 0((\11.) menlllaleJtness or physiuI coordiMion oom eM 01 the ug are irnowll.
Wfiq/1 the patRot daily Inc! Wl'ighl!pin or loss of 1 kg ilal't the pltitnl.,mgh Iflfdaily, idfally II the Sime timeof da,;and it(ord
(approximattly 21h) or more in a period. Muwre intakund wtighl.long with hlood p!t1SOlt Ind fIIlIst the patitnt
cuQll/l in tht hospitalized pllitnt. (o.i/r weight is an iC(U/1lt mtasIJl! of I!port wtight 1011 or9iin of molt than 1 kg in iI 24-hour period.
fluicillatus JOd takn info intlkt,CIIIlpul.and instmible bslfS.
Advise lilt poatitftt to (ontillur 10 consume mougb ijquids to rtmain
IMJreis is indicaled by oulput signifk<lndy gl!oJIer than w.11R.)
but nol 0e!Iy hydrJled.. DrNil'Wl wlw:n akoholK
fIIwring but IIOlutflsi\'t wit inuktwill assisl in
mlint.aining normallkJid bal.lnct.
kId! tht pllitnt tlloll b"CHsiYt hflt condilions comribute 10tIKtlsm
swming, ilnd It.Jid ;md electrolyte loss ilnd tbil b"tril QUlion is warr;mted ill
thelf(Onditio!ls.

Monitor nUiritioMi SLlM and t!KOur;Jgf ipplllpri.tte intake 10 prmnl Inslruct liking potusiumwmrilgdiurttics (e.g., thilzidts,tbiazicle-
tlectrolyw: imbl diurtlics alust sodium Ind potusium loss. likt,and loop diurtlial \1:1 (omumf foods high in potusium:frtsh!ruits such
Pot.uiurn-sparing diurelics m., in sodilllllioss but pot.ssium as stfJWbtrrie.nd bananas;dried !ruiU such <II apricon and pn.rot\;
incrUIf.) lfI!'gtI.bln and such as tomoJIOf'l, bettS,ind dritd bUns;jUKtI such
as or;m9f,C]I"apl'iruit 01' and fifth mNIs.
lmllllCl p.llifms tlking pJtisslirn-splrirg di.RtiG 10 mil iXKk iI
potassirm such .s aboYt, nol \1:1 USf Ilk suktitultl (whKh oftrft (OfI1lin
potassirm lilts), ind 10 ClHIIUh with iI Ilulth ore p!OYider !rill! taking
tiumill and Of specialized sports btI'tr<l9fl.CTypOI arc
sports and Pa.l'trilk,mayhaw lelff amounh d
pJmWm but hal't high{aJboh)dnle amoo..IU th.Jt rna, Iud 10 M.stc:i
diJrei!, diarrhea. . nd pote"IIiiI for dt/tydriltion lrom lilt h)'pI'IOsmoiarityJ
for signs of h1Jll'flllyumia.lkf with {.ution i1p1tirnn with IlI'ltrud 1M plOOllO rtport signs arid )'IIIptoms of mtIIilus {t.l}-,
CThiaziM, IhluidHike, I nd loop di.rlttia (oJn (,)UIf pJlydipsia. pol)'phagia) or tleuled blood wg.Ir 10 lItaltfJ plO't"idK
e5{ItCiltt in diabttiaj INbttic palitnts may Iftd 10 mollie)! their blood 9UcOlt Itoitls mOIl!
fl!qur.lIly eflttof 1M diuretic: ill! kllOWn.
Cbsem 'If sunburning if pflllofl!ltd sun tJp01lr1! hu oco.rnfd.(Somt Instruct the paIR"1 Inci proItiedothing if pllllonged
diJrtticscaust skin Pilo!OIfnsiIMty.) sun e:posurt is Inticipaltd.

for signs of ink<lion. (Some diumic:s m., dKrUSf wIIitt blood Instrud the pltirnl \1:1 Jfporl .ny It.J!ikt symOfM:Shor!neS 01 hl!iIIh, !Mr,
(til CIlUIIU and lilt bodYl ability to fight is a sort rMLIise,joint pain,or prolound latigur.
possible ildl'tf5efftect of<iuretK tMfiPY.)
'-timt u.dtlsliinding of drug durapy:
UlfoppOllltlre admilistroJlion ofmedotiom aid dtring Tht pltirnt shouk! bt i1ble to stall! lilt rtasort lor lilt drug,
.\StI.SrntfIII \1:1 !I5an.s Iht rilticNlt lor drug thmpy, desired Ihmpl'Ulic: and i1PJ1ropiate dose and IClleduling;what iJ6.otlSt tfftc:ts 10 obstrvt lor and
0UIl:00"Ift, most common adI<eI5t tlfa, p.lI3rnettf1 for wht!lm al l tilt wbe!l1O rtport ilnd tht ilnticipattdlength of mtdiutillfl tMrapy.
htaIth (;ill! any necmary monitoring or
liAr rurilg lM"Iil'Wl tooptirnilt.wl rmfota' ktytrading
,.Iimt sdhdrninistlillion of dn.g tht'ilPJ:
When administering tilt mfdiution,iIItru{\ the patienl tndfor ftmily in The pltitnt alld tl! iblt to discuss ipproflriate dosing ilIld
tilt propl'IIfJ-administr.lli1lfl of tht drug.f.g.,r-arfy ill 1M da, 10 prmnl .dmnSlflltion
disruption of from nocturia..{ProPfr admw.istration imprum the
tfftclilotntu oftht drug.)
306
LibraryPirate
OUplfr21 Dru9,/orHypellemkln 307
NURSING PROCESS FOCUS PATIENTS RECEIVING DIURETIC THERAPY (Con/muM)
Evalulltion of Outcome Criterill
tht of drug ihtrap, by oonfinning that pititm gNkand txpKted hnl' bffil ml't (Sle PlanninifJ.
Str TIIbIt 111 for Q 1st Ii /hili to wIidr rIleit IIIrlill) 1ilnI gppIy.
CALCIUM CHANNEl BLOCKERS
Cah:iummann!!'l bkldm(((BsJ e.urt benE1i.cial effectson the heart and
blo<Xl vessels by blocking calciwn ion channels. They are used
in the treatment of HTN and other cardiovascular diseases.
23.8 Treating Hypertension
with Calcium Channel Blockers
Calcium channel blockers (CCBs) comprise a group of
drugs used to treat angina pectoris, dysrhythmias, and
HTN. \Vb.en CCBs were first approved for the treat ment of
angina in the early 1980s,it was quickly noted that a "sideef-
feet" was the lowering of blood pressure in hypertensive pa-
tient . CCB. a..., u.ually not us.:d .... monotherapy for
chronic HTN. They are, however, useful in treating certain
populations such as the elderly and African Americans, who
are sometimes less responsive to drugs in other antihyper-
tensive classes. Doses for these agents are listed in Table 23.4.
Contraction of muscle is regulated by the amount of cal-
cium ion inside the cell. Muscular contraction occurs when
calcium enters the cell through channels in the plasma
membrane. CeBs block these channels and inhibit CaH
from entering the cell, limiting muscular contracti on. At
low doses, CCBs relax arterial smooth muscle, thus lowering
peripheral resistance and decreasing blood pressure. Some
CCBs such as nifedipine (Adalat, Procardia, others) are
selective for calciwn channels in arterioles, whereas others
such as verapamil (Calan) affect channels in both arterioles
and cardiac muscle. CCBs vary in their potency and by the
frequency and types of adverse effects produced. Verapamil
(Calan, Isoptin, Verelan) is featured as a prototype antidys-
rhythmic in chapter 2600, and diltiazem (Cardizem, Dila-
cor, Tiamate) as an antianginal in chapter 2500.
Two calcium channel blockers, clevidipine (Oeviprex)
and nicardipine (Cardene) are important drugs for treating
patients who present with serious, life-threatening hyper-
tension. A newer drug approved in 2008, clevidipine is in-
fused until the target blood pressure goal is attained. This
drug has an ultrashort half-life of one minute, which allows
for rapid adjustments to blood pressure. \Vb.ile clevidipine
is indicated only by the IV route for hypertensive emergen-
cies, nicardipine is also available by the oral route for essen-
tial hypertension and angina.
23.9 Treating Hypertension
with ACE Inhibit ors and Angiotensin
Receptor Blockers
The renin-angiotensin-aldosterone system (RAAS) is one
of the primary homeostatic mechanisms controlling blood
pressure and tluid balance in the body. This mechanism is
SELECTIVE: FOR BlOODVESSEL5
' .... odpjne (Nmas<:j
ftlodpilt (Plmdl)
PO:S- l0 mgOlKtdai, (nw:: 10 mglday)
PO:S- l0 Ill9lday (max:1O mgldol1)
FMhed >kin. Mlid1rf, dinirltn, pfflp/rfrol

rOlJJfirlorionJarigue,
dyWrlflion
i>radipineIDynoCirc)

Q (MaW, PrOGIrdia,othm)
rilOldipine (ti5O(0I'")
PO: 1.25- 10 ""I bid (max:20 mglday)
PO:20-40 ""Itid or SR bid (mu: 120 mgfday)
PO: 10-10 mgtid (max: 180 mgldol1)
PO: 10-10 mg bid (mu:60 mglday)
NONSELECTtVE:FOR BOTH BlOODVESSEL5 AND HEART
dikimm (urdinm, DioKor; llamatt)
p.I9!' 348 for the Pru!ot)"pt Oruij box 00 )
I
PO: 60-110 mg !U5lailtd edt.!\!' bid (rnax:540 Ill9lday)
PO;80-160 mgtid (nw::480 mgldol1)
LibraryPirate
108 UnII4 Tte c.,dkIY.",ul., .00 Urinary Synem,
..,. Prototype Drug I Nlfedl plne (Ada/at, Procardlo, others)
Therapeutic Class: Drug for hypertension and angina Pharmacologic Class: Calcium channel blocker
ACTIONS AND USES
Nifedipinr is'! ((8 grOl'r.11y pll'se:nDtd for HTN.nd fariant or 'taIOlpMtic:
k is ocas:oOiIIy UIed 10 tINt Raynaud's pheool1ll'OOn .nd hyprrtrophic:
cardiomyopathy.Nifedipinr,Im b)' blocki09 rakium dunnrll in my-
om:lyl and moJiar mlooth musdr, including thlM in thr COlOOiry ,IlIt'rirs.
This Il'sulu in Ies!oxygrn utilization b)' hNrt.an in cardiac
and ,I filII in blood PIl'lIUI'I'. k is milabllo "capsules and as
t,Ibleu(XU.
ADMINISTRATION ALERTS
Do not admin:nl'l formulations of nifedipinr il an im-
pendi09 MI iSlUspeued,.or within 2 Wftks followi09 ,I confirmed MI.
Administer "psules or ublets upsuies or utmded-
1l'Ie.IIt ublw all' or rMhed, rmirr dolt will bedr-
li"l'!'ll'datonu.
Pll'9
o.
nqrattgoryC
PHARMACOKINETICS
il1 .. t: 10010min PO


Duration:4--l! h (24 h rxtrnded 1l'1e,I1t)
ADVERSE EFFECTS
rffrru of nifedipiOl' all' grnerally m inor and all' Il'I.trd 10 nsodilalion
IlKh a, periphml edema, and Au,hing.lmnrdYte-arti09
forms of niled ipiOl' "n ralJW Il'IIeJ urhyurdia. To avoid I'I'bound hypotension,
thedrug should btdisc:ontinued gradually.ln rall'ulfS.nifedipilr m.ycauH'.J
pmdoJiiul inrll'asr in a09io.l ".io, possibly II'Iated to hypltmsion or heart
lailull'.
Contraindications: only contraindication is prior hype!>l'OsitWity to
nifedipiOl'.
INTERACTIONS
I)ug- l)ug: giml cOIICurrently.1IIhH ,Inlil)"pfnflllie\ haonadlitftrifm
with rifedipilll' III blood /lll'=r. Coooi"rmt!llt of with ,I lieu bIcIcRr
inm.N'i 1M rill; of COO(j@Sti"lthtartfaln.NlediplII'lIIa1l1mNserumlt"ltl.of
!igolin.leadilg to bradycardia and digoxin polflfioll!l
mDlilati"9 action of and cook! lead to 'Y1K1Ipf taM by a_drop
inbloodpll'l.lUJI'.
lab Tl5ts: M.l\r lImN vakIeI for tilt foIowill9lab tfllS: ,IlaIn p/IoIphalMt,lDH.
ALT.cPK,and ,1ST.
IlerbaVFoo:J: GriPfrnit pcr nYY rnhaoo Jhp ab!orption of MPIatonin
IIIa1 lImN blood IHSI-lR ind lltan
of OYl'rdow: Tht monliktly sign of O"I'!'rdo!age li)'pottnsion,
whim is tll'ated with mopll'S50rs. Cikum infusions may bt irduttd
I1tI'8" 111 MyMIsIniJU fix a MnJnq 1'rIxt55 fooIl 'ipK/It 1II1M It!!g.
NURSING PROCESS FOCUS PATIENTS RECEIVING CALCIUM CHANNEl BLOCKER THERAPY
Assessment
Bi stline aSSf!!mrnt pri or to admini,tration:
Undtrstand the drug ha, bten pll'SUibed in orck-r to aslfSS for
theraPfUtic tfuru.
Obtain a compietf heakh hillory includi 09 cardia<. se:ular (including M I. hean
failull'), mUl{Uloskfleta1 condition, that mightll'lUk in fatigue,
....,.,Iknffi.IIIJ!C1e or joint ".in), and the possibili!)'of pft'gn'nq.Obuin. drug
illwdinj .Ilrfljin.w".nll" ..... ,ipliun .lId OK d,IIIJ',I"''''''
akohol UH'.8e ,lien 10 possible drug intmction,.
E'lilwtf appropriate laboralOry potmum 1M,
fulKtion and lipid profile.
Obtain fiul sign, (espe<ylly BP and pullf), brNth lOUnds.and
"n:!iac monitoring (t.g. ECG.ca,diac output) if ,Ippropriate.AsIfSS for Ioution
.nd charactf" .nount of rdtma, if f'Il'H'nt.
Assf,sment thlllughout administration:
AsH'15 klr desirtd therapeutic NitcU (r.g.,1owt1l'd blood f'Il"lUll' within
limit!;; .150 or ,Ibll'llt ' 09ina.nd dysrilythmys if pll'll'l\t).
Cominue periodic monitori09 of Mctro/ytts,especilily potassium.
AsIfSS klr adl'el"!l' rffrm: n,IUII'a. (orutipation. mUlculoskflrtal
fatigue or fWI iog.. diuinffi. or smwl dysfunction. Myalgia,
,Inhralgia. perip/ll'lal or lacy I signifium con,tipation, in,bility to
maintain ADu M to mUl{Uloskfleta1 wukOl'l5 or pain .J nd unapla iOl'd
numbllffi or tingli09 of utll'mities should bt Il'ported im miatfly to the
hNhh caft' prmic!et
Potential Nursing Diagnoses
DfclNlfd C.rdYC IlItput (dilem proem)
Fatigue (II'Iated to oldrug
Altmd r"sue Pfrfusion (Il'lated toadWIt effKls 01 dlUlJ thmpy)
Activi!), InlOlrrancf (Il'lated riff(\! 01 drug th!rapy)
v., .. 1 Dym([lrtion ( ... Inod 10 dn'] r""'.py)
Dtficient Knowledgt (drug ther.py)
Risle for F.Ils, Ri,k for Injury (Il'latrd to hypotrnsion, diuinffi
associated with 'Mile tfferts)
LibraryPirate
OUplfr21 Oru9,/orHypellemkln 309
NURSING PROCESS FOCUS PATIENTS RECEIVING CALCIUM CHANNEL BLOCKER THERAPY (Conl/nuw)
PliInning: Patient Goal s and Expected Outcomes
Thr wiH:
UprrirlKf thrl<lpeutic: elFeru kg.,decrrm blood presSUIl' to 6 ublished
from, or nperirlKt idml!' rfferu.
an undtBtanding olthrdrug's UI!', effects. and pll'GlUliom.
Demonstrate pflllll'l" of lhe medication {e.g.,doIe, timing. when to notify proYider}.
Implementation
Interventi ons and (Rati onales) Pati ent and Fami ly Educlition
Ensuring therapeut ic effects:
Contin.or frrqurnt meslllll'ntl as drKribed Nrlirr for ther.!peUtK effects. (Bbod

Te.Kh thr or family how to monitor pulsr and blood pressurt.
and Jllisr should br within normallimitlor within set by Ensull' Ul!' and fulKtioning of all)' homr ftIuiPllll'llt obuined
health a ll' prv;idtr.1f drug is givrn for an9naandfordysmythmi.s, significant
improYfflll'nt i1 pain, improvrmtntJ

E lKourigt appropriate (hange . for (onsulmion as

En(OlJl<lge tht to adopt a hti hhy lifestylr oflow--fat food
nffiltd. (Healthy liirstylt (hanges will suppon and thr nffil for drug choic:es, ilKlNStd exm:isr, dt<1l' ,ned akohol roll\Umption, and
thrrapy.) mKlking (essation.
Minimizing adft rst effms:
Continue to monitor blood preslOre lying. sunding to

Teach the patil-nno rise slowlyfrom lying or to sunding to
detect onhostatic hypott nsion. (autious with who i Il' at ilKft'asrd al'Oid dizziness or falls.
riskfor hypotension.(CCBs a ul!' wodilation,ll'sulting in Iowt'rtd blood

InltlU thr patimt to stop taking thr mtdiution ifblood PIl'SSUft' is
pIl'IlUll'.Orthostatic hypotension II\a)' in(lNst thr risk offillsand injury.)
90/60 mmHg or brlow (or according to pal<lrnetm srt bt' thr hulth
aft' and notify pro'Iidtr promptly.
ContinUl' to monitor periodic: rle<:trolytt Int!s.espewlly potmilrn,ECG as

InltlU thr patimt on tht to mum ptliodicallyfor lab work or
appropriatt,and hepatic: and function labl (Hypokalemia II\a)' ilKlNl!' thr
"G<
risk

Advisr the paurnt to any a walitt identifKalion card or Wtir rneGKal
idtntifintion jtwtlry indicating CCB therapy.
Enwll' liIirty, tspttially in tht rldtrty.ObSl'lVl' fordiuiness.Monitor

InltlU thr patirnt to a II for assistalKr prior to getting out of brd or
ambulation until thr elfe<u of thr d rug all' known. (Dillinm from onhosutic: to walk aiont, and to avoid driving or otht r iwities
hypotemion may occur.) ft'quiring altnness or ph)'iiul (oordination until tfir(t1 of
tht drug ill' known.

Wtigh tht daily and weight gain or lOIS of 1 kg or more in i 24

Hm thr patirnt weigh selfdaily, at thr sallll' timt of day, ind
hour ptriod.{Daily weight is i n i(CUratr mti WIl' of fkJid statUI and takes into ft'(oro wtight along with blood pIl'IlUll' ind pulst mtilUft'mt ml .
.K(oum inuu,ou1pUl, and insrnsibit losses.) Hm thr patirnt report 1011 or gain of moll' than 1 kg in a 24-
hour ptriod.
ObsrrYe for paradoxic:al in{ft'aI!' in {Iiest pain or angina

Inluu thr patimt to immrdiately repln (htlt pain or other angiru-
hypotenlion may causr thisand II\a)' indicate blood PIl'SSUft' has dt<rt ised 100 lil<t I)Imptoml, tspttially if symptoml inaeal!'.
quic:kly ortoo sub!canti.lllyJ

for signs of t.I ii.Jft', wch as ling dysPIIN or posrural

Insuu poatientlo immediately repon IhIll"lntIS of
nocturnal dyspnta, rales or "".Kkles"in lungs.or frothy pink-tinged sputum. blNth, frothy sputum, profound fatigUl', or of utll'mities as
((CBlnn declNst myourdi.ll (ontrmility, in(ft'asing tilt riskof htan failull'.) signs ofhtartfailull'.
ObsrrYe for hyperstnsitivity ft'.Ktion, and a ngiotdtma, t lpt(i.l11y of foKial art a.

InltlU thr patimt to immrdiately 5eek mical attention for
diffirulty brtuhing. throat tightnrss, hiYft or rash, IllUlCIt
IIl'mor;.or angiotdema around thr f.Kial alN.
OblfNl.' for constipation.(C(Bs may aUl!' tonstipation due ro decll'ased

InltlU thr patient to ilKft'aI!' Auid i nd fibrr intal<t to f.Kilitatr <tool
peristalsis.) p,llSage.

If (onstipation romidtrtht usrof a stoolsofteneror IaxatiVt
illl'{ommt odtd by thr hu hh nrt providtr.
(Continued)
LibraryPirate
310 UnII 4 Th .. C.rdlaY.<;(ubr.nd Urinary Syuem,
NURSING PROCESS FOCUS PATIENTS RECEIVING CALCIUM CHANNEl BLOCKER THERAPY (ConrtlUroJ
Implementation
Interventi o ns a nd (Rati o nales)
Patimt understanding of drug thuap-,:
Usr opportunities during the administration of mrdiutions and Iliring
to discus, lationale for drug tllrr,p)', dtsill'd outromes,
IIIOiI rommOil advrB!' rlfrru. p,rameters for whrn to (,II health Ill'
,nd any III'U1s.J f'/ monitoring 01 prrautions. (Using timr ckJring nursing mr
helps to optimize and lrinfon:r uy te.Khing
Patimt srlfadministration of drug thr rapy:
When administering the mrdiution, instruct the patirnt a nd/Ol family in proper
(,Ifadmin isnUon of drug. (Propu adminismtion improYes the rfffi:tiYents, of
thedrugJ
Patient a nd Fa mil y Educati on
The ,hould br able 10 51atr the le<J\OO fonhr drug.
appropriate dose, and Ithtduling; wh it adverse tffrru to obmn 101
and when 10 Il'port;and anticipated Irngth of medication theIOpy.
The patirnt ,hould br able 10 dis(\m appropriate dosing and
adminismtion 1Iffik.
Evaluation of Outcome Criteria
Evaluate the oIdrug theilPI' by (onfinning that patirnt goak and rxprdrd 0IJ1IOIIII'I hom mrt (_ Plannin().
5H lUfou IisllidnJlplllwIM:hrhrll rllningaaims GppIy.
illustrated in Figure 23.4. Drugs that affect the RAAS de-
crease blood pressure and increase urine volume. They are
widely used in t he pharmacotherapy of HTN, heart failure,
and MI. Doses for these drugs are listed in Table 23.5
Renin is an enzyme secreted by specialized cells in the kid-
ney when blood pressure falls, or when there is a decrease in
Na+ flowing through the kidney tubules. Once in the blood,
renin converts the inactive liver protein angiotensinogen to
angiotf.'rnin I. When it passes through the lungs, angiotensin I
is converted to angiotensin II, one of the most potent natural
vasoconstrictors known. The enzyme responsible for the fi-
nal step in this system is angiotensin{onn rting rnzymr (ACE). The
intense vasoconstriction of arterioles caused by angiotensin
II raises blooo pressure by increasing peripheral resistance.
Angiotensin II also stimulates the secretion of al oosterone,
a hormone from the adrenal cortex. The primary action of
aldosterone is to increase sooium ion reabsorption in the
kidney. The enhanced sodiwn reabsorption causes the booy
to retain water, increasing blood volume and raising blood
pr ..... " inc,"""",_< hlnncl
through two distinct mechanisms: direct vasoconstriction
and increased water retention.
First detected in the venom of pit vipers in the 1960:s, ACE
inhibitors have been approved for HTN since the 1980:s.
Since then, drugs in this class have become key agent s in the
treatment of HTN. ACE inhibitors block the effects of an-
giotensin II, decreasing blood pressure through two mecha-
nisms: lowering peripheral resistance and decreasing blood
volume. ACE inhibitors enhance the effects of the t hiazide
diuretics; thus, drugs from these two classes are oft ... n used
concurrently in the management of HTN. Some ACE in-
hibitors have become primary drugs for the treatment of
heart failure and myocardial infarction, as discussed in
chapters 24 and 2700, respectively.
AdverSt' effects of ACE inhibitors are usually minor and
include persistent cough and postural hypotension, partic-
ularly following the first few doses of the drug. A persistent,
I"",,,,,sed blood I
p",""re
Increas.&d oodium
reabsorplion
I""'e ...... d blood
pressu,,"
Flgure13.4 The renln- anglotensln- aldosterone pathway
LibraryPirate
0I .. 1I0I2l ON9,lorliype"""1on 3 11
TABLE lJ.S I ACE Inhibitors and Angiotlmsin II RC!cC!ptor BlockC!rs for HypC!rtC!nsion
On"
Route and Adult Dose (max dose where Indicated) Adverse Effects
ACE INHIBITORS
bffiaztplil (loteosin)
uptopril(upo!m)
o ffiilapil (If.HotK)
tosinopri (Mooopril)
PO; 111-40 mg in i 0:IIt or dvidtd Oul (nw:40 mg/day)
PO; 6.15- 15 mg lid (mal: 450 mglday)
I/flllilldlt, dizziIm,
/rtpolt1llkl\.raJli
PO; 540 mg in i or IWO cividtd dwt (mil: 40 mglday)
PO; mg/day (mal:80 mglday)
AIIQionImi
0:IIt phroomenon
(Prinivil,le!torttk, lffirilJ PO; 10 mg/da, (max:8() ffi9/day)
129forth/, Pllllotypl'Drug box OO)
mmipril(Uri'loJI()
ptrinOOpn (Aaon)
quinapril (Aaupril)
l'irripril (AIt"tj
U"indolipril (Malik)
PO; 7.5-30 mgfday (mal:lO mglday)
PO; 4 mg daily (mal: 16 mljiday)
PO; 10-20 mglday (mal:80 mgfday)
PO; 2.5-5 mg/diy (mal:2O mg/day)
PO; 14 mglday (mad mgfday)
ANGIOTENSIN II RECEPTOR BLDCKERS
Undl'Sirtan (Auc.Joo) PO; start il16 mgfday (mal:l2 mglday)
(kI!trn)
irWSirtin (Al'ipro)
PO; 600 mglday Of 400 mg cjd-bid (mal: 800 mgI day)
PO; 150-300 mgfday (max:lOO mgfday)
Ios.Jrtin ((Olia')

PO; 25- 50 mg in i 0:IIt or IWO dvidtd dwt (max: 100 mglday)
PO; 211-40 mglday 'mal: 40 mgfday)
telmiSirtin (Mkartil) PO; 40 mgfday (max:8() ffi9/day)
nlSirtin (Oiovin) PO; 80 mglday imal:l20 ffi9/day)

IIQII6 indci!tt ammon idYmI' lMousidwffilo
dry cough is believed to be caused by accwnulation of
bradykinin, a proinflammatory substance. Hyper kalemia
may occur and can be a major concern for diabetics, those
wilh renal impairment, and patients taking potassiwn-
sparing diuretics. Though rare, the most serious adverse ef-
fect of ACE inhibiton; is the development of angioedema.
Angioedema is swelling aroWld the lips, eyes, throat, and
other body regions. In advanced cases, angioedema may
lead to airway closure, due to the intense swellinp; in the
neck. When it does occur, angioedema most often develops
within hours or days after beginllingACE inhibitor therapy.
Late-onset angioedema has been reported after months and
even years of treatment with these drugs.
A second method of modifying the RAAS is to block the
action of angiotensin II after-it is formed. The angiotensin II
r&eptor blockers (ARBs) block rect'ptors for angiotensin II
in arteriolar smooth muscle and in the adrenal gland, thus
causing blood pressure to fall. Their effects of arteriolar di-
lation and increased sodium excretion by the kidneys are
similar to thoseoftht' ACE inhibitors. Angiotensin II recep-
tor blockers have relatively few side effects, most of which
are related 10 hypotension. Unlike the ACE inhibitors, they
do not cause cough, and angioedema is even more rare with
the ARBs. Drugs in this class are usually combined with
drugs from other classes in the management of HTN.
A third method of blocking the RAS is to block recepton;
for aldosterone. The two drugs available that block these re-
ceptors in the kidney are spironolactone (Aldactone) and
eplerenone (Inspra). By preventing aldosterone from reach-
ing its receptors in the kidneys, less sodiwn is reabsorbed
and blood pressure falls. These drugs are approved to treat
HfN, heart failure, edt'ma, and to reduce morbidity and
mortality associated with post-MI in patients with lcit ven-
tricular dysfunction.
T REATING THE DIVERSE PATIENT
Management of Hypertension
in African Americans
incidfnct of 11TH is lignifiuntl)' higher in AfrKan Americam than i1 OIl1fr tth-
nit grtt.pS. As expKted from this high imnet, Nri:in Amtrium operiera
grHltI" ufget-Of9iIn damage than other populations. In in effort to the
high morbidity ind mortiIity, i991NM- thmp)o rna)' be IIf(e5-
Sir)' iDOrKOIIII' r!Si!tant H1N i1 AfrKan Amtriuns.
Studits h.M SuggestN thilt [Main drug dillts are 1m
tffIoctiYe in Afric.i n For 6IImpit monotheriPY with ACE inh ibiton,
II f"r(tptor bIocktrs Of bm-adrtnergit inligoni!ll dots Mtl!-
duct blood prt'Iwrt islllKh in African [Omp.lrN to otlier ethnic
groups. physiciim f"r(ommeod initiatingthffilpy with two drugs to
wre i!lequatt on dinicaltrials in African FDA-
BiOi!. i fillfd--doSl' [Ombinition of isosorbide dinitrm ind
hydrilazine thit ippHri 10 be p.lrtKularf)o at lowering blood pressure
in this population.
LibraryPirate
31 2 UnII 4 Th"C.rdloY.<;(ubr.oo Urinary Syuem,
.... Prototype Drug I Enalapril (Vasotec)
Therapeutic (lass: Drug for hypertension and heart failuR' Pharmacologic (lass: ACE inhibitor
ACTIONS AND USES
Enalapril isoll!' of tilt mon pR'SuibN ACE inhibitors for
yptopril (C.POIM), tilt first ACE inhibitor to be malketed, malapril pro-
longed h. Iflife, which jltnnits oJdminisuation orut 01 !wict is 'Yolilable
as Dr.II tabltu IV injection. acts by II
and aldosteroll!' 10 prodK. a ,ignili<ant R'dlKtion in blood prfUUrewith
frw miol/! ,dv' rsI' may betMd ar monothmp)'01 in {ombi-
nation with otht r ntih)"ptl\ensil'tS. Va5effiK is a (ombin. tion of
t ulapril and
ADMINISTRATION ALERTS
M. y product . first-doll' phenolllfllOn r=king in profound hypott nsion,
which mjY rtluk in !)'OCGpe.
Do if tht patient is prtgnantlht drug is pRgnalK)' mt-
goryD.
PHARMACOKINETICS
il"lset: I h PO; 15 min IV
J1ejk: 4-8hPO;4hlV

DUlation: 12- 24 h PO; 4 h IV
ADVERSE EFFECTS
diJretKs, ACE inhibitors wch <II fnalapril havt little tlFta on . IKIrolytt
b.lalK. but may (')u1I' hyptibltmia. btu--adrentrgic blockers, tht ACE
ilhibitors (.I1JIt few o:ardiic advmt clItcts. En.lapril ma, ratJll' orthostatic h,-
pension when tho! mows quickly fmm a supine to an upright position.
A r. pid fall in blood pit!MIre may o(Qn bllowing the first dos . Otlltl oJdY!'rsuf-
fem ildudt lIt. dirhe and dizziness. ACE inhibitors yn (.lUll' lift-lhll'aitlling
,mljotdtma, lI!'utropl'nia, or agla nuloqtoVs.
(ontrai nd irations: Ena Ia pril is {ontr. indicat.d in p.titnts with pOol hyptrsen-
and 5houid not bt <l dminislm<1 during pregnancy olla.:tuion.
INTERACTIONS
I)ug- l)ug: M-.n gWfn {Ofl(uJfill!ly,oIIwr
with fllilapri l on blood prI"I ...... Thiazidf diulMiG ilKlMf loss.
PomsUn or poIiI\sillll-spaOlIg dUtOO OOMl' Ihf riIlr:of
h)"p1::aIfnN. fnalapril rna, indua liIIIi..m tOIUy by rfduOlIg d&Jraooo of
litlium. HSAID'i rna, rPdua 1hI' h)1Hlle:rSivt jjon of N:E inhibiun.
Lab Tem: May iKJ&N vakIe5 of Ihf 8U Ii, ,lkaIinf phosphalillf, !enim
polill'>ilm, IfIIIm (JNlilinf, AlI,D1 AST; rna, IOlII\f I poIitMo MA tiler.
HerbaVFoIXI: lklknown
Treatment of O"ft' rdose: Tht roostliktly ,ign of OYI'Jdowge is hypot. nsion,
whidl may be treated with . n IV infusion of norm,1 salint IOknion.
Rtflr 10 MyMnIngD fur tmIrtIJ /'ro(e\J Foots sp/tt 10 1M <tIJg.
NURSING PROCESS FOCUS PATIENTS RECEIVING ANGIOTENSIN-CONVERTING ENlYME (ACE) INHIBITOR
AND ANGIOTENSIN RECEPTOR BLOCKER (ARB) THERAPY
Assessment
Bistline asselSm.nt prior to administration:
Understand the re. lOn !he drug his been PlfI(ribN in ordtr to asst"lS for
thtrapMic: tfftcts.
Obt.in a (omplete lItakh hino" ilKluding {Irdia<u(ular (including he. n
failurt ), dia btt. s, rtnal dill'all', and the possibility of pregnillK)'. Obt. in a drug
histor, ilKk.oding .11e"lies,cuJTtM prel(ription ilnd OK drugr,htrbal
prepilatioJl!,.nd akollal ulI'.8. <l ltn to possiblt drug int. ractions.
E-I.1uatt .pprop nate laboratory findings, M Uo1)'1t!, t"lpt(ially potmiJm
li .. r fun<lion l1udies,. nd lipid
Obt. in viulligns BP and pulse),brfillh sounds,ilnd
{Irdia.: monitoring (t.g. ECG,Yrdia( OUIput) if appropriate.AsII'II for the
location and (har-1C1er l.mooM of edem<l, if plI'II' nt
Assessment thro ughout administration:
AsItiS for drsirtd therapnrtic .fftm !e.g.,IowtR'd blood prtSlUrt within
tltablilhtd limits).
CominUf ptriodic roonitoring of MUoiytt!, fl pt(ially potassium.
Aslt!! fol tfftm: htldllllt, rough,orthosutk hypott nsion, fatigut or
wt.kntl5, 1)'111 ptom, of hyperkalemia, or II'IW I dysfunnion.
Angioedema,1lI rtir:ularly involving tilt filial <l IN, should be rep:lned
immediillt'ly to tilt h.3kh {Ire prwider.
Potential Nursing Diagnoses
Dtcre. sed Cardiad\Jtput (distill. proctll)
AhtR'd Tissut Ptrlusion (reLat.d to Idvtrse efftcts of drug thtr. py)
Auiity Intoleranct (reIat.d to .dv. rse elF1I of drug ther.py)
Saual Dysfunction (related 10 ildvtrse tlFem ofdrug thtr.py)
DeIKitm Knowltdgt (drug therilPY)
Risk lor f.11s, Risk for Injury (relaltd to hypol'JI!ion, diuiJltll
associated with oJdY!'rst tffm)
Risk lor Imbal.inced Nutrition, More than Body Requiremenll

LibraryPirate
0I .. 1I0I2l ON9'/orliype"""1on 3 13
NURSING PROCESS FOCUS PATIENTS RECEIVING ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITOR
AND ANGIOTENSIN RECEPTOR BLOCKER (ARB) THERAPY (CoIIrJnued)
PliInning: Patient Goal s and Expected Outcomes
p,titnt will:
Exptritnl:t tlltrlpMic: efferu k g.demalfd blood presSUII' to t sublished
Be from, or uPfritrn idww
,n undeBlanding olthtdrug's U1t"lt/efll' fIj.ts, and II'lJIill'd prruutions.
Demonsu,tr proptr of!ht medication (t.g.,dose, timing. to notify providtr).
Implementation
Interventi ons and (Rati onales)
Ensuring effects:
ContinUl' nqUl' nt aSSffitnents as d!<l(ribed Nrlitr for !htra pwtic: efflS.
(Blood plt'lSUII' and should bewithin oolTllilllimil5 orwithin j)ar;lmtltB
ill by lItakh (II!' providtt)
E O(oorlogt ,ppropriate lifrstylt [han91's. Prol'idt for dittitian (onsulmion "
(Healthy lifrstylt m,n9l's willsuppon and minimizt the nffil for drug
thtrapy.J
Minimizing adft rse effKls:
ContinUl' to monitor vitalsigndake blood plt'lsure lying. ytting,and sl,nding
to dHe<t onhost,tic: hypottnsion. Be j)i nirula rly [,utious with the first frw
doses i nd with eldtrly who,ll' it risk for hypottMion.(MEIS i nd
ARBsuust modilation, resulting in IaMII'<I blood pressulI'.A signifium drop
in BP lNy oc:rur with the firstfew dom.Orthostatic hypotension IN)' inUNSt
tilt risk offalls and injJry.)
ContinUl' to monitor periodic: Mtrolyte Int is, r-IPfcial1y potassllrn, hepatic:
and lI'Ilallunction and KG" appropriatt.IHyptrblemii lNy
tilt risk of dysrh)<thmias.)
Ensull' j)ititnt in the tldtrly.ObSffit for light-htadedness or
diuiness.Monitor ambulalion until effl'[\lof drug arr from
onhosmic: ilypDtension may oc:rur.)
Monitorfor ptBistent dry COll9h or [OII9h seYI'rity.1A change in tht
It"I'l'rity of the cough may indicate anotiltr dMilt pI"O(eS or lNy resuk in the
nttd to [OMKk. druc;r. from otlltr d ..... J
Monitor for h1Jlel"kalemia. (RtdlKtd aidoltt'lOnt lewis lNy W ilt
hyptrblemii,epffially in j)itients with diabetes or impaired kidney 1u00tion.)
Patient and Famil y Educati on
TNC:h tilt p,tient, f,mily,orc.JII'9Wer how to monitor blood
pr6lU1l'. E nsUII' ptOPfr a nd 1u00tion ing of any home
obt,inN.
Enc:ourage the patient to adopt i lItakhy lifestyle oflow-f,t food
[hom, inc:lI'iitd dwt'iItd ikohol [onsumplion,and
smoking
Instruct the j)ititnt to take the fiBt doseof the new pr!'l(ription !.tfoll'
bedtime,nd to USt mnion during the II!'J:I few doses until drug
tfffds all' known.
Ttac:h !ht patitm to riSt slowly from lying or sitting 10 standing to
avoid diuinrss or falls.
Instruct the j)ititnt to stop taking the medication if blood prl'SSUII' is
90160 mmHg or bt<Iow,or It! by heakh Ull'
oolily the plVt'idrr promptly.
Instruct the j)ititm on the nted to II'tum for lab work.
tht j)ititnt to carT)' i w,lttl idrntifKoltion md or WNr mtdica l
identifiution jewtolry indicating MEl! ARB ther,py.
Instruct the j)ititm to ull for assistancr prior togetting out ofbed or
attempting to walk alone,ind to avoid driving or other ac:til'itits
II'qJiring mtmal alertness or physic:,1 coordination
tht drug all' known.
lilt patitm to anticij)itea dry COll9h that may ptBist Ind to lISt
oonpharmmliogic: measult'llo OTC COll9h lozenge; or hird
in"".>td Auid
Instruct the j)ititm that iftlte(OII9h btc:omes troublesomt whrn in
supint position, sleep with tht head on additiOllilI pillows.
Advist the j)ititnt to (onsult with the health urI' plOl'ider about the
lISt of antihistamifll'S to prnistent (ough unll'litl'td by
oonpharmmilogi4: measul!"S.
Inl1ruct the j)ititm to report promptly any d\angt in the severity or
fll'qUI'IKY of alIJ9h. ArT; (ough oKrompanied by shonness ofbll'ith,
ltYer,or dltst j)iin should be immediately.
Instruct the j)ititm on the sigMof hyperulemia (nau .. a, illl'9ular
profound mw orfaint
and to II'pon them
!ht patitm to avoid sak subsiilU!!1 [onuining potassium
[hloride (1((0, (onsuming snadn advt nMct is "I' learolytt-fonifltd,
sptcializtd spons drinln thit (onuin highftls of potauium,or
inue offoods high in potmllm difll'll'm from their normal
d"-
(LOnrlnued)
LibraryPirate
314 UnII4 TheC.,dlOYOiscuIOl' 0100 Urinary Systeml
NURSING PROCESS FOCUS PATIENTS RECEIVING ANGIOTENSIN-CONVERTING ENlYME (ACE) INHIBITOR
AND ANGIOTENSIN RECEPTOR BLOCKER (ARB) THERAPY (ConftluOO)
Impl .. momt"tion
Interwntions and (Rationales)
Patimt U.claltancling of dn!g
1M000ponuniOeduring ldminiltl1tion of nwdiuIions Ind during
to dftM! 1M fordfUg t/wfapMic
cMtOJllft, IIIO!it {OI!\IlDJ1 tfftm, IWMnttefS forw/wft to uII 1M
hNlth Il'IJ ne!Wj' m<IIIitomg or 1ft
cbing Ilning help! to optimizt. ind!einbtt IIOOmg arm.)
Patimt iflf-ldmi niltllltion of dill, tlltr.,:
WlIm IdminiRerinq 1M mtdiutiofl, imtnICC the Inclfor IoImiy"
proptI ItI-.dministmiorJ of drug.e.9." the &-it cIIM oftlw_
pmuiption It Hdtime. {P.r IClministrmon tMfffn-sof
""ruoJ
Patient and Family Eduution
Thr p.nimt shedd _ for drug,
dost,lOd Kheduling;whar.drrme toobsfflt for to
Ind 1M 'nOOpaled IrngttI 01
Thr pUnt shouid Iblt 10 diKv!uppnlpriltt domg iJld
idminiw.uiln nMI.
Evaluation of Outcome Criteril
b.lu.netile oIdlll!l the!ilPY by COI'Ifirming mil P'litflt goak .nd outOOme! h.m: (1ft'I'limning1.
StIr TalW liS /IHWr*AlJInNbi/ln'. dst of drogs 10 v.Ijdt /IIf$t fIri"i Dim IfP):
23.10 Treating Hypertension
with Adrenergic Antagonists
The adrenergic receptor has been a site of pharmacologicac-
tion in the treatment ofHTN since the first such drugs were
developed for this disorder in the 19505. Blockade of adren-
ergic receptors results in a number of therapeutic effects on
the heart and vessels, and theseaUionomic drugs are used for
a wide variety of cardiovascular disorders- Table 2l.6 Iists the
adrmergic antagonists used for hypertension.
Mdiscus5ed inch.apter 1)00, the autonomil; nervOUS!'5-
tern controls involuntary functions of the body such as heart
rate, pupil size. and smooth muscle contraction, including
that in the bronchi and arterial walls. Stimulation sym-
p.atheticdivision causes figh t-Of-flight respoOSoe$such as faster
heart rate, an increase in blood pressure. and brOl1(hodibtion.
Antihypertensive drugs have been developed that bind.
the sympathetic fi ght-or-llight response through a number
of distinct mechanisms, although aU have in rommon the
effect of lowering blood pressure. These me<:hanisms in-
clude the following:
Blockade ofbeta,-adrenergic receptors in the heart
Blockade of alpha,-adrenergic receptors in the anerioles
Nonselective blockade of both alpha ,- and bet a_
adrenergic receptors
Stimulation of alphal-receptors in the brainstem
(centrally acting)
Blockade of peripheral adrenergic neurons
BETA-ADRENERGIC BLOCKERS
Of the subclasses of adrenergic antagonists, only the beta-
adrenergic blockers are considered first-line drugs for the
pharmacotherapy ofHTN. By decreasing the heart rate and
cont ractility, they reduce cardiac output and lower systemic
blood pressure. Some of their antihypertensive effect is also
caused by blockade of beta,-re<:eptors in the juxtaglomeru-
lar apparatw, which inhibits the secretion of renin and the
fo rmation of angiotensin II.
Beta blockers have other important therapeutic
applicatioru. By decreasing the cardiac woridoad, beta
blockerscanease the symptoms ofangioo pectoris. Syslow-
ing conduction through the myocardium. belli blockers are
able to treat certain types of d)"Srhythmias. Other therapeu-
tic uses include the treatment 0{ heart failure, myocardial
infarction, and migraines. Prototypes ofbet;l-adrenergic an-
ugonists can be found for metoprolol ( Lopressor. Toprol) in
chapter 2400, atenolol (fenormi n) in chapler 2500, pro-
pranolol ( Inderal ) in chapter 2600, and timolol (Timoptic)
in chapler 4900.
The adverse effects of beta blockers are predictable based
on their inhibition of the fight-or-l1ight response. At low
doses, the beta blockers are well tolerated. and serious ad-
"""'" Ihl':
beta blockers will slow the heart rate and cause bron-
choconstriction; therefore, they should be used with cau_
tion in patients with asthma or heart failure. Many patients
report fatigue activity intolerance at higher doses, be.
cause the reduction in heart rate c3uses the heart to become
less responsive to exertion. Less common, though some-
times a major cause of is the effect of beta
blockers on male sexual function. These agents can cause
decreased libido and erectile dysfunction ( impotence). Be-
cause abrupt cessation of belli-blocker therapy can result in
rebound HTN, angioo, and MI , drug doses should be ta_
pered over several weeks.
LibraryPirate
01",1<,21 ON9' lor Hyperten,"'" 315
TABLE 23.6 Adrenergic Antagonists for Hypertension
Drug Route and Adult Dose (mall dose where Indicated) AdveIW Effects
BETA-ADRENERGIC ANTAGONISTS
oKrilnoioi (SffirJI)
ater.o(,j 347
for tilt Prototypl' Drug box 00)
(KrrIonr)
biIoproIoI(abm)
lMIoproIoI (lqlrffior, ToproI)
oadolol (CDI'}Ird)
piIdoIoI(Virun)
PO;400-800 mglday (mn: 1200 mglday)
PO; 25-5& mglday (mil: 100 mglday)
PO; mgiday (max: 40
po; 25-5 mglday (mn:20 mglday)
po; 100 m9lday-bid (max: 450 mglday)
PO;40 mgJday (max:l2O mg/day)
PO; 5 mg tid (mal:60 "'9Iday)
Folique, imcrn/1i4 dlWl'inru. impoufJCt Of dtcmJJtd
ibido. brl!ll)wdio. 000 rrduJioo
AIJanlAoc)Wil la(ynomasm,S!fflM Jo!mon
drug ab!wt1Y
withdrawn papitations rW:iund hywn:nsioo.
d'Orbythmjal MI
propranolol 3M
lor thr Drug box 00)
(Timoplk) 771
lout... Prototypr Drug box 00)
PO; mg tid or daily (max:320 mglday) IV;05-l0 mg
t'/tIl4 hoII'5 PRH
po; 10 mg tid (mal:60 "'9Iday)
ALPHA,-ADRENERGtC ANTAGONISTS
Q rIoxal!Jlin (Cilldura) po; 1 mg at to 16mg/day ina Ii. M or
two divided 11016 (max: 16 "'9Iday)
OrlhoJ!QIK hYPoumion,dlzjnru.1wd1rf, tQ/iglJt
Firg-9ose Dhroomenort@drKiJrdia,!IystioN
pral!Jlin (MiniprtSs) 137
for tt... Prototypl' Drug box 00)
teruolin (llytrin)
PO; 1 mg It btdtimr;may to lmg bid- tid (max:lO
mglday)
PO; 1 mg it btdtimr;may 1- 5 mglday (max:lO mglday)
ALPHA,-ADRENERGIC AGONISTS (CENTRA LLY ACTING)
donidor (Uiaprl'sJ
(AIdorntI:)
ALPHA, - ANO BETA BLOCKERS
(COII'g)
(tIormodynt,
PO;O.1 mg bid- tid (mal:O.8I119iday)
PO; 250 mg tid [f tid (max:lglday)
PO;3.m mg bid (rna1:50 "'9Iday)
PO; 100 mg tid (max: 1200-1400 mg/day)
ADRENERGIC NEURON BLOCKERS (PERIPHERALLY ACTING)
edema, JedoriM, depmlkt\. htodtxht, tty
mroill. dtclfQJed lbii/o
Hepa, otoxidly, hrn!oIy!k iIOmlia (jIanulomoprnia
HtfldodIt,dnlWlirltlJ,Dt/y,dfprruioo,kf""gy,
impoltOO!
Bm!Ymdia may WOlin! hNn jJ)d mall!;
I)IlW!pIDI of hypoglyumy
I PO;15mgdaityi .. tialty:mayrtdxuoO.l -(llSmglda, I
ALPHA, -ADRENERGIC BLOCKERS
The alpha,-adrenergic antagonists lower blood pressure di-
rectly by blocking sympathetic receptors in arterioles, caus-
ing the vessels to dilate. The alpha blockers are not first-line
drugs for HTN because long-ttrm clinical trials have shown
them to be less effective at reducing the incidence of serious
cardiovascular tvtnts than diurtties. \'/hen used to treat
HTN, the alpha blockers are usually used concurrently with
other classes of antihypertensives, such as the diuretics.
Doxazosin (Cardura) is a prototype antihypertensive in-
cluded in this chapter. Other prototypes for alpha blockers
in this textbook include prawsin (Minipress) in chapter
l JOlO, and tamsulosin (RontaX) in 'hapter 4600.
The alpha,-adrenergic blockers tend to cause orthostatic
hypotension when a person moves quickly from a supine to
an upright position. Dizziness, nausea, nervousness,and fa-
tigue art also common.
ALPHAl -ADRENERGIC AGONISTS
The aJph<ll-adrenergic agonisf5 de<:rtase the outflow of
sympathetic nerve impulses from the CNS to the heart
and arttrioles. In effe<:t, this produces the same responses
as inhibition of the alpha, receptor: slowing of the heart
ratt and conduction wlocity, and dilation of the arteri-
oles. The alpha, agonists cause sedation, dizziness, and
other CNS effects. Abnormalities in sexual function may
LibraryPirate
31 6 UnII 4 'It" C.,dkIY.",ub, .nd U,'nary Syne<m
.... Prototype Drug I DoxazOSIn (Cardura)
Therapeutic (lass: Drug for hypertension and BPH Pharmacologit (lass: Alpha,-adrenergic blocker
ACTIONS AND USES
is a alpha,-adreotl'lK blocker aY.ilabl!- only as t. blell.Be--
causr it is for bIoc:king alph. , recepton in mcul.r \fllooth mUldr, it
has trw on other .utonomic 0lll.ns and is prefrmd over non-
beta blockeB. ilouzosin dilate .r\l1firs and tins ,lIld is c.l"bl!- of
c. using 01 rapid, profound 10111 in blood pr6!Ure. DOXil zosin and It"Vl'r.l othn
bIoc:keB also relax smooth mu scI!- 01 round the prostatr gland.
Patitnts who hoi\!' benign prostatic hyprrplaliol (BPH) wmetirnrs this
drug to relieYr S)'"ll ptom s of dysuriol (chapter 4600 ).
ADMINISTRATION ALERTS
Monitor for profound hypottnsion and pcmibl!- syneopr
following thefiBt frw d=s bfcalM this drug may produc:ta first.oose
phtnomr non.
The fiBt-dosephenomenon can fI'Our whtn the medication is resumed
after 01 pr-riod iwithdrawal and with dosagr incre.m.
Swallow (aflilra XL wool!-:Do not cMh,chrw,or split the tablet.
Prf9nancycategory 8
PHARMACOKINETICS
ll1 .... t Jh


Duration: 14 h
]
ADVERSE EFFECTS
On staning douzosin therapy. some I"titnts tlprrierKe It"fious orthostatic hy-
potension, .khough tolerancr often deeIops to this side rffert after a trw
dom. Dizzinrss and hradachr are also rommon adl'!' lW rfi"Kt5,although they
.re stYere enoogh to disrontinuation of thmpy.
Contraindications: Douzosin is conmindicated in I"tients with prior h)optr-
=sitivity to alpha bIoc:keB.
INTERACTIONS
J)ug- J)ug: WIIPn givfn COll(Ull!llily, othfr .nlil)"pfnfnlim M<f adJitiH rtffCtS
with doxarosil on blood JII'SIUrI'. Oral ciMliIint m.ly GlUIoI' mild mIN51' (lO'l6j in
tht half-life ofdoxazolil.
Lab Tests: lklkoown
IlerbaVFood: lklknown
Treatment of OverdOSf: Thr most li kt/v sign of 0I'!'rd0sagr h)opotrnsion,
which is treated with 01 v.soprl'swr andfor IV infusion
Rtftr 111 MyMnmgn a MnInIJ /'reII fooIl sp1/t 1II1M <trJg
NURSING PROCESS FOCUS PATIENTS RECEIVING ADRENERGIC-ANTAGONIST THERAPY
Assessment
Bastline ISHss ment prior to administ ration:
Undmtand thereolson the drug has bren Prl'!cribed in ordtr to for
therapeutic rifrcb.
Obt.in a (ompletr heakh history ineluding cardmalCular (including MI, hun
failufl'j,musruloskeletal (pre-rmting ronditions that might r6Uk in f. tigU!',
Wl'iknffi, IlI/ICI!- or jointl"inj,and the ponibilil)' of pregn.ncy.Obtain 01 drug
histor, ineiudinj .lIelllies,cufTl'm pR'I(ription.nd OTC drugs,herb.J1
ard akohol UII'.8t oIlrn to pcmiblr drug imrractions.
E"liluatr appropriate laboritory findings, electrolytt-!, potmilm 1M,
gUcosr,hrl"tic and It'IIiII function lIudie, .nd lipid profile.
Obtiin vitll signs BP and pukel, brllllh sound!,and
<llIlil< monitOling ( . g. [CG,<lIrdil<outputj ij IPPropriat . ,..", .. for the
location and chuac\l1f{.moum of edemol, if prmnt
Assessment thRl ughout administrat ion:
As\o!"l5 for desirrd therapeutic effrclS (e.g., Iowrred blood within
limts).
CominU!' and <afl'ful monitoring ofvital signl,liaily wrighl,.nd urinary
and cardiolc output .1 appropnatr, eJlf<ioI ll)' if IV is used.
CominU!' prriocfK monitoring of electro/ytt-!,tlJIf<ioIll)' potassium.
As\o!"l5 for and promptl)' repon adl'!' M rffrcts:bradjUrdiol, hypotension,
dysrhythmioll, rtflu tachycardia, dizzinrs s, hudac:he, or drcfl'.sed uriniry
output. Sr'/ffI' hypotension, dysrhythm ioI s1l"lpitationl may indicate
drug IOJKity oIn:1should be rr poned.
Pot ential Nursing Diagnoses
Drcfl'ase<i Cardiol< Output pfO(ffi)
FatigU!' (rI'lated to adYern rffrmof drug thrrapy)
Akered TISWI' Prrfusion (fI'lated to therapy)
Activity Intolrrolner (related to drug ther.py)
Sexual Ovslunetion (reIatrd to eifeds of drug thnpy)
Dfficitnt Knowledgt (drug therapy)
Rilir. for Follis, Rilk for Injury (related to
.Hsociolted with rffecll)
LibraryPirate
0I .. 1I0I2l ON9,/orliype"en,1on 3 17
NURSING PROCESS FOCUS PATIENTS RECEIVING ADRENERGIC-ANTAGONIST THERAPY (Contlnuw)
Planning: Pati e nt Goals and Expected Outcomes
Ihr wiH:
UprrirlKf thrrapeutic: efferu drprndrnt on thr rralOn thf drug is being giYfn (f.g.,drut'alf<i blood presSUIl').
from, or rxperirlKr idVfB!' flferu.
an olthrdrug's ust, art;fB!' flfb, and r?qJill'd pll'CilutioM.
Oemonmatf proper of the mediation kg.,dost, timing, whtn to notif,o providrr).
Impl ementati on
Interventi ons and (Rati onales) Pati ent and Family Educati on
Ensuring therilpeutic effects:
ContinUl' ImjUl'm aSlffiments as drsc:ribed fur thera ptUtic: efferu. Oil TroKh thr or calt'9il'l how to monitor pulsf ilnd blood
wt-ights should remain at or {lost to wt-ight.(Pulst, blood prtssure,and pres sure as appropriate. Ensure proper ust and functioning of any
respiratory r<llr should be within oormallimits or within parameters IfI u,. thr hoIIII' equipmrm obtaintd.
hNlth carf providrr.An ilKlNse in 0'IeI" 1 kg (approximately 21b) perday

Hlftlhr wt-igh along with blood presSUIl' and
may indiulf fluid giin.)
Rrpon i WE'ight gain or loss of 10011' than 1 kg in a 24-
hour period.

[lKourol9f appropriate liflostylt changes. Providt for (onsulmion "

[mourage thf a huhhy lifestylt of low-fat food
ntfdtd. (Healthy liflostylt (hanges willsuppon and minimill' lhr ntfd for drug {hoic:ts, lI'du{t{[ wdium inrakt, ilKreasfd mrtM, deerei ltd akohol
therapy.Adrentn;lic: bIocken deell'ilSf hun ratr and m.ly Itild to rlt'KM {onsumption, and smoking (Nation.
i"tok-r"Kt.A<.uvity "'",uld t.. very 9,dIlUdU,.)
Caution tilt j)iltitnt about sudden ilKrulfI in oKtiYit)' 1twI. i!epon
diuinl'lI, j)illpitations,or shonnfSs ofbrfath that whilt
fllmising.
Minimizing adft lSe effKts:
ContinUl' to monitor vital signs.Takt blood pressure lying, sining, and standing to TN<h tilt patient to 1M sIowlyfrom to or standing to
de\e(t orthostatic: hypotf nsion. cautious with i reat ilKreastd awid dizzilil'Siorfal1s.
risk fur hypotension. Notify thf hralth care providtr if blood prt"!!lI1I' or pullf
In llnKt thr patitnt to stop taking mtdic:ation if blood JmIUII' is
deell'all' beyond tstablished parallll'tl'ls or if hypotf nsion i Il({omj)il nitd by
90160 mmHg or below,or per j)ilramflr r; SfI by thr huhh call'
rffirx udJ)'Urdia. (Adrenergic: antagon illS decll'all' hrart rate and (lust
PlWidtr, and notify pJOl'ider.
modilation, rfSulting in IoWl'II'd blood prNUII'. Onhostatic: hypotension may
in{rust thr risk offalls or injury. RrIIex um)'Cardill mil Y lignal that thr blood
presSUII' has dropper! too quic:kij orloo sulnlilntiilly.)
ContinUl' {Irdg{ monitoring kg., [(G) for dysrlrythmias in till- InllnKt the patient to report j)illpitationS,mfSt pain,or d)'lprlfil
hospitalized patitnt. (Extecllill monitoring dtvic:H will deteo: early lign s of immtdgteiy.
adY!'B!' ffferu as Wl'1I" roonitoring for theraptUtK rfflomJ
To allay poniblt anxit ty, teach thr thr rationalt for all
rquipment ulf<i and tflf IIffiI for irtqurm monitoring.
Wfigh thr j)iltitnt and II'pJn weicjht gain or loss 011 kg or mort' in i 24-

Hift thr weicjh cbily, at thr >IIIII' tillll' ofday, i nd
hour prriod.(Daily weiCjht is il{QJrate lIII'ilSUII' of lkJid SlaM and takes into 1I'(0rd Wl'ight along with blood pressurr and pullf mNSUlI'lIII'nts.
I((ount inukt,output.and illlfllsibil' 1015f1.) Hift thr II'port a giin or Ion of moll' than 1 kg in a 24-
hour period.
Give thr first dose oftill' drug at bedtimE'. Obserie for excffiive drowsiness.(A

InslnKt the patil>nt to take the fir;t dose of medic:ation at bedtime
fir;t-doll' II'sponSf IIIiI)' rf"IUk in greater initial drop in BP than subsequent to awid driYing or other haurdous oKti'litiH for 12 to 24 hour; after
dosts. Some adrenf rgic: blor:ken may (lust lignifiunt drowsilll'Ss and are ulf<i thr fir;t doll', or wlll-n till- dosage is ilKlI'altd,umil efferu of the drug
uutiously in the who arr at risk furfalls.) ilre known.
ContinUl' to monitor blood g1ucOlf and approprine lab 'Mlrl (AdR'nI'''l ic:- TN<h diabttic: to monitor blood WCj<Ir IOOre freqUl'mly and to
blocking drugs may intfriere with sOlllr 0IiI1 dgbftK drugs or{harqe thr way iI be i Wall' of subtlt ligns of hypoejl)'<emg (f.g.,nfl'/OUInI'lI,
h)'p09l){tmic: lI'oKtion is peltfiYfd) on oral antidiibttic: drugs should promptly II'pJn
any (onsistrnt (hangtl in thrir blood sugar It-tcls to thr hrakh (III'
PlWidtr.
Assess thr patient's mfOtal SUM ind mood. (Adll'lll'lllic: blocker; m.ly UUII' Too the j)iltifOt to report ulI/SUil fffiings of >ldlll'l5,despondfllC):
. ) ipatiry, or drpression.
(Conr/ooefi)
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"


t

31 8 UnII4 'It" C.,dkIY.",ub, . nd U,'nary Syne<m
NURSING PROCESS FOCUS PATIENTS RECEIVING ADRENERGIC-ANTAGONI ST THERAPY (Connnued)
Implementation
Interventi ons and (Rati onales)
Provide IoH'yl'{omiort wch on an righted room.(AdrentI1jK-
blocking drugs yn (,JUS!' and dilfKull)' Iffing in low light
00 not .bruptly dil<onlinut tht mtdiution. (Rtboond irypmrnlion a nd
tao:iryurdia may O(wr.)
Patilflt undtlltimding of drug thrrap-,:
Ulr opportunities during of mediYtions and during asmlments
to discuss ratior alt for d rug thmp)', dtsired thtrapMK outtomes, most
rommoo pa"mmrs lor to ull tht hl-akh (alt'
and any 1H'(!"I\,Iry monitoring or preuutions.(Using timr oiJring nursing Ull'
hl-ipi to and rrinfon:r uy te.Khing
Patilflt stlfadminist rati on of drug therapy:
When mtdKations,inl1l1K1 patirnt and/or family in proper self-
administration improl'!"l tht of
thl-drugJ
Patient and Family Educati on
Caution thl- about driving 01 otht r .[tivities in 1o ..... light
{onditions 01 at night until thl- t flem ofthl- drug are mOONo.
Tt"h tht family,or not to Slop mtdKation abruptly
and 10 call thl- {alt' PlOllidef if paOr-n1 unable to t1u thl-
mrdiYtion for molt' than 1 d.y dJr to illness.
patient should able to stalt thr INion 10, thr drug;appropriatr
\(hrdJling;what.dm-st to for.nd whr-nlo
It'porr; equipment ntfdtd as appropriatr and how to usethat
equipmt nl;and thl-lt'qJilt'd Itngth of mtdication nffiltd
with. ny spl'<ial instllKtion s regarding lI'IIfWing or (ootiluing
prescription al a
InstnKt p.titnt in proper IoIIoW!'d u,.
It'Ium-dtmonstr.tion.
Thr patient should able appropriate dosing .nd
administration 1H'eds.
Evaluation of Outcome Criteria
Evaluate thl- ofdrug thl-rap)' by {onfirming that patient goals.nd OIJ\(OIll!"l (Iff "Planning; .
Sn T!It Ii5lddrII!P /IIwNchrhN
occur. Less common, though potentially severe, adverse
effects include hemolytic anemia . leukopenia, thrombocy-
topenia,and lupus. With the exception of methyldopa (A1-
domet), which is sometimes a preferred agent for treating
HTN occurring during pregnancy, these drugs are rarely
prescribed.
ADRENERGIC NEURON BLOCKERS
The earliest drugs for HTN were nonselective agents that
blocked nerve transmission at the ganglia or at both alpha-
and beta-adrenergic receptors. Although these nonselective
agents revolutionized the treatment of HTN, they produced
significant adwrse effects. The only drug remaining in this
class is I"e"'rpio", which is. rar"ly used today.
23.11 Treating Hypertension
with Direct Vasodilators
Many of the antihypertensive classes discussed thus far
lower blood pressure through indirect means by affecting
enzymes (ACE inhibitors), autonomic nerves (alpha and
beta blockers), or fluid volume (diuretics). It would seem
that a more efficient way to reduce blood pressure would be
to cause a direct relaxation of vascular smooth muscle. In-
deed, drugs that directly affect vascular smooth muscle are
highly effective at lowering blood pressure but they produce
too many adverse effects to be drugs of first ,hoice. These
drugs are listed in Table 23.7.
TABLE D. 71 Direct-Acting Vasodilators for Hypertensi on
Dru,
Q hyoi"aluilH'
minoxidi
nitroprussidr (Nitropresj
Routeand Adult Dose (max dost'where Injlcated)
PO; 10-50 mg qid (max:300 mglday)
I
PO;S--40 mg/day [max: 100 I1191'd.y)
IY;OJ-{I.S m(glkglmin
Adverst' Effects
hypoleruion, nlJid fIIlmlion, htododIf,
IUDII" " If1joo !jMJ9!azilrJ IfWl' bypotrolj:m MI

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DN!lSfOf liyplftenslon 319
..
Prototype Drug I Hydralazme (Apreso/me)
Thnapeuti( (lass: Drug forhyperttnsion and htart faill.Kl! Phannlcoiogi( (lau: Direct-acting vasocilator
ACTIONS AND USES
WI1 ont of!ht filSt ml intihyptrtfMivt drugi tNrktttd in tilt
United KIS th,ougk a dilKl modiiatiOft of wriilsmooth musde;it
his lIOefft 011 is begun with low dose!, wlJch ill! griClJaJI)o in-
crwtd until tM !htfjpwtJ:: is momm
of thmpy. to 1M drug and. dougr inuulr may
wry. A/tllougk hydralazine prodlnS an t'fft<tivt Iftition in blood prmul!,
drugs in other dlsse hnt largely ItpIKtd it lilt to 501ftI)'
conmns. The drug is as tablets and in formubtions for thr

ADMINISTRATION ALfRTS
.
Abfupt withelfjWill of the dfU9 may rebound hypenrnlion .nd
mil'\)'.
.

PHARMACOKINETICS
Onstt : 20-30 min PO; 10-30 min IM;S-20 min IV
Ptak:Unknown
Halflife:3-7h
lMation: 2'" h
Direl;t vasodilators produce nfla ta(.J(lIii, a w mpensa-
tory response to the sudden decrease in blood pressure caused
by thl- drug. Reflex tachyc:ard.ia forces the heart to work
harder, and blood pressure increases, counteracting the effect
of the antihyperttnsive drug. Patients with coronary artery
disease could experience an acute angina attack.. Fortunalely.
refle.'\" l:lch)Ordia can bf prevented by the concurrent admin-
istration of a beta-adrenergic bJocker,wch as propranolol.
A semnd potentially serious side efft"(t of direct vasodila-
tor therapy is sodium and water retention. As blood pressure
drops, blood flow to the kidneys decreases and renin is re-
leased as the body activates the RAAS mechanism. Dueto the
vasodi lation caused by the drug therapy, the angiotensin re-
leased does not cause-vasoconstriction. but doesst imulate the
release of aldosterone, causing the kidneys to reabsorb
sodium and thus water. As the kidney retains more sodium
and water, blood volwne increases, thus raising blood pres-
sure and canceling the antihypertensive action of the va-
sodilator. A diuretic may be administered wncurrentl y with a
direct vasodilator to prevent fluid rett'ntion but warrants ex-
ADVERSE EFFECTS
reIitlt.a.yardia, palpiutiont, IkIshing, MUlti and di.Jnhu Ire
common, bIIt IM1 reo!VtilWripy taking bydrlLiZiM of
1m rectiw a bftHdreMfgic bI<Ki:ef to (ountmct reflex ,acbrwdia. Rile!);
thr drug may procb:r lup.lllike syncIllllf'If mil IM1 ptMt for 6 mood!! 01'
Ionge-. SodiJm .mel i\Jid retmtic.n is. polftlti.lliy rfrKtBf,-
UIM of thtse ad_ tffKlS, the 1M of tr,dr1lizint is limited fl'lMtty to p,i-
tients whose 11TH unnot with othtr,wftr mtcI'KaOons.
Contraindimions: of ilS tffts 011 tilt heart, hyd,aliziM is COI"I-
IIaindicutd in p,itifnuwih iIlgiJ'll,rhtumltic
Patiel1u with lupus shoukillOl meiYf hydraluine, is the elrug rail \\'\lOtfI
symptOll\'l.
INTERACTIONS
Oruc.t-DfllJ:AdrriMllmg MtlllIItw
_ h)'flCltHlsion. This indudfs .. ibjdHsf5115fd ill antih)'llfl'lrmMs.
t..I b ltits:.IMy produao I bM-po!itiw (OOI'I'IIK 1fIIS.
HerbaVFoM: Unblown
TrNtll'ltnt of OWdOSf: Tilt most liktly sign of is bypottnsion.
whicb mi)' bt with 'HloptSSOf an IV infusion offluids.
IIlftJ 1I M)NrJM9I'Jr Ix Q /iuflillf I'nxm Ffars sptI( 1I rills drIIJ
trem<' caution. EJu.:essive diuresis and lowered blood volume
may lead to excessive hypotension and cin:ulatorywllapse.
One direct.acting vasodilator, nitroprusside (Nitropress),
is a traditional drug of choice for hypertensive emer-
gency, a condition in which diastolic prtssure is greater
than 120 nunHg, and there is evidence of target -organ
damage, usually to the heart , kidney, or brain. This poten-
tially life-threatening condition must bf controlled quickly.
Nitroprusside, with a half-life of only 2 minutes, ha5 the
ability to lower blood pressure almost instantaneously on IV
administration. Care mU5t be taken not to decrease blood
pressurt too quickly because overtreatment can result in hy-
potension and severe reslriction of blood flow to the cere-
bral, coronary, or renal vascular capiUaries. It is essential to
continuously monitor patients receiving this drug because
the drug is metabolized to cyanide (thiocyanate), which is
very toxic to tht' body. Other drugs for hypertensive emer
gencies include diazoxide (a direct vasodilator), nicardipint'
and devidipint' (calcium channel blockers), and enalapril
(an ACE inhibitor).
LibraryPirate
320 UnII4 and Urinary Systems
NURSING PROCESS FOCUS PATIENTS RECEIVING DIREa VASODilATOR THERAPY
Aueument
Bileli.e prior toitdminbtr. ion:
Undersund "" rrl50n "" drug III! IieeIpreaibed in otdtr to ilstSllor
tfmts.
ClJt.l Ji" hill", ilcludill\l (.udiou(uIM IImt
,I'd neurologic r_kIdiftg 1M! 01' hil1Dry
oI'CYA,lIud irKruwd Jilrllnnill die
possibit1 01' l-,sItmic rrytMlNlows.
ClJt.l Ji .. dIug hiuOfY iIIduding pmai,tioft wi OKdfug1.MId
prtpaf.riom. It tier! 10 POlSi:IIe JitmctiaM.
MUtt! IPPlOpMe Iibor.tory
polisrum IMI!,htpatir.nd fIMioft midir!, ,nd lipid
Obu Ji btstlile wri;Jht.l'iblli!lm, puke oIIimrl/y, blHtlI ,nd "nrt soundI..nd
urdi i( lI'HIIIitorinv (e.g. KG. wdilc outplll). klnl mr IIIQlion nd cNActtf 01'
pnipht.-tI edtm. if prtIfIll.
Aslell ment HlIlinillralion:
ksn! i>r dnil(d thffiIptlltK tfftl":l1 (r.g., Iowtlld blood prtlllIrt wilhin
tltiblishtd limkl).
Continue and (.rtI\JI monitoring
.nd cardiac ,lnd ditily ts pt<i.11y iflY idmin is lMd. Blood
prr:lSurrarKI mUll lit monitortd t'lrry S minllltl 0111 OIdertd ...mile on IV
infusion 01 drug. (lfTI.siYe monitoring,r.g., .rttriallints,.rt ofttn Ultd for
purpoSfJ
Continut ptriodic of potauium.
u.ntinue
ItIpif.tOfYI)'lttfllS.
Alltss lor iIId pNllptly tffr<tnlKtilM!
ItfIn Ixhywdia,hf6dlcht,dKrt.\fd urrury
tdtma, I!Id priapism. SMrt hypoItnsion.
N)' indialt dlU\llOllicity ,nd sbwld Itt immtdiattly
ffIIOllm
"lhelYlinltd
Potential Nursing Diagnoses
0em1Std (Ifdiic G.itp.1! (dissf PflICHI)
Akt ltd Tiuur (rdaltd 10 de<l$ of drug tlln.fIY)
Risk b IrnINloInced FloidVobnr (1N1td 1O.1Sf th 01' drug
""'nl
Risk b kIjwJ (of91n sysums;rdaltd 10 adftnttlltsol' dIug

Risk br impailtd Skin Incet1 (1N1td to idYerst th 01' drug
""'nl

Exptlitnu thmpevtit rffts drptndel"lt on the _ tIIedlug is IttWlg cjtnJ (r..g.. dtml1td blood plftllft).


tltmonllT.1e proptr stIf-.dmil isll.tion 01' tilt mtdiQtion (e.g. dolt, tini1g, whm to natly ptOI'idrf).
Impltmentilltion
Inttl'"venti onl and (Rationales)
IRllring thffilpeutit elfetl l:
u.minue IrrlJlent l:ilnsnltml.s.bow lor thmparlk rifutl..lV infusion 01
may be litrlled Ir!qutntly to i(hit'l!! desirtd dlfm.Vitillsiglll,
(.!!Iii( ilnd urinaryoutput,.nd daily wtights should within limits Itt ""
mr ht.kh cilrr providtr.!Pulsr, blood prtSSUrt,ind fatf lhould be
within nonnil ilimitsorwithin ampublt paramettrs.An in wtight
1 kg {approllimitely lib) per day may indiotf ectSsWe Huid ipin ilnd m.y
rrquirt judkious diJrtlic ttrfflPY.)
Patient and Family Education
To .lIiIy possible .nlirty,leldilht pltirm.f.mily, 01 (.rtgim the
rationale lor all rqJipment used ind Ihr nftd klr frtqlltnt
monitoring.
Tu (h tilt p.tiem.f.mily,olGlJ!9im how 10 monitor pulst and blood
prt'IWf t 1\ appropriate patiem is on oral ther.py at homr. Ensort
the proptr and functioning 01 <1Jry homr rqJipmrnt obllintd.
tile patient wtigh stHdaily liong with blood prtSSUrt i nd pulsr
mtlSUrtmrnts.lnmur::t patiem to rtporl iI wright gain Of IoSI 01 mort
tbin 1 kg in. Z4--hour period.
LibraryPirate
CIIopttr ll Drug./ortfypMen.1on ]21
NURSING PROCESS fOCUS PATIENTS RECEIVING DIREOVASODILATORTHERAPY (Conft'luld)
Impl ementation
Interventions and (Rationales)
Minimizi lg adftt'lf effKts:
Continue 10 monitor vit .. signs frtqutndy.8t caU!iM willi tilt wIIo.re
ill ri>l for hypolemion; patimls will hi.1n'y of CirdioK or
rmbl!rolHCUl.ir iKlltmia, wIich may beworwotd bydraNsrd blood pmUJre;
p.ltient. with dtbydr.tion: Id patients with IupustrYtbem.tosus. Notify tilt
tm pnMder imllrlilRly ff blood
ellablilhfd pmmetM 01' l i> xcomp.nird '" t.rn,urd'iol.
(llirect-i(1ing WlIsodilaoo calM signnt rtSIIlting in the
for dwnatiully rapidly Iowmd blood oKCOIIIp.lnird '"
reflex
Conlinue YJdiac monitoring (e.g., Wi) and inYMive monioring (e.g.,card'1oIC
OI.tpul..rtfflilline uardeml in tbe hospitalizrd p.tient. (Monitoring
mill indmcting tilly signs of ill wtll ill monitoring far
tber.pwtic tffecu.)
Continue flrqueftt physiul IUHSmtnB, particularly lINDIogir,urciK.,ilrId
ltIpiriitOfY,\mmtdiilti)' .,." in levtl of (OII!(iIlwIm, htlache,
orch.Jnges in hurt or MIg KUICh.(VuodilatOl lhtravY filii)' WOrlftl
nrurologic, unliac. or mpaory OOncitionl 011 bloorl plflsure drops.nd
perfusion 10 viul organs dimiMllts.)
Wtiqh tlrr jIoIDrIll daily and It'pOrt a weigh! gain or Iosl of 1 kq or more in 24-
hour ptriod or signific.lnt wright: iI an i(ur;ne
of fluid !taM,nd likes into oKCOUnt inlilkt, OUIpU!"nd inlenliblt 1osst1.)
Conlinue kllIIOfIitor IV inMion .ite. l!equentty.(Dirm"ilCting nsodilatoo lii0i,
calM til_dam.gt if 00lIn..)
:c-:-'---:----::-
for siqm and symptOms oflupu! in p.ltif,nts taking vasodilatOl\,
paniculilly hydIJIouiIll'. {HycllJlouinr llil bHftlinkrd todruq-irldllCed IupuiJ
f1H oral drug mrlilpy,gM tht finl doseof IIIe drug at bedt.inIr. (A Iint-4ose
rtIpOlIIf IIIiIJ JtIIIIt in i initial drop in BP tllin Usequent rIo!e..)
00 IIOt abrvpct, diKontinue tilt mediutiorl.(Rebound hrpentnsiorl ft
ta<lrycarlia filii)' occur.!
.ppropriatr ifestyIe changrs..1'rO'fidt for rliftitian con!Ulution ill
nreded. {Hulthy lifrltyle dIoIngtl wiD suppan and minim izr tilt IIred Jot- druq
ther.ip,. DiR"ct YilodilitOB ciroI'ase blood prenure IUbmntially and (OOOfJrel1t
beu blod:n 1M ma, dKru!r hun rar:r.GMn.1onr or tim mil, It.d
to 9t'Kise intoIrfanre. Artirit,-IeYeIs!holM lit inmi!ed 'fell grlUiIly. Alcohol
rolllUmptioo mil, inrruse tM risk ofblood .dvrrse rfrKn.)
Patint unclm:tanding of dnrg therapy:
Use opponlMlOO during xlminimillioo of mrdicatioM and during omfSlllltntl
to rfllC\J15 tilt ratim.1e for drug 11Ho1i!l1, drsirrd thrraprvtK oulcome, lII0I1
rommonlyobserml . dvmr dfrru, poIlimtlrB for whtn ID [ill tIrr hNklI cart
necrwry monitorinqor plt(,)ution ... {1.Img timedurinq
nulling Mips to op6mizr.nd reirlorte key INChing .Itil.)
Pati ent and Family Education
Inllrucl tilt p.ltient to It'pOrt .ngilli-likt srmptoms (e.g., chts!"1m,
biCk iI nd'or neck pol in), palpit.tion!" fiintnel, diuine!" dnM'linns,.
orlitilcli<M.
To allay possible 19th tilt patient, family,or Cilffgivtr tilt
IJtion.lefof an Vlrd andllle rwd
monitorilg.
Whtn on col thtrlpy ill homr, teach IIIe famitr,or caregiwr
10 immediattly (MIIgH in mmul mUll orletlof
cor&iGusnesl" palpitations, dizzintll" dyspnu, inmuinq prodllCtift
couqh (ejIiaIly if frothJ'pulum iI
Whrn on wi thtrapy at homr, h.w tilt patient wrirjh seNdail-,;
ideilly al the SilJne time of day,.rId It(GId weight iliong wir:h blood
prtlWIt ICI pulst mnsurements.H.M me patif,nllt'pOft, weight
g.linorkmofmare III..! 1
ifincrNsing.
In.truct IIIe patitntlD report illI)' burning or.linginq pain, swtIl"lII9.
warmth, at IV instrtion
---:-::---c:-:-:--
InSlr\.lCltM p.ltient to rtport .ymptom. wc:h as,"buttfflty "Ill" om
tht nose.nd cherks,1IUIde oKhrs, and btiguewhm uking aIJI
Yil sodi tilton. jIoInicublly hyd,.l.zint.
Inltruct IIIe patient to iii" tbe fim. dcM of mediution.1 brdtime
.nd to MIid driving or'" haurdou! ilctivirif$ for 12 to 24 hours
.ftrr Iht fitst dose or when tilt dosq is incre, 1fd IIRtii effects of the
druq are known.
T9Ch dlt patient not 10 st .. mediutioa abruptt, iIld toa.1I tilt
cart p!OYider if patiffit iI ulliblr to like mediQtioft for
than 1 day Ib to iUne ...
EnClllJfigt the paUrnl toarlopt. lItilthy lifestyle of Iow-I.t food
sodi.lrn inukr,inClNSed akohol
cOllllJllllllion smaking JrlSiition.
u.Ulion tht jIoItient about sudden Mille in artMty 1rwI. Repon
diuineu, palpitatiolll,or shortnesl ofblNm that OCCllB while
mrtiling.
Tilt patimt should be.bIe ID lIall' IIIe reilson for IIIe drug;
and IdmLling;what rflKts to oo.rMJot-
.nd when torepart;.nd thr .micipalrd lenqth 01 mediution thmpy.
{COOIJncJed}
LibraryPirate
322 UMl4 n.. Ordlc-=ubr and UrlNry Syn .... '
NURSING PROCESS FOCUS PATIENTS RECEIVING OIRECTVASOOILATORTHERAPY (Continued)
Implementation
Interventions li nd (Rationales)
' .li ent selfatM!i nlll rat ion of drug tMrip1:
Whm .JdmDskriJH,1 instruct \he, patient fMIil)o. or in
proptr self..admilisu.Jtion (PropeI.Jdministr.uian impllWtS tilt
tffKtil'tlltsS of the drug.)
Patient and Family Education
Instruct the patitnt in idmirmmion
Ittu .. demonmuion.
The patitnt is able to disaM ipprcpiittdosing and idministl1lion
"m.
Evaluat ion of Outcome Cri teri a
Ev.JIuolll' \he, rffKtiftllffi of drug tlitral'1 b,<onfinninq thilt paoot goal!.Jnd hift !lid
Srt iIIDIt 1J.J kit, it rI drugs 10 .tIIdr rlttst IIfIWg ,pp/ttnifIII_.
, 'if Chapter REVIEW
KEY CONCEPTS
The numbered key concepts provide a succinct summary of the Important points from t he corresponding numbered section
within the chapter. If any of these points are IlO1 dear, reft'f" to the numbered section within the chapter for review.
D.l High blood pressure Is classined as es.wntial (primary)
or sewndary. Uncontrolled hypertension can lead to
chronic and debilitating disorders such as stroke, heart
altad:, and heart failure.
23l The three primary f.ictors controlling blood pres.sureare
cardiac out put. peripheral resistance. and blood vol ume.
D.3 Many factors help regulate blood prt'$Sure, including the
vasomotor center, b;!roreceptors and chemoreceptors In
the aorta and internal carotid arteries, and the renin-
angiotensin system.
23A Hypertension has recently bten redefmed as a sustained
blood pressure of 140/90 mmHg after mulliple measure-
ments made over several clink: visits. A person with sus-
taIned blood pressure of 120-139/80--89 mmHg is saki
to be prehypertensive, and Is at increased risk of doevel -
oping hypertension.
DS Be\:ause ant ihypertensive medications may have uncom-
fortable side effect"" lifestyle changes such as propt'l" diet
and exercise should be implemented prior to and during
pharmacotherapy to allow lower drug doses.
D.6 Pharmawtherapy of HTN often begins with low doses
of a single medication. If this medication proves ineffec-
tive, a eCOnd agent from a different class may be added
to the regimen.
23.1 Diuretics are often the fi rst-line medications for HTN
because they have few side effectsandcan w ntral minor
to moderate hypertensio n.
23.' Cakium channel blockers block calcium Ions from en-
tering cells and cause smooth muscle in arterioles to re_
lax, thus reducing blood presure. CCSs have emerged as
major drugs in the treatment of hypertension.
23.9 Blocking the renin--.angiOiensin system prt'VenlS the in-
tense vasoconstriction caused by angiotensin II. These
drugs also decrea.sl' blood \"Olume. whidr. enhances their
antihypertensive effect.
D.l0 Antihypertensiw autonomic agents are available that
block alph3, -adrenergk recl'JllOrs, block beta,- and/or
betaradrenergic receptors, or stimulate alph3
r
OOrelW.'rgic
re<:eptor.; in the brainstem (centrally acting) .
D. ll A f ....... medications lower blood pressure by acting di -
rectly to relax arteriolar smooth muscle, but these are
nOi widely used due to their numer0U5 skle effects..
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NCLEX-RNO REVIEW QUESTIONS
o The patient has been given a prescription of furosemide
(tA'lix) asan adjunct to treatment of hypertension and re-
turns for a follow-up check. Which of the following Is the
most ob}ective data for determining the ifjraivtnl:Sj of the
drug Ihenpy!
1. Ab<;enceof edema in kMerextremities
2. Wdghlloss of 61b
}. Blood pressure Jog notes blood pressure 120!70mmHg
10 134/88 mmHgslnc:edJscharge
4. Frequenq of midiill'. of allru5l six times Pl'l" <by
o The nurse prepares to administer hydrochlorothiazide (MI-
crozide) 25 rug to a patient with hypertension. The potas-
sium lab result Is 2.5 mEq. The nurse's besI action Is to:
1. hold the medication and notify the health care provider.
2. administer the drug wilh orange juice.
}. admini<iter the drug as ordered.
4. glw the patient a banana and recheck the potassium
""'l
o The pal lent Is on IWO antihypertensive drugs. The nurse
reoognires that the advantage of combination therapy is:
I. the blood pressure decre.tSe faster.
2. !here will be fewer sidt' effects and sreater patient
rompllance.
}. !here is less daily medication dosing.
4. rombirution thenpywU! treat the patient's other
medical oonditions.
CRITICAL THINKING QUESTIONS
1. A 74-year-old patient has a history of hypertension, mild
renal failure, and angina. The patient is on a low-sodium,
low-protein dlet.lbemost rKent BP Is 106/84. Should the
nurse give the patient benazepril (l.otensin) as scheduled?
Provide a rationale for thedKislon.
2. A pnient with diabetes is on atenolol (Tenormin) for hy-
pertension.identify a teaching plan for this patient.
1. A patiem is having a hypertensive crisis (2301 ]30), and the
BP needs to be lowered. The patient has an iV drip of ni-
troprusside (Nitropress) How much would the
nurse want to lower this patient's BP? identify three nurs-
ing interventions that are crucial when administering this
mediation.
Sa Appendix D !oramwers (md rationales for all activities.
OrugtfOfHypertemlon 123
o The dass of antihypertensives that Increases urine pro-
duction by affecting the renin-angiotensin- aldosterone
pathway Is the:
I. calcium channel blockers.
2. adrenergic blockers.
3. ACE inlubitors.
4. dIrect-acting vasodllators.
o The nurse is preparing [0 administer the first dose of
enalaprll (Vasotec). Identify the potential adverse effects
of this medication: (Select all that apply. )
l . Reflex hypertension
2. Hyperkalemia
3. Ptrsistent ooug.h
4. Angioedema
5. Hypotension
o A patient with Significant hypertension unresponsive to
other medicatIons Is given a prescription for hydralazIne
(Apresoline). An additional prescription of propranolol
(lnderal) Is also gi\'en to the patient. The patient inquires
why [wo drugs are needed. The nurse's best response
would be:
I. giving the !ml drugs together will lower the blood
pressure even more than jusf one alone.
2. the hydralazine may cause !achycardia and the
propranolol will help keep the !lean ra!ewithin normal
limits.
3. the propranolol isto pmoentlupuserytbemat06US from
developing.
4. direct-acting vasodiwtors such as hydralazine ca\.lSlli' fluid
retention and the propranolol wiD prevent excessive
fluid buildup.


M)1'AJrYlgKil is your ooe SUIp IIJ' onIdle chaptef n!\'I!W m!ler\a15 alld
n!WUJC8S. PnllaJB tur SIII:C8SIi 'Mth aldibonal pradic:!
questlDns, Imeracllwi S.:I K1IdIe:s. web 1m. anlmations
ancIl'icIeo&. and mIlel
RegISter yDIJ ICct:!!! COCII! Imm me froo1 d your _ at
www.JllYll ...... gkllcom.
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DRUGS AT A GLANCE
ANGIOTENSIN-CONVERTING ENZYME (ACE)
INHIBITORS AND ANGIOTENSIN RECEPTOR
BLOCKERS
Q "Jlnopr1l (PrtnlVlI,Zestlil) PJilI 119
DIURETICS pilrJtJ19
Q furosemJdf (LoSlX) pilrJt JJO
CARDIAC GlYCOSIDES {II19tJJO
Q digoxin (D/gffek,Lonoxln, Uln<lI'l((IPS)
roqt1Jl
BETA-ADRENERGK BLOCKERS (ANTAGON ISTS)
""m
Q metoprolo/ (LOpmSOt, ToproIld) pi1Jt JH
VASODILATORS {II19tJJf
PHOSPHODIESTERASlINHIBnORS
ANDMISCElLANEOUSAGENlS ,..315
Q mltfnone (PrtMrot) pot}t JJ6
KEY TERMS
dtfrload pr19tJlS
(imliac output (!JfJt Jl5
tardi po!Jt j}6
contradility fXl9t J2S
Drugs for Heart Failure
LEARNING OUTCOMES
Alrer reading this chaptn-, the student should be obit to:
1. Identify the major that accelerate the progression of heart
failure.
2 . Rel.,t .. how the symptom. iI wit h he.ll rt fllll ... r .. "'"y be caused
by weakened heart musde and dimini shed (/lrdille output.
3 . Explain how preload and afterload affect cardi ac function.
4 . Describe the nurse'. role in the pharmacologi c mllnllge ment of heart
failure.
S. For each of the drug classes listed In Drugs at II Glance, know
re presentative drug examples,lInd eKplal n thei r mechanisms of action,
primary actions,and important adverse effects.
6 . Use the nursing process to Ulre for patients v.hoare receiving drug
therapy for heart failu re.
Frnk- St.rlinglaw paJtJ15
rvgtJi$
inotrolliuffffi l15
ptriphtraltdtma fJlJ9fJ}6
pholphoditlttrast r;II9tJJ$
Jnloid {IIl9tJ15
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H
eart failure is one of the most common and fatal of the
cardiovascular diseases, and its incidence is expected
to increase as the population ages. Despite the dramatic de-
cline in mortality for most cardiovascular disease (CVD) that
has occurred over the past two decades, the death rate for
heart failure has onl) recently begun to decrease. Although
improved treatment of myocardial infarction (Mljand hyper-
tension (HTN) has led to declines in mortality due to heart
failure, approximately one in five patients still dies within 1
year of diagnosis of heart failure,and 50%die within 5 years.
Historically, this condition was called congestive heart failure;
however,because not all Incidences of this disease are asso-
ciated with congestion, the more appropriate name is heart
failure.
24.1 The Etiology of Heart Failure
Heart failure (HF) is inability of ventricles to pump
enough blood to mtthe body's metabolic demands. Heart
failure can be caused by any disorder that affects the heart's
ability to receive or eject blood. Whereas weakening of car-
diac is a natural consequence of aging, the process
can be caused or accelerated by following:
Coronary artery disease (CAD)
Mitral stenosis
MI
Chronic HTN
Diabetes mellitus
Because there is no cure for heart failure, the treatment
goals are to prevent, treat, or remove the underlying causes
when possible. For example, controlling lipid levels and
keeping blood pressure within normal limits reduces the in-
cidences of CAD and MI. Maintaining blood glucose within
normal values reduces the cardiovascular consequences of
uncontrolled diabete>. Thus, for many patients, HF is a pre-
condition; controlling a .... ociated di.ca.c. will
PHARMFACTS
Heart Failure
Heart fJiufl' (Hf) with age. k affect!:
1% of those 40 to SO)'!'.<lB old.
S% of those 60 to 69)'!'.<lB old.
10%ofthoseolderthnage 70.
MOfI' than 57,000 propedir of Hffach yUf.
incidrlKf of !Uridu mdiac dmh is u much u nine higher in
jlatirnl5 with HF tllJn i. thrgrnml popuLliion.
Heart fJiufl' is the moll comrron oospiul disdlarge diagoosis in patirnu
Jgr650rolder.
African Ameriuns hal'!'one and J 1IJifto two times the ilKidenO'of HF u
whitt!.
Hurt fJilufl' is twice as in hypertensM patirnnand fiW'
JS in persons who haW' nperienced J heJrt atuck.
CNplfl24 OI\Jg'fu' ...... nF.,Iu'e 325
greatly reduce the risk of evenmal HF. No longer is therapy of
HF focused on end stages of the disorder. Pharmacotherapy
is now targeted at prevention and slowing the progression of
HF. This change in emphasis has led to significant improve-
ments in survival and the quality of life for patients with HF.
24.2 Cardiovascular Changes
in Heart Failure
Although a number of diseases can lead to heart failure, the
result is the same: The heart is w13ble to pump the volume
of blood required to meet the metabolic needs of the body.
To understand how medications act on the weakened my-
ocardiwn, it is essential to understand the underlying car-
diac physiology.
The right sideof the heart receives blood from the"{enous
system and pumps it to the lungs, where the blood receives
oxygen and releases carbon dioxide. The blood returru to
the left side of the heart, which pwnps it to the rest of the
body via the aorta. The amount of blood received by the
right side should ex:lctiy equal that sent out by the left side.
If the heart is Wlable to completely empty the left ventricle,
HF ma), occur. The amount of blood pumped by each ven-
tricle per minute is the cardiac output. The relationship be-
tween cardiac output and blood pressure is explained in
chapter 2300.
Although many variables affect cardiac output, the two
most important factors are preload and afterload. Just be-
fore the chambers of the heart contract (systole), they are
fIlled to their maximum capacity with blood. The degree to
which the myocardial fibers are stretched just prior to con-
traction is called preload. The more these fibers are strttched,
the more forcefully they will contract, a principle called the
Iilw. This is somewhat similar to a rubber band;
the more it is stretched, themore forcefull), it willsnap back.
The Itrength of contraction of the heart is called contractility.
Up to a physiologic limit, drugs that incrru5 prelGold and
contmcrility will increase the cardiac outpllt.
A mange in contractility of the heart is called an inotropic
effect. Drugs that increase contractility are called positive in-
otropic agents. Examples of positive inotropic agents include
epinephrine, thyroid hormonE, and
dopamine. Drugs that decrease contractility are called
negative inotropic agents. Examples include quinidine and
betaadrenergic antagonists such as propranolol.
The second important factor affecting cardiac output is
afterload, the degree of pressure in the aorta that must be over-
rome for blood to be ejected from the left ventricle. Ala sim-
plifiEd example, if the mean pressure in the aorta is
80 mmHg, the left ventricle must generate a minimum of
81 mmHgto open the aortic valve,and even greater pressure
to eject the blood from the ventricle and push along the pulse
wave through the rest of the systemic circulation. lbe most
rommon cause of increased afterload is an increase in 1"'-
riphtral resistance due to HrN. As blood pressure increases
with HTN, the mean arterial pressure also increases and the
force the ventricle has to generate to eject the blood with each
heart beat increases. The greater afterload caused by chronic



j


LibraryPirate
326 UnII4 TheCJ,dkIY.",ub, ' 00 U"""ry Syuem,
HTN creates a COfl'ltam increased workload for the heart.
This explains why patients with chronic HTN are more likely
to experience HE Lowering blood pressure creates less after-
load, resulting in less workload for the heart.
In HF, the myocardium becomes weakened, and the heart
cannot eject all the blood it receives. This impairment may
occur on the left side, the right side, or on both sides of the
heart. If it occurs on the left side, excess blood accumulates in
the left ventricle. The wall of the left ventricle thickens and
enlarges (hypertrophy) in an attempt to compensate for the
increased workload. Owr time, changes in the size, shape,
and structure of the myocardial cells (myocytes) occur, a
process known as cardiac remodel ing. Because the left ventricle
has limits to its ability to compensate for the increased pre-
load, blood "backs into the lungs, resulting in the classic
"Jffi1ptom< of cough shortnes..< of h""'th. ,,,,ft
ure is sometimes called congestive heart failure (CHF). The
pathophysiology of HF is shown in ,.. Figure 24.1.
tncreased myocat<Iiat oxygen demand from t.ypMteosion, myDCllrdiai
infarction, mitral 51"""";s, diabetes mellitus, or othet disordare
Dect9ased myrx:ardial contractility/stroke volume
Decreased cardiac output
Incr" ...... d pmI""d
Pulmoollry edema
I
D"",,,,,,,,,d blood pre5l!Ure
Dea" ...... d blood
flow to kidnor-
I
I
ADH Reoin-angioteosin
system activatad

Sodium moo Increased
water peripheral
. ....,
,,,sistanca
I
I
Edema oIlimbol

Increm!Mld
altarloed
blood volume
Incre ...... d I
myccardiat

Flgure24.1 Pathophysiology of heart failure
Although left heart failure is more common, the right side
of the heart can also weaken, either simultaneously with the
left side or independently of the left side. In right heart fail-
ure, the blood backs up into veifl'l, resulting in peri phf ral
rdema and engorgement of organs such as the liver.
Through proper pharmacotherapy and lifestyle modifi-
cations, many patients with HF can be maintained in an
asymptomatic state for years. When the heart reaches a stage
at which it can no longer handle the workload, cardiac de-
compensation occurs and classic symptoms of HF appear
such as dyspnea on exertion, fatigue, pulmonary conges-
tion, and peripheral edema. LWIg congestion causes cough
and orthopnea (difficulty breathing when recumbent).
When pulmonary edema occurs, the patient feels as if he or
she is suffocating, and extreme aILueIy may result. The con-
clition often wo",,"n< M nighT.
Drugs can relieve the symptoms of heart failure by a
nwnber of different mechanisms, including slowing the
heart rate, increasing contractility, and reducing the my-
ocardial workload. These mechanisms are shown in
Pharmacotherapy IlIustruted 24.1.
Overtime, the heart may lose its ability to compensate for
the increased workload placed upon it. The most common
reason why patients experience decompensation is nonad-
herence with sodium and water restrictions recommended
by the health care provider. The second most common rea-
son is nonadherence with drug therapy. The nurse must
stress to patients the importance of sodium restriction and
drug adherence to maintain a properly functioning heart.
Cardia, events such as MI or myocardial ischemia can also
precipitate acute HE
24.3 Treatment of Heart Failure
with ACE Inhibitors and
Angiotensin Receptor Blockers
ACE inhibitors were approved for the treatment of hyper-
tension in the 1980s. Since then, research studies have
clearly demonstrated their ability to slow the progression
of heart failure and reduce mortality from this disease. Be-
cause of their relative safety, they have replaced digoxin as
drugs of choice for the treatment of chronic HE Indeed,
unless specifically contraindicated, all patients with HF
and many patients at high risk for HF should receive an
ACE inhibitor. The ACE inhibitors used for HF are listed
in Table 24.1.
The two primary actions of the ACE inhibitors are to
lower peripheral resistance (decreased blood pressure) and
inhibit aldosterone recretion (reduced blood volume). The
resultant reduction of arterial blood pressure diminishes
the afterload, thus increasing cardiac output. An additional
effect of the ACE inhibitors is dilation of veins. This action,
which is probably not directly related to their inhibition of
angiotensin, decreases pulmonary congestion and reduces
peripheral edema. The combined reductions in preload, af-
terload, and blood volume substantially decrease the work-
LibraryPirate
CNp1tI24 Drug. /0, 327
PHARMACOTHERAPY ILLUSTRATED
24.1 Mechanisms of Action of Drugs Used for Heart Failure
@ = Sti .... lalion
e = Inhibition
Adrenergic; block ...
o..c ......... cortliac
worI<load by skM,ing the
heart rale (II,) and
decreasing blood ptMIIu",
(II,) (Example: carvedilol)
neurons
pmIoad (Elo.ample:
;.o1Kl/bide dirilrale)
Pho.phodie. l . .....
inhibitor.
Inc ........ cardiac output
ACE inhibit or.
Inore&H cardiac
output by Iaft'ering
blood preo.s<n and
dec..,BIIing ftuid
..
by r.creasing the f"",. of
myocardial oonlraction
(Example: milri""",,)
Cardiac glyco. ide.
Inc:rea ... cardiac output by
inueaeing the force of
myocardial oonIraclion
(Ellample: digoxon)
load on the heart and allow it to work more efficiently.
lients taking ACE inhibitors experience fewer
symptoms, hospitalizations, and treatment failures. Several
ACE inhibitors have bet'n shown to reduce mortality follow-
ing acute MI when therapy is started soon after the onset of
symptoms (chaptt'r 25(0).
Another mechanism for blocking the effects of an-
giotensin is the use of angiotensin receptor blockers
(ARBs). The actions of the ARBs are similar to those of
the ACE inhibitors, as would be expected, since both
classes inhibit angiotensin. In patients with HF, ARBs
(Ellample: lieinopti)
Increased un"" output
show equivalent efficacy to the ACE inhibitors. Valsar-
tan (Diovan) and candesartan (Atacand) were approved
to treat HF in 2005. Because research has not yet
demonstrated a dear advantage of ARBs over other
medications, their use in the treatment of HF is usually
reserved for patients unable to tolerate the side effects of
ACE inhibitors.
Please refer to Nursing Process Focus: Patients Receiv-
ing ACEI (Angiotensin-Covering Enzyme Inhibitor) and
ARB (Angiotensin Receptor Blocker) Therapy, page 312 in
chapter 2300, for additional information.
LibraryPirate
TAB1124 11 Drugs for Heart Failure
Route .lnd Adult Dose
"'""
(mu dose where Indlc:atedJ Adverse Effects
ACE INHIBITORS
PO;&'lS-12S mg lid ,_: 150 nl9Idoy) /IfportmM.COIJ9/l
tlliil.priI [\ItsoI) (SH 112 fortlle PO;LS 11'19 qid-bid nlgf4;y)

ProtoCJpe boxCIO)
aooipcslrm. blood d!ry"w,
fosilopril (Monopri) PO;HOmt/clI, (nlu:40"9'doy)
o IiIilopriIIPrillMI,Ustril) PO: 10fI'I!I/dIJ Imu:40 mg/d;y)
lPlliipril (AcCl","O PO: 10-1(1 mg/clIJ (mu:20 ragloi;y)
r.mlprl (,IJta(t) PO;lH.O 11'19 bid (mu: 10 mg/d;y)
ANGIOTENSIN II RECEPTOR BLOCKERS
(AQ(.)nd) PO; 4 mglday (max:l2 mg/diy)
I
"fOIISlio (liIwan) PO;40"'9 bid 320 mglclIy)
DIURETICS
100fJllt High (tiling
IMIntlillido! (BuIael) PO: O.S- l "",day (m .. : 1 0 "9'oI;y)
fIro5oM'lklt (Lm) PO:1G-ICI mg In OlIO! ormort dMdtd dosts EItc/llJlyfr imIHIkIlcr1, Mhos/DOC hypiltlnJioll

!!rl!cl!jJjon
lontmide (1)eN6ex) PO: 10-1(1 mg/clI, (mn: 200 mg/d;yl Irtpclnamm!i. O!O!OJjicity (JoopdiMig)
rJIItuiM IlIHI T1IkIzIdHlkr
Idrodllorolhiuide (Miawidtl (Sft 304 PO:lS-ZOO mg In i Y. dow or !Ilrff 1'I:iI:111i\Jn.,pui"ll:
btlle ProIolyprDrug boJOO) li"ridtd (m.u:lOCI mgIda,)
/lrrHrt./fJriI, 9)Ol'Il1I!!OSli illllO.Ilj, ffrigut
PassIum-Spdting (AIdosI!tOUAllfagoolliJti
Doow l",lomiil bml:obIHnlt
tpltrfllOllt(lO\ID) PO;lS- SCI mg doliIJ (mu: 100 mgldoyl
SfllrorooLKtont IAldtontl (Sft m PO: S-200 mg in doStl(INIt 200 mgfday)
btlle PrOlotyptDrug bolOOl
BETAADRENERGIC BLOCKER
""""" '''''''
PO: 112S mg bid b 1wt ( .... :25- 5011'19 bid) iltSllllllht orllcltitSldibldrl,.
o mttoprolol91.et*d PO;lS mg/doy for 1 "!It; Jl5111g1cl1, fOf sr"lm
1Ndyc,. aJllMion
( .... :200 mg/doy) Ag@nu!ocytosij.Wyrm!lW"Sfmm- )obrnr.rt
i!!!!i!!m iI!!ilR!!!!i!irif!!! il i!!!1!1b: 'll'il!Wwn
ptlpit.nioM, ttixI!!Id hmffi!l!iDll thl9ltr1ioo
rtryhytbmjA, or mrordal jyhrmia iN. OI'QII
OIRECTVASOOILATOR
Idr&Dit 'll'ith dnmtr (BiOil PO; 1-2 Qbku liel (f ull UIiIf\(OIILlins 20 Ia9

dmuatr .-!d37 511'19 Irjtdrilizillf) tlzzinm" fPlt% rld!Yflrtlo
(rMI:2 ublKsldiIJl
Fainti!!!lt3!m: Iifadadof !m!f trtl!!!rtrl5ion wiIto
qrrn1w hpjditr rurtjgo rbvrVlarirt)
1V:11IKiJIkg bam fdlll'lmlt., cmtinuom inllllion Hnxormlkon,imtfMli mum rlf"flfirliM,MnltKItr
.n 0.01 nltg/kgfmin.
DnrhythmLu
CARDIAC GLYCOSIDE
o dio;p:in (D9tH,liJlOllin, unoxiciJIIl PO;O.llHSmg/daJ Ntvltf, ImIitiI"/i /ItQdht, tlWltm:rs wd! OJ
stfirtg bolo$, Q 'IfIow-vrttt linge, /I( /lUrif19
Qyy!rttbmja< J.II hlott
PHOSPHODIESTERASE INHIBITORS
iwmrinont (1_) IV:I.7) on9 boM gMli !IoMtt GftI" 2-l min;!Iom HmdIIt,ftJP:lF1'fIIion
S- 10ITl(tt\gfmln (m'lt 10 mgJ'cgIclIy)
Dnrtrythmwi
o rriIrI"Ior1e (PTirrvtor) 1V;5CI ITI(g Mr 10 min; tMn OJ7H1.75I1KgIkg!min
Irdio IIlI1IID!l oJdJm,r indic.Jrrl s.trioIaaolwntrlf!m..
LibraryPirate
CNplfl 24 Drugs /0, 1-1<>"" 329
.... Prototype Drug I Llslnopnl (PnmVlI, Zestn/)
Therapeutic (lass: Drug for heart failure and HTN Pharmacologic (lass: ACE inhibitor
ACTIONS AND USES
BffiuW' of it! valUl' in the tlNtment of both H F and hypmenlion,lisioopril has
br(ome one of mosl drugs.lisioopril ads by inhibit-
ing angioll'lllin-(ollftrtilg and aldolterone IKlMion.
Blood prl'lsure is dKremd and cardiac oulpUI is iIKINIf<i. A5 with olher ACE
inhibitors, 2 to 1 wtt'ks of Ihtfapy may br required 10 IN(h maximum effectivf-
and W'Yefal monthsoftherapy may br r"ftded for cardiac fuIKtion to re-
turn to normal. An additbnal indication fo, lilioopril is to improl'l' survival in
p"ienn when giYen within 24 hours of oI n anne MI. of migrainn is
an off-labrl indication forlisinopril.
ADMINISTRATION ALERTS
Mtasuft' blood ;m prior 10 administering lisinoprillo br
lhat effects are lalting for 24 hours and to dtltfmine whethmhe p.atitnt" s
blood Pft'ISurr is with in ac:ctplable range.
SafrlY andeflic:aq hm btt'n fllablished for the UW'ofthis medication in
children agt 6 and o1cP.r.
Geriatric p.atitnll blood IrYeIs rt l"ed to renal
Pft'Cjnancy category ((fim trimnter) or D (W'{ond and third trimesten).
during the If(Ond and Ihird trimesters of prl'gnancy mol Y rnuh in injury
or dtath 10 the MUI.liKontinUl' UW' II soon al pr!9C\i1 nq is luspt(Ied.
PHARMACOKINETICS
Onsd: I h

Halflife:12h
Duration: 24 h
24.4 Treatment of Heart Failure
with Diuretics
Diuretics are common drugs for the treatment of patients with
HF because they produce few adverse effects and are effective
at increasing urine flow and reducing blood vollUlle, periph-
eral edema, and pulmonary congestion. When diuretics re-
duce fluid volume and lower blood pressure, the workload on
the heart is reduced, and cardiac output increases. Diuretics
are rarely used alone but rather are prescribed in combination
with ACE inhibitors or other HF drugs. Because clinical re-
search has not demonstrated their effectiveness in slowing the
progression of HF or in decreasing mortality associated with
the disease, diuretics are indicated only when there is evidence
of fluid retention. In patients presenting with fluid retention,
especially with symptoms of severe pulmonary congestion or
peripheral edema, diuretics are essential medications. Selected
diuretics are listed in Table 24.1. Additional details on diuret-
ics may be fOlUld in chapter 3000.
Of the diuretic classes, the loop diuretics such as
furosemide are most commonly prescribed for HF because
of their effectiveness in removing fluid from the body. Loop
ADVERSE EFFECTS
lis inojlil is toleraled well by most most rommon
aft' coLgh, headac:he, dillinl'll,orthostatic: hypotenlion, and rash.
may ocrur during theC"apy; Ihus, Mc:trolytt Itftls art usually monitored pm
iea lIy. Dlher indudt taste dil1urbi IKn,{hfit pain, nau IN, VOID itirg. and
diarma .Though rare, oI ngioedmloi is 01 W'rious adW"II' dl.
Contraindicationl: lisinopril is in j)iltienll with
kalemi! and in who have prn iously angiOl'dtma "used
by A(Einhibilor therapy.1t should not br used during pft'Cjnancy brUlU it is
a calt<;0ry 0 drug during the and third trimfltm.
INTERAalONS
DrurOrug: InOOrnfthidn III 0!IlfI HSAIl); may i lleoo with wnoprit ( AIIil j
d
Iisinopc1 and diantia, combiIfd tMrapy with or 0!IlfI anlih)1Jfrlfnsft d"ugs
shcUd W monitorfd. WIIfn isiIopri is taken COIKII"rl'flily with potiS.WI)
sparilg dilROO, r,pHbIMU may Mi.lisinopril may ooa", lithilln ImIs !lid
IaUII' illium
l.i b Testl: May {jIM positiw MA titH and MNs.! vakJrs of thco folowing: 8U H.
IfnIIl tiintlin,lfnIIl albinf phoIp/Iatast,.l.SL and N..1
HerbiliFood: iob of foods rich i1 poIillium and polaIlilm-bud salt
Slb5Iinles should lit iWOidfd bKilM of thco pomily of hypHblfmia.
Treatment of OvrrdoW': {lUW'S hypolension, which may br
with the administration of normal saliCll' or a vlSopIffior.
lit frr ro M;rNUrlbrgKJI for Q NuflirrI} I'rtms fOOJHPKI/{ ro rlrls
di uretics are also able to function in patients with renal im-
pairment, a n advantage for many patients with decompen-
sated HE Another major advantage in acute HF is that loop
di urttics act quickly, especially IV formulations, which work
within minutes.
Thiazide diuretics are also used in the pharmacotherupy of
HE Because therare less effective than the loop diuretics, thi-
azides are generally reserved for patients with mild to mod-
erate HE They are sometimes combined with loop diuretics
to achieve a more effective diuresis in patients with acme HE
Potassium-sparing diuretics have limited roles in the
treatment of HF because of their low efficacy. Spironolac-
tone. however, is an exception. In addition to being a
potaosium-sparing diuretic, spironolactone is classified as
an aldosterone ,rntagonist. Clinical research has demon-
strated that spironolactone blocks the deleterious effects
of aldosterone on the heart. Spironolactone ha$ been
shown to decrease mortality due to sudden death, as well
as slow the progression to advanced HE
Please refer to Nursing Process Focus: Patients Re.:eiving
Diuretic Therapy, page 305 in 23010, for additional
information.
5

,


=
LibraryPirate
]]0 UnII4 The ,nd Urinary Syl1l'm!
fIT Prototype Drug I Furosemide (LaslX)
Therapeutic Class: Drug for heart failure and HTN PharmcologicClass: Diuretic(looptype)
ACTIONS AND USES
Fur=mide is often ustd in the 1rN1ment of acute HF btaUIl' it 1'01, the .bility
to rrlllOY!' large .mounts of elms lkJid from the poatient in a s.hon period. When
given lV;diJrriis begilll within S giving p.atients quick their
di5trrs,ing symptom!. FuJOll'lllide a(ts by prrftnting the of
sodium <lnd chloride in the loopofHenIe of the with
othe, diJft'tiu, furoll'01ide is jXlnKularly beneficial when ca,di output .nd re-
n.1 flow are severel)o diminished.
ADMINISTRATION ALERTS
Checkthe p.ltien(I II'rum potmiJm !Mis thedrug.
Ifpotassium the health urr plO'/ider befoll'
admininering.
!lui' to the prolon9l'd in inf.rmand neon.tes, the drug
mUll be UJed with uution.
Geriatric p.atientl may lower dam.
category C
PHARMACOKINETICS
il1l1't 30-6) min I'O;S min IV
60- 70 min 1'0;20-60 min IV
3D-60min
Dur. tion: 6-8 h PO; 2 h IV
24.5 Treatment of Heart Failure
with Cardiac Glycosides
Cardiac glyoosides were once used as arrow poisons by
African tribes and as medicines by the ancient Egyptians
and Romans. Their value in treating heart disorders lIas
been known for over 2,000 years. Extracted from the beau-
tiful flowering plants Digitalis purpurea (purple foxglove)
and Digitalis larraM (white foxglove), drugs from this class
are sometimes called digitalis glycosides. Until the discovery
of ACE inhibitors, cardiac glycosides were the mainstay of
HF treatmen t. Digoxin (Lanoxin) is the only drug in tltis
class available in the United States. The routes and dost' for
digoxin are listed in Table 24. 1.
The primary actions of digoxin are to caust' the heart to
beat more forcefully (positive inotropic effect) and mo re
slowly, thus improving cardiac output. The reduced heart
rate, combined with more forceful contractions, allows for
much greater efficiency of the heart.
Although digoxin dearly produces symptomatic im-
provement in patients, it does not reduce mortality from
HE Because of the development of safer and more effective
drugs such as ACE inhibitors, digoxin is now primarily used
for more advanced stages of HF, in combination with other
agents.
The margin of safety between a therapeutic dost' and a
toxic doseof digoxin is quite narrow, and severe adverseef-
ADVERSE EFFECTS
efIeo:u of furoStillidl', lie thole of mon diuretic:s, potential
t leurolytt imbalan(fS, tht !IIOII imporum of which is hypokalemia. BeuIM
fur=mide is 10 t fftoctiYe, Hu id 1015 mu51 bI> carefully monitOfl'd to pft'\'ent pos-
sible dehyd'<ltion hypott nsion. HypoYOlemi.J may call1l' orthostatic: hy-
potension.nd synropt.
Contrai nd ica\ions: indude hyper lI'ositil'ity to furostmide or
sulfon 1m .nurY, hep.atic (oma, . nd 1I'"lelt' Huid or tleurolyte depletion.
INTERACTIONS
1Wg- 1Wg: BKIUII' may<aU\f il pati@nts!DIg
GlI1bc: o#osidM, (ombination thenpy w;m dgoIin mll5l <afefUly
{oo(Wfl'nt Ull'with B,orodlfl
augs un rrsUI i1 hypol:almU. Wh@oIjiI'Mwithlithium,eliminationof ithium
dKRNd, UUIiIg. hq.a rill; of fll"0II'I0idf may dimirish the
and indn.
Lab Tests: futI\.Iom_ milY ilIrtR Mil@! foI the foIoMog: blood ghKOIf, BUN,
\8"l1li aIII)'liIt, (hoIfsnorol, trigIywidn. m _ fIfctroI)1H.
IlerbaVFoo:l: I..IrUown
of o.,.rdo,@: o..rdoll'will"""kin hypolenlion 'rwIl'fluid
<lnd eledrolytt Tft'atmrnt is supportive, with of fluids.nd
t leurolytH, and the possible administration of a mopIl'!lOr.
I!tftr III MyMlsblgKl (or IWJng 1'ror.t5.1 Fool! spK/II( 1I fM ituJI.
feets may result from lUlfllonitored t reatment. Digitaliza-
tion refers to a procedure in which t he dose of digoxin is
gradually increased until tissues become saturated with
the drug, and the symptoms of HF di minish. If the patient
is critically ill, digitalization can be accomplished rapidly
with IV doses in a controlled clinical environment and in
which potential adverse effeets are carefully monitored.
Patients who begin treatment outside the hospital may ex-
perience digitalization with digoxin over a period of 7
days, using dosing. In either cas .. , the is to deter_
mine the proper dost' of drug that may be administered
without undue adverse effects. Frequent serum digoxin
levels should be obtained during therapy, and the dosage
adjusted based on the laboratory results and the patient's
clinical response.
24.6 Treatment of Heart Failure
with Beta-Adrenergic Blockers
(Antagonists)
Cardiac glycosides and other drugs that produce a positive
inotropic effect increase the strength of myocardial contrac-
tion and are often used to reverse symptoms of HE It may
seem surprising, then, to fmd beta-adrenergic blockers--
drugs that exhibit a rregaril"e inotropic effect- prescribed
for this disease. Although this class of drugs does indeed
LibraryPirate
CNplfl 24 Drugs /0, ...... n Fallu,e 331
.... Prototype Drug I Digoxin (Dlglte/vLanoxm, Lanox/caps)
Therapeutic (lass: Drug for heart failure Pharmacologic (lass: Cardiac glytoside
ACTIONS AND USES
The primar; belll'fit 01 digoxin is its ability 10 ilKl'I"lI' lhe (om,actility or
strength of m)Ourdial (omraction--..a inotropic ac:lion. Digoxin ac-
(omplilhes Ihis by inhibi:ing Ha + K+ ATPall', lhe (ritic.J1 t lll)'lIII' I'I'spolllibir
10, pumping \Odium ionsout of lhe myocardial (ell in achange lor potassium
ionl. Assodium acrumulaltS, ca kium iolll ll'Iusrd hom their stor.Jge ami
in tht (ell. The l'I'itall' of y kium ions proilucrs a mOl"!' fOll:tful (omraction of the
lI"I)'OCardial fibers.
By ilKlNsing myowcial (ontractility, digoxin dirffily cardiac out-
put. thus alleviating sympoms ofHf and improving lOirr.JlKe. The im-
prwrd cardiac output in uriIII' prOO:Ktion and
reduction in blood wlulll', distressing 5)'mptoms 01 pulmonar; (00-
9I'stion and peripher.J1 rdtma.
In addition to its positi .... inotropic efffcl, digoxin affects im conduction
in the hea It Digoxin has bility 10 sUPIHffi the sinomia I (SA.! node and \low
(omtion Ihrcugh the ilriumltrirular (AV) node. Btca!M of thell'
<Iction1, digoxin is IOmetimrs used to is dilru\1f<l in
(hapter 26CX>.
ADMINISTRATION ALERTS
Take the apic.J1 pulll' 1 full minute, noting rhythm,.nd qualil)' IJt..
administering. If the pulll' is below the paramtlt rt"ltablishrd by the
he.kh provider (LlWIIy 60 bealS per minutt ), withhold lhe
ootify Ihr provider.
Cllt<k for re<tm II'NI! digoxin Itvtllt"lUlts before administmng.1I the
IrRI is highrr than the par.Jmrtrr established by lhe heakh provide,
(usually 1.8 nQlmU. withhold thedole and notify lhe prOYidrr.
Use with caution in gmalri( and pediatric: patirnll bK.iUII' thrll' popula-
tions may hoM' I'I'nal and hepatic: metabolic t nl)'mrs.
PlI'9nancyCillrgoryA
PHARMACOKINETICS
Onset: 111-90 min PO;S- lO min IV
h PI
Halllife: 1--4 days

]
have the potential to worsen HF, they have become stan-
dard therapy for many patients with this chronic disor-
der. Only two bela blockers are approved for the
treatment of HF-.....Q.rvedilol (Coreg) and metoprolol ex-
tended release (Toprol-XL). The doses of these agents are
listed in Table 24.1.
Patients with HF have excessive activation of the sympa-
thetic nen'ous system, which damages the heart and leads to
progression of the di<ease. Beta-adrenergic antagonists block
the cardiac actions oi the sympathetic nen'ous system, thus
slowing the heart rate and reducing blood pressure. Workload
on the heart is decrfased; after several months of therapy,
heart size, shape, and function return to normal in some pa-
tients. Extensive clinical research has demonstrated that the
ADVERSE EFFECTS
The most daogtfOUS adYme tffra of digoxin is its abilil)' 10 (lNte dysrhyth-
mi is, pmirularfy in patirnts who hal'!' h)'pokairmia 0' impaired I'I'ni I fUKtion.
Beow diurtliu can caUIl' h)1Kbirmia nd often UII'd 10 Il'I'al HF, (Gocur
I'I'm Iv. oldigoxin . nd diull'tiu must beca,tfully mooitOll'dOther ad!'J1I' rf-
ncts 01 digoxin thrr.Jpy naUSN, vomiting,latigut, . norexia, ,nd mual
disturlBntfS suc:h is ming halos" linge, or burring. I'triodic
serum drug lewis should be obtainrd 10 drtrnninr whether the digoxil (on-
(entration is within the theraptUtil: range.
Contraindi (ations: PaUton with AV block or !'Iltrirular unre-
lated to HF !hoold nOI re<t iYe digoxin bK.JUIl' Ihe drug II\a)' WOBrn theW' (on-
ditions. Digoxin YIouId be administered with caution 10 oldtr adults btcausr
thell' patients aptrience a higher ilKidenc:e of adYl'llt tffrcts. Patients "l'iith re-
nal impainntm should re<ffle mr doll'! 01 digoxin, beuull' the dllJ!j is a-
(1'I'1rd ly this route. The drug should be UII'd with caution in patirnts wth MI,
(or pulllOnale,or hypothyroidism.
INTERACTIONS
DrurOrug: Oigolillilmm wilh many trugs. Concwrenl UII' of digolill wim
diu rHiG can IlIUII' hypotakomia and irKri.R the rilIr of wim ill
mllilcn,spiOlloiaClOfll',OI potmium INd 10 and
reduce .... the!apMiI: iOion of digoxin. AOOIililtr. tion of.il with other
poW"/I! iIouopic agenlS yn aulo! effioaI on hoo <llIlIiKlility. Cooo.wIHIt
!lie beta bIockHI may ,t\Ifi il brody<;lldia. Antacids DI dIoIfIIeri-
Iowfrill OOM)I can dKrNIe the absorption of !igoIin.1f uki:.m olOOiiniliered IV
digollin,it un ilafilo! therilkol ()inidiM, vmponi,
am iod.Joof. and will demu the diltribulion and exuetion of digolin.
thu! inaNsing the rill; of digcl:il tollidty.
La bTl5IS: Unknown
Herbi Hood: GiRSfng may ilafi lo! the riIk 01 digollin ilia huang .and
ephfcIr; may ilriKt d)Yh)11v1iu.
Treat ment of Overdos!: Digoxin CIVffiIoII' un be fatal. Sptc:ific therapy ill-
wlm IV infusion 01 digoxin immulII' lab (Digibind), which contains <IntiJodiH
specific for digoxin.
IIrftr III M)NUIlIIJqm Alr Q Mmlnlj Pnxrll fIlM Jp1k III/lis drug.
proper use of beta blockers can dramatically reduce the nwn-
ber of HF-associated hospitalizations and deaths.
To benefit patients with HF, however, beta blockers
must be administered in a very specific manner. Initial
dose, must be 1/10 to 1/20 of the target dose. DOles are
doubled el'ery 2 weeks until the optimum dose is nached.
If therapy is begWl with \00 high a dose, or the dose is in-
crea.\ed too rapidly, beta blockers can worsen HF. Beta
bloders are rarely used as monotherapy for this disease,
bu t instead are usually combined with other agents, espe-
cially ACE inhibitors.
The hasic pharmacology of the beta blockers is
in chapter 1300. Other uses of the beta-adrenergic block-
ers are discussed elsewhere in this text: for hypertemion in


,


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LibraryPirate
ll2 Un'U lh"C.,dIoYHCU'" and U"""ry Syll""'''
NURSING PROCESS FOCUS PATIENTS RECElV'NG D'GDX'NTHERAPY
Assessment
Bilsflinf il55fss mfnt prior to administration:
Undermnd the rtuon the dlll9 hils betn prtscribtd in order to asSHS for
the,apeutic tffws.
Obtain a heakh histol1 including mdio'mcuiar (including prrvious MI,
hem faiull', renal dyslulKtion,dysrhythmias (rsptCially lINn
bloc:kJ,ilnd prt'glliln()' 01' l,ctation.Obtiin ,dlllll including allergies,
current PIl' scription .nd OlC dlU\Js. herbal pll'p.uations,ilnd akohol usr. Bt .len
to dlllll
Obt,in vit.!1 UQns and BP). brfil Th lOUnm,and
ECG.Aslt1s for location and characttr of rdema if prmnt.
[v,iwtt 'ppropriate laboratory *,trol)'lts,tljlfCially potJSli.lm ImI,
Il'nil l function studies,.nd lipid profiles.
ASSfSSrMnt thro ughout administration:
klr delirtil tlitraptlnic rffKu (t.g., htan ratt ind blood Il'lUm
to,or lI'I1\ain within,oonnal fimits; urintOUlput rtlUlIII to, or is within, norll'lll
congestion (if prt!eflt) improl'ed; peripht ral tdell'll (if
prtst nt) impJOI'td; inti of skin c.lpi lIal1 and otlitr
of jC)eqlllte perfusion all' within oonnallimiU; fitjglll' lesltnl).
Cominlll' periodic: roonitoring of pltmium, Il'nallulKtion,
.nd drug kYtk.
Asse'15 klr oJdYel"It nat.lltil, . norecia, visual
dizzintu,ordrowsintss. A pulst riTt btlow 60 0' .bol'e 100,
j)i Ipitations, munt dimntss 01' syncope, pe Bi slent i JIIlIl'Xia or \"Omiting.. ,nd
visual changes !hould bt ttporud ID thr hNkh art provider immtdiatrl)'.
ExercM caution when giving di\1Oxin to pedi.tric pllifnll,OI' j)ititnts
with rml inlUfficitl"K)'.lmmiTurt 01' dec:lints in ttn.llunction l1'li ke thm
popul.tions mort suSt:tpliblt to . dent
Potential Nursing Diagnoses
Orused Cardi.lc Output proctsS or rtialf<l tooJdme
efftcts of drug tlitr,py)
Fdtigue (distilse process or Il'lattd elftm of dlllll thmpy)
Aht rtd TMIII' PtrliJsion (reIatrd to disNsr proem)
Ac:tivitylntoieranct (reIattd to 01' .dver\t dftcts of
dlllllthmp)')
Otf"itnt Knowltdgt (drug tlitrapy)
I" ., . "'r.II,.;,.""o ,." ...... o .. ,,,,
Planning: Patient Goalsand Expected Outcomes
The patient will:
Experitnct tlitrapeutic tfftc:ts kg., ht'rt "te.nd blood rtmain within urint cotP'JI inatilsts to oonnal. fMiglll' lung
SO\Jnd! peripht,.!1 tdema dec:rtilt1).
Be from, or experience minima!. ,tlYersr tfftcts.
an undtrstanding of t lit drug's oJdYefSt effem, iI nd I"fquill'd prtUlJlions.
Otmonn"tt proper self-j(jminist"tion of rooIic'tion (e.g, dOlt, timing. wlltn to notify provider).
tmplementation
tnterventions and (Rationales)
Ensuring therlpeutlc tfftm:
ConTi nIII' frrtp'rn ilSlt1 YIIt nll is describtd fa rlitr for therapeutic: tffeds. (Blood
prtsillfl' and pulse should Il'turn to within normallimil>orwilhin pararnttm
It! by tht pfOllidtr;urine output returns to within nonnallimiU; pfriplitral
tdema dec:rtases;and ung IOUnd!dear.)
Enrou"9t appropriate lifestyllo changes. Provide for consultation ill
fIffiIed (Htikhy lifestyle chaJlC}l'l will IUppon the btntrns ofdrug therap)'.)
Patient lind Family Education
TeiICh The how to mooilOl' pullt and blood
pttllUrt. Enill,e tilt proper \/If and fUnctioning of any hoJlll'
equipJlll'm obtaintd.
Encouri9t the j)ititm to adopt a htalth)o lifl'll)'le of Iowfat food
choic:ts, inctta\td nereM, deCll'a\td akohol consumption, ,nd
smoking ctslilion. PWlide tduutioJlilI materials on
sodium food choice.
Instruct tilt patient to increast imakl' of pltmi.lmric:h foods mh as
bananas, apricots, kidfit)' potatOl'!, and punlJl buner.
LibraryPirate
IlIopltrU ]3]
NURSING PROCESS FOCUS PATIENTS RECEIVING DIGOXIN THERAPY (Coof illufti)
Impl e me ntation
Interventio ns and (Rationales)
Minlmlrl., achotrst fffem:
Continue 10 monitor vitahigm.Takun .plol pul!e (AI') !of 1 full III,fore
giving ttw, drug. Hold the drug and notify proYider ifhurt me is bfIow 60 or
.... l00.Monitor the Wi during dirJiuliufion ptriod for dysrhythmiiland
brady(atdit. (Digoxin is a positive inol.oflund OOws IINrt II iI strtnglhtM
comractilitJ.)
Continue 10 monitor ptrioci: M trolytt 1Mb,.nptciaIJ potmiJm.mwl
imction Llbs,drug Ievrk,.nd [{G. (Hypoulr,mi.l inc:re.\fS 1M risk: of
dyubythmi.ls.Serum digoxiIIlMIs should Itffijin Ins thaftl .8 nglmLl
Weigh tMp.atRmdailyand kg OItIIOIII:in .24-
hour ptriod. weight is .ft acrur.1t measure of IUd SUM .nd ukts into
I(OUnl int'R,output,and Io!m. 'Neght gain 01 edtmil Ny signal
imptnding hra" f.ilurt with ffIIucfd organ ptrMion,mmuiating ltIIin
!tItale.)
Monitorforsigns of woneing hNrt faiIIR (t.g., inCINSing dyspnu 01 poItur.J1
ftotturnal ct,spnu, ralft OI "aad\ts"in kirI9I> frothy lfIUIum) .nd
reporl immt<imly. (If signs iIId symplOfM worsen,otlle trtalmtnt options may
neoedtoMmmideredJ
Rtport signs of poIsibitligoUr toxicitJ immediile/y to the providoef alld obuin a
Sffim drug IMI.(Digoxin IMh should ItllWlin les m.n 1.8 nq/ml.Sigm and
i)'IIIptoms sum,as br.dyurdi.l, naum .nd 'IOmiting..norma, vilual chingfs,
depression 01 (h.1lC)eS in ItoweI 01 fatigut. I}'IKOpt
shoold III, ItjIOftrdJ
1M mra autiotl when the dow of mtdic.Jtion ordertd.nd 1M
I'Xtrtmt UUlion when liquid dost!,nptO.ly for pediol!ric patients.
(Diqoxin 1Iai. bng toxic IMh m.y wi!h only slNlamounu
of idditional cWg.)
Pltient umloel5t.nding of d .. g the..,:
1M opponooities during idminillrllian of medic.JtioM and during oIIWSgntnU
10 discuss rition.1e fordrug ther.j7)',dtsirtd most
common forwheo loall thr and illY
mon.ring Of prtUIItian (1MIg tirM during nulling a It hrl,s to
optimize and ltinfOKt wing irta5J
Patint HIf-ad .. inistrltion of drug tM ... p,:
When idministering mediations, instruct ttw, bmily,ora.r in
proptr llII-.administr.tion tKhniques. (Proptr .dminislmion imp lOftS thr
rf'IKti'ftntss of thedrug.)
Patient and Filmil )' Educiltion
Teac:h thr IHtient, f.miIJ,olCiregivel- how 10 tlku ptriphtr,1 pulse
beloit Wine; the drug.Assist tht patitnt to find thr puM lira most
conl'tllitnt ind Id. diily puke r.1tS .nd bring rmrd to
tiCh hralttl<alt -mitlnstrlKl tht patitnlto not late tht drug if the
pullt is btIow 60 or , bow l00and to moWt the proWIerfor furthtr
diJt<oOll.If the 01 buys i IIt1hoi<opt to like
pulst,ttr5Q1t proper .... rstlnding oIl1Nrt rounds 'ul>-6JtI of
hNnbrat is (liE hNrttM:.t), appropMr stet1losropt IM,.nd h_
or cartgNtr ltIum
InslllKtthr patient on 1M IIt'ed to Jttvm for I.b worl
thr patil!nt to tarry Willet idttrtfution cMd 01 wrar mtdicJl
identification jtwtIry iIIdiating dipin therapy.
HaYI'IM patient weigh ItIfdiily, idtaIy 111M diy,and
IKOrd wtight ilong oMth puke mtoIIUrenttrts. H.'/! the lIMitJlt
repOluwtightlossOfgiinofmortthan 1
.24-1!cu ptnxl.
InsllIKt thr IHtient 10 report.ny StwR shortnessof
bftllh, frothy lputum, profoo nd f.t9. 011 Wl'ning of txtrtmitits ill
possiblr, rigltl of hea" f.lbt.
InstllKt the patient Of caregNtr on signs to report to prvtider.
Enc:OIOJt ttw, palient 10 promplly rfIIOfI.ny signi{K.nt change in
0'fl'I.1I Malth or mtntil idirity.
('lIIian the lIMient on tiking ttw, PJt(i\t dowof medication ordeftd.
nol doubling dost if a dose is missed, and to 1M txlremt caution
when muswing pediatric patients.
InnllKtIM patient in adminismtion tKhniqun, IoIIoWfd by
rerum-dtmonmation.
1hr p.ltierl should 111,. 10 disruss .ppropriatt dosing and
.dministr.uion IIffik.
EVlluiltion of Outcome Criteria
kJluatt thr of drug therapy bJmnfinning that patient goals otrId txpttd OI/I(ome h.'/! bffil rntt (_"PLinning1.
Sfr WIlt l4.11111l1ff"rardiK
LibraryPirate
ll4 UnII4 Th" O rdkIY.S(ul. r.oo Url .... ry Syne<",
.... Prototype Drug I Metoprolol (Lopressor, ToproJ XL)
Therapeut ic ( lass: Drugforheartfailureand HTN Pharmacologic ( lass: Beta-adrenergic blolier
ACTIONS AND USES
Metoprolol is beta bIoc:krr , '/<Iilllble in t.bltt, sus"ined-
IV fonns.At it bm,l"f(tptors in
brondlial smooth IllU\(te. The drug ..cIS rroucing sympnhetK Slimul ilion of
tilt lItart, thus cardiac workload Metoprolol found to slow
the pI"Ogl!1sion of HF and to sign ifiuntly rmt tht Iong-tt nn oonsequtnm of
tht di stali'. k is usu.11y combined with other HF drugs IUCh <II ACE inhibitor!.
Metoprolol isako for angina,HTN,and for rro!Kiog urdia[ rompiiu-
tions following an MI.
ADMINISTRATION ALERTS
During IV administration, monitor thf ECG, blood nd
frrqll!'ntly.
AllI'Ss tht plJlst .nd blood administration.Hold if the
pulse is briow 60 bNlS ptr or if the patienl is hypotensiYf.
ArlYiII' tht p;llienl oot 10 crush or chew sumined-fl'lull' "blets.
Safloi)' and effKaC)' in childrt n undu . Of 6 Me not btt-n rstilbli shtd.
Dosn should be for t klerly patients bt u IM they at risk for
f.lIl .
category C
PHARMACOKINETICS
IAlstt: II)...IS min;lUItainfd unknown
Pe.k: 1.S-4 h; 6--12 h sumintd
3-4h
Duration: 6 h (24 h sul1ainfd
chapter 2JOO, for dysrhythmias in chapter 2600, and for
angina/myocardial infarction in chapter 2SOO.
Please refer 10 Nursing Process Focus: Patients Receiving
AdrenetWC-Antagonisl Therapyon page 316 in chapter 2300
for additional information.
24.7 Treatment of Heart Failure
with Vasodilators
The two primary drugs in this class, hydralazine (Apreso-
line) and isosor bide dinitrate (lsordil ), act directly to relax
blood vessels and lower blood pressure. Hydralazine acts on
arterioles. It is an effective antihypertensive drug, al though
it is not a drug of first choice for this indication. lsosorbide
dinitrate (lsordil) is an organic nitrate that acts on wins.
The drug is not very effective as monolherapy,and tolerance
develops to its actions with continued use.
Because the two drugs act synergistically, isosorbide dini-
trate is combined with hydralazine in the treatment of HE
BiDii is a fixed dose combination of 20 mg of isosorbide
dinitrate with 37.5 mg of hydralazine. The high incidence of
ADVERSE EFFECTS
BaIM it is selectMo for blocking 11m, rKtploo in the he,,!, IIII'toproiol has
flow adverst on othtr autonomic targets and thus is non-
beta bIoc:krrs suth as propraoolol for p;ltitnlS with repiratory disor-
ders. genmlly minor and to its .utooomic .ctMty,
IUCh assiowiog oftht hean rail'.nd multiple
on the he,rt. patients with hean should br urefully monitorro. Dthtr
adYerll'effrcn inckidt abnormal sexual fuigue,
<l ndifllOll1nia.
Contrai nd ications: This drug is contrai ndicufd in patients with <l l1hma, cardio-
grnic shock, brad)'Cirdiol, ht<ln bIoc:k than first and
u rdiac
INTERACTIONS
I)ug-l)ug: US!' willi dMpDr may rM! il bradyan!ia.lhl
IIlriKfjIIi"115 may CilMincrmed etft<ts.lMwithakOOolor
antih)'pr!lMli"ll5may iladditiw mayenl>.ar"a the
.. io. .. ,,"
Lab Tl5Is: M !loproloi may incrNlf for the IoIowiog: uric add,
pot.&ium, antiu:lHr antJ:oocly.
III'rbaVFoo:t: I..InI;nown
Treatment of Overdose: Atropint or can be to
br.ulycaroia calISI'd by """,,oprolol OYerdoIl'.Hypotfll sion may be by <I
nsopresor sum as or dobu"mine.
adverse effects, including reflex tachycardia and orthostatic
hypotension, however, limits their use to patients who can-
not tolerate ACE inhibitors. Hydralazine is featured as a
prototype drug in chapter 2JOO. A Nursing Process Focus:
Patients Receiving Direct VasodibtorTherapy can be found
on page .no in chapter 1300.
A third vasodilator used for HF is very different than hy-
dralazine or isosorbide dinitrate. Nesiritide ( Natrecor) is a
small-peptide hormone, produced through recombinant
DNA technology, that is structurally identical to human
beta- type natriuretic peptide (hBNP). When heart failure
occurs, the ventricles begin to secrete hBNP in response to
the increased stretch on the ventricular walls. hBNP en-
hances diuresis and renal e.u:retion of sodium.
In therapeutic doses, nesiritide causes vasodilation, which
contributes to reduced preload. By reducing preload and af.
terload, the drug c:omperuates for diminished cardiac func-
tion. The use of nesiritide is very limited because it can rapidly
cause severe hypotension . The drug is given by IV infusion,
and patients require continuous monitoring. It is approved
only for patients with acutely decompensated heart failure.
LibraryPirate
24.S Treatment of Heart Failure
with Phosphodiesterase Inhibitors
and Other Inotropic Drugs
Advancoo HF can be a medical and prompt, ef-
fective treatment is neces5llry to avoid organ failure or
death. In addition 10 high doses of use of positive
inotropic drugs is often neces5lll')'. The tWO primary classes
of inotropic agents used for deoompensated HF are phos-
phodiesterase inhibitors and agonists.
In the 1980s, twodrugsbwlmeavailable that block theen-
zyme in cardiac and smooth muscle. Block-
ing phosphodiesterase has the effect of increasing !he
amountofcalcium for myocardial contraction. The
inhibition results in two main actions that benefit patients
with HF: a positive inotropic action and vasodilation. Car-
diac output is improved becaus. of the increase in contractil _
ity and the decrease in left vmlricuiar afterload. The
phosphodiesterase inhibitors have a very brief half_life and
are occasionally used for the control of acute
heart failure. listed in Table 24.1.
Because of their toxicity phosphodiesterase inhibitors are
reserved for patients who have not responded to ACE in-
hibitors or cardiac glycosides, and they generally used
for only 2 to 3 days. Prior to 2000, inamrinone was called
H OME & COMMUNITY CONSIDERATIONS
- ---- -----
Psychosocialluues and Adherence In Patients
with Heart Failure
P.nimu with ,lid Ikk IIf SO(iil SUHOrt who Hf bHn
lhown tI bt 1m mmlt with thriI drug tbeliPY Itgimft"t. P,1irm III' aka
1m IiRIr III politioN' iftstyIt mooific;lIi,," w4Ien dtpms.d. 1hr
mnr lhedd 1I\e5 iIsurs in jNlimu with HF int_ ippfOpri.
.. whr!J JNf bt .mrII'd 10 utdiic rthibiution pro-
gr-,whidl 11m bren sMwa to inoHIt hi! bteII
!hit IRstyi!, dwlJ!le ft i-equently rtliled kI tlltd lUg
snuil desft MId p!ObIft"nll.Many p.lltimu tht
igliml !hoe drug's benefiu w 6ettrmine tht .I riJKu
--":Ih tho pltifnb CiA l1li10"9"" .. whot they (1)11-
siltr I nomIillifnl}4e. thIy II\f)"
(lgp", l>I Orugsfot Hearl ns
amrinone. The name was changed to prevent medication
errors: The name amrinone looked and sounded too simila r
to amiodarone, an anlidysrhythmic drug.
Bela-adrenergicagonist!; occasionally used for HF indude
isoproterenol (lsuprd), rpinephrine, norepinephrine,
dopamine, and dobulamine. Dobutamioe has bn a tradi_
tional drug of choke in this class bealuse it has the ability to
increase m)0C3rdiai contr.Ktility rapidJy and drectivdy, with
minimal changes to heart rate or blood pressure. This is im_
portant because increases in heart rate or blood pressure in_
crease the oxygen demands on the heart and possibly worsm
HE Therapy with dobutamine is usuaUy limited to n hours.
The two most common adverse effecls of beta agonist!; are
and dysrhytlunias. The basic phaonarology of
!he beta-adrenergic agonist!; was presented in chapter 1300.
Epinephrine is featured as a prototype drug for anaphylaxis
on page4]4 in chapter29, and dopamint is featured asa pro-
totype drug for shock on page 412 tn chapter l 'JOC.
COMPLEMENTARY AND A LTERNATIVE T HERkPIES
Carnitine for Heart Disease
Cimitilll' iia MlUril llructurally limilir to ,mino acm. ks primiry
function in mrllboIiim is to mctYe Kid! from th' bloodstrum into "lis,
whtrt Clmitine aslilu in tilt brtakdown of lipid! th' prodlJClion of ,n-
' f9)'.Tht bt!t food (Imitiroe artol1)ln mtil,fJSh,mUl(le mUII.lrod
milk produm.Camitint is milal:W II I IUpplemtnt in srwil forms, irKlJd.
ing L -umitine, lk.imitine, Inc! KrtyI-l-umitiroe. lk.irnitin' is modal'"
with poumial mltllfrn,and \hCIYId bt 1Oided.
C,mitint hal bttn dtimed to mtwIKt lrod !pOrts peflorrn.lJl(t.
he.Jn btl/tit, mrlllOf)', immUO! function, illd rrWe lenity. k is sometinfs

Camitint hll bttn olmliftly IludiecI. ThM is IIIIid evM:Itna 10 S<lJlport
suppimlmtatioo in pilRnb who ift dtOOtnt Although i_I
dirt wpplits )00 mg ptr d.y, man jNIit!lu, SIKh is or thow
willi Min mar Iftd additionll WOOOIS.Umitirlt
hi! bttn Ihown., in jNlienuwilll
clamilint IIIJY prtWnI 1M DUt.mll(t cI dJlrhy1hmill in!hoearty Itq$ cI
hNrt 1iINw. 1111 aka bttn lhown III de<rtllt IMk
whit ilcruling II)l wrum Inm, thus helping tI minimize 0IIt rJI!hoe major
rill! fKtDn will br.rt RtltMh hllflllllhown

01 'Mig1"l1M\.
LibraryPirate
))6 1tIIIM . The CirdloYascubr M1d Urinary Sy!lenll
Protot ype Drug I Ml lf1none (Pnmacor)
Therllptutlc (111.51: Drug for heirt failure PhannlCologlc Clm: inhibitor
ACTIONS AND USES
01 tile two phosphodintrmr inhibKon a .... is grnmlly
beause it 1Ir0l1tf ftwerside effe.m.k isgiwlr
tr,ttrously and is primarily !MIl IOf IfIt lIrorHtrm tlltlil", of adnrKtd HUbt
drug 111$ a rapid OrtW of action.lmmediite tfrNtt of .n
Otued Joru of lI'I)toullbl <ontraclioft and an Mase urdiac output.
ADMINISTRATION AlERTS
Wlltn tIIis mediGtoon is .dministtrtd IV,' miaod11t set ,nd M
poolp should IN- UItd.
Saftt,o ,nd fflicacy IIiIIl' not been HlirblMtd in geriatric and pediatric
patients.
PrtgMncy utt90tY (
PHARMACOKINETICS
DlittHOmin
PI!":IOmin

Dur.Iion:Yariablt
. :i Chapter REVIEW
KEY CONCEPTS
ADVERSE EFFECTS
most seriIM of milrinortf is Y!rtOOrlar d)oI;r!Jythmil, lWiich
IIIiY O(cur 1 of 10 patientmking tile drug. The p,atienl's ECG IIr<ruId be
monitortd mrrtinUOl6ly IiJring the inMiOl'r of tilt drug. 8Iood j:ftlMJrt is .110
conrinLlOlllIy moniIDrtd during IfIt infusion to prt'lft\t hypottmion.ltis serio
ous side tffts in<kIdt headache,n,usea, and 'oOmitillg.
Cootraindications: The only CDIItr3indiotion to mimone is prtYious hyper
-ivily to tilt drug. Milrinont should be used with uution ill patienB with
pl(ftisting d)oI;rlrythrniis.
INTERACTIONS
trug-q MiRilnt ilfr.Jl:nrilr hypotl'lllialL
Cntion sboItI be IIsed wilen admiMlllmj miri_"lritbligoxill. dotrdlinllrw, (If
GIller mtropitliMJl,WIO' thIoir pMi.,.. ilKKfOlic .tfem. tMlINrt be
-..
L Tesu: lIIIbIown
IifmVFtod: LnI;_
TlNunent of Derdow: Ovmlose UUle h)'polfltSUr, lWiid! is uutfd with
the idministrilion 01 normal saline or i
111* lit /rIf1U'filqXl ffII. /UJJII9 PreI'! FocJ/l fllKlt/r II 1M d'uJ
The numbered key concepts provide a succinct sununary of the important poi nts from the corresponding numbered section
within the chapter. If any of these points Ife IIQt clear, refer to the numbered section wi thin the ch.apter for review.
24.1 Ht'art failur .. is clo!;.-Iy associated with chronk hyperten.
sion, coronary artery disease, and diabetes.
24.2 Th .. body attempts to compensate for HF by increasing
cardiac out put. Preload and afterload are two primary
factors determining cardiac outpUl.
24.3 ACE inhibitors reduce symptoms of HF by lowering
blood pressure, reducing peripheral edema, and increas-
ing cardiacoutput. They are drugs of choice for the treat -
ment of HE
24A Diuretics relieve symptoms of HF by reducing fluid over-
lood and de<:reasing blood pressure.
24.5 Cardiac glycosides increase the force of myocardial con-
traction and were once drugs of choice for HE Because of
their low safety margin, and the development of more ef-
fec1ive drugs, their use hasdeclinoo.
24,6 Beta_adrenergic blockers.s\Qw the heart rate and decrease
blood pressure. They can dramatically reduct' hospitaliza
tions and increase the survival of pnients with HF.
24.7 Vasodilators an relieve sympt omsof HF by redudng pre-
load and decreasing the ca.rdiac workload. Nesi ritide (Na-
trecor) is a newer YlIsodiiator approved for the treatment
of acute HE
24.& Phosphodiest ... rase inhibitors and oth ... r inotropic agents
increase the force of myocardial oontraction and improw
cardiac output Tbt-y are used for the short term th ... rapy
ofacute HE
LibraryPirate
REVIEW QUESTIONS
D The patient Is prescribed dlgOlln (Lanoxin) for treatment
of HF. Which of the following statements by the patient
indicates the need (or further leaching!
1. KI may notice myheart rate deqease,"
2. K] ITIiIy feel tired during early treatment.-
l. KThisdrug will help my heart muscle pump less blood."
4. "My heart ralewill speed up."
D The nurse reviews lab studies of a patient
digoxin (Lanoxin). Intervention brlhe nurse is required if
the resuits indude a:
1. serumdigoxinlewlofJ.2ng/dL
2. serum potassium level ofJ.O mEqlL.
}. hemoglobin of 14.4 gldL
4. serumsodiwnlevelofl40mEqIL
o Nursing inlerventioru during initial therapy with ACE in-
hibitors must include:
I. monitoring ECG.
2. monitoring intake and output.
l. monitoring blood pre5SUre.
4. monitoring
D The teaching pbn for a patient receiving thiazide diuret-
Ics should Include:
1. taking the apical pulse.
2. including citrus fruits, melons-and vegetables In the
d.
CRITICAL THINKING QUESTIONS
1. A patient isnew\ydiagnosedwlth mild hean failure. Thepa.
tlent has been started on digoxin (Lanoxln). What objective
evidence would indicate that this drug has been
2. A 69-year-old patien! has a sudden onset of acute pul.
monary edema. The plltient has no past cardiac history, is
allergic to sulfll antihiotics,and routinely takes 00 medica
tlons.. The health care prol/ider ordt'JS furosemide ( Lasix)
to relieve the pulmonary congestion. Whllt interventions
are essential in the care of this patienH
1. A patient who Is diabetic and hypt'Jtensive Is started on
ACE inhibitors fo r mild hean failure. What teaching is im
portant for this patient?
Su Appendix D /ortln5"'l'n and rationales for all activitia.
3. decreasing potassiwn-rkh food In the diet.
4. checking blood pressure three times a day.
o Lisinopril (Prinivil ) is part of the treatment regimen for a
patient with HE The nurse monitors the patient for the
side effects of this drug which may Include: (Select aU that
apply.)
I. hyperkalemia.
2. hypokalemia.
3. 0XIg.h.
4. diuiness.
5. headache.
o Therapeutic effects of inotropic agents given for
heart failure indude:
I. the heart T<lle increases 10 nannai, allowing the llP to
,",
2. edema is decreased because of diuretic effOClS.
3. the BP returns tonormal and urine output rlsesas the
heart contracts more foo:efu1ly.
4. the heart's conduction system returns to a more regular
pattern.


M'/f*IrsIngM Is JW" Mt SlOp 101 dlilpler I't">4e-tor mattrialS lild
fV901Jrce5. for IMlh alktitiooal ua .. Ex-5t,1e prar;tica
QlleSIiJrls, IntertlCllve 8SIi[lmlflllS ancl aClil'lIIes, wm links, aninalions

fiegl5er yro- acc::t9S IIIIIr! Imm Iht trmt of)llll.lr boOIc at
www.mrnuru.akll can.
LibraryPirate
DRUGS AT A GLANCE
ORGANIC NITRATES (ia9tJ4/
Q nllTOg/yctfln (NlfrOJlat Nlfro-81d, MfrO-
OUr, olhm) pogOl4
BETA-ADRENERGIC BLOCKERS (ANlAGON ISIS)
",, " J
o o/enolol (Tenormln) fJIIj! J47
CALCIUM CHANNEL BLOCKERS p!XJt J.j)
Q diJ/lozem (Corofzem, Clift/II IT, Dilator
)(R, TazrJo Xl; TlClza() pu;t 348
THROMBOLVTI (S fli9t J48
o relepku4I ptJgt liI
ADJUNCT DRUGS FOR MYOCARDIAL INFARCTION
",,",
KEY TERMS
anginil fUjt)19
il thelOsderosis fX!(}t 339
(orona ry artery bypass graft (CABG) su fgrfy
'"'''''
{oronary artery diseaS!' ((AD) pIl9l' jJ9
Chapter 25
Drugs for Angina Pectoris
and Myocardial Infarction
LEARNING OUTCOMES
Aft,r 'tad/ng this chopler, the Jfudent should be obit to:
1. Explain the relationship between atherosderosls and coronary artery
disease.
2 . Describe factors that affect myocardial oxygen supply and demand.
3. Explain the pathophysiology of ling Ina pectori s lind myocardial
Infarction.
4 . Describe the nurse's role in the pharmacologic manage ment of patients
with angina a nd myocardial Infarction.
S. Explain mechanisms by which drugs Clln be used to decrellse cardlliC
oxygen demllnd lind relieve angina pain.
6 . Ide ntify dasses of drugs that are given t o treat the symptoms and
compli cations of myocardial infarction.
7 . For eac h of the drug cillsses listed In Drugs at a Glance, know
representative drug elUlmples,and explain their mechanism of lIctlon,
primary actlons,and Important adverse effects.
8 . Use the nur sing process to care for patients who are receiving drug
therapy for angina and myocardi al Infarction.
glyroprotein IIbll llii
myomdial infarction (MI)
myocardial pI!9f 119
transluminal (oronary
angioplasty {PlCA} pagt J1
plaque
si lent anginil {XJgt 11
mblranginil

vilSospastlc(Prinzmftal's)ilnginii 140
LibraryPirate
A
ll tissues and organs of the body are dependent on II
continuous arterial supply of oxygen and other vital nu-
trients to support life and health. With its high metabolic re-
qui rements,the heart in particular demands II steady source
of oxygen. Should the arterial blood supply become com-
promised,cardiovascular function may become impaired, re-
sulting in angina pectoris, myocardial infarction (MI), and
possibly death. This chapter focuses on the pharmacologic
interventions related to angina pectoris and MI.
25.1 Etiology of Coronary Artery
Disease and Myocardial Ischemia
The heart, from the moment it bt>gins to flUlction in utero
until death, works to distribute oxygen and nutrients via its
nonstop pumping action. It is the hardest working organ in
the body. functioning continually during both activity and
rest. Because tlte Iteart is a muscle, it needs a steady supply
of nourishment to sustain itself and to maintain t he sys-
temic circulation in a balanced state of equilibriwn. Any
distW"ban'e in blood flow to the vital organs or the my-
ocardium itself---even for brief episodes---can result in life-
threatening consequences.
The myocardiwn receives its blood supply via the right
and left coronary arteries, wlticlt arise within tlte aortic si-
nuses at tlte base of the aorta. These arteries furtlH.'r
into smaller brancltes that encircle tlte Iteart, bringing car-
diac muscle a continuous supply of oxygen and nutrients.
Coronary (CAD) is one of tlte leading causes of
mortality in tlte United States. The primary defining char-
acteristic of CAD is narrowing or occlusion of a coronary
artery. The narrowing deprives cells of needed oxygen and
nutrients, .. condition known <IS myo<ilrdiol i" homio. If the is-
chemia develops over a long period of time, the heart may
compensate for its inadequate blood supply, and the patient
may experience no symptoms. Indeed, coronary arteries
may be occluded as much as 50% or more and cause no
symptoms. As CAD progresses, however, the myocardium
does not receive enough oxygen to meet the metabolic de-
mands of the Iteart, and symptoms of angina begin to ap-
pear. Persistent myocardial ischemia may lead to heart
attack.
The most common etiology of CAD in adults is
atherosc lerosis. the presence of plaque--a fatty, fibrous material
within the walls of the coronary arteries. Plaque develops
progressively over time, producing varying degrees of in-
travascular narrowing, and a situation that results in partial
or total blockage of tlte vessel. In addition, the plaque im-
pairs nonnal vessel elasticity, and the coronary vessel is un-
able to dilate properly when the myoamlium needs
additional blood or oxygen, such as during periods of exer-
au;uJlluI"tiuIl uu.un; Krauu;illy, f.'<'riu<.!, uf
40 to 50 years in some individuals, but actually begins to ac-
crue early in life. The of atherosclerosis is illus-
trated in Figure 25.1.
(lIoplHn Drug. (0< Angina """1Orl<.nd Myoc.rdl.llnbrctlon 339
,OJ
Moderate
narrowing
of lumen
Th ......
partially
occluding I..........,
Figurf 25.1 AtherosclerosIs In the coronary arteries
Source: MJMMI er 01., Human DlsNse>: A Sy<;tematk: Approach,
6th ed, 115. p.?rmllslori ofrwrSCfl f lixat/oll,
tic, Uppef Saddle Rlvr!r, N1
ANGINA PECTORIS
Angina pfttc."is is acute chest pain caused by insufficient oxy-
gen to a portion of the myoaudium. More than 6 million
Americans have angina pectoris, with over 350,(X)() nt'W
cases occW"ring each It is more prevalent in tltose over
55 years of age.
25.2 Pathogenesis
of Angina Pectoris
The classic presentation of angina pectoris is steady, intense
pain in the anterior chest, sometimes accompanied by a
crushing or constricting sensation. The discomfort may ra-
diate to the left shoulder and proceed down the left arm and
it may extend posterior to the thoracic spine or move upward
to the jaw. In some patients, the pain is experienced in the
midepigastrium or abdominal area. Recent studies
that women do not always present with the classic symptoms
of angina. In women, gastric distress, nausea and vomiting,
a burning sensation in the chest or chest wall, overwhelming
fatigue, and sweating may be more common symptoms. For
most patients, the discomfort is accompanied bysevere emo-
tional distreliS-1l feeling of panic with fear of impending
deatlt. There is usually pallor, dyspnea witlt cyanosis, di-
aphoresis, tachycardia, and elevated blood pressure.
Angina pain is usually precipitated by physical exertion or
emotional excitement---events associated with increased
myoCtlrdial oxygen demand. Narrowed coronary arteries
containing atherosclerotic deposits the proper flow
of oxygen and nutrients to the stressed cardiac muscle.
LibraryPirate
140 UnII4 The ,nd Urinary Syl1""'!
Angina pectoris episodes are usually of short duration. \Vith
physical rest andlorstress reduction, the increased demands
on the heart diminish, and the dis<:omfort subsides within 5
to 10 minutes.
There are several types of angina. When angina occur-
rences are predictable as to frequency, d u_
ration, the condition is described as classic or The
pain associated with stable angina is usually relieved by rest.
A second type of angina, known as vasospasti( or Prinl metal',
angina occurs when the decreased myocardial blood flow is
caused by 5P(l5111S of the coronary arteries. The vessels Wl-
dergoing spasms may or may not contain atherosclerotic
plaque. Vasospastic angina pain Occurs most often during
periods of rest, although it may occur unpredictably, and be
Wlrelated to r est or activity.
Silent angina is a form of the disease that occurs in the ab-
sence of angina pain. One or more coronary arteries are oc-
cluded, but the patient remains asymptomatic. Although
the mechanisms underlying silent angina are not completely
Wlderstood, the condition is associated with a high risk for
acute Ml and sudden death.
When episodes of angina arise more frequently, become
more intense, and occur during periods of rest, the cond.i-
tion is called unstable angina. Unstable angina is a type of acute
coronary syndrome in which a portion of plaque within a
coronary artery ruptures. A thrombus quickly builds on the
displaced plaque, and the artery becomes in serious danger
of occlusion. This condition is a medical emergency requir-
ing aggressive medical intervention because it is associated
with an increased risk for M!.
Angina pain often parallels the signs and symptomatology
of a heart att ack. It is extremely important that the health
care provider be able to accurately identify the characteristics
that differentiate the two conditions, because the pharmaco-
logic interventions related to angina differ considerably from
those ofM!. Angina, although painful and distressing, rarely
leads to a fatal outoome, and the chest pain is usually imme-
diately relieved by nitroglycerin. Myocardial infarction, how-
ever, carries a high mortality rate if appropriate treatment is
delayed. Phar macologic intervention must be initiated im-
mediately and systematically maintained in the event of M!.
The nurse should Wlderstand that a number of oondi-
tions-many unrelated to cardiac pathology- may cause
chest pain. These include gallstones, peptic ulcer disease,
esophageal biliary disease, pneumonia, musculoskele-
tal injuries, and certain cancCTS. \I/hen a person pr=nlll with
chest pain, the foremost objective for the health care provider
is to quickly determine the cause of the pain so that proper,
effective interventions can be delivered.
25.3 Nonpharmacologic
Management of Angina
A combination of variables influence the development and
progression of CAD, including dietary patterns and lifestyle
choices. The nurse is instrwnental in teaching patients how
to prevent CAD as well as how to lower the rate of recur-
PHARMFACT5
Angina Pectoris
0Yer9 million haY!' angina pectoris; 500,000 new mes oc:rur

lO% of the dl'athsdUl' to rardiovmu]a, are auributed to
smoking.
Myocardial Infarction
Morethan 1.1
About one third of the patitnn experiMC:ing lolls will die from
About 60% of the patienu who died wddenly ofMI had no
symptorm of the disem.
More than 20% of men and 4O'lb of will die from MI within 1 )'I'ar
after bring diagnostd.
renee of angina episodes. Such support includes the formu-
lation of a comprehensive plan of care that incorporates
psychosocial support and an individualized teaching plan.
The patient needs to understand the causes of angina, iden-
tify the conditions and situations tltat trigger it, and de-
velop motivation to modify behaviors associated with the
disease.
Listing therapeutic lifestyle behaviors that modify the de-
velopment and progression of cardiovascular disease (CVD)
may seem repetitious, as the student has encountered these
same factors in chapters on hypertension, hyperlipidemia,
and heart disease. However, the importance of prevention
and mrumgement ofCVD through nonpharmaoologic means
carmot be overemphasized. Prncticing healthy lifestyle habits
can prevent CAD in many individuals and slow the progression
of the disease in those who have plaque buildup. The follow-
ing f;u;tors have been shown to reduce the incidence of CAD:
Limit alcohol consumption to small amounts.
Eliminate foods high in cholesterol or saturated fats.
Keep blood cholesterol and other lipid indicators within
the normal ranges.
Do not use tobacco.
Keep blood pressure within the normal range.
Ext-rcise regularly and maintain optimwn weight.
Keep blood glucose levels within normal range.
Limit salt (sodium) intake.
When the coronary arteries are significantly obstructed,
the two most common interventions are percutaneous translu-
minal (oronary angioplasty( PTCA), with stent insertion, and (oronary
mery bypass graft (CABG) surgtry. PTCA is a procedure whereby
the area of narrowing is dilated using either a balloon
catheter or a (aser. Because the artery may return to its orig-
inal narrowed state after the procedure,a stent is sometimes
used in conjunction with a balloon angioplasty. Angioplasty
with stenting typically relieves 90% of the original blockage
in the artery. The patient usually receives aspirin therapy 2
hours prior to the procedure and hep.arin for 24 hours after
LibraryPirate
TREATING THE DIVERSE PATIENT
The Influence of Gender and Ethnicity on Angina
AlHjfU more in ftlllille than but tilt prmmofMI is
hilhtr among men than women.Among rthni 1Jtl4l\ the iKiitn' of alHjna is
hillirst amongst Afritan AmMc.ans, foIlJwfll by Hilparic AmtriaM and (au-
cawns,andlow.-!t inkian pojUamM.AfritanAmerianfrmaes hM-lWir tilt
riskof angina COOlpiredwith African Amtrian
IlecauleWOllltll mol)' wol)' oo.any
epigastrior,ht!i alN pail,rsprciallyocQJI1;ngwith emtiJn,shluld
milimtheirdismmM,deIay-
ing trNtment.Wralrmmnudie hM-suggrstedthatwomrnand propirfrom
South kia with angina ma)' dilial Until more dtfinilil'r
sll.dirs [ooductro, d any gtnder or ffiOlIJraged 10
!l'!'k mmedatr attrntion for {lirst diKombrt ocrumng with emtiJn or rmo-
mnal Siresam nat drlay pmiJltnatmtnl
the completion of angioplasty to minimize the risk of
thmmhllS formM;on.
Coronary bypass surgery is reserved for severe cases of
coronary blockage that cannot be dealt with by less invasive
treatment modalities. A portion of a vein from the leg or
chest is used to create a "bypass artery." One end of the graft
is sewn to the aorta and the other end to the coronary artery
beyond the narrowed area. Blood from the aorta then flows
through the new grafted vessel to the heart muscle, "bypass-
ing" the blockage in the coronary artery. The result is in-
creased blood flow to the heart muscle, which reduces
angina and the risk of MI.
25.4 Pharmacologic Management
of Angina
There are several desired therapeutic outcomes for a patient
receiving pharmacotherapy for angina. A primary goal is to
reduce the intensity and frequeng> of angina episodes. Ad-
ditionally, successful pharmacotherapy should improve ex-
ercise tolerance and allow the patient to participate more
actively in activities of daily living. Longterm goals include
extending the patient's life span by preventing serious con-
sequences of ischemic heart disease such as dysrhythmias,
heart failure, and MI. To be most effective, pharmacother-
apy must be accompanied by therapeutic lifestyle changes
that promote a healthy heart.
Although various drug classes are used to treat the dis-
ease, antianginal med.icatioru; may be placed into two basic
categories: those that terminate an acute angina episode in
progress, and those that decrease the frequency of angina
episodes. The primary mearu; by which antianginal drugs
accomplish these goals is to reduce the myocardial demand
for oxygen. This may be accomplished by the following
mechanisms:
Slowing the heart rate
Dilating veins so the heart receives less blood (reduced
preload)
',,"pltll> Drug.fo< """ron..nd M)'OC. ,d!.1llnr.rctlon 341
HOME & COMMUNITY CONSIDERATIONS
Cardiopulmonary Resuscitation (CPRJ
and Other Education for Heart Disease
CoIOllilI)' lINn is tilt killrr in thr United For this
INson it is im[ll'l"ui\<rthit indMduals leam CPR and rnc:ouraqr othrIS to
(01lI!' In additiJn, nUM! in a position to tducall' those
in on mtlhods 10 lower thtir risks for (0I01Ii1)' lINn dis-
t.!lI'. EckJutiJn [Il'I"taining to positiYt lifestyle ,h.!nges,cootrolling hypertrn-
sion,.nd smoking [esalion important to tiKlNSt an indiidwl's
(hangl's!lKh M dt{ft'Ming dieul)' fat intake
of fruit and in rtgUlar rIIt ntiallO
limiting OIl!"S risk 10, (OIOnal)' hfilrt dill'all'.
Causing the heart to ,ontract with less for<:e (redu,ed
contractility)
Lowering blood pressure, thus offering the heart less
resistance when ejecting blood from its chambers
(reduced afterload)
The pharmacotherapy of angina uses three classes of
drugs: organic nitrates, beta-adrenergic antagonists, and
calcium channel blockers. Rapid-acting organic nitrates are
drugs of choice for terminating acute angina pain. Beta-
adrenergic blockers are drugs of choice for preventing
angina pain, although calcium channel blockers are used
when beta blockers are not tolerated well bya patient. Long-
acting nitrates, given by the oral or transdermal routes, are
effective alternatives. Persistent angina requires drugs from
two or more ciasses,such as a beta-adrenergic blocker com-
bined with a long-acting nitrate or calcium channel blocker.
Pharmacotherapy Illustrated 25.1 illustrates the mecha-
nisms of action of drugs used to prevent and treat coronary
artery disease.
Approved in 2006, ranolazine (Ranex.a) is a newer drug
for angina. Ranolazine is believed to act by shifting the me-
tabolism of cardiac muscle cells 50 that they utilize glu"lSe
as the primary energy source rather than fatty acids. This
decreases the metabolic rate and oxygen demands of my-
ocardial cells. Thus, this is the only antianginal that acts
through its metabolic effects, rather than hemodYllamic ef-
fects: Ranolazine does not change heart rate or blood pres-
sure. The drug is well tolerated, with dizziness, nausea,
constipation, and headache being the most frequently re-
ported adverse effects. It is used to prevent anginal episodes:
It will not tenninate an acute attack. The drug is only ap-
proved for chronic angina that has not responded to other
drugs.
ORGANIC NITRATES
After their medicinal properties were discovered in 1857,
the organic nitrates became the mainstay for the treatment
of angina. Theirmechanismof action is the result of the for-
mation of nitric acid, a potent vasodilator, in vascular
smooth muscle.
LibraryPirate
342 UnII4 Thi>C.'dkIYao;(ul .. . o<I U,I",,'Y synem,
PHARMACOTHERAPY ILLUSTRATED
25.1 Mechanisms of Action of Drugs Used to Treat Angina
e" t. -adren"rgic ""tagonist
Decrea"" the heart ,at" and
myocardial contractility
Reduce c ... diac output and
"","0""
Sympathetic
OOrYDUS syslom
Calcium channel block ..
[);Iale arterial sm:>olh muse"',
reducing blood pressure and
dacreuing cardiac worldoad
So"... aI"" dacreaH the .... art
,at", reducing the wotkIoad on
the heart, and dilate the
CDR>nII'Y art""",,
Organic nitrat".
Dilate vein. , reducing t he amount 01
!l!oo<:! ttl!! "-It

Dilate the coronary wi..,.; ..... bringing
mono blood to t .... myocardium

25.5 Treating Angina
with Organic Nitrates
The primary theT3peutic action of the organic nitT3tes is
their ability to relax both arterial and venous smooth mus-
cle. Dilation ofveins reduces the amount of blood returning
to the heart (preload), so the chambers comain a smaller
volume. With less blood for the ventricles to pwnp, cardiac
output is reduced and the workload on the heart is de-
creased, thereby lowering myocardial oxygen demand. The
therapeutic outcome is that chest pain is alleviated and
episod ... of angina become Ie fr"'luent. The organic ni_
trates are shown in Table 25.1.
Organic nitT3tes also have the ability to dilate coronary
arteries, which was once thought to be their primary
mechanism of action. It seems logical that dilating a par-
tially occluded coronary artery would allow more oxygen
to reach the ischemic tissue. Although this effect does in-
deed occur, it is no longer considered the primary mech-
anism of nitT3te action in stable angina. This action,
however, is crucial in treating vasospastic angina, in
which the chest pain is caused by coronary artery spasm.
The organic nitrates can relax these spasms, allowing
more oxygen to reach the myocardium, therebyterminat-
ing the pain.
Organic nitrates are of two types, short acting and long act-
ing. The short -acting nitrates,such as nitroglycerin, are taken
sublingually to quickly terminate an acute angina episode.
LOllg-acting nitrates, such as isosorbide dinitrate (Dilatate,
lsordil), are taken orally or delivered through a tT3nsdermai
patch to decrease the frequency and severity of angina
episodes. Long-acting organic nitrates are also occasionally
used to treat symptoms of heart failure, and their role in the
treatment of this disease is discur.sed in chapter 2400.
Tolerance is a conunon and potentially serious problem
with the long-acting organic nitrates. The magnitude of the
tolerance depends on the dosage and the frequency of drug
administration. Although tolerance develops rapidly, after
only 24 hours of therapy in some patients, it also disappears
rapidly when the drug is withheld. Patients are often in-
structed to remove the transdermal patch for 6 to 12 hours
each day or withhold the night-time dose of the oral med -
ications to delay the development of tolerance. Because the
oxygen demands of the heart during sleep are diminished,
the patient with stable angina experiences few angina
episodes during this drug-free interval.
LibraryPirate
(hopltllS Drug.to< Angina Pl!<:rorl<.nd Myoc.,dl.llnbn:tion 343
TABLE 15.11 S"I"ct"d Drugs for Angina and Myocardial Infarction
On"
Route and Adult !:lose (max dose where Indicated) Effects
ORGANIC NITRATES


(lmdll'.1Imo, Moooktl)
Q nitrogly(m. NiUo.DtI',
HiIfo.Bid.OIlltrs)
Inhalation; (O.IS--{lJ mQ PRN
PO:l.S- 10 mg qid (max:48O mglda,)
I/eQdocht, posrurol hypcrP1l5ion, fluJlilll}
offlKt, dizmts\ rash (rrmJdtrmol poKh),
ro/eroOCt
PO:20 mgqid (miX: 240 mgldaywith IUSlitiotd
An"phyla!!is. (iKUialOf1 {OIIaW OX 10
h)'pllrolioo !Y"'o!! d!.!: 19onhomtic
Sl; I tablt! (0.1- 0.6 019) orllplay (0..- 0.8 mg}MIll-) min
dosts in 15 min)
--
BETAADRENERGIC BLOCKERS
oKtIlnolol (Sfflrll) PO; 400-S00 mg daily (max: 1,lOO mglday)
o atenolol (TtIIOfIIIin)
fMloproIoI Toprol XL)
fUdoioi (Colgan!)
PO;lHO mgfda, (max: lOOlll9lday)
dlllWlinm, irnporffi(t
or iJrorrMd Iibid4 brod)'rGrdio,.lIIIiI
(oofulion
PO; 100 019 bid (max: 400 mglda,)
AannuloCYlon Ia!yomloum,
PO;4O mgdaily (max:l40 mglday)
proprlnolol ndtral LA) (stI' (Iq 364
for lile ProlOlrpe Drug boxOO I
PO; 10-20 mg bid-tid (max:l20 mglday)
StMm )ohmoo !yndrome"natilrlam'
if OW is abrup!IY
palDjmigm rebound hmrrtmljon lit-
ibfN1rojngdWl)1bmja\ or MI may
maltate (Bf'linoI) (stI' 771 PO; 15-45 mg tid (0111:60 mglday)
for lile ProlOlrpe Drug boxOO)
CALCIUM CHANNEL BLOCKERS
amlodipiOl' (Noms!} PO;5- 10 mgfda, (mn: 101ll9lday)
btpridl ('I.!sI:or) PO;200 mglday (max:l6O mg/day)
"'"

periphtr edemo, /igIrllIlodlftlru,.
nDul&diorrheo
ditimm (CaniIl'm, (,uti.J Ililic:000XR, bnia 10 mg tid-1jid (max:480 mglday)
HrQiWPXkkv MI 'HE ronfuWo mood
XL niloK) UttrJdr,d rtIrnt; 20- 240 mg bid (max:540 mglday)
""'"

niffdipiOl'
PO;lO-4O mg tid or30-60 mg SIt bid (max: 110 mglday)
PO; 10-20 mg tid (mil: 180 mglday)
poll}.' 308 for thd'nllol)'pl' Drug bolOO)
'/ffapamil (ulan, CamI.\ls,lsoptin SR, Verrlan)
(stI' (Iq 366 for lile POlIOIrpe Drug boxOO)
Exttndrod II'lult: 30- 90 019 000' daily
PO;SO mgtid-qid (max:480 mglda,)
BETA-ADRENERGIC BLOCKERS
(ANTAGONISTS)
25.6 Treating Angina
with Beta-Adrenergic Blockers
Beta-adrenergic antagonists or blockers reduce the cardiac
workload by slowing the heart rate and reducing contractil-
ity. These drugs are as effective as the organic nitrates in de-
creasing the frequency and severity of angina episodes
caused by exertion. Unlike the organic nitrates, tolerance
does not develop to the antianginal effects of the beta block-
fUf wllU Imtl,
arrd coronary artery disease because of their antihyperten-
siveaction. They are considered drugs of choice for the pro-
phylaxis of stable angina. Beta-adrenergic antagonists are
not effective for treating vasospastic angina and may in fact
worsen this condition. The beta-blockers used for angina
are listed in Table 25.1. Beta blockers are widely used in
medicine,and additional details may befound in chapters 13,
B,24, and 2600.
Please refer to Nursing Process Focus: Patients Receiving
Adrenergic-Antagonist Therapy on page 316 in chapter 2300
for additional information.
CALCIUM CHANNEL BLOCKERS
25.7 Treating Angina
with Calcium Channel Blockers
Blockade of calciwn chatmels has a number of effects on the
uf whi ... h tu
beta blockers, calcium channel blockers (CCSS) are used for
a number of cardiovascular conditions. including hyperten-
sion (chapter 2JOO) and dysrhythmias (chapter 2(00).
The calcium channel blockers used for angina are shown in
Table 25.1.
LibraryPirate
344 UnII4 TheCJrdkwasc:ubr.oo Urinary Syuem,
.... Prototype Drug I Nltroglycenn (Nltrostat,Nltro-BId,Nlrro-Dur, others)
Therapeutic (lass: Antianginaldrug Pha rmacologic (lass: Organic nitrate, vasodilator
ACTIONS AND USES
Nitroglyc:erin, aide! .nd most olg'nic nitrate, c.n be dtliYtred
by. numbel of difftlmt route: oral, mrulingual, IV,
tr.nsdelnwl, topical,.nd t XltndtdffINlI' forms. It nwy be LIken while an
acute angina is in progfffi or just pOOllo physical giYell
sublingually, it lI'achH puk pbsm<l levels in 2 10 (minutes, thus terminating
angina pain lapidly. (tltst pain that doH not II'Spond within 10 to 1 S minute
aflt l two or d=s 01 !\Jblingual nitroglyt:erin may indicatt MI,and
gerl()' medicalll'lYic:H Ihould be contacted. The mnsdermaland oral !USLlined
lele.1I' forms all' for prophylaxis only, sinU' the)o havt a leiatiYely 5Iow onm 01
action.
ADMINISTRATION ALERTS
ForiV administrillion. UII' a glass IV boule .nd spKiallV tubing,
pianK .b!ort.. niuno ignifiantly, thus II'dKing the pat;"'t dose.
Clrm-the IV bottle 10 ifdKt the degladation of nitr.tes<k.ot to light fXPO\UlI'.
lJ>t glom whtn applying nitrogl)'lerin or ointment to
in istration.
Plfgnancy rnegollY (
PHARMACOKINETICS
1Al1ft: 1- 3 min sublingua 2 - S min buccal; 4O-fIO min trarudtnnal pa\(h
Peak: (-8 min sublingual:(- 10 min bucal; 1- 2 h mnsdtrmal patth
1 ..... min
Duration: 30-60 min sublingual;l h 18- 24 h t .. nsderm.1 pillch
ADVERSE EFFECTS
The ad'Ierst tffrru of are usua ",Kliov.J scular in naMe and rarely
life thlutming. kGJ!/If an dibte is <I
tommon side effect and may be 1I"Iert' .lXasion.lly, tilt Yl'IIOUS dilation
by nilrogl)'Ctrin prodJm Itfln tKh)'C<lldi.J. Somt hukh call' pKll'idm PII'-
Ilribe beta-adrmergic bIoc:ker to diminish this undtsirable in
I<l te. M.O)' 01 tilt side tffrcts of nitroglyarin diminish afltl a few doSI's.
(ontlaindiciltions: Nitroglymin should not be given to patitnll with pre-
nisting hypottnsion or with high i ntrm.nial pll'SSUII' or he.d traumil. Drugs in
this cia" <I II' in pericaKiial tampon.dt <l nd COilStn.:tWf peri-
urditis bK.iUII' tilt lItan unmt irKrulI' cardiac output to m.intain blood
PII'SSUlt whtn mod ibtion occur!. Sum ined-fl'le.1I' forms should not be 9il'l'n
to p.titnts with glaucoma the)o may incrt'.tIt intr.O(uial pll'swre. DIo-
hydlation 01 hl'POl'Olemia should be tollf(\ed before nitroqlyuorin is aclminis-
ltlious hypottruion may IHUIt
INTERACTIONS
i)ug-i)ug:Cooai"II'Il U\f with inhibitoo lsiIdfnafil
[Ltvitla],or tad.!lali rna, cause IfHlni!ening ir!poten'iion.1Id
GlIliovillClllar coIiplof.!Ist with <l 1coIU ...r anlil)"pHlensi'll' drugs may (;llI1f
adcitivehypotl'lllioo.
lab Tl5ts: liioi)' iooNlf voilutl 01 uillaly GlIechoIamines and YMA
IIKlfluations.
lk>ibaVFood: Unknown
Trutmrnt of OverdOS!: Hypotension may be with adminismtion 01
IV oornwl "IiIII'. If mtthemoglobilll'mia is suspKIed, mtthylent blUl' may be
administt red.
NURSING PROCESS FOCUS PATIENTS RECEIVING NITROGLYCERIN
Assessment
8i1seline prior to administrati on:
Under!Llnd tilt re,lIon the drug his been plecribed in ordtr to asll'lS for
thtrapMic:
Obtain a completf lItalth hillolY indudi ng "rdiov.llular (including
prMM fli krrt, v.lMrllrdismf),CerrbrovllCuiar 1M II('UlOlogic
(including level 01 conlliousnm, history of "rdiov.srular accidtnt (CVA),
injul), incll'ilsed inua.c:lanial plI'Ssure), II'nal or hepatic dysfunction,
dysrlr;thmias,<lnd prtgnancy or iactation.ObLlin drug hislOlY including
IlIeCllits, QJCTI'm prescription and ore herbal pll'pllrations,.nd
.Icohol aware that !/If of d)'dunction drugs within tht past
2( 1048 houlS may ca!lll' profound.nd prolongrd hypotension
nitratf"l.re lien to possible drug intelactions.
Obt.in bastlillt viti I signs (Hpt<ially blood pressurt {BPI and
pulscl, and ECG.Aslf"Is for Ioc:ation and chirlCll1rof <l ngillol if QJCTI'mly
plerm.
Enluatt .ppropriate laboratol) findings,Mc:llo1ytH, len.llUnction studits,
.nd lipid profile.Tloponin <l ndfol cruont kin<lll' lab may be ordtred
to out MI.
Potential Nursing Di agnoses
DIoc:II'.!ed Caldiac Output (disulI' pIO(Hsor rebted to ml"ll'ffleo:tsof
drug therapy)
Altered TisltH' Perfusion (re-lated to disNll' proc:t1S)
p.in (hudacht, II'Iated 10 tfWcts of drug therapy)
procr!sor rebted to <ldvtl"ll' efleo:llofdrug thel<lPY)
Activit)' Imoleranc:e belated to dill'aII' proc:t lS or of drug
thtraPl')
Ol'ficitm (drug
Risk for Falls, Risk for InjJl) (related to acll'l'lII'
LibraryPirate
c"",,,tll> Drug. (0< Angina PKW<I< .nd M)'OC.rdlallnbrctlon 345
NURSING PROCESS FOCUS PATIENTS RECEIVING NITROGLYCERIN (Conrlnued)
Assessment
Assess m!nt throughout iI dministrati on:
Ailes lor therapKIIK flffi:n (!.g., dlen pIIin hill IUmidtd or hal
signiflCilmly ItIstntd), hean ratt.nd blood plf\5ure remain within normal
limits,ind ECG remains within normallimil, without ,igfll of ilchemia or
infarct
ContinUl' periodK monitoring ofECG lor ilchtmiil or infarct.
ComilUl'mqUl'nt mooitoringofblood pres>ureand PUMWhtoeoltr r'i
nitrate are lIItd or wIItrl giving (t.<j. dIIioguaO nitrattl. With
subiingu.1 nitratl'l, talet BP milutrsaftergiving thtdosf and
hok! drug ifBP it leI than 90/60, pUl(' isOYtr 100 (or
Ailes Ior.nd report ,dvtl1eflffi:n:!l(elivr hypotension,
fl'fiex tadtyurdia (from too-rapid dKre_ in BP or
signifmt hypottnYonl. headadle that dots not IUbsidt within 15- 20
miootrs or when i(wmpllnitd by IltUrologK (hange. or dKrea ltd urinary
<JUIpuL s.,.",.. hYI"'I. n,ioo, 1Nu ..... dy>'h)'lhmi., >houkl bt .."."Ird
pIIin R'm.ining aft. r thlff lublingual
nitroglyc:erin tablellgil'trl 5 minutt'l ,hoold he fl'ported immiatfly,
el'trl if hatltl5rotd,al thit may he a of imptnding ilchemia or
infarction.
Potentilll Nursing Dillgnoses
Planning: Patient Goals lind Expected Outcomes
Ihf p.tirm will:
EJ:ptritrK! therapMK (t.g.ingin, sumidts or substamially diminilhtt. hean rate and blood pressure rem.in within tltablishtd pififMtfl5, ECG it
within oormallimits).
from,or UPf.wOCt idyffll'
olthedrug's = . a.ffll' rlFb,and fl'qJired precaution!.
DtrnOnltratt Propl'l :se/f-adminituation of the medj(oltion timing. when to notily providtr).
Implementlltion
Interventi ons and (Rationales)
Ensuring thtraptutic rffeds:
ContinUl' ifl'qUl'ntatSfl5mtrlls at abol't lor therapeutic tlFIS.{At
modillltion OCQJllfrom nitrattl, prtload and alttrlo.id
tile of the he.Jn and ntyO(ardial ownation nct(lI;
chest diminishe.)
ContinUl' to monitor ECG, blood pressufl', and pulsr.(Nitratrs caUl('
... odiLotion and I"'"iblt BP aid. in dourminin9
drug frrqUl'OC)' and dosr. KG monitoring helps dttf(! .a.ffll' eIFIS such
iI fl'fltl QCh){ardia, ilchtmia, or infarctionJ
E"I<Iluare the r"ftd lor adjun<tive Ueatllll'llt with htalth nrt prO'lidfr lor
angina prMmion arod lfI'atment(c.<j. btta bkKkets,.Jspirin thtrapyl or
fUnhtr" c.rdiat nudiet.(Patirnts with unstable angina lOa)' rrquirr
adjuoctivr drug thtr"apy or definitiYf (olrdiac nudiet to dti. rmine the nffil
lor other trNtmtrlt
For patitnts on traOlderma I patches, remOVf thr lor
6-12 hoollat at dirtmd by health taR' proyidtr. (lhit helps
ordtlay thedtvtlopllll'llt oftoltraocf to nitrattl. Rrmoving the
at when nrdi wortlo, d it lelt'lltd, htipsKioid possiblt
angina lattaW during the da)'!iOlf when workload is gfl'.ttr.)
En<ourigr .ppropriate lin,sl)'lt changl's.PlOYidt lor dittitian consultation is
nffiltd.(Healtiry lifell)'lt (h.ngl'l will suppon th! btllffin of drug
therapy.)
Plltient and Fllmily Educlltion
Alk the pIItitnt to b.wfly desaibt the location and rhilractl'l of (USt
riling snit lor rapid ilsessmtnt) prior to and .Jltergil'ing nitrattl to
iI!eSS lor tilt mtnt of relid.
Trach tht patitnt, family. or mrgivrr how to monitor pul'S! ind blood
prt.IU .... EOIu"" the proptru,," and functionin9 of an)' 00 ...... ".,ipmtnt
obtained.
[n<ourage the patitntto dilculSany chaogt'l in
ifl'quency of angina cpisodts with provider.lnstnJCt tilt poatitnt not to ukt
daily alpirin without dilClMing with tht health caR' proyidtr filiI.
IflltnKt thr p.titm on tht proper l/Ieof nitroglyrerin.Jnd rationale for
removing Ira nsdenn.J I pat{hes. Alto iflltruct the patimt on trallldermal
to alwaY''''1l"IOft the ok! tilt ,kin uodtrntath
gently,.!nd to I1lt.ltr littl brioR' applying a new p, tch.
En<ourage the patitntto adopt a healthy lifel)'lt of low-fat food choKe,
in<1N1td !Xl'rtM, dKreilfd .kohol conlUmption,.Jnd !moking (e lation.
Prwidt tduutiooal matf riaiton Iow-sodium food choKt!.
(Conllrwefi)
LibraryPirate
346 UnII4 U'I .... ry Syne<",
NURSING PROCESS FOCUS PATIENTS RECEIVING NITROGLYCERIN (Confinued)
Implementation
Interventi ons and (Rati onales)
Minimizing ildftBe rflfits:
CominUl'to monitor vitill (lutious with t lderfy who
aft' at iIKrt.lSM risk 10, j)iltienl! with a prMlisting
of (l rdiac or cM' bromculard"rsull', or head injury, which may be
b)' YoIIodilation. Notify thf IINhh (1ft' provider if
.ngina lMIains unR'iiewd or ifblood PR'lSUR' or dt(R'aSI' bt)oond
j)ilramtlt B or ifh)"pltension is Ilcomj)ilnied b)'
tllhyurdia.(Nitratn may calM vil lOdilation. ,esuking in thr potential for
hyplttnsion oKcompanitd by mIeJi tac:h)'(ilre!ia. Rtflutachycardia ilKR'illI'I
myocardial dtlllilnd, wol1tning il nginil.)
CominUl' monitoring (f -9. ECG) if IV nitratts arr ildministerM.
(Monitoring device i llist in rlttecting NIIy ligns 01 amrll' rflecn 01 drug
thtraP\', myou rdial isditmia or inlardion, as Wl'1I i S monitoring for
therapeutic
CominUl' physica lasll'llmt nU, panicularly OI'urologic. cardiac, and
R'lpiratory.1 mmtdiateiy rt'pln any cha II9t1 in of colI\{iouslltlS,
headiche, or changes in hr,n or lung sounds.(Nitrate therapy may
prt-uisting IIl'Uroiogic.cardiac,OI JtlpiralOry wnditicrn as blood prrssurt
drops ilnd prrlusion to vital organsdiminishes.lung congetion mily signil l
imprnding lINn lailuR'.)
ReviM tilt mtdications taken by patirm befort discharge.and rfl'irw
. 11 prrICription ilS Wl'il as orc medic.Jtions with tht patientCulTI'm UII' of
drugs with nin-alts.(ER'(tile
ri)'slunction drugs toWl'r BP and when combintd with nitr.lI6, can resuk in
II'veII' il nd hypotension.)
Pati mt understanding of drug therapy:
Usr opportunities during .dminimation 01 medications and during
,sll'!.\mrms to discus It he rationale for drug thffilP\', drsiR'd theraprutic
oukomrs, moll common paramt ttrs lor when to call the
heahh tift' iI ny nKn l,U), monitoring 0' prKolutions.(Using
timt dJring nun.ing (l R' helps to reinfon:r kry INChing
ft'asJ
Patimt selfadministrat ion of drug therapy:
When mtdititions,instruct tilt lamily, or in
proprr II'H-adm inistration 01 drugs and whrn to contact provider. (Proptr
.dminimation in{rt.lsrs thl' 01 thr drug.)
Pati ent and Family Education
InstnKt thf j)iltitnt to repln dizzintls, laintntls, j)illpitations, or hudamr
unrrlitvtd after liking nonnaKotic analgtsic; (t .g., oKt tamioophtn).
InstnKt tilt j)iltitnt on nitr"n to rill' from lying to sitting or slinding
slowly to avoid diuilltlS if tilkingsublingwl or
until dlll9 arr known.
To polSiblt .Me!)" ttil(h tilt patient the rationalt for all fqUipment
U5ed and tIM- OI'td for lrequent monitoring.
When on oral therapy ilt hornr,instnKt tilt patitnt to immtdiateiy repln
rna II9t1 in mrntaislilllll 0' lew! of colI\{iousntl S, palpitations, dizzintl
ri)'spOl'.,or inclNSing if frothy is
pJtltnt.and Ittk medicalattenrioo.
InstnKt tilt patient to not tak!- sikll'nafil (Ylilljra), \\Irdenafil
tarblafil (Ci.alis) while tilking nitratn and to diICuss trt atmrnt OptiOlll for
rrffiile dysfunction with thr IINkh caR' provicII'r.
Tilt patitnt should be .ble to state tilt 't illOn lor drug;,ppropMt doll'
.nd to obSI'rw lor and wht n to ft'IIOI"I;
fquipmtnt IIffiird as appropriateand how to lIII' that fquipmtm; il nd tilt
requi'M length 01 mrdic.Jtion nerrll'd with i OY spKial instructions
ft'9arding renewing or continuing prrscription .
Tilt patitnt should be able to statr howto lIII'sublingual "
homt:
Takroll!' nitroglycerin (NTG) tilbiet uncler tht tongut br angina/chell
j)ilin. Rtmain lI'atM or lay down to i1Void diuinm orlalls.
II chrs\ pain continUl'l, ,tpr.t 001' NTG t.biet.unOO tilt tongut,in S
minutts.
II cllrst pain continUl'l, rt pM NTG,unOO the tongue, in S milllln.
Ilcllrst pain continUl'l,l"Ien ij rmtd.do not tilkr fUnher NTG unless
Ipr(i/icatly di'Iro b)' IINhh w r providr,.CaIl EMS s)'Stem (t.g., 911)
lor asYsUIKf.Do rIOfdrm II'Hto room.
If blood pressurr monitoring fquipmrnt is aVililable ilt IIomr, thr
la mily, or lib.- blood prnsull.' prior to and th ire!
dolI'S. Hold the drug ilnd COntllt EMS il BP IeSI than
90/60mmHg.
Evaluati on 01 Outcome Crite ri a
LibraryPirate
Cho,lt. n Drug' (0< Angina PKto<" . nd Myoc:.r<:ll.1lrn/orr:llon 347
.... Prototype Drug I Atenolol (Tenormm)
Th@rap@utic(lass: Antianginal drug Pharmacologic (lass: Beta-adrenergic blocker
ACTIONS AND USES
Attnolol is one of lilt most frequmtly p=ribed drugs i n tilt United Sta16 dUl'
to iu s,fely "Id in numbtt'of chronicdisorden,
ill(luding lINn failull', angina, and drug blocks
bt" .-,dll'll!'rgir in tilt t l'ffo:tr.ffit Sl in truting ,ngina is u-
to its ,bility to sbw ,nd contr,,;tilily, bolh 01 which
Iowtr m)'CK.irdial Ol)'9tndemand As with othtr be" blockers, therapy
,11y btgins with low g"dwlly inueall'd until the theraptutic
tfirct is ,,;hieYed. k<aIM of its 7- to bail-life, it may be t,ken cb ily.
ADMINISTRATION ALERTS
DJring IV adminismtOn, monitor ECG blood ,nd
,hould bt "'filed befort, during. , nd aftt r tilt is administered.
and bIoo:d oral administruion. Hold if the
is btIow 60 btu, ptr minult or il tht p"tient is
m,y prKipitue broll(hospl!m in p"tients with ini-
tial dosn.
Pregnancy c.JItgory D
r PHARMACOKINET1CS
Onstt: I h

Halllife: 1--4 min
Duration: 24 h
CCBs have several cardiovascular actions that benefit the
patient with angina. Most important, CCBs relax arteriolar
smooth musde, thus lowering blood prerosure. This reduc-
tion in afterload decreases myocardial oxygen demand.
Some of the CCBs also slow conduction velocity through the
heart, decreasing heart rate and contributing to the reduced
cardiac workload. An additional effect of the CCBs is their
ability to dilate the coronary arteries and bring more oxygen
to the myocardium. This is especially important in patients
with vasospastic angina. Because they are able to relieve the
acute vasospasms of variant angina, ceBs are considered
drugs of choice for this condition. For stable angina, they
may be used as monotherapy in patients unable to tolerate
beta blockers. In patients with persistent symptoms, CCBs
may be combined with organic nitrates or beta blockers.
Please referto Nursing Process Focus: Patients Receiving Cal-
cium Otannel BlockeJ Therapy, page 308 in chapter 2300, for
the oomplete Nursing Process applied to patients receiving cal-
cium dmnnel blockers.
MYOCARDIAllNFARCTION
Hearl attacks or m)'OQlrdial inlarrt ions(Mls) are responsible for a
substantial number of deaths each year. Some patients die
before reaching a medical facility for treatment, and many
others die within 48 hours following the initial Ml. Clearly,
ADVERSE EFFECTS
Being , bela,...Jdll'llt rgic blocker, atenolol has few d-
Ims on tht lung. Tilt mOil frequently Il'pOned tfftcts of umdol in-
flligut. br"lywdia"nd hypoll'llYon.
Contraindi u tions: atenolol,lows lINn ratt, it 5/tould not be md in
pat ienll with IM' rt br, clyuroia,AV hu n block, wdiogrnic ,hock,or derorn-
ptnm!d hean I, ilurt. Out to it! modilation it is rontraindiuted in j)a-
tiMts with hypolension.
INTERAalONS
Drug-Orug: Uinarllenl UII' with calcium cilannfl blockers may [MOO in n<nMo
ur <iac 5l.WffSlion.lisf with!igoxin may slow AV conductiCIl, iYlilglo '-'
twd.(lOOIItrl Ull'1I atenolol w1th oWr anut,pHtenli"ll"l may in addtiw
h)"pOlel.sion. Antir:hoIilli'lr;co; may CiIU\t dfcrNIfd almplion 11001 the GI tr.I:l
li b Tests: A1PnOIoI may inuru valuiol II the foOowilg bbod tflll: uric add, iPds,
pcKaIlillll,O!alirine.and mnuciNrmbody.
HerlwliFood: Unknown
Treatmrnt of Overdose: Tilt mOIl of atenolol al\'
hypotm,ion , nd bradyurdia. Atropine or ilOprolell'llol mil)' be 10 re-
.... . Al"l'nolol Gin be from lilt by

111'1'8" 10 M)Nurlmg.Q! for Q Nlmirrl} I'rIlml foolHpt(1k 10 rlrls drt!g.
MI is a serious and frightening disease and one responsible
for a large percentage of sudden deaths.
25.8 Diagnosis of Myocardial
Infarction
The primary cause of MI is advanced coronary artery dis-
ease. Plaque buildup can severely narrow one 01 more
branches of the coronary arteries. Pieces of unstable plaque
can break off and lodge in a small vessel serving a portion of
the myocardium. Exposed plaque activates the coagulation
resulting in platelet aggregation and adherence
(chapter 2700) . A new dOl quickly builds on the existing
plaque, making obstruction of the vessel imminent.
Deprived of irs oxygen supply, the affected area ()f my
ocardium becomes ischemic, and myocytes begin to die in
about 20 minutes unless the blood supply is quickly restored.
Necrosis of myocardial tissue, which may be irreversible, re-
lease, certain amarkt' r" enzymes, which can be measured in
the blood to confirm Ihe patient has experienced an Ml.
Extremechest pain is usuaUythe first symptom ofMI,and
the one that drMs most patients to seek medical attention.
An electrocardiogram can give important clues as to the ex-
tent and location of the Ml. The infarcted region of the my-
ocardiwn is nonconducting and may produce abnormalities
of Qwaves, Twaveo>,and SoT segments (chapter2600) . lab-
oratory test results are used to aid in diagnosis and monitor
LibraryPirate
348 UnII4 TheCJrdkwasc:ubr.nd Urinary Syuem,
..
Prototype Drug I Dlltlazem (Cardlzem, Cartla XT, DI/acor XR,. Taztla XT,Tlozoc)
Therapeutic ( lass: Antianginaldrug Pharmacologic (lass: Calcium channel blockel
ACTIONS AND USES
likt calcium bIoc:kers,diltimm inhibiu lilt lIanspoit of clkium
into myouidial tells. k has tht abilit)' to rtlax bolh {oronalY and ptriphtlal
blood W"III'k. bringing moR' oxygen to !he m)Vuidium . nd rtducill9 uidia.c:
workload.1t is in tilt heatment of atrill and hyptrtemion,
.H well as .uble and v,soij).!stic all9ina. When gil'll as cap-
1U1e!, it is . dministt rtd onre daily.
ADMINISTRATION ALERTS

()jrill9IV <I dminimation, lilt palient must be conliruou!oiy moo ilortd.and
uidioYeBion equipment mUll be available.

tablm and "psuies should not be CMhed 01 split

Pltgnancy rnegolY C
PHARMACOKINETICS
Q,SfI: 3Q-60 min (2- 3 h lUSuined reiNlI')
Peak: 2- 3 h (6-11 h lusl.ined Jt'ie<l ll')

OUluion:6-! h 02 h sust.ined
progress after an MI. Tablf 25.2 describes some of these im-
portant laboraTOry values.
Early diagnosis of MI, and prompt initiation of pharma-
COTherapy, can significantly reduce mortality and The long-
Term disability associated with MI. The pharmacologic
goals for treating a patifnt with an acute MI arf as follows:
Restore blood supply (reperfusion) to the damaged
myocardium as quickly as possible through the use of
thrombolytics.
Reduce myocardial oX}'gfn demand with organic
nitraTes, beTa blockfrs, or CCBs to prevent additional
infarctions.
Control or prevent MI-associated dysrhythmias with
beta blockers or other antidysrhythmics.
Reduce posT-MI mortality with aspirin, beTa blockers,
and ACE inhibitors.
Manage st'Vfre MI pain and associated anxieTy with
narcotic analgesics.
THROMBOlYTICS
In treating MI, thrombolytic thfrapy is administered to dissolve
dots obstructing the coronary arteries, thus restoring circula-
tion to thf myocardium. Dosages and descriptions of the vari-
ous thrombolytics are givt'n in chapTer27 on page 38JOC> .
ADVERSE EFFECTS
a!'f genelally OOIIl'OOus.nd ,lIt !'fialt<! 10 v. lOdi-
lation: lIt.ldaclIt, diuinffi, and of the anlde and Abrupl with-
draw.1 may pmipilate an acUlf . ngillill
Contraindications: Ililtimm iscOIluaindicattd in patienuwilh AV hun bloc:k,
lick si!lll II"I!'fl' hypotem ion, or a_rysm, or Undel-
going inlracranial SU"lff1. This drug mould be UIed with ('lIIion in patiloms
with rPnal or Iv.,.uic imp>illlll'nl.
INTERACTIONS
1Wg-IWg:CoooI"rm!M of dllimm Mth otIIfIlilldiomaU
dgoxin If bMHdrfnHI,ic bkdm, Illil)'UlMpartill If hoo:bIock, '-'
bikn,or IIIiI)' irKrNli'!igoDl or quiridinetem whfn
tak!on (ooumntly.Adci!i'll' mar om. if Mwilhf!haool, 11m
bIockl.>r5, or antil?!p5Ien!i'll'S.
Lab TelS: tktnown
ilflbaVFoo:t:StJcmi MIIIand r,jnsenIj tfNo HlKlivfnes of
dlliazHII. G.ric. haw!hom,and goIden ... 1 may ioofalf tfNo
ofdiliazflll.
Trtatnlent of Ovtrdole: All\lpine ot isopmttltnol may be used to
br.dyuidia caUSt by dihiazem OYerdoSl'. HypoTension may be R'"I'med by. va-
SOpft'llOl wch as dopamine or dobutamine. Cakium chloride can be adminis-
Tt li'd by!low IV push 10 IM'III' hypotemion or lItan bIoc:k induced by (C8s.
Rmr II MyMfihrgR for MnJrtg l'reiI fools spt(itt 111M ItrJ9.
25.9 Treating Myocardial Infarction
with Thrombolytics
Quick restoration of cardiac cin:u.lation with thrombolytic
medications reduces mortality caused by acute MI. Aftfr the
dot is successfully dissolved, antiooagulanTThernpy is initiated
to prevent thf formation of additional clots . .. Figurf 25.2
illUSTraTes the pathogenesis and TreatmenT of MI.
Thrombolytics are mOST effective whfn administered
from 20 minUTes TO 12 hours after the onset of MI symp-
toms. If adminisTerfd after 24 hours, the drugs are mostly
ineffective. In addition, research has suggested that patients
older than age 75 do not fxperience rfduced mortality from
these drugs. Because thrombolytic thfrapy is expensive and
has the potential to produce serious adverse effects, it is im-
portant TO identify circumstances that contribute to success-
ful thfrapy. Thf development of clinical practice guidelines
to identify those paTifnts who benefit most from throm-
bolytic therapy is an ongoing process.
Thrombolytics have a narrow margin of safety betwren
Ji.-,ulvi.uK duls a"J I'ruJu"i"lI '''fiuus aJ."r ... .,rr"ds. Al-
Though thfrapy is usually targeted to a single thrombus in a
specific artery, once infused in the blood, the drugs travel to
all vessels and may cause adverse fffects anywhere in the
body. The primary risk of thrombolytics is excessive blred-
ing due to interffrence with the normal clotting process. Vi-
tal signs must be monitored continuously; signs of bleeding
LibraryPirate
C"",,,tllS Drug. 10< Angina PKW<I< .nd Myoc. r<:l"'lnbrctlon 349
TABLE 25.2 1 Changes in Blood Test Values Following Acute MI
Blood Test Initial Elevation After MI Peak. Elevation After MI Duration of Elevation No<mai Range
0:
Hh lH4h
ESIt
fim""
Itdimmlation
,,,,,,,

8- 72h Hcb)'S
_.,
m)'C9obin Hh Hh
troporinl Hh 2H6h
troporin T Hh 2H6h
WB( blood

aI oount)
call for discontinuation of therapy. Because these drugs are
rapidly destroyed in the blood, stopping the infusion nor-
mally results in the rapid termination of adverse effects.
Please refer to Nursing Process Focus: Patients Receiving
Thrombolytic Therapy, page 384 in chapter 2700 for the
complete Pro"" .... applied to patient. receiving
thrombolytic therapy.
25.10 Drugs for Symptoms
and Complications of Acute
Myocardiallnfarction
The most immediate needs of the patient with MI are to en-
sure that the heart continues functioning and that penna-
nenl damage from the infarction is minimized. In addition
to thrombolytic therapy to restore perfusion to the my-
ocardiwn, drugs from several other classes are admi nistered
soon after the onset of symptoms, to prevent reinfarction
and ultimately to reduce mortality from the episode.
ANTI PLATELET AND ANTICOAGULANT DRUGS
Unless contraindicated, 160 to 325 mg of aspirin is given as
soon as an Ml is suspected. Aspirin use in the w...,ks follow
ing an acute MI dramatically reduces mortality, probably
due to its anti platelet action. The low doses used in mainte-
nance therapy (75- 150 mglday) rarely cause GI bleeding.
The adenosine diphosphate (ADP)- receptor blomrs
cJopidogrel ( Plavix) and tidopidine (TicJid) are effective
antiplatelet agents that are approved for the prevention of
thrombotic stroke and MI. Because these drugs are consid-
erably more expensive than aspirin, they are usually consid-
ered for patients allergic to aspirin or who are at risk for GI
bleeding from aspirin.
Glycoprotein ll bll lla inhibitors are antiplatelet agents with a
mechanism of action distinct from that of aspirin. These
HtIa)'S 21- 198 uritllL (vilUel ViI}
'Nidt!y bf,1Wffn iabsand
imong telling prOioWS)
male\: 1- 11 mmihr
frlllil!'l:l - ZOmm/lv
dU"ation of Itrt'lSll'SpoIIIf m91dl
8- HtIa)'S SO- ISOuriuA
HtIa)'S HSll9lmL
7-10tla)"i llm(gll.
10- HtIa)"i 0.01-<1.1 n9fI.
l -7t1a)"i ts- l0.8 x 10' m'9il
agents are sometimes indicated for unstable angina or MI, or
for patients undergoing PTCA. The most common drug in
this class, abciximab (ReoPro), is infused at the time of PTCA,
and continued for 12 hours after the procedure is completed.
On diagnosis of MI in the emergency room, patients are
immediately placed on the anticoagulant heparin to
additional thrombi from fonning. Heparin therapy is gener-
ally continued for 48 hours, or until PTCA is completed, at
which time patients are switched to warfarin (Coumadin).
An alternative is to administer a low molecular weight he-
parin, such asenoxaparin (Lovenox). The student should re-
fer to chapter 2700 for a comparison of the different
coagulation modifiers and the dosages for these medications.
COMPLEMENTARY AND A LTERNATIVE T HERAPIES
Ginseng and Cardiovascular Disease
Ginseng is of oldtst koown he!bal rt'medies.flonaf 9i1Mfl9 is
throughout China, Kortoa, ind Siberia, quinqutfoiw is na-
tWe to Ullid.l tht United There ill' diif!'rence in chemiul
romposition beIWffiIthe two lpKies of ginseng; American girung is not
<onsidorft! tqUi'I.l.m to SiNn..n gin"'II9.Tho pbnt', popubrity h .. 1m to it!
"unction from 'tniin l'I'9ionl, ind mum of tile (ommertiil ginl<'fl9 is row
grown (ommercially.
has been ustd ior(enturifs to promotf gener.ll boost im-
fun,tion, and li'dU(f fMig!ll'. Thtfe ill' (ia ims thn tht herb !owen
blood ind "n help in the rnanagemem of
Gin"'1J9 is thotH}ht to (akium nne! anugonist Tho htrb ap-
ptiB blood iIowlotheheart in timesoflowOX)9fll IS
with m)'OUrdiil ischemia. Some rtSur(h has Ihown t1wt lowers
blood llI9ir lewis in patients with Iypt 1 diabete.ln addition, IortIt studies
h.M found girung to OOosttlit S)'SIMI. Tho should ,,!Ilion
dients who take ginsmg, HUIM herb--1lrug in\l1l'a<tions possible with
ukiJm warfirin,and loop diurt'OO.
LibraryPirate
350 UnII4 TheCJrdkwa",ubr ,od Urinary Sy""'"'
Right
coronary
"""
Right
vootricle---
II
Inlerior vena ---I"'i

(a) Blockage of left coronary artery
with myocardiel ischemia
Superior


Lei! coronary
"oy
(b) Infusion of thrombolytics
Right _ _ __
"""'ride
I\,,--Leltvenlride
Inferior V'Ilna

""
(c) Blood supply restarted to myocardium (d) Thrombus dissolving
Flgure25.2 Blockage and reperfuslon following myocardial Infarction: (a) blockage of left coronary artery with myocardial
I",hemla;(b) Infusion of thrombolytlcs;(cj blood supply returning to myocardlum;(d) thrombus dissolving and I",hemla clearing
Source Rgurf'S (a) aM (e): MlJIv!hm et a1. Human Olse.lses: A Systematic AppfOilCh, 6th f!d., Cl lOO6,p. 105. /lepffiroo by pronI15JooofPf!(HlOO
Educarlon, Inc., Uppff SaddkRlver, NJ.
NITRATES
The value of organic nitrates in treating angina was discussed
in Section 25.6. Nitrates have additional uses in the patient
with a suspected MI. At the initial onset of chest pain, sub(in-
gual nitroglycerin is administered to assist in the diagnosis,
and du",," may b., lak"" 5 mi"nl<:>c apart Pain
sists 5 to 10 minutes after the initial dose may indicate an MI,
and the patient should seek immediate medical assistance.
Patients with persist ent pain, heart failure, or severe hy-
pertt'nsion may receive IV nitroglycerin for 24 hours follow-
ing the onset of pain. The arterial and venous dilation
produced by the drug reduces myocardial oxygen demand.
Organic nitrates also relieve coronary artt'ry vasospasm,
which may be present during the acute stage of MI. On the
patient's discharge from the hospital, organic nitrates are
discontinued, unless they are needed for relief of stable
angina pain.
BETA-ADRENERGIC BLOCKERS
Beta blocken; reduce myocardial oxygen demand, which is
critical for patients experiencing a recent MI. In addition,
they slow impulse conduction through the heart, thereby
LibraryPirate
.... Prototype Drug I Reteplase (RetavaseJ
Therap@Oti((lus: Drug for dissolving blood clots Pharmacologic ( lall: ThcomOOlytic
ACTIONS AND USES
\hlOUgh n!(OIIIbinatlt DNA b,-deaving pial-
minogen 10 fOflll plismin. Plismin thtn dtgr.dn the fibrin mwix of tIlrombi.
likt othft dlUJl in 1M elm. rl'lepUlI' Wluld lit giftn as lOOIlas pmilIr after
tile omtt of MJ Iymptol'l'll. Adminilterl'd b,- rI bolus, it UIUlIIy within 20
minuttl.A lKood bcM ,uy bt injttd 30 mioulIeS after t:M fin!, if to
dmthfthrombus.AfterdJulot hal bem dissolwd. tlwrapy with i1fp.lrinOf in
iltematn.r anticoagulant itIrttd 10 iddition.Jl dol! from Iooning.
may bt IIStd of-l.1btllO I<utt irld dHonic dttp \lein \h,ombo-
si!; O(dJdtd
ADMINISTRATION ALfRTS
ItmJnstiMt !he drug imlnl'dial.tly prio, to lISt with dilutnl prtMded by
Iwirll1lmil-do not shih.
Do not 9M iny othtrdrug limultaneously thlOugh tilt samt rllint.
Rtttp&.se ind 1IePirin incompatible Md mUll nMr bt <Ombintd in
!be lilnl' soIInion.
(
PHARMACOKINETICS
Onwt: Immtdiate
Pu k:Unkoown
I!.tIfl ife: B-16 min
Duration: UMnOWO
]
suppressing dysrhythmias. which are serious and some-
times fatal compliotions following an MI. Research has
clearly demonstraled thai beta blockers ca n reduce MI _
associated 1Il0rtaiityifthey are administered within 8 hours
ofMI onset. These drugs may initiaUybe administered IV in
the hospital, and laler switched to oral d osing for home
therapy. Unless contraindicated, beta-bJO(ker therapy con-
tinues for the remainder of the patient's life. For patients
unable to tolerate beta blockers, calcium channel blockers
are an alternative.
ANGIOTENSIN-CONVERTING ENZYME (ACE)
INHIBITORS
Clinical research has demonstrated increased survival for pa-
tients administered the ACE inhibitors captopri l (Capoten) or
ADVERSE EFFECTS
TIlt moll striouIilMMeffM ofltltpliseil abnoonll blttding.Blttdin, may
bt ilt injection liln ilnd iflltftion lites. Dywhythmia\ may
O(QA" during myocardial
ContraindiuUons: Rettplill' ii CDIItraindiuled in p.1tienb willi actM tleotd-
ing or hiltol"Y ofCVA, 0' who hi'o'r hid I't<tnt surgical pm<tdu,e.
INTERACTIONS
Dn..IrI)uo;ConarIffftt tllffapywilll pWtMt

"'-
li b ltIu: RtttpYse dfgIidfs plMiIIo9MIiII blood IH.m
pbsmiMgtft inI fitfinogflllMls.
HffbiV1oM: GillIgo lilotroJ should bfQU5til "IIJ iIaMt tbelist; 01
.....,
Y, Nlnmt of CM,rdole: ThM iI no !jl(cifK fo, IM!rdost.
RPM III IIIDMIIl/IIj I'rIxffi F/nJptkllltMsdl1Jf
lisinopril (Prinivil, Zestoretic) following an acute MI. These
drugs are most effective when therapy is started within 24
houri after the onset of symptoms. Oral doses are normaUy
begun after thrombolytic therapy is completed and the pa-
tient '. condition stabilized. IV therapy may be use.:! dur-
ing the early stages of MI pharmacotherapy.
PAIN MANAGEMENT
The pain associated with an Ml can be debilitating. Pain
contlol is essential to ensure palient comfort and to leduce
sIres.;. Opioids such as morphi ne sulfate or fentanyl are
given to ease extreme pain and to sedale the anxious pa-
tient Pharmacology of the opioids was presented in
chapter 1SOO.
LibraryPirate
352 UnII4 The urdkIY.",ul.r.oo Url .... ry syne<",
_' Chapter REVIEW
KEY CONCEPTS
The numbered key concepts provide a succinct summary of the important points from the corresponding numbered section
within the chapter. If any of these points are not dear, refer to the fillllbered section within the chapter for review.
25.1 The myocardium requires a continuous supply of oxy-
gen from the coronary arteries to function properly.
Coronary artery disease, which indudes both angina and
myocardial infarction, is caused by narrowing of the ar-
teriallumen due to atherosderotic plaque.
25.2 Angina pectoris is the narrowing of a coronary artery, re-
suiting in a lack of sufficient oxygen to the heart muscle.
r:he<' ("lin on emotional or ph)"'i""l <'Terrion is the mos'
characteristic symptom, although some forms of angina
do not cause pain.
25J Angina management may indude nonpharmacologic
therapies such as diet and lifestyle modifications, angio-
plasty,or
25.4 Goals for the pharmacotherapy of angirw are to termi -
nate acute attacks and prevent future episodes. Thory are
usually achiewd by reducing cardiac workload.
25.5 The organic nitrates relieve angina by dilating wins and
coronary arteries. Theyare drugs of choice for terminat -
ing acute episodes of stable angina.
NCLEX-RN REVIEW QUESTIONS
D The patient is being discharged with nitroglycerin (Nltro-
stat). Patient education would include the instructions:
1. "SwaUow 3 tablets immediately for pain and call 91 e
2. Put one tablet wKleryour tongue for chest pain. If pain
does not subside, you may repeat in 5 minutes, taking
no more than three tablets."
3. "0.11 your when chest pain. He will
teU you how many IlIblets to take."
4. "Pbce three tablets under your tongue and call 91 I."
o A prililllry mechanism of action that makes nitrntes use-
ful for a pat ient with angina indudes:
I. they increase hrurt rate to increase cardiac output.
2. they increase preload so more blood isavail.1bleto be
pumped to the circulatory system
3. they increase contracrility so the heart works more
effectively.
4. they decrruse alterload so the workload of the heart is
da-reased.
U The nurse recognizes that the mechanism of action of
beta-adrenergic blockers in the treatment of angina is:
I. slowed hean rate and decreased oontracrility.
2. increased contracrility and heart rnte.
3. relaxation of arterial and venous smooth muscle.
4. decreased peripheral resistance.
25.6 Betaadrenergic blockers relieve anginal pain bydecreas-
ing the oxygen demands on the heart. They are drugs of
choice for prophylaxis of stable angina.
25.7 Cakium channel blockers relieve angina by dilating the
coronary vessels and reducing the workload on the
heart They are drugs of first choice for treating va-
sospastic angina.
25.8 TI,., <!iagll..,,;is uf illfuLtiUll
chances of survival. Early pharmacotherapy with anti -
dysrhythmics targeted reducing the workload on the
heart and inhibiting fataL dysrhythmias.
25.9 If given within hours after theonset ofMI, thrombolytic
agents can dissolv", clots and restore p<'rfusion to affected
regions of the myocardium.
25. 10 A number of additional drugs are used to treat the
symptoms and complications of acute MI. These in-
dude anti platelet and anticoagulant agents, beta block-
ers. glycoprotein liB/IlIA inhibitors, analgesics, and
ACE inhibitors.
o The patient should remove the transdermal nitroglycerin
patch at night to:
I. prevent overdose.
2. pm"l'nt adverse reactions.
3. ensure the dosage is appropriate.
4. delay development of tolerance.
II PlIl the (ollowlng nursIng tnterventJons In order (or a pa-
tient who is experiencing chest pain.
I. Administer nitroglycerin sublingually.
2. Assessheart rate and blood pre;.sure.
3. Assess the l0C3tion. quality, and intensity of pain.
4. Document interventions and outcomes.
1:1 Erectile dysfunction drugs such assildenafll (Yiagra) are
contraindicated in patients taking nitrates for angina
be.::ause:
I. theyconlllin nitrntes, resulting in an overdose.
2. they decrease blood pressure and may result in
prolonged and severe hypotension when combined with
nitrates.
3. they wiU adequately treat the patient's angina as Wl'U as
erectile dysfuncrion.
4. theywiU increase the possibility of nitrate tolerance
developing and should be amided unless other drugs
can be used.
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CRITICAL THINKING QUESTIONS
1. It. patient on the medial! unIt Is complainlngof chest pain
(4 on a sale of 10). has a history of angina, :lnd l5 rtquest-
log Ills PRN nltroglyculn spray. The pat lenl's blood pres-
sure Is 96/60 mmH! at prnenl. Identify what nurse
should do.
2. A patient is reco,"ering from an acute MI and h.asbeen put
on alenolol (Tenormln). \\lhalleachlng !.houJd Ihe patient
receive prior lodischalW' (rom the h.ospltalr
(,,"pt .. lS Drug. fo< .....-.gIna Pecto<" and M)'Durdl.lllnfilfCtlon l5J
3. A patient with chest pain has been giwn ttle calcium chanOO
blocUrdiltinml tVror a Ile3rt l'lIlo!of 118 bf:Iu
per minute. Blood pn:ssurt at thl$ Is 100160 mmHg.
Wllal pl'Kllulions should the nunc' taker
Su Apptndix D for allj"'UJ and rlltio,mlts for all


1<;)QIr -lIIlJII b orOIe c/llplBI ,new arcI
r9:IIllCH. Prepare for suo:ess WIth .1liUcN1 ttClO:--$\JIt Pl'\ldlte
QUI:ISIions. !rI(I aethiIi .....t:J 1m. IIlimatiols
and WIoos. nI rrae'
RegISter l'IIO.I' eode from 111, Iron! oj !IOU' book.,

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DRUGS AT A GLANCE
SODIUM CHANNEL BLOCKERS JlljfJS9
Q (Procanbld) fII1Ijt 361
BETA-ADRENERGIC ANTAGONISTS/BLOCKERS
""J6!
Q propronoJol (lnderat InnoPronXL)

POTASSIUM CHANNEL BLOCKERS JUjtJ6J
Q omlooorooe (Cordorone, P/lcI1fOrK!j

CALCIUM CHANNEl BLOCKERS {J!lIJt365
Q veropamll (Colan, Ccwera-Hs, Isoprln SR,
Verekm) fXI9I' Jt6
KEY TERMS
action polrntial JY.XJ1155
auioventri(ular bundle pJt 356
atrioventrkular lAY) node jJQI}l J56
automaticity f<!(jt1S6
bundle branchu {XIgt 156
calcium ion mannel {XJIJtJ58
rardioversion/drfibrillation paqt 157
Chapter 26
Drugs for Dysrhythmias
LEARNING OUTCOMES
After reading this chapter, me student should be able to:
1. Explain how rhythm abnormalities can affect cardiac function.
2. Illustrate the flow of electrical impulses through the normal heart.
3. Classify dysrhythmias based on their location and type of rhythm
abnormality.
4 . Explain how an action potential is controlled by the flow of sodium,
potassium,and calcium ions across the myocardial membrane.
5. Identif",: the importance of non pharmacologic in the
lr" .. lrn""l uf uy.rhylhrnid .
6. Identify the general of action of anti dysrhythmic drugs.
7. Describe the nurse's role in the pharmacologic management of patients
with dysrhythmias.
8. Know representative drug examples for each of the drug classes listed
in Drugs at a Glance, and explain their mechanisms of action, primary
actions,and Important adverse effects.
9. Use the nursing process to care for patients receiving drug therapy for
dysrhythmias.
depolariution jX1Jt
dysrhythmin f'JIIt 155
edopidoci/pa{rmakers pogt 156
(ECG) f'JIIt 156
fibrillation pt.TJelSS
impla ntablf cardi overter defi bri nators (K DJ
pu;em
polarized
potomium ion mannfl f'JIIt 158
Purkinjefibers pi1I}t 156
refradory period fl!gt 158
;we156
fl!gtl56
50dium ion mannrl pi1I}tJ58
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D
JYhythmias are abnormalities of electrical conduction
that may result in alterations in heart rate or cardiac
rhythm. Sometimes called arrhythmias, they encompass II
number of different disorders that range from harmless to
life threatening. Diagnosis is often difficult because patients
often must be connected to an electrocardiograph (ECG)
and be experiencing symptoms in order to determine the
exact type of rhythm disorder. Proper diagnosis and opti-
mum pharmacotherapy can significantly affect the fre-
quency of dysrhythmias and their consequences.
26.1 Etiology and Classification
of Dysrhythmias
'Whereas some dysrhythmias produce no symptoms and
have negligible effeas on cardiac function, others are life
threatening and require immedimt' treatment. Typical
symptoms include dizziness, weakness, decreased exercise
tolerance, shortness of breath, and fainting. Patients may re-
port palpitations or a sensation that their heart has skipped
a beat. Persistent dysrhythmias are associated with increased
risk of stroke and heart failure. Severe dysrhythmias may re-
sult in sudden death. Because asymptomatic patients may
not seek medical it is difficult to estimate the fre-
quency of the disease,although it is likely that dysrhythmias
are quite common in the population.
Dysrhythmias are classified by a number of
methods. The simplest method is to name dysrhythmias ac-
cording to type of rhythm abnormality proouced and
their locations. Dysrhythmias that originate in the atria are
sometimes referred to as supraventricular. Atri.1l fibrillation, a
complete disorganiL1tion of rhythm, is the most common
type of dysrhythmia. Those that originate in the ventricles
are generally more suious, as they are more likely to inter-
fere with the normal function of the heart. A swnmary of
common dysrhytlunias and a brief description of each ab-
normality are given in Table 26.1. Although a correct diag-
nosis of the type of is sometimes difficult, it is
essential for effective treatment.
TABLE 26. 1 Typesof Oysrhythmias

OI ... lOr 26 0"'9' for Ophythm", 355
Dysrhythmias can occur in both healthy and diseased
hearts. Although the actual cause of most dysrhythmia! is elu-
sive, they are closely associated with certain conditions, pri-
marily heart disease and myocardial infarction. The foHowing
are diseases and conditions associated with dysrhytlunias:
Hypertension (HTN)
Drdiac valve disease such as mitral stenosis
Coronary artery disease
Medications such as digoxin
Low potassiwn levels in the blood
Myocard ial infarction
Stroke
Diabetes mellitus
Congestive heart failure
26.2 Conduction Pathways
in the Myocardium
Although there are many types of dysrhythmias, all have in
common a defect in the generation or cOIrduction of electrical
impulses across the myocardium. These electrical impulses,
or action potrntiall, carry the signal for cardiac muscle .:ells to
contract and are precisely coordinated for the chambers to
PHARMFACT5
Oysrhythmias
[lysrhythmias JIl' It"\jIOffiible for mOlt' than 44,000 dutm n(h 'ft.lr.
!erial dymythmill O(Qlr IIIOIl' IOmmonly in mt n tlun in worun.
of uri.rl with age. The)o Jifr(t
<05%of thOSl' Jged 15 to 35.
1.5% ofthost up to Jge 60.
9l(i of thoW' OVl'r age 75.
IOOut 15% ohtrous O(Qlr in p-atitnts with atriJI dysrhythmias.
A IaI9t majori\)' of !Udden (ardiac dNths all' btlil'wd to b)'

hill fibrillnion .fft<tl 1.5102.2 million in tilt United SUIf<.
Name of Dysrhythml.
Atrioll or I'tntrirularoo)'Qldia Rapid lItan beat gruttrtlun 100 beau innllu;m!!riIwmdlyurdioi mort' W'l'ous
thin atrial udlyurdiol
Aui.ol or I'!'ntrirularflutttr
Aui.ol or I'tntrirularfibrillati:HI
Hurt bIodr:
I'mniIIUf! aui.ol or pmnatUl' I'!'Ttrilwr (ontr.rctions (PVCs)
Ripid,rr<]Ular nay betWffil 200-300 beau/ min; atrial may tll'atmtnl but is
not uswly I'tntrirularftu1itr trNtlllffit
'kr} rapid, !JI(oordillilltd disorIFonization 01 rh)"ltm Il'IUhing in lad; of .!ltqualt
wdia>c: (ontrinion; II'qurtl irnrntdialt trutmm
Area 01 lIOTIUIT"Idunion in tit m)'CQ'lli!m; may be partial or aHIlpletr; dassifitd as first, W'(ond, or

An utra ben ofttn ori9illil"ing fKrn J !OIItt other than the SA nodt; not normally W'l"iouI
O(Qn in high fi"equtnt:,
1m than 6) bNil ptr miMt; may pilmlaur
LibraryPirate
356 UnII4 TheCJrdkwasc:ubr ,nd Urinary Synem,
beat in a synchronized manner. For the heart to function
properly, the atria must contract simultaneously, sending
their blood into the ventricles. Following atrial contrnction,
the right and left ventricles then must oontract simultane-
ously. Lack of synchronization of the atria and ventricles or
of the right and left sides of the heart may have profound
cofl'iequences. The total time for the electrical impulse to
travel across the heart is aboutO.22 seoond. The normal con-
duction pathway in the heart is illustrated in >- Figure 26.1 .
Control of synchronization begins in asmall area of tissue
in thewall of the right atriwn known as the sinoatrial (SA) node.
The SA node or pacet1lt1kerofthe heart has a property called
ntomaticity, the ability of certain cells to spontaneously gen-
erate an action potential. The SA nooe generates a new ac-
tion potential approximately 75 times per minute under
Te<ling mndilion., wilh ",ns" of fiO 10 100 '-t.o
per minute. This is referred to as the normal sinuslhythm. The
SA node is greatly influenced by the activity of the sympa-
thetic and parasympathetic divisions of the autonomic ner-
vous system.
On leaving the SA node, the action potential travels
quickly across both atria to the ItriO'ft'ntri(ular(AV)node. The AV
node also has the property of automaticity, although less so
than the SA node. Should the SA node malfunction, the AV
node has the ability to spontaneously generate action poten-
tials and continue the heart's contraction at a rate of 40 to
60 beats per minute. Impulse conduction through the AV
node, compared with other areas in the heart, is slow. This
allows the atrial contraction enough time to completely
empty blood into the ventrides, thereby optimillng cardiac
output.
As the action potential leaves the AV node, it travels rap-
idly to the atrionntrirular bundle, or bundle of His. The impulse
is then conducted down the right and left bundlf branches to
the Purkinje fibers, which carry the action potential to all re-
gions of the ventricles almost simultaneously. Should the SA
andAV nodes b<x:ome nonfunctional , cells in thcAV bundle
and Purkinje fibers can continue to generate myocardial
contractions at a rate of about 30 beats per minute.
Although action potentials normally begin at the SA node
and spread across the myocardiwn in a coordinated man-
ner, other regions of the heart may begin to initiate beats.
These areas, known as fCtopic foci or "topi( may
send impulses across the myocardium that compete with
those from the normal oonduction pathway. Although
healthy hearts often experience an extra beat without inci-
dent, ectopic foci in diseased hearts have the potential to
cause the types of dysrhythmias noted in Table 26.1 .
It is important to understand that the underlying purpose
of this conduction system is to keep the heart beating in a
regular, synchronized manner so that cardiac output can be
maintained. Some dysrhythmias occur sporadically, elicit
no <ymplom<, do nOl aff""l cardiac o"lpHl. Th"", type..
of abnormalities may go unnoticed by the patient, and
rarely require treatment. Others, however, profoundly affect
cardiac output,result in patient symptoms, and have the po-
tential to produce serious if not mortal consequences. It is
these types of dysrhythmias that require pharmacotherapy.
26.3 The Electrocardiograph
The wave of electrical activity across the myocardium can be
measured using the electrocardiograph. The grnphic
recording from this device, or (ECG), is useful
in diagnosing many types of heart conditions, including
dysrhythmias.
Three distinct waves are produced by a normal ECG: the
P wave, the QRS complex, and the T wave. Cll.1nges to the
wave patterns or in their timing can reveal certain patholo-
gies. For example, a long PR interval suggests a heart block,
and a flat T wave indicates ischemia to the myocardium. El-
evated ST segments are used to guide the pharmacotherapy
of MI. A normal ECG and its relationship to impulse con-
duction in the h""rt is shown in .. Figure 26.2.
"'"'" tntornodat
alrial plllhways
"'"'"
tnl"rvootricUar

RighI bu1dle branch
Pu!1<inje system
,.. Flgure26.' Normal conduction pathWay In the heart
Source: Pf'aoon fdOO1rton/f'H Calege.
AV junction
,""oc'lr- 't--- Bondle 01 His
,-1--- LeI! bundle branch
r;:'7'---- Purkinje liben!
LibraryPirate
Internodal atrial
conduction pathways

\'6<--------- Bunda brar.chw;
';-------- Puoonje network
Atrial V""tricuia,
depoiariZlOtion ,epoIariZlOtion
V""tria.ola,
depolarization
I I I I
-
,
02 , ..
"
'-----v---' '---.--'

,
Q"
,
". Flgure26.2 Relationship of the electrocardiogram to electrical conduction In the heart
Source Peawn fduaJf/oo/PHCoIlege.
26.4 NonpharmacologicTherapv
of Oysrhythmias
The therapeutic goals of antidysrhythmic pharmacotherapy
are to prevent or terminate dysrhytlunias in order to reduce
the risks of sudden death, stroke, or other complications
sulting from the disease. Because these drugs can cause seri-
ous adverse effects, antidysrhythmics are normally reserved
for patients experiencing symptoms of dysrhythmia or for
those whose condition cannot be controlled by other
means. Treating asymptomatic dysrhythmias with medica-
tions provides Little or no benefit to the patient. Health care
providers use several nonpharmacologic strategies to elimi-
nate dysrhytlunias.
The more serious types of dysrhythmias are corrected
through electrical shock of the heart, with treatments such
as elective cardiovrnion and drfibri llat ion. The electrical shock
momentarily stops all electrical impulses in the heart, both
normal and abnormal. The tempof3ry cessation of electri-
cal activity often allows the SA node to automatically return
mndllction to SiOllS rhythm.
Other types of nonpharmacologic treatment include
identification and destruction of the myocardial cells re-
sponsible for the abnormal conduction through a surgical
procedure called catheter ablation. Cardiac pacemakers are
sometimes implanted to correct the types of dysrhythmias
that cause the heart to beat too slowly. cardiOerter
(I(D) are placed in patients to restore normal
rhythm by either pacing the heart or giving it an electric
shock when dysrhythmias occur. In addition, the ICD is ca-
pable of storing information regarding the heart rhythm for
the health care provider to evaluate.
26.5 Phases of the Myocardial
Action Potential
Because most antidysrhythrnic drugs act by interfering with
myocardial action potentials, a firm grasp of this phenomenon
LibraryPirate
358 UnII4 TheC.rdloY.<;(ubr ,nd Urinary Syuem,
is necessary for Wlderstanding drug mechanisms. Action po-
tentials occur in both neurons and cardiac muscle cells due to
differences in the concentration of certain ions found imide
and outside the cell. Under resting conditiom, Na+ and 0.1+
are found in higher concentrations outside m)Ucardiai cells,
and K+ is fOWld in higher ooncentrntion inside these cells.
These imbalances are, in part, responsible for the slight nega-
tive charge (80 to 90 mY) imide a myocanlial cell membrane
relative 10 the outside of the membrane. A cell having this neg-
ative membrane potential is called pdarim:!.
An action pot ential begins when .odium im mannel. located in
the plasma membrane open and Na+ rushes into the cell pro-
ducing a rapid depolarization, or loss of membrane potential.
Duringthis period,CaH also enters the cell through calciumim
mannels, although the infiu.'I: isslower than that of sodium. The
entry of Ca
H
into the cells is a signal for the release of addi -
tional intracellular calciwn that is held in storage inside the
sarcoplasmic reticulwn.lt is this large increase in intracellular
Ca
H
that is respomibleforthecontraction of cardiac muscle.
During depolarization, the inside of the plasma mem-
brane temporarily reverse; its charge, becoming positive. The
cell returns to its polarized state by the renlOval of Na+ from
thecell via the sodium pump and movementofK+ back into
the cell through potassium ionmannrls.ln cells located in the SA
and AV nodes, it is the influx of CaH, rather than Na +, that
generates the rapid depolarization of the membrane.
Although it may seem complicated to learn the different
ions involved in an act ion potential, understanding the
process is very important to canliac pharmacology. Block-
ing potassium, sodium, or cakiwn ion channels is the pri-
mary phannacologic strategy used to prevent or terminate
dysrhythmias. Figure 26.3 illustrates the flow of ions dur-
ing the action potential.
The pwnping action of the heart requires alternating pe-
riods of contraction and relaxation. There is a brief period
of time following depohlrization, and most of repolariza-
tion, during which the cell cannot initiate another action
potential. This time, known as the rrfillctory period, ensures
Cl aas II
Beta-adrenergic blocker
+20mV
OmV
CI I
Sodium channel
........
Procainamide
(a) Resting state before
action potential
An channel gates closed
Propranolol
CII M IV
Calcium channel blockers
' Verapamil
(b) Depolarization
Sodium and calcium
channel gates open
(e) Repotarization
Potassium channel
gates open
Flgure26.3 ton channels tn myocardtal cetts
(d) Return to resting state
An channel gates closed
LibraryPirate
that the myocardial cell finishes contracting before a second
action potential hegins. Some antidysrhythmic agents pro-
duce their by prolonging the refractory period.
26.6 Mechanisms and Classification
of Antidysrhythmic Drugs
drugs a(t by al tering specifi c electrophys-
iologic properties ofthe heart. Theydo this through two ba-
sic mechanisms: blocking (\ow through ion channels
(oonduaion) or altering autonomic act ivity (automaticity).
Antidysrhythmic drugs are grouped acoording to the stage
in which tbeyaffect the action potential. These drugs fall into
four primaryd asses, referred toasdasses [, II , [lI,and [V,and
a fifth group that indudes Iniso::ellaneousdrugs not ading by
oneo(the first (our m('l;hanisms. The five categories of anti-
dysrhythmics and their medu.nisrm are listed in Table 26.2.
The use of antidysrhythmic drugs has significantl y de-
clined in recent years. Resear(h studies holve found that the
use of antidysrhyt hmic medications for prophylaxis can ac-
tuall y ;ncreast: patient mortality. This is because there is a
narrow margin between a thel'1lpeutk effect and a toxic ef-
f<>eT with ([nIp? ThM (.Mtlbc rhythm. Thl'}' hnvi! thi!
ability nO! only tocorrtCl dysrhythmias but also to worsen or
even create new dysrhythmias. These prodysrhythmic effects
have resulted in less use of drugs in class I and increased use
of drugs in class II and dass III (specifically, amiodarone).
Another reason for the decline in antidysrhythmic drug
use is the success of nonphannaco[ogic techniques. Research
has demonstraled thaI catheter ablation and implantable
defibrillators are more suw.'s.sful in nlOlnaging certain types
of dysrhythmias than is the prophylactic useof medications.
SODIUM CHANNEl8LOCKERS (CLASS I)
The first medical USt of quinidine, a sodium channel
blocker, was recorded in the 18th century. Doses for the
TABLE 26.2 Classlficatton of Ant.dysrhythmics
am
"'0'"
OIoptt, 16 Orugl 101 OysrtrythmJu 359
sodium channel blockers, the largest class of
mies, are in Table 26.3.
26.7 Treating Dysrhythmias
with Sodium Channel Blockers
Sodiwnchannel blockers, t hedass I drugs., are divided into
three subgroups, lA, IB,and IC, based on subtJedifferences
in their mechanism of aclion.lk-cause the action potential
is dependent on the opming of sodium ion channels, a
blockade of these (han nels will prevent depolar izat ion.
The spread of the action potential a(ross the myocardium
will slow, and areas of ectopk pacenlaker activity will be
suppressed.
The sodium channel blockers are silnilar in structure
and action to local anesthet ics. In fact, lidocaine is a class I
antidysrhythmic that is a in
chapter 1900. This anesthetic_like action slows impuLse
conduction across the heart. Some class [antidysrhythmics,
such as quinidine and procainamide, are effective against
many different types of d ysrhythmias. The remaining class J
drugs are more specific, and indicated only for life-threateni ng
ventricular dysrhythmias. Although a prototype for many
decades, quinidine is T3rely used tod3Y due to the availabil-
ity of safer antidysrhythmics.
All the sodium channel blockers h3Y(' the potential to crc-
ate new dysrhythmias or worsen existing ones. The reduced
heart rate caused by the drug can cause hypotensi on, dizzi-
ness, and syncope. During the ECG
should be monitored for sigll$ of cardiotoxidty, such as in-
creases in the PR and QT intervals and widening of QRS
complex.. Somedass I drugs haw significant anticholinergic
effects such as dry mouth, oonst ipation. and urinary reten-
tion. Special precautions should be wi th older adults,
because anticholinergic side efferu; may worsen urinary
hesitancy in patients with prostate enlargement. Lidocaine
can cause eNS toxicity such as drowsiness, confusion, and
(onvu1sions.
hdtcatlons
111.1
IA Dt\a)os IIIMs {oocMtion 'eIitJ; iOON\eI
d .. , tion
Atrial {Qn\l'i(tions,.P'iC!,.
V'tIIIIicINr
IBmmplt;lidoulnt
IC
U; BuaaIi'rntr9{ antaqari liS eumplt;
_ ...
m;PowsiJm chanMl bIoUtfI tumplt:
illiod.illllll'
fHMwn dIirJJ@llIIocbrseuJ!1llt:
,,",pmII
'/'(CeitJolttl (oocMtion ftloIity;
dt<rulot! Ii;.ntion of rtion poIto\i,1
ltIl-ignitkolnt on rtpOlirization; lioM{onduction
-"
SlOW! tonduction 'IfIodIr. dt<rmn aLlomatidtr. prdongs
-.,-
SlOW! rtpOIolriu1 ion; looN It! d .. i1ion action
p!OIongI rthctory period
SlOW! COI'Id\r(tQ) 'ItIodr. dt<rmn {OII\ooiIity; praIongI
-.,-
Sftl'll' wntrio:ular

tIlIJioUr dyIr\Iythmlal
St-il'll' vtntrkIAir dysrIrythmlai
LibraryPirate
TABLE 26.1 Antidysrhythmic Drugs
Drug RoutE> and Adutt Do5e (mall dose where Indicated) Adverse Effects
Ct..ASSIA:SODIUM CHANNEL BLOCKERS
o PfWNmide (Proanbid)
quinicint glUUI!I.Jte
quinicine Mlflte
PiI; 100-100 m9!;d (max: 1.100- 1,600
SffiII1 drug 1M! is 1-5 /1I(g/ml
PiI; 1 glo.lding dose br 250-SOO mg bid
IV; 15-18 mgi\g as loading dose !low inMion Otf 30 min
followed by 1-4 mglmin oH maintrflalKe dose by comioooos
infusion
PiI; 200-600 m9 (max:3-4 gldq)
PiI;200-400 m9 (max;3-4 gldi1l;thelilptt.tk
SffiII1 drug 1M! is 2-5 /1I(gfml
Ct..ASSIB:SODIUM CHANNEL BLOCKfRS
IlIooint (Xykx.aine) (st!! pigl! 20
for !he Prototypr Dn.I;I boxOO)
mmetine (Mexitil)
phm)1Oir1 (DUnlin. Phenytet) (set!
page 175 for the PIototype: Drug
",,,,,,)
IV;H mqhnin inlWon rlte(mn:lmglkgptr S-10min)
PiI;200-100 mg tid (mu: 1.200 mglday)
PiI; 100-200 mg tid (mu:625 mglday)
1V;5G-IOO m9"tIJ 10-15 min unll dyytJythmw b
temdllillrd (mu; 1 glday)
ClASS Ie: SODIUM CHANNEL BlOCKERS
lIfGIinide (bmbowf)
prtipifmone (Rythmol)
PiI; lOOrng tid (mu400mglday)
PiI; 150-300 mg tid (mn;9OO mglday)
ClASS II: BETA-ADRENERGIC BLOCKERS
iCebulolol (Stliln
HIlIoIoI (BrlYibkx)
o propr.molol (100011, "noPr.m Xl)
PiI;lOO-600 mg bid (max: 1.200 mgldaJ)
IV;SIl rocgIkgImin mlinlmlocedw (max: 200 mcgllgfmin)
PiI; lG-3G m9 lid"'1id (max:4!IJ
IV;O.5-1.1 mg "tIJ 41lou1J
CLASS III:POTASSIUM CHANNEL BLOCKERS
o MnIodirttlt(Cofdmne,hctrOllt)
doiecilidt (lil:osyn)
Itontdaront
bltilide (Cl:lMrt)
SOIIIoI" (ktapm. 8fl:apiCt M, Sorint)
PiI;400-600 mg/day (mix: 1,600 mgld.,. as loadill9 dose)
PiI; 125-500 mcg bid tt.1Cd0fl oorininedt.riUkt
PiI;400mgljd
IV; 1 mglnlwclo-m 10m"
PiI;80mgbid (miX: 320 mgfdayl
ClASS IV:CALCIUM CHANNEL SLOCKERS
diltiaztrn (wdiltm, Xl, Dlac:0f XR,
Tiztia Xl, TIUa<) (Itt Pi9t 348
for !he Prototype Dn.I;I box
OO
)
Q I'ffipamit (ulan, (OYtfl-HS, isoptin
511. Vtrdan) (sttpigt li fof!he
Proto(ypt Drug b.: (0)
1V;5-10 mghl (O/l!inuous infuslOl1 for. fl"llximlll1l of 24 II
(max: 15 mghl)
PiI;240--480 mg/day
IV;S-10 mg dil't(t:may Itptatin 15-]11 !Tin if ntt<lt<l
MISCELlANEOUS ANTIOVSRHYTHMICS
IIgoxin (Di!1tel.lanOJin, lanoxiGlpsJ
(spilgt311 fe. thtPrototyptDrug
"'''''')
1V;'-12mgglvmua boIusin.ie<tionMfY Hmin ISi"lttdtd
(max: 12 mgflkMJ
PO;O.11S-G.5 mg !jd;therape:utk SffiII1 drug itl'rl is
O.8-1l11)'ml
Irdio ir"ocIiatt common irocIbtes serioui IIMne effects.
NlllIUO,lI1IIIirillJ dillrrlw,ftymoutll. umory
"'-
May i!RXMe MW e. WOIJfI\ tlisfoo
ooei" twooll'mjoo blood dymsjaS (miridM jljd
kiM fprouinamjdpl
NIIusta, IIlmiriIlJ drowsinm, dilziJrn, /ootgY
May D!!!d!Kt IltW dysItIythmias e. WOIJfI\ Nming
ones' hypotm!ion.ln!tyrri. CNS to"ddty
(Mdgg'oo ma6gn,JQ! bmmbmnu 1)00;"1 WlDJ'l
t)likpl:iru!; if Ibruptly "';!hIRWII [phrnttoinl
NIIusta, IIlIIIiriIlJ dilzinm,hfodadlt
May D!!!!kKe IltW W!!Ot!! tlmioo
9MSlnpot(f)!ion. bra!Iyt;ma
nrigut. insomIio, dJmnirltSI,impoltnaordturosal
btodycDllfD, Qnd(lltIfusio/l
Aqr!IuW!o!k.!armcmpasm SiMll5-.ioImoo
.wp!'N!.msf 1M drug klbrmllyvmhdr.wm
paRium n:bouod I!mJrmigo lfr:itruImi19
!ttvhythmin-qlTMlG!!!ii! jid!m!b m.nocrur
&lrred rlsiaI
KIfIIiri"lQ./MO,mQ
May pn:dKt IlfW !MrtrytbmiH q W9rV!l aisljng
SM' hyootmslon. bradyooia QrlM!O!!i.J .. Ue
syndrome [ampQ!'tt) .!!!Poedtm' [dofelilidsl (!(S
!I'jrjty m"rtiIdr1
;tin, lItDdodit. dillintSS, ptriphtrQl NtmII,
Ight .. MIIW4 dDlrlw
IIm!IQI9Jjcjty M) (HE (pn/lQion AQOd cbi!lCl!"
May pn:d!rt !WW dMn1bmiH q W9rV!l aisljng
""
NIIUIlO, Klllliling,1iloddc /Itt, tnI rim tlsrurbllrlm
May D!!!!bct !WW ctnshythmiH q WOfH!\ tlisljoo
"'"
"Sotalol i! I beta bIomr, but btQUSoI! ill ardiac. tHem Ill' siniltr to those of amiodarollt,it is ronsidmd I elm III mug.
'"
LibraryPirate
,", Prototype Drug I Procalnamlde (Procanbld)
Class: Ant idysrhythmic Pharmacologic Class: Sodium dianne! blader/class IA
ACTIONS AND USES
Prouinamidtis in 19SO,th" is(litmically
local aneslhetic: prouifl!'.Procainamidt bIoc:kllOdum ion channtls in m)'lm-
dial (elk, thus rmlKing automaticity and slowing rondlKlion of aclion po-
tt ntial KrOSS the myomdum. This slight Mlay in ronduction vtIocity
the rdractory ptriod ,nd .:an IUppl\'SS dysrhythmias. Poxainamidt is rdemd
to as , broad-spwrum drug beuUIf it has <Ibilil)' to roITKI many
type of atrial and Yenlrirular dysrlrylhmias. most {ommon dosaqe form is
the Ulmded ft'Itasttablet; prooinamidt isalso milable in "1lIU1e,
IV, and 1M TIlt Itrum drug is4 10 811KglmL TIlt
Ult of prooinamidt has dKlined to of moft'
Ipt(ifund
ADMINISTRATION ALERTS
Un lUpine position during IV adminismtion btuUIt hypoten-
sion m.ly OCCUt
Do not break orcrush tablets.
Pregnancymtgory(
PHARMACOKINETICS (PO)
Onset: lOmin

Half life:lh
Duration: 1 h (8 h IUSiaintd ft'1e, 1t)
ADVERSE EFFECTS
/lausu, vomiting, <Ibdominal pain, hypotension, and htadache aft' common
during procainamidt therapy. High doses m.J)' effKIIsuch ,scon-
fusion or psythasis.like a II amidysrllythmic: drugs. procain.l midt has ability
to product ntW dysrhythmiu or worstn existing ones. A syndrome
mayocwr in ]0% to SO% of p-atitnll taking 1M'! a )'Nr.
Conuaindi{itions: Procainamidt is comraindicaled in patifnlS with {omplete
AV block, 1M' ft' CH F, blood dysera sias, a nd m)'ilthenia gravis.
INTERACTIONS

acmnislered with O!ha antidlolinfrgic sidf fifloaswi l
oaur l prOGliiarnide is IMd III(WIently with anticlulilfrgic !kugs.
liI b Tesu: ProGainamidt may ilKll'U vaiu@!1or ihf AlJ, li'liiii1
ili:ailll' plmplmase, lilli, arKIlflllm FaM-plMivI' Coombs Itsl arKI ANA
tilMmayOCCUI.
HerbaVFood: lInknown
l INIment of OYl' rdOSf: Supporti\'l' ireaUllmt is to Ie"I'l'lSing hy-
with mopl\'SlOlS and pft"lmting or tft'uing prouinamidt-induced
dylrhythmiotl..
It!ftrrc M)Nrmlfl9l1!lbrQNulllfll} Pnxm
NURSING PROCESS FOCUS PATIENTS RECEIVINGANTIDYSRHYTHMIC DRUGS
Assessment
Baseline assf51ment priort o admini strat ion:
Undtrstand ft'ason drug has 1ln prt'I{ribed in ordtr 10 mfls for
thtra ptUlic: (t. g., at rial, Vl'mricular dysrlrylhmiasl.
Obtain a complete htakh history including urdiovaswlar (including
preYious dysrhythmias, HTN, Ml,hean the possibility of
pregnancy. Obtain a drug history induding {um'nt pltSuipbon and
OK drugs, herbal akohol aim to possible drug
int ..... tions.
Obtain vital signs (epKially BP and pul!!'), KG
rIryIhm),caroiar: monitoring (such aSlllrdiac rulpul if appropriale),and brNth
soo.nIs. AsS!'-u forlocatiln and charan"! amount of rotm.t, ff pltSenl
E'f<Iluateappropriatt laboratory pomsium
1e1'l'l,ll'n<l1 and liYrr function studies,and lipid profilel.
Assfss mf nt t hro ughout iI dministrati on:
AslfSs for cle-sirm rifects (t.g.,{onlrol or t liminalion of
dysrll)'lhmia, blood prffiU Il' and pu1lt within limits).
ContinU!' ift'qumt monitoring of KG (rominuous ij hospitalized). Check
PUM quality, vokJnll',and If9Ularity along with ECG.Al5es forcomplainll of
palpitations and (orreialt symploms with ECG findings.
ContinU!' ptriodic: monitoring of tspeeially polmum.
AslfSs for advent rifKII: dinilll'ss, hypolension, nausu, vomiting,
hNdac:he, fatigU!' or WUkfl!'l5, flushing.or I6UiII dysfunction. Brac1)Urdia,
lach)'cardia, or fI!'W or dilrerrrli dysrhyth mialshould lit reponed to
hNlth Ull' immediately.
Pot ent ill l Nursing Dill gnoses
Cardia{ Outpul (related to to
ac1l'!'rlt tffech ofdl\Jgtherapy)
TIlItI!' Perfusion (related to Pl'XflstI,or to
ac1l'!'rlt rifech ofdl\Jg therapy)
(reined to dysrhythmias)
FatigU!' (r!lated to dysrhythmiasor to adYl'rst of drug therapy)
Activity (ft' lated to drug therapy)
Smlal Oysfunction to adverst ell"KII of drug
Deficitnt (drug lhetapy)
Risk for hils, Risk for Injul) (ft'lated to hypotenlion,diuilll'n associated
with dysrlrylhmias, or 10 ac11'!'M rifKII of drug Ihmpy)
(Continued!
LibraryPirate
362 UnII 4 TheCJrdkwasc:ubr.oo Urinary Syuem,
NURSING PROCESS FOCUS PATIENTS RECEIVING ANTI DYSRHYTHMIC DRUGS (Contillutd)
Planning: Patient Goals and Expeded Outcomes
The patimt wiH:
Experitnc:e thelapeutic tfhru dtpendent OIl the rt'aIOII the drug bting gWen (e.g.,decrmofd and blood pl"ffiUlt .nd plJM within normal
limin).
Be free from. 01 experierue minimal. . dmse tifed,.
an undemandin 9 of lhe drug's UI!', adoror tifrru, j nd rtquirt'd prtaUlions.
oflhe medication (e.g.,dOlf, timing. when to notify health tale providtr).
Implementation
Interventi ons and (Rati onales) Patient and Family Education
Ensuring therapeutic effect,:
Co,uiflll' lIsessment,oII aboYtfor tlitrapMic efftcu.(OysrftythmiH To <lliay possible anlliet)o, te.{h the lamii)o,ortalt'giYe, thr ,atioule
haYf diminished or art' rlimilated. Blood prmlR and pullf Ihouk! bt within for .11 equipment Ustd a nd the need for f'equent monitoring.
oormalliniu orwithin pa!llmetefllfl by IINkh tart' p!O'<idtr.)
EnOlUr.ge appropriate lifestylt {hanges. Providt for mnsultation .II Enc:ourage the patient to adopt a ht akhy lifestyle oflow--fat food {hoKe!,
.--ltd (He. khy lifestyle (hanges will IUppon and minimin the need for inc: lNsed exm:isf, decrt'. sed (Jlfeine and <lkohol (OIllUmption,.nd
drug therapy.) smoking {ffiation.
Minimizing ildwrse eflKts:
ContinUl'to monitor ECG and pulsefur quality and volume. Take pulse furl Texh the megil'el" how to uke a pffiphe!lll pulse for 1
full minute to .HItS, for It'gularity. ContillUl' to 0II1ffi fu, {ompl.inll of full minute beflR taking thedrug.Assist the find the plJM aru
palpitations, {or,eiating palpitations or plJllf ilT\'9ularitits with ECG. (Not a II that most (onYfnitnt and fell Rord daii)o plJlst r.tl'S and
dysrh)'thmiH rt' sym ptormtic. Corrtl.ting symptom, with the ECG may It'gularity . nd bring It<OIlI to u {h IINlth urt' isit.ln,1nKt the patimt to
help tht need forlunhersymptom managl'ment.) ootify the heakh cart' provide, if pulst btlow 60 or abovt 100, therr
ooticNble challC)l' in It'gularity from prrviousl)o or if palpitltions
develop 0' wa'lfn.
Take blood prrnurt i)oing.sittinq.and mnding to deted onhost.!lic the patient to 1M from or litting to IIdnding to jwid
hypltension. Be cautious with the fim few doll'! of the drug and with the diuiness or lalls.
eldtrty who a,e at ilKfl'ased risk for hypotension.(Antid)'lrhythmic df1191
InstMt the patimt to take the fi,st dose of the new plt:l{ription btfort'
may ta!M hypotension. A finHlost elft may OI{ur with a signifitant d,op
bedtime .nd to be uutious ckJring the ntxt few dOles until drug effects <l rt'
in BP with the first few doIt5.0nh0static: hypoten,ion may ilKfl'alf the risk
koow".
oflaUsand
Texh the (JrrgiYtr how to monitor blood prtssurr if
rrquire<i.EllIUrr proper UIf and fUnc:tioning 01 any homeequipmem
obt.ined.
IlIIIlI.lt the patient to nctil)o the heakh cart' pla<ider ifblood pl!SllI"e
9OIro mmHg or beIov.\orpt' palametm IfI bt' IINkhull' providt,.
Cominut 10 monitor ptriodi< .. pt<i.11y potmium,rrnol ImtrU<llhe patimt on n .. 11 10 rt'tum periodi<. llyfor I. b ...,rI<.
funnion labs,and drug itYelS <l ' nteded.(Hypoblemia in{rt'aIl'! the risk 01
Mvise the patient to uny a wallet idtntifK.i tion md or we .. medical
0' high levrls of drug may Ie.d
idtntifiution jewelry ind itating antidys,hythmic therapy.
to inc:lI'astci 0' mort' lethal
the patient d!ii)o JOO report a weight gain or loll of 1 kg or more in HiYe the patient weigh !elf d.Jii)o, iduli)o the of d8;,.nd
2HlOu, period. Continue to oIIll'!S for noting Ioc.tion <l nd {harXler. It'(ord weig ht along with pulst mealUrrmenll.H.we tht patitm It'pon a
(Daily weight mu,ate measurr of lkJid !tI1UI.nd into x{ount weight loll 0' ljiIin 01 mort' than I kg (appl"Olimately 21b) in a 2+hou,
illlfnsible IosItS.Wrilht gain 0' edema may inditate period.
advtl"ll' drug tifrmor...,rsening mdio\\Jl{ular distase promlfl.)
Monitor for blt'ath I01IIds <I nd lINn sounds (e.g. iKrming dyspnea or posltJ"al InstMt the patimt to immediately rt'pJn any I!'YI'fl' shortnffi ofb,eath,
fIO(tumal dyspnea, ralts or" (fol{kIt( il lurqs, frothy pink sputum. frothy sputum, profound swtiling of v:tremitits.H pollible sign,
1IlIIl1IUr; or alra hean IOUM) alii II'por! UrKreaIDg lung ofhein f.ilurt or po.rlmon.1)' toxicity.
rongestion or _ or \\OJBI' ning hean munnur; may ildicate inpending lINn
lam. Potassiun-<hannel bIodctrs an' .lIOriited with pJntonaI)'
Repon anyviswl {hallgl'"l. skin to the health tart' Teol{h the patient to It'pon any vision {hanges promptly and to maintlin
pra<idt,.(Potmium-{hannei blotkers may (JUst photOltnsitivity, ,kin It'gula, eyt euminations.
rashes, . nd blurred vision.)
Teol{h the patient 01 to 'NUr protffiiYe {lathing and <l PPty
u",-rm-, "'IIuLlrt, during "",iud> of ,uo
LibraryPirate
01",1<,26 ON9' for Oy;<hytt\ml.. 363
NURSING PROCESS FOCUS PATIENTS RECEIVINGANTIDYSRHYTHMIC DRUGS (CoortlUro)
Implementation
Interventi ons and (Rati onal es)
Patirnt understandinQ of drug tht rapy:
UII' opplnunitif, during administration of during
alltSllIII'nB todisnru ,uiorult fordrug thtrapMic:
common parameter'S for when to (all
cart pra<ider,and any monitoring or time
during nursing optimi:eand .IINS.)
Patirnt stlfadministrilt io n of drug tht ril PY:
When administtring lTIfdiCiltiolll, illltnKt tIM< patimt, famii)',orCilrt<jmr in
proptr setf-ildministration tKhniqUfl.(Proper ildminimation inaNltS
efiKtr.enellof tlM<drug.)
Pati ent and Family Educati on
The patifm andlor family should be to IIUt tIM< for drug;
approp.wlt Om and adYl'rll' efiKl! 10 oblffi'l' for and
wlM<n to rtport;equipment nffiItd ill ud how to lI!e that
tquipmem;and tIM< Itngth of lTIfdication thtrapy nmled with
any spKial illltnKtiolll renewing or mminuing presc:ription as
approp.wtt.
Tt l(h tht patitm to drugs" M'fIty 'pa{td apan iI> and not
to doublt 0011' if iI 0011' is misstd
Tmh tht patitm not to dilcontinue tIM< meditation abruptly and to ull the
health cart pra<ider if the patient is unabit to take meditation for
thil n 1 day due 10 iIInes.
The patient is able 10 diswlI appropriate dosing and aclminiltmiln Iftds.
Evaluation of Outcome Criteria
Evaluatr tht rffettiYl'OflI ofdrug tlM<rapy by (onfirming that patifnt 6pKttd out{omes ha\\' bttn IIII't
';t\' rabIt 16.J fur Q ilr ikugs (/Illiel-N/ /0 I'IIIth tlltse 1IIM9 DOfll 4'J11'r. W lUling I'rIIml flKl/S IIIbIn. rMp/ff 2100 iltormolioo rrlDred Iillptdk ((lfegoritl
<IlIi"lfImi.tugs
BETA-ADRENERGIC
ANTAGONISTS/BLOCKERS (CLASS II)
Beta-adrenergic antagonists are widely used for cardiovas-
cular disorders, including hypertension, MI, heart failure,
and dysrhythmias. Their ability to slow the heart rate and
conduction velocity can suppress several types of dysrhyth-
mias. The beta blockers are listed in Table 26.3.
26.8 Treating Dysrhythmias
with Beta-Adrenergic Antagonists
As expected from their effects on the autonomic nervous
system, beta-adrenergic blockers slow the heart rate and de-
crease conduction velocity through the AV node. Myocar-
dial automaticity is reduced, and many types of
dysrhythmias are stabilized. These effects are primarily
caused by blockade of cakiwn ion channels in the SA and
AV nodes, although th""" drugs also blo-ck sodium ion chan-
nels in the atria and ventricles.
The main value of beta blockers as antidysrhythmic
agents is to treat atrial dysrhythmias associated with heart
failure. In post-MI patients, beta blockers decrease the like-
lihood of sudden death due to their antidysrhythmic effects.
The basic pharmacology of beta-adrenergic antagonists is
explained in chapter 1300.
Only a few beta blockers are approved for dysrhythmias,
becauseofthe potential forserious adverse effects. Blockade
of beta receptors in the heart may resul t in bradycardia, and
hypotension may cause dizziness and possible syncope.
Those beta blockers that affect beta ,-adrenergic receptors
will also affect the IWIg, possibly causing bronchospasm.
This is of particular concern in patients with asthma, or in
elderly patients with chronic obstructive pulmonary disease
(COPD). Abrupt discontinuation of beta blockers can lead
to dysrhythmias and hypertension.
POTASSIUM CHANNEl BLOCKERS (ClASS III)
Although a small class of drugs, the potassium channel
blockers have important applications in the treatment of
dysrhythmias. These drugs prolong the duration of the ac-
tion potential and reduce automaticity. The potassium
channel blockers are listed in Table 26.3.
26.9 Treating Dysrhythmias
with Potassium Channel Blockers
After the action potential has passed and the myocardial cell
is in ,IMe, '""Pohri7J1lion depend, on repbce_
ment of potassium inside the cell. By blocking potassium
TREATING THE DIVERSE PATIENT
Asian Patients' Sensitivity to Propranolol
Studies haY!' shown IIIaI AMilIII may lIII'IaboIize propriInoIoI more tPtkIy than
wllians, probably dot 10 a lack of spKific drug IIH'tabolizing fIIl)TII!
(mephenytoil d lin a sir
nifitamlygll'attreifKton heanlil1t i1 many patientsof AsiIr1

INdionsdutto hilhdrug irYI'Is.
LibraryPirate
364 UnII 4 'It" C.,dkIY.",ub, . nd U,'nary Syne<m
..... Prototype Drug I Propranolol (lnderal, InnoPran XL;
Therapeutic (lass: Class II antidysihythmic Pharmacologic (lass: Beta-adrenergic antagonist
ACTIONS AND USES
Propr.nolol is . IIttNdll'ntrgic .ffKling 00., Il'(rpl0B
in hun, . nd beta, IffePlors in plJlmonary .nd \\!\(\Jlar smooth mUI(Ie. Pro-
pranololll'dKrs hun rate,lIows myomdial (ondKtion ..m.:iQ,.nd Iowl'B
blood PIl'IIUIl'. Propranolol is most rlFKtift in UNting !.J(h-,urdia th.t is
causrd b)' stimulation.1t is applO'/rd tOUNt. wide fan-
fly of iKiuding hypfflrmion, angina, .nd migrailll' headKhe,.nd
for prt'"!'ntion 01 MI. ihI' drug is .vailabir in ublet, caJIIUIes,
and IV iorlllJlatims.
ADMINISTRATION ALERTS
Abrupt disrorMinunion II\a)' calM MI, hyptrtenlion, and
lard)'llhyrhmias.
Sw.llow t.blers whole:Do not UUlh orcw contents.
If plJlsr is iffi lhan 60 br.rs ptr mirute, notify the health caft' provider.
Plf90ancy catrgory (
PHARMACOKINETICS (POI
il"lset05- 1
Pto.k: 1- 2 h (6 h wendt<!

Duration:6- 12 h (24 h enendtd Il' Ie_J
channels, the class III antidysrhythmics delay repolarization
of the myocardial cells and lengthen the refractory period,
which tends to stabilize dysrhythmias. Most drugs in this
class have multiple actions and also affect adrent'rgic recep-
tors or sodium channels. For example, in addition to block-
ing potassium channels, sotalol (&>tapace, &>tapace AF,
Sorine) is considered a beta-adrenergic blocker.
The potassium channel blocker s are reserved for serious
dysrhythmias. Amiodarone (Cordarone, Pact'rone) is one of
the more frequently used drugs in this class, and is featured
as the class III antidysrhythmic. It may be used to treat many
different types of atrial and ventricular dysrhythmias.
Du["liliu" (TilusylJ) aJJU iuulili,j" ( OJrv"rl) ar" giv"lJ lu
terminate atrial flutter or fibrillation. Sotalol ( Beta pace, Be-
tapace AF, Sorine) is approved for specific types of atrial and
ventricular when safer drugs haw failed to
terminate the dysrhythmia.
Drugs in this class have limited uses because of potentially
serious adverse effects. Like other antidysrhythmics, potas-
ADVERSE EFFECTS
Common .amse rfferu 01 propranolol fatigur, and
bradycallfia. Because of biliQ of prop'. noloIlO llow hun patirnu
with ca rdi.Jc: dilordtrs SIKh as heart fa iuft' must lit cartfally moniiOll'd
Adftrse rlFeru sum as diminished libido and impotencr may in nonad-
heft'llcr in male p.titms. Propranolol br ust<! caUlioully in diabttiu dur
to irs hypJglyo:rmic ell"Kts and beuusr it m.y ' 1IY!k' the of hypo-
glyo:emia as the .drenrrgic "fight-or-flight ' to hypogl)l:emia i; blocked. This
drug br used with c. ution in patitnts with Il'dicrd Il'oal btciuse
thedrug II\a)' cumuliII' 10 IOl ic in !he blood ind cause dy!;rhyrhmias.
Contrai nd ications: BeulM 01 iu dtpressM.- ell"Kts on the he. It propranolol is
comraindicated in patients with cardiogrnic !hock, sinus bradprdia, greater
than firstgll'l' heart block, and lINn f.iull'. i!euuse it constricts smooth
IIIJI(Ie in the airwa)'l,!he drug is conmindicattd in patients with (01'0 or
Uthlllil.
INTERACTIONS
1Wg- 1Wg: (0IKII"1m adrnirislBion with oIhfr beta may p-OOUCf
i!nd toi)'lalooorhypot!Mion Ioa)'fffit.SfatM
both i!nd 00l1li dIDleI blockm SUpplll! rormr:lii)',
<roaIIIMI U!l' loa)' INdIO ad!iIiI'f tfiHtjurdia. PhrnoIhialilll5 can id:Ito the
h)polfllliw ! 1I"!m 01 propr;InoIoI. Propraoolollhould 001 be givfn wiOin 1 WI'fks of
an MAO inhlJilor, as bradycardia and hypotenlion (OWd fMlAl.lN of !!IIao:d
or ar:ucids (0II1aRn9 .luminllll h)'droDde IJ!I wil !low 1M abIorpJi..- of
propranoIoIlnd Il"IIo.n its therapMc III"I'ffi. AOOIioistmioro of blli ... :lrrnergk
agonisn sudo as wil.nugonizf llot aaionI of JroIIOfIOIoI.
Lab TfSU: PrDp"aoolol may fw O:IMI' for uriy;y
IkorbaVFoo:J: Untnown
of Olerdou: Tll'atment is urgeted to hypotension with
.nd with atropilll' or isoprotermcl Inlr'l'mous
glucagon 1t"V!"rse! the cardiac deprffiion caused U, b!"tl blor:ktr o\'elllose by
t nhancing myocardial conmailiQ, iOCK.sing lINn 'ate, and improving AV
nod, conduction.
siwn channel blockers slow the heart rate, resulting in seri-
ous bradycardia and possible hypotension. The>e adverse ef-
fects occur in a significant nwnber of patients. These agenlS
can dysrhythmias, especially following the first few
doses. Older adults with preexisting ht'art failure must bt'
carefully monitored because they are particularly at risk for
adverse cardiac effects of potassiwn channel blockers.
Amiodaront' can produce pulmonary toxicity in a
icant number of patients. Sotalol and ibutilidecan produce
torsades de pointes, a type of ventricular tachycardia that
can become rapidly fatal if not recognized and treated.
Treatmt'nt of torsades de pointes includes IV magnesium
".Hal" ur l'ul"",,iuJH dduriu".
In 2009, a nt'W potassium channel blocker was approved.
Dronedaront' (Multaq) is chemically similar to amiodarone
but is claimed to have a reduced incidence of adverse effects.
Like sotalol, dronedarone has multiple actions on the heart.
Dronedaront' is approved for the treatment oi paroxystrurl
or persistent atrial fibrillation or flutter. The labt'ling
LibraryPirate
OI ... lOr 26 0"'9' for Ol"'hythm" , 36S
.,
Prototype Drug I Amlooarone (Cordarone, Pacerone)
Therapeutic ( lass: Class III antidyslhythmic Pharmacologic Class: Potassium channel blodo:.er
ACTIONS AND USES
Amiodarone IIlIKlUr.lly ,imilar 10 thyroid hormolil'. k appllll'fd for lilt
trMment of fHlrirul.uloKhycaroia that l1IiIy plO'/r life thll'alrning..
.Jnd itM bttome.J drug of choice for thr trrllment 01 atrial dysrhythmia, in
patimll with he.Jn I.J iUIl'.ln .Jddition to blociing polaSsium ion rna nlll'k,!Ome
01 drug'sactiom on thr lItan 1l'1.1I1' to its bIockadtohodium ion channr ls.
Amiodaront ava ila blr 01\ orallablm and.J s an IV infusion. IV infusions all' lim-
itro 10 short-trrm thtrap/. normally only 2 to 4 days. Whtn givrn orally, its on-
lI'IoloKtion may takr II'Tfral Its e1fll, un lall. to 8 Wl' rln
alter tht drug disconlinJfd, sincr it M an ntmdtd Ihal may rnfrd
100 days. Tilt tht raptuticll'rum IrYeI 01 amiodarolll' 0.5 to 2.5 mcglmL
ADMINISTRATION ALERTS

Hyplkaltmia and hypomagnetmia 5hou1d lit mlll'<1ro prior 10 initiating
' .... rap)'.

Pregnancy U1tgory 0
PHARMACOKINET1CS (POI
Onll'l: 2- ) d to 1- 3 \\'Ie
Iflk:l- lh
Halllife: I S- loo days
Duration: 10- 150 day;
cludes a boxed warning stating that dronedarone increases
the risk of death and is contraindicated in patients with se-
rious heart failure.
CALCIUM CHANNEl BLOCKERS (CLASS IV)
Like beta blockers. the calciwn channel blockers are widely
prescribed for various cardiovascular disorders. By slowing
conduction velocity, they are able to stabilize certain drs-
rhythmias. Doses fOJ the antidysrhythmic calcium channel
blockers are listed in Table 26.3.
26.10 Treating Dysrhythmias
with Calcium Channel Blockers
Although about 10 caleiwn chatmel blockers (CCBs) are
available to treat cardiovascular diseases. only a limited num-
ber have been appro\'ed for dysrhythmias. A few CC& such
as diltiazem (Cardium) and verapam.i.l (Calan) block cal-
ciwn ion channels in both the heart and arterioles; the re-
mainder are specific to calcium channels in vascular smooth
muscle. Diltiazem is a prototype drug for the treatment of
angina.as discussed in chapter 2SOC>. The basic pharmacol-
ogy of this drug class is presented in chapter 2300.
Blockade of calcium ion channels has a number of effects
on the heart. most of which are similar to those of beta-
adrenergic blockers. Effects include reduced automaticity in
ADVERSE EFFECTS
The most .moos from amiodarolll' occurs in tilt lung.. wiIh tilt
drug (,lu,ing , ,yndrome.AmiotbrOlll' l1IiIy ako UUII'
vision, rashr-s, pholosrnsitivity, naulI'a. wmiting. anorma. laligUl'. dilzilil'ss
and hypotr nsion. Becau,r medication concr ntrated b)' Cfltai n and
has a p-oIonged haK-life,advrrll' rffts may slow to ll'SoMo.
Contr.indic.tions: Amiodarolll' contraindicalt d in patients with
brad)'Uroia. caroiogfn ic shock, sick sinus syndromt .1I'ft1l' sinus node dysrunc-
tio n, or thiro-dtgll't' AV bloci.
INTERACTI ONS
DrurOrug: AmiodilroM (l!I) io:KmII' SI'IIIm dgoIin IPwk by mum as JO!oI.
Amioda1nlo H"IlarKts 1M acrionI of iIIlicOigWnI5: Thill, 1M dolt of
warfotilllllll bf cut by much iIIhiIIlLM wiIIl ttIdM 0/
<.okiumdlanntll>lockm Il10)" ...... orw ..... 1ndy<a"b ....... arrnI, .... 1fI
IIIi'f ilKfl'<ftpher:rytoin "'wI!!\ItO- to thrfffoid.
La b Tests: May iooUW' YilIII"I r .... 1M following tflt!: nudNr AU,.IST, MId
'ifI1IIl Aalinf p/IoIphalilf. T
Herba liFood: LM wiIIl edilloKN may QIM an inoMIed rill; of hfpItoIOIidIy . .\Iot
1IIi, an iIcrNIfd fffPCI of MTiod;IIOOf.
T Il'atmenl 01 DYerdose: Tll'atmrnt d amiodarOlll' is targeted to revtr\-
iog hypltension with lllsopmIOIJ, and bradyurdia with atropilll' or iIoprotell'noI.
III'ftr I!I M)MJ1l11rqKJ/ Alr Q MJrf/1I} I'rI:Jmj foots J{lKI/{ I!I druiJ
the SA node and slowed impulse oonduction through the
AV node. This slows the heart rate and prolongs the refrac-
tory period. Calciwn channel blockers are only etTective
against supraventricular dysrhythmias.
ulciwn channel blockers are safe medications that are
well tolerated by most patients. As with other antidys-
rhythmics. bradycardia and hypotension are frequent ad-
VeTS<' effects. Because the ca rdiac effects of CCBs are almost
id entical with those of beta-adrenergic blockers, patients
concurrently taking drugs from both classes are especially
at risk for bradycardia and possible heart failure. Because
older patients often have multiple ardiovascular disor-
ders, such as hypertension. heart failure, and dysrhyth-
mias, it is not unusual to find elderly patients taking drugs
from multiple classes.
A VOI DING M EDI CATION ERRORS
Durill9 a moming thr nurll' thai a WllIic,1 patP.nt has
dtffioped an irregular hran r.llt 01 110 bean per minulf. Thf nurll' lIOIiflfl
t ilt rtsidrnl physician, who orrIm .J stal tlectrocardiogram. A l'ntricUar dys-
dtttro and tilt physician ttlls tht nUBf to admini51fr
150 rng IIlsinglr bolus to IItfollowfd bf a mntinuous infusion 011 gol lido-
(,lint in 500 mL of 5'1f. dextr= in watt r. Tilt IIIBr oot SUII.' whal tilt usual
Ioaocfng What should tilt nurll' dol
SttAppmd/l () foIlht



,


"


,
,
,




"
i
-"-
LibraryPirate
",. Prototype Drug I Verapamll (Colan, Covera HS, /soptm SR, Verelan)
TIM!raptutic (lass: Oass lVantidysrhythmic Pharmacologi< (lass: Calcium channel blocker
ACTIONS AND USES
Vtr'pifllll wu the lint eel.1'f.IIOWd by the FDA. The drug .eu by inhibiting tt.t
flow of ukium ions bolll into JII)'OUfdill uns itId in Yisrulir smooth musdt,
In tht Mart. this action mnduction 'fHKity and Slabifim
In tile 'lHStb"cakium bIoWdt Iowtrs blood urdIK
workloid.Vtupamil Iiso dilatt'l tile In .mon thit is impor-
\.lilt when 1M drug is uwd 10 trtal .ogin. (chapter 2S00j. Tlledrug is iYii.
in oral, oral IV fonnuLrtioM. The StIIJm
IfwI
ADMINISTRATION ALERTS
Swlftow tht Cipwle whole: Do IIDt open Of .11ow pilitms to chew the
{oottllB.
For IV administration,impt<t the drug f1RPUJtion to makf WIt thf
tion is dw and (O(oriess.
PJ!9MJq (
PHARMACOKINETICS (PO)
Onset. I-2 h
Ptod:: 30-90 min (4-i h tJ:ttnded
Half-lit.: l --! h
OUfition:1- 7 h PO (24 h eJ:ttnclfd releil!')
26.11 Miscellaneous Drugs
for Dysrhythmias
J
Two other drugs, adenosine (Adenocard, Adenoscan) and
digoxin (Digitek, lanoxin, lallOXicaps), are occasionally
w.ed to treat specific but do not act by the
mechanisms previously described. These miscellaneous
agents are listed in Table 26.3.
Adenosine (Adenocard, Adenoscan) is a naturallyocrur-
ring nucleoside_ When given as a 1- to 2-second bolus IV in
jection, adenosine terminates serious atrial tachycardia by
slowingcondudion through the AV node and decreasing au-
tomaticifyoftheSA node. Its primary indication isa
dysrhythmia known as paroxysmal supraventricular tachy-
cardia (PSVf), for which it is a drug of choice. It is also used
ADVERSE EFFECTS
gtntr.lly miOOf.OO indudt
potellsion. &aIM tIipolmil un UIM bmlyumil, pititoo with hein f.ikJre
should monitored.
(ontraindimiom: is mnlr.Jindiuttd palitrJb with AV twrt
blod, sick sinus syndJOmt, snere h)'pottmion, 01 bletdiog 'Jlfllf)'Un, or !host
unciel9oiJ19 SUJgtf)'.1Jse widl uUlion in patitntt with 01 he-
pitic impairment.
INTERACTIONS
IN}-I:nqVmpnW IllS tIlf.t.ility blood Inft! d Iiqollln (Di;t8:.
I.anoIIIn.lanoJlkapsl ,SiJKt digoin and ffiapimil botb !low mndrIctiDn throu9l tht
AV JICdf. thIi(OII!ImflIIllf moMOIfd III mil brid)unii.lkI'
with drlJ9S,lndldiflg IHtJ 1*rd:M,rn.l!' QU\f
...-
liob fests: lkltMwn
HerbalJfoocl:Gr\it;;':f Nt iJlONSf JMl!.H.lwthonI JJ\q '-
iIdiitM hnJolrnllw elfl'm.
lrutrnfnt of Omdose: Ot/"'apimil_doItll targetfd
h),polfnsioo willi "MOpIl5SOfS. Y1cium salts sud! is ukkn cttwidt Nt bt
"fJUstl'ffd 10 iIaNI!' tIM> a!IOlIlt fI QIkiIrn iHtlbIf to tht myot.lnf and
.,-
IIffrr IJJ IIfMlilrlfO fix , MnIIt9/'rrKm FoCIII SfHd* IJ) J1IIs lhJ
to assist in the diagnosis of coronary artery disease or dys-
rhythmias in patients wllo are unable to undergo an exercise
stress test. Al though dyspnea is common, adverse effects are
generally self-limiting because of its IO-second half-life.
Although digo:tin is primarily used to treal heart failure,
it is also prescribed for certain types of atrial dysrhythmias
due to its ability to decreaseautomaticifyofthe SA node and
slow conduction through the AV node. Because excessive
levels of digoxin can produce serious dysrhythmias, and in-
teractions with other medications are common, patients
must be carefully monitored during therapy. Additional in-
format ion on the mechanism of action and the adverse ef-
fects of digoxin may be found in chapter 24
00
, where this
drug is featured as a prototype cardiac gJycoside for heart
failure.
LibraryPirate
01",1<,26 ON9' for Oy;<hytt\ml.. 367
KEY CONCEPTS
The numbered key concepts provide 3 succinct summary of the important points from the corresponding numbered section
within the chapter. If any or these points are not clear, refer to the numbered section within the chapter for review.
26.1 The frequency of dysrhythmias in the population is dif-
ficult to predict because many patients experience no
symptoms. Persistent or severe dysrhythmias may be
lethal. Dysrhythmias are classified by the location (atrial
or ventricular) or type (flutter, fibrillation, or block) of
rhythm abllOrmality produced.
26.2 The electrical conduction pathway from the SA node,
to the AV node, to the bundle branches and Purkinje
fibers keeps the heart beating in a synchronized man-
ner. Some myocardial cells in these regions have the
property of automaticity.
263 The electrocardiograph may be used to rewrd electrophys-
iologic ewnts in the hean and to diagllOse dysrhythmias.
26.4 Nonpharmacologic therapy of dysrhythmias, including
cardioversion, ablation, and implantable cardioverter
defibrillators, are often the treatments of choice.
26.5 Changes in sodium and potassiwnlevelsgenerate theac-
tion potential in myocardial cells. Depolarization occurs
when sodium (and calcium) rushes in; r<vOlariZlltion
occurs when sodium ions are removed and potassium
ions are restored inside the cell.
NCLEX-RN" REVIEW QUESTIONS
D A type i diabetic on insulin reports that he takes propra-
nolol (Inderal) for his hypertension. This raises a concern
and the nurse will teach the patient to check glucose lev-
els more frequently because:
1. the beta blod:l>r can produce insulin resistance.
2. the I\m agents used together will increase the risk of
ketoacidosis.
3. proprallOlol will increase insulin requirements by
antagonizing the effects at the receptO[l;.
4. the beta blocl<Ercan mask symptoms of hypoglycemia.
D When monitoring for therapeutic effe;;t of any antidys-
rhythmic agent, the nurse would be sure to assess:
1. pulse.
2. blood pressure.
3. drug level.
4. hourly urine output.
o Because of itseffect on the heart, verapamil {Calan, Covera-
HS, isoptin SR, Verelan} should be used with extra cau-
tion or is contraindicated in p<ltients with:
1. hypertension.
2. tachycardia
26.6 Antidysrhythmic drugs are classified by their me;;ha-
nism of action, namely, classes i through N. The use of
antidysrhythmic drugs has been de;;lining.
26.7 Sodium channel blockers, the largest group of antidys-
rhythmics., act by slowing the rate of impulse conduction
across the heart.
26.1 Beta-adrenergic blockers act by reducing automaticity as
well as by slowing conduction velocity across the my-
ocardium.
26.9 Potassium channel blockers act byprolongingthe refrac-
tory period of the heart.
26.10 Calcium bloch>rs act by reducing outomaticity
and byslowing myocardial conduction velocity. Their ac-
tions and effects are similar to those of the beta blockers.
26.11 Digoxin and are used for specific dysrhyth-
mias but do not act by blocking ion channels.
3. heart failure.
4. angina.
o Common effe;;ts of antidysrhythmic medications
include: (Select all that apply.)
1. hypotension.
2. hypertension.
3. dizziness.
4. """""=
5. panicattack.5.
D A patient is given a prescription for propranolol (Jnderal)
40 mg bid. The.lll2!. important instruction for the nurse
to give this patient is:
1. take this medication on an empty stomach. as food
interferes with its absorption.
2. do not stop taking this medication abruptly; tht'dosage
must be decreased gradually if it is discontinued.
3. if the patient experiences any disturbances in hearing,
the patient should notify the health care provider
immediately.
4. the patient may become very sleepy while taking this
medication; do not drive.
LibraryPirate
368 UnII 4 .. . nd U,I""ry Syne<",
II A patit'nt was admitted from tht' emergency department
after receiving treatment for dysrhythmias and will IX'
started on amiodarone (Cordarone, Pacerone) because of
lack of tht'fapeutic t'ffects from his otht'f antidysrhythmic
therapy. When the nurst' checks with him in the after-
noon, he complains of feeling lightheaded and dilzy. The
nurse will first assess:
1. whether there is tht'possibilityof slet'Jl deprivation from
tilt' stress of admission to the hospital
CRITICAL THINKING QUESTIONS
1. A patient with a history of COPD md tachycardia has re-
cently bet'n placed on propranolol (lndt'fal) to control the
tachrdysrhrthmia. What isa priority for the nurse in mon-
itoring this patient?
2. A patient is started on amiodarone (Cordarone, Pacerone)
for cardiac dysrhythmias. This patient is also on digoxin
(Digitek, Lanoxin, Lanoxicaps), warfarin (Coumadin) ,
and insulin. What is a priority teaching fo r this patient?
2. whether an aUergic reJction isoccurring with
anticholinergic ]ike symptoms.
3. whet her the amiodarone level is notye! therapeutic
enough to treat thedysrhythmias.
4. whether the patient's pulse and blood pressureare
within normallinlits.
3. A patient is on verapamil (Calan, Covt'f3-HS, lsoptin SR,
Yerelan) and digoxin (Digitek, Lanoxin, Lanoxicaps) . .... 'hat
is a priority that this patient needs to be monitored for?
See Appendix D for answers arid mtionaJes for all activities.
EXPLORE
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I'tSOOltU Pfe!Wt fot suc&eSl 'MIll aMllional IDCIice
QutiSliln ... Inlti111ctiv, a.;si.,.vnenis arJj ac\iloitie ... wtlb li""5,
aM and more!
fleo;t lsler you' access o;odtI frum Iron! ot )'QUr book at
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DRUGS AT A GLANCE
ANTICOAGULANTS {XI/tJlJ
Parenteral Anticoagulants pt1IJt313
0, hepartJ (HtplocJc} P'J'It 115
Oral Anticoagulants p1//t3l5
o warflll1l1 (Coumodtl) pt1IJt Jl6
ANTIPlATELTDRUGS fXJ1t3l';
ADPRectptotBlod:tu pogtJ81
o clopldogrel (PIavIx) (Xl9t.w
lib/lila Receptor Antagonists
,...,
Drugs for InlermittHit Claudication ptJ9IJU
THROMBOLYTICS poI}tJl1
O olrepw{Ar:rtwu>) f1II}tJlJ
HEMOSTATICS p;lI)tJU
0, omlrtO1pro/C ocld (Amkot) PIIft J86
KEY TERMS
antkoagulant ptI9t m
antithrombin III (Xl9t m
doningfa<ton ptJ9t170
coagulation IUltllO
{XXJl170
pajt m
fibrin {Xl9tllO
fibrinogH {XI/tJJO
fibrinolysis pII(Jt 171
Chapter 27
Drugs for Coagulation
Disorders
LEARNING OUTCOMES
After ft<lding mls chapter, the "udent should able to:
1 . Illustrate the major steps of hemostasis and fibrinolysis.
2. Describe thromboemboKc disorders that are Indications for toagulatlon
modifiers.
3. Identify the primary mechanisms by which coagulation modifier
drugs act.
4 . Explain how laboratory testing of coagulation parameters Is used to
monitor anlicoagulant pharma<:otherapy.
5. Describe the nurse's role in the pharmacologic management of
coagulation disorders.
6. For each of the dasses li sted In Drugs at a Glance,.know
drug examples.and explain the mechanism of drug actlao, primary
actlaos, and important adverse effects.
7. Use the nunlng process to care for patients receiving drug therapy for
coagulation disorders.
glycoplOtein IIbllla (!O}t J)
hemoplliia pajl J7l
helTlOStM pajll'l:l
heJTKJStllic:s ,. m
inttnni"rntdndKation{1C} pqJaJ
p!IIJt m
plasmin pi1IJt 111
ptIIJt171
prothrombin pIIIJt Hl
prothrombin actiwator (J<JJt 1lIl
dvombin pogeJlO
ptJIJtJl1
dvomboftwbolicdisorders pajl1l1
Ihrombolytio pqJlJ
IIvomlNs pi1Jt1l1
rissutplasmin09"l Mti,UOf (lPA) pqJ7!
_ Willebrand's ftase (lWDl pq Jl1
LibraryPirate
370 UnII4 U'I .... ry Syne<",
H
tmOstaSis, or the stopping of blood flow, is an essential
mechanism that protects the body from both external
and internal injury. Without efficient hemostasis, bleeding
from wounds orintemal injuries would lead to shock and per-
haps death.Too much clotting, however,can also be danger-
ous.The physiologic processes of hemostasis must maintain a
delicate balance between blood fluidity and coagulation.
A number of diseases and conditions can affect hemosta-
sis, including myocardial infarction (MI), cerebrovascular ac-
cident (CVA), venous or arterial thrombosis, valvular heart
disease, and indwelling catheters. Because these conditions
are so prevalent in clinical practice,nurses will have frequent
occasions to administer and monitor coagulation moclifier
drugs.
27. 1 The Process of Hemostasis
Hemostasis is a complex process involving a number of
dotting factors that are activated in a series of sequential steps.
Drugs may be used to modify several of these steps.
\'/hen a blood vessel is injured, a series of events initiate
the dotting process. The vessel spasms and constricts,
which limits the flow of blood to the injured area. Platelets
become sticky, adhering to each other and to the damaged
vessel. Aggregation is fa cilitated by adenosine diphosphate
(ADP), the enzyme thrombin, and thromboxaneA,. Adhe-
sion is made possible by platelet re:eptor sites (glycopro-
tein lib/lila) and von Willebrand's factor. As the bound
platelets break down, they release substances that attract
,. Flgure27. J Baslcstepslnhi'mostasls
more platelets to the area. The flow of blood is reduced,
thus allowing the process of roagulation, the formation of an
insoluble dot, to occur. The basic steps of hemostasis are
shown in ,. Figure 27.1.
\'/hen collagen is exposed at the site of injury, the dam-
aged cells initiate a series of complex reactions called the
coagulation cascadr. Coagulation occurs when fibrin threads
",,,,,hwurk bluuu
develop a dot. During the cascadt', various plasma proteill'i
circulating in an inactive state art' converted to their active
forms. Two separatt' pathways, along with numerous bio-
chemical processes, lead to coagulation. The intrinsic path-
way is activated in response to injury. The extrinsic pathway
isactivated when blood leaks outof a vessel and enters tissue
spaces. The two pathways havt' conunon steps, and the out-
come is the same-the formation of the fibrin dot. Thesteps
in each oo3guJation cascade are shown in ,. Figure 27.2.
Near the t'nd of the cascade, a chemical called prothrombin
ilctiYator or prothrombinase is formed. Prothrombin activa-
tor convt'rts the dotting factor prothnmbin to an enzymt'
called thrombin. Thrombin then converts fibrinogrn, a plasma
protein, to long strands of fibrin. Thefibrin strands provide a
framework for the clot. Thus, two of the factors essential to
dotting, thrombin and fibrin, are formed only after injury
to the vessels. The fibrin strands form an insoluble web over
the injured area to stop blood loss. Normal blood dOlling
occurs in approximately6 minutes.
It is important to nott' that sevt'ral clotting factors, in-
duding fibrinogen, are protein .. made by the liver that con-
stantly circulate through the blood in an inactive form.
Vitamin K is required for tht' liver to make four of the dot-
ting factors. Because of the crucial importance of the Jivt'r in
Vessel injury
Vessel spasm
Plalelets adhere
to injUry site and
aggregate 10
larm plug
Insoluble librin
slr&nds form and
coagulate
LibraryPirate
Uve.
Injured vassel
r1'IiI!Jf ""''', ""
damaged cell s
J
Facto. X
J
PfoIhron-bin activalor (ProIhrornbOnase)
1----------- -------,
: (t) :
i Th ......
J
i
i :$
----1-+ Fibrinogen : I
i PIIIsma :
L ___________________
Injured vossel
Insoluble fib,..,
" ....
Figure 27.1 Major steps In the coagulation cascade:
common pathway
creating thesl! clotting factors, pat ients with serious hepatic
impairment usually have abnormal coagulation.
27.2 Removal of Blood Clots
Hemostasis is achieved once a blood clot is formed and the
body is protected from eXce5Sive hemorrhage. Thl! clot,
however, may restr ict blood flow to the affected area;
lation must eventually be re5tored so that the tissue can re-
sume normal activities. The process of clot removal is called
fibrinolysis. It is initiated within 24 to 48 hours of clot forma-
tion and continues lUltii the dot is dissolved.
Plasminogen
TIssuo plasminogon
Thrombolylico
Flgure27.3 Primary steps In fibrinolysis
CNpltl 27 Drug; /0, C""'Iulation DIso,der, 371
PHARMFACTS
Clotting Disorders
von disuSf (vWD) is moll wmmon blffiling
b)' J rlerlCifficy of thr protein yon f.l(tor
(yWF), which pbys a r* in pl.neltt oJggrl'gation and ads ua writr for

Marl' than 2 million paliffil5 raoc:h )'Nrdrvrlop a deep Vl'in
(DVT).
Marl' than 60,000 patients uch yurdit of pulmoury rmboli.
Hrmophilia A,ord.llSic hemophilia,is.l hmdilary (ondition in which a
prISOn licks doning fidorVIII;itaoc:(ouots brlKl% of all hemophilia (ilSI'!..
Hrmophilia B, or "ChristmudisriSf,"is i heJfdilary abmKr of (Ioning

Moll' than 1S,000 peoplt in tilt United have hemophilia A or B.
Fibrinolysis also involves several sequential steps. When
the fibrin dot is formed, nearby blood vessel cells secrete
the enzyme tissue plasminogen activator (lIlA). TPA converts the
inactive protein plasminogen, which is present in the fibrin
clot, to its active enzymatic form, plasmin. Plasmin then di-
gests the fibrin strands to remove the clot . The body nor-
mally regulates fibrinolysis such that ullwanted fibrin dots
are removed, whereas fibrin present in wounds is left to
maintain hemostasis. The steps of fibrinolysis are shown in
". Figure 27.3.
27.3 Alterations of Hemostasis
To diagnose a bleeding disorder, a thorough health history
and physical examination is necessary. Laboratory tests
measuring coagulation must be obtained. These may in-
clude prothrombin time (PT), thrombin time, activated
partial thromboplastin time (aPTT), and in some instances,
a bleeding time. Platelet count is also important when as-
sessing bleeding disorders. Additional tests may be indi-
,ated, based on the results of initiallaborntory analyses. A
summary of these tests is shown in Table 27.1.
Thromboembolic disorders occur when the body forms unde-
sirable dots. Once a stationary dot, called a thrombus. forms
Clot breaking up
into "okIbie fragments
LibraryPirate
372 UnII4 TheCJrdkwasc:ubr.nd Url",,'Y Syuem,
TABLE 27.1 laboratory Testing for Coagulation Disorders
''''
()@sc:rlpllon
Activittd dotting limt Used to
phinnao:OIheraP1;'1so lIII' d
and afltr IUf9I'l)' or mtdiul pnKtOJll'S
Activittdpartial Used to heparin phi!Tllalllltrapy
thrombopiaSlil timt
(aPm
Used forgentral ro.llJUlation
.-
lISfd to monitor heparin or LMWH
phannao:OIlltraP1 in with hrparin
l6istalKt
Platdetaull Part of a blood IOIIlt
Prothrombin timl' (PT) to monitorwarfilrin tlltropy
Thron"bin Used to for fibrilKl9ftl dtfitiffiq;
may iN' lISI'd to monitor 01
heparin phi!Tllalllltropy
"Coaoglbtion valU6 all' alwi)' s ilKi'liduaiitd for patimt.
COMPLEMENTARY AND ALTERNATIVE THERAPIES
Garlic for Cardiovascular Health
G.irlic W/ium lOfivum) is oftllt besHtuditd hrrbs. StI'er.l1
ltanG'S, known oil!, 11m iH'en isobted from garlic: and to
haY!' pharmacologic ,,,Mly. Dosa.gt forms in{kIdt PlI' paft'd garlic: oil or
the bulbs from tilt plant
Modtm (bims for garlic: 1M! haY!' forused on tilt IiIdiomtubr
tll'abntm of high blood lipid and Othtr
moderndaims ill' garlic: tbxI gluc:OIt IeYeIs and has antibacter-
ial i nd antirotOpl.lIIic: activit)'.
Likt m,ny othtr garlic: liktly hiS OI"IIt hNlth iInItfits, but
stitmific studies all' ohtlliatking ,nd the l6uh! all' mnm.Garlic:
hiS bun !hown to tilt aggll'9'lDon or "nic:kilH'''" of platelet;, thus
pnxkKing an intKoagubnt rifed (R,hman & Thm is 11'-
stan:h to Ihow that tilt hMl hils a !mall on blood (ooltsterol,
akhough !he rflee!! seem to be- loon tefm. EmlKe on the elfrcts of tilt herb
on blood prrSIUft' is mimi
Garlic: is saft for {OIIIUmption in modemt ,moum!.Patimts LIking ,mic:o-
agubm mrdiutions lhould limit their int,kt of garli( to a\'{lid bltrding (om-
pliutions. Oia brtic: patitnu lhould monitor their blood glut<M IMIs dostl)' if
taking high dos6 ofg.Jrlic.
NormalValues Significance
70- 100 IKOIHk; 400-500 It(onds ruing indiute' risl::forblttding
(oronary byp.ID ,nd thit OJII' may IItI'd to iN'

lS- 351K01Hk; 15- 2 tim6 indiute' risl::forblttding
the prl'uutmmt ,nd thit htpilin OJII' may IItI'd to iN'

1--9 minLl6 (fommn) long blMingtimt may ioditatea low
platdet (ount or antic:o.gu,nt thn"iP1
O.l--{l.7 for htpirin; Hi91l'i1luts indiute , risk for blttding
0.4-1.1 for LMWH ind that htpirin or LMWH may
IItI'd to iN' I!duc:td
150,000- 350,000 ValU6 iH'Iow 20,000 indiute
thrombot)1Optlia
IIiR should iN' 2.0- 3.0 to prMnt DVT; Hictll'illue, indiute' risl::for blttding
2.5- 3.5 toplMnt mtrial thrombosis ind that mi)' I"ftd
to iN' rttlotrd
Il-1S SKOnd! ProIongtd vlllU6 may (1((\1" with
htparin phirmiloihn"iP1
an embolus. Thrombi in the venous system usually form in
the wins of the legs in susceptible patients due to sluggish
blood flow, a oondition called deep win thrombosis (DVT).
Thrombi can also form in the atria during atrial fibrillation.
An embolus from the right atrium will elllSe pulmonary
emboli, whereas an embolus from tht' left atriwn will cause
a CVA or an arterial infarction t'lst'Where in the body. Artt'-
rial thrombi and t'mboli can also occur following surgical
procedures, and arlt' rial plUlctures such as angiography. Pa-
tients with indwelling catheters and mechanical heart valves
are susceptible to thrombi fonnation and frequently receiw
prophylactic antiooagulant therapy. Thromboembolic dis-
ordt'rs are the most oommon indications for pharmacother-
apy with coagulation modifit'rs.
Bleedingdisorders are characterized by abnormal dot for-
mation. The most oommon nonhereditary bleeding disorder
is a deficiency of platelets known as thrombocytopenia, which re-
sults from any oondition that suppresses bont' marrowfunc-
tion.lmm unosuppressant drugs and most of the medications
used for cancer chemotherapy may cause this oondition.
in a vessel, it often grows larger as more fibrin is added. Ar-
trrial thrombi are particularly problematic because they de-
prive an area of adequate blooo flow, causing tissue
ischemia. Cessation of blood flow may result in infarction or
tissue death. This is the else in Mis and many CVAs.
Hemophilias are bleeding disorders caused by genetic defi-
ciencies in specific dotting factors. Theyare typified by pro-
longed coagulation times, whim result in persistent
bleroing t hat can be acult'. The dassic form, hemophilia A,
is caused by a lack of dotting factor Vlll and accounts for
approximately 80% of all cases. Hemophilia B is caused by a
deficiencyoffactor IX; about 20% of those afflicted with he-
mophilia have this type. Hemophilia is treated byadminis-
tering the absent dotting factor and, in acUit' situations, by
transfusing fresh frozen plasma. (vWD) is
Pieces of a thrombus may break off and travel through the
bloodstream to affect other vessels. A traveling dot is called
LibraryPirate
Choplfl 21 Drug; lor CNgutation Olsord<'" 373
TABLE 271 1 Mechanisms of Action of Coagulation Modifiers
Mechanism Type of Modtflcatlon
i'rrm.tion ofdol formation klhbilion of spKific: doIting factors
klhbilion of plitelet actioos
I


ThrOOlbolytic:
1Itm01iitic:
RtrnoIril of an aistilg dol
PromoIion of dot formation
(lot dissoll'fd by ttw, drug
klhiJition offilril dtstruction
H OME & COMMUNITY CONSIDERATIONS
Patients Taking AnticoagulantTherapy
The drugs gMn for(OiOjulitioo disordtrs require patient education.
The Pitient is it a high risk for blffiliog romplimions. The must
(onsider the eduutionallMl and ability oftht patient to understand im
ponall' of following mtdication instructions. To ensure that alltwk of
b ming <iI pobiitios i", awrn:d, wrino II, "friba t .udiO/Yiwi t.nd
lion mflhods of shook! bt ilKkidtd.Pitieon shook! dearly un
dermnd the nerd fur ,mending IoIlovrup olfic:t ind liboratory appointllll'nti.
Iftht patient is ullibll' to understand till' instruc:tions of agt,rog'
nitiYt impainntnt, or Stll\Ol)" impa r nsure that a "regivtr has rrcril'td
and undersunds tlll'dischirgt instructions. k is n prcially imponant that the
Qrtgivtr know signs of plSliblt blttdiog and Ihr imponalKt of rrportiog
Ihf"\e signs immtdiatelyto the health (ire prwider.
the most oommon inherited bleeding disease. This disorder
results in a decrease in quantity or quality of von \'/illebrand
factor (vWF), which has a role in platelet aggregation. This
type of bleeding disorder is treated with factor VIII concen-
trate as weU as desmopressin (DDAVP), which promotes the
release of stored vWF. For the most severely affected pa-
tients, plasma products containing vWF may be required.
27.4 Mechanisms of Coagulation
Modification
Drugs can modify hemostasis by four basic mechanisms, as
swnmarized in Table 27.2. The most commonly prescribed
coagulation modifiers aretheanti(oiguiants, which are used to
prevent the formation of clots. These drugs can either in-
hibit specific clotting factors in the coagulation cascade or
diminish the clotting action of platelets. Regardless of the
mechanism, all anticoagulant drugs will increase the normal
clotting time.
Once an abnormal clot has formed in a blood vessel, it
may be critical to remove it quickly to restore normal tissue
function. This is particularly important for vessels serving
the heart, lungs, and brain. A specific class of drugs, the
thrombolyti(!, are used to dissolve such life-threatening clots.
Occasionally, it is necessary to promote the formation of
clots with drugs called hrmostat iu;. These drugs inhibit the
normal removal of fibrin, thus keeping the clot in place for
a longer period. Hemostatics are used t o speed clot forma-
tion, thereby limiting bleeding from a surgical site.
To prevent serious adverM' effects, pharmacotherapy with
coagulation modifiers is individualized to each patient.
Drug--drug interactions are common with anticoagulants,
and can either increase or diminish the anticoagulant effect.
Kidney or liver disease can contribute to drug toxicity. Pa-
tients taking coagulation modifiers require regular physical
assessment and laboratory monitoring.
ANTICOAGULANTS
Anticoagulantsare drugs used to prolong bleeding time and
thereby prevent blood clots from forming. They are widely
used in the treatment of thromboembolic disease. Table 27.3
lists the primary anticoagulants.
27.S Pharmacotherapy
with Anticoagulants
Anticoagulants act by a number of different mechanisms,as
illustrated in Figure 27.4. Thesedrugsareoften referred to
as blood thimras, which is a misnomer, because they do not
change the thickness of the blood. Instead, anticoagulants
impart a negative charge to the surface of the platelets, which
inhibits the clumping action or aggregation of these ceUs.
By inhibiting certain clotting factors, antiooagulants
lengthen clotting time and prevent thrombi from forming
or growing larger. Thromboembolic disease can be life
thr""tening; thus, therapy is often begun by admini. tering
anticoagulants intravenously or subcutaneously to achieve a
rapid onset of action. As the disease stabilizes, the patient is
switched to oral anticoagulants, with careful monitoring of
appropriate coagulation laboratory studies.
PARENTERAL ANTICOAGULANTS
The traditional drug of choice for parenteral anticoagula-
tion is heparin. Heparin acts by enhancing actions of an-
tithrombin III . Antithrombin III is a protein in plasma that
inactivates thrombin (and several other procoagulant en-
zymes) and inhibits coagulation. Within minutes after intra-
venous (IV) administration of heparin, the loss of activated
clotting factors prevents the formation of fibrin clots.
The heparin molecule has been shortened and modified
to create a newer class of drugs called lowmolec: ularwfight hfp"
arins( LMWHs). The mechanism of action of these agents is sim-
ilar to that of heparin, except their inhibition is more
specific to active factor X (see Figure 27.2). LMWHs are par-
enteral anticoagulants that possess the same degree of anti-
coagulant activity as heparin but have several advantages.
Their duration of action is two to four times longer than
LibraryPirate
374 UnII4 TheC.,dklv.sc:ub,.oo Urinary Synem,
TABLE 27.3 Anticoagulants
Drug Route and Adult Dose (max dose where IndlcatOO) Adverse Effects
fondapamUl(Arillra)
I W'. " .. h ,.
I ''''''' ..

QMmi<I (fmdopaioox)
Go) litpam (HepIock) 1'1' iofulion; 5 ,<KKI--40, 000 uriulda, anaRh)'!aQj
SubartaOl'OUS; 1 5,llOO-lO,<KKI bid
Q warfaril (Ccunadinl PO;2- 1511l9fday
LOW-MOLECULAR-WEIGHT HEPARINS (LMWHs)
daltrpam (FrollJOill Subcu:iOl'OUS; 1,sOO-5,<KKI unilslday for 5- 1 0 days (max: 18,000 Mioor blm!ing. nolllM, K>miring. hmrorOfflll, 1ooJ (Xirr. fmr
iOll'rnatiooal unijsld.,)
anaRh)'!illis
fflJXiparin (Lamm) Subcu:iOl'OUl; 30 mg bid for 7- 10 d.,s
tiIz.Jpamlinl'lOlltp) SubartaOl'OUS; 175 dlily for itlwI6days
OIRECTTHROMBIN INHIBITORS
ilgitrob.!O (Aw.II,tlo'muo) Imu: 10 IIKgl1!glmil) Fwtr,1I<RIIf4
biYairudil(An9omax) 1'1';0.75 mgIkg initial bolus loIloftd by 1.75 1IHJ11!g,t! lor 4 h
bIfflfing. bk (bivoltudn)
dtsirudin (lprivask) SubrutantoUl; 15 mg bid lor9- U d.,s Imax:80 IIl9fday)
XriOUI inlemal
Itpiodo 1'1';0.4 m9 initial boIuI (mal:44 mg), follllYlfll by
0.15 1IHJ11!gl1l (max: 165 mg,t!)for HO days
Iloiio irolirn. <OI!IrroJIl advmot d'IU;lIIIIIaIiniIIi/irolirn .. ..nw. .dm .. dfHt .

Hoopllrio and
l.t>w "'''''' ....... ,
weight hepDrino
Lepirudio
... Flgure27.4 Mechanisms of action of anticoagulants
that of heparin. The LMWHs also produce a more stable re-
sponse than heparin; thus, fewer follow-up lab tests are
needed, and family members, caregivers, or the patient can
betrained to give the necessarySC injections at home. These
anticoagulants are less likely than heparin to cause throm-
bocytopenia. LMWHs have become the drugs of choice for
a number of clotting disorders, including the prevention of
DVT following surgery.
A third class of anticoagulants includes direo;;t
thrombin inhibitors such as lepirudin (Refludan). These
drugs bind to the active site of thrombin , preventing the for-
mation of fibrin clots. They act on circulating thrombin, as
well as on thrombin that has already bound to a dot. These
drugs are infused wHil .a therapeutic aPTT value is ob-
tained, usually one and .a half to three times the control
value. The thrombin inhibitors have limited therapeutic
uses. Bivalirudin (Angiomax) is administered in combina-
tion with aspirin to prevent thrombi in patients lUldergoing
angioplasty. Argatroban {Acova, Novastan) and lepirudin
imlicaTed for prevent ion or IreMmeol of Ihmmhocy_
topenia induced by heparin therapy. Desirudin (lprivask) is
a newer antithrombin agent that is given subcutaneously
15 minutes prior to hip replacement surgery for prophylaxis
ofDVT.
The fmal type of parenteral anticoagulant is a drug ap-
proved in 2009 to treat patients who have a congenital defi-
ciency of antithrombin Ill. These patients have a high
incidence of blood clots, especially DVT. Antithrombin
(Atryn) is unusual because it is obtained from genetically-
engineered goats. The goats are engineered through recom-
binant DNA technology to secrete human antithrombin
in their milk. The drug is then purified and powdered for
reconstitution as an IV infusion. The drug is indicated for
the prevention of peri-operative and peri-partum throm-
boembolic events in hereditary antithrombin deficient
patients.
LibraryPirate
Choplflll o.ug, /0, Coagulation Ol1Order,
p,. Prototype Drug I Heparin (Hep/ock)
Therapeutic (lass: Anticoagulant (Parroterol) Pharmacologic ( lass: Indirect thrombin inhibitor
ACTIONS AND USES
Heparin i< a natural 1Uj)ltlnCt fouoo in tht liYl'l' aOO in lining ofblood YeS-
1eIs.1t; oormal funuion 10 prolong coagulation timt, tlltfflly prev!'nting H-
CffiiYt doning within blood YeSlI'k. As a rtlUlt, heparin prev!'nt; lilt
tnlafgemtnt of Got;.J 00 formuion of new ones. k has 00 ability 10
diJStiveHisting dots.
The biOOing of ht parin 10.J ntithrombin III in.JuWales II'V01I"al doning facton
.JOO inhibit> thrombin 00Id of action for IV i< immedialt,
wht rw h!parin may tiki- up to 1 hour 10 iChiM a thtr.ptUtic
rifrcllhi< drug i< also ca led unfrtKrionortd IItparin, 10 di<tinguilh it from the
LMWIk. IOOicalions for indudt DVT, pulmonuy tmboli<m, unstablt
<lngin.J, ewlYing MI, and ,rt"ltntion of Ihrombosi< in high-risk palimn.
ADMINISTRATION ALERTS
i< poorly .hI".brd b)' mil""'" """"I'#of "pid 1IIP,.boIi<m
b)' the IItpatic tIIlylllf ht parin.tll'. Thtrefore, it must tie gim! ffllltr sub-
MantOUsly or th'0U911V bolus injtaion or coolinuous infusion.
Whtn gjying IV IItpam,a wtighl-bmd oomogram may tie he-
pa rin nomogram synmr calculales lilt appropnatt heparin using pa-
lienl ,PTI IIIIUI', ,00 dinical iooication for tilt drug (t.g.,
'Mt coronary UII' of the nomo-
gram dtcrmes the ""net of medication calculation tlrors aOO for om-
or uncltr -tlltraptUlic doses.
Whtn admini<ttring IItparin subcutl otOWly, Ot"Il'r draw biCk the syringe
pkmgt! 00' the has tntmd the skin, aOO massage the sile
,fter Doinglithercan to or tissllt diJllilge.
1M administration i<cornraiOOicaltd dllt to blttding risk.
PlI'9na"'1 caltgory (
PHARMACOKINETICS (SUBCUTANEOUS)

Pto.k: 1 h

Duration: 8- 12 h
ORAL ANTICOAGULANTS
The most commonly prescribed oral anticoagulant is war-
farin (Coumadin). Warfarin acts by inhibiting the hepatic
synthesis of coagulation factors II, VII, IX, and X. Often, pa-
tients begin anticoagulation therapy with heparin and are
switched to wamrin when their condition stabilizes. When
transitioning, the tW() drugs are administered concurrently
for 2 to 3 days becaust warfarin takes several days to achieve
optimum effect.
Pentoxifylline (Trmtal ) is another oral anticoagulat that
works by a different mechanism than heparin. Pentoxi-
fyIline reduces the vlioosity of red blood cells and increases
their flexibility. It is given to increase the microcirculation in
patients with intermittent claudication.
ADVERSE EFFECTS
Ab nomal may occur during IItpa rin tlltrapy. Should aPTI becollll' pro-
longed ortoxicity obsmtd, stopping tilt infusion wilill'sult in dimini<htd
anticol9Jlanl oajyity within hours.
Contraindications: Heparin lhould not tie 10
inlf mM di<ordtll, hyptrtmsion, II'Ctnt lrauna, in-
umarial htlllorrfrage,or bacterial moourtiiti<. throllbocy-
toptnia (HIT) i< a complication Ihat ocrurs in up to of patitnt;
IiIking the drug.More symptoms usua apIINr S 10 10 days d ther-
apy, thIS, freqUtnl blood Iabor.llOry should tie coOOucttd during this pt-
riod.Athough thrombocytoptnia UlUally Itad! 10 HCffiiYt HIT causes
the opposite efFect: an ;,eTNSt in aawll' thrombotrnbolic Tilt
may lI'fious and thrombolis. Although the
half-life oflltparin i< britt it may <I tht drug i< disronhnUl'd for
p1atelt-.s 10 rompieleiy II'COV01l".
INTERACTIONS
Oral anocoagwnu, incluring warfarin, poreotiatf 1M action of
Mparill Drug\ thai inhlJil plat!ltl aglJfeg.!lioo, sudl aspirin, incIcrnmIacil, atd
ibu jnIlo. may incluc@blfeding.HicOliflf,digoxin,lflfiqdnel,..-anlililtamine;
may inJ\lJirnicoagWtim.
Ll b Ti5U: Hfparin may iOONlf tIw folowing v.kIe!: fi"fe fitry UI!, AST, and All

Herbalifood: Hemal qrpItmfnts that may aflKI such
!P"!M te.J,fnmlW,..- ginkgoWUd bf.mided bfGlw Ihfy mayiocflW' them
"-
Treatmfnl of O"ft'rtiOSf: If hemorrhagt a sptCiIic
protafrilll' sul/alr,may tIe<ldministmd IV (1 mg fortvl'ry 100units ofheparin)
10 IItparin's .JOtica-agulam acrivity. Protimilll' hal.JO Otll'\ of
iCtion of S and i< also an any,goniltlO the lMWHs.
Rl'1'ft" Ie M)I'IUrllng/l1l fer Q Nufllf!/} I'rtm.! fJJ5 spKlk Ie rills dill/}
The most frequent, and potentially serious, adver!K effect
of all the anticoagulant agents is bleeding. Patients who have
recently experienced a traumalic injury or surgery are espe-
ciaU)"at rislc. Specific antagonists may be administered to re-
verse the anticoagulant effects: Protamine sulfate is used for
heparin, and vitamin K is administered for warfarin (see the
drug prototype features in this chapter).
ANTIPlATElET DRUGS
Antiplatelet drugs cause an anticoagulant effect by intt'rfer-
ing with platt'let aggregation. Unlike the anticoagulants,
which are used primarily to prevent thrombosis in veins,


,


"
LibraryPirate
"


!

376 UnII 4 'It" C.,dklv'l(ub, .nd U,'nary Syne<m
,.. Prototype Drug I Warfari n (Coumadm)
Therapeutic (lass: Anticoagulant (oral) Pharmacologic Vitamin Kantagonist
ACTIONS AND USES
Indications for wuf.rin Ih!'l"py indudt thf pre!'l'ltion of (riA. MI. DVT nd pul-
monal)' !'I'Ilbolim in patirnt; undtfl10ing hip or sUIgrI)',or in thosr with
Iong'le,m indwelling (rn!!.,1 '/eI'oIM cathrten 0' prosthetic heart The
drug may he gil'!'llio prnem thromboembolic in highrisk palienlS fol-
lowing an MI or oWl .trial fibrillation
Unlib- with hfparin, thf anticoagulanl actMI)' of warf,rin (.In tab- It'Iml
days to its mnimum upl.irn why hep.rin and warfarin thr r
apy .re ol'!'l'lappld. Wa rf,rin inhibits the aoction of it.min K. Without adequate
itamin K,the {Ioning fmon II,VII,IX.andX
(loning faaoo normally cirrulating in the bIood,it days
for thfir plasma Jto/els 10 fall nd for the 'nticoagulant rflKt of warf.rin 10 'Jr
pear.Another for the slow Oll\d is that m of the warfarin bound 10
plasma proteins .nd thus unmilabll' to prodKr iu eift The therapMic
range of serum ... arf,rin IeYeIs from 110 10 mcg/mL,IO .{hie'le.n INR
HIlii' of 2.0 10 3.0.
ADMINISTRATION ALERTS
If bleeding O((UII during th!'l'apy, the anticoagulant ef
il'cts ofwarf.;n (.In he rmlKrd by 1M or subcut.neous of
vitamin K,.
Plf9nanq categol)' X
PHARMACOKINETICS (POI
Q,wU-7 dqs
PNk:0.5- 1diys
Halfliil': 0.5-3 days
D.!r.tion: 3- 5 days
ADVERSE EFFECTS
The most Sfrious adYl'fII' rffKt of w.rfarin ,bnann.!1 biffilifl!j. On
uation of lher,py. thr ,ntico'lJll.m oKtiity of warfarin may for up 10
10 days.
Contraindications: PnienlS with trauma ctiYe internal bleeding.
dilOrdrn, intraocranial hemorffia,gt. 1t'I!'I'I' bactt rial en
Il"I!'I'I' hepatic or renal impiinnenl4100ld 001 take warfarin.
INTERACTIONS
I)ug- l)ug: prolHn bincing is for nlrni'lOUl dr",--1Irug
inll'liK1ions, ilWdiIg an ifl(ffUd efIKr: of warfarin wfth aIutIoI, H'iA Ill,
5SRII and other ... SifloidI,nibicOO and oonel. [00, 9 warli!rin
merapy, iIIf pititnt !hooId not iIII'/ other prmiption or OK d!:ugI oolels
awowd byillf hmh
lab TI511: Untrlown
HerbaVFoo:J: lMof wirfarin with hIom.l oISgf@l'l1m,gngo,
fHerfew. garlK. UiIlbfrI)'. chamornie, and gingH may iKmsIo 1M rill: of blHding.
Trmtment of Omdow: The s.petitK for 0'I!'I'd0M' is oral or par
entml of vitamin K, When .dminill!'l'l'd IV, vitamin K,
thf 'nticoagulant efftcll of warf.rin with in 6 houn.
_ JIIMyM1t<.logKlrft1t. MI<Ing PrlXP!Mtf "'1M droiJ-
NURSING PROCESS FOCUS PATIENTS RECEIVING ANTICOAGULANT THERAPY
Assessment
Butline assessment prior to .dministration:
Undmtand lhe drug has heen p=ribed in order to ust'Ss for
lhe,apeutic efHcts (e.g, olthrombosis from developing wIltn
phlebitis is
Obtain a (ompitte ht.lth his!ol)' induding urdmasrular (induding HTN.
MI. he.n f.iu,,).nd penphf,,1 (induding
Ihrombophlebiris). (induding previous pulmonal)' rm boI ism),
oeurologic (indJding rtCem htad injury, (VA). lIfpatic or renal diIN
d .. brTP" fH'PIir uh, diu-all'. hy""" .... "'<IforoiPmi.o. ,nd Ihf. po< af
. ko .... lism or pfl'gn'IIC)'.Mkwornm of length and
heavinessof uSlaI mrrntrual flow. Obtain. drug inW:ling allergifl.
rurrflll . nd OK drugs. he!bal and .kohoi lM.
10 possible drug interoKtiorn.
Obtain bmlilll' wtight, vital signs, KG ippropriilt'), .nd 1OUnds.
MIeSI for of angina. and br presefl(t of dylJllIN or
dies! piin. As II'!S e1urmitifl b, Iymptoms of thlOOlbophlfbitis (r.g, warmth,
swelling, lendenesl in (.Iii; posm...e Homan's sign) .nd for Ioution .nd
maraoctl'l/,1IIOII1I of rdrm. , if present
Enlunr .ppropriate laboralOry findings (e.g . <I PTT, aPT, .nd/or IIIR),
rompim blood(ount ((SC), liYer function studifl, .nelial blood
galeS (ABGs) u.!pproprinl'"nd lipid profilei.
Potential Nursing Diagnoses
P,in (malrd 10 lessrned p!1fusion)
Intiftcu...e Tissue Perfusion 10 dtc:JNlrd cill::ulation in afftcled

Impiirm Skin Integril)o (in IoWl'reltrrmitifi 10 intffrcti...e tilwe
perfusion)
Anxiety to possible hospitalization, ufl(ertainty Ut'tr mioUllII'Is of
illlII'Is)
Delicitnt Knowledge (drug lherapy)
Ri!k fo, Injul)' (blerding. 10 .a.efll' eifKtS of .mico.gJI. m
therapy)
LibraryPirate
NURSING PROCESS FOCUS PATIENTS RECEIVING ANTICOAGULANT THERAPY (ContkluPd)
Asseument
Assessment tllto _ghout IClministrl tion:
ASSfts for dtsirtd thmptUtil: etf!<ts (e,g.,uu of phlebitis exhibits signs of
impJOVtmenl witfl oo IJIllplOms of lluorN:losis formonion;signs

angiNI or ptriphfral tx1rtmil)' llIin &miniWd Of is tliminltN;
peripMfJl pJstoi.rt improving in cp.wrtty and "fOIumt).
Contirot periodic monitlrilg ah pPlopriw lib 'IiIbts (q. IfTlPr.alW'otiNIO.
ASSfts for 1!Mr..t efftS: bleeding n IV silt!, wounds,_si'o'e
t(chymosis,pete<hiie, bli<lItifJY stools, Iul "colfee-
ground'" e mesi!, tpistaxi!, blttd"lII9 from gurm, bemopt)"$is, ptoIon ged
anO'or hmy mmwlIiIl flow; Ind for (lit blMding.wd! as pMlOf,
diuines!., h,potensian, u(byardia,abdominal wall
SWf:Hing or fimmtls,. klmbil pain. ordrtutd 01 (onsciousJlfSS.
Pot. ntia l Nu rsi ng Oiagno$U
Planning: Patient Goals and Expected Outcom.-s
Thf wiD:
Experimte t!lef.pMiI: tfi"tS dependent on tilt rtason the drug is being glvtn (e.g., PJM!ltion of thrombo$is or mellSion of elisting thrombosis) .
frt(! fulm,or idvfrw effects.
VfriNlizr In undmtanding oftht dfU\l's USI!, .!ivtrwritS,iIld
of tilt (t.9.dow.timir9. whfn \(I JICIlify pto"rider).
Impl . m. nt ation
Int. rv. ntl ons and (Ratlonal u) Patkent and Family Education
---\--
Ensuring thtrlp. utic effects:
ConlinII' frlqumt asZSflH'IIb as d&riII'd earlifr for efFts,. t'.g.
mting Irta Ii pllrbitis exhibits lignsolirnpro'lftfltnl;ggns.rd symp\(lJllS
of existng tiwombosis IIIow impJMmellt;lrd ptriphml pUsHiIt
improWlg in qlDlity Ird YObnt'. help prtYtflllht bmlatioll
of t!wornbi or PfeY"lt tlisting tbrombi from inawing in silt.)
wty imbuillion in the patient Ind
finge of motion fROM} if tilt patient is on be1:iftSt or has
mobility.l't'rform pusie ROM in JNtirms wIIo unatw to oI ctit
ROM.(Eirly ambulatioo "nd ROM susis and tIvombosis
form.tion, itlsming the Mtd for "nticoagulant tbmpy.)
ASSfts tilt poIOent's and occasions oftrol"feilMr mrodtd ItngtM of
sitting during air or tilr Ir.Jvd IN, limit blood flow 10
t'Xtrtmitits Inci vtnM rtlUrn,promoting tilt formation of thrombi.
FrtqUent strttchinglnd ambulatir9.lnd increasing lkJids to miinuin
normll os rrIOWritylviscosity ml, dwtiSt tbrombosis formation and Itsst n
the rwd for oInticoagUlant tlltrol P1.)
.ppropriate dlangn.Ptovide for dietitifn (CInSuiulion .s
nml!'d.. (Smoking incruSotl plattlell11Jlrtg.Jlion and promotts Iht'
formation of tbrombi. HtlltlJ, liftst)'lt dlangn will wpport iM min imilt'
tM ntfd for df119 tMfJP1.)
Minimizil, tfft'rts:
Mr:Initor fl>r s9J$ ind symplm1S of eJ{tssi'o'e visible blffiling: bleeding IV
sitts,. wounds,.txttssi'o'e hmllruria, bladlt, JI)' stools,.
rt<U1 bftding. HI'Itsis, episuxis, blffiling from gums.
hemoptySis, prolonged indI Of ht.vy menstrualllow, lnd for ocwlt
blding. (FrtqUt'fl1 .SSftsmtnt for both vistit' iIld (uh blmfing is
to pn'YCIIl htmorrhagt' and to Slillt tolrty (O(!tc\ive tn:'atmrm as
appropriatt. )
To ,lila, Iraitt)', poItirnt, folrnily, orumfrmtlM.' rational!'
for . 11 fq.JipmentiMd (t.g.,.nrifmbolil: itllffmitttnt pJIt'UmatK
compttSsion dmm) Ind tM M'ed for frrquent monitoring.
Assist the patient with ambuWtion postopeflllvtJ, liM ttach lICliYt ROM.
Tuch the firnil)',or Urt'i.jlvtf Ilow 10 ptrform p.ssivt IllM
e .. 1tists for wIIo _ to a(IM ROM.
Ewlt' patimts iIId coolUmrf$aboiJ: thrombosis prmIItion Iklting
PfrKdK sIRlthinll!bort pt'Iiods of .mbulation,noid lining for
prolonged and iJICrtlSing Huid inuR.
EJICOUri9uht patimt 10 oI dopt a htillth)' ift'styleof Iowfll food choil:t!,
Ufftiflt' i nd oIkohol (onsumption, and
smoting {Kl<Ition. pfllidt in approprim (t.g.,diMitiin) as

Tuch tht pitient f.rniI)',OI cart'i.jlvtr .nd symptoms of t'lttSsie
blding. iJICkiding occult blffiJIng.tf mt'mll
OftrtM sitt should bt held up to 15 minutH. tfbletding (ontinuH,is
5MIt, Of is by dIz:zintls Of 5)'nCQ111'. immrdiatt medial
attelltm (e.g., 91 1) should bt obt.ined.
Women of me!lsuuallgf should rtpor! be;wy Of PftIionged
mtmtru.J1 bleeding and should trtp a "p.d (GUnt".wI rtpOl"llD tilt htlltlJ
{11ft' prumn.
(Conrlnued)
LibraryPirate
]78 Unit. and UrlNry Sy""'"
NURSING PROCESS fOCUS PATIENTS RECEIVING ANTlCOAGULANTTHERAPY (COIIllnued)
Impl ementati on
Interventions lind (Rationales) Pat ient li nd Fa mily Education
CaminlJl' to Ilbs (apn.,Pland/OIINR),CBC,and pj,Itlm. inslrUCt on nrfd to periociQIJIor Lib work i nd 10 Ikn lab
(Thtr.peOOc aPTI "nd II !MIs "I! usu.a, 15-2.S timts the norm,,1 ptrsonntl that .lnti<oaguLint therapy is bMg \Md.
mnlrol Vlu,.INR is usuaIy 1- 35 014. VlOO below ttw, noon
inslrUCt tht patimtto (.IffY a .111tt identfution (.Ird orwu, medical
ievtlsof the drug;..-aIun tile noon indicatt I hisI/I
idrmirl(.ltion jrwrlry indic.ltmg antiCoiglMIU
poltnti.ll for bleoeding "nd Ilemonbage.QIC, tspe(i.lt,. RBC, Hgb "rd Ikt.
Ind pIa\M!neIs ,houId lml.Iin nonnallimits.lltaNsing niue on
tIw e B( maJ ild nit bkfd ing and tIw nted IlII!WSS for 1ocMion.)
CantinlJl' to pulws lor quality and 1'OIu!rre,.nd kh the patiml b:Il!pOrt .... J 511ddu pain in It9s or (.II-/ts,
mmpllinu of Ingina or(1IHr if lIN or of wlldtn OIllt1 or dJstfll'l, orllf"W-(lll\d anginll plin immediitrly.
..:companied by dysprIu b fII'W or w6dtn onset of pain is
nt<HSlf)"to prompt tJUtmeni of possible embolI
opportunities for i""ry or bIefdi!tg whert possiblr:.Il1Oid 1M inllru(f the patiml on ways to minimizt cwor\l,lnities b injury or
injection!, pmide 10ft toothbM h, iM br Cllllious wlltn providi"9 blffiling wllm pouibk:
tspe(i.lDywithedtrfy. hi"ll!' mort sUn. (AntJ:OiIjuLims 11M tht Swikh to a softtoothbrusIJ .nd insp!!J!ms after bruslJing.
rill of bIding Ind Ci\MS of e'lrn minor iIIffiIiog should be MIicIfd when
lM.n tltruic fuor if pouitlk or be (.wtious with i safttJ rnor,hoIding
possibkJ
prolonged pltSwrt SIN. nKks.
Ik mllru witIJ food wlltn rurmg focd
AlIOid conoo !If1S, imustmrnt pirkridH, other physiulICIMUrs
111., may C.IIM imenst ormlen! bumping,jOIllinq.or ..,.
frrqlJl'mly I\ltSS tldt,.,. brnily If)I'mbm on IntKOirPanl thtrapywho
11m mort frIgiIeskin Ind may sUn ItilfSOI Kdrymosis
IIlDrt fmr,IentIy.
Ooseiy Mluile .In p!l!'S(riptions or 1M of Ole nwdiOOons for dIug inslrUCltlle patiml to consul! the heillh C.Irt p""..idtr briM liking IIIJ
drugs with inousing fII'W prtSCripbonOl Ole meditation, inWding herbal p!tIIoltions.
dwnu for bleeding.AlI OT{ mediutions ron1.lining
i rtcontr_icned)
Mainl.iin IIOfTJIiI inaNSts OIdKlNIfI in YiTimin K-ridl kh lilt paUmI to main1.lin a normal dift,.-roi:Iing inouws 01
foods (e.g. uk) and limit 01 dKrtases in 'liumin K -rich foods I nd lim it 01 dimi Ilmbol intake.
tlimillollt ikoIIoI imakt. IY",min K is I\t(tSsaf)" foftllt sl'lthtsisol cloning V"umin K plOTein suppiemeftl drinks
.nU. Suddtn in(rtiJleS 01" in diftary intaktaf WOlin I - rid! bst) thai ohm Mft itamin I .dded Ihould Iiso lit, noided.
.... tir:Oi9ULinlS,
Adrise to llIOid emssive inl.iktaf _1IhoI v.+.ilr on 0IiI1
paJlKularlycnl.lntico.gulanl inlikt of iIcohol, _ TWO
iniKoagU"nts.
drinks Pfl"diJ in mtn 01 one in womrn,mq tht afOlilI
iMicoagwnts.)
AsSt!.S ilf .IJIJS)'IJ\ptoms ofiwpariti1 (t.g..dirktning urine, light ordiy- inslrUCl the patiml to in, sign! of possilk!
mlored nook. lkin,jaundicf of!der.io orskin,ilxlomioil pain rsprriIlly Hpf'ciaU, lbcb!Jinal discomfort that Ioxaim to tilt Roo.
in right upper 1RUQ)) in rmiviog 0111 inticO.l!J!Linl
Wlipy. (Drug-induc:ed htpatiti1 is I possibk .dftBt' riFt of or.1
.micoagul.illl ttw,rapy.)
Patienl uRclmtanding of drug thmpr.
1M oppoflllnilies during idministration af medications Ind durinll The patient should lit, Ible to state the rtuon lor drug;.pplOjlri.nedoSt
aslf1SmenI! to dis.:uss rollionalt for drug Wflp)', dtsiRdthtrapNtir:: Ind S(he<kJiing; what advt!w tHfm to obsmoe for and wlltn III rtport;
Ol/l(omes. mosl (ommon idftrseelltm, parametffl forwben to Gil M.1Ih tqUipment as appropriate and how to 1M that fqIIipmtnt;and tIw
art pmidtf,and.ny nKtssaf)" monitoringo, time ItrJgth of mediuOOn thfflp)' with l OY sptci.ll instructions
cl!riog rusing C.Irt helps to Ind mnfon:r Ry Irhiog arm.) rtgardiog II!'MWing 01 coJllinunJ presaiption as approprialt.
LibraryPirate
Chopltl 27 0nJq< /0, Disorders 379
NURSING PROCESS FOCUS PATIENTS RECEIVING ANTICOAGULANT THERAPY (COlltlnued)
Implementation
Interventi ons and (Rati onales)
Patint selfadm inistnt io n of drug therilPY:
When administering iflltnKt in
proptrstiladministration tKhniq!le'l lollowed by retum dtmoflltration.
(PJOptr drug administration inaeoMl tIlr rifectiY!'nrss of thr drug.)
Pat ie nt a nd Family
'!radJ thr family, Of carrgiYl'r i1 proper seII-mirilirition tKmiqut!:
InjKtions of heparin Of lMWH !hould administr.ro in thr latt)' layers
of thr ilbdomrn or just abM thr ilioK (ld avoiding thr ptriumbiliul
alN by51m (lin.).
Skin ischwnup("pintlJrd1and
InjKtion is giY!'n withoot alpirating lor blood rrtum.
skin and hold slight prellUft' 10 Iilr but do not m;lIUge afU.
HaY!' fam it;, Of cart9iY!' r return-dtmonmillr trlhniqur umil
proptr tKhniqur is UIKI and they ilft'lomfortable giving injKtion.
Tralh patient on Ofal antKoagutantlto take tllr mKiitation <II thr
IiImttime rol(h day.
Evalulltion of Outcome Criterill
E'/<Iluate thr tffe!til'eOtls oldrug tllrrapy by mnfinning that patrnt gNlland ou\(omes haY!' brm met (= Planning").
5H WIlt 17.J far Q Ist /hf> rn wtidJ rhtst f.minl} IKtm Gpp/y.
antiplatelet agents are used to prevent clot formation in ar-
teries. The anti platelet agents are listed in Table 27.4.
27.6 Pharmacotherapy
with Antiplatelet Drugs
Platelets are a key ,omponent of hemostasis: too few
platelets or diminished platelet fundion can profoundly in-
TABLE 27.4 1 Antiplatelet Agents
crease bleeding time. The following four types of drugs are
classified as antiplatelet agents:
1. Aspirin
2.ADP receptor blockers
3. Glycoprotein lib/lila receptor antagonists
4.Agents for intermittent claudication
"n"
Route and Adult Dose (max do'>!' where tndtcated) Adver'>!' Effects
1 ... "'-_ ..... ,,.;.
alpirin (ASA,am,t!Ntil1lk add) PO; 80 mgldly to 650 mg bid
(w pilqt 230 for the PJOIOIypt Drug
t'!!!.!l! blsmm

(US cffeas ltipyridameJlrl anaphylaxjs
(Pmantinl'j PO; 100 mg qid

ADP RECEPTOR BLOCKERS
Q dopidogrel (PlavD:j PO; 7, mgldly
praSlJllri (Effient) PO; 60 mg IoatIng dolt folowed by 10mglday 1!K!uHddollim f!!!!:,!;! l!!ffiiog. blood
tidopidinr (rKlid) PO; 2,0 mg bid (max: 500 mgldly)

GLYCOPROTEtN ItB/lltA RECEPTOR ANTAGONtSTS
aooDnib (RroPro) IV;0.25 mgiJo;g initial !Qusam 5 min;1ilen 10 mt9l'bJlmin for 12 h
(m;lI: 10fIKg/min) mioor/llttdllg
rplilbilidr (htt9'i IV; 100 mlgi1l:g om min;thrn 2 mlg/kglmin for h Il'fomb!!n1!l1!!:!!ia
tirofib.Jn (Aggrilstat) 1V;0.4 mcg/kglmin for 10 min;then 0.1 fIKg/kgImin for 12- 24 h
AGENTS FOR INTERMITTENT CLAUDICATION
dlollolzol (PlmtJ PO; 1 00 mg bid D)5p('pli4IXX1SfG, 1'mli00i dzzinru,
pentoxifylilll' (Trentalj PO;400mgtid
ffl)'Qf9io, htodacht
Tam't(,Jrtli ind polpit.J1iom lsilostazoll eNS
Mt
inootr ammon inticatrs IMOIIS adw-rw
LibraryPirate
380 UnII4 TheCJrdkIY.",ubr.nd Url""ry Syuem,
Aspirin deserws special mention as an anti platelet agent.
Because it is available over the counter, patients may not
consider aspirin a potent medication; however, its anticoag-
ulant activity is well documented. Aspirin acts by binding ir-
reversibly to the enzyme cydooxygenase in platelets. This
binding inhibits the formation of thromboxane A" 3 pow-
erful inducer of platelet aggregation. The anticoagulant ef-
fect of a single dose of aspirin may persist for as long as a
week. Concurrent use of aspirin with other coagulation
modifiers should be avoided, unless approved by the pre-
scriber. Aspirin is featured as a drug prototype for pain re-
lief in I SCOO, i. also indicated for prevention of
strokes and MI in chapter 2500, and reduction of inflam-
mation in chapter 3300.
The ADP receptor blockers are a small group of drugs that
irreversiblyaher the plasma membrane of platelets. This alter-
ation changes the binding of ADP to its receptor on platel<1s
so theyare unable to receive the chemical signals required for
them to aggregate. Both tidopidine (Tidid) and dopidogrel
( Plavix) are given orally to prevent thrombi fonnation in pa-
tients who have experienced a recent thromboembolic event
such as a stroke or MI. Ticlopidine can cause life-threatening
neutropenia and agranulocytosis. Clopidogrel is ronsiderably
safer, having adverse effects oomparable to those of aspirin.
Prasugrel (Effient) isa newer ADP receptor blocker,approved
in 2009. It is indicated to reduce thrombotic events in patients
with acute coronary syndromes who undergo PCI.
Glycoprotein lIb/ IlIa receptor antag onists are relatively
new additions to the treatment of thromboembolic disease.
Prototype Drug I Clopldogrel (Plav/x)
Glycoprotein li b/lila is an enzyme neces.saryfor platelet assrega -
tion. These drugs are used to prevent thrombi in patients ex-
periencing a recent MI, stroke, or percutaneous translwninal
coronary angioplasty ( PTCA). Although these drugs are the
most antiplatelet agents, they are very expensive.
Another major disadvantage is thm they an be given only
by the IV route.
Intermittent daudication (l() is a condition caused by lack of
sufficient blood flow to skeletal muscles in the lower limbs.
Ischemia of skeletal muscles auses severe pain on walking,
particularly in the calf muscles. Although some of the ther-
for are in tre:oting I e,
two drugs are approved only forthis disorder. Pentoxifylline
(Trental ) acts on RBO; to reduce their viscosity and increase
thei r flexibility, thus allowing them to enter vessels that are
partiallyocduded and reduce hypoxia and pain in the mus-
cle. Pentoxifylline also has antiplatelet action. Cilostawl
(Pletal ) inhibits platelet aggregation and promotes vasodi-
lation, which brings additional blood to ischemic muscles.
Both drugs are given orally and show only modest improve-
ment in IC symptoms. Exercise and therapeutic lifestyle
changes are necessary for maximum benefit.
AVOtDtNG MEDtCATtON ERRORS
A mothtr dMlops W,rf,rin (Coum,din)
2 mg day isordmd. What qutStion ,boutthis order!
Sir .I{IfItndIrOibr /ht54!gqtlUd_.
Therapeutic Class: Antiplatelet drug Pharmacologic Class: ADP re<:eptorblocker
ACTIONS AND USES
is indic,lIfd for plI"'ntion of throm boem boIK eYl'n1l in palients
with a f"e( t m hillory of MI, CVA, or ant rydimll'.lt is ,Iso approYed
for thrombi prophyluis in patitnts with unll,bIe angirw, induding thOll' who
f"e( eiYing mrul,r bypass or 'ngioplasry.lt m<l y he gi!'n off-
l,btl to thrombi formation in pillienll with (oronary IIt nts, <I nd
10 pre't't'nt !'in Ihromboll'S.8euUll' drug is
it is pl"rl(ribf<i for pillients unable 10 toler.lte Hpirin, which h" similar
anticoagulant "tivity.lt is gWtn orally.
prolongs bleeding timt by inhibiting plolelet di-
realy inhibiting ADP binding to its f"e(eptor. This binding is illl"'rlible ,nd
platelet will he ,lfenfd for the ofits life sp,n.
ADMINISTRATION ALERTS
T,blen should not he or split.
drug" Ie"t S days prior 10 surgtry.
PrtgnallQ GIItgOry 8
PHARMACOKINETICS (PO)
Onset: 1- 2 h
!flU h
Halflife:8 h
Durat ion: Unknown
ADVERSE EFFECTS
is gmmlly welllole"ted. ao:i!'lll' elfem indudt flulikt
syndroltK', diuines, and rHh or pruritus. lib> other {oaguLllion
modifiers, bleeding is a adYffiee!'l1l
Contraindications: is (onmindicatfd in p,tieot; with <I ctm

INTERACTIONS
[)ug- [)ug: LMwith thrombol)1ic:
(f N SAIlS, i1ducing i!piin, wi ilKfNl,f tIN> rilk of bIKoIing. B.vbino:rs, rifompin.
(f carbarnauPllfmay m-tlN>aoti<:NQWriatMlyof 1M uoIt
altifi.ngill, jnIMe W!apiIIIIi , (f Zift!ltast may diminish
tIN> i ntiplilfk>t aaioos of dJpidoIpl.
Lab prolongs bIKoIing tiM.
IkorballFooo: Herbil thilil!l'(I {\ligWtiCIl sum
IN,ginigo,tish 9iricl!li)' ilmN tIN> rill: ofblHdilg.
of OYerdOll': In mrs of poisoning, plotelet transfusions may he
lIe{rss.Jry to plI"'nt htmonhagt.
RtI'tr 10 MyMIsJrtgKI tllf Q MnJrJq fooIl spK1It 10 IIrI! Ituq.
LibraryPirate
0\0p1IIf 'U Dnq; for eo..gul;otlon DI5order, ]81
NURSING PROCESS FOCUS PATIENTS RECEIVING ANTIPLATElH THERAPY
ISS6wmnt prior 10 administration:
Undel5undlbt
therlpMK dtatm risk of dtwloptntnl of(vAund Mi l
Obtain a htalth hislOfl inWcling unliomaAir r .. dJding HTN,
MJ, PICA witIJ Slfllt plac:tlllflll} and lWfiphrfal
(indlding prt'fious pull!IONf1 tmbolisml. lltUlOJogK (indudinglfttltl
head injury and (VA}, hrp.Iit 0111'1111 ptpIK
1M oIakoholism or pll'9nalKJAst
WOfllfll of mrnstnJll.gt lboul tht length.nd htivinffi 01 USUII menltnlll
flaw. Obt.in. drug irdodiog pRSaiplion ind m(
hffb.JI ilnd akohol-.BIo alen III drug
intefauioM.
Obtain bilfliM Might, lUI signs, ECG (if bll'olth sooods.
"'iel for plI'Wn{e, lJloIity, Ioution of.ngina, and fOf pmfII{t of
or{1Ies1 exlttemities for IYmpIOmI of (t.g.,
wirmth, in (al( positM /loman's and for Iocmon
arJd dlirmnh mounl 01"'1, if pll'WnL
.ppop rMlt whomory findings (e.g., bltfding limd, (Be .nd
pLJitIeti, II'IliI I nd lim function sludift, Ind lipid profilrs..
b t ll nttnt thlO.ghout
ASies for dnftd IhtflpMK &b no symp!!lm! of thrombM
fonnalian).
CoI\tinut periodic ntonitoring of lib v.kIts (t4-, (Be, plill'leH,
bleeding tirMj.

e,ilulis,bitfdng from gums, ind for oo:wit sudlill
frrpc:ttnsion, !iJCh)'!'lrdia,abcbminal pain,_111 d abdomirwl wal swrIingOf
firmlltlS,Unbir pain,Of clrmlltd lDnI(ioo\ntss..
Potential Nursing Diag n05U
IrwfFtaivt TISWt hflusion (lriitted 10 llratiSed dmJlilian in afltcled

Imp.lill'd Skin Inlf9rity fin lowe!" utll'lllities II'lited to intffffiivt tissue
prrMion)
Mxitnl Knowlrdgt (drug thtnpy)
Risk lor Injury (bImling,rNttd III adYmf rfftru of t/wrapJ)
Planning: Pltlent Goals and Expected Outcomes
lht piltiem wiI:
bptritrKt tM.ptulK dfts dtptndtnl on the 1I'l!Orl 1M drug is being 9itn (t.g..prMnlion cfevA due to thllJfllbosis).
1m:' from,or rxptrifncr iClftrse
VtrNlizt 1ft Ultdtl5l.nding of the drug's lISt, .ltftrse tfttI, lod preuutiolls.
Oemonslralt proprr !elf-admiration of tht mediGltlon timing. whtn to notify pnMdrr).
Implementation
Interventions and (Rationales)
lMurlng thttlpeutlc tfl"tm:
Contin ... ;mc>>mrnt> '" ckscribod Icrthoropoubc clkru,c.g. no
symptomscf thrombotK moio:t;signsand symptoms u to 9isting
pmphtlli. run. I insufliUrncy show gradual im wd1 as
pll'ious ptriphefal pain bas or &
pmpht,,1 puMs all' imprll\'ing in IJloIIiIy DI mumf. (Antiplitelel: drugs
hrlp pll'Wllt the formatXJn of panirularly in 1M ilntriorlsJUml.)
EIKOUfilCjt .ppropriatt IifrstyIr {ilangH.J'rooridt for rlirtitian {onsdtition II
(Smoking illUNseI platrlrt ilg9ll'9ilion and promotts the
fonnation of thrombi. Hulthy rrftstylr dwngts will suppon and mininm
tilt nted fordrug tIltllp)'J
Patient and fami ly Education
k.o<h pil!ionts of d""",,,,,, .,..,ptom. toot..cn.: for,ckpmclrnl on
II'lIOn thtdrug bas bftn ordtmI 5UdcItII onltt of klltss
tlftiog onr sicIr or limb [CYA[; mid, p.r Ie txmmit-; witbouI: pmphtll!
p.rIlotI [mm.locdusion)).
Irw p.rtiflltto a htalthy ifrnyIrof Jow--bl food dJoim,.
{alftillt.nd otkohol {OII!Ifmption.
J'rooridt for appropriorlr mmuilation (f.g, dittitian) as Iftdtd.
PrO'ridt informmon on !IIIOUIg {tsloltion.nd tmphasirtht riskth.n
smoking poses in mo:ular diirasts.
(Continued)
LibraryPirate
NURSING PROCESS FOCUS PATIENTS RECEIVING ANTI PLATELET THERAPY (Coo"'"""
Impl ementation
Int ervt oti on5l1nd (Roti onoles)
M.,imizing.dWl'lt tffem:
Monitor 101 signs and symptoms ofbftdirg: oozing allY orwounck,
tcd1ymosis, herMurw, stools, rffiil blmling. "wfftt-
ground tpinuis, from gums,. prolongtd lind/or ht.wy
menstNoli flow, fOf occult is diuinesl,
tach)'Cilrdi.l, abdominal pii", of abdomilllli wlIll sWI!lIing
Of firmllffi, "'mbar plIin, Of deutllsed kvtI of (OIIKiousne5s, (The risk of
bWding nom IIntipialflet thtrllpy is not as u it is for i1111it:CWguI.UItS.
but it lllouid be monitored while tilt paticflt is on .ntip!attlet thmpy.)
(onlillucto monitor lipi;llrvtb.I(8( al!d
pl.Jleltt shoold I!main within normal patients wid!
lIneNI dirusf COOOIrTrot lipid disoldm lind may need .ddition.1
trtllttMnl nUts on tilt (Be may indicate mesiw blefding
lind the need 10 HIeSS for IoutioJl.)
CDntiftut to manitOf ptriphffill polit! for quality and <Dmplaints of
angina orchnt pain,t!ptdally if new Of of sudden onset or aompanied by
dyspnN. (Monitoring for ntw or sudden OI'Istt of pain is ntmury to tfllUn!'
promptl1!atrntflt of possible emboli.)
Miflimize oPPOftunitin iof injJ!), or bietding when!' possible: avoid 1M
inje<tion!" pro'IicR toothbMh, alld Cllltious whtn providing <art.
tspecially with 1M fldtlfy who havt mol! fr.tgile skin.tArttipiatelet drugs
raist tM riskof bletding and potffiti.ll UU!l'S ofbletding should bt <Il'Oidtd
whtn possible.)
(iostly ffiluate iIIl new pmaiptions or list of Of( mtdicatiom 10, drug
interactions. (Many d rugs i ntelitt witlr antipla teltts. ill(ltuing the <hall( t
for ore mtdkatiolll containirlg uJicy\ate!"e.g..l5pirin,and
NSAlDs.e.g.. ibuprokn, should not bt taktn unlts!othtrwist ordertd b,. a

Main\lin a nomul and limit akohol in\lkt.(blrniYt intakt I;If al<Dllol.
two drinks diy in mu or Ont in wornttI, may
of a ntiplatelet d rugs and ill(rta It the risk of bletding.)
Patifllt understandi ng of drug therapy.
1M opportUnities during ildmin istlation of mtdicatiom a nd durin !I
ilSSfSSmcnts 10 discuss the rationale for drug thtr<lpy, 1hcrapeutic
outcomes. most (ommon adYme paramttm for when to caU tilt
ht.Jkb any monitoring or plt<autions. (Using
ruring nursing Mips to OJ)timin and tty ffit h ing

Patifllt \elfadministrat ion of drug thuap,:
Whm administering roo:Iiutions. instruct tM family,or cln!'giver in
proper stlf-adm inistration (PlOptr administr.ltion will ill(ltast
tilt tffecti_sof tilt drug.)
Potient lind Fomily Ed uc;.ation
Team tIM! patitnt OfCilrtgrm signs lind symplDrm of tllCtSSivt bftding,
jnduding IX(UIt bletding,and 10 I!port any (onctnlS to the health (ill!
plOYidtr prompt"'.
Womffi of iI9t should I!port or prolongrd
mtnStruaI blttding olACI kttp <ount".nd I!port to tilt hNIth <al!
plWider.
Inslruct the patieftl on ned til I!tum Pfriodiuily for lahorkand to
aim lab personnel tllit antiplatelet thtrapy i5 bting 1Md.
InltnKtthtpatiefttto w!)'a wallet mtmcatioftc..udOfwtar Illfdiul
idtntilOtioo jtwt try indiuting antipl.i tflt!:
Ttarn tilt patiffit, family, or uregie- to I!por1 ol iff sudden pain in dlfU,
Itqs, or new-olllet anginal pain immtdiattly.
Inslruct tilt patie!ll on wqs to minimize opportunitin for injury or
bletding whM possible:
SwiKh to a soh toothbrush and inspen!PJfII! after brushing.
Ike an tMC rwr if possible or lit tl1r.1 U1utious with a ukl)' r.ll1lI,
holding plOloft9td prMSUn!' !Ml lmall nicks.
Be uUlious with food pl!pal"ition,er ptd.J11y wlltn cutting food.
Avoid cootut sports, amustmtnt park ridt!" or othtr physic:allCtivitits
that mat <'lIst intUst or violent bumping,j05t1ing, or itjury.
Fl!qutntly a!st11 toIdelfy family mtmbm on antipl.ltelet tMapywho
w mol! fragile skin and may txpeMtn<t skin !em or e<:dlymoses
molt frtlpntly.
InltnKt the patieftt to (l)fllUlt the health <alt plll'o'idef belon!' taking any
ntW pn!'S(ription or OlC Illfdiution, inWding Mrbal
1M patiffit til rnaintiin a 1lOrma! did, m>iding l"liCt!m.t intikt of
alcohol.PfOOdt for dittary conwltation as netdtd.
1M patiffit should be able to lUff ttaSOn for drug;appropria!e dost and
scheduling; what ildYcrsttffn toobstrvt for and when to report;
tqUipmtnt .-led as appropriate and how to lrst that tQuipmtnt;olACI tilt
length 01 medication thflilPY ncded with any sptcial imlrvctions
n!'garding ItIltwing Of <Dntinuing presaiption as applOpriate.
Tead! the patiffit, f.Jmily, or uregiver in proper sdf-administration
tKhniqutl.
Evaluatio n of Outcome Criteria
Evaluaff thteffmMntII oIdM) tlltnpy by coofirming that goal! and exptcttd outcomes 11m bttn mH (Sft! "Planning1.
Stf TIII!It ]7.4fDta I;.r tI dlugJ fD w/rIdr thtst IIInhIg IIl/iIm m.
LibraryPirate
Chopltl 21 Drug< /0, Disorder, 383
TABLE 17.5 I Thrombolytics
On"
Q TPA)
lSI
for ProlOlrpe Drug box OC
(KabikiMll' )

Route and Adult Dose (max dose where IndlcaU>ci)
IV; 60 mg thtn 20 mgl1l o'm next 2 h
Adverse Effects
l
SuptrfidDlbludflgl1li
rt
ecrionsire\ Q//ergkrHcWIIl
'jrriolll jmema( b!etding jm@mnjalbw gabage

THROMBOLYTICS
IV; i1 30min
IV; 2SO,00G-15 milion rrm60 Rin
IV; lo-SO mg infwd um S moods
It is often mistakenly believed that the purpose of anticoag-
ulants such as heparin or warfarin (Coumadin) is to digest
and remove pre-existing dots, but this is not the case. A to-
tally different class of drugs, the thrombolytics, is needed for
this purpose. The thrombolytics are listed in Table 27.S.
27.7 Pharmacotherapy
with Thrombolytics
Thrombolytics promote fibrinolysis, or dot destruction, by
converting plasminogen to plasmin. The enzyme plasmin
digests fibrin and breaks down fibrinogen, prothrombin,
"'" Prototype Drug I Alteplase (Actrvase)
and other plasma proteins and clotting factors. Unlike the
anticoagulants, which can only prevent dots, thrombolytics
actually diswlve the insoluble fibrin within the dot. These
agents are administered for disorders in which an intravas-
cular dot has already formed, such as in acute MI, pul -
monary embolism, acute ischemic CVA, and DVT.
The gool of thrombolytic therapy is to quickly restore
blood flow to the tissue served by the blocked vessel. Delays
in re-establishingcirculation may result in ischemia and per-
manent tissue damage. The therapeutic effect of thrombolyt-
ics is greater when they are administered as soon as possible
after dot formation occurs, preferably within 4 hours.
Because dotting is a natural and desirable process to pre-
vent excessive bleeding, thrombolytics have a narrow mar-
gin of safety between dissolving "normal" and "abnormal"
Therapeutic CI ass: Drug for dissolving dots Pharmacologic Class: Thrombolytic
ACTIONS AND USES
ProdlKrd through rKombini m DNA I to
l)'m!' human iiiSUI' pb,mioogrn acti"ffior (TPAj .k with thromoolytin,
the primary mion to(OOYerl plolSminogen to pblmio,
dilroirn fibrin (blS. To a(hitft muiOlJm tffKt, theripY ,hould bt<j in immrdi-
after tilt OriW of elm not rn.ibit allffijic: rm-
lion! with is a drug of (OOKf 10, tl"fitmem of
evA dlH.'to thrombus and isulofd ofl-iabtito 1"1',101"1' oflV (athtten.
ADMINISTRATION ALERTS
Drug must btgil' n within 12 hounofonm ofsymptomsofMland within
1 hounof thrombotic (VA for maxiOlJm effectiYeroMt
Avoid paremml injr(1ions during infusion to deuuS!' risk of
blffiling.
Pll'gnancymegoryC
PHARMACOKINETlCS
Onset:
Peak: 5- 10 min after infUsion is di,ronoflll'd
10 min
Duration: 1h
ADVERSE EFFECTS
The mOil (ommon effrCl of is bleeding, whic:h rTIiIY ouu, su-
pertKiilly at rftdle pun(1uft' ,itl'S or interTlillly.lntrmaniil blffiling is i r.ne,
though poIsibit, m rw rifm Sign! of blffiling I!Kh as spomaotOlJl K(hy-
OIOIe, or t pistu is !hoold immediately bt I"I' ponrd to tilt htalth
mr prwidtr.
Conlraindi (ations: is in actil' internal bleeding,his-
tory of CVA within the past 2 month traurTlil or surgery, !f"I'1"I' unc:oo-
trollrd hypertension, imramnial neoplasm,or rTIiIlforrTliltion.
INTERACTIONS
UII' with .. ts,OI HSAlIlI,
inWctiIg ilpi"in, INY iOOtalf thf IN of 1iHding.
lib Tl5Is: Aktpla!e will i10Me PT and aPn.
HerlIaVFood: lNwithsupplfmtnlS thitaflKr: roagw!ion sIKh olS
IN. giok\lO. filii oil 9ioQPt 01 gric:!ohould bf a'lllidfd. thty """ ifl(JNI(' thf
rr.tofliHding.
Trratmenl of Oerdose: Therr is 110 lpI'{ifKtrutment for
IftfPf III M}MJrllng/l1f fer Q Mmi"9 I'rIKm F/KJJ5 J{lt(1k III rills drug.
LibraryPirate
384 UnII4 Th"C.rdloY.<;(ubr.oo Urinary Syuem,
NURSING PROCESS FOCUS PATIENTS R,eElVING THROMBOlYTICTH'RAPY
Assessment
Bilsrline assess mrnt prior to administrati on:
Understand the INson the drug h" bft.n Ple(ribtd in ordel to lor
thelapeutic tffrds (e.Cj., tft'atmem 01 MI, (VA, pulmonary
Obtain a (ompiete heakh history induding wdiolla!(ular,ptripheral
va!(uial nturologic (ilKludingll'(l'nt
ft'(l'nt SUl9fnts or inj.rRe, hepatic olll'llal ptptK ukrr
dilNle, ft'(em (hildbinh (within 10 days), 01 the I'OIsibility 01 pregnan()'.
Obtain a drug histOl)' ilKluding alle"lie, arrrrm prt'IUiption and OlC
herbal prepaluiolll,and ikohol USI'. 8l' alffi to possible dlllO interactions.
Obuin baS!'lilK'"M'ighl, vital ECG, and bft'ath sounds.AsSffi the
p,eflKe, location 01 angina, i nd lor p,erlKe 01 01
(hen pain. nturologic nullS.
[vawtt (aPn; aPT,INR,blffiling rimel,CBC and
piatelm, Il'IIiII and liver function ,rudi6,ABG, (antrial blood ga,) a!
.ppropriate,.nd lipid profile,.Suppan the patient during other II'lJIill'd
tens (e.g. a or MRI prior to thrombolytic thmp)' fo, (VA).
tlubli,h all monitoring equipmmt and lIKelollY lines or amn9" for theil
illSl'flion (e.Cj. E(G monitoring,1Y, Foley
Assessment thro ughout administration:
CominUl' iII'"",m alll5l111ents fo, thel1lptu!ic: dfr(ts (e .Cj., angina h"
diminished signifKolntly or and ECG findings within normal
lespilatol)' l'Ifon and ABGs ,ignirKolntiy impltlYN).
CominUl' fII'"",m monitoring 01 appropriue lab vaoo (f.g., 11gb, Hct,
platelm, RBC,
Monitor vital signs ind ECG l"Iery lS minutes during the filii houl 01
infulion,and then 30 minute during the lMIainde, 01 inlurion ilnd
for the fim8 hooll.
Aslffi fo, adYerSl' tffrm: blffiling at IV site, WOUnds,6(ffiift
ruh)'lllOlis, peterniae, hematuria, blar:kttarry stools, Iffial blel'd ing. "roifff-
glound" emew., bftding lrom
.nd lor <Karlt biffiling. IU(h ill hypotmlion, rdia,
.bdomin.l poin, .. of .bdominol w.lI ,_lIing or firmn ... ,lumbar polin.
or drclNll'd Itvel 01 (on!(iouwss.
Monitor nturologic ,taM e,pecially thrombolytin all' USI'd
forCVA.
Potential Nursing Diagnoses
Pain (maiN to ItIIml'd perfusion)
Indti"f!' flSsue Prrflrsion (lI' ia!l'd todl'CINSI'd ciltuiation in .fitl'd

Impaired Gn lu:ha nqe (pulmonary fnt bali)
Impaired Skin Integrity(in matl'd to ilK'fitift tilMle
perflrsion)
Anxirty (ft'lated to (ondition, hospitalization)

Risk follnjury (bleeding and hemonh.9", rNtl'd to adftrw 01
therap)')
Pl anning: Patie nt Goal s and Expected Outcomes

EllperirlKe theraprutir: dl'ptndent on the ft'iIIOII the drug i, bring gil'tll (e.C)., Il'perflrsion oI(oronary anerits).
8e 1m from, olexpeOen(e
Verbalize an understanding 01 the drug's uS!', ad'/erse tffrru, a nd requill'd preautions.
stll-administration olllKffi'ry po'Hhrombolytic ml'diutions (e.g.,doIf, timing. whm to notif)o plOllidfl").
Impl ementati on
Interventi ons and (Rati onales)
Ensuring theril peut k rffrets:
CominUl' fII'"",m mesments mleaibrd ea rlit! lor therapeutic HIts,
f.g.,p'l"Iious angina has diminis.hl'd significantly 01 is fliminatl'd and ECG
findings show deaNS!' in is<hrmia. (Thrombolytin rapidly dilsoWeellilting
0011 to allow I,,"""perfulion 01 the all",)
PosHhelapy, en (OUlage appropriate lifrltylr (hangel. Provide fo, dirlitian
(OlllUkation a! I"ftded. (Smoking iIKIN ItI pl"t.let agg"'9iltion 01 nd
promotes the lormation 01 thrombi. He.khy (hanges will suppan
nd minimize the need lor furuft' drug thelap)'.)
Pat ient and Family Educati on
the patient about all p!O(NUI!"!.nd theilllKffift)o priol to
beginning thrombolytic therap)'.
To allay anxiety, teoKh the or (ale9i!'1 the lationale for all
equipmmt uSl'd.
Enroulolgt' the patient tompt , he.khy ollow-Iatlood (hoice,
ilKlI'aSl'd ufleinr and akohol (olllUmption,oInd
1I110king PIOYide fo, iI ppropriat. (onsultation dietitian) a I
...
LibraryPirate
Chopltl 27 0nJq< /0, O""rde" 385
NURSING PROCESS FOCUS PATIENTS RECEIVING THROMBOLYTIC THERAPY (Conrfnuro)
Implementation
Interventi ons and (Rati onales) Patient and Family Educliti on
Minimizing adft rle eft"ms:

for ligrn and symplomlof blffiling. 5lKh u
Allay anxitl)' by ft'aslUring the p;iltitnl and 6plainiog ralionale fo,
Itypottnsion, t!oC:lryu rdil, diuines, sudlle n r
ift'qUtnt monitoriog.PKIYidt adeqWIt' pain ft'litf as appropriale.
pain, or dem.!ed bel of (onsciouslll'ss. (Fft'qUent asleSSIIltnl lor both
visible and oc(ull bietodiog illII'Celal)' to Ulernivr hemorrbq
and to lIan wt, (Onffiil' liNIment as risk iI elevated
up to 2 to4 dI)'lo poIHlf<llment ,nd if the iI milintained on
antiroaguLint or therapy poIHhromboIytiG.)

Monitorviul signl and ECG rl'l'ry 1 S minutes duriog the fim hour of To allay anxiety, team the family,or uft'9imthe rationale
infulion,and !hen ffl!Y 10 milllMl dJriog ft'IIIiinderofinfusion and lor lor ,II rquipmtnl!Md .nd the rwd for monitoring.
lilt firsl 8 hours. Report dy! rhythmias (Obu iniog vi,,)
Teach the patient to repon all)' dyspnea,or aogini
sigrn frequently will ilSffi for of the drug indudiog
poltinfUlion.
hypoltn<ion u<hyurdia asso<iarod with blHding and lor
d)'lrhythmias. Dysrhythm i.I s may occur poItperMion of the (orona I)'
arlene or may beaslOCi.lted with adYenr tffNu.)

Maintain the patitm on bedrel and with limited ictiVity during Ihr Provide in 6pLlnation and rilionale lhat aaivity will be limited duriog
infulion.(Limited ph)'liul mivil)' and bedrest thechan(e for infusion a nd lor up to 8 hours plsHroatllll'lli.
bruiling, iojury, a nd bleediog.)

Mooitor neu,oIo gic: SUM fft'qUemly, especially if th rombolytiG are !Md for To alLly anxiety, team the patitnl the rationile for the frequent
CVA. (A 9Jddeo diange in neurologic: staM 0' sudden I!"',r headache ila asl!'l!O\tnu aod pKlYidt ft'assuraoc:r.
poIIible lign of an intracraoial bietod with inm,srd imrmanill pRssure.)
Instruct the family or uft'gim 10 report all)' change in the patitni's memill
lIatus or 1M! of ronsciousoru drJing the postinfusion period immediately.
Avoid proe:eduresduriog the iofUsioo aod up to 8 hours Tu(h the patient that aoy required will be
poItinMion. (An punmr ft' site or lilt of procedure will (Ie ate an maintained to the for a prolonged period oltime.
additional for bleeding.Whelll'Yl'l" 010 PlIKedUft' mUlt be u;rd,
the mUlt be maintained uoder presore fo, 10 minutes or longer 10
prtmIt hemorrhage.)
Continue to monitor lab work (Hgb, Hct, (ounu,and bftdiog rime) Provide an opLination for the nHd for activity ft'Itriction and
freqUtnlly CBe aod ABGI may also be monitored. monitoring during this til1M'.
Activity may be limited duriog thil poltiofusioo time period. (The risk of
bleeding remainl high for 1 to 4 day; postinfusioo.)
Patint unMrstanding of drug thtrapy:

US!' opponuoities during admioiltratioo of Ihrombolytic: thmpy to explain The patitnt should hal'ean of rationale behind
II-.. wionilr In, drug therapy. dMired theraprutK re",ired thrombolytic: th. ,apy. "'luipmrnt. and monitnring thaI will be
monitoriog for efft<1\, and pft'Cautions thaI wm be taken during the the w e required in the postiofusioo period.
infulion ind in the postinfusion time period.(Uliog time dJriog
Allow family member> limelO dis{\J\S iNrs,cOIKrms,and provide merral
nur>ing Uft' helps to re'ISUft' the patient ind allay iOXiety.)
to suppan aod aoc:ilLiry provider> uappropriate.

Provide supparr and to the family and uft'9iYenduring the
til1M' of tlNtme nt (Providing suPPOrt. and i pproprialt'
rtferrals, e.g., pastoral (ilre or lO(ial \elVU suppart,asliru family members
in astressful
Patint HIfadm inistution of drug thtupy;
Provide edJutioo during the poItinMion period about required Teil(h the io proper
(ilre foilow-ull postiofusioo drug therapy! f.g., aotic:oagulaou or \e(hoiques of amic:oagulanu or antiplateiet drugl as appropriate.
antiplatrift drugs),and lifesl)'lechinges. (Utiliziog til1M' during nursing
hdpi to teaching and aSIffi lor all)'que tiorn or roOC:fIIIS the
family, or may hoM.)
Evaluation of Outcome Criteria
Evailliltr the of drug therapy by roofinning that patient goakand 6pffifd hoiVI' been met (lee Plaoniog").
5tI' TIIbIt 17.5 for Q i5r!h1/> Ie wIidr rheit IIIflifJl} Iilns
LibraryPirate
386 UnII4 TheCJrdkwasc:ubr.od Url",,'Y Syuem,
TABlE27.6 H@mostatics
Drug Route and Adult (max dose where Indicated) Adverse Effects
Q (Amic.u) IV;(-, 9 for I h,llIffi I- U5 gIh ,Iuil bIding iHontrolltd Mergk lkinrtGrliom, htodQcM
AnaphyliBk ibrooilOlh broomOllN1Dl
nep/nIOlicilV
'prolinin (Tlu)'IoI) 1V;2 milWon KIU by >00,000 KIUI1l duing
trinwmK add IV; 10 mg/kg,llne to kiIIlintI daly for 2108 da)'!
PO; Two6SO mrt!' troo daWyfor a maximum of 5 days
clots. Vital signs must be monitored continuously, signs
of bleeding call for of therapy. Because
these drugs are rapidly destroyed in the dis-
continuation of the infusion normally results in the imme-
of thrombolytic After the dot is
succer.sfullydir.solved with the thrombolyti c, therapy with a
coagulation modifier is generally initiated to prevent the re-
formation of clots.
Since the discovery of streptokinase, the first throm-
bolytic, there have been a number of subsequent genera-
tions of thrombolytics. The newer drugs such as
tenecteplase (TNKase) have a more rapid onsel and longer
duration and are reported to haw fewer side effects
older drugs in this class. TPA, as alteplase (Acti-
vase). has replaced urokinase as the drug of choice in clear-
ing thrombosed central intravenous lines. Because
urokinase was obtained from pooled human donors and
had a small risk for being contaminated with viruses, it was
removed from the market.
,.. Prototype Drug I Amlnocaprolc Acid (Arnlcar)
HEMOSTATICS
Hemostatics, also called antijibrinoiytics, have an action op-
posite that of anticoagulants: They shorten bleeding time.
The class name hemoswtics comes from the drugs' ability to
slow blood flow. They are used to prevent excessive bleeding
following surgical procedures.
27.8 Pharmacotherapy
with Hemostatics
The final class of coagulation modifiers, the hemostatics, is a
small group of drugs used to prevent and treat excessive bleed-
ing from surgical sites. In addition, an oral form of trane:GImic
acid (Lysteda) was approved in 2009 for the treatment of heavy
menstrual bleeding. All the hemostatics have very specific in-
dications for use, and none are commonly prescribed. AI
though their mechanisms differ, all drugs in this class prevent
fibrin from dissolving, thus enhancing the stability of the dot.
The hemostatics are listed in Table 27.6.
Therapeut ic (lass: Clot stabilizer Pharmacologi c ( lass: Hemostaticlantifibrinolytic
ACTIONS AND USES
Aminouproic add is precribed in ytuarions in which is IlUrssWe bleed-
ing dilloiYfd plt'matureiy. Thedrug.!ds by
plasminogtn, Plt'(ursor of thf elll)'mt plasmin that diqtslS the fibrin dot.
During hemorrhagf, tIK-drug (,n giYellIV to in 1to 1
hours. k is ,Iso mibblt in ubltt form. It is most (ommonly prtscribed Iollow-
ing 1UJ9tf)' to I!dtn is 100
to400mtglmL
ADMINISTRATION ALERTS
Aminooproic acid hypotension and bracljUrdia when gNfn IV.
Aslf"Is vital signs frtqllfntly and thf patitnt on a (ardiac: monitor to
assess for dysrhythmin.
Pregnancy cattgOl)' (
PHARMACOKINETICS (POI
()(lft: Unknown
PNk:lh

D.!ration: Unknown
ADVERSE EFFECTS
Btcalllf aminouproic ,rid trods to stabilize (1011, it should uutiowJy
in p,titnn with a history of thrombofmbolic Rapid IV ,dminisuuion
may hypotension and/or Side tifls uegenmlly mild.
Contraindications: Aminouproic acid is (onmindicattd in pititnll with dis-
lfIIlin,ttd imliv.tI(IJiar(lotting or \e'IM' It'nal impairment
INTERACTIONS
I)ug-l)ug: fiyper<Nglllition may 0\1 with IOOInffllllll' of estrogi'rlI and oral
<DIlriKfII1i'll"l.
Lab Tests: Iklknown
Ik>rbaVFood: Unknown
lINiment is no
Rtfff IIMyMl5/ngK1 Mnlngl'rei! IIIMItug.
LibraryPirate
Choplfl 21 Drug; lor CNgulation Olsord<'" 387
, ' 1-. Chapter REVIEW
KEY CONCEPTS
The numbered key concepts provide a succinct summary of the importanl points from the corresponding numlx>red section
within the chapter. If any of these points are not clear, refer to the numlx>red section within the chapter for review.
27.1 Hemostasis is a complex process involving multiple steps
and a large number of enzymes and clotting mctors. The
final product is a fibrin clot that slops blood loss.
27.2 Fibrinolysis, or removal of a blood clot, is an enzymatic
process initiated by the release of TPA. Plasmin digests
the fibrin strands, thus restoring circulation to Ihe in-
jured area.
27J Diseases of hemostasis include thromboembolic disor-
ders caused by thrombi and emboli, thrombocytopenia,
and bleeding di,orden ,uch a, hemophilia and von
Willebrand's disease.
27,4 The normal coagulation pr0ct'5S can be modified by a
numlx>r of different mechanisms, including inhibiting
specific clotting factors, dissolving fibrin, and inhibiting
plalelet function.
NCLEX-RN" REVIEW QUESTIONS
D The nurse's understanding of Ihe clotting mechanism is
important in administering anticoagulanl drugs. The
nurse understands that which of the following clotting
factors are formed after injury to the wSS{'is?
1. Fibrin, vitamin K
2. Thromboplastin, fibrinogen
3. Prothrombin, thrombin
4. Thrombin, fibrin
D The patient receiving heparin therapy asks how the
"blood thinner" works. The besl response by Ihe nurse
would be:
1. "heparin makes the blood less
2. "heparin does nol thin the bkxxl but prewnts clots
from forming as l'aSily in the blood
3. "heparin decreases the nWllberof ptateletsso that blood
clots more slowly."
4. "heparin dissolves the dol."
o Nursing inlerventions for a patient receiving enm:aparin
(Lownox) may include: (Select alilhat apply.)
1. teaching the patient or family to give sulx.utaneous
injections at home.
2. teaching the patient or family nol to any OTC
drugs without first consuhing with the health 0lR'
provider.
3. teaching the patient to obserw for unexplained bleeding
such as pink, red, or dark brown urine or bloody gums.
27.5 Anticoagulants are used to prevenl thrombi from forming
or enL1rging. The primary drugs in this Oltegory are heparin
(parenleral) and warfarin (oral), although low-molecular-
weight heparins and thrombin inhibitors are also available.
27.6 Sewral drugs prolong bleeding time by interfering with
the aggregation of plalelets. Antiplatelet drugs include as-
pirin,ADP blockers,glycoprolein lIb/IlIa receptor antag-
onists, and miscellaneous agents for treating intermittent
claudication.
27.7 Thrombolytks are used to diMolve ai,ting
clots in patients with Ml or CYA.
n.! Hemostatics or antifibrinol)1ics are used to promote the
formation of dots in patients with excessiw bleeding
from surgical sites.
4. teaching the patient to monitor for the development
ofDy[.
S. teaching the importance of drinking grapefruit juice
daily.
o The nurse receives the patient's lab values throughout
warfarin drug therapy. The expected therapeutic level is:
1. aPTT of threeto four tinJeS the normal control value.
2. aPTT oneto two times the patient's baseline lewl
3. aPT one to two times the patient's last resuh.
4. aPT one and a half to two and a halftimes the control
value.
D A patient is receiving a thrombolytic agent. alteplase (Ac-
tivase), following an acule myocardial in1rclion. Which
condition is most likely attributed to thrombolytic ther-
apy with this agent!
I. Skin rash with urtiOlria
2. Wheezing with labored respiratioJl.'i
3. Bruising and epistaxis
4. Temperatureelevation of 100.8
o A patient has started clopidogrel (Plavix) afterexperienc
ing a TIA (transienl is.:hemic attack). The desired thera-
petllic effects of Ihis drug will be:
I. anti-inflammatory and antipyretic effects.
2. to reduce the risk of a stroke from a blood dot.
3. analgesic as well as clol -dissolving effects.
4. to stop clots from becoming emboli.
LibraryPirate
388 Unlt4 TheCirdkIYa!uu.r iIld Urinary SystHnI
CRITICAL THINKING QUESTIONS
1. The nUI'St' is working on a medical unit in which a patient
suddenly develops [eftsided \\o-eakness and garbled speech.
The nurse catls the health ClIn'provider, who diagnoses the
patient with a eVA and orders heparin 5,000 units IV and
a heparin drip to run at 1,000 units per hour. What should
the nurse dor
2. A patient has had an anne MI and has l"e'Ceived a1teplase
(Act ivase) to lyse the dot. "What nursing anions should
have been taken prior to administering the medication to
the patieni1
1. A patient is receiving enouparin subcutaneously after be-
Ing diagnosed with thrombophlebitis.. What precautions
should be taken when giving this medication?
See Appendix D for anSWf71 and rationales for all activities.


MyttJrsirlgt<i! is yoo.rr one $!CO tor Mhoe thaD!er revtew lI"'atenas lnd
l1l3,lurws. Prepaoe b :;o.n:1SS with a!kltional NClex- prnodioo
quesIioI1s, illleraCWe assrj1ltl\!llls and lIdrIiIIes, iMMl lilks, animations
an::! widoos. and mere!
RegISUr your at:eeS!l the Iron! 01 000k as
www.-yn .. 5ingklUom.
LibraryPirate
DRUGS AT A GLANCE
HEMATOPOIETIC GROWTH FAaORS (XTJt J\tl
Erythropoietin pagt191
Q epoerln alfo (Epogen, Proem) fXl}t J9.'
(olony-Stimulating Factors tJ'm
Q fllgrosrlm (Neupogm) {1J(}I'195
Plat eletEnhancers pu;elW
ANTIANEMIAAGENTS f1JI}tJ98
Q cy<lnocoboJamln (Co#omlsl, NQ5CoboIJ
"" ..
Vitamin BIl and Folic Aci d {IJge 398
Iron fOJt J99
o fetTOU5 wlfale (FrosoJ, others) POIJf 401
KEY TERMS
anemiil fX1I}tJ9l
(olony-stimulating factor(CSF) PU;f 394
erythropoietin {JQIIt 191
ferritin (X1IJt399
Drugs for Hematopoietic
Disorders
LEARNING OUTCOMES
After reading this chapter, the student should be able 10:
1. Describe the process of hematopoiesis.
2. Explain how hematopoiesis is regulated.
3. Explain why hematopoietic agents are often administered to patients
following chemotherapy or organ transplant.
4. Explain the functions of colony-stimulating factors.
S. Classify types of anemia based on their causes.
6. Identify the role of intrinsic factor in the absorption of vitam in B".
7. Describe the metabolism, storage, and transfer of iron in the body.
8. Describe the nurse's role in the pharmacologic: management of
hematopoietic disorders.
9. For each of the drug classes listed in Drugs at a Glance, know
representative drugs, and explain their mechanism of drug action,
primary actions, and important adverse effects.
10. Use the nursing process to care for patients who are receiving drug
therapy for hematopoietic disorders.
folicacidffolate (X1IJt399
heITliltopoiesis fIO'It m
hemosidrrin Jl1Jt 399
intrinsicflctor paJtJ98
pemicious(mr galoblastic)lnrmia (X1IJtm
stem(fn {IOtItNJ
thrombopoietin (JO"/t 397
transferrin fIO'It 399
LibraryPirate
390 UnII4 TheC.rdloY.<;(ubr ,nd Urinary Sy""'"'
T
he blood serves all other cells in the body and Is the only
fluid tissue. Because of its diverse functions, diseases af-
fecting blood constituents have widespread effects on the
body. Correspondingly, drugs for treating blood disorders
will affect cells in many different tissues. This chapter will ex-
amine medications used to enhance the functions of ery-
throcytes, leukocytes, and platelets. Pharmacology of the
hematopoietic system is a small, though emerging, branch of
medicine.
28. 1 Hematopoiesis
Blood is a higWy dynamic tissue; more than 200 billion new
blood cells areformed every day. The process of blood cell for
mation is called hematopoirsir, or hemopoiesis. Hematopoiesis
occurs primarily in red bone marrow and requires B vitamins,
vitamin C,copper, iron, and other nutrients.
Hematopoiesis is responsive to the demands of the body.
For example, the production of white blood cells can in
crease to 10 times normal in response to infection. The
nwnber of red blood cells can increase as much as 5 times
normal in response to blood loss or hypoxia. Homeostatic
control of hematopoiesis is influenced bya number of hor-
mones and growth factors, which allow for points of pharo
macologic intervention. The process of hematopoiesis is
illustrated in .. Figure 28.1.
Hematopoiesis begins with a sum {ell, which is capable of
maturing into lInytypeofblood cell. The specific path taken
by the stem cell, whether it becomes an erythrocyte, leuko
cyte, or platelet, depends on the internal needs of the body.
These needs are transmitted to the stem cells bywayof hor
mones and other regulatory substances. These control sub
stances include erythropoietin and chemicals secreted by
leukocytes known as colony-stimulating factors. Through
recombinant DNA tt'l:hnology, some of these regulatory
agents are now .available in sufficient quantities to be used as
medicatioIl'i.
PHARMFACTS
Hematopoietic Disorders
A pmjnant woman', body 45% blood b.iUIl' it {ontains
nlllritnuand oxygtn for fetus.TIIt in blood
procb:tion around Wffk 20 of prl'gnanq.
A dtficitnc:y ofvitamin vitamin S. may tht blood
amino acid found in blood.An
elevattd blood IrwI of OOlllOC"fSteilH.' a risk factor for hun dMill' and
,"".
VtgI'tanans who do not rat IIII'm,mh, or milk products arl' . t
high risk fordewloping vitamin H" Vtgmrians may find
adtqwtt amounts in fortifuod (moals, rutritional suppltllll'nts,or
of fol ic acid during Jlrl'9nancy Iw found to It'(]UCf
n!'Ural tube birth dmas in newborn.
HeolV)' mtnstrual ptriock may It'IUk in ronsiderablt iron loss.
ma,,,,w
D
Megakaryoblast Leukocyte Erythrocyte
I
atom ""U stem ""U

Th"'mbopoielin Colonystimutating
tlllorieo.A<intt
..
!

" ..
.-

'.-
0" .......
a
c
-.
Platelets Macrophagos Erythrocytes
.. Flgure28.J Hematopolests
The management of hematopoietic diseases often in
volves simply replacing a deficient substance that is essential
to hematopoiesis. In some cases, the drug is identical to, or
very closely resembles, the deficient factor. For example, the
drug epoetin alfa (Epogen, Procrit ) is identical to the natu
ral hormone erythropoietin and stimulates the production
of r .. d blood cell. in the same manner_ As another example,
administration of antianemic agents such as ferrous sulfate
or vitamin Bl1 supplies factors that may be deficient in some
patients.
Some of the hematopoietic drugs h.we become important
adjunct medialtions in the treaunent of alncer. Antineo
plastic drugs often are toxic to bone marrow and cause dra
matic reductions in circulating erythrocytes, WBCs, and
platelets. Hematopoietic drugs may be used to boost blood
cell counts in these patients.
HEMATOPOIETIC GROWTH FACTORS
Natural hormones that promote some aspect of blood for
mation are called hematopoietic growth factors. Several
growth factors, shown in Table 28.1, are used pharmaco
logically to stimulate erythrocyte, leukocyte, or platelet
production.
LibraryPirate
01 .. 11.,21 DN9' for Hem.topol"Uc: D""rders 391
TABLE 28 1 Hematopoietic Growth Factors
On"
Routeand Adult Indicated)
__ "",",", .. , 1 .. '"'......"V ...
Adverse Effects
Go) Proott) ulllu/kg/dolo! mrte Iimts/wt, Uiualy
lPlpirory irrtKIiOll, tdemo
I "" .. "'f .......... ""'_ ..
st.vung WIth 50-100 IIInsAgldw 1'rg!T of
he.!! [)ilu[t MI
16%) by mort
th.n ku POlnll In'ny 1.-wk pmod
COLONY-STIMULATING FACTORS
Go) rdgraslin !HtuplHJftl): IV; 5 mc:g.t:91dolY II!' ilflllion,may irKrulo! by 5 mc:gikgldoJY fMikll)'!Idnlmt, fmor,rlilpl1fQ, 1lfUlf4 M1miTifl9,OOIN'
gr.IIJIocytKSF (max:10 Smc:glkgldayslb.:lItlnfOlJU' dolo!, pon (J/lrgromallimJ
may inuulo! by 5 m(9lbjlday (max:l0 mOj/bJlda,1
Boot pain . rJhralgia.ltwml:!oqtpw!'.Ml!ltO!lS
ptqfilgmtim mg PfI' difmothft.p)' tydf .llfall14 h .flft
IIfIit.ullil ef!wi!lo
dlfmOlheiaP'l' uOOKl@(yusramoiml
(llutilN'j: 1V;15O mc:g/IIWdll inlultd Il'Ift 2 h for 21 btgin H h afttr
boot m,rrowtrinsfulion.nd oot Its:! thin 14 h.ftfr dolo! of
dlfmotheiaP'l' or 11 haftfr LtIt racli.tion IheiaP'l'
PLATELET ENHANCERS
oprrl'lrlin (NfIIIIIf9i) SulKutarItOUI; SO m(gikg OIKI' daily 51,ning h.ftfl fdtmq, fwlr, lrIadodIf, dilIilN'S'l, dylplN'Q, foriqIJI. ralh,
(ompleting difmother.p)' for 14-11 11111 pIiIlfie'l (OIInt
OO!MI,
at ltallSO,OOOJmd
fllrombopag (f'romau.) PO; SO mg OII(f daily (max: 75 mglday)
rompJoltim (HpI.le) 1 mc:g/bJ (mal; 10 m(9lbj/Wk)
IIQIio ilKkaTt ammon idmse Sfriousadwl'lo! fflfaS.
28.2 Pharmacotherapy
with Erythropoietin
The process of red blood cell formation, or erythropoiesis, is
regulated primarily by the hormone trythropoietin. Secreted
by the kidney, erythropoietin travels TO the bone marrow,
where it interacts WiTh receptors on hematopoietic stem
cells with the message to increase erythrocyte production.
Erythropoietin also stimulates the production of hemoglo-
bin, which is required for a functional erythrocyTe.
The primary signal for the increased secretion of erythro-
poietin isa reduction in oxygen reaching the kidneys. Serum
levels of erythropoietin may increase as much as 1,OOO-fold
in '"""pon", to ",'vere hypmria_ Hemorrhage, chmnic oh_
structive pulmonary disease, anemia, or high altitudes may
cause this hypoxia.
Erythropoietin is markeTed as epoetin alfa (Epogen, Pro-
crit). Darbepoetin alfa (Aranesp) is a newer agent thaT is
closely related to epoetin alfa. It has the same action, effec-
tiveness, and safeI)' profile; however, it has a two to Three
times longer duration of action that allows it to be adminis-
tered once weekly. Darbepoetin alfa is approved for the
Treatment of anemia associaTed with chemOTherapy or
chronic renal failure. IT should be noted that when given as
an adjunctive agent in cancer treatmenT, the anemia must be
secondary to the chemotherapy, not the cancer itself. Re-
search has shown that the administration of these drugs
T,(h)'{,Jrdi. ffbri lt nMroooi . plein! fffusion.
arul dia,is
h llrQIgio. mydrjo, pIIrtllhtlio, irmmnio
Boo!: ma!JOW"fibrO$iutromwmboliwn hrmalologi(
{fltrornboo')(]i
LIFESPAN CONSIDERATIONS
Epoilltin Alta as the NlllwUBlood Doping"
"Blood doping. withdr,.,.ing blood from.n aThlell'.nd then rH"osiusing it
befort' a (ompelitift sponing has befn used bysoll\t nhlell'l in <I n at
tempt to g.in a (OIIIpelitift tdgt. With RBCs .nd hightr hemoglo-
bin, thf oxygeIl-urrying ('J)a(iry of tilt blood is thought to boosting
endu"IKe. Bmll'lo! the blood ustd is the athldf'S <Mn, drug
!(rt'I'ning do6 oot dtTtr:t folfign drugs or sulnu nm. Chal'9f1 of blood dop
ing diffiruh to btuuse uhlell'l an boost RBC.nd hflllo,
globin Itftk by tr.ining at high 'kitude, whi4:h stimul,1l'I ROC produ(\ion.
Blood doping. mIneS with. prir:t.Thf blood wiume ,nd
moosity holft led to hyptrll'OSion, thrombosis,.nd dtnh.
Blood doping hiS dianged with The milability of <l1f . Bfrall'lo!
epoetin nimulate RBC prOOxtion, the aThletl' to withdraw less
blood initi<lll, .nd then rt'ly on fpoftin to boost RBCs r'len mort' POII-
rt'tr.nslusion,of fportin may be u!o!d .Ione. BtraUSf it mol)' be used Wffkl bIo
a sporting drug.nd sublt'lKf Il'Its m,y again bIo nf9iTiw!. The
physi4:'1 (onlfqUfllctS of blood doping !lKh II hjoprrll'OSion, thrombosis,or
dtolth rt'mlin. AdoltKfnts panir:ip"ing in (OIIIpelitift sports oKtil'itif's may
<lutmpt to fmulatf profesiorwlsports figurt's or may h.Y\' hf,rd about fPO'
tlin and question its adYanl'gtl The IIJl'lf kty role in providill9 oKW.
r.1l' info!Jllolnon <lbout fpoeti n and (ounseling <ldoies'nts .bM the riskl
.nd adYl'l'lf fPOflin or .ny OIhersporu.enhanr:ing drugs.
does not benefiT patit'nts when the anemia is caused by the
malignancy; in fact, mortality is increased in these patients
by the administration of the drug.
LibraryPirate
392 UnII 4 'It" C.,dkIY.",ub, .nd U,'nary Syne<m
..,. Prototype Drug I Epoetln Alfa (Epogen, Promt)
Therapeutic (lass: Drug for anemia Pharmacologic (lass: Hematopoietic growth factor,erythropoietin
ACTIONS AND USES
Epoetin alia is mille through rtlombinant thooloqy . nd is functionally
idmtiul to humin BecalM of in ability 10 stimulate etythro-
poirlis, iili. is tffrctive in tINting disorders cat/ltd by rItticierq in
red blood formation. Patients with chronic II'nal failull' often canoot secn!'te
l'IIough endogell:llls and btotfrt from epoetin administration.
fpoetin is wmetimes gil'fO 10 patitnts undergoing cancrr chemotherap)' to
counteract the ak'Olia uUSfd by .ntioeoplillic .gtnts. k is occasionally pre--
scnDed for j)atil'llu prior to blood transfusions or SUlgtry,.nd to tll' at anemia in
H IV-inftaed patifflu. Epoetin alf. is usually .Jdministered by tilt subcutaneous
route th times per Wffk until. theraptUlic II'Sponst is oKhieed (usually 2 to
6Wffks).
ADMINISTRATION ALERTS
The suocutall!OUS nxlte is gtoerally pn!' ferred IV, since IooMr all'
I"ftded .nd is slower.
Do oot shake the via l beca!M this may dtacti'late tilt dlll9. Yrsibly insptd
the IOkrlion for paniculate matter.
Plf9nancy cattgory (
PHARMACOKLNETICS (SUBCUTANEOUS)
()JSft 7- 14days

h
Duration: Unknown
ADVERSE EFFECTS
Epoetin alia haslnl' ral FDA bond warnings that indudt tilt fol 'a.ving:
The dlll9 may inclNse the risk of II'rious wdiomrulu nffits, throm-
boembolic mortality.
The dlll9 may shorten survival time and promoll'tumor progression in p.-
tifots with certain cancers sud! as bn!'ast, cervical,. nd lung CI nm.
The druq may incll"lI' mortality and II'rious urdiomrula, tl'fOts in pa-
tMoots with chronic II'nal laikrn!' .
The dlll9 may incll'.!II' the risk for deep vein thrombcr;is (DVT) in
perisurgel)' patients not rtleMn9 antic:o'lJllant prophylaus.
H)'p!'nemion may occur in as many as 10% of patients II'criving the drug,
.Jnd a conrulft' nt .ntih)'p!'nensive dlll9 may indicattd. Other ad-
efFects include htacbcht, fem, nausN,dianllt., and edtllY.
Patifnts taki ng epoetin .J Ifa who all' on dialym nwy n!'quire ilClI" ltd doses
of heparin to m.Jintain adf<JUiIf anticoagulation. Transitm ischemic att.cks
(nAs), hun attacks, and strokes 11m occurred in chronic II'nal lailure paritnll
on dialysis being trmed with epot1in all .
The efFectiveness ofepot1in will be 9,e<ll1y rtducrd in pa1itnts with iron
dtrKMoncy or other vitamin-dtplettd statH. Most p.tMontSll'Cti"l' iron supple-
ments during therap)' to compensate fo, tilt incn!'.!II'd rro blood rell produnion.
Contraindications: Contraindications indudt uncontrolled h)'pfrtl'llsion, and
known hypersmsitivity 10 m.Jmmalian [ell produru.(all' must I;e taken not to
.Jdminister Ha 10 paritnts with myeloid nwlignancMoslIJ(h as lIl)'eiogt-
nousleuktmia beca!M the dlll9 nwy tumor growth.
INTERACTIONS
I)ug- l)ug: 1'-aft' with ilia.
lab Tests: lktnown
IIorbovr 00:1: Unknown
of Dmdosr: Ol'ffiloll' may lead 10 (too nwll)' f ry-
throcytes), which can COlll'<1ed by phlebotomy.
RtI'tr 10 My/UsJni}Kl (Ix Q MIsbIIJ PrIXt55 fools spK/II( IrIIM iJ"ug.
NURSING PROCESS FOCUS PATIENTS RECEIVING EPOETINALFA
Assessment
Billfline assess mnt pri or to administrati on:
Under>tlnd tlltre'lOn tilt drug has bren prescribed in order 10 asSl'll; for
ther.peutic tffiru (e.g.,anemia srcondary tochronic ,enal folikr n!',cance,
1I1'atment.!.
Obtain a complete lItalth histol)' including mdion scular (including HTN, Mil
.nd periphe'oIl'.Jl[ular (induding prfYious pulmonary
embolism), nf\I\Jiogic (including (VA), or hepatic or II'n.J I disrast. (lbta in a d rug
history inckrdinj .IIeJllies,rulT!'nt prt![ription. nd ore drugs, htrhal
preparations, lid alcohol !M.St alen to possible drug intmctions.
Obtain baSl'lineWfight and l'italsigns, especially blood pll'SSUII'.
[nlune .ppropriate laboratory findings (e.g., (II( aPTT, IHR, tri nsff rrin .nd
II'IIIm ferritin kY!'k,II'II.1 and liver function studies).
Potential Nursing Di agnoses
loefitclivr TissUl' Perfusion (rtlated 10 underlying disordef)
InlOler.nce (related to underlying disorder)
FaDgUl' (1I'1attd to undtrlying dilOrdtrl
Deficitnt Kna.vledgt (dlll9 tlltrapy)
Risk for Injury (1I'lattd to oId'lelll'drug efftru)
LibraryPirate
00..,1<' lS DN9' for Hematopolelk Disorder, 393
NURSING PROCESS FOCUS PATIENTS RECEIVING 'POETIN ALFA (Coo',,"',
Assessment
Assess ment thro ughout ildministrati on:
Continue 10, tlltraptUlic effects (e.g., Hct, RBC (ount signif"iI ndy
implOVfd patient's oKtiYity general seru of'M'lI-bting hill impl"l)Yed).
Continue monitoring of appropriate lab 'laluts (e.g., CBC,aPTT.INR).
tspedall)' blood prtIlUfI',during tilt first 2 wrt'ks
oftherap)'.
Asltss 10, adverse effects: HTN, lItada(ht,neuroiogic (hilngts in lenl of
(omOousnffi or signs and symptoms of seizu,e oKtivit)',angina,
signs of thrombosis deYcloprnent in peripheral ntremities.
Potentii!ll Nursing Dii!lgnoses
Planning: Patient GOi!ll s i!lnd Expected Outcomes
The patient will:
uperie-rKe tlltrapeutic effects dtpendem on the 'filIOn the drug is gr.tn (f.g.,nperience incrust in oKtivity fevd less fatigue and shortnffi ofbreillh
onljlenion).
from, 0' experienct adverse efftas.
Verbalize an un&manding oftlltdrug's UIf,adverse efferu.and f1'qJirro prl'(lutions.
Demonstrate proper stIf-idministmion of the mediGition timing, when to notif)o provider).
Implementati on
Interventions and (Rati onales)
Ensuring tht rilpeutic effects:
Continue iIIlNments ill ilboe for therapaJtic: effects. (RUC (ount
inuNsI"I rapidly in first 1 weeks oftht rapy.C8( and platelet (oum should show
(ominued improvemmt Blood plffiufl' and pullf should remain within normal
limits or within parom<I<r> ,," by 1110 h<.kh cor. p ...... k.J
E ncoorol<jt adeqwl\' perioIk and adequatt fluid intlke. (The patient may be
signiflUntly fatigued due to low Hbg and H{lAdeqJate fluid intlR helps
maintlin adtqUilI\' lkJid ill Hct levels
Minimizing adft rse effKts:
Continue to monitor for adverse effects, HTN, peripheral thrombosis,or
Ifizurt' ictr.ity.(A> Hct rapidly ifl{rt'uI"I during tilt first 1 weKS of thtrapy, HTN
or Ifizurt's may ocrur. Peripheral thrombosis, in{Uding (oronaI)' or may
akooc:rur.j
Asltss mnspormion needs of the patient and wer to appropriate rt'sour(tS is
nffiled.(Driving may be up to 90days after initiation of drug
Continue to monitor am priorto dialysis in patienllwith chronic renal failure.
(The he",rin may need to be as tilt Hct incrt'lI6)
Wlltn to prern.lturt' infams,IM prt'IfMlive-frre fonnulations.
(Epottin may (omain pft'lflYuim slKh ill benzylakohol, which may (11M
MiHal galping syndrome.,
Encoorol<je adeqwl\' diml)' intake of iron, folic ac:id,and vitamin B".Provide
dietal)' (onsult" needed. Consider nutritional IUppltmmts ofthest nutrients ij
tilt diet is rtSpllllf to epoetin ilia miy be dtmaled ijblood
IeYeb of iron, fol ic oKid, and itamin Bu are deficient)
Pi!ltient i!l nd Fi!l mily Educati on
Inmumhe patient on the IlffiI to retum freqJemly for follow-up
labwork.
Encourage tilt ",tient to rfit wlltn fatMJied and to space i ctivitil"l
throughout the day to allow for idtquate rt'St periods.
En(ourage inuke of water and non-hyperosmolar beveril9!"l.
TNCh tilt or how to monitor pulsr ilnd blood
prt'SIUft' ill iI pproprial\'. Ensurt' the proper 1M and functioning of all)'
horne tquipmrm obtained.
InllnKt the to report he.Hbc1lt (espKially
ij 5Udden onset or It"Vtft'j,changr-s in of {onsciolJllII"Is, WI'iIknI"Is
or numbness in IjItrt'mities,or pft'monitory signs of Ifizurt' ilctivity
(e.g., aura), angina, orsymptoms of periplltral thrombosis (e.g., leg
pain, ",Ie ntremity, diminislltd periphml pulsl"S).
Advise the patiem to (onsult with the health (1ft' provider about
driving orother hillan:lousactivitil"l duringthe first It"VfIiIl momhs of
drug therap)'.
uplain any chalHj!"l in medication routine to the patient and provide a

To allay anxiet): offer part'nt> rationales for all provided lor
the infant
TNCh tilt patient to mainu in a heakhyditt with adequateamountsof
iron,folic ac:id,ilnd vitamin B" (f.g. found in 1IINts, dail)',rggs,
Iortified (eft'als ind green vegeubles, citrus fruits.dried
beans and peas).
rContlrnJedj
LibraryPirate
394 UnII4 TheCJrdkIY.",ubr . nd Url",,'Y 5y11","'
NURSING PROCESS FOCUS PATIENTS RECEIVING EPOETINAlFA (Conflnuwl
Implementation
Inte rventi ons a nd (Rati ona les)
Patient undentanding of drug therapy:
Use opportunitifs during adminisuation of IIH' dic.itions and during . ISmllH'ou
to discuss ratiollllit fordrug thmpy,desirtd OU\(OIlH"S, IlIOIt
oommon for to oolily health (il1l'
. nd lII'{rswry monitoring or preuutions. (Using time during nursing ('Il'
help, to and kry te.Khing
Pati""t .elf-admini. trati on of drug therapy:
When . dminiltering lIH'<Iiutions,instllKt the Of ('Il'gi!'r in
proper rrH-administr.nion IoIIoWfd by return deroonstmion.IProper
.dmini5lr.llion inuNm tilt drug.) Proper tr<hniqU!'
indudes:
i.J1 should lit gendy routed to mill contents and 1II'!'f shakrn. Viah.re
kept under refrigmtion .nd ,hould lit in the hand
All i.Jh are for OIII' -tillH'!M and any remaining amount should lit
dilurded.
II indWl'lIing subanantOlll 10ft (e .g.,llIIUfIon soft !athrler), the
family, or Llll'giver should lit taught a pproprull' site inrrrtion
te<hniqut as !{hl'dult for rotolling sites.
Pati e nt a nd Fa mi ly Educati on
patient should lItabk to state INIon for the drug. . ppropri.J1l'
and Nfem to 00rr1ft for and whrn to
report;.nd the anticipaled length of medicalion thffilpy.
Teach the famiiy.or in proper IfII-administration
10ft mheter (e.g.,lnsul\on 10ft wheter) is
IrIt in plm for injtions, teach the patient the proper ofthe
uthrler, and any I(heduir for rotating ,ites.
Ha!' tilt lamily,orcarrijmr Il'tum-deroonstrall'
until me proper iI UIed .J nd all' {omfomblt giving the
injection.
Evaluation of Outcome Criteria
28.3 Pharmacotherapy with Colony-
Stimulating Factors
Regulation of white blood cell (WEC) production, or
leukopoiesis, is more complicated than t'ryIhropoiesis be-
caust' there are difft'rent types of leukocytes in tht' blood.
Pharmacologically, the most important substances
ling production are {olooy-st imulating factors ICSFsI. Also called
leukopoit'tic growth factors, the CSFs comprise a small
group of drugs that stimulate the growth and differentiation
of ont' or more types of leukocytes. Doses for these mt'dica-
tions are listed in Tablt' 2B.I.
When the body receives a bacterial challt'nge, the produc-
tion of CSFs incrt'3ses rapidly. The CSFs are active at very
low concentrations; each stt'm Ct'll stimulated by these
growth factors is capable of producing as many as 1,000 ma-
ture leukocytes. The CSFs not only increase tht' production
of new leukocytes, they also activate existing white blood
cells. Examples of enhanced functions include increased mi-
gration of leukocytes to the bacteria, increased antibody
toxicity, and increased phagocytosis.
CSFs are named according to tht' types of blood cells that
ther stimulate. For example, granulocyte colony-stimulating
factor (C-CSF) increases the production of neutrophils, tht'
most common type of granulocyte. Granulocytelmacrophagt'
colony-stimulating factor (GM-CSF) stimulates both neu-
trophil and macrophage production. The process of identify-
ing the many endogenous CSFs, detennining their normal
functions, and discovering their potential value as tht'rapeutic
agents is an emt'rging area of phannacolo gy.
Tht'goal ofCSF pharmaotherapy is to produce a !"lipid in-
crease in the number of neutrophils in patients who have
suppressed immunt' systems. CSF therapy shortens the
length of time patients are susceptible to life-threatening in-
fections due to low numbers of neutrophils (nt'utropt'nia).
Indications include patients undt'rgoing chemotherapy or
receiving bone marrow or stem cell transplants, or who have
certain malignancies. By raising neutrophil counts, CSFs
can assist in keeping antineoplastic dosing regimens on
schedule (and more rlfective) .
Fil grastim (Neupogen) is similar to natural G-CSF and
is primarily used for chronic neutropenia or neutropenia
secondary to chemotherapy. Pegfilgrastim ( Neulasta ) is a
form of filgrastim bonded to a molecule of polyt'lhylene
glycol ( PEG). The PEG decreases the renal excretion of
the molecult', allowing it to rt'main in tht' body with a sus-
tained duration of action. Sargramostim (Leukine) is
similar to natural GM-CSF and is used to treat nt'utropt'-
nia in patients treated for acute myelogt'nous leukemia,
and patients who are having autologous bone marrow
transplantation.
28.4 Pharmacotherapy
with Platelet Enhancers
The production of platelets, or tltromboqtopoiesis, begins
when mt'gakaryocytes in tht' bone marrow start shedding
membrane-bound packt'ls. These packt'ts enter the blood-
stream and be.:ome platt'lets. A single megakaryocyte can
produce thousands of platelets.
LibraryPirate
0Up1tl2S Drugs for Hemilopolefk: 39S
po, Prototype Drug I Fll grasnm (Neupogen)
Theraptutic (lass: Drug forincrnsing neutrophil produdion Pha rmac:oIogic (lass: Colony stimulating fador
AalONS AND USES
Filgmtim is G.(Sf p/OdlJ(ed thlllugb ItM1Ibinotllt ONA te<hnoiogy.1tI
two primiry .ctions 10 neutrophil prOOlICtion in 1M bone marrow
inc! to the phi9OCY1K .00 {)1otoxic fulKbons of txisling roeutrophils.
This is particuLlltt important for with neutl"Opmia.which often is as
sodiled with .00 fufl9il inftctions. Administliltion of tilgras-
tim will the length of time of JleUtJopeJlii in pnienn
bont marrow hn by anlinroplastic Igffttl Of in p.atienlS fol-
lowing malTOYl or stem h may.!so be used in pititnn
with AIDS-related is idministertd wban.JltOUIIy Of '"

ADMINISTRATION ALERTS
Do not admin&erwithin 24 hours btfmOf dlMIOthellPJ with cyto-

Prtgnancyutl!gory(
PHARMACOKINETICS ISUBCUTANEOUSI J
Onstt.:. h
P9:2- 8h
Half-lilt:lS h
DlI'ation: 1 wk
ADVERSE EFFEaS
Although filgr;mim is wtli toltrattd, tbt dl1J9 is associlttd with potCllti.J11y If-
rious idwr..e fffKtS ind clost monitoring is piin miY o(aJr in up
to 1J9Io of pat1ttllS If(tjying tilgliIstim.A small ptltl!fltagt of pititMS may !It-
an allelqic FrtqUl!flllaboratory Itlts al1' 1Il'Ss.ary 10ellWI1' that
fX<tSsivf IlUmbtrs of nMlllphib, or leukocytosis, dots not O((\Ir. leubxyte
(000\5 hi9her rNn 100,000 mls/mml ilKrwt lhe risk of Ifrious .dlfml! ri-
ftru wch is I1'Spimory failul1', intracranial hemonflagt,l1"Iinal hemorrhage,
<lnd MI. rupturt of the !ws OIJrrtd in a lIIIall ,...mbtr of pititnts..
Contraindiations: Tht only (ontraindiGItiOll is hyptflfnsitiYity to f. aJli pili
INn "'is mKrobt is II!td to ,MIKe thf If(ombillilnl drug.
lNTERAalONS
Drug-Drug; 8fCiUse ilIl!illtOP6ti: dllI9S and b<t0l5 prodIKf
oppoIitf rJrKl5,rqaitim is IIOIDninistfflld iIIltJast 241Hu51fifr a
!tIlion.
1.1. f the IoIIcwilg maybtincrNsed:lMocyttalilnt pMpIWst,
wn.m alt.JlN nI LDH.
Hl'lbillIFoot Untnown
fheR is
1Ir.., tI /rtyNrNlJIIgIOt frx, Nun/III) I'IIxm ffKJJj ipfdk *' this d1IJ9.
NURSING PROCESS FOCUS PATIENTS RECEIVING COLONY STIMULATING FACTORS
AsseS5ment
Baseline tlSH5Imtnt priorto 6dminhtriltion:
Undtnlind IIIf the has betn prNribtd in order to for
IflfrlpMic riFects It.g., neu\lIIptnia. h!ukopmia, se<ondary to(ifl(tf
UNtmtnt, HIV, post- bone marrow transplanlL
Obuin i complete heilth history irKb:ling or Clllltllt infections,
wrgI! rit1, injuries or 'Mllinds, )'9st infections It.g., tlwsh), vHcinitioo histOf)",
c.udiac conditions If.g.,dyrhytllmias, (HF), or I1'spirKOf)", I1'IIoIl,uld htpatic
<I drug hislory including pMplion <lnd
Ol( drugs. hefbal Pftpilillions,.ndakoilolust.Be.lerttopossibledl1J9
inltQ(lions.
Obtain iwltlinf "Wti9ht Md vi(.Jl5igns.AsstSllevtl offatilJ.lf.
Evaluab! appropnm wbOfatory findings (e.g.,(BC, WBC 01 absolutt neutrophil
count [ANell, JMlI.nd liver function nudil'S, uric acid 1fflk,;tAd Wi.
[ANe = TOIiI WBe counl multiplied II, 1M IOtai ptf{emq of nMrOpililis
(segs pUs b.inds); e.g.,WBC 5000 X 10.45segmentedneutlllphih + 0.05
= SOOO X 05 = AH(oflSOO.]
Assess mtnt Ihra.ghout adminlstratlon:
(Olltinut oJIleSsmcnt for tMlilptUtK dfe<ts (t.g., (BC <lnd WBC 01 AN( has
no signs 01 symptoms ofini.tion).
(Olltinut monitoring of .pproprialf lab valutl {t-9. (Be, WEI( Of ANe,
Ket, pblfh!t (QUnt, ren.J1.nd hepitic labs, uric oKid 1MIs).
Monitonilil sig ns and It'ftl of fatigue.
Assess for elfects:bollf pain {tspially Iowtr bid, posterior iIiH
and sttmum), fever, IIiIlIIfl,anortxia, hyptruricemia. _mil, Sf Mprtlsion on
E(G,angina. rtspiratory diststS!, and allergic: rmtion.Continut 10 alleS! for
infection . 00 rtlol\ed to tmtment (t.g.,chnnolMlilpt).
Potential Nursing Diagnoses
Anxitty {rtbttd tocolKems ibout stRoUSIItSI of undtlJying
insufl IKtlfini lKill (OIKe!llS)
Ftar {l1'wted 10 concuns aboot seriousntlS of undtrlying disoldtt;
(OIKems)
N.tMly (rmltd 10 disonltl Of drug treatmtnt
of disorder)
Filigut (mated 10 underlying disorder Ofdrug tre.lmenl of disorder)

Risk for Infeclion Irmted \Co undffiying disorderor drug tltilment of
disordtr)
Riskfor Impiirtd Ofll MIKOlII hbrantl (related to drug treatmtm
Of dilofder)
Risk forurtgiottr RoIt Straw. (family ... d
(Comrnued)
LibraryPirate
] 96 UnII 4 Th"OrdkIYa",ul.r and Urinary Syne<",
NURSING PROCESS FOCUS PATIENTS RECEIVING COLONY-STIMULATING FAOORS (Continued!
Planning: Patient GOllls lind Expected Outcomes

ExpentlKt tfftru dtprndent on the It'aIOII the drug is being giYeO (t.g.,oprntncr inumt WBUAN( no signs or s)'Illptoms ofinfKtion).
St fire irom,or experiencr minimal,,,I"lerst rifKlS.
VMlalino an understanding 01 the drug's u:;t, oJd'Ierse tfftru, a nd Il'qJil1'd Pll'Uutions.
DtlMllstralt of the rnMiution (f .g.,do!t, timing. when to nooft pfOl'idtr).
Implementlltion
Interventi ons li nd (Rllti onales) Plltient li nd Famil y Educllti on
Ensuring theril peutic effeds:

ContinUl' flrqJem olS:iI'S!IIItrru illCienribN til rlitr for tilmptUO( tfi'KlS. (A Instruct tht piltitm on the nffil to ll'Iurn for IoIIow-tJp
1M in WBC and! or AN( (OIln!; will dtpend on condition uMm, e.g., dtpth iI nd lab work.
I!ongth of nadir from cytotOXK cherrothelapy.)

En(Oll"gt adequate I1'st ptriods,nd adeqwtt lkJid in"kt. (Patient tna)' be r-:--&; OUragt the pilDentto It'5t when fatigued and to spiKt oKtMtits
fil tigued dtJIo to the dfllCj therapy ror the distil:;tcondition. throughout the to allow for ,dtquatt I!1t ptliock.
Adtquatt ftuid int,kt helps mainlilin adequatt urina!)' output and prtVrm
ElKouragt the inlilkt of w.ttl" and non-hypemmolar bel'e<ages.,nd
UTk)
drinking WMntI'e<
Minimizing effects:

(ontinUl' to monitor for ,mr:;t tffKu: pain (esptCwliy lowtr buk, Instruct tht piltitm to It'port il lI)' Stfflt' _ pilin not by
posttrior ilwc mm, and IIt mum), nalM', ,nomiil, hyperuricemia, nonnaKotK anaiqeia.
,nemia, ST dtpmsion on ECG, angina,ll'Ipimory .nd . lltrgK
Teach the patitm to imrnMiattly I1'pon any pillpitations,diuill6\
I1'mion.Continut to for inlKtion il nd fatigue It' lattd to dfllCj
angillil,or dyspne,.
t.g., chemotherapy. (Bone pilin tt nds to IXcur 1 to 3 days prior to
Gout-prOlll' piltitnu should repon signs and of gout . nd
'; ;ft .. "'"""fWW,;" u
.. _ ....... ... .. y, ,y " .. .. y ... u-. ....... , ... u ... .....
inclt',u tiuid intake 10 enhanuo the rt nai f iimimion oi uric acid .
gm.m """",,sion on [CG may occur with pol.nli.1 for soriou.
dysmythm ws. RfSpiratory di surss may dtfflop a!ttl" tht .dm in i SUili ion of
s,rgramostim a nd should bto rtponrd immNiatt ly. caUIl'
goutlike conditions.)

Mainlilin m. tirulous inil'ction control measul!"!. Rtpon any !oigns and symptoms Instruct tht piltitm in hygitntand inil'ction control mt iisurrsllKh as:
01 inil'ctions ormer imrnMiatt ly. (TM piltient will cominue to be,t risk for Freqlll'llth;rndwashing.
infKtions umil WBClANC rist. OpportunistK inil'ctions sum as and
AI'oiding uowdtd indoor plac:rs.
virum SIKh as herprs maY lXcut will be!d by heil hh ('It'
AI'oiding peopl!o with known inIKtions or )'Dung childl1'n who h;rl'l' iI
proYicler for Il'pOning ftl'e<. e.g.. all)' ttmjlfraNIt' Ultl l005'F,dtptnd..,t on tht
higher risk 01 h.riing iln inil'ction.
underlying dill'<I:;tcond"rtion and dfllCj ther<lPY.)
CooI:ing food thoroughly, allowing thefamily or talt'9il'!'r to prt pal1'
r<lwfoods.nd to dean uP. but thr patitm should not consume raw
!ruiU or I'!'geIabits.
Tt,rn tht patifm to I1'pon lll)' ft'l er and symptoms ofinfKtion SIKh as:
wounds w"rlh redness or drainilgf. inclt'asing cough,ilKJNsing filligue,
whitt pilttoo on oral rrAKOUS and "rIchy aginill
dis<h;rrge. or blisttr-like l'!'Sidrs on skin.

Mon"rlor ECG jlfriodKallyfor ST stgmem dtprt'ssion or dysrhythmias ilnd I1'pon Team thr p,titm to I1'pon all)' diuill6\or angina
immtdialely. tna)' uuse !oigniliunt ST dtprtssion with potorlrial imrnMiately.
ror lfI"ious dysmythmias,npecially in piltients with prt'lious cardiac

Monitor for !oigns of dyspntil or rrspirato!)' distl1'lI. rspeciallywht n Ttach the patitm to I1'pon lll)' dyspne',lt'Spirato!)'
mompilnitd by OO)'Cardia and hypotension. and rt port imm.diattly. pillpiwions.ordiuiness immediately.
(Sargrarrostim may UlIII' It'Spiratorydislll'ss iIIgranuloc:yttcounts 1M,
r!pf(ially in piltimtl with prNxilting rnpiroltory dilordtrs.)

Mon"rlor for !oigns and symptoms of ,ll!orgK-type It'ac:tions.(Tht piltitm m,y be Teilch the patitm to I1'pon symptoms of ailergK INCtion SIKh as rash,
to proteins from E. cdi usN todtl'!'lop tM dfllCj.) unitil ria, whflozing.and dys Plltii immtdiately.

Mon"rlor hfPiIIK status during dfllCj adminisuuion period (Filgrmim may Instruct tht piltitm to It'port il lI)' signifium 01 ICl!orii
c,ustan tlf'l.tion in lim tnl)'l11l's.) or skin,darkenrd light or day-colored \lools.
LibraryPirate
01 ... 11, lS Oru9' for Hematopol"Uc 0"",<1"" 397
NURSING PROCESS FOCUS PATIENTS RECEIVING COLONY-STIMULATING FACTORS (Continued)
Implementation
Interventi ons and (Rati o nales)
Stop iidminimation whtn WBC (ounts IN<h IeYeI
(ii'" plO'lider.(FiIg,aniIlIllilY nopped ....t.en neutrophil loom, ft'ath
lO,OOO/mm'; wrg ... nonim II\a)' (ounts ft'alh
20,OOO/mm' 0' u ordeF.d by the laft' provider.)
Patitnt understanding drug thf rapJ:
U,e opponunititl duril g .dministr,tion of medimion, ,nd during
.,msmenu to di!(ul' tht for drug
Ol/llomts, mo>st (ommon .dverl<!' pmmt tt rs for wht n to (ilil tht
health (ilft' provider, ,rd nt(6 Wry monitoring or pft'uutions. (U,ing
during nursing help, to optimize .nd ft'infon:t ttl(hing

Patient selfadministration of drug tht rapy:
iidministering mlitations, instrllU family,or in
!el1-.dminist"loo ttdmiqU6 followed by ft'!Um dtmonmuion.
(Proptr iidminim,tion r.(ft'<lS6 tht of tilt drugJ Proptr
indude:
Viallhould to miHomtou.nd nffll kept
under rtfrigtr.tion aid genti)' in hand.
All vi.1s aft' U5<1'only and remaining ,mount should
dist.ardtd.
II indwt-lling lUocutntou, soft (t .g. Insuflon soft mheter) is!Md.
tht patient should ' ppropri,te ure, inlfllion u
'ppropriate,or I(iledule for rotating sites.
Patient lind Fli mity Educlltio n
patient.bout impon.nle 01 ft'tuming ft'gularly for bb

I.mily,or wtgil'!'r should to ,lait reason br
t.1t drug,iPPropri.lI'dosl' and I(htduling;what tffem 10
brand when to length 01
meditation
UlI'9im in proper I<!' H-,dminimation
t!lhnique. ,oft whettr (t.g.,lnsullon soft
ifft in platt for teath tilt or I.ft'giver thl
proptI(ilft' of ,itt , aO)' for rotlling sites .
f.mily, or laft'giver retum.oemonstratt
t!lhniqut until tilt proptr ttlhnique is !Md nd they .ft' (omforuble
Ijingtht injrdion.
Evaluation of Outcome Criterill
the drug tht"py by (onfirming that OlI(omrs hal'!' bfen mtI
Megakaryocyte activity is controlled by the hormone
thrombopoieti n, which is produced by the liver. Thrombopoi-
etin is not available as a medication, although it is currently
undergoing clinical trials.
The oldest and most widely available drug to enhance
platelet production is oprelvekin (Neumega) . (Produced
through recombinant DNA technology, oprelvekin stimu-
lates the production of megakllryocytes and thrombopoi-
etin. Oprelvekin is functionally equivalent to interleukin-\\
(IL-IJ), a substance secreted by ntonocytes and lympho-
cytes that signals <:elk in the immune system to respond to
an infection.
Oprelvekin is used to enhance the production of platelets
in patients who are at risk for thrombocytopenia caused by
cancer chemotherapy. The drug shortens the time that the
patient is thrombocytopenic and very susceptible to adverse
bleeding events. Theonset of action is 5 to 9 days, and ther-
apy generally continues until the platelet count returns to
greater than 50,OOO!mm' . Platelet COWlts will remain ele-
vated for about 7 da}'5 after the last dose. Oprelvekin is given
only only by the SC route. The primary adverse effect is
fluid retention, which occun; in about 60% of patients and
can be a concern for patients with pre-e:risting cardiovascu-
lar or renal disease. Visu,'Il impairment may occur during
therapy. Nun;ing care for patients receiving treatment with
op relvekin is similar to care for patients receiving the
oolony-stimulating mcton; for WBCs.
In2008 two new plMelet enhancen; were approved. Romi-
plostim ( Nplate) and eltrombopag (Promacta) are approved
to improve platelet function in patiems with chronic im-
mune (idiopathic) thrombocytopenia purpura (ITP).
Chronic ITP is a disorder characterized by inadequate
platelet production and/or increased platelet destruction.
Patients with ITP experience a high risk for bruising and
bleeding, which may occur anywhere in the body. Both drugs
increase the numberof platelets by activating the natural re-
ceptor for thrombopoietin. Eltrombopag is an oral agent
whereas romiplostim is given by the subcutaneous route.
ANEMIAS
Ant mia is a oondition in which red blood cells have a dimin-
ished capacity to deliver oxygen to tissues. Although there
are many different causes of anemia, they fall into one of the
follmving categories:
- Erythrocyte lo.ss due to hemorrhage
_ Increased erythrocyte destruction
_ Impaired erythrocyte production
LibraryPirate
"


!

398 UnII4 TheC.,dklv.sc:ub,.oo Urinary Synefm
TABLE 28.2 Classification of An"mia
Description Examples Morphology
MamKytiI: - 1IOIIIIIXI'Iomic:
Mi(f()()1k- h)'pXhromi(
Nonnocytic: - oormodlromic
Lugt. abnonnally shaptd rrythrocyte OOIInillltmoglobin
Small .bnorm.Jlly shaptd rrytlvocyte with lil'm'.t\td htmoglobin
0emKti0n 01 depletion of OOIInal rrythroblilSll 01 mat!R rrythlO(yte
i'fmiciolfi'ntmia, 'III'mi.
intmi . th.!Imtmia

CflI.ntmia, htmoIytic:.ntmia
Anemia is considered a sign of an wtderlying disorder,
rather than a distinct disease. For therapy to be successful,
the underlying pathology must be identified and treated.
28.S Classification of Anemias
Clar.sification of anemia is generally based on a description
of the erythIOcyte'5 5iz.e and color. Sues are de,cribed as
normal ( normocytic), small (microcytic j, or large (macro-
cytic). Color is based on the amount of hemoglobin pres-
ent and is described as normal red (normochromic) or
light red (hypochromic). This classification is shown in
Table 28.2.
Although each typeof anemia has specific characteristics,
all have common signs and symptoms. If the anemia occurs
gradually, the patient may remain asymptomatic, except
during periods of physical e:rercise. As the condition pro-
gresses, the patient often exhibits pallor, which is a paleness
of the skin and mucous membranes due to hemoglobin de-
ficiency. Decreased exercise tolerance, fatigue, and lethargy
occur because insufficiem o."t)'8en reaches muscles. Dizzi-
ness and fainting are conunon as the brain does not receive
enough oxygen to fimction properly. The respiratory and
cardiovascular systems compensate for the oxygen deple-
tion by increasing respiration rate and heart rate. Chronic or
severe disease can result in heart failure.
TABLE28.3 Antianemic Agents
ANTIANEMIC AGENTS
Depending on the type of anemia, several vitamins and
minerals may be given to enhance the oxygen-carrying ca-
pacity of blood. The most common antianemic agents are
cyanocobalamin (CaloMist, Nascobal), folic acid (Folvite,
olher,), and ferIOw; 5ulfale (Feo"",l, 0Ih"r5). TheM: agent.
are listed in Table 28.3.
28.6 Pharmacotherapy
with Vitamin 8
12
and Folic Acid
Vitamin B" is an er.senlial component of two coenzymes that
are required for actively growing and dividing cells.
Vitamin Bll is not synthesized by either plants or animals;
only bacteria can make this substance. Be.:ause only minus-
cule amounts of vitamin B" are required (3 meg/day), defi-
ciency of this vitamin is usually not due to insufficient dietary
intake. Instead, the most common cause of viI a min B" defi-
ciency is absence ofintrinsi: factor, a protein secreted by stomach
cells. Intriru;ic factor is required fur villlmin Bll to be ab-
sorbed from the intestine . Figure 28.2 illustrates the metab-
olism of villlmin B". Inflammatory diseases of the stomach
or surgical removal of the stomach may result in deficiency of
intrinsic factor. Inflammatory diseases of the smaU intestine
urug lIOUie and Adult tJoos!! (max dose where rndlCatedl Adverse Effects
qanocobillamin lCaloMi 5l, Hascobill)
I "'.., "'"._30 , f. 5-10 ... """,

IOO-200rtKg/mo
-
folbdd (FoIvitd roilM/lUooulII'ouS!1V; Ie! than 1 mglda,
IRON SALTS
ftrlOlJl fuma,att PO; 100 RIg tid orqid N=t4 '-1IIIIn. rorulipllrion, dork ltOM
PO; m...f.OO mg qid; m.y be gradU.!lIy irKrt,std to 650 RIg qid QirdilWa!(uia, (01101118, aggr.l\\ltion 0( U{ffi or
i! lII'fdedand toitrmd htDali< fIN'?Iis, (iron
PO; 7,0- 1>00 mglda, in 1- 3 dMdeddose
""""
IV; of S10 RIg followed by, !MIIId S10 RIg M

ron dextran (OnftfTIIII) 1MIiV; doll il individUiliztd and delermined from i table
supplitd by the drug manufoKlII"tflhatcornlate,body
to lItmoglobin \\Ilues (max: 100 RIg within 24 h)
Irdit< indir." rnm""", Mfmy offHr<;J..IldWi!iIIg.indir" ... Yriou< .dVH",Hf'rI<.
LibraryPirate
IF" factor
' '''-.,.,""
.. Flgure28.2 Metabolism of vila min Bu
that affect food and nutrient absorption mayalso cause vita
min B" deficiency. Because vitamin B" is found primarily in
foods of animal origin, strict vegetarians may require careful
meal planning or a vitamin supplement to prevent deficiency.
The most profound consequence of vitamin B" deficiency
is a condition called pernidous or megaloblasticanerniil, which af-
fects both the hematologic and nervous systems. The
hematopoietic stem cells produce abnormally large erythro-
cytes that do not fully mature. Red blood cells are most af-
fected, though lack of maturation of all blood cell types may
occur in severe disease. The symptoms of pernicious anemia
are often nonspecific and develop slowly, sometimes over
decades. Nervous system symptoms may include memory
loss, oonfusion, lUlSteadiness, tingling or numbness in the
limbs, delusions, mood disturbances, and even hallucinatiofl'i
in severe deficiencies. Permanent nervous system damage
may result if the disease remaifl'i lUltreated. Pharmaoother-
apy includes the administration of cyanocobalamin, a form
of vitamin B" (set' the prototype drug feature in this chapter).
Folicuid, or folate, is a B-complex vitamin that is essential
for normal DNA and RNA synthesis. As with B" defi-
ciency, insufficient folic acid can manifest itself as anetnia.
Th e QUfst ion: Doe folic: add rmuu the inddl'nc:1' of rubt rll'fKts if
takrn prior to pregnancy? It has for rlrurll's that
folic: idd rll'fic:iI'n{1 ruring th!o risk of Ill'Ural tuilt
rll'lKts in the IN'wOOrn,and that adrqua1l' amounu ruring
{.In rtduc:t th!o rill folic: id
protliYt> rffl if taken prior to pregnancy?
Th e Stull,: TIll' authors studies perfonntd siIKe 1996. Rl'learth
supporttd the (ondusion thilt folic: illid supplrmtnution ruring the
perKontl'ptional period did inrll'ed redUtr the risk of neural rubt rll'fKts.
Furthermort, supplementation with 0.4 mIg WilS not ilS!01Wtd with any
ilcivtlll'l'ifKts.
Nursing lrnpli tations: Hal/of all IRgnanc:ies illI' unplanntd.Thus, tht nurn
should folic ildd supplemr mation for all women with a
lI'aIOnablr poIsibilil)' of pll'gnancy.
5aru: Wt>lI" l, irtiloKlrltJ> K. Allltl M.&5)f 5 (lOO9). (of{ k1fI
fJt/t(/',:Ai1 !IpOOII>I1fllrtErldtm
fwllrtll.i PrMIrlIw 5tntt! ill.tflm. Anrlilll OI'lnternat IMdIdtli 15IJ:6J1--6J9.
In fact, the metabolism of vitamin B" and folic acid are in-
tricately linked; a B" deficiency will create a lack of acti
vated folic acid.
Folic acid does not require intrinsic factor for intestinal
absorption, and the most common cause offolate deficiency
is insufficient dietary intake. This is often observed in pa-
tients with chronic alcoholism because their diets are often
deficient in this nutrient, and alcohol interferes with folate
metabolism in the liver. Fad diets and malabsorption disor-
ders of the small intestine can also result in folate anemia.
Hematopoietic signs of folate deficiency are the same as
those for B" deficiency; however, no neurologic sigfl'i are
present. Folate deficiency during pregnancy has been linked
to neural birth defects such as spina bifida.
Treatment of mild deficiency or prophylaxis of folate defi-
ciency is accomplished by increasing the dietary intake of
folic acid by including fresh green vegetables,dried beafl'i,and
wheat products. In cases when adequate dietary intake catulot
be achieved, therapy with folate sodiwn (Folvite) or folic acid
is warranted. Folic acid is discussed further in chapter 4200,
where it is a drug prototype for water-soluble vitamins.
28.7 Pharmacotherapy with Iron
Iron is a mineral essential to the flUlction of several mito-
chondrial enzymes involved in metabolism and energy pro
duction in the cell. Most iron in the body, 60% to 80%, is
associated with hemoglobin inside erythrocytes. Because
free iron is toxic, the body binds the mineral to the protein
complexes ferritin, hemosidtrin, and transferrin. Ferritin and he-
mosiderin maintain iron stores inside cells, whereas trans-
ferrin transports iron to sites in the body where it is needed.
After erythrocytes die, nearly all the iron in their hemo-
globin is incorporated into transferrin and recycled for later
use. Because of this efficient recycling, only about 1 mg of
iron is excreted from the body per day, making daily dietary
LibraryPirate
400 UnII4 U'I .... ry Syne<",
.... Prototype Drug I Cyanocobalamin (Ca/omlst,Nascobal)
Therapeut ic Class: Drugforanemia Pharmacologic Class: Vitamin supplement
ACTIONS AND USES
Cj'ilnocobal.min is a purifif<i form of vitamin B" th.t is indiwf<i for patienu
with vitamin B" dtficiency anMlY. TlNtrnt nt is molt often by weekly, bi-
Wffkly, or monthly 1M or sulxui.ntous injtuions.Or.1 fit.min B" formul.tions
milablt primarily as nhmin supplemtntation,.hhough thty af"! only d-
ftctM in patitms who havt sullkitntamounu of intrinsic: f.aar.lnu.nasal
spray formul.tions ,milablt that providt for d.i ily (C.lominl ar OlUt-weekly
(Hallab.1) dosagt. Btuust ther intrana;al farmular:ions nhibit variatk.1I-
!OIption.nd bioavailabilit)', thty art ustd formomtRQrKetMrapy.1ter normal
vitamin B" ItYtIs w by part nttral
P.rrottral adminim.tion rapidly rntrses mon signs ind 5)"IIIptorm of B"
defKitncy,lISwlly within. bttn prolonqtd,
symptoms may takt to f"!lOm,.nd IOmt neurologk damil9l' may bt
permanentln most mu>! olltn bt m.inlaintd for the
del ollile patient's
ADMINISTRATION ALERTS
If PO mind with fruit jukH, administtr qukkly btuUSt
mDrbic: acid .IIM tile stability ofvilamin B,,.
Prrgnanq rnegory A (C when ustd
PHARMACOKINETICS
Onset: D.ys toWffks
Peak:8- 12 h (P01,1- 2 h (intr.n.san,ind I h (IV)
Half life:6day\
Duration: Unknown
l
iron requirements in most individuals quite smaU. Iron bal -
ance is maintained by the increased absorption of the min
era! from the proxitllill small intestine during periods of
deficiency. Because iron is fOWld in greater quantities in meat
products, vegetariall'i are at higher risk of iron-deficiency
anemia.
Iron deficiency is the most common cause of anemia. More
than 50% of patients diagnosed with iron deficiency anemia
have GI bleeding, such as may occur from GI malignancies or
chronic peptic ulcer disease. In the United States and Canada,
iron deficiency most commonly occurs in women of child-
bearing age due to blood losses during menses and pregnancy.
These conditions may require more than the recommended
daily aUowance ( RDA) of iron (chapter 42(0). The most sig-
nificant effect of iron deficiency is a reduction in erythro
poiesis, resulting in symptoms of anemia.
Mild iron.defici.>ncy anemia may be preVi'nted or cor_
reeted by increasing the intake of iron-rich foods, such as fish,
red meat, fortified cereal, and whole-grain bre;lds. For more
sewre deficiencies, ferrous sulfate (Feosol, others), ferrous
gIuoonate (Fergon), and rerrous fiunarate (Feostat, others)
ADVERSE EFFECTS
from ulKommon.Hypokalemia is possitk;
thus. I!'IUm Itl'tk'f"! monitorecl periodic.lly. A small of
rt<eiving Bu ahibit ralhts, itching, ar amf r \igns of Anaphy-
laxis is poISiblt,though ral!.
Contraindicatians: Comraindicatiom indudt \emitivity 10 cobak Jnd folk
.nemia. CYJnocoba Ia min is rontraind iuted in patitnu with It-
pulmoni ry diltal!'.nd !hoold bt ulI'd C.utioUiIy in patitnts with ht.n
dM.m btuUIl' of tilt pott ntial for lOdum l!1ention (iusfd by the drug.
INTERACTIONS
I)ug-l)ug: Drug il1noKtionl with cyanocobalamin indudt dtouNII'" .bsoIptioo
wflen IJ'Iffi {OII{\I"rmtiy with aIat.oI, fIfOOI1<in,and
fIIiI iIfMf withtllfr.!p@Utic:fE'IjIOIlI!'to<)WlO(obaIamil.
Lab 11511: lktlIOWIl
Ik>rbaVFood: Unknown
IINtment Na O'/trdo!..Jgt has bffilf"!ported.
RtI'tr III MyIUIInqQ fDI Mnbrg /'ro(t']5 fuIsp/It: IIIIM Ikr!g.
are used as iron supplements. Slow-release products, called
iron carbonyl (Feosol-caps, Ferronyl), are more expensive but
are less dangerous following accidental exposure in children
because there is a longer period for intervention before toxic
effects materialize. Iron dextran (Dexfernun) is a parenteral
supplement that may be used when the patient is unable to
take oral prepaf3tioll'i. Because iron oxidizes vitamin C, many
iron supplements contain this vitamin. Vitamin C also is be-
lieved to enhance iron absorption. Depending on the degree
of iron depletion and the amount of iron supplement that can
be tolerated by the patient without significant side effects, 3 to
6 months of therapy may be required.
In 2009, the FDA approved a new iron salt. Ferumoxytol
(Feraheme) is approved to treat iron deficiency associated
with chronic kidney disease (with or without dialysis) . The
drug consists of iron oxide protected by a carbohydf3te
.h"ll. The .h,,11 remain. intact until the drllg ent"rs
macrophages, whereby the iron is released to its stof3ge de-
pots. The advantage of ferwnoxylol over existing iron salts
is th.1t it can be administrated safely by the IV route and can
raise iron levels more rapidly.
LibraryPirate
OI ... l<r lS Oru9' for Hemitopo""1< O""rd .. " 401
..
Prototype Drug
I
Ferrous Sul fa te (Feosoi, others)
Class: Age-mfor anemia Pllarmacolog ic Class: Iron supplemem
ACTIONS AND USES ADVERSE EFFECTS
Frrrous sulfilr is an iron SUppiMltnl {omaining 20% to 30% rkrmental iron.1t Thr most isGI upld. Taking mr,drugwith
ismilable in a widf variery of ONgI'lormsto or rapidly re'/rl\!' symp- food will dininish GI symptoms but (an <trmi\l' mr, absorpti:m of iron b)' SO% to
toms of iron--drrKirnq anrmii. forms of iron indudr frrrous lumirate, 70%.In iddition, an!aCids should oot br taktn with frrroui sulfatr brcao:M Ihr)o
which contains tltmental iron,and fen-ous gUo:Mite, which contains 129f. also Itdt.Kt absorptiGn 01 tilt minml.ldtally, iron should lit min-
rlrment.ll iron. Thr dose 01 thrsr various prepar;nions are basrd on Ihrir iron istrrrd 1 hou- brloreor 2 hounaftrr a meal.lron prepariDons maydarllrn stools,
contmlln gl'nrral,patirnB with iron deficitnc, I!!pond rapidly to thr i dmin- M this isa harmlrss sidfeffra.Constipation is ilKlNlr in
istruion of ferrous sulfall'. Although. positivr thrl1lprutic re5oponsf may br dirt.lry fibtf may br ildic.nfd. dosrs d iron are vrry 1OlK, and patienB
i{hirwd in 48 houn, therapy may continur lor srmal months to rrpltnish thr sIKUd br advisrdto taq.thf mrdiation aKliy.s dirrctfd.
storagl'deplB for iron.
Contraindications: Iron salts druqs Ihould not br usrd in hfmolyti anemia
laboratory muation of hrmoglobin (Hgb) or hematocm (Hel) valurs is
without documentation of iron derKirncy iron will not rorlr(t this ron-
conducWd rrgularly, is rl(rs! iron is toxic. Althoogh a positi!' thrrapMic rr-
dition and it may build to toxic: 1eYeIs. Thr drug should not br adm inil1rffll to pa-
!poIU may lit in 48 houn, thrrapy may rontinur for snrral months.
tienB with hrmochrornatosis, prpti ukrr, rrgional t nttritis, or ukrrativf colitis.
ADMINISTRATION ALERTS
INTERACTIONS

When ad ministrring IV, u rrlulto pre-Y!'nt inlikl1ltion, as iron is highly ir-
Drug-Drug: .I.bsorp!ion rtdlKfd "Ithfn 001 ion ...m an with
mating totissurs.
MlUOOs, prOlonpump or <akium drcrNII'! thf

u th. Z-Irl<k mrthod (dr.p mu.d.) whrn giving 1M.
ab>orption 0(1l'In<Jd ..... Midronar: . To pr ... rl! ""' ....

Do not crush tablet or rmpry conttnB 01 upsukrwhen administrring.
intflactioni, i!iadvisabk> 10 00 iron to 1 hcHn iIao or after 0Ihtr


Do not givr tablet;orcapsules within 1 hour 01 bedtime.

Prrgnancy utfgory A
L1 b Tests: fflrous suit ... may dea&R!fII.WII <akium IewI and ioo&R lfIum
bii nm
Herbi VFood: F ood, dairy products, wi absorption 0( frrroos
PHARMACOKINETICS
\Ufate. Foods M11 in vitallin ( !lKh as oralMjO and strawWrriI5 (;lI) iIotalf
Bfcausr iron isa naturalsubst.lnce,it is difficuk to otcain pharmacokinrti
thf abIorptiJn of iron.
valurs.
Treat mem of D"ftrdOSl!: Thr ntidoll' for acute iron intoxication is defurox-
aminr(Dtslenl). This parenteralagrm binds iron, which is subsequtntly rl'-
mOl'd by thr kKlneys, turning Ihr urinr rrddish brown color.
III'ftrlJl Pn::mJ
NURSING PROCESS FOCUS PATIENTS RECEIVING TREATMENT FOR ANEMIA (FOLIC ACID, VITAMIN Bn,
FERROUS SULFATE)
Assessment
Basrline nsrssmenl prior 10 adminislr. tion:
o Undentand thr INIOn thedlllQ has prrscribed in order tOillfSslor
tht rapruti tflrm (t.g., t)'pr of anrrnia:lfCondiry to inft.tmmatol)'
disf.N,lack B",rtd.
o Obtain a rompiete h. akh history induding (irdiO'/i\(\Jlar,GI, h' paric,or Jl'llil
disr.N. Obtain a drug history including illt"lies,rulTrnt prf"ICription ind OK
druqs,and hfrbal prrpal1llions.Br alen to possiblt drug imrractions.Obtain a
die\al)' history, including akohol Ulr.
o Obtain b-mlilll' wright and fat9Je boeI.
o Evakiatr i ppropriate labomoryfindings transferrin and
!e!Um f .. min rrnal and liverlunction studir1.)
As_smrnt throughout administration:
o Continur assrssment for thrraprutic rllecu (e.g., Hct, RB( (ount improved,
patient'sactMt)' Irvel, and genrral !ell" oIwt'lI-bring).
o Continur monitoring of appropriatr lab valurs (r .g., CBe. rlearolytes, hrpatic.
indfl'llillunction).
o Assess lor advrl\!' tflrru: it{hing, skin ra!h, hypoulrmii, nalllN, vomiting,
hrartbum,ronstipation, bli{k stools (iron prrparations),or allfr<jic reactions.
Potential Nursing Diagnoses
o rlSsue Prrlusion (mated to underlying disorder)
o Activity Intoirraocr (matfd to underlying disorder)
o Fatigur (rrlatrd to disorder)
o Imbalancro linrilion, Lt Sl; Than Bod, RequifMltnll (relatfd to lack of
intake or lack 01 ablOrption of nutl"irms)
o D!'rKirrrt Knowlrdgddrug thrrapy)
o Risk for Injury (mated to underlying disorder or advrl\!' drug tifrcu)
(Conr/nued)
LibraryPirate
NURSING PROCESS FOCUS PATIENTS RECEIVING TREATMENT FOR ANEMIA (FOLIC ACID, VITAMIN B
n
,
FERROUS SULFATE) (ConltlUed)
Planning: Patient Goals and Expe:<: ted Outcomes
The pilient win:
ExptneIKt tflefapeutic ttftS <!tptndtnt on the die drug is lItill!lgil'ft'l !t.g.,e.ptrienc:t inutue in IClMty 1MI,Im Ind shonntSs
on tmUon) ,

Verllizt an unr:lcmanding of the drug's th,and rtqIIirtd prtoutions.
DtmonWollt proper stIfadminimation oftht !t.g.dme, timing. whtn 10 notify proicler).
Implementatio n
Inter venti ons and (Rationa les)
hsuring theripeutic effect s:
Cootinur mmmtnts t arlier fo! thrfapeutK th.!R8( .nd Ikt
counu llliy riIt OWl' J 10 6 months. Molt gl1du.i1l)' incruiing r,eh of Ictivity
and Itss IOl'n(IIainl! of f.t9Jt as <ounu rise.)
adrquatt of rartrinlt whentm {ommr
iong-ttllll wwienMt.tion as ,pprojIMt.lM.lintaining. hNItIr)o may
the nted lor Iongrrrm suppltmtntatioft 01' win tIIh.IKt thtrapeutit
tffKUJ
FoIIowappropriatt .dministration gumlines. {Following .ppropri;rtl:
administration muimizes Ibsorption for tnhiMfd therapeutic
tffM,Oral formulllions ml1 specialldministrarion rtqUiremenu.}
Mini.,izing 1m rw effKts:
Cootinur to for oJdoimt tfffib, indOOing rash, hypokilltmia,
nausta, vomiting, mnstipation, heanbum,staining of M, btadc stools (iron
tllttgic I'9<tions. (llypokaitmw.nd subsequrnt
dysrlTJthmiis may OfCUf with Viumin B
lr
ministrllion. Stailling of the 1Mb
fum liquid 0111 and bl.d: stools Ofwrwith irIIfl.J
Plan iCtMtin 10 allow lor ptfiods of ItSt to btl, patitftt constl'l't -9)'.
(FatigUf flam .Jltmia due todKrtaSfd Hgb Itl'd! is common.)
"tlent u. dt,standing of drug: tf1 t rapy:
Ust opportUnities during Idministration 01 medications i nd during
aSstSSmtMS to discuss ratiOllaJr lor drug thera"" dtsirtd thmpMic
outtomes, most common iIdvetst efflS, for wilen to (1/1 the health
(alt and.ny lIeslary monitoring or pRGllllions.(Uiing timt during
nlllSing cart htlps 10 optimizt and rtinforcr key uidling IIUS.)
Patient of dlllg therapy:
When mtdiGtions, inruuctthe paUM!, family,rx ClltlJiYrf in
propn w:1f"!m iNstr.tion dtscn'btd nrlirr.nd of plllptl
intl1mu!QJ1ar injt<tion techniqUf forVit.min BII followed by ItIUm
dtmonm atio,dPropn administmion wiB in<rt.w: the efft<tiftntSS of the
d"",
vitarnim.nd Iron prtp.ntims out oftht reW! ol)'Jung childrfn. (Iron
poisoning mi)' lit f.taI in)'OUJl9 childltfl.)
Pat ient and famil y Education
inslRKt tilt on W nfflilo return lor periodic lab work.
the to of folic Kid,. vitamin B" irm
rich foods sud! as:
Fo/'Kacid: !ruits..nddrifd bNru MId peal
'(rt.min mNI, and milt produm,ind
fortified bltakfast enuls
lion: mms, fish, poullly,ltmils,.nd buns
Tueh the IpKiIic .dministrillion guidtlintl" ilduding:
folic be ukrn on tmpty SIOnW! rxwith food.
'(rtamin BII:Must lit gWen 1M iI castS of pernicious anetl'lia. Tike
onl formulations wid! JMaIs,
lion: Tauon tmpty prepilalions should be sipptd
through a maw-with thr S1I1w htId lOwud tilt back of the mouth
to awihuining tffih.lllcII'Isilg intake of '( ItI min ( -flch foo:Is
may i Iso rfihatKt ilOll absorption.
InslnKt iIIr patirnt 10 moIitrx lor s9ts and I}'IIIptDrnI of hypokilrmw
rrusdt !taWs!" and 10 rtpl ponfdJ.
TtKh the 10 inertatt ftuid and fibtf iltakr as part of hi!alltiy
did whitt on iron and rxailiquid fOl'mulations
and sip througil straw p&.ctd in the Nd of the mouth.
the patitllt 10 ItSt when fatigutd .nd 10 actiritits
througllout tilt da,to allow for ItSt periods.
The f.mil): orcartgiftr should lit abJr to lIill! lot
drug;aPPfOpMt dow: and Khecflllint; what l6ftrw rifms to
for.nd when to report; and lhe .nticipated length of
mrdlulion tbnapy.
The should beablt to disaru appropNlt doosing and.ny
sptciil tKhnKjurs 10 drug t.krn.
Hnl' the rtlurn-Ormonstl1lt die
1t<hnicpJe until the ptoptr is used and thty.rt mmlorublt
giving the injMioll.
Tfidl the 10 kttp iron p!l'parations and lliumim <onuiring
iroII, in iI SKUll! pL.ct if childrtft art prtSrflt in tht homt.
Evalueti on of Outcome Criteri a
402
LibraryPirate
OIlfetr 11 Drugs for DI5ordE<s 403
. 'lY: Chapter REVIEW
KEY CONCEPTS
The numbero?d key concepts provide a succinct summary of the Important polnlS from the corresponding numbered section
within the chapter. If any of these points not clear, refer to the numbered section within the chapter for review.
21.1 Hematopoiesis Is the process of blood cell production that
begins wi th primitive stem that reside in bone mar-
row. Homeostatic control of hematopoiesis is maintained
through hormones and growth fadors.
28.2 Erythropoietin is a hormone that stimulates the produc-
tion of red blood cells when the bodyexperlences hemor-
rhage or hypoxia. Epoetin alfa is a synthetiC fonn of
erythropoietin used to treat specific anemillS.
21.3 Colony-stimulating fadors (CSFs) are growth factors that
stimulate the produdion of J.eukocytes. They are used to
reduce the duration of neutropenia in patients undergo-
Ing chemotherapy or organ transplantation.
2&..4 Platelet enhancers stimulate the adivity of megakar-
yocytes and thrombopoletln, and Increase the produdlon
NCLEX-RNO REVIEW QUESTIONS
o An eldf,orlypatient d iagnosed with iron_defJdencyanemia
will be taking ferrous sulfate ( Feosol, others) orally. TIle
nurse will teach required administration guklelines to the
patient, induding: (Se\e(:t all thai apply. )
1. take thetabletson an empty stomach If po5Slble.
2. fluid intake and increase dietary fiber while
laking this medication.
J. If liquid prepanulons are used, dUule with Vo-aler or juice
andsipthrough a !Uawp\aced in the back of the mouth.
4. mOO ordi5001vt tablets in waler jf
they are too big to swaUow.
D Erythropoietin regulates tbe process of red blood cell
( RBC) formation. The nurse understands this mechanism
Is adivated by a redudion of OIygen reaching the:
I. brain.
2. hem.
J. kidneys.
4. """"
o The patient with a diagnosis of cancer is receivingepoetin
alfa (Eposen, Procrit) as part of the treatment regimen.
The nun;eevaluates tbe of this drug by:
I. assessing the patient'senergyleveL
2. monitoring the patient's hematocrit and bemog.Iobin
""'-
J. monitoring the patient's bkxxl pressure.
4. assessing the patient's level of consciousness.
of platelets. Oprelvekln, only drug In this class, Is pre-
scribed for patients with thrombocytopenia.
2&.S Anemlasare disorders in whkh the())(ygt'Il.carrylngcapac-
Ity of the blood is reduced owing to hemorrhage, exces-
sive erythrocyte desl:ruction, or insuffICient erythrocyte
synthesis.
21.6 DefICiencies in either vitamin 0" or folic acid can lead to
pernkious anemia. Treatment with q:an()l;obalamin can
reverse symptoms of pernicious anemia In many patients..
although some degree of nermuo; system damage may be
pt'"Tmanent.
28.1 Iron defiCiency Ls the most common cause of nutritional
anemia and can he successfully treated wit h iron supple-
ments.
o The nursing plan of care for a p<ltienl receiving epoetin
alfl ( Epogen, Procrlt ) should Include nreful monitoring
for symptoms of:
I . angina. or a dtange in lelod of cOIlS(iousness.
2. severe hypotension.
J. impaired liver function.
4. 5e\"f,'fediarrhea.
o lb best monItor for ther:apeutic effects from fiJ&rastim
( Neupogen ), the nurse will monitor:
1. Hgband Hct.
2. WBCorANCrounts.
J. electrolytes.
4. RBCoount.
o The nursing plan of care for a patient rKeiving mgrastim
( Neupogen) should include:
l. frequent observ.iliollS for infeaion.
2. frequent monitoring of vital signs, especially blood

J. periodic ECG monitoring.
4. intake and output measurements.
LibraryPirate
.. 0.. UnU The Cirdlolo'ascub./ iOd Urinary Systems
CRITICAL THINKING QUESTIONS
1. A patk>nt newlydi3gnosed wi th renal failure asks the nurse
why he must receive Injections of epoetln alfa ( Epogen,
PrlXrit ). Develop teaching points to desc: ribe the indiCll-
tions (or this drug.
2. A patient Is receiving filgmstlm (Neupogen). What nurs-
ing intervtntions are appropriate to safely administer this
dmg and provide patient safety throughout therapy!
3. A pat ient is receiving ferrous sulfate (Feo!iOI,othersl. What
teaching should the nurse provide to this patient!
Set /tppendix D for tltt5,.,m tIIrd mtionales for all activiTies.
EXPLORE rm"iI!lit1ht3!tl:r------,
MytlIl'Jingll.ills you r one SlOp !of onl.ne tl'lljltet' mmnli!r and
resoorces.. f'lopiIf8 fw WC!:8SS wi th i1ildil'OOal praWce
que!!liDns, IlIIerar:lIie 1!IS(1W!tentl! DnCI ectl'.tieiI . .. links, ellkMtlons
and videos. and morel
Aegi:!tsr J'DII" access COd&! from 1M fmnI Df -,our bDt* a1
WWW.mvn<l'K>gkit..cGm.
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DRUGS AT A GLANCE
FLUID REPLActMENT AGfHTS 1U}tJI
Blood Ind Blood Products pt1/tQ
Crystalloid Solutions Jll9I'411
Colloid Solutions paJto
(0) norm<Jlsefum lllbumin (AJbumlnar,
PlosbumJn, others) PIXJlf1
VASOCONSTRICTORSIVASOPRE5SORS pogtO
ptJI4J J
INOTROPIC AGENTS ptl/tfIJ
o dopamJnt (Dopasflll,lnm:rpln) IJ1IiW}
AHAPNYl.AXJS ,.41J
Q fPlMphrn.(Adrrno/lfl) pogtf/4
KEY TERMS
anaphyla<rN; shod pDgI a
wdiogtliuhock ptJI4aj
<oIoiIk ptIIJtU
Chapter 29
Drugs for Shock
LEARNING OUTCOMES
Mter re<ldlng rhls the Sfudtnf should be able 10:
1. Compare and contrul lhe different types of shock.
2. Relate the general symptoms of shock to their physiologic c/l uses.
3. Explain the initial treatment priorities for II patient who Is In shock.
4. Compare and cont rast the use of coll oids and cry$tallolds In fluid
repillCement ther,p)'.
S. list the drugs used In the prn.rfTIKotherapy of anaphyluls and discuss
IMir indiGlltiom.
6. For eitCh of IIw dasses shown In Dtugs at a know representlltlve
O"ug ekaffiples, and explain their ITIKhanlsmof action, p!'lmalY actions.
.nd Important adverse effectl.
7. Use the Iepoflhe nursing process to care for patients who are
receiving drug IherapyfOf shock.
crysuloids poqtG
hypoYOitI1icWKk pqo
pl//t4ll
f\turo9!'nicshoa (XIqtJiJ
stpticlhod pq);
""'" ""' '"
LibraryPirate
406 u.,u Tho (a,d""'a5CU'a' and Urinary Systeml
S
hock Is a condition In whkh vltlll tissues lind organs are
not receiving enough blood to function properly. With-
out adequate oxygen and otner nutrlenlS,ceRs cannot carry
out normal metabolic processes. Shock Is II medical emer-
10 .. "' .. Sa , ... c ..... sas symptoms of .hock
may lead to irTeYenlble orgllf'l dllmllgt lind dellth.lhis chap-
ter examinH how drugs lire used to aid In the treatment of
different types of shoo::k.
29.1 Characterist ics of Shock
5hodc isa oollection of signs and symptoms. many of which are
nonspecific. A1lholl8h symptoms V;lry among the different
kinds of shock, some s imilarities exist. lbe patient appears
pale and may claim to fet'l sick or weak without reporting spe-
cific compLaints. Behaviorol changes are often some of the
earliest symptoms and may include restlessness, an.tiety, oon-
fusion, depression, and apathy. l.:Ick of sufficient blood flow
to the broin may cause unoonsciousness. Thirst is a common
complaint. Theskin may feel cold or clammy. Without imme-
diate treatment, multiple body systems will be affected and
respirotory or renal failure may result. Figure 29.1 shows
common symptoms of a patient in shock.
The central problem in most types of shock is the inabil-
ity of the cardiovaS(ular system to send sufficient blood to
"'"
.,..
0....,
' CoO
Reapi"'ory
Rapid bmalhing
ShrIUaw
respiration
Metabo.i ....
Law tlKllpllra\u",
"'"'
' Acidoaia
Law uri .... output

R ..........
AAAiOlly
eo_
. """",",
ewelj",, .. " " ...
T8Chycartb
ThrMdy puIM
Low card.., output
Low blood pruaI'"
F1g1Ke29. J Symptoms of. patient In sl'lock
the vital organs, with the heart and bnJin being affected
early in the progression of the disease. Assessing the
tient's cardiova!iCular st3tus will provide important clues for
a diagnosis of shock. Blood pressure is usually low and car-
diac output diminished. Heart rate may be nJpid with a
weak, thre:ady pulse. Bre::IIhing;$ rapid ' hallow.
Figure 29.2 (page407) illustrates the physiologic changes
that occur during circulatory shlxk.
29.2 Causes of Shock
Sbock is often classified by naming the underlying patho-
logic processor organ s)'!itt'lll causing the disease. Table 29.1
describes the different types of shlxk and their primary
causes.
The diagnosis of shock is meiy b3sed on nonspedfic
symptolll5.A careful medical history, however, may give the
nurse valuable dues as to wh.:!t type of shlxk may be pres-
ent. Forexample,obvious traum3 or bleeding would suggest
hypowlemic:shock, related to volume depletion. [(trauma to the
brain or spinal cord is evident, neurogenkmock, a type of dis-
tributive shock caused by a sudden I06S of nerve impulse
commWlication, may be suspected. A history of heart dis
ease would suggest mdiogenic Ihcxk, which is caused by inad-
equate cardiac output due to pump failure. A recent
infection may indicate septic shod:, a type of distributive
shock caused by the presence of bacteria and toxins in the
blood.Ahistoryof allergy with a sudden onset of symptoms
following food or drug intau may suggest lhoa,.
the most severe typt' I allergic response. The phannacother-
apyofanaphylaxis is included in Section 29.7 (page 413).
29.3 Treatment Priorities
for a Patient with Shock
Shock is treated as a medical emergeno;y, and the first goal is to
provide basic tife support Rapid identification of the underly-
ing caust' Followed by aggressr.e treatment, is essential, because
the patient's oondition may deteriorate ropidly without spe-
cific, emergency measwes.1t iscr itical to use the initial nursing
PHARMFACT5
Shock
C.rd"""",K. " ... k, it "'I""otb ...,...1, (U "IU>(
!elh,1 ronn of shoc:k "Id h.H an to moruli!,
Hyporolrmic ihcxkarrieu rMe.
With ,nap/lyiauic or distributlft shrxk,duth (,n ensuewithin minufn if
trrurTIent is IlOl mil,blr to trrat tllecondition: Neuroqenk shoc:k is.
form ofdistributiYr shcxk.
It is fltillYttd that SOO to 1,000 ast5 offaQI an.lphy],ctK shcxk occur
eKh)'ritl' in tht Unittd Slam.
xplic sllodr.. uswIIy CMIIfd by I}I'mfle9itlYe ",ttrii, his.l morulity
mr of 4O'Iji to 709& but an "" as high 1\ 9O'*.clepeftding on the
UUIoIlivr Of9inism.
LibraryPirate
Blood pre.s8Um compensation
Increased rani'"
angiotensin """ration
Incroasad
admnetgic
ltCtivity
Normal Homeostatic: Response
( lIo",tll' Drug. for Shoc:k 407
Blood voume
Increased aldosterone
"""mtion
Incmase<l antidiuretic
hormone (ACH) """",tion

Vaooconstrictora
Norepinephrine
Inotropic agenlo
Dopllmine
J
Inc .... sed blood
,....,. "'"
cer<liac output
Pharmacologic: Inlurventions
,.,... .....
Crysialloide
. 5". dexlr<l....-t-!:p
Colloids
Albumin
Incmased blood velu:ne
,. Flgure29.2 Physiologic changes during circulatory shock:pharmacologlc Intervention
TABLE 29 1 I (ommon Types of Shock
Type of Shock
Anaphybnil:
Cardio9ffiit
Definition
Arult alft9ic: ruction
Faillft of tilt heart 10 pIIIlP IlIfIitiffit blood to tiSllIf5
lois ofblood volllnt
Vasodilation dut to of tilt nm'OIIS syIlffil
or undmtimulition oftlit lY"'pathetk l)'IIffil
organ dylfunaion a! i reuk of patoogt nit organilllll in tilt blood;
often i pr!'(II'lOftOi lW diltrel\yndromt and
intra\li!\Clllar (oagulation
Underlying Pathology
ruction lOan !UdJ .J I WIIbh.
or .Jnimal
Lffi
plAmon.Jry tIllboiism, or myocardial or pmyldi.!l infffi ion
Htmorrha.,. bums, dilftlis, or Sl'l'trt or
dianfIN
Tr.Juma to tlit !pinal lid or
or pain, or drugs that dtprts\ tilt (tIltr.J1 nm'OIIS lY\ltm
Widtlpfrld inflammatory repollSl' to
parilitkinft ction
LibraryPirate
408 UnII4 TheCJrdkIY.",ubr ond Url",,'Y Syuem,
interventions of maintaining the ABCs of life support-
airway, breathing, and circulation-to sustain nonnal blood
pressure. The patient is immediately cOIUlected to a cardiac
monitor, and a pulse oximeter is applied. More invasive mon-
itoring (e.g., arterial line monitoring of blood pressure and
pulse rute) is often required and should be started as soon as
feasible. Unless contraindicated, oxygen is administered at
15 Umin via a nonrebreather mask. Neurologic status and
level of coll'iciousness are carefully monitored. Additional
nursing interventioll'i coll'iist of keeping the patient quiet and
wann and offering psychologic support and reassurance.
The remaining therapi .... for m<><:k depend on the specific
cause of the condition. The two prilllilry pharmacothera-
peutic goals are to restore normal fluid volwne and compo-
sition and to maimain adequate blood pressure. For
anaphylaxis, an additional goal is to prevent or stop the hy-
persensitive inflammatory response.
flUID REPLACEMENT AGENTS
Various drugs are used to replace blood or other fluids lost
during hypovolemi, she<;k. fluid repla,ement therapy in-
cludes blood, blood products, colloids, and crystalloids, as
listed in Table 29.2.
29.4 Treating Shock
with IV Fluid Therapy
HYl'o'olemic shock can be triggered by a number of condi-
tions, including hemorrhage, extensive burns, severe dehy-
dration, persistent vomiting or diarrhea, and intensive
diuretic thernpy. If the patient hao loot oignifioont blood or
TABLE 29.2 Fluid Repla,ement Agents
Agent Examples
Blood produa\
bb:>d
pIa!olna prolrin fraction
Ireh fr=n pia IIIU
JlKb'd bbJd (1"11
Cd""' plallllil prOirin fr iction
PLllmatrin, PPF,
dextran 40 IGrollan 40, Hyston. Rhtorn.Krod9) or
dextran 70

oormal SfflJII altllln .. , h!ll1an I
Pli5burrin)
Crystalloids oormal ;IlintIO.9% sodium dIIoride)
lanmd Ringer'1

I hyprrtooio: ;Ilint 13% sodium dIIoride)

Not Ull'd for \hod:;
other body fluids, immediate maintenance of blood volume
through the IV infusion of fluid and electrolytes or blood
products is essential.
Blood or blood products may be administered to restore
fluid volume, depending on the clinical situation. \'lb.ole
blood is indicated for the treatment of acute, massive blood
loss (depletion of more than 30% of the total volwne) when
there is a need to replace plasma volume and supply red
blood cells to increase the oxygen-carrying capacity.
A single unit of whole blood can be separated into its spe-
cific constituents ( red and white blood cells, platelets,
pl .. ,ma protein" frem froLen pla,ma, and g1obulin.s), which
can be used to treat more than one patient. The supply of
blood products, however, depends on human donors and
requires careful crossmatching to ensure compatibility be-
tween the donor and the recipient. In addition, although it
is carefully screened, whole blood has the potential to trans-
mit serious infections such as hepatitis or HIY.
The administration of whole bloexl to expand volume
and to sustain blood pressure has been largely replaced by
the use of fluid infusion therapy. Drugs used to expand fluid
volume are of two basic types: colloids and crystalloids. Col-
loid and crystalloid infusions are often used when up 10 one
third of an adult's blood volume has been lost.
Colloids are proteill'i or other large molecules that stay sus-
pended in the blood for a long period because they are too
large to easily cross membrunes. \'lb.i1e circulating, they
draw water molecules from the cells and tissues into the
blood vessels through their ability to increase plasma on-
coli , pressure. Blood-product colloids include normal hu-
man serum albumin, plasma protein fraction, and serum
globulins. The non- blood-product colloids are dextran (40,
70, and high molecular weight) and hetastarch (Hespan).
These agents are administered to provide life-sustaining
support following massive hemorrhage and to treat shock,
as well as to treat burns, acute liver failure, and neonatal he-
molytic disease.
Crystalloids are IV sol utions that contain electrolytes in con-
centrutioll'i resembling those of plasma. Unlike colloids,
crystalloid solutions can readily leave the blood and enter
cells. They are used to replace fluids that have been lost and
to promote urine output. Common crystalloids used in
shock include normal saline, lactated Ringer's, Plasmalyte,
and hypertonic saline. Additional information on the role of
crystalloids and colloids in correcting fluid balance disor-
ders is included in chapter 3100.
VASOCONSTRICTORSIVASOPRESSORS
In some types of sh<><:k, the most serious medical challenge
tit" i, I'Yl'u["Il,iuIl, wl,iul J.,""Ulll" so
profoWld as to cause collapse of the circulatory system.
Vasoconstrictors are drugs for maintaining blood pressure
when vasodilation has caused hypotension but fluids have
not been lost (i .e., anaphylactic shock) and when fluid re-
placement therapy have proved ineffective. These medicn-
tioll'i are listed in Table 29.3.
LibraryPirate
Cllopltll' Drug' for Shoc:k 4 09
Prototype Drug I Normal Serum Albumin (Albummar, Plasbumm, others)
Therapeutic (lass: Fluid replacement a9ent Pharmacologic (lass: Blood product,colloid
ACTIONS AND USES
Normal mum albumin i, a prottin OlractM from whole bIood.plasma,OI pla-
cflltil human plasma. Albumin rmurallycomprim about 60% of all blood pro-
. lt< normal Nndion. 1<1 main"in plas ... olKotic pro"u,," ond to
Ihuttlt, wb.tance through tilt blood, inWding fat\)' acidl,ctrtain hor-
OlOotSand a .ubnamialrurnoo of drug molecule.Afttrotraction from blood
01 pluma, albumin nffilizfd to pollibl!- cootlmination by tilt htpa-
viO/\tS or HIV.
IV, albumin tht oncotic of blood and
(,lUstS fluid to I1IOVl' from tht Jj"ue to tht geooal ciKUlation. k
stort plasma volumt in hypovolemic shock, or to blood prottin. in pa-
tienn with hypoprottintmia, which ImjUl'lltiy OCQJrs in poatients with hepoatic
cirThosis.1t has an immediatt onm of action and i'/ailable in (OIKfIltraoom
of5%and2S%.
ADMINISTRATION ALERTS
InNst mom mwly brcaust tilt risk 01 i rapid
Huid lIlift
i large"9<lU9l' (16- to 2O"'Jaugt) IV cannula lor administration 01
tht drug.
Pregni nqc.tltgDr1(
PHARMACOKINETICS
i lbumin a natural SUbstllKf, it not poIIiblf to obtain phar-
vaws lor Wppiemfllts. .-'
29.S Treating Shock with
VasoconstrictorsNasopressors
In the early stages of shock, the body compensates for the
initial fall in blood pressure by activating the sympathetic
nervous system. This sympathetic activity produces vaso-
constriction, which mires blooo pressure and increases the
rate and force of myocardial contractions. The purpose of
ADVERSE EFFECTS
BeuUlfalbumin a mural blood the patitnt may havfimiborJies to
the dorm album in and i Ilfrgic pos,ibl!-. HaMvel', coagulation lac:-
tors, ontibodie<, ond most blood protein ...... bHn
tilt in(idfncf 01 allflllK from albumin not high. Signs of allt rw in-
dude .. Ill, dyspnea, and po! libly hypott nlioo. Prott in overload may
OCQJr ij rnmive amoums of albumin iofustd.
Contra indica! ions: Comraindications include It'YI'rt i ntmia or (,I rdiac: in
the prmOU' 01 normal or in(INSfd inm'/il(ular wiullll',and allfrgy to album in.
INTERACTIONS
DIIII}-Drug: Unknown
l.i b Teru: Normal <;tItIII albumil may i"IoNsI' senJm alblint p/lospIaIR.
HerbaLlFood: lInkncwn
Treatmf nt of OYerdo,e: Therf no 10rO'lfrdost.
these compensatory measures is to maintain blood flow to
vital organs such as the heart and brain, and to decrease flow
to other organs, including the kidneys and liver.
The body's ability to compensate is limited, however, and
profound hypotension may develop as shock progresses. In
severe cas.es, fluid replacement agents alone are not effective
at raising blood pressure, and other medications are indi-
cated. Sympathomimetic vasoconstrictors, aIso known as
TABLE29,3 I Vasoconstrictors and Inotropic Drugs for Shock
Orug
Routeand Adult Dose(max dose where Indicated) Adverse Effects
IV; d9ialiling dosf 2.5- 5 IIKg Mf16 hotI"s for 24 h; maintmana ri5uo/ disruroooces
Prototypflmj to; OO) doll' O.IlH.5 mglday sudr al )'fIIow/9fPffl Of blurring

dobutamioe lDobuun) IV;infustdat i rate 0(2.5-40 IIKglkg/min for a muo( 71 h
o dopamint "tropinJ IV;2- 5 m(gIkg/min initial dosf;may be D.1Ustd
in blood preswrt (hypotemion
to20- SO m'9fk9/min
(Jf hypttlmsion)
o epintplJine lAlRnain) Subalintousl O.I-{l5 mL 0( 1:100 f'lety 10-15 min;
Ta!1!l':(,lrdia !i!bra!!:t!;ar<Iia !"erOOsfl
IV O.1-1US mL 0( I: lOOlMIY 10-15 min
bypweOlj!Jl dyyhy!bmjn ntnmjul jnjrqjoo
Ijte IwPWI'O)joo
0.5- 1 mcg/min, tin-itt to reponll';l/StI.Il rang r
S-lOllKg/min
phenylephrine (tIeo-S)TIfp/M"ioe, OIhel1) 1V;0.I - O.18 mg/min until stabilize,tbm
pagf III for the Prototypl' Drug 0.04--0.06 mglrrin for mainttnalKr

inckattammoo Idvmf uodellining inckate 5triOll1advmf
LibraryPirate
410 Unll4 The 100 Urlrlilry Systems
NURSING PROCESS FOCUS PATIENTS RECEIVING IV flUID REPLACEMENT THERAPY FOR SHOCK
Assessment
luelin assen mut prior to a.,iniilralion:
Ulldmland w ruson tht drug hil bm1 preaibed" onrr to for
liltraptvti< tffem (e.g... tyjIt' of shod).
tbuin a Impi!ott hulth history "duding urdiouSCllw (indudill9 HTN, MIl.
neuroIogK (indJding CVA or twd injuryl.burns.tndocriM,aMl hepitic or rflIII
disase.Obuin. drug hislOf)' irdxling afleogies,rurl!lll pnscription .nd OK
dlUCJ$,and hMlal prtp.lrations. Be to possible drug interittions.
(])bin "-1in(Wfight.nd vital signs. IeI'l'I of <onsciousrorsl,brtnh !OlIIIIh.
.nd urin.ry and Glrdia< output.
.ppropriate findings kg.. Hgband HCI. WB(
elKtrolytts rterial blood 9iSt's, lDul protein and .lbumin Imls, am aPT or
INII, blood MIUI!S, 1!Il.I.nd li'IfI function studies).
AsIUsmtnl thro ughout administration:
AsItSS .,.. dtsftd thtr.Ioptlltic: effu dependent on lilt _on lor 1M drug
(t.g.. BP, pulst, wdii( OUlput rttum to witflin Jtpublt r.nge,idtquib! urine
output).
Continue frtcpJenund urtful moniloring of viuhigM,and urinar1.nd ur<b:
output iI5
AsItSS"" and prOOlpl1y adw-BI' dfrcti:uchyurdia, hypMmsion,
of mnsciOlMfI1, e.sing .. lung
congestioft. frot!rt sputum, lIKrt.std urinary output,or .lltJgic
I!actions.
Potentilll Nursing Diagnoses
Cardiac Output (ulliiowlrular)
Irdhor:til'l' Tisill!' hrMion (rardiopulmon..,. shod:}

Intfftil'l' Airway ClwlIIKr (anaph.,w:is)
Otficitnt Ruid Volimt (1I01umt loss. third-spacing)
Anxiety or Ft.r (rNttd 10 COI'KtmI about _riry of mncfttion)
Dtfidtnt Knowledge (drug IIItrap)')
Risk for Injlry (rtlattd 1O.<heIst tffKlS of drug Of
administralion)
Risk for UctsSWt flJid Vdumt (rtllted to drug therapy)
Planning: Pati e nt GOll ls and b:pected Outcomes
1M p.ilitnl will:
ExptMoce dfptndtnl on 1M l!iI5OI1 thr drug is bfing gi_ improvtd blood jlf('ISln.<aIliiac and outpul witlWl imits).
from,or nperimce minimal,aclYerw efkcts.
VMializr an Ulldmtanding of the drucis!M, a.:IvrM eIfrrts,l!Id f'rIIUirtd prKIutionl.
Implementation
Interventi ons and (Rllti onales)
hsuring therlpeutk effedl:
ContinU!' iI\eSIMnts IS alxnoe forthKapell'lic tffects drpmdtnl on
1M I!HOn tM drug lherapy isgMfl.(PuIst, blood rtSpiralOry rate
should lit wirlIin lIOImallimits or within p.lr.1I'II!1efS set bJo 1M health Cil!
prvridtr nd ABGs andlOf pulse oximetry t1twithin ampl,ible
(.rd'1aC output is witu. narnwl imilS and urine OUlp.ll has
Prome supponiYt nursing mmUftl;e.g., moistening lips if patient is
rwtions for.n PfOlt<iurts,iIId frtqumt orienlUion.(Supportie
nUllOing muwl'l.'l Mlp 10 dMeast patirm, family, and (mgivl:f anxiety.nd
supplfI1lent the r.pruti<: drug tffr<ts to optimizr OI/Iromt..Patirnt m.y be
intubated andlor Sotdattd.)
Mini.,izing ulYerw effKls:
MoNto, for of IUd wkJlI'II! rmsS,f-9-, inuumg BP,
tact.,.Citd ii, bounding pulst, confusion. IIKrt a ling 1M I of con5iousftm.
Continue frtcpJe nt rardiK monitoring, tog, KG, and {i rdiM: output and urine
ou\jllJl (Because of 1M maul condition of tM p.llitflI: in shock.a delicatt
btlWftfl Huid voIumt tJlUIl and deficit tmu. asstsSmtnU
musl bt madr to drtKl: .nd.void rflem. Enema! alld invasive
monitoring dmce wil dftKl: early signs of Wl'1! is
for lhe-aptlllic effrrts.)
Fl!qVtntly monilor (ae. Mdroiyte.aPTT..nd aPT or INR
solJUons nwy calM elrrtrol)'te imbilincts.{oIoid solutions may mlUCt
blood roagulitioft.)
Pat Ient and Fllmll y Educll tlon
To .!by .rOOrty,lNch the p.atitnt.nd f.mily aboul thr rationale fOf .11
equipment used and thr need fOffrtquent monitoring.
ExpLain II PfOCt<iUrtSIO thot P'litnl btfol! brgiMing.Prome
htqJtJII allUran and I'trt.lltimuli lIM patielll is intuWItd.
11II1nK1 tht p.ilitnt 10 !!pOrt palpiulions, IhortnrslofblNlh,Ml
Madacllr
ContinU!' 10 rxpIain 10 thr patirnllhe rationale for aft equipmtnt
used, proc:tWte <omplete<j,and the netd for frequent monitoring.
To .lIiy .rOOrty,loo the p.atitnt, famiy,and ral!gfm about the
rationale for monilOfing of lib voJluts.
LibraryPirate
(1101'1 .. 2' Drug,forShoc:k 411
NURSING PROCESS FOCUS PATIENTS RECEIVING IV FLUID REPLACEMENT THERAPY FOR SHOCK(ComlniN'd)
Implementation
Inte rventi ons and (Rati onales)
Wtigh patient d.Jily and Il'port Might gain or lou of 1 kg (approximately 21b)
or mOIl' in a l (.-hour pMod.lDaily Might an a((urate mNWIl' offluid siaM
and takes imo mount irunsibit Iorm.Weight gain or
may signall'J(i'\sil'l' lkJid l!JiJlIII'.)
Clorely monitor for signs and symptoms of alitrw if O1lloidsare !MI!.(81ood or
blood produru, iI nd (oIloids GlUII' allergic: and ana phy!actic: Il'idions.)
Patint understanding of drug therapy:
lIII' opponunities durill9 of meditations and during asmlmtnlS
10 disrus5 the rationait for drug therap)', dtsill'd Ihtraptutic: 01/101 rntS, and
nt<rssary monitorill9 or (Usill9 timl'durill9 nulloill9 (.;Ill' ht ipi to
optimizr a nd Il'i nfor{e IUpportiYl' drug treitment ind (.;11'1'.)
Patient and Fa mily Ed ucati on
uplain to tilt patitnt!llt rationale for i ll eqJipml'nt lMd for
'Mighill9 me patitm and tht IIffii for frtquent monitoring.
lnstllKtthf patient to Il'port dyspllN, it(hing.. m-lings of throat
(hfst pain or tightening..or headache
immodiml)o.
Iht patiem andlorbmiy Ihoukl heableto !latean lJIdtmindilg oftht
ll'olIOIl for !he aug. equipmt m wd, !he pruble lenjm of medic:ation
!herap)' and any Il.pJXI!1iYI' lIl'ilmI'IIlImat will he 1jYI'n.
Continue to prOYide lupponiYl' (.;Irt to tilt family or caregiYer due to
me lIft'lsful MUll' of the patient'l {ondition.PrOYide refrrral to
appropriate (e.g., palloral Gill', locial srrvim).
Evalulltion of Outcome Criterill
E\\!luilf the eifeuiYl'll<'lI of drug tlltrapy by ronfinnill9 that patitnt goalsand eXpffied ou({omel haYl' bten ml't (Ite Plannin(].
StI' iIbIt 19.1 fIX ill (/ rfIp d'r!g5 lo w1rtJr Ihtst 1lIIM9 <KOOIIS 1JIIII1.
Stl'1lAo MJIlingI'rocm fooJs l.tllt!,{oo{Xl111 14flXpoIirMirrcrTopClI9"'IlI iMdi" lilt
III'IImmrliJlrod oo.
Prototype Drug I Noreplnephrrne (l.evophed)
Therapeutic Class: Drugfol sh()(k Pharmacologic Class: Nonselective adrenergic agonist:vasopressol
ACTIONS AND USES
Norepinephrine a sympalhom iml'lic: that i ets on alpha-ad 1l'III'19ic: 1'1'-
{epton in \\!I(\J1ar smooth mUl(ie to rai5t blood PIl'"lIUIl'. To i
lesm degree, it allO ltimulites btta1-ll'(eptors in the thul producill9 J
positive ioouopic: mponlr that may irKll'lIf cardiac output.ltl primary indica-
tions all' Jane shock and urdia( Ultl!. Norepinephrifll' vasopIl'Isor of
(hou for 1I'ptic: shock btocause .much has demonltrated that it signilicandy
de{1l'1IfI monality.1t giYl'll b)' mt IV route and hu a duration of Ito 1
minutes after tht infusion is tt nnimed.
ADMINISTRATION ALERTS
Sunan infusion only afterensurill9tllt patencyof tilt IV.Monitor mt llow

If mran sation OU\I rs, idminilter phemolam illl' to the i Il'iI of in fihration
"soon as pollibit.
00 not abrupdy disrontinue infusion.
Pll'9nanqme.;JoryD
PHARMACOKINETICS


Halflife:Unknown
Duration: Unknown
ADVERSE EFFECTS
Noll'pilll'phrinr i pov.wful \\II(I(OnllrKtor; thus, rontinuous monitorill9 of
the patitn!' I blood prffiUrt Il'qU ired to prevent me deYl'lopment of h)'ptrlen-
lion. Whtn first reflex bradpn:lia sometimes txperitn(ed. h
alia has !lit ability to prodlKe I\!rious typtl of ilthough less 10
than other v.J IOpll'Isors.1i nUa"liSation O!rurs, the drug may WIIf II'rious
and 10ft injury. Blurll'd rision and photophobia are ligns of 0YI'n:I0SI'.
Contraindi {Jtions: NOIl'pinephrifll' should not bto administered 10 patitnts
who all' exptrienc:ill9 hypottnsion to blood voiuml' derKits because \\!SO-
(on!lriction already exists in IlJ(h patients. may cause
tiona!. It"Vl're periplltral and vilaral '/aI()(onllrKtion with dt<reJsed urilH'
rotput. Norepinrphrint is oot usualI)' gwen 10 patients with munterk or pt-
ripheral mrular thrombosis, hemllf tlltre in(ll'ased risk of inc:lNlill9
(hemia and wol1tilill9 !he infirttion.
INTERACTIONS
DrurDrug: Alpha and bmbloc:kM may iIIlligOllU 1M drug\
ConwMy,ergol albioids and
effem. DigoIil,IIaIotIianf, ind qdopropalM' !IIi'f ilKfNlf 1M rilk of
LlbTeru: Uni:nown
HerbaVFood: Unknown
T real ment of OYfrdosr: Qilrontinuill9 the infusion usw ll'Iults in a rapid re-
of rifeal mh i l hyptnrnsion.
lifter Ie M}M!rJmgm for Q Mmirrq I'n:Im! forus lpf(1k Ie IIri5 drug.
LibraryPirate
i
o
,


41 2 UnII4 Tte c.,dloY.",ul., .nd Urinary SY'tem,
vruopressors, ale used to stabilize blood pressure in shock
patients. \'/hen given intravenously, these drugs have rapid
onsets with short dUl1ltions, and will immediately raise
blood pressure. Because of adverse effects and potential or-
gan damage due to the I1lpid and intense vasocoll'itriction,
vasopressors are used only after fluid and electrolyte
restoration has failed to rais" blood pressure. These drugs
are considered critical care agents: The infusions are contin-
uously monitored and adjusted to ensure the desired thera-
peutic effect has been achieved without significant adverse
effects. Thel1lpyis discontinued as soon as the patient's con-
dition stabilizes. Discontinuation of vasopressor th"rapy is
always gradual, du" to the possibility of rebound hypoten-
sion and undesirabl" cardiac effects.
Vasopresson used to treat shock include dopamine
(Dopastat, Intropin), norepinephrine (Levophed), phenyle-
phrine (Neo-Synephrine,others), and epinephrine. Because
dopamine also affects the strength of myocardial contrac-
tion, it is cOll'iidered both a vasopressor and an inotropic
agem (see Section 29.6). Epinephrine is usually associated
with the treatment of anaphylaxis (Section 29.7). The basic
pharmacology of the sympathomimetics is presented in
chapter 1300.
Prototype Drug I Dopamine (Dopastar, lntropm)
INOTROPIC DRUGS
Inotropic agents, also called cardiotonic drugs, increase the
force of contraction of the heart. In th" of shock,
they are used to increase the cardiac output. The inotropic
agents are listed in Table 29.3.
29.6 Treating Shock
with Inotropic Agents
As shock progresses, the heart maybegin to fail;
put decreases, lowering the amount of blocxl reaching vital
tissues and deepening the degree of have
the potential to reverse the cardiac symptoms of shock by in-
creasing the strength of myocardial contraction. For
pie, digoxin (Lanoxin) increases myocardial ooml1lctility and
cardiac output, thus quickly bringingcriticaJ tissues their es-
sential oxygen. Chapter 2:ZOO should Ix> reviewed, because
digoxin and other medications prescribed for heart failure
are sometimes used for the treatment of shock.
Dobutamine (Dobutrex) is a selective beta,-adrenergic
agent that has value in the short-term treatment of certain
Therapeutic (lass: Drug for shock Pha rmacologic (lass: Nonselective adrenergic agonist; inotropic agent
ACTIONS AND USES
Dop.miO!' is lilt immtdi"e mmbolic plffiJoor to norepinephrine. Akhough
dop.mine is dmifitd as a 'ym p.toomimetic, in mt<hanism of oKtion is dtptn-
dent on tlltdose.At low dosn, thedrug slimulalesdop.miO!'r<jK re--
r5pKg in lilt kidO!')"S, leading 10 mod iLllion a nd an incft'aIf<i blood
flow through Ihr kidneys. This m.us dopamine of panicular v.1ut in tft'uing
hypa<olemic and caroiogfnic !hock. At higher doteS, dop.mine stimulatts
beta,-adft'lII'r<jic ft'Ceptorl, Glusing lilt lINn to beat moft' fOKriully <lnd in-
caroioK output. Anothrr beneficial of dopamine whtn given in
higlltr dolrs is ill abili!)' 10 stimulate alph.J-adft'llt19ic thus causing
moconrniction !nd raising blood pft'!Wft' .
ADMINISTRATION ALERTS
Give thisdrug as a (ontinUOl.JS infUt.ion only.
EIl!Uft' tilt pall'lIC)' of tht IV prior to btginning tilt infusion.
BeulUll1tft'are difftft'nl dosagt rangH hasrd on thtraptU-
tic Nrecl. dl\lQ cakulalions btfoft' giving tilt drug.
Ilo\ra'INtioo occun,adminisler phtntolamine 10 tlltalt<l of infikrilion
as lOOn .1
Pft'gnancy cmgory (
PHARMACOKINETICS
1- 2 mil
f'eilk: Unlmov.n
mil
Duration: ltslilian 10 min
]
ADVERSE EFFECTS
BecalM 01 its profound elffCls on tilt caroiolllsculil, S)"Ittm, patitnll rrceiving
dopamillt must be monitoft'd for signs of dysrhythmi.u and
Ad'ieBe .ft' normally bec.iUI!' oltllt lhort h.lf-
life of tilt drug. Dopamillt is a micam drug thai can GlIM !!"11ft', ilft'Vl'rloible
skin and soft tisIII!' dam.gt if tlltdrug infihr.tts.
Contrai nd icationl: Dopa mine is conlraindicated in patimts with ph_hromo
cytorn. or fibrillation.
INTERACTIONS
il1Jg- il1Jg: (000I"1fIl adrniislration with IMO ilhibitoo or .bIoids
inmu iIIphi-.KUnerljic fiffCII. i'hfl1'!loilmay dKl&JII' OOpam Iion.1leta
bIocbrs may inhibit iIIf inotropic etJKto; 01 dopamine. AJjiw blOOM ilhibit
\\IIIXDIISIriai.lligmIin and nYnY i nelillftics inclNlt iIIf rilt of
dysrh)Uwnias.
Lab TKls: lktnown
IIorbaVFoo:l: Unknown
Treatmrnt ofOYerdose: Discontinuilg tilt infusion usually ItIUIts it ripid ft'\IeI-
sal of idml!' effrcn such as hyprntrnion. Tht lhort--acting alpha-.ldrtoogic
bIocur plltntolamine may be administMd to lubiizt tilt patim(1 mndlion.
litter III MyMIsIniJR for a MIsJnq Prors Foo/s spKl/Ic IIIIM /trig.
LibraryPirate
types of shock, due to its ability to cawt the heart to beat
more forcduJly. Dabutamine is especially beneficial when
the primary OIUse of shock is related to heart failure, rather
than hypovolemia. The resulting in cardiac output
assists in maintaining blood flow to vital. organs. Dabuta-
mine has a half- life of only 2 minutes and is given only lISan
IV infusion.
Dopamine (Dopastat, Intropin) aetival" bQth beta- and
alpha_adrenergic receptors. II is primarily used in shock
wnditions to increase blood pressure by causing
vasoconstriction activation) and increasing the
focce of ... ,.dial contraction (bela,
has the potential to cause dysrhythmiu and is
given only as an IV infusion.
ANAPHYLAXIS
Anaphyla:cis is a potentially fatal oonditn n in which body
defenses produce a hyperresponse to a foreign substance
known as an artligen or IIl1ergrn. On first exposure, the al-
lergen produces no symptoms; however, the body responds
by becoming highly sensitized for a subsequent exposure.
During anaphybltis, the body responds quickly, often just
minutes after exposure to the allergen, by releasing massive
amounts of histamine and other mediaIDfS of the intlam-
matoryresponse. The patient mayexperitnce itching, hives,
and a tightness in the throat or chest Swell ing occurs
around the larynx, OIusing a nonproductive cough and the
voice to i>ewme hNrst. As anaphylaxis progresses. the p<I _
tient experiences a rapid fall in blood rres.sure and diffi-
culty bruthing due to bronchoconmiction. The
hypotension c:tU5<lS reflex tachYC3rdi3. \oJithol,lt 'n,dic:tl in
tervention, anaphylaxiS leads to a profound state of shock,
which is often fatal. Figure 29.3 illwtrates the symptoms
of anaphylaxis.
COMPLEMENTARY AND A LTERNATIVE T HERAPIES
Horse Chestnut for Venous Insufficiency
Hono!(htwu 5. larqttm Illti10f IIlC11.11hmttm
Evropt dtu 5 _wUtd thl'JU9hout lMworicL nefruil of t!Iii 1m! (011-
IilinslftcklM IIonfdtetnW,wbidI_wl!lfdicin.il Ptsofthl!
Im!.kt tilt UnWi Gulled. 1rM.
TfaditW I.MS for dltstrart of joint in-
lIMn iMOIY disordtn and to im plllft ,iltulation. Modt'llllSi9t 5 prim. rily for
,hfOOK \'t1l(MJ$ in suffKimcJ (('11),. SyndfOlIII' th it mar indude Wi ricost tins,
Irg pain, il(hing,.nd skin uktls.
twsw(h hiS shown thit Of II dole of hoM cllHtnu may im-
pn!'Ir ('IllYmptoml (Pinlef & Ermt 2(06). Rmxtioll in Irg swelling, pain
and oWJr td.ing the druq for 2 to t6 Wftb.
50mf dltrniuh in hontdtetJtut taO: nd patitnu should ollly
1M 1M botanitIl undu tfIe guG.fIU' of I hNlth (.III! ptD'I'ider: I!omuNde
Iftpafllionsshould_bfIMd.Stindaalizrdbmsofhone(lIes""'tllt
ransiclmd $1ft "low intmcticm If lJ QUf l hotst dItst-
IIUI is uktft (llll(Ull!ftdywiltl mcdifim .. druqs.

( ... pt .. zt DIuc.I' for Shock 41)
/
Fest Mart fill.
o Decroa!l8d eordiae
00,,",

(
......


Sttondloconstridicn
.--





Hmamine
retell""
29J Symptoms of llnaphylaxls
29.7 Pharmacotherapy
of Anaphylaxis
M .....
V .. odilalion
., .......


\
"""
. ....,
.-
The pharmacotherapy of anaphylaxis is symptomatic and
involves supporting the c:trdiovascular system and prevent _
ing further hyperresponse by body defenses. Various med_
ications are used 10 trel( the SynlptOms of anaphylaxis,
depending on the severity of the SynlptOms.
Epinephrine, I: I 000, giwn suocutanoouslyor 1M, is an ini _
tial drug of choice beause it causes vasoconstriction and c:an
rapidly relieve symploms of bronchoconstriction. If neces-
sary, the dose may be up to three times at 10_ to 15-
minute intervals. Crystalloids or colloids may be nt'('ded to
prevent shock if the p<ttient presents with volume depletion.
Antihistamines such as diphenhydramine (Benadryl ) maybe
administered 1M or IV to prevent further release of histamine.
A aJbuterol (Ventolin, ProventiI) is of-
uy tv tl ...
of breath caused by histamine release. High-flow oxygen is
lISually adminislered. Systemic g1ucocort icoids such as hy_
drocortisone are given to <bmpen the delayed inflammatory
response that may occur sewro] hours the initial evenl.
Nearly all drugs have the ca.,..bility to allJM' anaphylaxis..
Although this isa rare adverse drug effect, the nurse must bIi'
LibraryPirate
;<


t

414 UnII4 lhI>C.,d""'.sc:ul. raodUrlnarySyl1"""
prepared to quickly deal with anaphylaxis by understanding
the indications and doses of the various drugs on the emer-
gency cart. The most common drugs causing anaphylaxis
include the following;
Antibiotics, especially penicillins, cephalosporins, and
sulfonamides
NSAIDs, such as aspirin, ibuprofen, and naproxen
ACE inhibitors
Opioid analgesics
_ Iodine_based contrast media used for radiographic exams
Although obtaining a patient history of drug allergy is
helpful in predicting some adverse drug reactions, anaphy-
laxis may occur without a previously reported incident.
Howevt'r, previous severe hypersensitivity to a drug is al -
ways a contraindication to the future use of that or closely
related drugs in the same class. Unless the drug is the only
one available to treat the patient's condition, the drug
should not be administered.
If a drug must be given for which the patient has a known
allergy, the patient may be pretreated with antihistamines or
glucocorticoids to suppress the inflammatory response. If
time permits, patit'nts may be desensitized. Desensitization
.... Prototype Drug I Epinephrine (Adrenalm)
for penicillin and cephalosporin allergy, which takes about
6 hours, has been shown to be effective in preventing severe
allergic reactions to these antibiotics. A typical desensitiza-
tion regimen would involve administering an initial dose of
0.01 mg of the antibiotic and observing tht' patient for al-
lergy. The dose may then be doubled every 15 to 20 minutes
until the full dose has been achieved. Desensitization has
alsu [Uf pati""ls with a,(hHla
who require aspirin therapy for another condition.
HOME & COMMUNITY CONSIDERATIONS
- - -
Recurrent Anaphylaxis
Palifnn with a history of I!(UfI!nt bt prtllJibNl
10 be imramusruLul), ia.n .utomatic: injtct.bIIo rievic:t
(EpiPm).lnl1rud patitou 1"t9.!ding .. dilposal.nd
lilt proper injection E lKourage patients to tilt medication-flff
"tr.int( pm 10 proKt ic:t tht Advist patitnu to fXptll
mrdic:.Jtion to rtm.Jin in tht pm following injection and to report.ll
requiring pm lJIa9t to thtir lIt.Jhh (.re proYider. patitnts 10
'M'ar. medic:aI.1ert br'(fltl or IIf(kLuf stating"allerq(.nd 10carl)'.J med-
itation .1Ierg)' list in walltt or purse.
Therapeutic (lass: Drug for anaphylaxis and shock Phannacologic (lass: Nonselective adrenergic agonist;vasopressor
ACTIONS AND USES
Subc:utalll'OlIS Of IV is I drug of dJoic:f for bmlU it
can R'rot ofthr symptoms within minutH.Epilll'phrinr isa
.JdR'llflgic: srinwLning both alplY- and beta-adrenergic:
Il'ptors. AI molt im after injrllion, blood re rnn dut 10 nim-
ubtion oI.lpha, IfitptOrs. Atw.Jtion of Itptors in tht brolKhi opms
lilt .irways .nd relm Ihr patit nt's shortnm 01 breath. (.rdiac: outpul in-
(re.m1 dUf 10 stimulilion 01 beta, 1fil'pIDII in the ht ut.ln addition 10 Ihr SC
and 1M inhali.tion,.nd ophtlYlmic: .re mil.blt.
The introKardi.( route is used lor cardiopulmonu"I rrsus(itation undtr fX-
lremeronditions, uswllyduringopm cardi.J( mal .. no othtr roult
iSpoisiblt.
ADMINISTRATION ALERTS
P.rmierall'pilll'phrinr is irritam th.tlN)' (.lUll' tislUf d.mage if fX-
u''alalion occurs.
Plf9nanq categol)' (
PHARMACOKINETICS
3- S min (subruianeous); S- IO min (1M)

Unknown
Dur. tion:l -4h
ADVERSE EFFECTS
Tht mOSI are ne!\'OIMf"I5,
pitations, ta(hyi.rdia, dizzillHs. hNdoKhe,.nd nioginglbumiog U lilt of
applic:.Jtion. plrentt rally, hyperttnsion..Jnd dysrhythmia!
oc(ur rapidl)';thrrmrr, tilt pititm lhould he monitored wtlull)' follow-
ing
Contrai nd i(ations: In life-threatening (onditions IIKh as.J n.phylam, art
no a blOlute rontraindications forth t UIf of tpinephrint. Tilt drug must bt usf<!
with (aution, in patitms with dysrhythmia!, U'l!brom(uiar
(ifnI)', hyptnhyroidism, nirrow-anglt gLnKlIma, hyptrlt nsion, or (oron.1)'
(hemi., bK.iUII' l'pineph rilll' m.), WOI"II'n thfs!o (onditKrn.
INTERACTIONS
])ug-])ug: Epiwphrine may rKlit in h)-potfnSion ij IIItd with p/IfoothWM or
iJI)'Iodn.Thfno may bf adtitiH (Mdoasutll efIKn with
MAOinhibbr\ tricydk iOd .... tI
iMibit thunions of rpilfplu ..... Epilll'phrine will dfmR the HlHll of b@Ii

..,n,.trint.
Lab Tl5Is: Epirlfphrint may pot.mium IHl'I.
IIerbaVFood:Untnown
T ru tmmt of Oertbsr: Ovrrdost ilia)' bf lI'riw!,.nd alpha- and beta-.HRnergic:
bIodr.trs art incicattd. H blood pressure remains tigh,. 'I<lIOdiator IN)' be admin-
intrrd.
LibraryPirate
~ Chapter REVIEW
KEY CONCEPTS
The numbered ko!y cOIKept5 provide ~ 5uiO(:1 summary of the important poinlS from the corresponding numbered se<:tion
within the chapter. If any of these points art DOt deu, ref .. r \0 the numbered sectIon within the chapter for review.
29.1 Shock isa clinIcal syndrome characterized by the lnabUity
of the cardionscular sys:tem to pump enough blood to
meet the metabolic nredsofthe tissues. Key body systems
affected by shock 3rt' the nern:lUs, renal,arxl cardiovascu-
lar systems.
29l Shock is often dassified by the underlying pathologic
process or by tile organ system thai Is prirmrily affected,
induding camiogenic, hypovolfmic, neurogenic, sept!"
and anaphylactic shock.
29J The initiallreatmt'nl of shock involves administration of
basic life support, replac...ment of lost fluid, and mainte-
nanl7e of blood pressure.
29.4 During hypovolemicshock,crystalloids replace lost fluids
and electrolytes; colloids expand plasma volume and
maintain blood pressure. Whole blood may be indicated
in ca.ses of massive hemorrhage.
NCLEX-RNO REVIEW QUESTIONS
o The patient in hypovolemic shod: is prescribed an Infu-
sion of lacmed Ringer's. The nurse recognizes the func
tion of this fluId In the treatment of shock is to: (Select all
that apply.)
1. replace fluid and promote urine output.
2. drawWllter into cells.
}. draw water from cells to blood ~ l s
4. maintain vascubr voIUIJlt'.
o The nurse eVlIluate5 the effectiveness of dopamine therapy
for a patient in shock. Which of the following may indi-
cate treatment is successful! (Select aU that 3pply. )
1. Impl'O' .. ed urine output
2. Increased blood pressure
}. Breath sounds are diminished
4. Slight hypotension OCWJ'S
5. Peripbinl puJses are intact
o Dobutamine (Dobutrex) is used to treat a patient experi-
encing cardiogenic shock. Nursing intervention includes:
1. monitoring for fluid o ~ o a d
2. monitoring for cardiac dysrhythmias.
}. monitoring respiratory
4. monitoring for hypotension.
29.5 Vasopressors ue critical care drugs sometImes needed
during severe shock: to maintain blood pressure. These
drugs are sympathomimetics that strongly constrict the
arteries and immediately raise blood pressure.
29.6 Inotropic drugs are useful in reversing the dKreased car-
diac outplll resulting from shock by increasing the
strength of myocardial contnetion.
29.7 Anaphylaxis is a serious hypersensitIvity response to an
aUugen that is treated .... ith a large number of difft'rent
drugs. including sympathomimelics. antihi5tamines. and
gJucocorticoids. Common drugs such as penicillins,
"_'Phalnsporins, NSAIDs. and ACE inhibitors may cause
anaphylaxis.
o Teaching for a patient receiving pluma protein fraction
(Plasmanate) should include reporting which of the fol-
lowing possible aID'erse react:lons?
]. Unuswl bleeding
2. Hypeiilytemia
}. Anaphybctic reaction
4. Hypotension
U Nursing aJiSe5.Sment of a pafient rewiving normal serum
albumln for treatment of shock should lnclude:
I. assessing breath sounds.
2. monitoring gJurose.
}. monitoring poIassium 1ewI.
4. monitoring hemoglobin and hematocrit.
o A patient is receiving a crystalloid infusion {lactated
Ringer's} for lreatment ofhypovolt'lllic shock. BeauSt' of
concerns for fluid volume overload, the nurse will fre--
quently monilor: (Select all that apply.)
1. bre:nh sounds.
2. potassium, gluoose, and sodium levels.
}. daily weight.
4. ~ of oonsdoumes:s..
5. aPTT, aPT, INR
LibraryPirate
416 UIIII.4 n-.. /J,dloY....:ulM ,00 UrlNry Symm.
CRITICAL THINKING QUESTIONS
1. A p.1lienlis on a norepinephrine (Levophed) dr ip for car-
diogenlc shock with a blood pressure of 84/40 mmHg.
Why Is this pal ient on this medicatlonr What nursing as-
.sessments should occurr When and how should the nor-
epinephrine drip be diSl;ontinued?
2. The health care provider orders J LofO.9'*' normal saline
(NS) for 22-year-old with vomiting and diarrhea.
and a heart rate of 122 bpm and blood pressure of
102154 mmHg. Is this an appropriate IV solution fOr this
patient? Why or why not!
1. A patient with a severe head Injury has been put on an IV
drlpof dextrose 5% water runnlngat 150 mlJh. The nurse
receives this tT:lnsfer patient and is reviewing the health
care provider's orders. Is the IV solution appropriate for
this patient? Why or why not?
See Appendix D for allSwers /ltId rationoles for 01/ oniv;ties.
OPlORE
... y .... ingKll i;}'(IlI" IDI skip lor orb dl<ipl8r '"",,"'N malt',ials ;nj
'esGUa!S. Preptre tor 3lI= with ilddiliooaJ NCLW-9lyIe p"";Ii;e
qlJes!lOns. (rte<actroe assigrvrenls and ""trollies. wtII hks. animm;
Itld vidoos, and JTlQfe!
IIfgos\ler l'l'J' code "om the lrQIII of fOU" book at
-.-.mynursift9kjt.com.
LibraryPirate
DRUGS AT A GLANCE
LOOP DIURETICS pl/l/tfJI
THIAZIDE DIURETICS pillJt411
o clllorollllozlcM (DMI/) pi1/t4]J
POTASSIUMSPARING DIURETICS ftl9t41J
o splronoIaCfOf'Ml(ll/OOC/OOfj ".4].1
MISCELLANEOUS DIURETICS Pfl9t414
Carbonic Anhydrase Inhibitors /D}t42S
Osmotic Diurtt ks (}f415
KEY TERMS
mbonknh,drnt ptlI}t414
poIjf420

Chapter 30
Diuretic Therapy and Drugs
for Renal Failure
LEARNING OUTCOMES
After reading this choprer; the studtn! should able to:
,. bplllin the role of the kidneys In maintaining fluld,elecl rolyte,lnd
add- base bal ance.
2. Explain the processes that change the composition of filtrate liS It
travel s through the nephron.
3. Describe the "djuslments In pharm"othefllp)' that must be considered
In patients with renal fllilure.
4. Identify Indi<:ations tordlurel l",
S. Oescribe the general adverse effKt s of dlurelk pharmacotherapy.
6. Compare and contrast the loop, thiazide, lind poUlsslufn'osparing
diuretics.
7. Dficribe the role-In the pharma<oIogk of renal
failure,and in diuretic therapy.
8, Foreach of the danes snown In Drugs at a Glance, know representative
drugs, and eMpialn the mechanism of drug K tlon, primary actionl, and
important advene effects.
9. the nursing process to care for patients who Ire re<elvl ng drug
thel'ilp)' fOf renal failure. and diuretic therap)!.
nfphron Jf1Jf418
rfablorplion ptJI}t4l!
plJ/t418
{1Jgt m
urinllylis (!I19t4ll
LibraryPirate
"


!

418 TheCardlcHo"ubr oodUt11101ry Systeml
T
he kldne)'$ S('l'Vt' an amazing role In maintaining home-
ostasis. By filtering a volume equivalent toalllhl.' body's
ntracellular fl uid every 100 minutes, the kidneys are able to
make Immedlit!e iKljunments to fluid volume, electrolyte
composltloo, and acid-base balance. ThIs chapter examines
diureti cs. agenl$ !hit! increase urine output, .nd other dru 95
used to treat kidney failure. Chapter 3100 presents iKldi-
tlonal agents for treating fluid, electrolyte, lind acid- basI.'
Imbalances.
30.1 Functions of the Kidneys
Whfn most proplf think ofthf kidnf}'S, they think of excre-
tion. Although this is certainly true. the kidneys have many
other oolTlC05t>.lic fur>ction ... lbc kidlK)'Jar( th( primaryo
gans for regulating fluid balance. eiedrolytecomposition, and
acid--trase baJall(eofbodyHWds. They also secrete the enzyme
renin, whKh helps regula!e blood pressure (chapter 2)00)
and erythropoietin, a hormone that stimulat es red blood
cell productio n (chapter 2800). In additi on, the kidneys
are responsible for the production of calcitriol, the active
form of 0, which helps maintain bone homeostasis
(chapter 47OJ11: .1t is not surprising our overall heaLth
is st rongly dependent on proper functioning of the kidneys.
The urinary system consists of two kidneys, two ureters,
one urinary b13dder, and a urethra. Each kidney contains
more than I million Mphrom, the functional units of the
kidney. Blood enters the nephron through the large renal
arteries and is filtered through a semi permeable mem-
brane known as the glomerulus. Water and other small
molecul es re:adily pa5S through the glomerulus and ('Iuer
Bowman's capsule, the first section of the nephron, and
then the proximal tubule. Once in the nephron, the fluid
is called filtritte. After leaving the proximal tubule, the fil-
trate travels t hrough the loop of Henle and, subsequently,
the di stal tubule. Nephrons empty their filtrate into com-
mon collecting ducts, and then into larger 3nd larger col-
lecting structures inside the kidney. Auid luving the
collecting du.::ts and entering subsequent porlions of the
kidney is called urine. Parts of the nephron illustrated
in .. Figure 30.1.
Renal Disorders
mOl't tIIon 17,000 kidney trlnlf'lanb Irt perfonntd
mort thin 70.000 PfopIr arton a Witting lor I rtplictment kidlle1.
Oneof f'lelY 750 ptOplt bom with a linglt kidlle1.A kidney
largtr and mort \\llnrratk!O injuryfrom he,nyl.mct lpotts.
About 21,000 Amrriam wfftr from dUllnit SO,OOO
die innu..ly fnm (JIM! rNlftllO tIR
T)'Pt iltht lNding rnM ofdwnK kidMy
kit 3091.10 4O'Kof 11_ me tldJ Fur.
Hyptrttftlion elM!fIIId Iuding YlM of [Iwnit kidney bibt.
_"ling lor abM 25" of 11_ (jle UtI! Itu
Many drugs are small enough to pass through the pores
of the giomerulusand enter the filtrate. If the drus is bound
to p13sma protei ns, however, il will be too large, and will
continue circulating in the blood.
30.2 Renal Reabsorption
and Secretion
When filtrat e enters Bowman's capsule, its composition is
that of plasma. Plasma proteins such as albu-
min, however, are too large to pass through the filter and will
not be present in the filtrate or in the urine of healthy pa-
tients. If these proteins do appear in urine, it mear\S they
were able to pass through the filter due to kidney pathology.
1.5 filtrate tra,'els through the nephron, its composit ion
changes dramatically. Some substances in the filtrate cross
the walls of the nephron to reenter the blood, a process
known as tubular ftllblolptiH. Water is the most important
molecule reabsorbed in the tubule. For every ISO Lof Wolter
entering the mtrate each day, approximately 178.5 L is reab-
sorbed, leaving only \. 5 L to be excreted in the urine. Glu-
cose, amino acids, and essential ions such as sodium,
chloride, calcium, and bicarbonate are also reabsorbed,
Certain ions and mol e<:ules too large to pass through Bow-
man's capsule may still enter the urine by crossing from the
blood to the filtrate in process called Potas-
sium, phosphate, hydrogf.'tl, and ammonium ions ent er the
filtrate through active Addie drugs secreted in the
proximal tubule include pmKilIin G, ampicillin. sulfisoxa-
zole, nonsteroidal anti_inflammatory drugs ( NSAlDs). and
furosemide: Basic drugs include procainamide, epinephrine,
dopamine, neostigmi ne, and trimethoprim.
Reabsorption and secretion are critical to the pharmaco-
kinetics of drugs. Some drugs are reabsorbed, whereas oth-
em are """reted into Ihcfih .... te. FOTexampie, approximately
90% of a dose of penicillin G enters the urine through se<:re-
tion. \'/hen the kidney is d3!naged, reabsorption and se<:re-
tion mechanisms are impaired and serum drug levels may
be dramatically affected. The processes of reabsorption and
secretion are iUustratoo in Figure 30.1.
RENAL FAILURE
iltlallaillR is a decrease in the kidneys' ability to maintain
electrolyte and fl uid balance and to excrete WlIste products.
The caue of renal failure may be due to pathology within
the kidney itself or the result of disorders in other body sys-
tems. The primary treatment goals for a patient with renal
failure are to maintain blood flow through the kidneys and
adequate urine output .
30.3 Diagnosis and
Pharmacotherapy of Renal Failure
Before pharmacotherapy may be comideroo in a patif.'tlt
with renal failure, an assess ment of the degree of kidney im-
pairment .. 11K' basic di agno:ltic to t i. a ..
LibraryPirate
(lIo",trIO DIJ'I'II(Thenpy and 0"'9' lor Renal F.llu.e 419
EtIo",nt
P9rmbwlr
,
."o.m. tubul.
GlomerU,,"
arta."
--
F '" FiU.ation: blood to tlbule
R" Reabsorption: hbH to blood
S" Secretion: blood to tubula
E'" E""",tion:tubule to
_mal ""vi......,.,.,.,t
FlgureJO.I Thenephron
which examines urine for the presence of blood cells, pro-
teins, pH, specific gravity, ketones, glucose, and microorgan-
isms. The urinalysis can detect proteinuria and albuminuria,
which are the primary measures of structural kidney dam-
age. Although it is easy to perform, the urinalysis is nonspe-
cific: Many diseases can cause abnormal urinalysis values.
Serum creatinine is an additional measure for detecting kid-
ney disease. To provide a more definitive diagnosis, diagnos-
tic imaging such as computed tomography, sonography, or
magnetic resonance imaging may be necessary. Renal biopsy
may be performed to obtain a more specific diagnosis.
The best marker for estimating kidney function is the
glomerular filtration rate (GFR), which is the volume of ftl-
trate passing through Bowman capsules per minute. The
GFR can be used to predict the onset and progression of
kidney failure, and provides an indication of the ability of
the kidneys to excrete drugs from the body. A progressive
decline in GFR indicates a decline in the nwnber of func-
tioning nephrons. As nephrons "die," however, the remain-
ing healthy nephrons have the ability to compensate by
increasing their ftl l ration capacity. Thus, patients with sig-
nificant kidney damage may exhibit no wltil
50% or more of the nephrons have"died
H
and the GFR falls
to less than half its normal value.
Renal failure is classified as acute or chronic, depending
on its onset. Acute renal failure requires immediate treat-
ment because retention of nitrogenous waste products in the
body such as urea and creatinine can result in death if Wl
treated. The most frequent cause of acute renal failure is re-
nal hypoperfusion, which is lack of sufficient blood flow
To """,I
To blltdder and "";n
eldernal enviromant
through the kidneys. Hypoperfusion can lead to permanent
destruction to kidney cells and nephrons. To correct this
type of renal failure, thecause of the hypoperfusion must be
quickly identified and corrected. Potential causes include
heart failure, dysrhythmias, hemorrhage, toxins, and dehy-
dration. Because pharmacotherapy with nephrotoxic drugs
canalso lead toeitheracuteorchronic renal failure, it isgood
practice for the nurse to remember common nephrotoxic
drugs, which are listed in Table 30.1. Patients receiving these
medications must receive frequent kidney function tests.
TABLE 30.1 Nephrotoxic Drugs
Drug or Class
AmphomidoB
Angiotrnsin-<onl'l'rling ffil)'IIIt
lACE)

Nonsteroidal infliOTnJttwy
d'ugs INSAIIlI)

RoIdiographic: (ontrJSI aogffil!
Indication

SySlmic:Jotiflllgal infffiioo
HTN, lINn
Viral iofffiioo
Inllimmi!ion
IliaoJIosi! of ItidfW1 n IeWr diIordm
LibraryPirate
420 UnII4 TheCJrdkIY.",ubr , 00 Url",,'Y Syuem,
Otronic renal failure occurs over a period of months or
years. Over half of the patients with chronic renal failure
have a medical history of longstanding hypertension (HTN)
or diabetes mellitus. Because of the long, gradual develop-
ment period and nonspecific sympto/Jl5, chronic renal fail-
ure may go undiagnosed for many years. By the time the
disease is diagnosed, impairment may be irreversible. In
end-stage renal disease (ESRD), dialysis and kidney trans-
plantation become treatment alternatives.
Pharmacotherapy of renal failure attempts to cure the
cause of the dysfunction. Diuretics are given to increase
urine output, and cardiovascular drugs are administered
to treat underlying HTN or heart fa ilure. Dietary man-
agement is often necessary to prevent worsening of renal
impairment. Depending on the stage of the disease, di-
etary management may include protein restriction and
reduction of sodium, potassium, phosphorus, and mag-
nesium intake. For diabetic patients, control of blood
glucose through intensive insulin therapy may reduce the
risk of renal damage. Selected pharmacologic agents used
to prevent and treat kidney failure are sununarized in
Table 30.2.
The nurse serves a key role in recognizing and responding
to renal failure. Once a diagnosis is established, all nephro-
toxic medicatioru should be either discontinued or used
with extreme caution. Because the kidneys excrete most
drugs or their metabolites, medications will require a signif-
icant dosage reduction in patients with moderate to severe
renal failure. The importance of this cannot be overempha-
sized: Administering the "average" dQse to a patient in 5eVfTf
renal failure can have fatal consequencef.
DIURETICS
Diuretics are drugs that alter the volume andlor composi-
tion of body tluids. They are indicated for the treatment of
HTN, heart failure, and disorders characterized byaccwnu-
Iation of edema fluid.
30.4 Mechanisms of Action
of Diuretics
A diu rrtic is a drug that increases urine output. The goal of
most diuretic therapy is to reverse abnormal fluid retention
by the body. Excretion of excer.s fluid in the body is particu-
larly desirable in the following conditions:
Hypertension
Heart failure
Kidney failure
Liver failure or cirrhosis
Pulmonary edema
The most conunon mechanism by which diuretics act is
by blocking sodium (Na+) reabsorption in the nephron,
thus sending more to the urine. Chloride ioru (CI- )
follow sodium. Because water molecules also travel with
sodium ions, blocking the reabsorption of will increase
the volume of urination, or diuresis. Diuretics may affect
the renal excretion of other ions, including magnesium,
potassium, phosphate, calcium, and bicarbonate ions.
Diuretics are clar.sified into three major groups, and one
mis.:ellaneous group, based on differences in their chemical
structures and mechanism of action. Some drugs, such as
furosemide (Lasix), act by preventing the reabsorption of Na
in the loop of Henle; thus, they are called loop diuretics. Be-
cause of the abWldance of in the f.iltrate within the loop
of Henle, drugs in this class are capable of producing large in-
ueasesin urine output. Otherdrugs, such as the thiazides, act
by blocking Na in the distal tubule. Because most Na has al-
ready been reabsorbed from the filtrate by the time it reaches
the distal tubule, the thiazides produce less diuresis than
furosemide and other loop diuretics. The third major clar.s is
named potassium sparing, because these diuretics have mini-
mal effect on potassium excretion. Miscellaneous agents
include the osmotic diuretics and carbonic anhydrase in-
hibitors. Thesites in the nephron at which thevariousdiuret
ics act are shown in Pharmacotherapy Illustrated 30.1.
TABLE 30.2 1 Pharmacologic Management of Renal Failure
Comphcatlon Pathogenesis Treatmrot
.....
l<idntyl arr unablt mough Epottin alfa (Prouil, Ep:>gm)
for rrd blood (ti prtdJaion
H)"pt!blrmia l<idntylarr unablt pota'Jl,ium Diml)' rrsuiction of po/yItyrrrH' I with
l<idntyl arr unablt p/mphalt Diml)' rrsuiction of pholphatt; p/mphalt bindtfs llKh OJ o:akium wbonatt
(<Mal SOO,othm),Ykium >Kt lilt ICaiptron. Pholllll,lanlliarum (.ubonatt
(foIrrnoI), or
HypmoIrmia uoablt suflidmt sodum ,lIId Dittary rmklion 01 sodum; loop tiIRtKs in 'IIditions, thiazide tiUrttKs in
wmr,ltading 10
H)"pOUktmiil I/yptrphosphalemia Itod I to 1011 of Y!dum Usually oorrffitd by !!'In-sing lilt tr;pI'rpholphatrmiil, but ldditional y kium
supplemmll may ill' nmssol)'
Mmbolk addosis l<idntyl arr unablt tlUl' tt mttabolic: Sod!l11 bit.Jrbmatt or sodium citrate
-
LibraryPirate
(lIopltllO DIu'ell, TMnpy and ONg. lor 421
PHARMACOTHERAPY ILLUSTRATED
30.1 Mechanisms of Action of Diuretics
o.molic di_;'"
Act on the pruoojmaI tubu'" .00 !he ""'" of
Henle, to create an 0Im0Iic fore. thai pub
water ;"10 t he ,Old Ihe
aliiolectrolyl_
.. ,
loop diuretic,
JIw:t on the Ii"*' of the loop
of Henle to block !he 01
.odium, chloride .,d w,' . Excretion
of 1.1nc .... M<i
It i5 oommon practice to combine two or more drugs in
the phafl1l.1ootherapyofHTN and nuid retention disorders.
The diuretics are frequently a component of fIXed-dose
combinations with drugs from other classes. The primary
rnliOllales for combination therapy are that the incidence of
ac!\'erse effects is docreased and the ph;lrmaoologic effects
(such 3sdiuresisor reduction in blood pressure) may be en-
hanced. For patient convenience, some of the5/: drugs are
combined in single.tablet fonnula lions. O\w 2S different
fIXed-dose combinations are available \0 Ireal HTN
(Table 2). 200). Examples of single-bblet diuretic combi-
nations that include diuretics indude the following:
AldaC\3zide: hydrochlorothiazide and spironolactone
Dyuide: hydrochlorothiazide and triamterene
Zestoretic: hydro.;hlorothiaz.ide and lisioopril
30.S Pharmacotherapy
with Loop Diuretics
The most effective diuretic; are the loop or high-l'eiling di
uretic;. Drugs in this class act by blocking the reabsorption
Thiazide diu..-!K:.
Act on !he 68I1y <Hlsllubule 10
block !he reabIorplion of .odium.
chloride. and water. E><cretion 01
pot ....... m ;. Wlcreued.
EIWIy distill
" .....
... .mg diuretic.
Act on \he I,,, dioolai tub ... ....::I
c:ohcMg to block 1M
of""-" rn::I reduce
Ito. _ion 01" pot...un
lllOdiun-poWIeium eKhange).
E><a-.6on 01" potao.ium ia not
of Na" and Cl- in Ihe loop of Henle. When givt'n IV, Ihey
have the ability 10 cause large amoWlts of fluid to be ex-
creted by the kidney in a very short time. loop diuretics are
used to reduce the edema associated with heart failure, he-
patic cirrhosis, or chronic renal fail ure. Furosemide and
torsemideare also approved for HTN. Doses for the loop di-
uretics are listed in Table 30.3.
Furosemide is the most frequen tly prescribed loop di-
uretic. A prototype fealure for furosemide was given in
chapter 2400. Unlike the thiazide diuretic.s, furosemide is
able to increase urine output even when blood flow to the
kidneys is diminished, which makes it of particular value in
patients with renal f.lilure. Torsemide has a longer half-life
than furosemide, which offers the advanl<lge of once-a-day
dosing. Bumelanide (Bumex) is 40 times more potent than
furosemide but has a stwrter duration of action.
The rapid excretion of large amoWlts of fluid has the p0-
tential to produce serious advt'rse effects, including
lion and electrolyte imbalancel.Signs of dehydration include
thirst, dry mouth, weight loss, and headache. Hypotension,
dizziness, and fainting can result from the rapid Huid loss.
Potassium depletion can be serious and cause dysrltythmias;
LibraryPirate
422 UnII4 TheC.,dklv ..:ula, 00<1 Urinary SY'tem.
TABLE 30 3 loop Diuretics
DN'
Route and Adult Do5t> (max dose where Indicated) Adverse Effects
(Bum!'lj 1'0;0.5- 1 fll9lday,1MI rrpti! at 4-- 10 inrmai lif IItI'dtd Mioor hypokoltmio, pI1WO/ hyportmioo, rmiflll,
(max: 10 mgldar) dl1inru, /'Qrigw
I'I'IIM;05- 1mg OW'I 1- 1 min, 1- 3 houl5 PRN
(max: 10 mgldar)
='
;
t1hKrynicadd (Ett:uinl 1'O;s()-IOO mg 1-1 times/day, may ilK/e.lII' 1r12S- SOmg PRH
(max:400 mglday). 1V;05-1 m9 or SOmg (max: 100
(It!' pag!' 330 I'O;20-BO mg in si"* <iNs (madOO mglday)
forttw, Proiotypt Drug boJ; OO)
I'I' IIM; 20-40 mg in or djyjdtd dole !4ltO 600 mglda!'
(Dmladu)
-
POllY; 10-10 mglday (max:100 mglda, )

potassiwn supplements mar be prescribed to prevent hy-
pokalemia. Potassium loss isof particular concern to patients
who are also taking digoxin (Lanoxin) because these patients
may experience dysrhythmias. Although rare, ototoxicity is
possible, and other ototoxic drugs such as the aminoglycoside
antibiotics should be avoided during loop diuretic therapy.
Because of the potential for serious adverse etfects, the loop
diuretics are normally reserved for patients with moderate to
severe fluid retention, or when other diuretics have failed to
achieve therapeutic goals.
tion. Their primary use is for the treatment of mild to moder-
ate hypertension; however, they are also indicated for edema
due to mild to moderate heart failure, liver failure, and renal
failure. They are less etfective at producing diuresis than the
loop diuretics and they are inetfective in patients with severe
renal failure. The thiazide diuretics are listed in Table 3004.
30.6 Pharmacotherapy
with Thiazide Diuretics
All the thiazide diuretics are available by the oral route
and have equivalent efficacy and safety profIles. They dif
fer, however, in their potency and duration of action.
Three drugs--chlorthalidone (Hygroton), indapamide
(Lozol ), and metolazone (Zaroxolyn)--are not true thi-
azides, although they are included with this drug class be
cause they have similar mechanisms of action and adverse
etfects.
The thiazides constitute the largest, most frequently pre
scribed class of diuretics. These drugs act on the distal tubule
to block Na+ reabsorption and increase K+ and water excre
The adverse effects ofthiazides are similar to those of the
loop diuretics, though their frequency is less, and they do
not cause ototoxicity. Dehydration and excessive loss of
TABLE 30.4 Thiazide and Thiazide-Like Diuretics
Drug
SHORT ACTING
Q dllorothiilidt (Dillil)
h)'ltodllorothialilr
piljt 304 Proiotypt
Drug boJ; OO)
INTERMEDIATE ACTlNG
btndroftLmelhWidt and oadol ol (u.zidt)
mtioluOIIt (Iaroxolyn)
LONG ACTING
ind.Jpimidt (LmoI)
mtllrfdothimdt (Aquatmlm, EndJIOII)
Routeand Adult Dose (max dose where Indicated)
1'0;250 mg- l glday
1'1';1.0 mq- 1 gld>y in <inglt O< two diYidtd do ...
PO;15- 100 fll9lday or rividtd dolt (m.x:SO mglday
forHTN; lOOmgfdayformu)
PO; I ubltt{dar (40-&:1 mg nmIoII5 mg bmdIoIhrmtlhialilr)
1'0;1.5- 10 mg d,iiy (max: 5 mg/dol)' for HTN;1OfII9Iday

1'0; s()-I 00 fll9lday (max: SO mglda!' for HTN; 100 fll9lday

1'0; 1.15- 1.5 mg d,iiy (max: 5 mgldol)' )
1'0; 1.5- 1 0 fll9lday (max: 5 mgtdol)' for HTN; I 0 fll9lday for
Advel"le Effects
Mioorhypcko/mlio,
Signifi9nl hypobl..,io. tIKi.
hypotension.
hmonatrrmj' byprodyCflllj.! ((())' blood
"""'"
LibraryPirate
Na+, K+, or 0 - may occur with overtreatment. Concurrent
therapy with digoxin requires careful monitoring to prevent
dysrhythmia.<; due to potassium loss. Potassium supple-
ments may be indicated during thiazide therapy to prevent
hypokalemia. Diabetic patients should be aware that thi-
azide diuretics sometimes raise blood glucose levels.
30.7 Pharmacotherapy with
Potassium-Sparing Diuretics
Hypokalemia is one of the most serious adverse effects of the
thiazide and loop diuretics. The therapeutic advantage of the
potassium-sparing diuretics is that increased diuresis can be
obtained without affecting blood K+ levels. Doses for the
potassium-sparing diuretics are listed in Table 30.5. There
are two distinct mechanisms by which these drugs act.
Normally, sodium and potassiwn are e.ll:hanged in the
distal tubule: Na+ is re3bsorbed back into the blood, and K+
is secreted into the distal tubule. Triamterene and amiloride
block this exchange, causing Na+ to stay in the tubule and
ultimately through the urine. When Na+ is blocked,
Prototype Drug I Chlorothlazlde (Dlunl)
Therapeutic Class: Ant ihypertensive,agent for reducing edema
ACTIONS AND USES
1M most (ommon indk,tion ior(hlorolhiuidt mildto lIlodmte HTN.1t may
br with omf r in lilt mukidrug thtrap)' of !f"I'l'Ie
HTN.1t is also presaibrd to tINt lkJid rr1fmion dR to htan flilure, liYel" dis-
fJIl', and (onic:ostf roid or rstltM}en mfrlp)'. Wlltn thf d",g is givfn orJlly, it
may aslollC) as 4 Wffb ro obtlin thf opcimum theraptutic: tflKI.
ADMINISTRATION ALERTS
GiW'oraldolel in thf momillC)toprf"lfm intflTUpted !leepdUl'to noaurY.
GiW' IV at a of 0.5 9 OYer S min when
Whtn idministt rillC) IV, take speliil Wf 10 avoid ntrmsation, bK.iUIl'
Ihis drug is highly irritatinglotissurs.
PlI'9
nJ
IKYUitgory(
PHARMACOKINETICS
PO;lS min IV
PO;30 min IV
Halflif! : 45- 120 min

Cll.1pt0l30 Dkl,"'I(Then py and 0"'9' lor Renal F. II",,, 423
the body retains more K+. Because most of the Na + has al-
ready been removed before the ftltrate reaches the distal
tubule, th ese potassium-sparing diuretics produce only a
mild diuresis. Their primary use is in combination with thi-
azide or loop diuretics to minimize potassium loss.
The third potassium-sparing diuretic, spironolactone,
acts by blocking the actions of the hormone aldosterone. It
is sometimes called an aldosterone antagonist, and may be
used to treat hyperaldosteronism. Blocking aldosterone
enhances the excretion of Na+ and the retention of K+. Like
the other two drugs in this diuretic class, spironolactone
produces only a weak diuresis. Unlike the other two,
spironolactone has been found to significantly reduce
mortality in patients with heart failure (chapter 2400).
Eplerenone (Inspra) is a newer aldosterone antagonist
that is claimed to exhibit fewer adverse effects than
spironolactone.
Patients taking potassium-sparing diuretics should not
take potassiwn supplements or be advised to add potassium-
rich foods to their diet. Intake of excess potassiwn when tak-
ing these medications may lead to hyperkalemia.
Pharmacologic Class: Thiazidediuretk
ADVERSE EFFECTS
Ur:tssioss of w'ter and can i)((lJr during chlorothi.uide phlN-
(otlil'rap)'. Symptoms ioc:Ude miBt, I!>thargy, mUl(I!> (lamping. hy-
polfnsion,and tac:hyutdii. lieuUS!' of thf polfmially sfrious of
hypokiltmia, pltienn (ooc:urrrmly takillC) digoxin should be utclully
tored. Thf intlke of foods should be ilKru!l'd, and supplt-
menll may be indicalfd.
Co ntraindi alli ons: This drug is (ontraindiutfd in with anuria,
hypokaltmiJ, Sf"lfll' hepni( or II'nal and hYPf llensitiviry 10
sulfonamide-!.
INTERACTIONS
DnJ}-D"'l: WhMg ..... ,onrmmtywilhotluor ilnlih)'lW'fl...u."\ odIiI .... PIfIorn
on tmd preIlln wil OUII". Wh@ndllonlthiazidfisadmir:i:lK>lHlwithMnphotflil:il
8 or (ortic:osIl'loids, the risk for IIypolr.Jltmi: fll"em inaNlel. AntidiabetK
mrdutionsllKh j\ 511l1orl)hmsand may bf ifss t.Jkin with
(hIorO!hia!icko. OIoItstyramRand theabsorption of
Coooirrto1l mnistralion wth dgon to
inaN>;N potas and magnesium lois. AkOOoI poitlltiates the Il)poltlllft anion
of \OIIIf thiazidlo dilnli:5,and inaNsf durflis.
Ll b TfllI: OlIorothiazidf may iOOfH StIIIII a!l)"Ift ,aIue\ ind
1Uf000omophthalffi (SSP) Iflfntion. Ma, 00-proIMlboood (PBlI
Uutl and iniOOm with urilf l'ltl1id domorminition.
Helba VFood: AbIoIption of <hIorothiazidf is ilKrNItd wIII'I1 ial;tII with food.
lkorkt and ora I iIof, il iargl' amDlftS, may WIWII h)1lotalem.. When IMd wi!lt
(hlorothialide. gintgo may inaNsf IMIod pII'IllR.lIIf with IIawthom may
inaddiriv-.> eIIerts.
TlNtmem of OYt'rdose: TlNtment indudt>s Auid andelectrolytf infuliooslnd
drugs !Mel to blood prtlsull'.
It!ftr Ie M)NUB InqnI for Q Nurlifll) I'rIKIn foals lp1k Ie IhII
LibraryPirate
i
o
,


424 UnII4 The Urinary Synefm
TABLE30.S Potassium-Sparing Diur"tics
Drug Routeand Adult IJosio (maxdo5e where Indicated) Adver5e Effects
"mikHid. (Mi,," .. or) 1'0;> (mu:lO rngIdoy)
tplmIIOfN' (lmpra) 1'O;1,- SO mgOlKtdaiy [max: 100 mgldolY fof HTN;SO m9i'doJY for hun faiull')
M'"", !ry"''*''Itmio, htDdht, frlrigtH,
gynK0/I1Q5Iio
" SjiItW'dlOllt (AldiClmt) 1'0;1,- 100 mg 1-1 timffidoJY (mu; 400 mglday)
triamtmot (Dyrrnium) 1'O;'iO-100 mg bid (mu; 300 mglday)
lidifl COIIIIOOII tfl'ffls;.!.!:lli!!i!!m.inditite strioos
30.8 Miscellaneous Diuretics
for Specific Indications
A few miscellaneous diuretics, listed in Table 30.6, have lim-
ited and specific indications. Two of these drugs inhibit
an enzyme that affects acid- base balance by
its ability to form carbonic acid from water and carbon
dioxide. Acetawlamide (Diamo.""!:) is a carbonic anhydrase
inhibitor used to decrease intraocular fluid pressure in pa-
tients with open-angle glaucoma (chapter 4900). In addi-
tion to its diuretic effect, acetazolamide has applications as
an anticonvulsanl and in treating motion sickness and glau-
coma. lt has also been used 10 treat acute mountain sickness
in patients at very high altitudes. The carbonic anhydrase
..,. Prototype Drug I Spironolactone (Aldactone)
inhibitors are not conunonly used as diuretics, because they
produce only a weak diuresis and can contribute to meta-
bolic acidosis.
The osmotic diuretics also have very specific applica-
tio/lS. For example, mannitol is used to maintain urine flow
in patients with acute renal failure or during prolonged sur-
gery. Since this agent is not reabsorbed in the tubule, it is
able to maintain the flow offtltrate even in case; with severe
renal hypoperfusion. Mannitol can also be used to lower in-
traocular pressure in certain types of glaucoma, although it
is used for this purpose only when safer agents have failed
to produce an effeCI. It is a highly potem diuretic that is
given only by the IV route. Unlike other diuretics that draw
excess fluid away from tissue spaces, mannitol can worsen
Therapeutic (lass: Antihypertensive,drug for reducing edema Pharmacologic (lass: Potassium-sparing diuretic,.aldosterone antagonist
ACTtONS AND USES
Spironolao:tone, most frrquemly potmilm--sparing diurHic: is
prill\l rily used to 111'11 m ild HTN,oftl'll in combination with antihyperttn
si"ltl.k molY bt lMIl to aSICK;,ted with kidney
it is tfleo:ti'lt in mwing lhe proglffiion ofhean faikrll'.
SpiroOOW({ IUS by inhibiting lhe hormolll' mrHtd by the
adren,1 (OrreX thit is responliblt lor increasing the II'nalll'absorption of U!+
in 9(hangt fOf ,thus (ausing watu II'tention. When lkiosimlll' is blocked
by spironol"tolll', N, and wale, 9ClMion is incll'alfli and bod)' II'lains
more potassium. Spironola({OlII' may also bt ultd to trtat prim'll hypera Idos
ttronism. k is availablt in ubltr: form, and as I combination with
hldnxhlorolhiuidt.
ADMINISTRATION ALERTS
Gi"ir with food to inmall' tire ablorption of thr drug.
Do not gM-
PlI'9nallQ catf901l 0
PHARMACOKINETICS
iAlset: 1- 2days
Pl!ak;1- ldays

Ouralion:1- 3 days or mort
ADVERSE EFFECTS
Spirooolmolll' does such an ffficifm job of lI'I'ining K that hyptrbltmg
lI\Iy r1tvtlop. TIlt risk ofhyptrbltm;, is inmased if the palil'llt tlkts potassium
supplemtnts or is taking ACE inhibitors.. Signs ,nd symptoms of hy
ptrblemia include mus<1e Wt'aklll'ss, fuigut, I nd bridyu rdi'.l n spirooo
laaolll'un CilUgYlII'ComiStia, diminished libido. '&I11I'II m,y
uptfifnu IIII'IIItrual illl'9uiaritifs, himrtism, anc! bll'lSI ttnlierlll'lS. When
serum potassium levtls III' monitoll'd ind lI\Iinrained within oormal
tffKtS from ulI(ommon.
Contraindications: Spirooola(tolll' is romraindiuled in patitms with anuria,
significanl of II'MI function, or hypmalemg. SpironoL!dont is
rontraindiuted during Pll'9nancy and LKtilion .
INTERACTIONS
1AlJg- 1AlJg: MIlt ammonirn <IIIotiM,iICidoIis
m.Jf !KCUL Aspirin and 0IhH s.alicylar:1'I m.Jf droNse thr riu"flK of the
mtdication. (oocUJltfllllll' with digoxin m.Jf dooNSf 1l1li' IIIi'm of digcl;i1. WIlI'I1
ubn with inhibitoo,and ARBs.h)llffb1ernj, II\I'f
rtIUt. (orKIUlmtllll' with illllih)"pl'l'1el"6im wit R'lUk in an addiIi"lf hypotalli"lf

Lab lests: SpironoLKtOlll' m.Jf i KIUlf cortisol nlkli'l, and m.Jf
wfth IffIIm gllKOIt dflHrllinalion.
IlerbaVForxl: Use with hawillJrn m.Jf in adcim"lf h)'POlensl"lf ffIem.
Tll'iltmt nt of Overdose: is supportive and miY ill(ludt oJ9!'nts 10
II'pw(t' Auid and lost through dilll'lis, and drugs 10 raM blood
PIl'SIUII'.
LibraryPirate
(1101'1,,10 Dkl,,,,I<lhe ... py and Dru9' lor RenoII 42S
TABLE 30 6 Miscellaneous Diuretics
0""
Route and Adult Dose (max dose where Indicated) Adverse Effects
CARBONIC ANHYDRASE INHIBITORS
(Oiamox)
(Neptll.Jnt)
OSMOTIC DIURETICS
giyc:mn (CoIaa, OImoglyn)

ulI'i(Uruphij
PO;l50-l75mglday
PO;SI>-I00 mg bid-tid
PO; 1.1>-1.8 gItg. 1- 1 h ocuLar
IV; 100 9 .. fused IWtr l--i. h
IV; 1.1>-1.S QI'kg 1- 15 h
fJrro/yrt imbolonm fllllIStQ, M1mi D'ng. dizzirlfSS
QrhWlion. blood dysaas@s. fludd p.m!y!is,
hrnIoIytil alllalli!: aomlY
fJrro/yrt imbolonm fllllIStQ, M1mi D'ng. dizzirlfSS
Hyponalltrllia @dMalliia
NURSING PROCESS FOCUS PATIENTS R'CEIVING DlURETICTH'RAPV
Assessment
Baseline assrssmrnt priort o administration:
Undt,mnd the II'iIson the drug has prt'S(ribtd in onitrto iSseS for
thmpMic:effeds.
Obmin i lomplttt IINkh history ilKluding wdiova!<Uludilfiif, and
or i drug hislOQ induding
prt'S(ription and OlC herbal plI'poIrations,IM of digoxin,lithium,OI
dlll9l,and alcohol UII'.Bt iltn to pouiblt drug intmctions.
['/illuate appropriate IaborMO!), findings SUlh i S elearolytes, gillloll', CBe,
01 Jl'llil fulKtion nudie,uric acid leYeh,and lipid profile.
Obtain 'ftight, vital signs (epffially BP i nd pulll'), b,eath IOUndS,ind
Ii,dial monitoring (t.g.,ECG,wdiac: output) appropriate. Asses 10, location
and Iharalterfamoont of Memi, if prmnlAl1N bill'line Iiti ring and

Assess mrnt thro ughout ildministration:
/0, do<i...d IhrrapMK ( . g., a<loquat. urill<'output.Iow.1I'd BP
for HTN).
ContinUl' pl'riodic: monitoring of (Be, lipid li'f!'r
limlrion studies, (II'iItininr, and uric ilid (eo,ocls.
Alses for and rt port
mUI(ulosIceIetal or (limping. nausta, I'Omiting, i bdominal
(limping. diarrhea,or litadillit.Tinnitus 01 hearing IoIS,1oss ofbalalKr or
incoordination, ;t'Itll' hypotension illOOl panitd by tathYUldiil
de<lI'ised urinr and weight9<lin or loss O\'ef 1 kg
21b) in a 2Hoo, pl'riod Ihould be II'plntd
Pot ent ial Nursing Dillgnoses
OefKitnt FluidVoume (relattd to rflects of diurtlin)

Card'1iK Output (relattd to elleets of diurtlic:s)
o...lKitm Koowltdge (drug thmpy)
Risk for Falll, Risk for InjJ!)' (lI'Iattd to hypotl'll5ion,diuiness

Risk for FulKtiolli IlnrononelKr (1I'1ated to diull'tic: use)
Risk for NOIKOOlprrallle (1I'lattd to idVflll' effects of drug therapy)
Plll nning: Patie nt Goal s and Expected Outcomes
Tht patitm will:
upI'ntlKe thuapeutic: eiff{lS deptrldtm on the lI'ilOn the drug is being given (e.g.de<lI'iII'd blood pmSUIl').
Bt from, or elpentlllt eiferu.
an understanding ofthedrug's IM,adw'II' elferu. and rrqJill'd precautions.
DMlOnstratf PI'Opl'l' \eIfidministration of the medication kg.,dose, timing, when to notify pI'llI'idtr).
(Continued)
LibraryPirate
426 UnII4 Th"C.rdloY.<;(ubr.od Url",,'Y Syuem,
NURSING PROCESS FOCUS PATIENTS RECEIVING DIURETIC THERAPY (COOUnuw)
Implementation
Interventi ons and (Rati onales) Pati ent and Famil y Educat ion
Ensuring thf'il peutic effects:

CominUl' fre!p'M ilS d,,!(ribtd t il rlitr for thtraPfUlic tffts: uriIII'

Ttim tht family,o,aregi'ltf how 10 IMnitor and blood
output inc:lt'ned, blood and puiS!' alt' within oormallimits or within plt'lSUIt'. Ensult'w p!OpfI" US!' and functioning of any homt
p.11i1mt1m!!'l by tht hNhh we providtl.(Diult'm may be rrodnal\' to equipmtnt obtained.
txtrt'llll' dl"ptllding on W 1)'pt of diJmic gi'll'll. BP ,hoold lit within nannal

Havt tht p.1titm wtigh !til daily ilnd It'(ord weight liong with blood
limits without the prestna of It'ftex tachy{ln:I ii J
plt'lSUIt' Ind measult'flltflts.

Daily should JI'fllain at 01 do!!' 10 ba.tlilll' wright (An in
wright Oftll kg perday may indic.!t" rmssiYt lkJid ljiIin. Adttlt'ilS!' ofOVff
1 kg ptrday indicatt t llltS'Mo diult'l6 ilnd dth)dration.l
Minimizing ildft rse rifttts:

CominUf to monitor yj",l.iglll.Til ko blood prturtlyir.g.,itting.' nd "ilnding

Tum rho 10 ri from lying o ining to "ilnding <lowl)- to
to dtiKl onhoSlilric hypoil'llsiolL 8t wniour with tht tldtrty who art at .woid diuinffi or falls.
inc:lt'iI!!'d risk for It'dKt circulating blood wlumt,

In.trod tht p.1titnt to .top tlking tht mediution if blood prt'SUIt'
ft'IIlking in _red blood Pftssult'.Dnhostatic hypott lllion II\a)' ilKlNS!' the
90160 mmHg or beIow,or palamtttrs It! by the ht ahh art
riskoffalk.)
and promptl)- notify the proyidtt

CominUl'to monitor tltatolytes.gwS!', CBC,Iipid profile!,li"ltlfunction

InstllK! tht p.1titnt on the to It'tum ptriodiuliy lor bb work and
(It'atinilll',and urit ilcid te-;m. (MOlt diult'liu {,IUS!' 1015 of Na + and K+ 10 inform bbolalOry pmorIntl of diult'lic therapy when providing
Ind may inc:lt'iIst lipid,gkKost, and urit acid blood or uriIII' slmplts.

Advi!!' tht p.1titm iI wallet idtntifiution card or Wl'iIr mtdiul
identification jtwtlry indiuting diuretic therap)'.

CominUl'to monitor heiring Ind balanc:t, .. poning tinnitUl or

Havt tht p.1titnt rrpon tinnitUl, il nd balana or coordilliltion
promptl,. (OlOtoool)' may with loop diurtliu.) probltrm immediattl)-.

En lUre saftl)', tspt<ially in the tIdtrIy. ObS!'1'fI' for diuilll'!5. Monitor

Instruct tht p.1titnt to all for prior togening out 01 btd or
Imbulation until tlfttt.of drug alt' known.(Diuinffi from OrthoStltK altempting lowllk alone,and Io.woid dri'ling or other adivitits
hypott nrion nwy oc(ur.) rrqJiring mtntll aleflntlS or physicll mon:linatiort umil thetffeo:tsof
tht drug art known.

Wtigh the p.1Iient dail)- and It' port significant ljiIin,or Mt.tsurt

Havt tht p.1titnt weigh !!'If daily, ideally at the SilIIIt timeof day.Havt
intlbo and output in the horpiulill'll wright an H(Uratt tht repln a weight 10" or gain of mort than 1 kg
rntiIsu .. of fluid ,tlIUI il nd ubos intoatcount OUIpul,lnd in!!'lllibk (approximattly lib) in .t lHtour ptriod.
is indicated by outputlignirKilntly g .. attr than intikt.)

Advi!!' the patitnt tocominllt to (Olllume t nouqh liquids 10 .. main
adequattiy, but not ovetty hydrated. Drinking wlltn thirsty, avoiding
akoholic btvtragts, .t nd trlWring l<ltqwl\' but not H(ffiM Silk
inuke will mist in maintaining normal fluid balanc:f.

Tt lm tht that htat ronditions (ontribul\' to
swrating and fluid and t ltctrolytt lOI5,and extra aution warranttd
in tlltst ronditions.

Monitor nutritiollill surus and tntllurage approprul\' intlke to p ..

InstllK! tht p.1titnt taking poulSium-wosriaq d'ure6u thiazidts,
t lenroiytl' imb.J iii IKts. (Be(\rol)'ll' imb.J b IKt, milY <KCU. with diu rtlin. Most thiazidt.Jikand loop diurttin) 10 consume food! high in
diJ .. tiu Glust Na+ and K+ 1os . PotmiJm-sPlring diu .. tia may ItsUh in Na + Ir!-rh fruits IlKh IS st,awOOr;" and fruits IlKh as
10 .. but K+ in{"'blt.) IpricO" t nd prunr.;.rgoubin ilnd I.tomlton,
and dried beilll;juict"lllKh i,orange,grapefruit or prunt ;andfrtllt
-,.

lortruct the p.1tiem "'king ootmiJnHD<!OOq dUttju to.woid bam
high in K+ such ardtstribed earlitr,oot tOust wk sm.mUil'! (which
ofttn roman K+ wits), ind with a heakh care Plll'lider befort
"'king ';lImn.nd mi""",1 ouppItrnmt. or 'pr<;'Iim! .porI>
(Typial ore sports and haw
Ie! Itr amounn of pot.mium but haYt ligh carbolrydlal\' amounn. which
may IrnI to inc:1t'iIed tiurtsis,diirrllta,im thepottntial for
dthychtiort from the hyptrosmoI.tril)'.)
LibraryPirate
NURSING PROCESS FOCUS PATIENTS RECEIVlNG DIURETIC THERAPY (Continued)
Implementation
Interventi ons and (Rationalu)
Ot-w for Ii9nsof hypoUImJia or wlh cwtion" p.ltitnb
taking cortKoste!Oids, AlE inhibitors, nmff<tptOl' blodtn (AR&),
dig<*in,or lidlium.RtpOfI symplorns 10 tile Wf pmicltt pJmptl)o.
thiazide..lilo:t, ind Ioopdiurttics on uusr hypoulemw;potassium-
SPiring cIi.Irtrics miy UUIt hypfrkalemii. CDIKUlTtI1l Ult willi (orn.;ostrroids
mi, inuult lilt iN. ofbypoblrmia.ConCLlrTftlI 1M willi ACE "bibitoo or
ARBs may ifl(rtasr IIIr risk of UIt with digoxin
incfll!asts lilt risk of poteolwily fatal dysJbythmiM and COIICIJfftnt list witb
lilhium may OOIt tOllie 1Mb of the dNg. 1
Ot-w for Ii9n s of hyperglyumii. Ust with caution in patirnl5 ...nth di.lbetts.
(Thiazide, Ihiazide..lilo:t, ind loop diurtrics may aIIsr
in cliibHics.)
Ob_ for symptOrm of gcuI.(OiurWa may c.Jusr hypmIricemia, whieh rna,
rtS4Jlt in goutlile "cWl\Cjwirmth, pain, ttndernru, ind
around joints, irthriti5liR symptoms,and Flfllilfd in
afftfd joints.)
for lll!lbuming if ptOlonged II.IfI CXpolUft has occumd.{Milny d-..n'oo
c.JlI5t ind .m rts.k of sunburning.)
Ob_ for sq. s of infeion. (Somediurrlics may dKrtl\e white blood cell
counts. Agrinulocytosis is a possille effm of diuretic thtiapy.)
P.tint of dnrg tht rlllY:
Ust opporlunitie5 during of mtdialionsand during
alStssmelllS 10 disruss tilt mionile fof drug 11Imp)', drsirtd thrrapeutic
OI/Icornn,most common riIKts, piraflll'tm lor wilen 10 c.n thr hr.1ttI
w e prarider,ind Iny _nwry monitoring or timr during
mIning art helps 10 optimizt and rtinflm key I9d1ing Irm.)
Patint sftfadm inislrit ion of drug thfriP":
Whrn administffing lilt mfd"Kon,imtlUCl tIlr patitnt, f.lmilJ,or unogiYtr fl
1M self-administration of thedNlI, r.g.,r.lriy in the day 10 pmml
disruplion of sftpfromnocturia.(PropeI.inistrltionincrtueslllt
tffI1vrIltsS of the drug.)
Patient and Family Education
ImtRKl p.llimllO n'port signs and 1IIIptorm ofhypobllmii or
hypM.ilrmii immfdiitrly til Ihr hulth QI! pmidrr.
Trach lilt patitln to folbw MOI1llMl"ldt<i d"lttary intattof high- or
Iow-potusUm foods mPPfOprim 10 tilt typr of dWlie 10
al'Oid hypoblrmw or
InslRlct the patient to rfPOrI signs Ind symptoms of diabtttS fMllitus
(r.g., potydipsw,poIyphigii ) or rlr-tnfd blood 10 lilt hrakh on'
proWltr.Oiabelic pilirnb JlV1 nrtd 10 monitor theif blood glllWSr
1Mb mort frtqllClltly unlil the rifects of tht diurttic.ln' known.
ImlNct the patienl 10 pftllI1jlIly n'pOri sigllS and symploms ofgoullO
the lItilttl prO'lidef.
k<Jdl tlltgoutlll1)1W incrtalt fluid intakt, wli'IQid
sbrIffish, orgin flll'ats {t .g., mr, bllIrJI), alcohol, and high-fructOst
bevtrlgM.
InSIMI the patient 10 wtar sunSl:rttn wi prote1vr dotting if
prolofI9'HI sun BpcI\.IIn' is I
InslMI the patienl to rfPOrI in, fluliu symptoms: shormns of
sore mroil, p,in,or profound
Tilt p.!tifnl, fimily,orcategi'lel should be to sUle tilt _ for
lhe dru!lipptOprint dolt and Sl:hedufing;what adYtrsr elFKtS to
oimfYt for and when 10 report; inc! the anticip.lttd Itngth of
medication tIlrrapy.
Tilt patifnt, family,orc.JnogiYn is iblt m!Zruss
.Inc! adminirnation fIefds.
EVlLluatlon of Out come Criteria
tM rfWti'lmtSl 01 drug IflrriPJ by ronfirmillll Ilia! patRnt 00i1l otrId Bpt(Ird been flll' 1 (see1'lanninl(l.
Stt ra5JQ.1 thvuqhJO.4foffsIJ rt whidI rIef
LibraryPirate
428 UnII4 The urdkIY.",ul.r.nd Url .... ry syne<",
edema and thus must be used with caution in patients with
pre-existing heart failure or pulmonary edema. The excep-
tion is the brain: Mannitol and urea can reduce intracranial
pressure due to cerebral edema. Osmotic diuretics are rarely
drugs of first choice due to their potential toxicity.
& COMMUNITY
Nutritional Therapy for Patients Needing
Diuretic Therapy
The patient lI'quiring diuretic: ther. py at hom!' nffils detailed
INChing. Till' should also pro'/ide tmhing with family or
carf<jil'!'B who art illYOiwd with food shopping and prtpoaralion. Depending
on the diurdic: prflCribtd, the focus lIYy bt 00 foods high or low in sodium
and polassium. Additionalleac:hing is needed II'9'Irding lNding and inler-
PfI'ting food labels. Thffl' may be added 50dilm and in proce!.\td
foods, btvmgtl (sports drinks), and sak substiMes. fdJutioo will help with
food shoppinglO tmIJrt thu electrolyte lewis rtmain IIOfIlYI during diumic:
llII'r.py .
. ';': Chapter REVIEW
---
KEY CONCEPTS
COMPLEMENTARY AND ALTERNATIVE THERAPIES
Cranberry for Urinary System Health
NNrt,< tl'l'f)'Ont is familiarwith till' bright red (ranbtroo lhat all'filten dur-
ing hoIidly time. MillM< Americans I.Md till' benie to UNt
wounds,and to anorexia ilnd for (omplaints.ln the 1900s,
it was noted tbat the ac:idity of IIII' urine inm'RI after filting cranberriH;
llIls IItoan the btlitfwt (rilnberry juic:e is a nalUlill lUll' for urinary trac:t in-
fKtions. The herb is I.i!:en a\ juic:e or dried berries.
(ranbtl!)' (omains a sign iliunl ilmount of vitamin ( and ollll'r ilmioooilnll
lIIat can promott lII'alth. Tht)' (omain ilsubst.lKt lIIat can pll'ftnt bmmil
from stic:king to till' walls of the bladder. Rel!'aKh Ihill "anbtnYs
can pK'I'I'Ilt I)'IIIPlomatic: urinary ""t infections in KIm!'
in women who hal'!' re!UlR'llt infections. It is import! m to Mle that ("nberry
should bt taRn 10 prtl'l'lll,OOI uriOiry trl(t inftions.
( .. nbtl!)' is illift suppltm!'nl,ikhough largt amounll may wMGI upl!'l
and diarrhea. The juic:e should be 100:II> aanbtny ud not ' cocktair juic:e, is
lIIat (oouins sugar which enh'IK6 growth ,nd m,y bt (oomindi-
caltd in patitnu. indjyidwk may 10 takt mnbtl!)' tap-
suits, which illI'a"lailablt ill most drug SIOI!1.
The [Jumi.>t:roo k.ey provio.l" SUflJHtary uf Ihe poi[Jls from lhe ... pono.ling nUHli.>t:roo ""-lion
within the chapter. If any of these points are not clear, refer to the nWllbered section within the chapter for review.
30.1 The kidnt'ys regulate fluid ,"Olume, ele.;:trolytes, and
acid-baSt' baianCt'.
30.2 The three major processes of urine formation are filtration,
reabsorption, and secretion. At;, filtrate travels through the
nephron, its composition changes dramatically as a result
of the processes of reabsorption and secretion.
303 The dosage levels for most medications must be adjusted
in patients with renal failure. Diuretics may be used to
maintain urine output while the cauSt' of the renal im-
pairment is treated.
3004 Diuretics are drugs that increase urine output, usually by
blocking sodium reabsorption. The three primary classes
are loop, thiazidt', and potassium-sparing diuretics.
NCLEX-RN" REVIEW QUESTIONS
D Which of tht' following actions by the nurSt' is most im-
portant when caring for a patient with renal diSt'aSt'?
1. Identify medications thm have the potential for
nephrotoxicity.
2. Check the specific gravity of the urine daily.
3. Eliminate potassium-rich foods from the diet.
4. EncOllI"llSt' the patient to ,oid every 4 hours.
30.5 The most emcaciousdiuretics are the loop or high-Ct'iling
agents, which block the reabsorption of sodium in the
loop of Henle.
30.6 The thiazldes act by blocking sodium reabsorption in the
distal tubule of the nephron, and are the most widely pre-
scribed class of diuretics.
30.7 Though less effective than the loop diuretics, potassium-
sparing diuretics are used in combination with other
agents, and help pre'en! hypokalemia.
30.8 Several less commonly prescribed classes such as the os-
motic diuretics and the carbonic anhydrase inhibitors
have specific indications in reducing intraocular fluid
pressure (aCt'tazolamide) or reversing severe renal bypop-
erfusion (mannitol).
D The patient adnlitted for congestive heart failure (CHF) is
receiving digoxin (Lanoxin) and furosemide (Lasix).
Which of the following laboratory levels should the nurse
carefully monitor?
I . PotassiWll
2. Creatinine
3. Calruim
4. Sodium
LibraryPirate
o Which of the following clinical manifestations may indi -
,ate the patient is experiendng hypokalemia?
I. Hypertension
2. Polydipsia
3. Cardia, dysrhythmias
4. Diarrhea
o Which of the following medkations must be used with
,aution in patients with a history of CHP.
I. ru:etawlamide (Diamox)
2. Mannitol (Osmitrol)
3. Bumetanide (BunleX)
4. Etha<:rynl' a,td {Ede.;;rlnj
CRITICAL THINKING QUESTIONS
1. A 43-)'\'ar-old man is diagnosed with hypertension follow-
ing an annual physical examination. The patient is thin
and states that he engages in fairly regular exercise. but he
des,ribe!; his job as highly stressful. He also has a positive
family history for hypertension and stroke. The health care
provider initiates therapy with losartan (Cozaar). After 1
months, the patient has noted no appredable difl'ereIH:e in
blood pressure values. The health ,are provider swit,hes
th .. patient to 105anan hydrochloro-
thiazide {Hyzaar}, which proves to be very effe.:tive. Why
is the new therapy more eff&tive?
2. A 78-year-old woman isadmilted to the intensivHare unit
with. <li'Cno.;. of he.r1 f:.il",,,_ The n",,,.. .<lmini.ters
furosemide (Lasix) 40 mg N push. What assessments
should the nurse make to determine the effe.;:tiveness of
this therapy?
(1101'1 .. 30 Dkl'l'!l<Th .. npy and Dru9' for Renal 429
II The nurse re;:ognizes whkh of the disorders as a ,ause of
,hronk renal failure? (Sel&t all that apply. )
I. Otronk urinary tract infe.;;tions
2. Di.1betes mellitus
3. Congenital malformmion
4. Hypertension
S. Hypotension
o A patient with a history of CHF will be started on the
potassium-sparing diuretk, spironola,tone {Alda,-
tone}. Whkh of the following drug groups should nOI be
used, or used with extreme ,aution in patients taking
potasstum-spartng dturettcs!
I. NSAIDs
2. Conioosteroids
3. Loop diuretks
4. ACE inhibitors or ARBs
J. A 17-year-old male patient is admitted to the ICU follow-
ing a car-train collision. The patient sustained a depressed
skull fra,ture and ison a ventilator. Twodays after surgery,
there are obvious signs of in,reasing intra,ranial pressure.
The nurse administers 32 g of a 15% solution of mannitol
(Osmitrol) per IV over 30 minutes. The patient's mother
asks the nurse to explain why her son needs this drug.
What explanation should the nurse offer?
See Appendix D for anSWeTS and rationalel for all activitiel.
EXPLORE
M)'Nursi1gKiI is YOUI OIl! stop for orIiO! chaple, 1l!V;!W materials and
"'iOU' CII .. for S!ICC\!I&S with additiorl3l 11ClEX"$\yIe pr.u;li c&
QU!S1ilns. InteractM! ani actlllltfes, web fi nks, anlrnatOO.
and iide05. and 1IlOfe!
f!oglSlo, YO"' 3<CO"" code frnm 1110 fro'" of )'OtJ' book at
www.myn .. u.gkilcom.
LibraryPirate

DRUGS AT A GLANCE
FLUID REPLACEMENT AGENTS {1J9t41l
Crystalloids and Colloids plqt4Jl
Q dexrron40(Genlron40,orhl'f'5) pagtm
ElECTROlYTES PIX1f36
Q rod/urn chloride (Noel) pagtm
(;) poross.llm chloride (KCL) fII1jf4J9
ACID-BASEAGENTS pu;t4J
Q miumblcQrbonore JUjtW
KEY TERMS
icidosi! JUj/440
.Ikalosis p!lgf I
.nion f!lHJ"4J,
buffer {X!qt 440
cation {!a/t436
colloids pltjt4J6
Chapter 31
Drugs for Fluid Balance,
Electrolyte, and
Acid-Base Disorders
LEARNING OUTCOMES
After reading this chapter, me student should be able to:
1. Describe conditions for which IV fluid therapy may be indicated.
2 . Explain how changes in the osmolality or tonicity of a fluid can cause
water to move to a different compartment.
3 . Compare and contrast the use of colloids and crystalloids in IV therapy.
4 . Explain the importance of electrolyte balance in the body.
S. Explain the pharmacotherapy of sodium and potassium imbalances.
6 . Discuss common causes of alkalosis and acidosis and the medications
used to treat these disorders.
7. Describe the nurse's role in the pharmacologic management of fluid
balance, electrolyte, and acid-base disorders.
8. For each of the classes listed in Drugs at a Glance,know representative
drugs, and explain the mechanism of drug action, primary actions,and
important adverse effects.
9. Use the nursing process to care for patients who are receiving drug
therapy for fluid balance, electrolyte, and acid-base disorders.
(rystalloids pq m
electrolytes pq436
extr.IC.llular fluid IEeF) compartment filN}t4l1
hyperkalemia PJI/I'4J8
hypernatremia po:JI437
hypokalemia pq438
hyponatremia pq 437
intra(enularfluid (ICF) companment PJI/I'431
o.moblity filN}t4Jl
osmosis PJI/I'4lI
pH fOJ14-I(J
tonicity pi!rJl431
LibraryPirate
T
he volume and composition of fluids In the body must
be maintained within narrow limits.Excess fluid volume
can lead to hypertension.congestive heart failure,or periph-
eral edema, whereas depletion results in dehydration and
poem'P< .hock. Body fluid. must also conl .ln specific
lmounts of essential Ions or I'lectrolytes,and be maln"lned
at particulllr pH values. Accumulation of excess acids or
bases can chllnge Ihe pH of body fluids and rapidly result In
death If left untreated. This chapter will examine drugs used
to reverse fluid balance, electrolyte, or add-base disorders.
FLUID BALANCE
Body fluids travel between compartments, which are sepa-
rated by semipermeable membranes. Control of water bal-
ance in the varioIU oompan ments is e:ssenti:al to
homeostasis. Auid imbalances are frequent indit:ltions for
pharmacotherapy.
31 .1 Body Fluid Compartments
11", Hf"dlnl bun, or l>uUy fluid ur wale" w1,kh
serves as the universal solvent in which most nutrients, eleo::-
trolytes, and minerals 3re dissolved. Water alone is respon-
for about 60% of lhe total body weight in a middle-agt
adult. A newborn may contain 80% wat er, where;ls an older
adult may contain only 40%.
In a simple model, waler in the body can be Ioclted in one
ofl;WQ places, or oompari meniS. The introKtlll.. ftuid(Kr}<om-
parlntmt, which contairu water that is inside cells, accounlS
for about two thirds of the total body water. The remaining
one third of body fluid resides outside cells in the tJiri<tlluiar
fluid (Em )mpartmtnt. The ECF compartment is further di -
vided into two parts: fluid in the pi<lsm<l, or irrtriwaSCljlar
space, and nuid in the intentiti<llspacesbetweencelLs. The re-
,

Celt: 2S l lnltlntilial
....... ,
Iuid: 12l 3l

" "
""'
,
M C
"
,


m

m

, , ,
m
, , ,

,

"

"

,

,
,

,

,
C>OITIPI'Itrr...-.r: a>rnpmrtmenI
M)'JI. of body -...ighI c/ body weigl!
FlgunJI.1 MaJor fluid compartmPnts In the body
lationship between these fluid compartments is illustrated
in Figure 31.1.
A continuous exchangt and miring of fluids occurs be-
tween the various compartments, which are separated by
membranes. For example, the plasma membranes of cells
sepu":Ite the ICF from th. ECF. Th. """,Uary membranes
separate plasma from the interstitial fluid. Although water
travels freely among the compartments, the movement of
large molecules and those with eieo::trical charges is gov-
erned by processes of diffusion and active transport. Move-
ment of ions and drugs across membranes is a primary
concern of pharmacokinetic.s (chapter 500).
31 .2 Osmol ality, Tonicity,
and the Movement of Body Fluids
Osmolality and tonicit y are two related terms central to un-
derstanding fluid balance in the body. Large changes in the
osmolality or tonicity of a body fluid can call.>;e signifi cant
shifts in water balance between compartments. The nurse
will often administer IV fluids to compensate for these
changes.
The osmolality of a nuid is determined by the number of
dissolved partides, or solut es, in 1 (I L) of water. In most
body fluids , three solutes determine the osmolality: sodium,
glucose, and urea. Sodium is the greatest contributor to os-
molality due to ilSabundance in most body fluids. The nor-
mal osmolality of body fluids r:anges from 275 to
295 milliosmols j>eI" kilogram (mOsmlkg).
The term 100iOtJ is sometimes used interchangeably with
osmolality, although they are somewhat different. Tonicit y
is the ability of a solution to a mange in water move-
ment across a membrane due loosmotic forces. 'Vhereasos-
molality is a laboratory value that can be pre<isely
measured, tonicity is a general term used to describe the
relative concentration of IV fluids. The tonicity of the
plasma is used as the reference point when administering IV
solutioru;: NorflUll plasma is considered isotonic. Solutions
that are isotonic howe the same concentration of solutes
(s.ameosmolality) as plasma. Hyp",onicsolutions (ontain a
greater concentration of solutes than plaSflUl, where;ls
hypotonic solutions have a lesser concentration of solutes
than plasma.
Through 0IIIIIni1o water moves from areas of low solute
concentrat ion (low osmolalit y), to artas of high solute
(hi gh osmolality). lfa hyparon;c ( hyperos-
molar) IV solution is admini stered , the plasma gains more
solutes than the interstitial fluid. Water wiD move, by os-
mosis, from the interstitial fluid compartme nt to the
plasma wmpartmenl. This type of fluid shift removes wa-
ter from cells and can result in dehydration. Water will
move in the opposite direction, from plasflUl to interstitial
fluid, if a h,paronic solution is administered. This type of
fluid shift could res ult in hypotension due to mo'ement of
water out of the vascular system. Isotonic solutions will
produce no net fluid shift. These movements are illus-
trated in .. Figure 31.2.
LibraryPirate
i
o
,


4]2 UnII4 The Urinary Synefm
Type of
infusion
(a) Isotonic
(b) Hyper10nic
(c) Hypotonic
Movement of Fluid
.. '" solute R uR

l.o,rnw
.. .... 11' .. plasms
------ ..
Equal osmolality: No not change








I ......... ,."ed osmoIaI;ty in plasma: W",,",
moW$ !tom cells and ;ntlH'Slitiailluid
10 pia""",


. '.


O"C ..... sed osmolalitv ;n plHfTKI: Wate,
moves !tom pI .... ma to ;nt .... titiailluid
, .. "'"
I_MOO

..
.. Flgurell.2 Movement offlutds and solution tonicity
31.3 Regulation of Fluid Intake
and Output
The average adult has a water intake of approximately
2500 mL/day, most of which comes from food and bever-
ages. Water output is achieved through the kidneys, lungs,
skin, feces, and sweat. To maintain water balance, water in-
take must equal water output. Net gains or losses of water
can be estimated by changes in total body weight.
The most important physiologic regulator of fluid intake
is the thirst mechanism. The sell'iation of thirst occurs when
osmoreceptors in the hypothalamus sense that the ECF has
become Saliva secretion diminishes and the
mouth dries, driving the individual to drink liquids. As the
ingested water is absorbed, the osmolality of the ECF falls and
the thirst center in the hypothalamus is no longer stimulated.
The kidneys are the primary regulators of fluid output.
Through activation of the renin--angiotensin-aldosterone
system (chapter 2JOO), the hormone aldosterone is se-
creted by the adrenal cortex. Aldosteronecauses the kidneys
to retain additional sodium and water in the body, thus in-
creasing the osmolality of the ECF. A second hormone, an-
tidiuretic hormone (AD H), is released during periods of
high plasma osmolality. ADH acts directly on the distal
tubules of the kidney to increase water reabsorption. This
increased water in the intravascular space dilutes the
plasma, thus lowering its osmolality.
Failure to maintain proper balance between intake and
output can result in fluid balance disorders that are indica-
tions for pharmacologic intervention. Fluid deficitdisorders
can cause dehydration or shock, which are treated by ad-
ministering oral or intravenous (IV) fluids. Fluid excess dis-
orders are treated with diuretics (chapter J()OO). In the
treatment of fluid imbalances, the ultimate goal is to diag-
nose and correct the cause of the disorder while administer-
ing supporting fluids and medications to stabilize the
patient.
flUID REPLACEMENT AGENTS
Net loss of fluids from the body can result in dehydration
and shock. IV fluid therapy is used to maintain blood vol-
ume and support blood pressure .
31.4 Intravenous Therapy
with Crystalloids and Colloids
When fluid output exceeds fluid intake, volume deficits may
result. Shock, dehydration, or electrolyte loss may occur;
large deficits are fatal, Wlless treated. The following are some
common reasons for fluid depletion:
Loss ofGI fluids due to vomiting, diarrhea, chronic
lax.1live use, or GI suctioning
Excessive sweating during hot weather, athletic activity,
or prolonged fever
Severe burns
Hemorrhage
Excessh'e diuresis due to diuretic therapy or
Wlcontrolled diabetic ketoacidosis
The immediate goal in treating a volume deficit disorder
is to replace the depleted fluid. In nonacute circwnstances,
this maybe achieved by drinking more liquids or by admin-
isteringfluids via a feeding tube. In acute situations, IV fluid
therapy is indicated. Regardless of the route, careful atten-
tion must be paid to restoring normal levels of blood ele-
ments and electrolytes, as well as fluid volume.
Intravenous replacement fluids are of two basic types:
crystalloids and colloids. Crystall oids are IV solutions that con-
tain electrolytes and other agents that closely mimic the
body's extracellular fluid. They are used to replace depleted
fluids, and to promote urine output. Crystalloid solutions
are capable of quickly diffusing across membranes, leaving
the plasma and entering the interstitial fluid and ICE It ises-
tintated that two thirds of infused crystalloids will distribute
in the interstitial space. Isotonic, hypotonic, and hypertonic
solutions are available. Sodium is the most common crystal-
loid added to solutions. Some crystalloids contain dextrose,
a fonn of glucose, commonly in concentrations of 2.5%,
5%, or 10%. Dextrose is added to provide nutritional value:
1 L of 5% dextrose supplies 170 calories. In addition, water
is formed during the metabolism of dextrose,enhancing the
rehydration of the patient. \'-1hen dextrose is infused, it is
LibraryPirate
01 .. 11., lt Drug<; for Auk! B.laoe ... ElKtrolyte..OO Ack!Base Ol1ord .... ' 433
metabolized, and the solution becomes hypotonic. Selected
crystaUoids are listed in Table 31.1.
Infusion of crystalloids will increase total fluid volume in
the body, but the comparfflllmt that is most exJXInded
pends on the solute (sodium) concentration of the fluid
ministered. Isotoni, crystalloids can expand the circulating
immWlscu/ar fluid volume without causing major fluid
shifu bt'tween .compartments. Isotonic crystalloids such as
normal salint' are often used to treat fluid loss due to vom
iting, diarrhea, or surgical procedures, especially when tht'
blood pressure is low. Because isotonic crystalloids can rnp-
idly expand circulating blood volume, care must be taken
not to create fluid owrload in the patient.
Infusion of hypertonic crystalloids expands plasma vol-
ume by drawing water away from the cells and tissues. These
agents may be used to relieve cellular edema, especiallycere-
bral edema. \'/hen patients are dehydrated and have hyper-
tonic plasma, a solution that is initially hypertonic, may be
infused, such as D5 0.45% NS that matches the tonicity of
the plasma. This allows tht' fluid to enter the vascular com-
partment without causing a net fluid loss or gain in the cells.
As the dextrose is subsequently metabolized, the solution
.... Prototype Drug I Dextran 40 (Gentran 4O,others)
TABLE 31 .1 Selected Crystalloid IV Solutions
Orug Tonicity
Normal saiillf 10.9% NaClI Isotonic
Hypl'rtonic: 13% NaCI) I/ypI'rtorir
Hypotonir salilt 10.4S% NoJCn Hypotorir
LKtattd Ringtr's Isotonic
Plilmt-Lytl' 148 Isotonic
Plilmt-Lytl' S6 Hypotorir
DEXTROSESOLUTK)NS
S% 0011011' in Wittf lDSW) Isotonic"
,% ootrw in normal salilt I/ypI'rtonir
,% de:1rOII' in 01% salillf kotonic:
,% ootrw in lKtittd fliogtfJ Hypl'rtonir
S% ootrw in 56 Hypl'rtonir
mmbolized quid!): the \OIUlion i, _imts ronsidmd
Irjpotorir.
Therapeutic (lass: Plasmavolume expander Pharmacologic (lass: Colloid
ACTIONS AND USES
40 j poIysrharide that too Lt to pass through r.pilb ry w,lIs.1t
ymilar to deJmm 70, mt pt delllran 40 h" a lower moltwl.r weight On-
Iran 40 .ill by "i,ing tilt O>ll1otic: of blood, tht reby rausill9 f\Jid
to rTIOVl' from ,p-i{fS of tiuUl'S to tilt intrava>cular spart
" ,In IV infusion, it has (ipability 01 pia,m.i "IOJ-
Unit within minutes.lter admininration.Cardiovallular I!"Spon>es ilKlude in-
clN,td blood pRSSurt, inllUled(irdiac improvM W'nous rmlm to
hNn.Dutrao40 is tllft'ifd rapidly by tilt Indiutiom ind:JdeftJid
rfP],(l'II"IPll t for ])alients fxperiendng h)'pO'loll'll"lic: sho<k dJf' to htmorrhage,
!UIgef)',or bum,. When giW'n for ac:Uil' !hock. it is inhMd .5 rapidly as
po>siblt until blood "IOlume is !!"Stored.
Dutran 40 .Iso ft'(]Ules plateltt and improom blood flow.
through its .bilil)' to ft'(]Ult blood mro>ity. Thtse propenits have ltd 10 its use
in pre-W'flting deep ''in thrombws.nd pulmon.ry
ADMINISTRATION ALERTS
m.ly be giYtn 1.2 to 2.4 glmin.
NoIll'mtll1tfKY adminisulloo,hoUrI lit infused nobstl'rthin 240 rngImin.
Dimro unustd portion, OlKt Opl'otd deJmn romain, no pretr-
vuiYes.
PlI'gn.nqutegory(
PHARMACOKINETICS
OnW'!:wral minutes
PNk:Unknown
Halflife:Unknown
Duration: 12-24 h
ADVERSE EFFECTS
ViLli sign! should be monitom:l continUOUlly during dau,n 40 infu!ions to
hypMl'nwn WIsed by pla,m. voIumt npan>ion. Signs oIlIuid Mr-
INd indude tar:h-,urdia, pl'riplltr.1 tdtma,distl'nded
raugh. A >m.1I pMtntagt of 10 dextran 40, with urtiuria
being the mo>l (ommon ,ign.
Contraindi"tions: 40 is (ont"indiuied in p-itients with rt nal failuft'
or dehydration. Other (onmindiution, inrUde ,tl'tft' CHF and hyper-

INTERACTIONS
Dru;rDrug: ThHtn nodiirMIy intHaaions.
I.i b TI5U: Dextran .0 may p"oIoo9 bk>edill9linf.
HerlIaVFood: Unknown
TlNtmtnt For with oormal ft'n.1 funrtion,dis<ontirw-
tion oftht infusion will mull in rtdunionof .Mrse wilh rl'nal
imp,irmtnt rrwy bellern from tilt 01 an osmotic: diufttK.
It!(pf ro M)Nunllrgm for Q Nunlnlj I'rfKnj fOOIllpKlk ro rIr/s dnJlj
LibraryPirate
4] 4 UnII4 TheCJrdkwasc:ubr.oo Urinary Syuem,
NURSING PROCESS FOCUS PATIENTS RECEIVING IV FLUID AND ELECTROLYTE
REPLACEMENT THERAPY
Assessment
Bilseline assess ment prior to administration:
Understand the the drug h" bffil PI&ribtd in order to for
theraptUtK tfifcts ! t .Cj., theraP'J', of shoc:k}.
Obtain a complete health hillo!), including wdiol/ucular (including HTN,
MI),neuroiogic (inckiding (VA or injury), bums,tnOxrine,.nd
hepatic or dimst.Obtain a drug hinOl)' ilKluding
plecription and Or( drugs, .nd herbal iltn to pol,iblt
drug
Obt.in .nd vital ,ign" of Conlliou!.neS (LOC),
IOUndI,.nd urin.ry output "appropriate.
E..,luate .ppropriatt labmtory findings (e.g., eltctrolyle1, (Se. uriIII'
glivity and urinal)'lis, BUN and tot.l prottin i nd
.Ibumin lnels,aPTT,.PT or INR, and Iml function nudifl).
Assessment throughout administration:
AsstlS fol dtlittd therapeutic (f.g., tlectrolytt va 00 Mum to
within nooni I range, adequate urine outputl.
Cominur monitoring of vital ,igns, urinary ootput.and LOC .,appropriate.
Alit\! for and PlQlllpdy repon ild'tent rffcru:tadtY<ardia, HTN,
dysril)'thmia!, dtcft'aling ux. IIKft'aling d)'lpllei, lung rongtStion, pink
tingN frothy !putum,dtcrultd urinary mu!(1t we.me, or
cr.mping, or allergic ll'<Ktion!.
Pot ent ill l Nursing Dill gnoses
Fluid Volumt
Cardiac: tMtput

Activity Intoleranc:e
DefKitm KIIO"II'Itdgt (drug thtrapy)
Rilk 101 Falb, Risk Iollnjury (related to il)opottnlion, dizrines'aI!O(iated
with .a.ersr tfkts)
Risk 101 Enmive Fluid Volume todrug thflapy)
Risk lor Hfilth drug eflemand dittary
neeik)
Plllnning: Plltient Goa lsll nd Expected Outcomes
rhe patient will:
up!'nenc:e therapeutic tfftcts dtpendent on the ft'iIIOII the drug is bring gil'fo (e.Cj., ilKlfilltd urinary output and relitfof deh)':lration, v.lut!
within noonal fimits).
Be frtf from, or experience m inifllill, tfftm.
Vtrbalizt an understanding of the drug's Ust, tfifcts,. nd Il'quill'd prKolution!.
Demonllrale prop!'r selh:fministration ofthf mtdication (f.Cj.,d=, timing, when to notify provider).
Implementllt ion
Interventi ons li nd (Rilti onil les)
Ensuring tht rapeutk effects:
Cominur a!stSVIlf nU a,dtlcribtd t arlitr for therapMic
Aslin the patitm with obt.ining fluids and with a, needN.(Urillilry
output i< within nollllllllimiu.OtctroIytf i> ""tom!. Tho .ldtrly,
inf.nts, and patitnu who u nnot <KCtlS fluid! or t at by ihemSl'ives, e.g.,
poIt.(VA,aft'at ilKll'iSI'd risk forfluid.nd t ltctrol)'lf
Minimizing ildftlSe effects:
Monitor for signs of lluid ..oonll' or e .Cj., iOOl'aling BP (emu),
dKftOiSing BP!deIirit.I, tachy<ardi., changes in qwlity of IllI1t (bwndng or
thrudy). Monitor for ligns of pottntial tIectroIytt including
naUIN, wmitinq. GI mmp inq. diarthta, ntUidt weakness, a.mping or
twitthing, pall'lthe!ia!, and irritabiil)'. Confusion, dtatasing LOC, iOOl'aling
hypoltnlion or HTN if aooc:iated with \i(hyca rdia, dtc:ft'iSI'd !line
output..nd Il'izUft'l a ft' Il'pOIItd (Many fluid and
inbalalKl"I h.M linilar 'ymptoms.When n!l"lSing the patient for
pall dl!lJ history, and rum-nt condition and
mtdiutionl to comate 5Yf!!PtomI to calJstS.)
Plltient li nd Family Educati on
the patient to cominur to COOIUnll' tnW9h liquid! to ft'fIIiIin
but not 0Yffiy hyd"ated. DrilkirJ;l when thirst): I'IOidrJ;l akDholic: btveli9fl,
m.imainilg I .... lthydirl,.ndtn..mg"""""'tt but not ow ...... k int.kr
wil Nist in m.Jintaining norm.Jllkid ind tltarolyte balalKe.
H.I'f the patitnt weigh stH and ft'(ord weight along with blood
pft'lSUft'.nd pulst mfiSUremtnls., .ppropriate.
Tta(h the famil)-,orcart9mr how to monitor pulst and blood
if lII'edtd.Ensuft' proper UIf.nd fUnctioning of any home
equipment obtained
Inllrud the patitm to Il'port change in fllU!(lt or fulKtion;
numbnes,and tingliog in lip!, fingers,.rm! or legs: palpitations;diniIll'II;
naUIN or vomiting; GI cramping; or dtc:ft'asN urination.
LibraryPirate
NURSING PROCESS FOCUS PATIENTS RECEIVING IV FLUID AND ELECTROLYTE
REPLACEMENT THERAPY (Continul!dl
Impl ementation
Interventi ons and (Rati onales) Pati ent and Famil y Educati on

monitOi (8(rIroro/yle,aPnand aPT OIINR 1tYek.((rystalloicl Instruct tht on tilt IIffil to mum for LIb worlc
IOUtionl may UUlt tltruolytt imbaLlOO'I. Coloid IOkrtionI may
normal blood monitoringof tltarolytt ItY!ok whill'on
rtpiHl"IIII'm thtraJ11 m;lY bot to tllllll' theraptUtic:dtl.)
(ontinUl' to monitor vital blood plt'llUrf lying, and

Tt am tht patifm to tilt from lying or to standing to.woid
standing to dftfit ortholtatic: hypott nsion.Bfuutious with diuinm orfalls.
who irf at ilKrultd tilk for hypotf nsion. (Dehydration and flffi rolytf
imbaLllKfl mi Y U!lSl' dizlintSland hypotf nlion.Orth05latK hypotffilion
may thf rilk ofin;.lIyJ

life!)" in tht fldtrl)o.Oblf"lV!' fordiuilll'Sl and

Instruct thf to ull for prior togming out of bed or
monitOior umt with lI mbuiation as 1I!'eded.(DizzintSl from tlettrolytf attempting tow,lk alolll'"nd to avoid dri'ling or other aaivitifl requiring
imbaLllKfl or orthostatit hypotf nlion m;lyour.) mental a!tnlltllor ph)"lilal (oordination if I"ftded.

p4titllt d.iIy dllll wright <II kr."of 1 kg

H.ov. p4titllt wrigh Idf d.il" 0011, 4tth ... n", timf uf d. ".nd .... urtI
21b) 01 min in a 24hour weight is an weight along with blood and mmUren1ffill.Hallf tilt
i(urat. of Auid status and takl's imo .({oom intake, OUlput.and patitnt It'pon lignifiunt weight loll 01 gain.
insensiblt Iolle. kight gain oredfmll may fluid tIUIlK'

Tudt thtpatitntthat ecssM 11M _atilg
ortlffirolyt. imbaLlIKf1..)
andlluid , nd txlr.t uution is wananted in
CIas. 1y monitor for signl and l)1I1ptOIm 01 al!trw if ulfif.

Instruct tilt 10 imm. diatdy c/yspnea,itming, fedin9lof
(Colloids may (a!lSl' allt19K and anaphylutit throat ch.n pain or tightffiing,or headac:1It.
CIas. 1y monitor IV dOl. 1y when potmilm or ammonium.

hl5lruct tilt to rf port any irritation, pain, IWflling at tilt
Doublt--(h.d doIH with another 11111. IV or in theann tilt drug is infusing.
ammonium irritating to tilt Vffi. lind ph!tbitis may r=1t.
is, "highaltn" medic.Jtion and doublt-<h.ding dam befOO'
adminiltfring prewn6 medic.Jtion MOil.)

Monitor nutritionalltllUl ind fll{ouragt , ppropriate lkJid intake to

Ttam th. p,tifm to (onlumf . nough liquids to adeqUlltf"ly,but oot
prewnt . ltaroIyt. imbaLlnm occur dJt to OY!'rIy, hydrated.
nutrition or fl uid intakeu Wfll u from drug therapy,t.g.,

InlNt the p;atitnt with h)'pokaitmia to consume foods high in K +: frrsh fruill
diureticl.)
sudt as Itrawbtrri5 and bananas; died fruill lOCh as apricotl and prunes;
I'rgttlbles and ItgUmtl sudt 01\ tOllllliOeS, bMI, and died btans; juite sudt u
OIallgt, 01 prune;and W mea6.lnsrnKl tilt patitnl with
hyptdaltmia to noiI tilt foodl mtntioned fa dil'r (for hypokaitmia) a I wei 01\
sah substitutes (v.tli:h often (ontain poD ISi:Jm salts), and to ronsuk with a
prv.-idtr befmo taking vitamin and milll'lallUpp\fflIfIltlOi
IpKializtd !pOrts btffiagtl. (T ypital ore IJIOrtI ilMroll)fl,f.I)., Gatoradt ,nd
Pov.o!radt.mav hal'!' amwnts but hilYthiQhurbohydrate
allKUllI, which may INdto inUNItd dilrm, (brrllta, and for
dthydrati:1O from h)"pMImlOlarity.)
Patint understanding of drug therapy:
lise opponunitifs during adminimation of mediulionl and during

The family, or uregiVl'l should bt ablt to state the re,l\on for the
Ulelmenll todi\(\J\S rationa!t fordrug tlieraJ11,dtsil!d tlieraptutit drug;appropnatf dcM and ICheduling;what adl'llf l'fffi lS to oblf"lV!' for
and any III'msary monitoring 01 (!king tillll' and when to tht antiop;aied length of meditation tlltrapy.
during nulling ht lpl to IUpporci'ltdrug
and (,ft'.)
Patint sflf.administriltion of drug therilPY:
Wlltn adminillffing th. rnedkation, instllKt th. patitnt, family,or

Thf p;atitm and ablt to dilQJll appropnatf doling
tartgivtr in propl'l s.lf-adminimation of drug,f.g., in theday to and administration needs.
pteffilt dilruption of Ittfp from IIO{lUria.(Proptr administration will
in(lUIf tht efle<ti"lenell of tht drug.)
Evaluation of Outcome Criteria
(valuatf thf . ffecti'ltneu of drug thtrapy by ronfinning that patitnt go.Jlland a pt<ted outcom.s hallf bttrl met {= "PLlnning1.
5tI' TM!Ie5 J 1.1.11l. 0111 J 1. 4 fDr 0 Ii5r If rht drugs 10 wNdlIhtst nIIIiDIJ IimI1JII1/y.
LibraryPirate
li


t

436 UnII4 ,,00 Urinary System.
becomes hypotonic. This hypotonic solution then causes
water to shift into the intracellular space, relieving the dehy-
dration within the cells. A solution of 3% normal saline is
hypertonic and usually reserved for Irealing severe hypona-
tremia (Na < 115 mEqlL). Excessive use is amided because
it can lead to expansion of the intravaswlar ( plasma) com-
partment and a r isk of hyperlension.
Hypotunic cr)'Stalloids will cause water to move out of the
plasma to the tissues and cells in the imraun,,/ar compart-
ment; th ese solutions are not considered effkient plasma
wlume expanders. Hypofoni<: crystalloids are indicated for
with hypt'm3tremia and cellular dehydration. Care
be taken not to cause dtpletion of the intravascubr
compartml'llt (hypotension) or too much expansion of the
intracellular compartml'llt (peripheral edema). Patil'llts who
are dehydrated with low blood pressureshou]d Ix- given nor-
mal saline; patients who are dehydratoo with fIOrmal blood
pres.sure should be given a hypotonic solution.
Colloidl are proteins, starches, or other large molecules that
remain in the blood fora long time because they are too large
to easily cross the capillary membranes. While ci rculating,
they have the same effect as hypertonic solutions, drawing
water mole.: ules from the cell s and tissues into the plasma
through thei r ability to increase plasma osmolality and os-
motic pressure. Sometimes called plnsma wlsmu:expnnders,
these solutions are particularly important in treating hypo-
mlemk shock due to burns, hemorrhage,or surgery.
The most commonly used coUoid is normal serwn albu-
min, whim is featured as a prototype drug for shock in
chapter 29QC>. Several colloid products contain dextran, a
synthet ic polysaccharide. Dextran infusions can double the
plasma volume within a few minutes, though its effects last
only about 12 hours. Plasma protein fract ion is a natural
w lume expander that contains 83% a1bwnin and 17%
plasma globulins. Plasma protein fraction and albumin are
also indicated in p<ltients with hYpoproteinemia. Hetastarch
is a synthetk colloid with properties similar to those of 5%
albumi n, but with an extended duration of action. Sele-cted
colloid solutions are listed in Table 31.2.
ElECTROLYTES
Eledrolytes are small charged mole-cules essential to
homeostasis. Too little or 100 much of an electrolyte can
TABLE 31 .2 i Selected Coll oid IV Solutions
(Plasma Volume Expanders)
DNg Tonicity
S%,lbumin
"'ro'
Dmrom 40 in IIOITU siliM Isotonic
Dm"n 40 in 05W Isotonic
Dm"n 7Q in IIOJlU siliM
"' ..

"' ..
p],1ITY pnltein fIKtiGfI
"' ..
result in seriolL'l complications and must be quickly cor_
rected. Table 3 t.3 describes electrolyt es that are important
to human physiology.
31 .5 Physiologic Role of Electrolytes
Minerals are inorganic substances needed in very smaU
to maintain homeostasis (chapter 4200). Miner.
als are held together by ionk bonds and dissociate or ioni:u-
when placed in water. The resulting ions have positive or
negative charges and are able to conduct ele-ctricity, hmce
the name tIKtroI)'te. Positi,'ely charged elect rolytes ue called
GIJIiom; those with a negative charge are.Jlliom. Electrolyte
eIs are measuroo in units of mil1iequivall'llts per liter
(mEq/L).
Electrolytes are essential to many body functions, indud.
ing nerve conduction, membrane permeability, muscle
traction, water balance, and bone growth and remodeling.
Levels of electrolytes in body fluids are maintained within
very narrow ranges, primarily by the Jddneys and GI tract.
As electrolytes are lost due to noould excretory functions,
they must be replaced by adequate intake; otherwise, elec.
trolyte imbalances will result . Although imbalances can oc-
cur with ion. K+ . Ca
H
are of grut,,",
importance. The major body electrolyte imbalance states
and their treatments are listed in Table 31.4. Ca lcium, phos_
phorolL'l, and magnesium imbalances are dis(:Ussed in
chapter 4200; the role of calcium in bone homeostasis is
presented in chapter 4700.
An electrolyte imbalance is a sign of an underlying med-
ical condition needs attention. [ mbalances Ue associ.
ated with a Large number of disorders, with renal
impairment being the most common cause. In some cases,
drug therapy itself can cause the electrolyte imbalance. For
example, aggres5ive therapy with loop diuret ics such as
furosemide (Lasix) can rapidly deplet e the body of sodium
and potassium. The therapeutic goal is to quickly correct the
electrolyte imbalance while the underlying oonditian is be
ingdiagnosed and t reatoo. Treat menlS forelectrolyteimbal-
ances depend upon the seveTity of the condition and range
from simple adjuo;tments in dietllry intake to rapid elec.
lrolyte infWions. Serum electrolyte Iev.:b mml bot careful ly
monitoroo during therapy to prevent imbalances in the
oppIJsite direction; levels can change rapidly from
concentrations to hyper-ooncentntions.
TABLE 31 .3 Electrolytes Important to Human
Physiology
Compound Formula Cation
""00

yo. l(J-

""HPO.
",.
HPOl"
Ptltmi!Jlt dIIorido!
'"
,.
0-
5Id!IIt biYrbonaIt ",itCO, HCO,-
--


0-
-..

",.
'N
LibraryPirate
OI..,l<r 31 Drug' for Auld Balane ... E1ec:rrolyl ... , 00 Acld-tl .... 01so<d .. " 437
TABLE 31 .41 Electrolyte Imbalances
""
CondlUon Abnormal Serum Value (mEq/lI Supportive Treatment"

Caki!lll IIyptrGikrrri.J
Hypouknnii
'"-
Hyptrdllmmia
I/ypodlIlKflIIia
MilgnciJm
H)'pOIIU9nNmii

Hypoplmphillemi'
Ptu,si!lll Hyptrkiirrnia
Hypobirrnii
Sodi!lll
Ilyponatrtmia
31 .6 Pharmacotherapy
of Sodium Imbalances
,11
<,
>112
<95
"
<"
"
<1
"
<35
I >145
"'us
Sodium is the major electrolyte in extracellular fluid. Be-
cause of sodium's central roles in neuromuscular phy5iology,
acid- base balance,and overall fluid distribution, sodiwn im-
balances can have serious consequences. Although definite
sodiwn monitors or sensors have yet to be diswvered in the
body, the reguJ.1tion ofsodiwn balance is well understood.
Sodium balance and water balance are intimately wn-
nected. As Na+ levels increase in a body fluid, solute parti-
cles accrnnulate, and the osmolality increases. Water will
move toward this area of relatively high osmolality. In sim-
plest terms, water travels toward or with Na+. The physio-
logic wnsequences of this relationship cannot be
overstated: As the Na+ and water wntent of plasma in-
creases, 00 does blood volume and blood pressure. Thus,
Na+ movement provides an important link between water
retention, blood volume, and blood pressure.
In healthy individuals, oodiwn intake is equal to sodium
output, which is regulated by the kidneys. High levels of al-
dosterone secreted by the adrenal wrtex promote Na+ and
water retention by the kidneys, as well as K+ excretion. Inhi-
bition of aldosterone promotes oodium and water excretion.
When a patient ingests high amounts of oodiwn, aldo-
sterone secretion decreases, thus allowing excess Na+ enter
the urine. This relationship is illustrated in Figure 31 .3.
Sodiwn excess, or hl'Pfrnatremia, occurs when the serum
sodium level rises 145 mEq/L The most wmmon
cause of hypernatremia is decreased Na + excretion, due to
kidney pathology. Hypernatremia may also be caused by ex-
cessive imake of sodiwn, either through dietary conswnption
or by overtreatment with IV fluids wntaining sodirnn chlo-
ride or sodiwn bicarbonate. Another cause of hypernatremia
is high net water losses, such as occur from inadequate water
intake, watery diarrhea, fever, or burns. High doses of gluco-
rortiwids or estrogens also promote Na-+ retention_
Hypotoric ftuid or tlkitonin
wilMnil 0
Hypotoric ftuid
Hyptrl00K 5ak IOIUlion
Hypotoric ftuid

Ditta!)' relridion
IUppltmrrm
Hypotoric ftuid.bufI'tfs,or ditlil1 pomsium Iffiriction

Hypotoric ftuid or dim!)' \Odium mtriaion
Ilyptrrori< 10k lOIurion or!Odium >Uppltrnont
A high serum sodium level increases the osmolality of
the plasma, drawing fluid from interstitial spaces and cells,
thus causing cellular dehydration. Manifestations of hy-
pernatremia include thirst, fatigue, weakness, muscle
twitching, wnvulsions, altered mental status, and a de-
creased level of consciousness. For minor hypernatremia,
a low-salt diet may be effective in returning serum sodium
to normal levels. In patients with acute hypernatremia,
however, the treatmem goal is to rapidly return the osmo-
lality of the plasma to normal. If the patient is hypo-
volemic, infusing hypotonic fluids such as 5% dextrose or
0.45% NaCI will increase plasma volume while at the same
time reducing plasma osmolality. If the patient is hyper-
volemic, diuretics may be used to remove Na+ and fluid
from the body.
Sodium deficiency, or hyponatrrmia, is a serum sodium level
less than 135 mEq/L. Hyponatremia may occur through
exussive dilution of the plasma, caused by excessive ADH se-
cretion or administration of hypotonic IV solutions. Hy-
ponatremia may aloo result from increased sodium loss due
to disorders of the skin, GI tract, or kidneys. Significant loss
of sodiwn by the skin may occur in burn patients, and in
those experiencing excessive sweating or prolonged fever.
Gastroimestinal sodiwn losses may occur from vomiting,
diarrhea, or GI suctioning, and renal Na+ loss may occur
with diuretic use and in certain advanced kidney disorders.
Early symptoms of hyponatremia include nausea, vomiting,
anorexia, and abdominal cramping. Later signs include al-
tered neurologicl function such as wnfusion, lethargy, wn-
vuisiollS, wma, and muscle twitching or tremors.
Hyponatremia caused by excessive dilution is treated with
loop diuretics (chapter 3QOO). These drugs will cause an
isotonic diuresis, thus removing the fluid overload that
caused the hyponatremia. Hyponatremia caused by Na+
loss may be treated with oral or paremeral sodiwn chloride,
or with IV fluids containing salt, such as normal saline or
lactated Ringers.
LibraryPirate
4] 8 UnII4 TheCJrdkwasc:ubr.od Url",,'Y Sy""'"'
I loa_sed K+ excretion I
Figure 31.3 Renal regulation potas\lum balance
31.7 Pharmacotherapy
of Potassium Imbalances
Potassium, the most abundant intracellular cation, serves
important roles in regulating intracellular osmolality and in
maintaining acid- base balance. Potassium levels must be
carefully balanced between adequate dietary intake and re-
nal excretion. Like Na+ excretion, K+ excrelion is influenced
by the actions of aldosterone on the kidney. In fact, the re-
nal excretion of Na + and K+ ions is closely linked- for
every sodium ion that is reabsorbed, one potassiwn ion is
secreted into the renal tubules. Serum potassiwn levels must
be maintained within narrow limits. Both hyper- and hy-
pokalemia are associated with fatal dysrhythmias and seri-
ous neuromuscular disorders.
Hyperkalemia is a serum potassium level grealer than 5 mEq/ L,
which may be caused by high consumption of potassium-
rich foods or dietary supplements, particularly when pa-
an: laking I'ul,,",-,iwll-'l'arinl': ,ud, a,
spironolactone (chapter j OOO). Excess K+ may also accu-
mulate when renal excretion is diminished due to kidney
pathology. The most serious consequences of hyperkalemia
are related to cardiac function: dysrhythmias and heart
block. Other symptoms are mllSCle twitching, fatigue, pares-
thesias, dyspnea, cramping, and diarrhea.
In mild cases of hyperkalemia, K + levels may be returned to
nornlal by restricting primary dietary sources of potassiwn
such as bananas, citrus and dried fruits, peanut butter, broc-
coli, and green leafy vegetables. If the patient is taking a
potassiwn-sparing diuretic, the dose mll'lt be lowered, or a thi-
azide or loop diuretic substituted. In severe cases, serum K+
may be temporarily lowered by administering glucose
and insulin, which C.111Se K+to leave the extracellular fluid and
enter cells. Calcium gluconate or calcium chloride may be ad-
ministered to ooWlteract K" toxicity to the heart. Sodium bi-
carbonate is sometimes infused to correct any acidosis that
may be concurrent with the hyperkalemia. Excess K+ may be
eliminated by giving polystyrene sulfonate (Kayexalate) orally
or rectally. Thisagent, which exchanges sodium ion for potas-
siwn ion in the intestine, isgiven concurrently with a laxative
such as sorbitol to promote rapid evacuation of the potassiwn.
Hypokalemiil occurs when the serum potassium level falls
below 3.5 mEq/ L Hypokalemia is a frequent adverse effect
resulting from high doses of loop diuretics such as
fW"Osemide (Lasb;). In addition, strenuous musrular a,tiv-
ity and severe vomiting or diarrhea can result in significant
K+ loss. Because the body does not have large stores of K+,
adequate daily intake is necessary. Neuroru; and muscle
fibers are most sensitive to K + loss, and muscle weakness,
lethargy, anorexia, dysrhythmias, and cardiac arrest are pos-
sible consequences. Mild hypokalemia is treated by increas-
ing the dietary intake of potassiwn-rich foods, whereas
more severe deficiencies require doses of oral or parenteral
potassium supplements.
HOME & COMMUNITY CONSIDERATIONS
Hypernatremia and Hyponatremia in Athletes
t ffts of sodum chloride when gil'l'n is il n riectlOly\e f1'plaoc:t mrnt
"If'. So ..... p.nil'll 11)'1'"",,1II'1II;' II)' uking ... h ubi"". Iw>_
litYing they will f1'plil(f lost dJt to IWNting. Th=who IWNt plOfusrij
dUl' 10 wolking outdooB or aen:iling (iI n avoid he.t-related probltms II)' oon-
IUming adequatf ilmoonu of watf l 01 b.tlilnud riectlOiytf SOlutiolll oon-
lOinrd in sporn drinks. The patient should OOll\UnJe s.k IObltu only when
innructed by the ht.1th (all' provider.
Conl'!'!5rly, hyponatfl' mia from exUSlil'l' fluid inuR has also drveloped il l
a problem in athlttrl, particularly OOVKe athlrtf l who h.M heud that
the)< to "u ep drinking"to maintain hjd.ation. Milny sporn drinklllla)'
(onuin some t lraroiytes but also high fllKlOIeorother SlJ9ilB. This (!Ntt S a
hyp.ertonit solution th" m.y palidoJiully (ilusr ill(fI'aIfd w"er /on. In-
mooing athlrtH, especially (hildfl'n, to drink when thirsty and maimain a
urine the (olor of dur oot dalk yellow or colorless, will help tlllUfI' 1101-
mal hyd"tion and sodium Iewk.
LibraryPirate
OI..,l<r 31 Drug' for Auld Balan(e, Elec:trolyte, . nd Acld-Ba ... Olso<der, 439
Prototype Drug I Sodium Chlonde (NaCl)
Therapeutic Class: Sodium supplement Pharmacologic Class: Electrolyte
ACTtONS AND USES
So:Iium {hloridt for hyporwtrrmi. wlltnstrum 1.11 IItIow
no (onsiru of 0.9% HaCl..rod wei to Ul'al mild hy-
porwlll'mia. When ,..rum sodiJm lalls bmw 115 m[q!l.. {olKtntraltd
1% Na(lsolution m.y lit iofuSfd. Ollll' r ilKlude 0.4S% and
0.22%, . rod both hypotonic arod isolooic soknions . 1l' milable. For itssstYm
hyponatll'mi., I <J t.bien.1l' . vailable.
Ophth.lm ic solutions of MaCI may bt!Md to tIN! (01"111'.1 tdtlN, and an OK
nasal spray available 10 relievI' d I): inA.mt<! rw.J I ml' mbr. n!'l.ln (oojulKtion
with o:ty1ocin,lO% HaCI may bt ust<! as an abonijoKienl latl' in pll'<Jnancy
whf n instillt<! imo lhe .mniotic 10K.
ADMINISTRATION ALERTS
Pll'<Jn.J ncymegoryC
PHARMACOKINETICS
sodium chloridt a nalur.lsubstalKf, phillllloKokilll't ic dol1a
ul'diffiruk to oblain.
lIT Prototype Drug I Potassium Chloride (KCI)
ADVERSE EFFECTS
P.tifnu Il'criYing /laCI infusions must bt monitortd frequenlly to
symptoms 01 hypmlallt'lllia, which ilKludt letharg)', confusion,muscit 1remor
or rigidity, hypotension,and rtstltssnflS. SOliii' of thl'lf symptoms . 1l'
.150 {ommon 10 hyponatll' mia, lab oHlI'Ssml' nt, must bt lakt'n 10 bt
(I' Main sodium .J Utslie within 1M oorm.1 n!/t. When infusing 1% NaClsoiu-
tions, tht flJll t m uld {hfck for signs of pulmOllilry I'dtlN.
Contraindications: drug should 001 lit adminisll1ll'd 10 p.atients with hy-
ptmUIl'fII Y, {oogesti'll' hurt failull', o. imjli irtd 1l'nallulKtion.
INTERACTIONS
Dru;rDrug: Thtrf aff oodi1icilily lignnl dfUl inli'fiKtions.
li b 115ts: l.o!ium dl10ridf inaNsfs thf IfIIJIl sodiJm 1fflI.
HerliallFood: Unknown
Treatment of Om do Sf: Iffluid accumulation occurs rut 10 a U'S, sodiJm, di-
Urtlin may bt to Il' ciKl' pulmonary or ptriplltral tdtma.
.... ter III M)Nuflln9l for Q NurIifIIJ I'rrKm fIK1l'i JjItdk III rIr/s dfI!9.
Therapeutic Class: Potassiumsupplement Pharmacologic Class: Electrolyte
ACTIONS AND USES
PoI.ssium {hloride a drug of cooic. for preventing or trNting hypoka itmia.1t
ilsa !Md 10 Ileal mild forms of alkalosis. Oral formulation, in{udt labien,
.rod liquids, usually heavily flavortd rut 10 the unpleasant t.111' 01 the
drug. potassium suppitllll'nts un caUSI' pepric Ukl' lI,thf drug should
lit diluted with pltntyofw.ter.Whtn gi'ltrlIV,potmium mUlt lit adminisll1ll'd
!lowly, silKl' bolul injections can D'll' rIoad lhe lItart and cau II' card iac
caUIl' ph.rmol cothtr.py with loop o. thiaridt diull'oo tilt most (ommon
QUII' of depletioo, p.ti. nu t.ki"'! th..,.. drug usUoi11y pr .. 0,,1
pm ssium supp1emtnlllO pIl't'nt hypokaitmia.
ADMINISTRATION ALERTS
Always gi .... oral medication whil!, paliffil Lpright 10 pll'Yeflll'lOpilagitis.
00 not cnIIh or illow PititM to chew tabieK
liquid forms btlOR' gjying thfOl.l9h.J nasogastrK lUllt.
Ik-;t r IV push or in .mounlS,and do nol acete1
an IV ralt of 10 m[qlh.
81' n1rl'fllely ull'lullo 'l'Oid t xuansation.rod infiltration.
Pll'<Jnancy megory A
PHARMACOKINETICS
StaUIl' potalSium {hloridt nalUlalsubstalKf, pha'IN{oi:inelic dati

ADVERSE EFFECTS
Nausu arod I'Omiting {ommon, btcaUSt polmiJm (hlorid!' initalts the GI
muro!a. The drug may lit t.lk!'ll with meals or anloKids 10 itsll'll ganric distlflS.
Tht most serious adl'ff"ll' rifo{ts 01 potassium (hlorid!' .J 1l' ll'Iated 10 the
bie acrulllJl'lion of mtsl K+. I-/yptrblemia mol Y oaur if thl' patient lakes
pot.ssium suppltments with potmum-sjliring diull'tiu. Ik-
LJ!/lt tllt kidnl')'lptriorm thin 90% oflhl' body,
duct<! can rapidly itad 10 hyptflcaitmia, p.rticularly in patients
uki",! potmiJm
Contraindications: dlloridt {oolfllindiulr<1 in palients with hy-
ptrbitmia, chronic mloIl fi ikJll', s)'Iternic oKidosis, !M'It dehydration, extl' n-
sm lissue is in II"I'fIl' burns. acill'nal insufficiency. or tilt
administration of a pol.ssium-spoilring diurttic.
INTERACTIONS
dln!icli and
ACE inhibiloo 10incfNll'thf rill;
li b Tes1S: Poiassium dlloridfo iooN\eS Ihfo IfIIJIl potassiOOIIHel.
HerliallFood: Unknown
Treatment ofOverdOlf: When 0Yerd01l' polasyum-sjliri"'!
ind all foods ind medications (ontaining signifiunt of potas-
sium soould bt withheld. T fNtmffi l ilKk.odes IV adminmralion of 10% ootfOll'
solution conuini",!lo-20 units of crystallilll' insulin. So:Iium bica rbonall' may
bt inluSfd to {OfTI'(t oKidosis. PoIysl)'ll'fII' IUlfonale may bt to I'fI-
hana polassium t liminuion .
.... ter III M)Nursl1rgl1l for Q NurIinl} I'rIKnl foors lfIKlk III rIr/s dfI!9.
LibraryPirate
440 UnII4 TheC.,dklv.sc:ub, aoo Urinary Synefm
LIFESPAN CONSI DERATIONS
Laxatives and Fluid- Electrolyte Balance
Wnh aging. slow!., food inlakf diminishes, ,nd physiul "tivity de-
and fKton can (h,fI9I' mo\'l'mem MIlO)' okltr
,dill; btlieft they must h.M a bowfI moYeIIIeIlI MI)' day and t,kf daily lax-
,oYeS. Chroni<: 1M of lautiYeS un in lkJid dtpidion and hypohiemia.
Stimulant lauti!'!, tlHo mon pmuibeil(1aIs
tro/ytt tr<lnspon in the irntllinallllKOsa.Thttldtrl)' <Irt !ll\(tplbIe
to Huid and rlKtrolytt dtpletion due to (hroni<: lauliYe 1M. The IIJIIt should
trac:h the patitot thn drilki"9 pient}' of Rum is imporum whtn taking i lax-
'Of\', that O'II'MI' oflamil'Mun reuk in 00e tfFfm, ,nd thi! these
,gent> should lit used onl, as dm trd by their hNkh PlO'lider. Tilt nullt
should JffOmmend that older patitots ilKlNM' (as toitrattd) and
insokJbltfilltr totiltdi(( to maintain timination
ACID- BASE IMBALANCE
Acidosis (eKess acid) and alkalosis (excess base) are not dis-
eases but are symptoms of an underlying disorder. Acidic
and oosic agents rna)' be administered to rapidl), correct pH
imbalances in body fluids, supporting the patient's vital
functions while the wlderl),ing disease is being treated.
31.8 Buffers and the Maintenance
of Body pH
The degree ot acidity or alkalinity ot a solution is measured
by its pH. A pH of 7.0 is defined as neutral, above 7.0 as ba-
sic or alkaline, and below 7.0 as acidic. To maintain homeo-
stasis, the pH of plasma and most body fluids must be kept
within the narrow range of 7.35 to 7.45. Nearly all proteins
and enzymes in the body function optimally within this
narrow range of pH values. A few enzymes, most notably
those in the digestive tract, require pH values outside the
7.35 to 7.45 range to function properly. The correction of
acid-base imbalance is illustrated in Figure 31.4.
The body generates signifiClnt amounts of acid during
normal metabolic processes. Without sophisticated mearu;
of neutralizing these metabolic acids, the overall pH of body
fluids would quickly fall below the normal range. Buffers are
chemicals thai help maintain normal body pH by neutraliz
ing strong acids and bases. The two primary buffers in the
body are bicarbonate ions and phosphate ions.
The body uses two mechanisms to remove acid. The car-
bon dioxide (CO,) produced during body metabolism is an
acid efficiently removed by the lungs during exhalation. The
kidneys remove excess acid in the form of hydrogen ion
( H+) byexcreting it in the urine. If retained in the bod)" CO,
and/or H+ would lower body pH. Thus, the lung and the
kidneys collaborate in the removal of acids to maintain nor-
mal acid-base balance.
31.9 Pharmacotherapy of Acidosis
Ac:idosis occurs when the pH of the plasma falls below 7.35,
which is confirmed by measuring arterial pH, partial
pressure of carbon dioxide ( P co,), and plasma bicarbonate
levels. Diagnosis must differentiate between respiratory
etiology and metabolic (renal ) etiology. Occasionally, the
cause has mixed respiratory and metabolic components.
The most profolUld symptoms of acidosis affect the cen-
tral nervous system, and include It'thargy, confusion, and
eNS depression leading to coma. A deep, rapid respira-
tion rate indicates an attempt by the iungs to rid the body
of excess acid. Common causes of acidosis are listed in
Table 31.5.
In ]XItients with acidosis, the therapeutic goal is to quickly
reverse the level of acids in the blood. The treatment of
choice for acute acidosis is to administer infusions of
sodium bicarbonate. Bicarbonate ion acts as a base to
quickly neutralize acids in the blood and other body fluids.
The patient must be carefully monitored during infusions
because this drug can Kovercorrect" the acidosis, causing
blood pH to turn alkaline
pH" 7.3&-7.45
Ac idosis
CNS depression

FlgureJI.4 Imbalances
Nonnal plasma
Al ka losis
CNS stirrulation
Convulsions
Ammooium dlIoride
Sodium chloride
pota&5ium
oN ....
LibraryPirate
OI..,l<r 31 Drug' for Auld Balan(e, Elec:trolyte, and Acid-BaS<' Olso<der, 441
TABLE 11 S I Caus@sof Alkalosis and Acidosis
Acldosl,
RESPIRATORY ORIGINS OF ACIDOSIS
or ihallow bruthingairwayoooruiaioo
to !6piralory (tote' in rntdJ ..
METABOLIC ORIGINS OF ACIDOSIS
diarrbta
Kidllf'/
Ili.Jbtte mdlilUi
we , akohol ingetion
Starloltioo
Prototype Drug I Sodium Bicarbonate
Th@rapeutic(lass: Agent to treat acidosis or bkarbonate deficiency
ACTIONS AND USES
Sodium bicarbonate is . drug of for (olrening I1II'Llbolic oKidosis.After
d'mociotion, th. b ic.>rbon.r. ion dirroly r.is<" tilt pH of A.iIk. Sod" m bi
may bt giYffi orally, if idosis is mild, or IV in me of dill'all'.
IV conmllatiom range from 4.2% 10 R49Uhhough lOdum biurbon.le.1Io
neutralimgaltrK . cid.it is not UII'd to dJr 10 its tendencylO
caUll' uncomfort. bit giltric distension. 0 .. 1 of sodium bic.r-
is known al bokinqwQ.
Sodium bic"bon.te may.ko bt UII'd to
t J1rdion of .(idic: lubstalKe. This pnxffi is u,..ful in tht tre.tl1ll'flt of
doII'S of .cidic: mNicationl SIKh ., aspirin .nd pherlobarbiLll.nd ., ad
the'apy for ct n.in d IIJ9i wch as metholR'lolte.
Sodium may bt !Md in chronic ren.1 f.ilu re to nfUlr.lizr tilt
m!'t.boIic: ido\i, that O{(Uts when cannot t J1rde irydlO9!'n ion.
When IV lOdum biurbon.tf it urint to more .Ika-
lint.LeI id is re.blOrOO:! in tilt ren.1 tubule, so more acid .nd idk mNi-
cine is This poxesl is known as ion trapping.
ADMINISTRATION ALERTS
Do nOl.dd oral pl!'piration 10 cakum-mntaining wiulions.
GiW' oral sodium bic.rbonate 210 3 hoots bmre or .Iter mNls and
medications.

PHARMACOKINETICS
Onst'l : 15min IV
h PO;unkna.vn IV
Half-life: Unkna.vn
Duration: 1- 3 h PO;8- 10 min IV
31.10 Pharmacotherapy of Alkalosis
Alkalosisdevelops when the plasma pH rises above 7.45. Like
acidosis, alkalosis may have either respiratory or metabolic
causes, as shown in Table 31 .5. Also like acidosis, lhe cen-
tral nervous system is greatly affected. Symptoms of eNS

RESPIRATORY ORIGINS OF ALKALDSIS
METABOLIC ORIGINS OF ALKALOSIS
Cornlipation for proIongtd pffiod,
IlI9I'stion of mess lOdium
DlJrffi n thot caUlf polOisium dtpIetioo

Pharmacologic (lass: Electrolyte
ADVERSE EFFECTS
MOSI of of sodum bic.rbonatt too.JpY.Jre tIM- rewh of
m<tabol'K .Ikoiosis Cilud by """,jying laomudr bKarbon.", ion. Symplom,
may ilKlude confusion, irritability, llow rl'lpi .. tion rate, .nd vomiting.
discontinuing the sodium bic.rbonatt infusion Iymploms;
pot.,sium chloride or .J mmonium chloride m.Jybtadminislere<l 10 rt'-
W'IW .Jrutt alkalolis. DJring sodium bicarbonale infusions, mum tlectrol)'lt l
lhould becartfully monilOrN, aI >Odium IeveII may 1M to
and fluid addition, high of bic"bon.te ion passingthlOlJ9h
tht kidnty rubulM K+ If{R'lion, and hypobitmia is possibit.
Contraindi cations: P.titnu who art iting or haW' conlinllOUS Gllooioniog
will iose acid and chloride.J nd may bt in a of metabolic .Ikalosis;tlitrriore,
tlM-y lhoold not lOdium bicarbon.lt. 8K.JUII' of tire sodium contem of
this drug. it lhoold be USN in patienu with cardiacdiINlI' and renal
impaitmerll Sodum bicarbon.te il comraindiutfd in patienu with
sion, peplic dianfrt.J, or vomiting.
INTERACTIONS
Druq-Drug: >ocilll! babonift maydfmalt tM.bIorplion
may IiKll'Urininalion of duuoamphetim,
le1raqdm rnay OONW
L1 b 11511: Urilary and lfIum pH mIMe with sodUn bO:boniI:f mnistrilion.
llIin.ry 1I'000iOOlji'l1iffl11rnay OONIf.
HfIba lIFood: Chronic l1li' with nilt or calcium suwk'mmu may GlU'if
Iryseriwl and possibIf Ioidnty

lrn tment 0Yerd0II' muhl in metabolic . Ikalom, which is IR'.Jtfd
by administeriH;J .cidic agerlU (Iff Xction 31.10).
IItfPf R1 M)NurJlngIJt for D Nlm/III} PrtrmI fIlM lfIKl/{ III rIr/s
stimulation occur including nervousness, hyperactive re-
and convulsions. In metabolic alkalosis, slow, shal-
low breathing indicates that the body is attempting to
compensate by retaining acid and lowering internal pH.
Life-threatening dysrhythmias are the most serious ad-
verse effects of alkalosis.
LibraryPirate
442 UnII4 The DrdloY.<;(ubr.oo Urinary Syuem,
Treatment of metabolic alkalosis is directed toward ad
dressing the underlying condition that is causing the excess
alkali to be retained. In mild cases, alkalosis may be cor
rected by administering sodiwn chloride concurrently with
potassium chloride. This combination increases the renal
excretion of bicarbonate ion, which indirectly increases the
acidity of the blood.
Patients with renal impairment or who have heart failure
may not be able to tolerate the increased water load that fol-
lows sodiwn chloride infusions. For these acute patients,
acidifying agents may be used. Hydrochloric acid and am
.9j: Chapter REVIEW
KEY CONCEPTS
monium chloride are two drugs that can quickly lower the
pH in patients with severe alkalosis.
A VOIDING MEDI CATION ERRORS
A ordm digoxin (l.noxin) 1.25 mg. but mt. m to writt O. m. Tilt
nudent nurll' gim digoxin 1.25 mg. Who is Tilt
prim"., nUIII'?The nursing inlll\l(\oll TIlt nurse m.nager?
SIt J{IptndIxOAlrlhtIlJgqmM<IlSWeI".
The numbered key concepts provide a succinct summary of the important points from the corresponding numbered section
within the chapter. If any of these points are not dear, refer to the numbered section within the chapter for review.
31 .1 There is a continuous exchange of fluids across mem-
branes separating the intracellular and extracellular
fluid compartments. Large mole;;ules and those that are
ionized are less able to cross membranes.
31.2 Osmolality refers to the nWllber of dissolved solutes
o;odil1tn, eIUCll .... , or me. ) in hody fll1id.
Changes in the osmolality of body fluids can cause wa-
ter to move to different compartments.
313 Overall fluid balance is achiewd through complex
me;;hanisms that regulate fluid intake and output. The
greatest contributor to osmolality is sodiWll, which is
controlled by the hormone aldosterone.
31A Int ravenous fluid therapy using crystalloids and colloids
replaces lost fluids. CoUoidsare large molecules that stay
in the intravascular space to rapidly expand plasma vol -
Wlle. Crystalloids contain ele;;trolytes., and are distrib-
uted primarily to the interstitial spaces.
31 .5 Bectrolytes are charged inorganic molecules that arees-
Sl'ntial to nerve conduction, membrane permeability,
water balance, and other critical body functions. Imbal -
ances may lead to Sl'rious abnormalities.
NCLEX-RN" REVIEW QUESTIONS
D Which of the following mechanisms is the most impor-
tant regulator of fluid intakel
1. Thirst
2. Ele.;;trolytes
3. Renin-angiotensin
4. Kidneys
31.6 Sodium is essential to maintaining osmolality, water bal -
ance, and acid--base balanCt'. Hypematremia may be cor-
rected with hypotonic N fluids or diuretics, and
hyponatremia may be treated with infusions of sodium
chloride. Dilutional hyponatremia is treated with diml'lics.
31.7 for pmp"" n"rve tnn""1,, fimc.
tion, as well as for maintaining acid-base balance. Hy-
perkalemia may be treated with glucose and insulin, or
by administmtion of polystyrene sulfonate. Hy-
pokalemia is corrected with oral or N potassium sup-
plements.
31.8 Buffers in the lxxly maintain overall pH within narrow
limits. The kidneys and lungs work together to remove'
exr;:ess metabolic acid.
31.9 Pharmacotherapy of acidosis, a plasma pH below 7.35,
includes the administration of sodium bicarbonate.
31.10 Pharmacotherapy of alkalosis, a plasma pH above 7.45,
includes the' administration of sodiWll chloride with
potassium chloride. In acme cases, an acidifying agent
such as hydrochloric acid or ammonium chloride may
be infused.
D Which of the following nursing interventions is most im-
portant when caring for a patient re;;eiving a plasma vol -
Wlle expander!
I. ARiess the patient for deep vein thrombosis.
2.0bserveforsignsoffluidoverload
3. Encourage fluid intake.
4. Monitor blood gases.
LibraryPirate
CJllfllfr Jt Drugs for Fluid Electrolyte.lIOd Dl5orde.-s 443
o The patient's serum sodium value is 149 mEq/L Which of
the following nursing interventions is most appropriate
for this (Select all that apply.)
1. Encourage the patient to eat a low-salt diet
2. Administer a 0.45% Naa IV solution.
J. Hold aU doses of glucoconicolds.
4. Notify the health care provider.
S. Haw patient drink as much water as possible.
o The patient complains of muscle cramping In the calves.
paresthesia ofthetoes,and the sensation ofthe heart sklp-
ping a beat. These symptoms may indicate which one of
the following imbalances?
I ,
2. Hypen:alcemia
J_ Hypoglycemia
4. Hyperkalemia
CRITICAL THINKING QUESTIONS
1. A 72-year-ol d man with a history of heart failure presents
to the emergency department complaining of weakness
and palpItations. The patient has been taklng furosemide
( Lasix) and digoxin (Lanoxin) at home. His curre nt ECG
reveals atrial fibrillation, and serum electrolyte tt'5ting re-
veals a potassium level of2.5 mEq/L The physician orders
an IV solution of I ,000 mLofiactated Ringer's with 40 mEq
KQ to infuse over 8 hours. What are the issues the nurse
must consider to safely administer this drug?
2. An IS-year-old woman isadmitted to the labor and delivery
unit fOrobservation with a blood pressureof 1861108 mmHg.
She has 3-4+ pitting edema of the extremities and
slates that her hands and face CBCreveals
an elevated hemoglobin and hematocrit. ThecerlifM.'d nurse
midwife diagnoses the patient with pregnancy-induced hy-
pertension and orders all IV of OSW. In addition, she re-
quests that the nuiSt' "push oral f1ulds."The nurse considers
whether the midwife's should be questioned. Disrus.s
the appropriateness of this order.
3. An 84-year--old woman has recently returned home after
being admitted to the hospital for persistent nausea and
\Umiling and dehydration. Her past medical history in-
o A patient will be sent home on diuretic therapy and will
need 10 increase the amount of potassium in the dJtoI.
What food choices would the nurse suggest be added?
1. Liver, red meats, lettuce
2. Apples, pears, celery, onions
J. Bananas, tomatoes, beans, fresh meats
4. Potato chip>, Ikorice, rice, corn
o Thenurse weighs the patient and fmds that there has been
a weight gain of 1.5 kgsince the previous day. What would
be the nurse's next highest priorltyr
1. ClIeck with the patient to see if there h.1\o1! been any
dietary changes in the last few days.
2. Assess the patient for signs of edema and BP for poo;ible
hypertension.
3. Contact dielary to change the patient's diet to reduced
sodium.
4. Request a diuretic from the patient's provider.
eludes gastric reflux. hiatal hernia, GI bleeding. anemia,
and coronary artery disease. Her current medication regi-
men Is metoprolol (Lopressor), SO mg PO bid; pantopra-
zole (Protonix), 40 mg PO daily; furosemide (Lasixj, 20 ms
PO daily; and betuloSt', 20 gOO mL PO at bedtime. Al-
though this patient's nausea and vomiting has resolved,
she is still at risk for fluid and electrolyte imbalances sec-
ondary to her medication regimen. Which dmg in partic-
ular places her at risk for fluid volume deficit, and which
electrolyte must be monitored? What assessments should
the nurse include?
Set Appwdix D far amwers and mtianaleJ far all activirieJ.
EXPl DRE
M-,flJrslnglOlls yos ooe SlOp for online chapter .... malerials aoo
feSOllr(;llii-. Prll!lilfe 1o. &UCCQ55 with additional tJO.ex-'-5Iy1u plattice
QuestkJ1s, InleradNe RSSIgnmenlS and activities, v.-eflilnu, Mlrmtlons
and anti flICIei
RegIster lOOr IICCI'!9$ eooe from the rlMI d vour IlMk lit
www.mynlA'silgidleom.
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LibraryPirate
CHAPTER 3l
CHAPTER 33
CHAPTER 34
CHAPTER 35
CHAPTER 36
CHAPTER 37
Drugs for Immune System Modulation
Drugs for Inflammation and Fever
Onlgs for 8acteriallnfections
UN ITS
The Immune
ystem
Drugs for Fungal, Protozoan, and Helminthic Infections
Drugs for Viral Infections
Drugs for Neoplasia
LibraryPirate
DRUGS AT A GLANCE
IMMUNIZATION AGENTS PIl}HfB
Vaccines
Q hrparlf/S B vaccine (Engem:-B,
RecomblvaxH8) )Q}t45J
Immune Globulin Prl!parations paJt450
IMMUNOSTIMULANTS pajt451
Interferons p4)}
Q lnterferon QIfQ1b(lnrrof..,V pagt64
Interleukins fXlC,4!iJ
IMMUNOSUPPRESSANTS {)451
Anti bodies plJl}t.f58
Ant imetabolitE's arK! Cytotoxic Agef1ts n&
Ca kinetlrin Inhibitors poqtfSV
Q cyclosporlne SCndlmmunej
,.,..w
KEY TERMS
Klieimmunity fklIIt449
nriboclies pt1J(441
ntigen fXl}t # J
Bul fXTJf "'
biologic piXJtf51
calcinwrin n457
cytokint 17451
imlllUnt' mponse pt1I}tUl
Drugs for Immune System
Modulation
LEARNING OUTCOMES
After reading this chapter, the studmt shoold be able to:
, . Compare and contrast specific and nonspecifi c body defenses.
2. Compare and cont rast the humoral and cell-.mechted immune
responses.
3 . For eac:: h althe major vac::cines,gi\fi? the rec;olTVTlended dosOlQ('
schedule.
4. Oistinguhh between active immunity and passive ifTVTlunity.
S. Identify Indications for pharmacotnerapy with biologic response
modifiers.
6. Explain the rteed for Immunosuppressant medications following organ
and tissue transplants.
7. Ide ntify the classes of medications used as Immunosuppressant s.
8. Describe the nurse's rote in the pharmacologi c manageme nt of
Immune di sorders.
9. For each of the drug classes listed in Drugs at a Glance, know
representative drugs,and explain their mechani sm of drug action,
primary actions related to t he immune system, and important adverse
effects.
10. Use the nursing process 10 care for patients re<eiving drug therapy fo r
Immune conditions.
lespollst
pt:I}t447
imlllUlO1lJPPltSsant pt:I}t451
1fJ1lt45J
{Q}t.fJj
systffll JlI)tW
pa!.Siw imllIunity
plasma ct. {Q}t447
T (eU {Q}t4S0
tiW {XJgt449
tOlloid Pf1i1t 449
r!jtction fkXjt.fJl
{Q}t448
{XJgt44B
LibraryPirate
T
he body Is under continuous attiKk from II host of for-
eign Invliders that Ind ude viruses, biKterla, fungi, <lAd
even single-<:elled animals. Our body defenses OIfe
capable of mooning a rapid and e ffective response aganSI
many of IhHe p,'IIhogenl_
ImmullOllllldWtOl Is a general term referring to any drug 01'
therapy that affects body defenses.. In patients, Im-
munomodulators afe used to stimulate body defenses so
that microbes or Cll ncer cells can be more effectively at-
tacked. On other OC(asions, It is desirable t o suppress body
defenses to prevent a transplanted organ from being re-
jected by the Immune system. The purpose oftnts cMpter Is
to examine t he ph<lrmacotherapy of drugs t hat are used to
modulate the body's response to disease.
32.1 Nonspecific Body Defenses
and the Immune Response
The lymphati c system provides the body with Ihe ability to
resist injury and protecl$ the body from pdthogcns. This sys-
tem consists of lymphoid cells, tissues, and organs such as
the spleen, thymus, tonsils, and lymph nodes. The different
components of the lymphatic system in continuous
communiC41tion and work together as a single unit to ac
complish dfeCl;ve immune
The first line of protection from pathogens is the
IIOIIspKilil delfnst sl'lolem, which serves as a senenl barrier to
microbes o r environmental hazards. The nonspecific de-
fenses are unable to distinguish one type of threat from an-
other; the response or protection is the same regardless of
the pathogen. Nonspecific defenses, sometimes called
innate defenses, include physical barriers such as the ep-
itheliallining of the skin, and the respiratory and gastroin-
testinal mucous membranes that are potential entry poinls
for pathogens. Other nonspecific defense5 are phagocytes,
natural killer (NK) cells, the complement system, fever,
and interferons. From a pharmacologic perspeclive, one of
the most important nonspecifK defenses is inHammation.
of ils significance, inHammation is discussed sep-
arately, in chapter ) }CX>.
The body also has the abili ty to mount a second line of de-
fense that is to certain threats. For example, a spe-
cific defense may act against only a single species ofbacteria
and be ineffective against all others. This is known as the
adaptive defense system, or more commonly, the immune tf-
sponsr. The primary cell of the immlUle response thaI inter-
acts with antigens is the lymphocyte.
Mkrobes and foreign substances that elkit an immune
response are oiled antigPm. proteins, such as those
present on the surf:K:e$ of pollen grains, bacteria, nonhu-
man cells, and viruses. are the st rongest anligens. It is esti-
mated that the immune s)'!item has the ability to recognin-
and react to over a billion difft'f'ent antigens.
The immune response is extremely oomplex. Basic steps
involw recognition of the ant igen,communication and co-
ordination with other defense cells, and destruction o r sup-
pression of the antigen. A large number of chemical
messenge.rs and inter.lctions are involved in the immune re-
... , many of whi ch ... yet 10 be discovered. The two
primary d ivisions of the immune response are antibody-
mediated (humoral ) immunity and cell-mediat ed immu-
nity. These are shown in Figure 32.1.
32.2 Humoral Immune Response
and Antibodies
The htnoral illllllUlle is initiated when an antigen en-
counters a type 0( lymphocyte known as a The Kti-
valed B cell divides r.lpidly to form millions of copies, or
dones, of itself. Most cells in this clone art called pIima(elk
whose primary function is to secrele litibodiesspecific to the
antigen t hat ini tiated the challenge. Circulating through the
body, ant ibodies, also known as immunoglobulins (lg),
physically interact with the antigens to neutralize or mark
them fordestruction by other cells of the immune response.
Peak production of antibodies o"urs about 10 days after an
initial antigen challenge. The important functions of anti-
bodies are illustrated in Figure 32.2.
After the antigen challenge, memory B cells are formed
that will the spifi c anligen-antibody inteTK-
Don. Should the body be exposed to the same antigen in the
future, the body will be able to manufacture even IUgher leY-
els of antibodies in a shorter period, approximately 2 to
3 da)'!i. For some antigens, such as those for measles,
mumps, o rchicken pox, mtmory may be retained for an en-
tire lifetime. Vaccines are sometimes administered to pro-
duce these memory cells in advance of exposure to the
antigen, so that when the body is exposed to the actual or-
ganis m it can mount a fast, effective response.
PHARMFACTS
VaccinQS and Organ Transplants
Vxcines 11M SI'M8poI &om ditworid, andthr poIiorirus
from 1M 'Nmml1lem6phtrt.
V.cines .. wlllli!NSt.Ie'!
from 175.000 .. 192110 ltIIIastIlWe 1980.
IlIII\ber of rnmIt! gift .. tht State'! hom
501,000 in 1962 to onl)o ibout 100 ems annIWII)o.
Of thtvudne-preftntablt dististS. PlWIJmococcal is tht
mollitthal, with 40,000 duths innwlly in thf Unittd S"te'!.
th.Jn 7'!I.000 patients for organ Ulnsplints. with 3,000
iddtd to !he lin rwfY month.
8fcallst oflidof millble tlinsplintt, many p.itirnu rflr fftty )lUI.
inWIing 2,OOOtidrwy p.iIirnts, l,l00 Mrp.lDrnb,
450 lIN II p.lUmb, md 361 big p.ilirnts.
Tbr IIIMtmmOlllJanSplinctd OIgiMatt Mr,lnd hNrl
LibraryPirate
448 UnitS Immune SY"'-""
Target. invaden outside ""II. (e.g . viru .....
bacteria. fungi. protist and toxins)
B-cell antibodies bi.-.::l
to viral antige .. and
.timulate the B cella to
divide and differentiate
antibody
\
' 0"
-t


(
-! )( I-
"
-..oryll ... 11
Pia""", cella .ecrete
antibodle. into the blood
and extra""lIular fluid
CEll.-MEOIATED IMMUNITY
Stimulate both humoral and ""II-mediated
immunity by releasing cytokines
Targeta defective body celie (e.g . infected
celie an:! cancer ""lIa). tran.plant.
r
...... -Q ----------
viral
antigen

Viral antige ..
pre.ented on the
.urfa:esof
dendritic ""II" or
macrophages.
and infected cells

T-cell re""pton bi.-.::l
to viral antigen.

helper T cell f



..
.' .




-t
-t '\-
-1
Cytokines released by
helper T ",,11a .timulate B
cella and cytotClllic T cella
..
..
:-
-"" help..-
-t
T""II
Memory cell. oonfer
future to this
virus
Cytotoxic T cells rel_
pore-fonning proteins
that destroy infected cells
Flgurel2. 1 Steps In the humoral and ceil-mediated Immune
Source: Audl>sirk, Terf'5/J;Audes/rk, Gerold; 8j{'r5, Brucl', Ufe Of) Earth, 91', 0 1010
VACCINES
Va"ines are biologic agents used to stimulate the inunune sys-
tem. Vaccinations are oneofthe most important medical in-
terventions for the prevention of serious infectious disease.
32.3 Administration of Vaccines
Va((ination, or immunization, is the process of introducing for-
eign proteins or inactive cells (vaccines) into the body to
immune activation before patient is exposed to
the real pathogen. As a result of the vaccination, memory B
cells are formed. When later exposed to the actual infectious
organism. these cells "'ill react by rapidly producing large
quantities of antibodies that will help to neutralize or de-
stroy the pathogE"fl. \I/hereas some immunizatioll'i are
needed only once. most require follow-up vaccinations,
called boosters. to provide sustained protection. The effec-
of most vaccines can be assessed by measuring the
amount of antibody produced after the vaccine has been ad-
LibraryPirate
'ho",tln Dfug.fortmmuMSystEfn 449
binds 10 antibody
FIgunJ2.2 Funcnom of anllbodles
So!.Ke: 5INmhotn. I'Iur!\ln Physiobgy:An AppIOaCI\Jndet C200I, p.lOO. ReplWfd by{lf'tl1"&lOn rJlWfIooEduc:otlM. tic. Ljpe' Sct1dIt
RIm,NJ.
ministered, a quantity called titfl'. If the titer fa Us below a
specified protective level over time, a booster is indicated.
The goal of vaccine administration is to induce Ionglasting
immunity 10 a pathogen wirhour producing an iUne5S in an
otherwise healthy person. Therefore, the microorganisms and
other substances used as vaccines must be able to strongly ac-
tivate the immune system but be modified 10 pose no signifi-
cant risk of disease development. The four methods of
producing safe and effective vaccines include the following:
Attenuated (live) vaccines contain microbes that are
alive but weakened (attenU<lted) so they are unabl e to
produce disease. Some attenuated vaccines cause mild or
subclinical symptoms of the disease. An example of a
live attenuated vaccine is the measles, mumps, and
rubella vaccine.
Inactivated ( killed) vaccines contain microbes that are
unable to replicate or cause disease. Several boosters
may be necessary 10 prolong immunity. Examples of
inactivated vaccines include the innuenza and hepati tis
A vaccines.
. 1oxoids are types of vaccines that contain bacterial toxins
that have bun chemically modified to be incapable of
causing disease. Exampl es include diphtheria and
tetanus tmwids.
Recombinant vaccines are those that contain partial
organisms or bacterial proteins that are generated in the
laboratory using biotechnology. The best example of
this type is the hepatitis B vaccine .
The type of response induced by the real pathogen, or it s
vaccine, is called Ktift immunity: The body produces its own
antibodies in response to e.'l:posure. The ael ive immunity in_
duced by vaccines closely resembles th.at Cllused by natural
exposure to the antigen, including the of mem_
or y cells .
P.min immunity occurs when preformed antibodies
transferred or from one person to another. For
LibraryPirate
I

j
"


t

450 UnitS The Immune Synem
example, maternal antibodies cross the placenta and pro-
vide protection for the fetus and newborn. Agents infused to
provide passive immunity include immune globulin follow-
ing "xposun: lu anliv"niu" fur a",..l..,rd
used to treat botulism, tetanus, and rabies. Drugs for passive
immunity are usually administered when the patient has al -
ready been exposed to a virulent pathogen, or is at very high
risk to exposure, and tnere is not sufficient time 10 develop
active immunity. Patients who are immunosuppressed may
receive these agents to prevent infections. Because these
drugs do not stimulate the patient's immune system, no
memory celli; are produced, and protective effects last only
2 to J weeks. Table 32.1 lists selected immune globulin
preparations. Pharmacotherapy lJIustrated 32.1 shows the
development of immunity through vaccines or the admin-
istration of antibodies.
Most vaccines are administered with the goal of
preventing illness. Common vaccines include those used to
prevent patients from acquiring measles, influenu, diph-
theria, polio, whooping cough, tetanus, and hepatitis B. An-
thrax vaccine has been used to immunize people who are at
high risk for exposure to anth.rax from a potential bioter-
rorism incident (chapter 1200) . In the case of infection by
the human immunodeficiency virus ( HIV), experimental
HIV vaccines are given after infection has occurred for
the purpose of enhancing tne immune response, rather
tnan preventing tne disease. Unlike otner vaccines, exper-
imental vaccines for HIV have tIlus far been unable to
prevent AIDS. Pharmacotherapy of HIV is discussed in
'napter 3600.
Vaccines are not withoul adverse effects. Common side
effects include redness and discomfort at tile site of injec-
tion, and fever, minor aches or arthralgias; and for live vac-
cinations, a "sub-clinical" case appearance of the disease
(e.g., minor rash with measles vaccination). Although se-
vere reactions are uncommon, anaphylaxis is possible. Vac-
cinations are contraindicated for patients who have a
TABLE32 .1 Immune Globulin Preparations
weakened immune system or who are currently experienc_
ing symptoms such as diarrhea, vomiting, or fever. Most
vaccines are pregnancy category C and vaccinations are of-
l"" in .. "ls wIlil an"r udiwry lu
any potential harm to the fetus.
Effective vaccines have been produced for a number of
debilitating diseases, and Ih.eir widespread use has pre-
vented serious illness in millions of patients, particularly
children. One disease, smallpox, has been completely elimi-
nated from tile planet through immuniution, and others
such as polio have diminished to extremely low levels. The
nurse plays a key role in encouraging patients 10 be vacci-
nated according to established guidelines. Table 32.2 lists se-
lected vaccines and tneir recommended schedules.
Although vaccinations have proved to be a resounding
success in children, many adults dieof diseases tllat could be
prevented by vaccination. Most mortality from vaccine-
preventable disease in ad ults is from influetll'.a and pneu-
mococcal disease. In 2002, the CDC published an adult
immuniution schedule that contained both age-based and
risk-based recommendations. Risk-based oonsiderations
include pregnancy, diabetes, heart disease, renal failure, and
various other serious and debiliMinj! conditions.
32.4 Cell-Mediated Immunity
and Cytokines
A second branch of the immune response involves T-
lymphocytes, or T (tlls. Two major types of T cells are called
ht'lper T cells and '")'\:otoxic T (t'lls. These cells art' some-
times named after a protein receptor on their plasma mem-
brane; tile helper T cells have a CD4 receptor, and the
cytotoxic T cells have a CD8 receptor. The helper T cells are
particularly important because they are responsible for acti-
vating most other immune cells, including B cells. Cytotoxic
T cells travel throughout the body, directly killing certain
bacteria, parasites, virus-infected cells, and cancer cells.
Drug and Adult Dose (rnaxdosewhere Indlcatedl Effects
cy\OfIIt9ikwiM globulin IV; 150 n h oImnsplanlation;thffi 100 m9fOl' 2,4,6, mxrkm fiTfi (poi", f/)"1hmIq.
(C)"toGam) and 8wk 50 rn9fkg for 12and 16 wk poll. m)'/gio), inf!uf,Ill1/ikf symproms (mdlli5t,
.. fmor, dilll hi?IldtIt
hepatitis 8 ilmnrotgiobUin (HEIG) 1M; 0.06 ml.J1o;g is soon 011 liter npolUre, within
...-
2( h, bI.c no I.!erlilon ] diY';repu,lt-lOdi)"l .fter "pol""
inllal'e!lOUl immUlll' globulin IV;I00-1oom9/mo
IVlG,lktigamJ
1M;11ml.J1o;gfollo\>i!,d byO.6ml.J1o;gMf'/ 1-4wk
labi!>s immuntglobutin 1M; (giutulJ 20 i labits mont
Imogam Rabits--H, II)'perab)
RholD) (Ba)'Roo.O, lMIlY;Ontvial 0I1oomcg 18 wk;folOWfd by ont vial of
WinRho SDF, MKRhoG.i.M. RhoG,l,MJ mi ridOll' 01' 120 n h ifinfilnl is
immune gIobuin (S;JyTet. 1M; 250 for prop/T)'Ialis
H)1le!Ttt)
/ralia 001II100II adverse fti'erls;.I!l!!!:!!i!!!! indjyte strious Idverse fti'MS.
LibraryPirate
' hlp"'!l DtIIgs for Immur.e SYSII!fn MoOJlnlOn 45 1
PHARMACOTHERAPY ILLUSTRATED
32.1 Mechanisms of Active and Passive Immunity
1IocMt ... V..:cine
AdrririotInd mcrrthe ... aft. u.. m.I
aCcine. booster ......,a". ........ tt..
imrrKne eystem 10 maintiwl ...augh "*""'Y
c ...... to mount a "'Pid to ..,
antigen.

AdrniI'ieu'J,bOII of
vaccine or eo.poeure 10
.. ..,tigen ,timlAat ..

a ntiboche n
.......ory c. ...
PH ai"" immunity
Adn-miotration 01
j!TYT\lI'IogiobUilll (anlibodiM)
giVM pauive i"."unity which
hu a last onset , but lut. only
3 to e month!.
T cells rapidly form dones after they are activated or sen-
siliud by an encounter with thei T specific antigen. Unlike B
cells, howtver. T cdls do oot produce antibodies. Instead,
activated T cdls produce huge amounts of q1oline, which
art' hormone-like proteins thai regulate the intensity and
duration of the immune response and mediate ceil-to-ceU
communiC3tion. Some q'lokines kill foreign organisms di-
rc.:dy. others induce inflammation or enhance the
k. iIIing power of rna<:rophages. Specific cytokines released by
activatffl T cells indude inlerlcukins, gamma interferon,
and tunlQr ne<:rosis factor. Some cytokines are used thera-
peutically to stimulate the immune system, as discussed in
Section 32.5. Sm:JJ1 of cytokines are abo secreted
by macro phages, B-cells, mast cells, endothelial cells, and
cells of the spleen, thymus, and bone marrow.
like B cells, some sensitized T cells become memory cells.
If the person then encounters the same ant igen in the fu-
ture, the memory T cells assist in mounting a more rapid
immune rt'Sponse.
IMMUNOSTIMUlANTS
Despite attempts over /Nny decades to develop effect ive
drugs 1113.1 slimul3te the immune system 10 fight disease,
RoopooH"""
.,tibodi ..
but Iho<1-Wwd)
TREATING THE PATIENT
Cultural Influ.nus on Immunizations

_ rI MId IIItII6Ig tht IfIUCl ddriM MId
IhouiMck of pmdIooI being immunWd. m.
muninlian IMk Ir. '11l0II\I Amc..n AmerQ\,IIis(Nnic,OIfId Arneriun
z.)UI'"

I'm UIy 'Airwd in mrdIIw:t willi iMvIiution flidtline. Ouldml are
!Ill tM ooIy IIjf IJIIl'IIKmg so:IIicitnc irtmuniution.ln 1999,lis(Nnio m
Mriun Amrric.all'l iqi!'d 65 older_1m 1-., tIwn White to !!pOll
b.wilg rmMd inbnza lind prwull'lOCO(U! wa<cine.limittd ICCN CO prnm-
tilof IlIVim Ind patirnt ,nd rutlnl btlim itwt
ar.lIII)'contrbJlto III
outrtlCh IOmt IUllesS,t r."hing
undermvf'd ethnic groups. Onto! the of HtclrhyPt6plt 1010, , set of
heakh objectives for the nltion in the filltdtudtof the llstctn-
riiminuing racial and tthnic: dilparities in hNlth. Ricil lud Ethnic
Approaches to Community Hulth (REACH) 2010Wle! none of the ([)('s
efforts to eliminatr the u,unthed in 1999, REACH funds commu-
nity co.JlitioMdHignf!i to implement UIIique strategies.
!io:rnmmtnt-funcltd hulth programs. wth II tilt (hildrtn'l Hulth lniti,-
Progllm (CHIP), wrr. 1110 initi,ted in IItt l!l9Os 10 promote prnrnli'te
1lt. 1th car. for Amtl'iu'l dliIWn.
LibraryPirate
452 UnitS The Immune SY""m
TABLE n .21 Selected Vaccine5 and Their SchQdule5
Vaccine ScheduleandAge
diphilltria, Imflll,incl Infirm.
IM;05 ml 011 aqtS 2 mq. mo,6 RIO,ancl 18 mo
haotmoplilus inftuenla type B (AnH IB, Hib TITIR, PrdvaxHIB) IM;05 mlil aqtS 2 mq 4 mo,6 RIO,ancl 15 mo;dikRn 12- 14Il10 who 11m no!
Crown isa (ombilalion ofhamKiphiusanci Bmuntl.
btftl...oo. .. utd rta;" a do",
hl'patitis A (Ha1Tix, VAQTA) Children: IM;O.5 mlal 12 mo, foIlowtd by a boosJ:tr 6Il10 10 12 mo laltr
1 ml followN by i boosJ:tr 6 motu 12 mo lattr
Q htpalitil B (Engfflx8, RKOIIIbi'IaX HBj
Children:15- 5 rnc:gat binh;lhffi 0.5 mlat 14 rna and 6- 18 rna
Twinrix is a (ombination ufhtpalitis Aand hl'patitis 8 montS.
Adrk\: 0 5 mlin thfN wilh IhI' se(ond dOlI' 10 days alltr thl' mt. and !hi' final dOlI'
6Il10 after IhI' fiI'II
human papiliomaYiM Children (fmlaltsj: IM;05 ml wim fnl dolt at '91' 11 Of 121!ilS
htninintr I((l)[I(j rose 2 mortm ifltr fim rose and till- mini dosr & months alltr !hi'
firndo", (itlN\! 24 Wffkl alltr!hl' fim dOII')
ilfhltrllj (Alluria, AuarD:. FlulIIat A!Nirin, AUlOIIt) Chidren: 1M twodo..s 1 moipart;thm annual dolt
Adrk\: 1M single anrwl do", Of inuillHil (FluMin)
lIII'aIIei,mllllpl.and nmla(MMRUj SlbMalltOlll;05 ml linglo: dolt at '91' 15 mo to poJJtny
Proqwd is a (ombinalion of MId R and varia-lia varniit's. 12- 15mo

pMumlXoual. poIynlent (Pnrumov.lX 23). Of 7\\Ilent (Plnnar) Adrk,(l'nrulllO\\lx 21 Of B):5UbrutillWJl Of 1M; 0.5 ml a,a dOlI'
Chidll'n (Prm.-arj: lM;fourdOll'uugel2 mo,. mo,6 mo,and 12- 15 mo
poIioviru>,inaailllttd (lPQj Chldll'n:>ib:uLJ1ItOIII;05 mlal 4-8 'lit, 24 mo,and 6-12 mo
ltII .... irus (RoIirD:, 2 mldo..s al 2 RIO, 4 RIO,ancl 6 mo (RotarD: doe nOlIl'llUII' a dolt
i16111O)
vakella (Varivax) Patiml> 12Il10 andoldft":5UIKIK.lIltOOl;05 ml, two oo..s gi'lm 4-8 wkapart
lhan 12 mo:05 ml as a single dOlI'
only a few such medications are available. These agents in-
clude interferons and interleukins produced by recombi-
nant DNA technology. Inununostimulants are listed in
Table 32.3.
secretion, interferons attach to uninfected cells and signal
them to secrete antiviral proteins. Part of the nonspecific
defense system, IFNs slow the spread of viral infections and
enhance the activity of existing leukocytes. These drugs have
antiviral, anticancer, and anti inflammatory properties. The
actions of interft'rons include modulation of immune func-
tions such as increasing phagocytosis and enhancing the cy-
totoxic activity ofT cells.
32.5 Pharmacotherapy with Biologic
Response Modifiers
\I/h"n chalJ..nsoo by <p"cific 3nti8"ns. cert3in c"ll. in th"
immune syst"m secrete cytokines that help defend against
the invading organisms. These natural cytokines have been
identified, and through recombinant DNA technology, suf-
ficient quantities have been produced to treat certain disor-
ders. Sometimes called biologi(rt',pon,f modifiers, some of these
agents boost spe.::ifk functions of the immune system. Bio-
logic response modifiers thai enhance hematopoiesis, such
as colony-stimulating factors, epoetin alfa, and oprelvekin
(Neumega), were presented in chapter 2S00.
lntrrferon, (IFNs) are cytokines secreted by lymphocytes
and macro phages that have been infected with a virus. Mter
The class of IFNs h.wing the grt'atest clinical utility is
th .. int .. rferons, for which six diff .. r .. nt
tions are available. These include IFN alfa-2b, IFN alfa-n3,
IFN alfa-nl, pegIFN alfa-2a, and pegIFN alfa-2b (note
that when used as medications, the spelling is changed
from alpha to alfa). In the two peg formulations the in-
ert molecule polyethylene glycol is attached to the int .. r-
feron. This addition e.ttends the half-life of the drug to allow
for once-weekly dosing. Indi cations for IFN alfa thel1lpy in
clude hairy cell leukemia, AIDS-related Kaposi's sarcoma,
non-Hodgkin's lymphoma, and chronic hepatitis virus B or
C infections. The use of IFN alfa in the pharmacothel1lpyof
hepatitis is presented in chapter 3600.
LibraryPirate
C""IU, n Dw!!. fo,'mmUM S)"''-'''' MoWla'''''' 45]
Prototype Drug I Hepatitis B Vaccine (Enger!x-B, RecomblVax HB)
Therapeutic (lass: Vaccine Pharmacologic (lass: Vaccine
ACTIONS AND USES
Hepatitis B mulll' is used to provide activr immunity in indivwals who all' <II
riskforelpolUll' to hepatitis BviM(HBY).k is indilattd forinlan" bornto HBY-
<II high risk fomposull' to blood, in-
ckiding nulVS, physici.ns, dtnttl hygitnists, morticians, .lnd
paramediu.8fulM HBY isutll'meiy diffiruh to is prudentfor
all hNlth call' wonm to 1l'Cei"l'l' HBV btginning their clinical ed-
uCiltion,unlts,conmindicated.The isako for all who
in high-lisk tmlal practic6, wch as heterosuual activitywith mukiplt
panntn, femalt p holllO\tlual or bisowl practicH or prISOns who
cont"' t HBY does nor pro-
vide protfClion aqain \I UpolUll' 10 (non-B) hepatitis viru Ie. H BY
is through ll'Combinant DNA tfihnology using )'Nst celklt is not pIl'-
pall'd from human blood.
Hepatitis B \\KCillillion ll'""ill'S three' 1M injtc.tions;the II'cond dole isgivrn
1 month alimhe the third doll' 6 months alimhefirst
is lII'arly 100% effeai"l'l' in providing immunit-; to HBV. Theeffectivelll'u of the
VilCcilll' in prodKing immunity in adults with age.
ADMINISTRATION ALERTS
In ildullS,use tIle!\Maid rnlJl(i!' for the injection me, unles iCOlilriIi ndicitro.
110111' of the forlllJlas of RffOlOOivuJ HB contain a
on' the vial 1m been with(j.,wn vaccilll'
should be used the vial dilurded.
Epinephrilll' (1 :1,(00) Ihoold be immediately milablt 10 tll'i11 a
alOlphyiactic reaction.
Pregnancy megory (
PHARMACOKINETICS
O. s.1: 2wk
Prak:6mo
Halfliff: Unknown
Duration: S to 7 Y
J
Interferon beta consists of two different formul ations,
beta-la and beta-lb, which are primarily reserved for the
treatment of severe multiple sclerosis (chapter 2(00). A
third drug in this class, IFN gamma-lb, has limited clinical
application in the treatment of chronic granulomatous dis-
ease and severe osteopetrosis.
Interleukins (ILs) are another class of cytokines, synthesized
primarily by lymphocytes, monocytes, and macrophages
that enhance the capabilities of the immune system. The U.s
have widespread effects on immWle function including stim-
ulation of cytotoxic T-cell activity against rumor cells, in-
creased B-cell and plasma cell production, and promotion of
At 30 JiIT"n,,,1 Ik hav"
though only a few are available as medications. Interleukin-2,
derived from T helper lymphocytes, promotes the prolifera-
tion of both T l ymphocytes and activated B lymphocytes. It
is available as aLdesleukin (Proleukin), which is approved for
the treatment of metastatic renal carcinoma. AIdesleukin
ADVERSE EFFECTS
The most tornmon adl'!' rse effects from HBY "I<lCcination all' pain ill the injtc.-
tion and mild to Ityer and thills.Approumall'ly 15% of piI1itnu
will experiente ')'Stemic eflecl!, usually hNcbche.
such il urticaria or pollibllo.
Contraindi tations: This is comraindicated in patieml with
tivit-; to )'I'all or HBY "I<lCcine. who demonmated \e"l'l'1l' Itjoptrsmsitiv--
;1)' 'a , .... r,,,, m.,.m' ..... iIlrin. , hnnlrl nn' rt'{.;.,. "'''''-1'''''' do"".Th. drug
should beadminismed with Cil ution in patients with fever or actil'!' infections,
or with tornpromill'd wdiopIJlmolOlry 'IiIIUS.
INTERAalONS
Drug-DIIJ!I: Unbiown
li b Tesis:Untnown
Herbi VFood: Unknown
Treatmfnt of OW' rdOSf: OI'!'rdosrs hal'!' not ll'Corded.
COMPLEMENTARY AND A LTERNATIVE THERAPIES
Echinacea for Boosting the Immunll Systllm
EdrimKro purpurlll, or purplt is i popular botanicallOltivr to the
United SIiIIH and cent,,1 (anad!. The 1IowerI, ltal'fS, and ,tem,
of this plant art lIalYeted and dried. Prtparatiom indudt dried powder, tine-
tUIl', lkJid nmrn, and trill. No singlt ingll'dient 5el' mI to be IflpDnsiblt for
the herb's i ctivity;alil1}l' number of ictMchemic.iis W
mmirlfd from the umm.
khillilCN Wi! used by Native Americans to tll'iII virious wounds and in-
is to boost the immunr s)'Stem t:, inell'uing phaqa--
C)'Iosisind inhibiting the b.icterialrnzyme ltjoaknonidur.Somesubstanee in
KhillilCfa apptilr 10 antiviral the herb is taken
to tll'ilt the cornmon cold and influeIW- an indication for which it hiS Il'-
'i.fd official approval in Grmtany.ln grneral Khinam isused ilia suppon-
for any dill'i\e involving inflammation and to enhince the
!)'!tem.Sm "1'1'; howe"!'I'r,it that
w immuOOlUppIl'ssant efil'ct;.
LibraryPirate
TABLE32.1 Immunostimulants
Drug ROUie and Adult Dose (max dose where Indicated) Adwrse Effects
akle5latin (PtoItl.iln):lnttrltukJt.2 ri;600,ooo (0.017 mgfl:g) t'ttJ 811 by I IS-min IV
infusion for 11IJt., of 14 dolts
fMil sympIfJIM rJoIIf, MIlIaisl), fOlh, tl'ltmill,

kltracltrmal (Tlcf); O.1 ml as wacdIM'
!JUlia,.,U," bypgfmwn Wb't9ub
IIJ0000bocytopHi.l oIi!lJ1ji iDlrja R!!mwry cdmy
Badlus (ai'MtiH-ubin (BCG)
vilUilM' (Ti,
(ThtlaC,sk bIaOdtl ilstilation for bliddtr wmoma
f)jlikt symptfJfM MIlia&), dyw,;"
anemiD
I!mI!ocy!Qpmy m@t UTI
INTERFERONS
Q inttrftrm alfi.2b IIntron-A) lMIstb:utaMOUS; ilaify cd 2 milkfl uriMIII tlnf

FMit mfl!f9ia.. fatigrJr,Modi!dJt. Q/J01I'Dl,
dillrrhfG
i'lterfcfon aHi(Ol)-1 (lnfel9tn)
i'ltufCll1 iHi-fil (Alferon H)
i'lterftron 1a (A1'OfIa,Rtbif)
30 millon lIliUlml3 tima'wt
Htpatilh:] milion ulitslm1tlm: timelwk Dr 18-24 mo
SubW:IJ1fOUs:9 fTK91tlret timewk
thfO!T!b!xyt!!proia ludd!! idl.'ation
seiZlRS (i'lIffltron beta! MI lintwtloo gamma)
Inaplrttui5 hf1lMrogxjdty
kltralMnll;O.OS ml (250,000 lUI ptr wart tMctlwk to/ up to 8 'Nt
1M 30 mcwwt
i'ltfritron
pegimffitlOll iHi2.
Pf9imerfcfon ilfa-l1I (I'tg-rnlWl)
SUbW:ilM'OUS (Rtbif); 44 m<g thIN
SubcWIM'OUS;O.2S mg (8 lIlits) Mr! 0I1Itr lSi,
SubW:ilM'OUS; IIll mcgtwk for 48 v.t
SUbW:ilM'OUS; 1.S
Prototype Drug I Interferon alfa-2b (Inrron-A)
Therap'utic Class: Immunostimulant Pharmacologic Class: lnlMferon, biologic response modifier
ACTIONS AND USES
Intefferon alfa-2b is a biologic roodifier prtpared by DHA
Ihnology that is iPProvtd 10 trW ClnCfrS (hairy maligll.lm
mfl.lnoma, non-Hodgkin'i IympbolN, AIDS-rtlalfod Si/(OIN), lIS Wfll
II vifil inffCtions {human papilloma ..uus. chronic Mpatitis virus Band Q.Off-
label indi<AltionllNY inWdt mronic mydogeOOUl leuklmw., Cinctt
viul.ll'nil cell Clncet wriulw-zosterviM, and West NileviM.
It is ilVaiwble fol fI, 1M, Ind administration.
Rebfuon in mrnbill.ltion dlUJ containing IFN illfa 2band ribil'irin,.in antivi-
ral qrn. Rebttron is indicillfod in p/larrMOliheraP'l' of Mpatilii
Ptgilltlieron alfl-2b (Ptg-lmlOll) has a rnoIKule of PEG i1ttad1ed to 1M inltl-
ftIon moIule, v.tIich gi'm t!lf drug an t:(ItJ"Ideod llalf-life. PegilltlM i11b-2b
is aPPlOt<i1O Ifut mfOllic hepatitis (viM although it may bt
used dJ"onic htpatitis B infections ind !le1lplilltic
ADMINISTRATION ALERTS
Thf drug illoold be administertd under 1M tlft'ful guidalKt of a IlNhh
Cirt Prll'Iider uperifficm with ill 1M.
SubclllanfOUS admininu.tion is for patieflu il rilli; for
(plartlet count lesllhan SO,OOOimmJj
c.all'gory (
PHARMACOKINETICS
tnset Unknown
Pe.U-12h(IMJ

Duriition:Unknown
ADVERSE EFFECTS
A fkdiu syndrorlM' of fMt mills, Ind fatigue OCCUI"I n S09G or pa-
tiMts, although this lISlJoIlly lIS Iherapy proglesse. Htac!ache, nlu-
sti, vomitinll dianbfa, and anOrtxill art ldilively (I)II1mon. Dfprtssion and
wicidal iOtation h.'o't bHn ftPOrttdandmay bt stYt,ul"ICUgh to It'quift' dis-
cominuation of the drug. With pwlonged therip)', Sfrious toxicity such as im-
JlJJnosuppft'Ssion, hepalotoxicity, and neurotoxicity may be obsered.
(ontraindications: Cofttraindiutions indudt hypti"Itnsitivity tI inttrftrons,
iIIIoimJlJJIlt !lfpatitis, and hepatic der:omptllS<ltion. Neollitti and infants
Ihould not m:tM!!hil drug becalM it contains benzyl alcohol, Ydlich iI associ-
ated with an inutased incidtllD! of neurolo9ic ilnd other S4!riouI (omplications
in mtS4! agegroups..
INTERACTIONS
1W:I-bu1; Use with ftllmlIN1GW mwdrowsi"ttss iIIId detijO"alion.
11lm! is idcitin nr".oiosl4lPft'SSm with am neopIastiG. Zidcrrudioe moll' JnaNSl
hlmalologic loxidt,:
IlI9f dKine\ i'I hlrnilClClit,leukocy1. (l)lJnn,fti pIaceIet C(llntl
OC(lf J....Sdit,"s oflhfrapJ.Htp.ltic ffIl)meS IN)' bKome 4uring IfH
tfIEfapJ and '""I 'fQU Wi lis<M:inuilion of tilt itug.lnterlt!Ol1 aIf ... 2b NJ tltwlf
uigI)'(frick!lewIL
HerballFood: !kIktlOWn
of Owrdou: Ovtldosf caW' lethi'!IY <lnd {OIN. Trtillmtnl is
by gtnet"al mtawrtS.
Rdfr III M'fMN19O ((If. Mnlngl'rtsS FufsptCMc to /IIIl1tug.
LibraryPirate
(hopltlll Drug. fo, Immulll' Sym'm MoWl.llon 455
NURSING PROCESS FOCUS PATIENTS .EeElVING IMMUNOSTIMUlANTTHE.APY
Assessment
Baseline assessment prio rto admini stration:
Undtrmnd the INson the drug has pr&ribtd in ordtr to mes lor
tlltr.pwtic: eifb.
Obtain I (ompittt IItl kh history ilKluding history 01 acMI
(t .g., chic:kenpox), ht patic:, cardiomsrular, ntUrologic:, or autoimmunt
distall', H IV infooion, lever or inltdions, prtgnallQ or brNstf<ling, and
prt'\'ious allt"lic: rtlponll' to immunizations or to produru (ontaintd within
immunization (t.g., ),!,ast to f99S or albumin ProdKIIJ.
Obtain I drug history,t-!pe(ially tht UII' of immullOlUPPl!1l<lnll or
(onic:OItt roids.
Obtain In imrruniution history Ind any ulIJsual ft'actions or ft'sponlt! thlt
O((Urm:!.
Obtain vitti signs, epteially tt mptraiurt.
['/;lluate appropriatt laboratory findilMJi (t.g., (&, platt lru, tit(troiytes, titm,
htpatic:.nd ft'nallabs).
Assessment throughout administration:
Asses lor p.ltitnt Idhl'ft' nce to romllll'nded immunization (t .g.
n<llor ft'ptued boosters in adults).
(ontinUl' ptriodic: monitoring 01(8(,lnd Ind ft'nallimction Studitsll
appropriatt.
Asses vital signs, e.pttially tfmptruUft'.
Asses lor and immediatt l)' ft'"IKIn
mlJl(tr 'M'akne., IiKhyu rdia, hypotension, dyspnta, pulmonary
.kin r. she, bruising or bleeding, or anaphylactic ft'actions.
Potentii!ll Nursing Di i!l gnoses
Htahh Seeking IIt-'h.Jl'ioo (oprffitd dtlift' to obtain vaccinations)
lneffeaivt Ht.kh Maintt nalKf to Iliuft' to rompiete
immuniution !(iwdutr)
DtfKimt ('/il{dnation !(htdJlt, It(ommendations)
Risk for Injury (mattd to drug
Pli!lnning: Pati ent GOi!ll s i!lnd Expected Outcomes
Tht patirM wm:
EJptritrK:f thtr.pwtic: effb dtptndtnt on tilt ft'. son tht drug is bting giYtn (f.g.,ictift immunity).
1It-'!ft't' front, or optritoce adW"ll' rfFb.
In undt,mnding oftlltdrug's UIf, adYfl"ll' eiferu, and ft'qJi ft'd plt(autions.
DffiIOn5lratt proptl stIfadministration of tht medication kg.,doII', timing, whfn to notify promr).
Implementati on
Interventi ons and (Rati onales)
Ensuring tht ril pt utk rffects:
Conlinuo os=smmt> os dr><,il><d Nrlio, for tho .. prutK p.llionl
should adherr to tilt rommended immunization !(hrrutr. Periodic: titers IIIi)'
be nffiitd to (onfinn immuniry,ept(ially in individuals who.ft' Mr 60 or
tholl' who aft' immuoosupprtSlol'd.)
For pMients UAve/ing MI'ItAI,obtlin immunization If(ommenti.nionl lor
dtstination rounuy. ((UfTl'llt It(omllll'ndarions may be found on thl' CDC
Tril"lttrr'. Htakh web
Minimizing adftlle rftKts:
ContinUl' to monitor vital rspteiilly trmpt,aturf,and ntUrologic: status.
(Immunizations and immunOllimul.nts may (.lUll' dtrmatologic,
ntUrologic: la.tfSl' rifts.An ioclN.r in
Ioulizrd ukfr.!tions orYiJnsof infooion at injt{\ion lite, tach,,:ardi.! or
p.llpitationl,dizzint1l,or(hangrs in of(onsOousne. molY indicatf
lignifiunl tiflSJ
Rtport .11 sig nifKint aa.e f!I' tifb 10 lilt hNlth (irt ptoYidtr lor ft'porti ng to
VAERS---Vaccint Adversr Rtponing Symm.
Patient i!l nd Family Educati on
th< potiml.nd fomily 0' wrgivr, 10 kp "",inolion rr<ord>
and to mnain rurft'nl with requift'd immunizations.
Eocoutagt older adults 10 d,awn 10 (onfinn immuniry.
Trl{h tilt patient to {onluh thf Wfbsitf briOit' pl.Jnning
O'Itntas to (on!Uh with tht hNlth (.1ft' prol'idtr about riW
and requift'd
Tra(h tilt patient to immtdiatrly ft'"IKIn art)' It'ltrOYfll0'' or u
inl1rud:ed by tilt htikh (ire in (lIOI(iousflffi wch
as or disorientation, dyspnti, or tac:h)Urdii or
pillpitltions.
(Continued)
LibraryPirate
456 UnitS Immune SY"'-""
NURSING PROCESS FOCUS PATIENTS RECEIVING IMMUNOSTlMUlANTTHERAPY (Continued)
Implementation
Interventi ons and (Rati onales) Pati ent and Family Ed ucati on

lR'at minor symptomatically. (Mioor m.ay lit trmed TNCh the patient to trm minor I)'mptomsas I"ftded but to Il"pOIt
with or as ordloR'd Ir; the taR' providtrfor low-ilradt (as dtl(ribfd Nrlier).
fe\lellltss thn lOn, for localized tl'ndtml'u,orfor minor anhralgias and
malaist.Cool to injer:tion mt .ruy help allt'/i.!tl' .rulaist,
injer:tion lOn'ne s.)

Aslffi for plIIibilil)' of pR'gnalK)', pR'vious history of ol\}ln transplantation, TNCh the patient to a!tn health me providen to ,lOy
and hom!' tnvironment in(kiding signifiumly immunoc:ompromised patients that may lI' q.rill' d derral of before
at from (htnlotherapy, brfoR' giving live virus immunimions.(Some vattination is Women who pR'gnant orwho br(OIlK'
rontinut to lit shed from the patiem in the posM(tination pR'gnam within the first 1 months after \\J(tination should (onlUk
Pfriod and may lit immunoc:ompromised patients i n the home with their health UR' provider.
environment Pregnane)' is a comraindiution for vaccination with the live
virum and women who become pR'gnant within 3 months of immunization
with a IiVI' should (onlUlt thrir heakh u R' providtr.)

Avoid or deft r immunizations in a ny patient with a autoimm dista!(. uplain to the patient the rffi to defrrvminations unlltr teruin
or tholl' taking cortic:osteroids. make it moll' diffrruk to disa'm drur;J ronditions and elllllR' that follow-up .I pplintmenn are made as
R'action infer:tiom rtIpOOlI' to vattine ilia)' appropr;a1l'to maintain currency with immunizations.
or unlltrtherapeutic <l nd an iIKrused risk of effer:1I111a)' Irsult.J

Aslffi thf patiem for pll"lious use ofSCG (onlUk with the health TNCh the patient thu prt"Vioos !M ofBCG may rrsult in a falll'-
taR' providtr beim giving PPD ("Mantoux1 !kin ttsting for 18.(8(G stimulate positiVI' 18 test.an unusualll'action to the PPO ("ManlOUl1 testor
immunity to tulltrrulosis and II'Ctnt vaccination ilia)' caUSf an that other teting may br R'quired to tonfirm or refutt (urrent
R'action to PPD injection or II'sult in a f.J lse positive R'action.) infer:tion.

Monitor for of opportunistic: and suptrinfer:tiom,or an ilKR'aSf in bruising InstrlKt the patient to immediately I!"porr in(R'asing malaill'
or bleeding in patients IfCriving therapy. may and weams,gingivitis orwhite pat(hes in mouth, yeast
o((ur, iIKR'uinl} the ris k of infrctions .I nd biffiling.) infer:tions, in bruising. or prolonged or exmsive bleeding to
Ihtprovirler.

CominUl'to monitor neurologic: and mental status in the patient rttriving

InstrlKt the patienl,famiiy,or c.Jregil'el to report
interferon thelllPY. (Psycholis, dtprrssion, .J nd luic:id.J1 ideations a R' potential iIKlI' asing ietharw, disorientation, confusion,(hangtl in IIthavioror
rffer:ts ofimerferon !M.) mood, agitation or ill}9rrssion, or atam.
undtrstanding of drug therapy:

Use opporrunities during .Jdministration of medic:.Jtionsand during <l lSmments The patient should br <lblt to sta1l'the lI'alOn for the drug;appropMe
to dilCl/SS fordrug thmpy,dnirtd therapeutic: OU\(OJlll'S, IIIOIt li nd what IIdYmr tffer:ts to obmn for and
rommon effts. paramettrs for when to call the heakh UR' when to rrpon them.
and any ne(esary monitoring or prtUutions.(Using time during nursing taR'
helps to optimizt and reinfon:e key tl'.Khing
self-administration of drug therapy:

SptCific to interferons, when the medic:.Jtion, instruct the p.nient, TNCh the patient to take the medication as follows:
family,or call'giver in the self-adminismtion of the drug. (Proper Rtconstitute the powdtr (if applic:able) with supplied dilutnt and
.dminimalion will inaNSI' the drug.) gmtly rotall' the yi.J1 brlWttll the palms. do not
solution to be SUII' it isdear and has 00 panic:uies.
Discard IOlution as instllKtt<i by the hNlth care pKlYider (lOme
vials R'main availab!t for U!I' up to 30 days.others all' for
oniy).Singie--usf syringes Ihoold be dismded afttr if
solution R'IIlains.
Do oot (hange manufatrul!fs brands withoot (olllllking with the
health care plO'/ider.
Haff the patient. family,or c.JR'gil'el the injection
ter:hniqut umil they aR' (omforuble with administtring dlll9.
Evaluation of Outcome Criteri a
halu.J1l' the of dlll9 therapy by tonfirming that patient goals and expemd outromes haft met (_"Planning! .
"" TIIbIt 11.1 for lis! (/ drugs re wIOCh rhest mnq gppIy.
LibraryPirate
must be administered in multiple, brief IV infusions because
of its short half-life. Therapy is sometimes limited by capillary
leak syndrome, a serious condition in which plasma proteins
and other substances the blood and enter the interstitial
spaces because ofuleaky" capillaries. Interleukin-ll, which is
derived from bone marrow cells, is a growth factor with mul-
tiple hematopoietic effects. It is marketed as oprelvekin
( Newnega) for its ability to stimulate platelet production in
immunosuppressed patients (chapter 2SOO).
In addition to and interleukins, a few addi-
tional biologic response modifiers are available to enhance
the immWle system. Levami.>le (Ergomisole) is used to
stimulate the production ofB cells, T cells, and macrophages
in patients with colon cancer. Bacillus Calmette--Guerin
(BCG) vaccine (Tice, TheraCys) is an attenuated strain of
Mycobacterium bovis used for the pharmacotherapy of cer-
tain types of bladder cancer.
IMMUNOSUPPRESSANTS
Drugs used to inhibit the immune response are called
immunosuppres5ants. They are used for patients receiving
transplanted tissues or organs, and to treat severe inflam-
matory disorders. These agents are listed in Table 32.4.
32.6 Immunosuppressants for
Preventing Transplant Rejection
and for Treating Inflammation
The immune response is normally viewed as a lifesaver that
protects individuals from a host of pathogens in the envi-
ronment. For those receiving organ or tissue transplants,
however, the immune response is the enemy. Transplanted
organs from donors always wntain antigens that trigger the
inunune response. This response, called t ril nsplilnt rejrction, is
often acute; antibodies can destroy transplanted tissue
within a few days.lbe cell-mediated branch of the intmune
system responds more slowly to the transplant, attacking it
about 2 weeks following surgery. Even if the organ survives
these challenges, chronic rejection of the transplant may oc-
cur months or even years after surgery.
Immunosuppressants are drugs to dampen the immune
response. One or more immunosuppressants are adminis-
tered at the time of transplantation and are continued for
several months following surgery. In some cases, they are
continued indefmitely at low doses. Transplantation would
be impossible without the use of effective immunosuppres-
sant drugs. In addition, these agents may be prescribed for
severe cases of rheumatoid arthritis or other inflammatory
autoimmune disease>.
Although the mechanisms of action of the immunosup-
pressant drugs differ,all suppress some aspect ofT-cell func-
tion. Some act nonsel.ectively by inhibiting all aspects of the
immune system. Other, newer drugs suppress only specific
aspects of the immune response. Obviously, the nonselec-
tive agents will provide more widespread immunosuppres-
sion, but carry greatH risk of adverse effects.
Chop", ll Dwg.forlmmu""Sys'"", MoWlat"'" 4S7
Because the immunosuppressants are toxic to bone mar-
row, they are capable of producing serious adVt'rse
During immunosuppressant therapy, the patient will be sus-
ceptible to infection from all types of pathogens: viral, bac-
terial, fungal, or protowan. Infections are common and the
patient must be protected from situations for which expo-
sure to pathogens is likely. Prophylactic therapy with anti-
infectives may bewme necessary if inumme function becomes
excessivelysuppre:5Sed. Long-term survivors of transplants are
also at high risk of developing cancers, especia\ly lymphoma,
skin cancer, cervical cancer, and Kaposi's sarcoma.
Drug cbsses that have activity in_
clude g1ucocorticoids, antimelllbolites, antibodies, and cal-
cineurin inhibitors. The g1ucocorticoids are potent inhibitors
of infianunation and are discussed in detail in chapters 33
and 0 00. Theyare often drugs of choice in the short-term
therapy of severe inflammation. Antimetabolites such as
sirolimus (Rapamune) and azathioprine (Imuran) inhibit
aspects of lymphocyte replication. By binding to the intracel-
lularmessenger {.laneurin, cyclosporine (Sandimmullt, Neo-
ral ) and tacrolimus (Prograf) disrupt T cell function. The
cakineurin inhibitors are of value in treating psoriasis, an in-
flammatory disorder of the skin (chapter 4SOO).
from Section 32.2 tb.1t antibodies are proteins
produced by the immune system to defend against mi-
crobes. In fact, Section 32.3 discussed how infusion of an-
tibodies can provide passive immunity. It may seem
puzzling, then, to learn that certain antibodies maybe ad-
ministered to patients to suppres5 the inunune response.
How is this possible?
When animals such as mice are injected with human T
cells or T-cell protein receptors, the animal recognizes
thesf as foreign and produces antibodies against them.
\'/hen purified and injected into humans, these mouse an-
tibodies will attack T cells (or T-cell receptors). fuur of
thesf antibodies are used as immunosuppressants. For ex-
ample, muromonab-CD3 (Orthoclone OKT3) is adminis-
tered to prevent rejection of kidney, heart, and liver
transplants, and to deplete the bone marrow of T cells
pr ior to marrow transplant. Basiliximab (Simulect) and
daclizumab (Zenapax) are given to prevent acute re.i ection
of kidney transplants. Infliximab (Remicade) is used to
suppress the severe inflammation that often accompanies
autoimmune disorders such as Crohn's disease and
rheumatoid arthritis. Note that the suffix in the
generic name refers to antibody. Because some drugs in
this monoclonal antibody class are used as antineoplastics,
the 5tudent should refer to chapter 3700.
AVDIDltlG MEDICATION ERRORS
An mltr wu wriufn to ,dminil1tr mttootlHatt 10 mg oJl(e a day for an
eleld)' pni!nt with mrumatoid up"'in why tht nUJ1e Ihould
qut!lion medimion ordtr.
D
LibraryPirate
4sa UnItS
TABU: 32.4 Immunosuppressants
"""
Route and Adult Dose (mall dose where Indicated) Adverse Effects
ANnBOOIES
(SjmulKt) IV; 20 1119 tint! two dow!5 (fil'5l do!e 1 h bdort 1lII)tfY;!KOIld loed fPfKfkm ilfriM liIr (pili,., tQffllmlt
dose IIqlilfl f r trinspWntl mydgkr), inlbrrlo-/it sympfrms (molabf. fmr,
(hils), 1Itodwht, diIzint1!
(ZeNp.xl IV; 11l191k9 start fil"!t no mort than 2. II priof to triMplant.
An. p!ndu k Iwpmcmjpn jnti:rtjoo<!may oulJrjn
then Itpta' MIY U day; 101 foul mort dolts
IniIlY djfftrmt body MIf:!ml !U!iI inJ!imJml
iIlIDimab (RemiGldt) IV; 3--5 m9fkg foIlowfd tr the !MIlt dose at 2 & wefts
!muromona!).COJ
r;;'Ioc)tt Immll'le gloIlJli'r 0r-
and Iymphoqrt ir!!I!\/!!!: qabuli'r l twn simplex or
IV; 10--10 mg/kgId.1y rytnmmakrdnl' Infmjnrn (roJJft'lmPluHm)
inlithylTlOC)'ll: (At9lfll)
mlftllllONlKD1 (Ortboclon!: OKTl) IV; 5 rngfiWy 10-1. da)'s
ANnMETABOLlTB AND CYlOTOXIC AGENTS
illikillfll (KiImt) SWrutifltOOS; 100 1119 0I(f daily /tjfiIII sire IffJCIionJ
maHH 9:
wtlioprint (ImUlin) POr1V; 3--511HJ.tg{iWy In tially:INY bt.1lllf to rtduct to l(lmrill!JMJIt.I'i:I
1-3l!1CJ"kg1day
'im'rr NJM' and mrnjtjnn OOnr romw
ioftllkJm
fl\iJilmncy hfIHlOIo:J:icity
cydopho5Jlhamidt (Cytox.ln) PO; lniti.ll: 1-5 1-5 mg/kgMIY MlIMing.aMlttb, 1IfIJ11OpI!1Ii4 4/opKi4
(S!:f 556 for tile Prototypr HOday!
Anaphyli!lk. 'n;roenj .. Ji mooa'Ytmlrgl j jmrwjtja!
..,,,.00,
100 mgi\g rdmpJNJY fi brmjl. tqpc cpjdmni! nmoIyit
Slmlll-Johnson Mm!!!b!!iil:!}stitil
n!l!!!Dtoxicity
fUIIH(ffII [ElIbttIl SibruuMOOl; IrIIIMttwk 01 0.08 mgfkg ft SO Ql\(UWI:
rnrd9iGJ, ,bdorrinol pGin, MlIMi/li hIadac/rt
Ickai!lOl IYDQ1Q1!m\')' Ml lKi!!

(Rh!:Ilfl\iuu, Tl!ull) PO: 15-10 mglday rw 5 days; 12 wk forthr!:t COIInlS
(S!:f 558 for tile Prototype
UkmmslO!Ntjtjs m'lf'kl'illpprn'ign alllWk
[)ugbox
OO
)
antmli !!m!!k gnho!ls. nal!!2tomll 511ddtn
dram J!JknQoaryfibmS\M!!ft/!1 mlllji
((!:IICtpt.Myfortic) POI!V; 720 mg bid in UHTbNtion willi (ortirouMlids Ind PfIiphttrJ ldmI4lfGlriIN. /ItQdht., /7mXIf.
C)'CIosporiIl!:, witlin 1. II of trampli M dyspfpsks, ttxbnilld pdn
antmla throntboM2I!:nla
'""""'"'
iWlill1U! PO; Hnv loading dose Irrtrofdi.l!fly i firf tr.In5p!ant. thltr 2 mglclay HypttehdtstmJmlil, 1II!h. ftrlilal9/tlilvilH,IIIIISla,
KlmilRj. ntIrriI, /JtXt pdll, llrijhlgdn.
/lypetfpidemia
HvprnrnSM IN*Q!!tria WEii !bmmlmtl"dl!'!lja
nt...mns
trmsillllimus {ToriseI) IV; 251119 0!1C!: W!:dIy O'B" 3O-ro min IWSo\ fdtlflQ, 1JICmiII,
IIyptrv/7ffflliG.llyprrfpidtnU
AM/!!i, inftQioll! intmtilial l!!!!l
dj'iUV gr mAJronn bjrtl! drfem
-
tlraldomldt (Thilomid) PO; 100-lOO mgf.wy (mil: 400 mgldily) timesat i!:au2 wk IWSo\ Trill ltutoptttia, ftm, diums, diaffilH,rnI1Iflst,
"""' ...
Iwjr rpjd!:wl JItCIIItt'ik binI] MOOs {Pl!'!![\,JJl'Y
Xllltll!s!:!liJik tJupll"D<ion nrutrnrtf'Oy
prripMr,! ntUropathr
LibraryPirate
TAlI.E 32.4 Immunosuppressants (COnltwro)
,..,
Routeand Adult Dose jlmM dose where Indicated) Adverse Effects
CALCINEURIN INHIBITORS
o QIdosporinto dose 14-1. mgIkg jv5t priorlo 2 Wftb,
111m 5-10 mlfl\9flb,
1hItism,1ImIOt Nniting
MI Im!rrt.!ltmia
1fIl!'(ti INInthm hmuM91ridty
uaoimllS (Pro.jml PO;O.lHJ in two 11 h;rjrt In!:
cq/dose8-12hlftel fl'therlPJ

tlbtttmind pdII, illSCllD\!, ptripIttId t(/frfl(J,
1'1; O.Gl-ll.05 l119J\g/d.Iy Infrion; 1I1rt no !OOIIeI
t!Yn, h jflfr I1olIIIpIam .. daJnCinulo pifm yn taV on!
Infrttjoo< hyl!!l! ....... De"'" ' ft !lfl!m!..;y
ftr!:rnors.oart!thei.l lllJd!Wd Im!rrt.!lmia
!!!f!!!it hypmtrmnit
Prototype Drug I Cydosporlne (Neora!. SondlmmuneJ
Therapeutic Oass: Irrmoomuppressanl Pharmacologic Oass: Cakinturin inhibitor
ACTIONS AND USES
Cpdosporine a i <omplu dlmJiul obtiinfd from a !Oil bqJs that inhibit>
hdptr T I:rih.Comp.1!;'d ID sollll!of thtoliwrmunosuppmsInlS,cydosporine
is len toxic 10 bone rnlflOW <tis. Whtn p!e(00ed for Iw.splint It(ipients, k is
omn lMd in mmbin.ruon will high dme of a gkJaKorOCoid lOCh oft pIN-
MoIII'. is apprlIfd fa! prophr\.ilis of kicInfy. hNre. MId 1M.
psoriisis; 1M JCt,ophth.lmil,ln condition 0( dimin-
isNd ttar pIOCbtion UIMd t.,. ow!.. inft.mllWlion.An IV loon is miWbR for
,md morsel uftr"ift{oIimorCrohn's dismf.
ADMINISTRATION ALERTS
Ntoral {rniuof,rookion}...d SandilllllUM' 001 biorqllinlmt omd tillI-
001 be IMd inwdiangrillll, wilhool: ckM supervision health
.......
Pregnillq (
PHARMACOKINETICS

hak: l-4h
Half.life: 16-27 h
Unknown
ADVERSE EFFECTS
The primary Q((OO in the with UplO 7'fn.
of pil!itml rtduction in urine autpUI. INtr hill" thf patitnu !akinog
tilt drug will hyptrtension ilnd tmMr.Othtr <OmmOn i!fft<ts
_ hudiJdle,ginginl hype!plasil,ilndmillfd Mj)itK 0,-
portllninic: inftiono; oc:rur dUM9 (y(mporioJe thry ff'ftr thin
with IOII1f of tM ocher immunosuPPffSSilnts. Periodic: blood (ounts irf IW'I-
Sill)' to thIt WBU do not f4l1 below 4,000, or below 75,000.
lDng--tmn tlJeqpJ tM mI: of lymphomas illII
stiIIUl'(tJ'S.
Conlni n diutiom: The only ronIr.Iinlic:, tion a prior hypmeMitiority to tht drug.
INTERACTIONS

rif.Jmpin ........ tifi.ngallhljl,ACI
t6AKk, iJnd IIWIIide ilnlibio!n r.ay iIcJNIe ImIl.
naN'it and lft.DI.k ma,
dfcrNIf hfpatic fIIl)mI5 ind lI'nary hMion ten

!hWd bt UIoI'd wilhautioo widI Mb.Jl illJlUlP-.mulatilrj

TrNllH'm of o-dose: Tilm is M forOftdose.
lUI II fooriIpKllcll1fMsdrug.
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460 UnitS Thl'lmmun<>Sysll'm
NURSING PROCESS FOCUS PATIENTS RECEIVING IMMUNOSUPPRESSANT THERAPY
Assessment
Bneline assess mnt prior to administration:
Undenund the rwon the drug h'l betn prncribed in ordtr to aIItsi for
therapeutk effects,
Obtain a completr hukh hinol) including prnious histol) or{urrrnt mr of
or activt inftctions (nptlially htrpts, mkella,and CMn htPitK.
(tmt t cardio\l.Jl(ular,lII'umiogic. or autoimmunt dMa\t; d trm.tologk
cooditions;HIV inftion;aod pregnane)' or brwtleeding, Obtain. drug histol),
tspe<ially the ust of corticostrroids.
Obtain a dimry history,nprcially tilt inl.ikr of gllptfruit juict.
Obllin bastlilll' vju Isigns., npeda blood PIffiUIt and temperaturr, ind
hrighlind weight.
Aslt.ll ol.l.nd dtnl.il ht.kh,
E-I.llHtt appropriatt laboratory findings (t,g.. CBC, eitctro/ytn,
9U:OSt,hrpnic ind It'llilllabs,lipid Ie\oeld.
ASlelSlnent throughout administration:
Asltss dtsirtd therapntic tfftcts (t,g.,no Siglll or symptoms
Itjtion, Itll!ft infl.mmatory rtsponlt or autoimmune Itsponsts art
suppresstd).
CominUl' monitoring of CBe,platelets, rrllill
function studits,.nd lipid it'Itls.
AsItIS l'iul blood prnsurt.nd temperature,
AsItIS and immtdiately Itport diilh, visible siglll of
inftction, n.UItiI, Omitinq. IIIlJI(It tlMlOO,
tach)'c.rd ii, h)'llfrtmsion,. ngi 1IiI, syncopt, d)'lplII'iI, plJlm onaf)' rongntion, ski n
or bItIing.ol dtcrt.std urine OI/IplJt.
Potential Nursing Diagnoses
Anxittyor F8r (rtiiTed to conctrlll.bout condition, trtiltmtot)
lneffectil't Tlltr.ptutic Regimen Mamgemtot to complexity
of dMalt,
Sor:iallsolation
DtrKient Knowltdqr (drugthelill'f)
Riskforlnltction
Riskforlnjury
Risk for Impairtd Oral Mucous Membr.ntl (malt<! to druglrUtmtM)
Planning: Patient Goals and Expected Outcom@s
Tbt patient will:
Expt'ritll(e thrraptUtic dftcts dtptndent 011 tilt dlll(l bring gi'lto (e.g., from signs of mnsplant rtsponlt
limited a"d dtcrtasing) ,
Bt 1m from, or txptrience m in imal. .dvmt
an unclentandi"9 of tht drug's Ult, adverse tfftcts,. nd requirtd pttc.lutions.
DtmonlU.\t proptr mtdication (r-9,dost, timing. when to norif)' plO'/idtr).
Impleme"tation
intervenlionsand (Rationales)
Ensuring therapeutic effects:
Com inut IStSSIlll'nt1 s dtscribtci earlitr for thmpeutic effects, (Monitorifl!l
will t.. ."",irKlu ll4n>pLo 01 ",i". uulpllL Se .. ",
inlb mrnatory (onditions and disordtrs should show 900wlly
Itm:ning inflamm.nion.nd pi in.)
Minimizing adverse effects:
CominUl'to monitor vital blood presSUft a nd temptri lUft.
(lmmunosupprrssant drugs may calM hypertmsion and illCrtillr the risk of
inftctiolllJ
Patient and Family Educati on
AdYist tht patitm on the monitoring
rtqUir",nt nl> i"'pn".,n,.",l Df rnumnt nl in juinl>
with lesstned lwelling).
tilt pititnt how to monitor blood prtllUrt.ElllUft the proptr
USt lind functioning of any hoIIII' obtained. Tilt patitnt
!hook! ft porl blood 140190 mmHg [II' per parallll'trrs
let by tht heakh cart plQ'/idtr. (hen pain or presSUft !hook! bt
ftpDl'lN
Tram tilt pititnt to rrport ftRr OY!'r 101' [II' instructed by tilt
health Wt providtr.
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NURSING PROCESS FOCUS PATIENTS RECEIVING IMMUNOSUPPRESSANT THERAPY (Conrtnuedl
ObSffi't for sicJns and symptOms inomt the
rnk of inftctiom., witkoppal'tUnistic infections wck is ktrpft,
\OOceili. (My..nd full9'l inft1:tions.)
Auess fol in 1M! Ii wnsciousness,disorieoutioo 01 confusion,or
II!mori..(NtlllOlogic dJ'lIgfIlIIiIY indicatt.dl'rl\l' drug tfteru.)
Continue to monitof (II(, plattlm, tlectrtiytts,gU:ost.Iier and rfll.1 function
Itudits,.ncllipid Itnk.(lmmullOlUppI!ISoInll may (illM Itukoptnii,.lltmia,
hypftglycrmiil, and hyptrUlemiaJ
ImpW oral IIII,ICDIII IIII'mlnnes Ind dtml hNlth.
inc!eilsrI tht risk of or.lundidiillis.nd gingMlil.Ch.I . nl:ifulllJill rime may Ill'
,...;.dJ
p.lbenl\ <ol1lllmption 01 gl4ptfruit ;:&,. juRt
iignif"rantly inclUStlcyo:losporint 1Mb .nclshould be mcIed wtrilt on
thtrapyJ
AS5tS1 for lhould 1lI'.woidtd for up to 4 mootiJs ilfttr
dii<ontiJaJing immunOSUpprtSiM liltrapy. WOIMr"I who bKomt pltgnant whilt
on the drug (011lll1t thtir healtll Qn! prowidtr.)
Auess for the deYtlopmtnt of hirwtism 01 alopeda. (Hirsutism is
whtrl the drug isdiscontinued. AIopii m.lY indicattsignilicanl

Pillt iut oodtrstillrMI ing of dlllg therapy;
Ust opportUllitits during administrnion of mtdications and during
to di$ruIS r.tion.1t fo, drug therapy, deirtd thtr.l PftJtic OIrt<OIIIt!., most
common rffKb, forwlltr1locaH tht htalth <4rt providn-,
and . ny lltCeQr) mOllitilMg or pttQutions.(Jking rimtduring m.ning urI
helps to OjItimilJe and rtinforu kty teidring il!i1S.)
Pilltiul seIfadm inislrll ia n of dN9 thmpy;
Wlll'n adminislering lM<Iications, imlnKl tht patifnt famrl"OIcal!gift r in
pnlptl thniqutS followed by IttUm cltmomtra!ion.(PIOpI'f
administriltion wi. inclfase the Ii tht drug.1.
Pillt ient iII nd h mi ly EdUCillti on
Ttadl tilt to rtpOrt signs Ind symptomsliinftioft
st.dI H:wounds with I!dness 01 draioq, IK!eHilg toUgh, ioctising
filtigue. whitt-f)il\l:heson 0111 mllCOUS memlHann orwhitt.nditl:1"tI
.1 cisclwrgt,or itd!r blilltr-ib skin.
1Mtrud: the patinu on inlNtion comrolllll"lUm,. indJding:

Awiding crov.ds, illlloM..
Awiding ptOpko witk known infKtion oqooog childrffl who
kightr risk of an inftioll..
CDoking food f.mit, or artgiwt to prfPil!
r.w foods .nd to dun up afrlfWank. Tht pitRRlIhc:dd not
COllsumt IlIW fruiliOi
Tud! the patimtto IfSlOrI .ny ftver pn- p.lwrll'ttrl brth' hulth
(iIR' S}I11ptOIlll ofinlKtion.
Instruct the patient 10 Ieth.IgY,
diioritntation,(I)nmon, dI.vtgts in irhmo.- or mood, WIred

Instruct the patien! 011 the nffii 10 rHUm fl!quently for WI
....
p.ltitnl to {illY. w.II,t identib:.!lion u.rd orWNI medical
idtntificiillion ;''M'Ir) indiGating inmuno!llflpre.lnt th'r'py.
Tud! the paDtnno m.lintain .. ,Iklll Qr.l1 h)'l}ient, KnpWing tht
OIal <avity daiy. Jtftplt'ljulardml.il"filill.nd<olllUhdmtistJboot
tht fl!quency
Too lhl' poUnt 10 4\Oid or 400
whilt on tilt without juict.rt ptrmissibit..
Discml pI!g!IiIlK)' and bmily plilming with WOIlll'l1 ofdrid-lII'aring
age..Xplain tilt ,ff! of medKatiorts on prtqrIan<y and
.nd Iht III'td to<isrussany PIe9lMKY plans with tht hultll (irt
till' rd kif JOjitiorwllmns
iKb:Iing barritrmdholh, with p.ltienIs tlking
me patient to notif, the providerof cballgfl to lwirgrow1h 01
tmurt.
The 01 (ilrtgivtr should be ablt to S!iIIt the If. SOII fat
tht dill!}: il pplDpNte dolt and sdltduinj:wlwt rifu to
oIMrw for and 10 If port ;.nd the anoop.ltfd Imgth of
rntcIic.tion thnapy.
Tud! the p.ilitnt to Llioe 1M rntdication as follows:
Ust enclosed to muSUlt 01 mixdrug.
Ust glass and not paper 01 plastic <ups unles pacbgt dirrions
indica!t thty itt 10 be used.
Mix drug with milk,d\oaIIalt milk. 01 OIiIIgt ;.rict. welL
After u ki ng lilt drug. rifnl' tht rup wilh addition.l1iquid to rlllUlf
the rlltirt dolt is l.ikrn.
EViII luilltion of Outcome Cr iteriill
mlllMt the tflti'lefll'Ss ofdrug thttapy by (I)nfirming tila! patRm gcNls and 9pttd outCOIMS h.1't bttII inti (set "laMing").
Str,.. J24 fllu to rtNdtlhtsumilllJIiDm 'IfI1
461
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462 UnitS The Immune SY"'-""
r tf Chapter REVIEW
KEY CONCEPTS
The numbered key concepts provide a succinct summary of the important points from the corresponding numbered section
within each chapter. If any of these points are not clear, refer to the numbered section within the chapter for rt'view.
H.l Nonspecific defenses deny entrance of pathogens to the
body by providing general responses that are not specific
to a particular threat. Specific body dt'fell'les are activated
by spedfic antigens, and each is effective agaillSt one par-
ticular microbe species.
Hl Antibody-mediated, or humoral, immunity involves the
production of antibodies by plasma cells., which neutrnl -
ize the forei gn agent or mark it for destruction by otht'r
defense cells.
32J Vaccines are biologic agt'nts used to prevent illness by
boosting 3J\tibody production and producing active im-
munity. Passi"e immunity is obtained through the admin-
istration of antibodies.
NCLEX-RN" REVIEW QUESTIONS
D A 55-rear-old female patient is receiving cyclosporine {Ne-
oral, SandimmWlt'} aftt'r a heart transplant. The patient
exhibits a whitt' blood cell count of 12,000 cells.lmml, a sore
throat, fatigue, and a low-grade fever. The nurse suspects:
I. transplant rejection.
2. heart failure.
3. dehydration.
4. infection.
D Which of the following statements by a patient taking cy-
dosporine (Neora!, Sandinunune) would indicate the
need for more teaching by the nurse!
I. "I will report anyreduction in urine OUtpU1to my
physician."
2. "I will W<ISh myhands frequt'ntly."
3. "I will take my blood. pressure at home every day."
4. "I will lake mycyd"-'porineat breakf""t wilh a g1ass of
grapefruit jui,e."
D The nurse should monitor a transplantpatit'nt forthe ma-
jor adverse effect of cydosporine (Neoral, SandimmWle)
Ih .. raryhy ".,.,.""ing which lah 1 .... 1'
I. CBC
2. Serum creatinine
3. liVl'T enzymes
4. Electrolytes
32.4 Cell-mediated immunity involves the activation of spe-
dfk T cells and thesecrdion of cytokinessuch as interfer-
ons and interleukins that enhance tht' inlmune response
and rid the body of the foreign agent.
32.5 Inununostinlulants are biologic response modifiers., in-
cluding interferons and interleukins, that boost the pa-
tient's immtulesystem. Theyare used to treat certain virnl
infections., illUllUnodeficiencies., and specific cancers.
32.6 Immunosuppressants inhibit the patit'nt's inuJlUne system
and are used to treat severe autoimmune disease and to
prewnt tissue rejection following organ trallSplantation.
o The nurse would question an order for immunostimulant
therapy if the patient had which of the following condi -
tions? (Select all that apply. )
1. Pregnancy
2. ~ n l disease
3. Infection
4. LiVl'T disease
S. Metastatic cancer
II Tht' type of immunity achieved through tht' administra-
tion of a vacant' is called:
I. active immunity.
2. passive inununity.
3. titer.
4. vaccint'.
o A 5-year-old child is due for prekindergarten immuniza-
tiollS.After interviewing ht'r mother, which of the follow-
ing responses may indicate a possible contraindication
for giving this preschooler a live vaccine (e.g., MMR) at
this visit and would require further exploration by the
n"...,,1
I. Her oousin has the nU.
2. The mother has just fini.shed her seriesofhepatitis B
vaccines.
3. Her arm got really sore after ht'r last tetanus shol.
4. They are caring for her grandmother who has just
finished her seoond chemoth=pytreatment for breast
cancer.
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CRITICAL THINKING QUESTIONS
1. A patient is taking sirolimus (Rapamune) following a
liver transplant. On the most rect'nt CBC, the nurse notes
a marked 50% decrease in platt'lt'is and leukocytes. Dur-
ing the physical assessment, what signs and symptoms
should the nurse look for! What are appropriate nursing
interwnlions?
2. A patient has been exposed 10 hepatitis A and has been re-
ft'Tred for an injection of gamma globulin. The patient is
hesitant to get a "shot" and says that h is immune system is
fUll' . How should the nurse
'ho", .. n Dfug. for Immu .... S)"lem ",odJl.lIon 463
1. A patient had a renal transplant 6 months ago and is tak-
ing cydosporine (Neoral, Sandimmune) daily. Identify
three precautions that the nurse should be aware of when
caring for this patient.
See Appel1dix D for alllWerS and ratiouales for all activities.
EXPLORE
is )'001 COl! stop lor CJI'Ijtne ellapler review mar!!riab aM
lor succlln with addillonal IICl.fX"'-sl)1oe practice
Questions. IllIeractll'e assil)M1nIS an;! actMties. wetlllri<s, animations
aM videos , and more!
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www.mynlllMlGkltcom.
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DRUGS AT A GLANCE
ANTIINFLAMMATORY DRUGS fllX}t4ff>
Nonsteroidal Anti-Inflammatory Drugs
(NSAlDs) pGqt467
Q Ibuprofen (Act.1I,Mollln,othersj prq*l9
Glucocortkoids (Corticosteroids) {XIJt470
Q prWnlJor/f! pagt411
ANTIPYRETICS pl1lJt41l
Q ocelamlnophen (1)"lenot olhfrs) {!OI}t471
KEY TERMS
ilnaph-,laxis {8/t4(f,
antipyretic f k l i ~ m
Cushinljssyndrome M , 47I
tydooxygeniSf (COX) PI1fJl461
Drugs for Inflammation
and Fever
LEARNING OUTCOMES
After reading this chapter, the student should be able to:
1. Explain the pathophysiology of inflammation and fever.
2. Outline the basic steps in the acute inflammatory response.
3. Explain the role of chemical mediators in the inflammatory response.
4. Outline the generl,l.trategie. for treating infh.mmation.
S. Compare and contrast the actions and adverse effects of the different
nonsteroidal anti-inflammatory drugs (NSAIDs).
6. Expiain the roie of giucocorticoids in the pharmacoiogic management
of inflammation.
7. For each of the classes listed in Drugs at a Glance, know representative
drugs, and explain their mechanisms of drug action,primary actions
related to inflammation and fever,and important adverse effects.
8. Use the nursing process to care for patients receiving drug therapy for
inflammation and fever.
histamine plljt4M
inflammation jllHjt4M
mast (ell f!II9t465
prostaglandins plljt461
salicylatt pl(}t468
salicylism {llq 468
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T
he pain and redness of inflammation following minor
abrasions and cuts is something everyone has experi-
enced. Although there is discomfort from such scrapes, in-
flammation is a normal and expected part of our body's
defense against injury. For some diseases, however, inflam-
mation can rage out of control,producing severe pain,fever,
and other distressing symptoms. It is these sorts of condi
tions for which pharmacotherapy may be needed.
INflAMMATION
Inflammation is a nonspecific defense system of the body.
Through the process of inflammation, a large number of
potentially damaging chemicals and microorganisms may
he
33.1 The Function of Inflammation
The human body has developed many complex ways to de-
fend against physical injury and invasion by microorgan-
isms. Inflammation is one of these defense mechanisms.
Inflammation occurs in response to manydilferent stimuli, in-
cluding physical injury, e."l:posure to toxic chemicals, ex-
treme heat, invading microorganisms, or death of cells. It is
considered a nonspecific defense mechanism because in-
flammation proceeds in the same manner, regardless of the
caur.e that triggered it. The specific immune defenr.es of the
body were presented in chapter 3200.
The central purpose of inflammation is to contain the in-
jury or destroy the microorganism. By neutralizing the for-
eign agent and rt'moving cellular debris and dead cells,
repair of the injured area can proceed at a faster pace. Signs
of inflammation include swelling, pain, warmth, and red-
ness of the affected area.
Inflammation may be classified as acllfeor chronic. Acute
inflammation has an immediate onset and lasts I to 2
weeks. During acute inflammation, such as that caused by
minor physical injury, g to 10 days are normally needed for
the symptoms to resolve and for repair to begin. If the body
cannot contain or neutralize the damaging agent, inflam-
mation may continue for long periods and become chronic.
In chronic autoimmune disorders such as lupus and
rheumatoid arthritis, inflammation may persist for years,
TABLE 33. 1 I Chemical Mediators of Inflammation
Mediator Description
'lIopl,,1l Drug. fOflnfl.mmaUon and 465
PHARMFACTS
Inflammatory Disorders
Anhritis, th!' most (ammon infiamm'tory d isotdtr, is tilt lNtIing tilUS!' of
disability in tht United SUil's.
InA,mm'tory bowt l disust ,fftIU JOO,OOOto SOO,OOO Amtriuns

In the Unittd St,tts"pproxim,teiy 70 million NSAID prescriptions ,ft'
""';tttn and ](I billion ovtr-tilt"ollJntl'f NSAID t,biets ,ft' !old 9th )'Nr.
It is rstimated th,t NSAIDs (aIM 16,SOO dmmannualiy,largtly
resuk ofGI (ompliutions. This is mortality than istilustd from
gutric:wKtr.
Worldwide, moft' th,n 30 million PfOplt (on",mt NSAlDs cWiiy"nd of
4O%aft' older th,n 60 )'NB of '9t.
with symptoms becoming progressively worse over time.
Other chronic disorders such as seasonal allergy arise at pre ..
dictable times during each year, and inflammation may pro ..
duce only minor, annoying symptoms.
33.2 The Role of Chemical Mediators
in Inflammation
\'/hether the injury is due to pathogens, chemicals, or phys ..
ical trawna, the damaged tissue releases a nwnber of chern ..
ical mediators that act as "alarms" to notify the surrounding
area of the injury. Chemical mediators of inflammation in ..
clude histamine, leukot rienes, bradykinin, complement,
and prostaglandins. Table 33.1 describes the sources and ac ..
tions of these mediators.
Histaminr is a key chemical mediator of inflammation. It is
stored primarily within mastcflls located in tissuespaces un ..
der epithelial membranes such as the skin, bronchial tree,
digestive tract, and along blood vessels. Mast cells detect for ..
eign agents or injury and respond by releasing histamine,
which initiates the inflammatory response within seconds.
Drugs that act as specific antagonists histamine receptors
are in widespread therapeutic use for the treatment of aller ..
gic rhinitis (chapter 3800) .
\'/hen released at an injury site, histamine dilates nearby
blood vessels, causing capillaries to become more perme-
able. Plasma, complement proteins, and phagocytes can
then enter the area to neutralize fort'ign agents. The affected
area may become congested with blood, which can lead to
B"dykinil
Pft'stnt in ,n illiClM form in pinna ,nd mut (elts; v,rodilator that tilu:;tS p.lin; t/fttts art simit" to tho!t of hiltamint
CorrpItmtnt Se-its of ,t Ita\! 2(1 prottins that in a U5tldt f"hion to nM"lU! Of dtstroy ,n 'ntigtn
Hiltamint Sicftdand rfiustd by mall (tlts;uu:;tS rilation ofblood I'tIstI5, smooth-1flISdt (OIIIIriaion, sWl'iting. ald itdJing
lMotrients Siortdand relt..lsttl by mall sinil .. to tholt ofhirumilll'
Pretnt in most USwtl "Ill !Iortt1 ,00 ft'lmtd b)' m"t upilla'l ptmIubitity,anroKl whitr blood (fils to silt of ilft,mmation"OO

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466 UnitS ThelmmuneSystMl
hiItarrine
b...tykifin
M .. ""
.--
... alrienu
.. H.I Steps In acute Innammatlon
Source Poooon fdurorfOn/PM
significant swelling and pain . .. Figure 33.1 illustrates the
fundamental steps in acute inflammation.
Rapid release of the , hemienl mediators of inflammation
on a large scale throughout the body is re$ponsible for
auph.,c.m. a life-threatening allergic re$ponse that may re-
sult in shock and death. A number of chemicals, insect
stinS'!, foods, and some therapeutic drugs can cause this
wide$pread release of histamine from mast ceUs if the per-
son has an allergy to these substances. The pharmaoother-
apyof anaphylaxis was presented in chapter 2900.
33.3 General Strategies
for Treating Inflammation
Because inflammation is a nonspecific proo;ess and may be
caused bysuch a vari ety of etiologie$, it may occur in virtu-
ally any or organ system. When treating inflamma-
tion, the following general prindpJe$ apply:
Inflammation is not a disease, but a symptom of an
underlying disorder. Whenever possible, the (IIUse of the
inflammation should be identified and treated.
Inflanunation is a nlltural process for ridding the body
of antigens, and it is usually self-limiting. For mild
symptoms, nonpharmacologic treatments such as ice
packs and rest should be used whenever applicable.
Topical drugs should be used when applicable because
they cause fewer adverse effects. inflammation
skin and mucous of the mouth, nose,
Sli .... IIII""'oI
"""""endings
(pain)
rectwn. and vagina are best treated with topical drugs.
These indude antiinflammatory (Te;lms, ointments,
patches,suppositories,and inl r.masal sprnys. Many of
these are available over the counter (OTC).
The gool of pharmacotherapy with anti-intlammatory
drugs is to prevent or decrease the intensit y of the infbm-
matory response and reduce feve r, if present. Most anti-
inflammatory asen'" arc nonspecific; the druS will ahibit
the same inhibitory actions regardless of the cause of the in_
flammation_ Common diseases that benefit from anti-
intlammatory agents include allet"gk rhinit is, anaphyla:tis,
ankylosing spondyli tis, contact dermatitis, Crohn's dise:lse,
glomerulonephritis, Hashimoto's thyroiditis, peptic ulcer
disease, rheumatoid arthritis, systemic lupus erythemato-
sus, and ulcerative colitis.
The two primary drug classes used for inflammation are
the nonsteroidal anti-inflammatory drugs (NSAIDs) and
the glucocorticoids (also called corticosteroids). For mild to
moderate pain, inflammation, and fever, NSAIDs are the
drugs of choice. Should innammation become severe ordis-
abling, corticosteroid ther.tpy is begun. Due to their serious
long-term adverse effects, corticosteroids are usually used
for only 1 to 3 weeks to bring inOammation under control,
then the patient is switched to NSAIDs.
A few anti-inflammatory drug classes are specific for cer_
tain disorders. For example, sulfasalazine (Azulfidine) is
specific to treating inflammator y bowel disease, and
colchidne and allopurinol (Zyloprim) are u5('d for gouty
arthritis.
LibraryPirate
'lIopl,,1l Drug' f ... lofl.mmaUon and 467
NONSTEROIDAL ANTI -INflAMMATORY
DRUGS
used drugs in medicine, including aspirin and ibuprofen. All
NSAIDs have approx.imatelythe same efficacy, although the
adverse-effect profiles vary among the different drugs. The
NSAIDs also exhibit analgesic and antipyretic actions. Al-
though acetaminophen shares the analgesic and antipyretic
properties of these other drugs, it has no anti -inflammatory
action and is not classified as an NSAID.
Nonsteroidal anti-inflammatory drugs ( NSAIDs) such as
aspirin and ibuprofen have analgesic, antipyretic, and anti-
inflammatory properties. They are widely prescribed for
mild to moderate inflammation. Doses for these agents are
listed in Table 33.2.
NSAIDs act by inhibiting the synthesis of prostaglandins.
33.4 Treating Inflammation
with NSAIDs
Pro,taglandins are lipids found in all tissues that have potent
physiologic effects, in addition to promoting inflammation,
depending on the tissue in which they are found. The
NSAIDs block inflammation by inhibiting cydooxygenaSl'
(COXI. the key enzyme in the biosynthesis of prostaglandins.
This inhibition is i1lustmted in . Figure 33.2. Because of their relatively high safety margin and availabil-
ity as over-the-counter (OTC) drugs, the NSAIDs are drugs
of choice for the treatment of mild to moderate inflamma-
tion. The NSAID class includes some of the most frequently
There are two forms of COX, cydooxygenase-I (COX-I )
and cyclooxygenase-2 (COX-2). COX-I is present in aU tis-
sues and serves protective functions such as reducing gastric
TABLE 33 2 Selected Nonsteroidal Anti-Inflammatory Drugs
On"
aspirin IASA ,lIld olhm) lit!' pagt m
for th/, ProlOlypr Drug box 00)
SELECTIVE COX-2INHIBI1OR

IBUPROFEN ANOSIMILAR AGENTS
didofffiK I Cataflam, SoIarm, VoItarrn,
.. ,"",
dillurisal
.-
u,noprWn INaIton)
ftlrliiprofm (Ansaid)
o ibuprofm Mouil,othm)
irmmtllladn IndcKil)
utoprofm
melcJxicjm(Mobk)
nabumtlone
naproxm IAk\>r, Anaprox, tiaprol}'n.
.""",
ox.JpnIli1(Diypro)
pi"o:Iic.Jmlfddtolll')
(TotKlin)
Route and Adult Dose (max dose where Indicated)
PO; 1 so-6S0 mg evPfJ ( h (mal: 4 glda:l) for pain or fM!"
PO; 3.6-- 5.4 glday in feu to divided dolts for .rihriti( (onditions
PO;80-l25 mg/da:l for MI or pre'lmtioo of thrombi
po; 100-100 mg bid (milx:800 I119lday)
po; 50 mg bid-.qid Imax:1OO IJI9/day)
po; 1000 mg followtd by 500 mg evtl)'8- 12 hoo.n (max: 1,500 mglda:l)
PO;lOO-oIOO mg tid- qid (max: 1,lOO mglday)
mg Ud- qid Imax: J,lOO mg/da,1
100 mg tid- qid (max: 300 mglda,)
PO;400-BOO mg tid-.qid (max: 3,lOO mglday)
PO;l5-50 mg bid or tid (m.x: 200 mglda,) or 75 mg !Ul!iilll'd-lffif
to two times/da,
PO; 75 mg tidor 50""l qid (m.x: 300 mglda,)
PO; 75-15 mg ona' daily
PO; 1,000 mglday (max:l,OOO mglda,)
PO: 250-500 mg bid (milx: 1,000 I119lday)
PO;6(I(I..l,l00 mg/da:l (max: 1,800 mglday)
PO; mg ont lOlWO tim6/da:llmil:lO mglday)
PO;400 mg tid (max: I,BOO mgfday)
Adverse Effects
SlOOIh pWfl.NQrmum 1XI6I'I!,


5ryerr G( bJerdjoo broQ(bollNlID
i nitilvlailb,lItmo!yti(illl'mii, !!ms
in dlldll'n mtlabolkiddosis

phQryrrs, fIIl/r
No Kfiouudyct\C
IIoUlM, clorrheG, romiring, obOOmiool
aumling, ritlptl'fio, dilJjflt'lj
I I
LibraryPirate
468 UnitS The Immune SY""m
j
CycIooxyg&nasa-1
(COX-I)
Prostaglandins
Thrornboxanes
I
Gastropro19ction
(Decreased acid
production;
incroa.sed mucus
production)
Incmasad platelet
aggregation
Renal pro19ction
Vasodilation
Bronchodilation
I Arachidonic acid I
,. figure 33.2 Inhibition of
acid secretion, promoting renal blood flow, and regulating
smooth muscle tone in blood vessels and the bronchial tree.
COX-2, on the other hand, is formed only after tissue injury
and serws to promote inflammation. TIms, two nearlyiden-
tical enzymes serve very different functions. The two forms
of cyclooxygenase are compared in Table 33. 3.
First-generation NSAIDs such as aspirin and ibuprofen
block both COX-I and COX-2. Although this inhibition re-
duces inflammation, the inhibition of COX-I results in
undesirable effects such as bleeding, gastric upset, and re-
duced kidney function. Most of the adverse effects of aspirin
and ibuprofen are due to inhibition of COX-I, the protec-
tive form of the enzyme.
SALICYlATES
Aspirin belongs to the chemical family known as the
Since the discovery of salicylates in 1828, aspirin
has become one of the most highly used drugs in the world.
Aspirin binds to both COX-I and COX-2 enzymes, changing
their structures and preventing them from forming inflam-
matory prostaglandins. This inhibition of cyclooxygenase is
particularly prolonged in platelets, where a single dose of
aspirin may cause total inhibition for the entire 8- to 11-
day life span of a platelet. Because it is readily available, in-
expensive, and effective, aspirin is often a drug of choice
for treating mild inflammation. Aspirin also has a protec-
tive effect on the cardiovascular system and is taken daily
in small doses by millions of people to prevent abnormal
NSAIDs block here
j
CycIooxygenase-2
(COX2)
Prostaglandins
J
Inflammation
Pain
""",
Decreased platetet
a9l1egalion
S&Ioctiva COX-I
inhibilors block
hm.
clot formation and strokes. The fundamental pharmacol-
ogy and a drug prototype for aspirin were presented in
chapter 1800.
Unfortunately, the large doses of aspirin that are needed
to suppress severe inflammation may result in a high inci-
dence of adverse effects, especially on the digestive system.
By increasing gastric acid secretion and irritating the stom-
ach lining, aspirin may cause epigastric pain, heartburn, and
even bleeding due to ulceration. Some aspirin formulatiofl'l
are buffered or given an enteric coating to minimize adverse
GI effects. In some patients, however, even small doses may
cause GI bleeding. Because aspirin also has a potent an-
tiplatelet effect, the potential for bleeding must be carefully
monitored. High doses may produce sil licylism, II syndrome
that includes symptoms such as tinnitus (ringing in the
ears), dizziness, headache, and excessive sweating.
IBUPROFEN AND IBUPROFEN-LIKE NSAIDS
Ibuprofen (Motrin,Advil) and II large number of ibuprofen-
likedrugs are NSAIDs that were developed as alternatives to
aspirin. Like aspirin, they exhibit their effects through inhi-
bition of both COX-I and COX-2, although the inhibition
by these drugs is reversible. Sharing the same mechanism of
action, aU drugs in this class have similar efficacy for treat-
ing pain, fever, and inflammation. For some patients, the
choice of NSAID is based on cost and availability: aspirin,
ibuprofen, and naproxen (A1eve) are the only NSAIDs sold
over the counter. NSAIUs ditter in their duration of action,
LibraryPirate
Chopltlll Drug' for Inflammal lon .1Id Fewr 469
TABLE jj.j I Forms of CyclooXY9"naSQ
Cydooxygena5e-l
""" ..
f'rt!tl\t i .. llti' .... '
Prntnt at >iI .... injury
Functions Proiffis gUtrK mlKtN,suppocts hlKtion, promOiti ilflammaTion, II'n5itim pain frm it
plattl<t aggItgation
hhibition II!' Undtsirible:ill(J!all'S risk bIffiIilllj.nd fll illfl' Dtsirable: mUlS itll4lpre sion 01 inftamllliltion
which may be important when patients are taking these
drugs on an ongoing basis. Although drugs in this class have
similar overall effectiveness, there is variability ill response
to NSAIDs, with some patients responding better to a par-
ticular drug. The choice of prescription NSAID is often
based on the dinical experiences and preference of the pre-
scriber.
Most ibuprofen-like NSAIDs share a low incidence of ad-
verse effects. The most common side effects are nausea and
vomiting. These agents have the potential to cause gastric
ulceration and bleeding; however, the incidence is less than
that of aspirin. Kidney toxicity is possible, and renal assess-
ments should be conducted periodically. Patients with sig-
niticant pre-existing renal impairment usually receive
acetaminophen for pain or fever, rather than an NSAID.
Ibuprofen-like NSAIDs affect platelet function and increase
the potential for bleeding, although this risk is lower than
from aspirin. An FDA boxed warning states that ibuprofen
and other NSAIDs are associated with an increased risk of
thromboembolic events (including stroke and MI) and that
the drugs may cause or worsen hypertension. For the occa-
sional user who takes the medications at recommended
doses and who has no risk factors, the drugs are safe and
rarely produce any significant adverse effeels.
SELECTIVE COX-2 INHIBITORS
Selective inhibition of COX-2 produces analgesic, anti-
intianunatory, and antipyretic effects without causing some
of the serious adverse effects of the older NSAIDs. Because
they do not inhibit COX-I, these drugs do not produce ad-
verse effects on the digestive S)'5tem and lack any effect on
blood coagulation. Upon their approval by the FDA, the
.... Prototype Drug I Ibuprofen (AdVli,Motrm,others)
Therapeutic (lass: Analgl'Sic.anti-infiammatory drug,antipyretic
ACTIONS AND USES
Ibuprofen is an drug thaI is pruribN for tht uutmml of mild 10 modtr-
piin, inllammalion. hs rfIK1mlll'ls is equivaltnt to llut of i !pirin
i nd othtr NSAIDs. hs actionl all' <kit to inhibition of prostaglandin synlhtlis.
Common indiutions piin with (hronic muswlosktlual dis-
ordm wc:h is rheumi lOid ind OIt_ nhritis, hmladlt, pain, and dys-
menorrlrN. (Iltwa bit liblus, dropl, and sokltions all' ava iIa bit in low dasH for
i dministration to children.
ADMINISTRATION ALERTS
GiY!' drug on an stortlich as toltr.ued.lf I'Omiling, or i b-
dominal pain give with food.
aWife tlut paTients with i sthrtli or who haY!' alltl<Jie to aspirin 'Il'
moll' likft)o 10 i hyperunsitivity Il'action to ibuprofrn.
Pll'9
ni
nqutog..,,8
PHARMACOKINETICS
Onset : 11>-60 min

Halflife: 2-4 h
Duration: 4-6 h
J
Pharmacologic (lass: NSAID
ADVERSE EFFECTS
elfem of all' gtnerally mild and indude naulu, lIranbum,
epigaslrK pain, i nd Gl ukrralion with [I(cuk or glOII biffililllj ilia)'
t1peo:iilly in patitnts laking high dolI'S for prolonged periods. P",itnts
with oKtive ptptK should 001 likt ibuprofrn. Chronic use of
may Itad to renal impairment
Contraindi citions: lbuprofrn hasan FDA blick boxwi ming thit its use is(on-
uaindic.iled for trNtmenl of ptrioptri tive pain in the lI'IIilllj of (orona ry artery
bypassgrah IUlgtry <kit 10 potential for a suoktorMI.Thisdrug is i lso mn
uaindic.ited in patients with signifICant Il'nal or and in
who hi Y!' syndrome of nilil pol)'JII, angioedemi, or bronc:hOlpasm due
to aspirin orolhtr NSAlD ulI'.h should be used uutiously in patienlS who hiY!'
lIrart failull' , IfIious i history of nrolo:t or MI.
INTERACTIONS
Drug-Drug: 8Kaw (OIn alfen pIotelftflMion,iIs Ull'shcUd bf.rroidi>d
wIIfn !akilllj anticoagWnts and oth@rc<glllationmodfirrs. AsPrinlMlin
dMMe 1M iCtion ofibuprofPII. lbul"ftrl may illClNIf pIiIsIIIiI
IMIs of lithium, lithium toxirity.llII' iCtionI of certain diumics IIIiI)' bf
wIIfn taken COllCU1P11t1y with with other N lAlls,akohol,
or (OIOCO'imoidllllil)' utI\t ll'lious aml'lll' Gl_1S.
liI b Tests: lbuprofm IIIiI)' ilKll'a\f blK>cing tine, aspanatr tranliminaSl' (AST), and
aLin-.e transamillR (.IJ.TIIMIs.lt IIIiI)' ilKrNlf hemoglobin and lIrma!ooit.
HmVFood: h'll'lttw,gri-.gillgtl, 1I" ginkgo IIIiI)' OON\o!
l INI ment of Oerdose: Thm is no Ipt(ific: tll'itment for oY!'n:ioIl'.Adminis-
uation of an aiblilll'drug rtliy tht urini ry 9lIl' Uon
Ili!ftrlOM)MJrs/ngnr fllrQN1JnIfII} I'nxm
LibraryPirate
470 UnitS Thl'lmmu""Syst""'
COMPLEMENTARY AND A LTERNATIVE T HERAPIES
Fish Oils for Inflammation
FiSh oiis,aiso known marine arr lipm foood prifNrily iI fish.
oils all' rid! !llUKrs poIyullQUJralfd fatty 0 of tilt
omrga) type.TiIt two mon lIu:iitd fatty acids br.d in fish oik arr EPA
apenlRnoi: acid) and mIA (docosahuafflJic: idl. Ttwsr fatty acids are known
for thrir trigiy<:rrideiowt'ring tiviry. and thry also havr antiinflammatory
ACtioos(0h,lOOS).
5erI"alll"lKlYniIms are beIiMd to aaront for t.r aajy
ity of EPA and DIIA. The two rompetitiYely inhibit !hi' (OI1'Imion of arac:hidoni:
ac:i:l to tilt proilAamfNlory prostagbndm, tie reducing tlltir synthtsis.
Intrrac:tions may O(Qlr btIWffn fish oil and aspirin and otht r
NSAIDs. Ahhoogh rarr,mh intrrac:tions might be rrunifuttd by in(reasrd
10 bruising. nostblfflk. hemoptysis, herruturia, i nd blood in tht
,,00[
selective COX-2 inhibitors quickly became the treatment of
.. fur moderate i.nflammation.
However, in 2004, postmarketing data revealed that rofe-
coxib (Vioxx) doubled the risk of heart attack and stroke in
patients taking the drug for extended periods. Based on
these reports, the drug manufacturer voluntarily removed
rofecoxib from the market. Shortly afterward, a second
COX-2 inhibitor, valdecoxib ( Bextra) was also voluntarily
withdrnwn, leaving celecoxib (Celebrex) the sole drug in
this class. Other selective COX-2 inhibitors are still available
outside the United States. In addition to its anti-inflammatory
indications, celecorib is used to reduce the nwnber of col-
orectal polyps in adults with familial adenomatous polypo-
sis (FAP). Patients with FAP have an inherited mutation in
a gene that results in hundreds of polyps and an almost
100% risk of colon cancer.
GlUCOCORTICOIDS (CORTICOSTEROIDS)
Glucocorticoids have numerous therapeutic applications.
One of their mmt "..,f,,1 pmperti"" is the s"rp ...... s
severe inflammation. BecJuse of potentially serious adverse
effects, however, systemic glucocorticoids are reserved for
the short-term treatment of severe disease. Glucocorticoids
are often referred to as corticosteroids. These agents are
listed in Table 33.4.
33.5 Treating Acute or Severe
Inflammation with Glucocorticoids
Glucocorticoids are natural hormones released by the adre-
nal cortex that have powerful effects on nearly every cell in
the body. When used as drugs to treat inflammatory disor-
ders, the doses are many times higher than the amOWli nat-
urally present in the blood_ The uses of glucocorticoids
include the treatment of neoplasia (chapter 3700),astltma
(chapter 3900), arthritis (chapter 4700), and corticoste-
roid deficiency (chapter 4300).
Like the NSAlDs,glucocorticoids inhibit the biosynthesis
of prostaglandins. Glucocorticoids, however, affect inflam-
mation by muhipl .. m .. chanism . Th"}' hav .. th .. ability to
suppress histamine release and can inhibit certain functions
of phagocytes and lymphocytes. These multiple actions
markedly reduce inflammation, making glucocorticoids the
most effective medications available for the treatment of se-
vere inflammatory disorders.
When given by the oral or parenteral routes, glucocorti
coids have a number of serious adverse effects that limit
their therapeutic utility. These include suppression of the
normal functions of the adrenal gland (adrenal insuffi-
ciency), hyperglycemia, mood changes, cataracts, peptic ul-
cers, electrolyte imbalances, and osteoporosis. Because of
their effectiveness at reducing the signs and symptoms of in-
flammation, glucocorticoids can mask infections that may
be present in the patient. This combination of masking
signs of active infection and suppressing the immune re-
sponse creates a potential for infections to grow rapidly and
remain undetected. An active infection is usually a con-
traindication for glucocorticoid therapy.
Because the appearance of these adverse effects is a ftmc-
lion of the do.., d"rMion of IreMment is often
TABLE 33 4 Selected Glucocorticoids for Severe Inflammation
Dru, Routeand Adult Dose (max dose where Indicated) Adverse Effects
betamrthi lOIII' (CtltIlOllr)
PO;O.6- 71mg1day (odol
""-
POIIM; 20-300 mglrla)' il rivmd 00srs
1IIIlhir9. irrwmtio,5IIdirJmrDi
IIlJid rmntiln, impoirFd \IOO/ld MdRj,
...

'""""'-
IrJdllKortisonr (Conrt lI)'rtocortont. othm) PO; 10-)20 mglday in thrte to four dividrd dosrs
vlar hypoY){fOlja (p\IfO!IOfO'ij!
(w 67) fa" thr Prototype Drug
I V 11M; I , - 800 mglday il to /ou" diYidrd doltS (rrul: 2 glday)
baM
bOi ool
mmdegfiltdQ!9W1h il dlildrm
MMrol) PO; 2--{,(1 mgiday in dividfd doles
malljoo o!'ilkoiOO!
pmtlisolone (Oraprtd, PII'IoM) PO; mg onrto four timrs/rIa)'
Q prtdnisonr PO; mg onr to foor timrs/rIa)'
triarndnolonr (Arntospan, Kmalog) PO; 4-48mg onr to foor timrs/rIa)'
Irdiainditnt rommon ad'/Mo! inditnts s.rrioui idYftlftffrm.
LibraryPirate
Choplt,ll Drug. forlllfbmmallon.1Id Fewr 471
Prototype Drug I Prednisone
Therapeutic (lass: Anti-inflammatory agent Pharmacologic (lass: Glucocorticoid
ACTIONS AND USES
Predoisolll' is a ,YIltht tic: gl!Koconic:oidlt. Jctioos art the rauk 01 bting mr-
tabolizN to JO actiYl' form, whic: h is also milablt as J drug (ailed prNoisolo1ll'
(Orapred, Prrlolil', othm). Whro usrd for iolLimm.ltion, duration of tlltrap, is
commonly limited to 4 to 10 da)'5. For long-term thenpy,akemuNbydoling
isulfd.Predoilont isocGHiooal1y used toterminatr iKUlr brolKoospasm in pa-
titnu with anhmi i nd u an anti lII'opbstic: i9ffit for patients with (rna in cao-
(tl\ wc:h as Hodgkin'IdiW',u, Jrutr lrukmri.l, aOO Iympoomu.1t is,milablr io
tablet aOO oralsoution forms.
ADMINISTRATION ALERTS
Adminiltrr 1M injections cIrt-p ioto thr mUICIr mi lS to aYoid atrophy or
absm!t1.
Do oot III!' if signs of a inftion prerm.
Whrollliog thedrug forlllOll'thao 10days,tlltdol!'mtIII btllowly taprred.
PlI'9nJIK)'(.iltgory(
PHARMACOKINETICS
Onset :Unlrnowo

Halllife:1Sh
Duration: 24-36 h
limited to the short-term control of acute disease. \'/hen
longer therapy is indicated, doses are kept as low as possible
and alternate-day therapy is sometimes implemented; the
medication is taken every other day to encourage the pa-
tient's adrenal glands to function on the days when no drug
is given. During long-term therapy, the nurse must be alert
for signs of overtreatment with glucocorticoids, a condition
known as Cushing'nynd rome. Because the body becomes accus-
tomed to high doses of glucocorticoids, patients must dis-
continue these drugs gradually: abrupt withdrawal can
result in acute lack of adrenal function.
FEVER
Like inflammation, fever is a natural defense mechanism for
neut,.,.lizinS foreign are
killed by high fever. Often, the health care provider must de-
tennine whether the fever needs to be dealt with aggressively
or allowed to run its course. Drugs used to treat fever are
called antipyretics.
33.6 Treating Fever
with Antipyretics
In most patients, fever is more of a discomfort than a life-
threatening problem. Prolonged, high fever, however, can
become dangerous, especially in yOWl8 children in whom
fever can stimulate febrile seizures. In adults, excessively
ADVERSE EFFECTS
Wht n ulrd for soon-1Mn thrraP'l. prNoisone hu few W'riou! adww tfifru.
Long-1Mn therapy may reuh io Culhiog's a (oOOition that in(kidts
lat redistribution to thr shouklrl\ ,00 facr, musclr 'Maklll'n,
bruising, JM bone that Nsily Offiul(' gastric UktB may occur with
Iong-1Mn thrrapy,an aODuker mrdic:ation may br PIl'ICribtd prophybctiully.
lkrwith uution in j)atirnu with peptic: (olitis,or diYl'flirulitis.
Contraindi u lions: Patiffitl with actiYl' fuoga or protOlOan io-
fections lliould oot take prednilOlil'.
INTERACTiONS
Drug-Drug: 8Kaw iIOd inmu jIIfOOisoM
1M> {roamnt u'" with oIIIIpboIHicin SOf
diurMiG which maybe I!'riouI fOf pMnlllAilg!igm:in.
OOIM prNlisoIII' yn raj", blood gluco!f t....eI!, diabetic pMnts may ill
.... ts.
l.i b 1151s: I'Iedni!ooI> may inhibit iIltibody n!lpilI"6f to tollid! lIOd YiCone; lIOd
may ioof6l' blood Ykium,polllSiim,lIOd th)llo ..... may dKJI'U.
Hm VFood: HHbaI I!Khao;aIoi>,budthom. Ind IfIlI\a ma,inmu
loss. Licm may IlOIffitil:! tIM> !lfw of ,00KlJtic00s. St Johrr"s WOO
may dKJNII' IfflIs.
Treat ment of OYI' rdole: Theil' is 00 tll'atmrot for OY!'rdoIr.
Rtftr I!I M)MJ1l1lrgl3/ A1r Q Null/Ill I'rtml fIKm lpP(1/( I!IIIrI'l
high fever can break down body tissues, reduce mental
ity, and lead to deliriwn or coma, particularly alllong elderly
patients. In rare instances, an elevated booy temperature
maybe fatal.
The goal of antipyretic therapy is to lower body tempera-
ture while treating the underlying cause of the fever, usually
an infection. Aspirin, ibuprofen, and acetaminophen are
safe, inexpensive, and effective drugs for reducing fever.
Many of these antipyretics are marketed for different age
groups, including special, flavored brands for infants and
children. For fast delivery and effectiveness, drugs may
come in various forms including gels, caplets, enteric-
cooted tablets, and suspensions. Aspirin and acetaminophen
are also available as suppositories. The antipyretics come in
various dosages and concentrations, including extra
strength.
Although most tevers are caused by inlectious processes,
drugs themselves may be the cause. When the etiology of
fever cannot be diagnosed, the nurse should consider drugs
as a possible source. In many cases, withdrawal of the agent
causing the drug-induced fever will quickly return body
temperature to nonnal. In rare cases, drug-induced fever
may be lethal. It is important for the nurse to recognize
drugs that are most likely to cause drug-induced fever, in-
cluding those in the following list:
Anti-jn!eajws: Anti-infectives, especially those derived
from microorganisms such as amphotericin B or
penicillin G, may be seen as by the booy and
LibraryPirate
472 UnitS Ttelmmu""Sysll'm
Question: Ii tlielt' any I"Imnc:r to support the 1M of ahemating
of ibuproffo ard for (hildrt n with
Th! Study: Miny hNlth (irr plllidm trNt ftbrill' (hildlt'n with ahtmatillCj
of ibuproren and ttaminopht n in tilt beliefthatlhis combirwtion
is molt' tIftcti'ol' or s,fl'llhan usillCj r ithefdrug indivWaU,.A rt'(tnt
study found , Irckof rvidelKt 10 wpport this practu.
Nursing Implicati:ms: Nul\e shoold IIOt as!Umt that usillCj drugs
is eithr r moll' rfil'l:tiYeorsaferthan usillCj tilt drugs individually. Nullt5
should that poart'On undl"lSland thr plOpi'! doling
forthe individlal antiPl'rttia,nd thtm not to (ombint or
alternile rntdkitioos withOUltlit ipplO'/al of thtir IINkh (ill' proYidtr.
produce fewr. When antibiotics kill microorganisms,
fever-producing chemicals known as pyrogens may be
released. Anti-infectives are the most common drugs
known to induce fevET.
Selective serotonin reuptake inhibitors (SSRIs): Use of
SSRls such as paroxetine (Paxil) for depression or other
HOME & COMMUNITY CONSIDERATIONS
Aspirin for Cardiovascular Event Risk Reduction
CulTl'nt pr,ctice relmd 10 and ne\JlO'/asc:ular nI'Ilt
and lrt'atllll'lli may tht of aspirin thtlllp)'. Tht bIood's dotting -
lion is m-:I by tht administllltioo of aspirin. This tlltlllp)' has Il'Olm-
mt ndtdfor I11I'II 01derth,n4O age,postrnrnopausal WJIIII'II, and I11I'II
yoIJllCjl'llhan 40 )'!'a r.; of '91 and prt'lIII'nop,usal women who w high (ho-
of a dOI-maled IllOkt or tllllllient is-
(hemic: ,niCk, or a histol)' of cicjilmt smoking. EYI'n though tht
ustd dcM for 1IICj-is nlrilabJ!o OYI'r tht counter, poatienu
should bf advised to (001011 Ihtir lItahh Lllt' proYidtr.; Wort initiatillCj stlf-
mtdiLllion wilh aspirin.
mood disorders can result in a high fever accompanied
by serious mental status and cardiovascular changes,
known as serotonin syndrome (chapter \ 600).
Conventional antipsychotic drugs: Drugs such as
chlorpromazine (Thorazine) may produce an elevated
temperature with serious cardiovascular and respiratory
.... Prototype Drug I Acetaminophen (Tyleno/, others)
Therapeutic (lass: Antipyretic and analgesic Phanna(olog ic (lass: Centrally acting COX inhibitor
AalONS AND USES
kttamioophtn rtdum!!"ltr by dilKt ietion iI tht II"Itl of til! hypothalamus
and dilalion of ptripheral blood I'tIStil, whic:h mabie! lWt'ating and dis
of lINt Amamiropht ll, ibuprofl'll, ind alpirin equal elfKacy in relieving
poain ind rt'dlKing f!'let.
Atttaminophtn hils 00 propertits;thert'forl!, it is not tf-
in tlt'atillCj anh ritis or poain caustd by oS!Ut following injul)'. The
primal)' tht lilPfiIic: uS('fUlfItIs of iKNaminophen is for tilt Irt'aillll'lli of ieYl'r
in dJildlt'n and fur It'lief of mild 10 moderate poain when ilpirin is (ootr,indi-
cated.ln tilt Irt',.mtnt of Sl"ltfe poain, fcamioophen may rombined with
opioids. Thisallows thr dcM ofopioid to bf rtdUd, thus risk of
deptndtnc:r and serious opioid tou.:it)'.1t is availabll' is rabltts, (iplets, sou-
and supposilorit-s.
ADMINISTRATION ALERT
Liquid forms lit' availabll' in varyillCj rolKt ntratiolll. US(' tht appropnatt
strellCjlh prodlKl in childru 10 ivoid
NeYI'f administr r to poatieou who (oosumr ,Icohol due 10 tht po-
II'Iltial for IItpalOtOlicity.
poalieO'.1 that iKttaminophto is found in many OTe produru and
that t X!mnt calt' must bf "letn 10 not duplicatt dosr-s by takillCj It'Itllll
of these prodlds (oOlUrrtmly.
Prt'9nanq cattgol)' 8
PHARMACOKINETICS
()Jset 30-60 min
Pt,ak:O.S- 2h

Duration:1-3h
ADVERSE EFFEaS
Aretrminophen is 9fnt rally liff,and admt efletu alt' unrorrmoo at thera-
pMic: dosr-s. Atttaminophen caUlfl 1l'1l CJilstric irrit.Jlion tha n alpinn, i nd does
nol affecl blood (I)igulation. k is not It'oommt ndtd in patients who ill' mal-
nourished.ln SIKh lilts, iant IOxicil)' may I!"IUIt.It adillCj to It'n.r1 fa iult', whic:h
Lln fatal. Other signs of aartt toxKit)' inc:ludt naUIN, wmi:ing. chills, ab-
domirwl disoomfort,and fatal hepatic: nKrosis.
A major 00nc:1'III with tilt 1M of high doses of etaminopllt, is III! risk for
Ii-It! dama9f. Til! drug has caUlfd livtr failure in a numbfr of patients, whic:h
hasll'luhed in tilt FDA issuing wamillCjs rt'9arding tht 1M of thr drug. Tilt risk
is signific:.JmI, glt'atr r in patifnu who(oosumt akohol.
Contraindications: ConuaindiLltions inc:kJdIo 10 ttamino-
plltn or phtnaretin and chronic: akoholism.
INTERACTIONS
I)ug-l)ug: A(flamioophen Williann flll'taboism, UIIIiI9 thf
to ilmuoola!, to tOD: IfwIs. HiljJHlos.! or Iongurm oIa:Mlli"lophtn
U\f II"Ia, rflWi: il elmlMl warfillillNeis and blffdillCj.lfI9'Ilioo 0( tIis mug with
aklt.ol, or oth!f IIfpiII000Iit IinIIjs IlKh is or billlilurallI, 001
ofthf poMibiity ofli'IH faim from llfpiltir:necrosis.
Lab Tl51s: AMillninoph!O lOa)' iKruse llfpiltir: Iunaion Ill! "laUe! IIlh iSl!'IIIO
bilirWin, aIp.arIiI' iIIIImtr.lnsli>ru tAST), and aIanifMo amilouansffliM (.I.lJ ).It
II"Ia, irKrNIeoollillY (5IIMl aooll'flll1!ric: Mid.
HfrballFoo:l: fINo paliI'fl! WUd i'llid takilg hl'fbs that II.wf thf poIt.ltii11 for li'IH
ilduci'"l <DfIIfr." (oltsfoot, and (haparTai.
T rt'iItment of Tht spt<ifit Ill'iItment for O'/trdol!' is Ite ora I or IV ad-
ministration of H-amykysteiOl' (h:mdotr) as soon as possibltafttr the OYI'r-
dost. This drug pro1l1tU tilt Ii-It!irom 1Oxic: mttabolitflof iKetallinopiltn.
III'ftr /IIMytmmgXl (or MlsJrtgl'rocllS /111M <tuq.
LibraryPirate
distress, called neuroleptic malignam syndrome (NMS)
(chapter \ 7CC .
Voiatileanesrhetic5 and depolarizing neuromuscular
blockers: Agents such as succinylcholine can cause life-
threatening m<llignant hyperthermia (chapter \ 900).
. [mmunomodu[ators: Interferon<; and monoclonal
antibodies such as muromonab-CD3 rna)' cause a f1u1ike
syndrome because they cause the release of fever-
producing cytokines (chapter 3:ZOO) .
Cytotoxic dmgs: Certain drugs used in cancer
chemotherapy and to prevent transplant rejection
profoundly dampen the immWle response and result in
fevers due to secondary infections.
Neutropenic agents: Drugs such as NSAIDs,
phenothiazines, antithyroid drugs, and antipsychotic
agents can ca use neutropenia and a subsequent fever.
'lIopl,,1l Drug. fOflofl.mmaUon and 473
Other drugs: Systemic hypersensitivity reactions can
result in high fever and anaphylaxis.
TREATING THE DIVERSE PATIENT
Ethnic Differences in Acetaminophen
Metabolism
(rr"in mnK populatiorn, ildudng Alians, NOOn Ameritam, .lIId Sulis, hal\'
higller 11TH of an that aflt<ts how they mmbolizt anain
ohgi.Morethan 200 aft' beIiMd to hal'!' a htrNtal)'
deficierq d tht rfIl)'111t. Patitnu
with G6PO deficirrKy art at 1M for dMIopiIg hemoIysisaftl'r ingestion d (fflain
drugs, iKUli"l ac:flamioop/Iffi. ConIIiaing dati mit on whflher thtrapMi:
d ac:fIamilophrn can mSf hrrnoIysis in thtst pa1itnts. be-
CilIIiI' ac:rtamioophen is 0IIl' of till' most cotrmon rh.ogs ingestN in intentional

drnq Mid dMj.
NURSING PROCESS FOCUS PATIENTS RECEIVINGANTI INFLAMMATORY
AND ANTIPYRETIC THERAPY
Assessment
Bastlin! assrssmf nt priorto administration:
J\'iIson drug has bn prescribt<i in ol"lltr to alses for
tfi"KIs.
Obtain a comprtt histOl)' ill(iuding rtlpiratol)'.
<II rtnlruluojic. dM Obt.oirr drug
history iocluding culltnt prrsr:ription and ore dlUlJS, ht rbal
and akahol us!.Bealento drug
intffiKtiolll.
Obtain aoel Wl'ight
['/<IluateapproptYtf laboratol)' findi"91 (f.g..CBC. coagulation j)a ntls,bWding
time. t lKtrolytes, lipid profir. ht patir: Of Ifnal funaion studifs).
Asstssm!nt thro ughout ildministration:
bellor desired thtrapMK effem kg.. temprratuft' rttums to oormal rangr.
pain isdt<l"Nstd or abst nt, signs <lnd symptoms of inflammation SIKh as
rtdllfll or IWI'liing aft' demastd).
Continue monitoring ofCBC.roagulation bWding time.
gIIKOIf.lipidl.aoel hepatic ilnd rtnal full(tion studits.
AIleS vital aoel Wl'ight periodir:ally Of Iymptoms warran1.For patitntl
on gllKocOfticoids,obtain Wl'ight daily aoel It'pOrt any Wl'ight gain OY!'r 1 kg in a
24-hour period or more than 2 kg in 1 Wl'tk.
ASles for aoel promptly rtport ildftrst tfi"t<tI:symptoml ofGl bIffiling (dar\!: or
"tallY" stools. hematemesis or cofffi!>-ground emtlis. blood in Itool).
abdominal pain, !M'If tinnitus. diu.illl'n. drows.illl'Ss, confusion. agitllion.
euphoria or dtpresoon, palpitatiom, mhyuroia. hyperten\ion, incft'aSfd
rt lPiratol)' rate i1oe1 dtpth. puirmnal)' conqestion. or edrrna.
Potential Nursing Diagnoses
Pain Of ChronK)
Hyptrthtrmia
FkJidVoIum! Il!'fKit to fe\\'l")
Riskfor Injul)' (rtlate<lto drug fffKls)
Risk for Inre.:tiom (ft'latN toad\\'f\f drug tfi"KIs of glu(lxortir:oKk)
Risk for Imj)airtd Skin InttIJRty (rtlatN to tfftm of
gkKocortir:oKk)
PliInning: Patient Goal s lind Expected Outcomes
Th! pitirm will:
thtrapwiK effKls (f.g.diminishrrl fe\\'r.dtCft'asN Of <lbsrnt pain. riMNSfd aoel symptoml of inflamllliltion).
fft'e from.or rxprril>lKt tfi"KIs.
an tfi"tdI, and n'qJiit'd plfl:aUlionl.
Demonstratt proptr seIf-<ldminisuation of medication (f.g . timing. whtn to notify provider).
{Continued!
LibraryPirate
474 Unit; ThelmmuneSyu,-""
NURSING PROCESS FOCUS PATIENTS RECEIVING ANTI -INFLAMMATORY
AND ANTIPYRETIC THERAPY (Continued)
Impl"m"nt .. ti on
Interventi ons and (Rati onales) Patient and Famil y EduCllti on
Ensuring therapeutic tfl"t cts:
0 CominUl' alSmmtntl asdts<riiltd earlil'r for tifecrs. (Diminished 0 Tu(h thr patiem to supplemtnt drug thtrapy with nonpharmaroiogic:
fr'lff, !)lin, or SigM and symplomsof infedion should aftrr taking the first musurr-s, r.g., ' RIC[' : Rest, hor(ool
Ou and (ominur to im plOft. Thr heallh mr provider should br notified if fe'Ief bandagr (r.g.,ACE wrap).and Ele<ialion ofinflamrd joinl or limb;
ft'maiM presem aftrr 1 daysor signs of infertion aft' prmnt) inaem fluid imake for positioning for (omfon;diYmionary
distractions (r.g., trlevision or rrusid; ind ft'st for pain.
Minimizing ildve r>e effects:
0
CominUl'to roonitor vital epKiall)' temperaturr iffe'lef is prrsrnt,and
0
TroKh the patifm to immrdialriy ft'pon fe'lff lhat doe not diminish
blood prl'SSurt and pulst klr !)Itito!! on gkKorortiooids.(Ftvershould brgin to brIow 1001, or per !)Iramell'lS sri by the health mt provider, febrile
diminish within 1 to l hour> abr taking thedrug.Gluu)(onQU)m may (.Iusr seirurr-s, (hangrs in brhavioror le<itl of ladr;wdia,
ilKft'asrd blood pft'SlUrr. hypertension, and loKhyUrdia dJr to inrnasrd palpitations,or inuNsrd SP 10 lhe heakh Uft' provider.
ft'll'IItion of fkJids.)
0 Tei(h thr !)IIii'm on gkKlKortic:oids how to monitor pulst and blood
plffiUIt. Ensult the proper UIf and rurKIioning of any hol1ll'
obtained
0 CominUl'to monitor ptriodic: lab work: hepatic: and ft'nal furKlion teu, (Se. 0
Inslrucr the !)Itil'm on the to return periodiully for lab work.
eleo:trolytts,glurost, lipid le<iels. and roagulalion studies or biffiling Iimi'. 0
Advisr lhe lliIIient laking gl\J(QU)nic:oids long Itrm 10 (.Iny a wallet
(Aspirin and "liql.1O< .!ftct platelfl.9'I"9"ion .nd ,hould br monilOrtd if
identiliution urd or_.r modiul idtmiliution it_I" indic:.ting
used Iong-trrm or if ml'SSiYt biffiling or bruising is ooltd.Armminophen tan
gllKQU)rtitoid thffapy.
br hepalotoxit. CortKl>lteroids a!fed tht (SC,and i widr range of electrolyre,
0 Tri(h the pitil'm to abstain from ikohol while taking a(ftlminophen.
gkKose.)
Mrn who (onsuOll' mort' thin two akDholit bfitl<lges prr day or
womrn than one akoholit bfitrage ptrday
should not rakt a(ftlminophen.
0
Monitor for ilbdomiOiI pain,blac:k or larry stools, blood in lhe 11001, htotalel1ll'Sis
0
Instrucr the !)Itil'm 10 immediatrly Itpon any signs ofGI
or roffn-ground etnM, diuifltlS,and if assorialtd with bftding.
loKhytaldia.(NSAIOsand giutocortic:oids may (luse GI bleeding.)
0
Trath the patil'm to takt thf drug with food or milk to demasr GI
irritation and loswallow rnterit-<oaltd lablets wh* withool
UIIIhing or bltaking.Akohol UIf should br i Wided or rliminattd.
0
Monitor for tinnitus, diffirulry hearing.light -headednl'SS, or with
0
Inllroo the !)Itil'm 10 imml'diatrly any signs or of
bilante and R'pCIn promptl)'.(NSAlOs and 1.l1ic:yla1l'S may brototOlit.) ringing.humming. buuing in Nr>,diffirulry with balantr,dizziorssor
vertigq.or nausea.
0
Monitor uri III' output i nd ft'Oi I runttion studil's periodiully. (NSAI Os and
0
Inllrucr the !)Itil'nt on NSAlOs and salic:yla1l'S to promprly R'pon
salic:ylatfl may br ft'Oi I toxic: during Iong-trrm or high-dosr thrra py.) mangel in quantity of uriot' ooiplll, darkening of uriIII', or tdema.
0
Tmh the patil'm on NSAIDs and salityiall'S 10 ilKrrase fluid imake,
epKially iffeverisprtsrnr.
0
Monilorelectrolyrr, blood giutOlf, and lipid le<irls periodiully in patients on
0
InslrtKI thr !)Itil'm 10 Iflum ptriod"KaOy for lab
(onic:osteroick (Giutocortic:om may (lusr hypergly(emia, hyptlllillft'mia,
0
Tram thr diabrtic: patifnt to Irll blood sligar moft' and
hyperlipidrmia,and hypokaiemia.lMbetio may requill' a (harogt in antidiabetic:
notif)o the htaith (irt prOYider if a (Onsistf nt tfevation ii ootrd
meditation if giutOlf ft'maiOl ele<iated.)
0
Monitor for signs and symptoms ofinfto:tion in patil'nt! on gluc:oconic:oidI.
0
InSlrtKI thr !)Itil'nllo imfMdiatt ly any signs or symploms of
(Gluc:orortic:oids supprrss me bodYs normal immulll' and inflammalory ft'Iponsr infectiom (t.g., intft'uing tt mperalult or fe'lff, 10ft' throat, rtciorss or
and may mask tilt IigM and symploms of infection.) s_lIing al whitr !)IlIhes in mornh, Yelic:ular ralll).
0
Monitor for I>Iteoporl>lis (e.g., bonr drnsir>' tflting) ptriodiully in patients on
0
Trath palil'm to maintain takium in tltt awid
gkKocortitoids. ElKouroJgl' adequatr takium inlake. avoidalKr of carbonated wbonattd sodas,ilnd to do _ighl-braring enrtisfl al leasllhlff to
wtighl-braring oerdsr. (GIuc:oconKoichafien 00111' mmbolism and four tirors per week.
may (ilUIf osteoporosis andhadurfl. Weight-braring oer(isr IIrl'\.Se 00111' and
0
Tram the postmrnopausal woman to (onsuk with Ittr plO'lider about
elKouragtl oorrnal OOIlf rrmodrling.Extmi-;r or Iong-trrm (onsumplion of
the need for additioOiI drug lherapy (r.g., bisphosphonile) for
wbonated IOdas has brrn linked to an in(ft'm risk of I>Itroporosis.)
osteoporosis.
0
Monitor for ufIJsual (hangrs in mood or a!fed in on (Onic:l>ltrrom.
0
Tu(h patil'm. famiiy,or(.lrrgiYtr 10 promptly Itpon o<l"lsive
(GlUC:QU)nic:oids may taUS!' mood (hange,euphoria,drpft'lsion,or IeYt'rr mood swings orunusual manges in mood.
in".biliry.)
LibraryPirate
',,"plOI n Drug. fD<lllfilmmat lon and 475
NURSING PROCESS FOCUS PATIENTS RECEIVING ANTI INFLAMMATORY
AND ANTIPYRETIC THERAPY {(onrlll/ed!
Impl ementati on
Interventi ons and (Rati o nales)
palienl on guocorti<okk d.1ily .nd Jtpofl. o,wighlgiin of 1 kg Of mOff
in 24-hour period or mOff th. n 2 kg per wffII or inuusing peripheral t<leml .
MtiWJt inl, kt and OIIIpuI in tilt hospit,lizfd pllient (D,ily weight is in
mealUf1' of Auid and tilkts imo auoum inlikt,outlJUl,and
inwnsiblt Patienn 00 will 101M ftJid
retention.)
Monitor'fision in patitnn 00 gkxocorticoids.(1ht1tdrugs m.,
cauo;e i",rustd intr,ocular pr1'surr ind an inmm<! risk Dr gl,u{ofllil,.nd m.,
causr uWim.)
Pati ent and Family Education
InsUUl:ltht patient to wtigh Itlf diily, idully at tilt limt time
Tht patient should Jtpon signifK.lnt weight gain or ill(rt.sing
ptriplltral edtm .
'eilCh tilt patient on glucocorticoids to maintlin t')'I!eums twice
,wiy or mOl! lf1'qutntl, as by the lit. [.rt provider.
Repon any pain, rainbow Iwlosaround viIion, or
b"'rringlnd in.lbility 10 focus immediately.
4void tht use of llpirin or in childrtn under 18 unltss tlCplicid, Instruct pirtnl! to NSAIIh or Icttlminophttr in (hildrtn under 18
b, tilt heakh Uf1' providtr.{Alpirin hal with .n for ft'ltr or p.in [ootrol,unltll othtrwilt ordertd by the provider.
incll'asrd risk of RtyI"s syndrome in children under 18,plrt icularly assoO.Jted rrac:h plrents to rud labm 00.111 DrC medication sand to iwid
with tht ftJ vill/$ and vlric:rlla infKtions.) formulations with IIpirin or Sllicylate on tilt label.
Do I\Ot !lop gkio:ocorticoiM Ibruptly. Drug must be llpell'd offif used patient to not !lop liking glucOlrticoidl.bruptly and to
thitn 1 or 1 wttks.{Adrrnal inlulficitlKY and (risis rna, occur with profound noti!)' the htakh UIl' provider ilunable to t1kt medication for mOl!
hypotrnoon,tarn,uroia,.nd other i.Mr;etfiem if thedrug is stopped than 1 d.1y due to
abruptly.)
Piliut undtrsu.ndlng of drug therapy:
Ult opportunities during admilliUr.Jtion 01 medications , nd during mesmtnlS
to dio.[UII; Iht for dM} lherap)',drlirrd thmptUtic
common ad .... plfllfl!'ttl'l forwhrn tocall tht hNlth cart provider.
and all)' nt(tllaf'l mooitorin9 or prtcautions.(lJ!iJ19 time dUfi"9 Cift
helps to optimilund trinfon:e tNching Ill'as.)
Pllien1 stlfadm inistration of drug thtrlPY:
Whtn the mrdication,in!lllKt the patitnt, loimily.orull'gi .... r in
ptoptr sell-adm of drug. e.g., with food or mill:.. (Proper adm
will ill(ftjlt tht eflectimltss of the drug. Houlthold mNsuring dmm such jI
Itjlpoom differ signifiuml, in sillt ,nd amount Ind should not be UItd for
pedialJic or liquid dolts.)
Tht family,or [iftgi ...... should be i1b1e to statt the INson for
tilt drug; appropri.rtt dolt dnd Ilheduling;whdl advtM t fTall 10
obit ...... for and when to thtanticipated Itngth of
tht"p)'.
rht family,or clrtgi .... r af1'able to disnru ipproprial\'dosing
.nd nteds, incliding:
Gluc:orrticoids should be tlktn in tht morning II tilt I<1mt lime
t ithday.
NSAIDund gkxocorticoids should be taken with food or milk to
drcreistGi upld.
liquid dolt! of Icwminophrn or tlSAllh should be mtlsured with
dosq (up,dropper,OI spoon.lf thi! mNSUring de'tict
is no langtr milablt, do NOT U\t I housthold spoon but obt.in
al\Other ulibrated mUluring [upordropptr.
Evalull tion of Outcome Criteria
foIaluattthuflecti\'efles of drug ll1tflP, by tonfirming that p.;rtitm goalsand fXpraOO outcomes h.Ye brtn met (Ite Planning1.
TGbIe j 11 fur Q hll.t rht drugs 10 Ihtst IlliifIIJ IICrm: ,.py.ltaromiroplrm iI 1M awmd iI rm Nuflilg I'rocrs.r Iixus rhart
LibraryPirate
476 UnitS Thl'lmmuneSyu,-""
r
tr
Chapter REVIEW
KEY CONCEPTS
The numbered key concepts provide a succinct summary of the important points from the corresponding numbered section
within the chapter. If any of these points are not dear, refer to the numbered section within the chapter for review.
H. l Inflammation is a natural, nonspecific body defense that
limits the spread of invading microorganisms or injury.
Acute inflammation occurs owr several days, whereas
chronic inflammation may continue for months or years.
H.2 Chemicals, pathogens, and physical trauma cause the re-
lease of chemical mediators that trigger the inflammatory
response. Histamine is one of the kry chemical mediators
in inflammation. Release of histamine produces vasodila-
tion, allowi ng capillaries to become leaky, thus causing
tissue swelling.
H.) Inflammation may be treated with nonpharmacologic and
pharmacologic therapies. When possible, topical drugs are
used because they produce fewer adverse effects than oral
or parenteral drugs. The two primary drug classes used for
inflammation are the NSAIDs and glucocorticoids.
NCLEX-RN" REVIEW QUESTIONS
D On discharge of the patient, the nurse discusses types of
over-the-coWlter NSAID medications that are available.
The nurse knows that which of the following arc med-
ications is often used for pain and fever but is not classi -
fied as an NSAID?
1. Aspirin
2. Ibuprofen
3. Acetaminophen
4. Motrin
D The patient has been taking aspirin for several days for
Duriu)o: th., a,.".";s,,,.,ut, tI,., uur,., th.,
p.1tient is experiencing ringing in the ears and dizziness.
What is the most appropriate action by the nurse!
1. Question tbe patient about history of sinus infections.
2. Determine if the patient has mixed the aspirin with
other medications.
3. leU the patient not to take any more aspirin
4. leU the patient to taketheaspirin with food or milk.
D While eduGlting the patient about glucocorticoids, the
nur.sewould instruct the patient to contact the health care
provider immediately if.
I . there is a decrease of 2 Ib in weight.
2. there isan increase in appetite.
3. thert' is any diarrhea.
4. there is any diffiQI]ty breathing.
D The nurse is admitting a patient with rht'Umatoid arthri -
tis. The patient has been taking glucocorticoids for an ex-
13A NonstE1"oidal anti-inflammatory drugs (NSAIDs) are the
prinlary drugs for the treatment of mild to moderate in-
flammation. All drugs in this class have similar effective
ness in treating inflammation. The .selective COX-2
inhibitors cause less GI distress but have significant car-
diovascular side effects.
H.s Systemic glucocorticoids are effective in treating acute or
severe inflammation. Overtreatment with these drugs can
cause a serious condition called Cushing's syndrome;
thu., theropy for inflammation is generally short term.
3).6 Acetaminophen and NSAIDs are the primary agents
used to treat fever. Certain medications may cauSt' drug-
induced fe;"\'r, which may range from mild to life threat-
ening.
tended period of time. During the 3S1leSSment, the nurse
observes that tht' patient has a very round moon-shaped
face, bruising, and an abnormal contour oftht' shouldt'rli.
What does the nurse conclude based on these findings?
1. The5e are normal reactions with the Wness.
2. Theseare probably birth defects.
3. These are symptoms of myasthenia gravis.
4. Thesearesymptoms of adVl'J"$t' drug effects from the
cortioosteroids.
D A 24-year-old patient reports taking acetanlinophen
(1)'I.,nul) for nu,."., kno .... s
that a patient who consumes excess acetanlinophen per
day or rt'gularly consumes alcoholic bewrages should be
obst'rved for:
I . hepatic toxicity.
2. renal damage.
3. thrombotic effects.
4. pulmonary damage.
o The nurse is counseling a mother regarding antipyretic
choices for her 8-year-old daughter. When asked whyas-
pirin is not a good drug to ust', the nurse b.uesher answer
on her knowledge that aspirin:
t . is not as good an antipyretic as is acetaminophen.
2. may increase fewr in children under age 10.
3. mayproduce nausea and vomiting.
4. increases the risk ofReye'ssyndrome in children under
18 with viral infections.
LibraryPirate
CRITICAL THINKING QUESTIONS
1. A 64.)Y.lT-oid diabetic patient ison prednoone lOr meunu-
told anhrltb.. The patient has reantly been admlU('d IOthe
hospital lOr stabi!Wtion of hypt'lilya=ia. What are lhe
nurw's prtnury concerns "'tim cuing for this
2. A 44-year-old patient is mI icat]on for a
painful tendinitis 01 the elbow. This patient has mJld hy-
pt'rtension, a history of alcohol abust', and nutri tional
defklls. Thi s j);llient has orders for atetamlnophen
(lflenoll , Ibuprofen (Molrin). and celeroxib (Ctlebrex).
Which one would the nurse give and why?
3. The mother of a 7_year_old child calls the health c:are
provider's olfi('.\' stating Utal he!" Wiughter has a \empt'r:I-
lure of I 0 1"1'. She51ates tbe child is abo complaining oibe-
ing tired and aU OYl"f. The mother asks how much
upirin she an giwr her daughle!" foc her temperature..
How should the nurse respond?
Su Appendix D !oranJIWn Imd rationales for Q/lacllvirits.
EXPlDflE ------,
your O'1e .. lor ot*II cNIpl .-alftls l'Id
ItWJrees. PIlIP' 101 MIl IddIkNl l,a.u4'-1ty18 pr1t1Ict
IS!igl'l'l'letltS n ICtIv*$, w!:b tw, Im!I!lDIS
and vi:teo6. and IIIIJI"
'PI' IICInI COIle from me h'I1 rI \'IIIIf book at
_ .I\'IYfIUllirtgltilcom.
LibraryPirate
DRUGS AT A GLANCE
P{NI(l lUNS fA1iIt4!4
CO) pm/dl'n G SodlHn/Pl:)/asso\lm
(EPHAlOSPORINS pq411S
Q ufotQKtne (Claforon)
m RAacuNES ptJtW
Q letrocydtlf (Sumyctl, odlm) fJIl9tfBt
MACROLIDES Plgt4i19
CO) trythromyc/n (E-Myc.t1, Erythrocln)
"" ..
AMINOGIYCOSIOES tllgH89
Q gefllllmldn (Gllramydn, omm) JUlI'491
ftUOROQUINOlOHES paJtf91
CO) dprofloxacJn (Cpo)
SUlFOHAMIDES (XlJt491
Q llfmelhopl1m- sulfamerhacllzolf>
(Boc fl1m. pogt494
ANnruBERCULARDRUGS IlIIJtf99
Q f50flJazld (lNH) pogtSCI
KEY TERMS
ft;stan<e pogt481
.m!bi< paJt479
nat. Pqt}
iltibiotil: /XIgtJ
mijnftin P9Jl419
Iwclt' riocidoll j1JgtJ
N<ttriostMic {'A1gt46J
be1a-lactilll ri ng
beta-laclin1st/ptnicillm- fO}tf84
Drugs for Bacterial
Infections
LEARNING OUTCOMES
Aft" readjng this chepler; the ntJdml should be obIt to:
1. Distinguish between the terms pathogenicity and virulenc!!.
2. E>cplaln how bacteria are desalbed and classlfled
3 . Compare and contrast the telTTls bacteriostatic and bacteriocidal.
4. Using III spectflc example, explain how resistance can develop to an antI-
infective drug.
S. Describe the nurs,'s role In the pharmacologic management of
bacterial infections.
6. Explain the Importance of culture and sensit ivity testing to antI-
infective chemotherapy.
1. Identify the mechanism of development and symptoms of
superinfections by anti-infective therapy.
8. for each of t he drug classes listed In Drugs at. II Glance, know
representatiVii' drug examples" and explain their medlanism of action,
primary actlons, and important adverse effects.
9. Explain howthe pharmacotherapy of tulxorculosis differs from thilt of
other Infections.
10. Use the nursing process to care for patients who are receilfi ng drug
therapy for b;Kteriallnfectlons.
bnIadspertnm u tibioti( fWJt48}
JX1IJl48)
9, ul nr9llti1ft bacteria {JIl1jt.fl9
9ll1mposl:irr bacteria pq.fl9
pq-I8J
{XJl}tm
mtillions ptXJt481
_row-lpKtrumardliotic: pq4l!1
pq481
padlogrl Nm
pathogenicity ptXJt419
Pflici lli n-bilding p!O(rin pogt484
plasmid f!lJ741!1
red-rnu syidromr fWJt499
PU;lW
luberdrs N4W
inknCf JX1IJl419
LibraryPirate
T
he human body has adapted quite well to living in II
world teeming with microorganisms (microbes). Present
in the air, water, food, and soil,microbes are an essential com-
ponent of life on the planet. In some cases, such as with mi-
croorganisms in the colon, microbes playa benefidal role in
human health. When in an unnatural environment or when
present in unusually high numbers, however, microorgan-
isms can cause II variety of ailments ranging from mildly an-
noying to fatal. The development of the first anti-infective
drugs in the mid1900s was II milestone in the field of medi-
cine.ln the last 50 years, pharmacologists have attempted to
keep pace with microbes that rapidly become resistant to
therapeutic agents. This chapter examines two groups of
anti-infectives, the antibacterial agents and the specialized
drugs used totrellt tuberculosis.
34.1 Pathogenicity and Virulence
An organism that can callS(' disease is called a pathogen. Hu-
man pathogens include viruses, b3cteria, fungi, unicellular
organisms (protozoans), and multicellular animals. To in-
fect humans, pathogens must bypass a number of elaborate
body defenses, such as those described in chapters 32 and
3300. Pathogens may enter through broken skin, or by in-
gestion, inhalation, or contact with a mucous membrane
such as the nasal, urinary, or vaginal mucosa.
Some pathogens are extremely infectious and life threat-
ening to humans, while others simply cause annoying
symptoms or none at all. The ability of an organism t o cause
infection, or pathogenicity, depends on an organism's ability to
evade or overcome body defenses. Fortlrnately for us, only a
few dozen patllogens commonly cause disease in humans.
Another common word used to describe a pathogen is
PHARMFACTS
Bacterial Infections
loftious di.N are tilt mill! mon mmman dtath io tilt
United State!, J nd first in tht world.
food.boml' iIIoess i'll'lJlOnsiblf for 76,000,000 iIIomes; 300,000
5,000 dtJtM th ym
Urinarylrl<l iof1ioo. (ur,,) Ill' th. 1110<1 mmman iokctioo I<quill'd in
oo.pitak,and nNrIy all aft' with tilt of a urio,ry
Ciltlieter.
MOIl' thao 1 millioo oo.ocomiill iofffiiom all' aluired NCh year. These
ioftdiom add 1 day for UTII, 7to 8 days for lUr<jiCiIl iofec.tiolll, and 6
to 30 days for pntUmanii.
Up to J])Il(, of all S.pneummiot frond in \OI1IUIN. of the Uoitfd Statn
aft' resistant to ptnicillio.
Nearly all IUJins ofS. Ql!1l'UI in the Uoitfd Stain all' resist.1lI to
penicillio.
About 71,000 ca\6ofE.mi poisoniog aft' replntd in tilt Unittd
Statts, with the mon common .ource
(hopm)( Drug. f","SKterlat Infections 479
virulenct. A highly virulent microbe is one that can produce
disease when present in minute numbers.
After ga ining entry, pathogens generally cause disease by
um, uf twu ",,,d,,,,,isms: ur lu"";" pro-
duction. Invasi"ft'nell is the ability of a pathogen to grow ex-
tremely rapidly and cause direct damage to surrounding
tissues by their sheer nwnbers. Because a week or more
may be needed to mount an immune response against the
organism, this "'pid growth can easily overwhelm body
defenses. A second mecltanism is the production of toxins.
Even very small amounts of some bacterial toxins maydis-
rupt normal cellular activity and, in extreme cases, result
in death.
34.2 Describing and
Classifying Bacteria
Because of the enormous number of different bacterial
species, several descriptive systems have been developed to
simplify their study. It is important for nurses to learn these
classification schemes, because drugs that are effective
against one organism in a class are likely to be effective
3Rainst other pathoRens in the same class. Common bacter-
ial pathogens and the types of diseases that they cause are
listed in Table 34.1.
One of the simplest methods of classifying bacteria is to
examine them microscopically after a crystal violet Gram
stain is applied. Some bacteria contain a thick cell wall and
retain a purple color after staining. These are called gram
positive bacteria and indude staphylococd, streptococci, and
enterococci. Bacteria that have thinner cell walls will lose
the violet stain and are called gram negative bacteria. Examples
of gram-negative bacteria include bacteroides, Escherichia
coli, klebsiella, pseudomonas, and salmonella. The distinc-
tion between gram-positive and gram-negative bacteria is
a profound one that reflects important biochemical and
physiologic differences between the two groups. Some an-
tibacterial agents are effective only against gram-positive
bacteria, whereas others are used to treat gram-negative
bacteria.
A second descriptive method is based on cellular shape.
Bacteria asswne several basic shapes that can be readily de-
termined microscopically. Rod shapes are called bacilli,
spherical shapes are called cocci, and spirals are called spirilla.
A third factor used to classify bacteria is based on their
ahi1ity to " . Tho."" that thrive in
environment are called aerobic; those that grow best without
oxygen are called anaerobic. Some organisms have the ability
to change their mflabolism and survive in either aerobic or
anaerobic conditions, depending on their e."l:ternal environ-
ment. Antibacterial drugs differ in their effectiveness in
treating aerobic versus anaerobic bacteria.
34.3 Classification
of Anti-Infective Drugs
Antiinfective is a general term that applies to any drug that
is effective against pathogens. In its broadest sense, an
LibraryPirate
480 UnitS Thl'lmmuneSyu"",
TABLE i4. 11 Common Bactti!rial Path09ti!nS and Disordti!rs
Name of Organism DI5ease(sl
BlKillusiWlrlKiJ Alllhw

(h/omydio 'knffioal diwIr, f'lt infection

AObt; apptaB in and forms
A(qrirftlfrom tid:: bite
Most torOmoo taUll' of trall\lllinftl diltillt in
UnittdState
&htridlio a:I Trllelel"s dianllta, un, meninljlis in dll<ten Pin ofhosl ftOI,l of the iltl'llinal tr,a
IIotIOOflli/IIf PIINIIOIIia, llIffiingitis in dikRn, baarremia, otitilllll'dia, Some ire part of the oormalimt ftora LWtI'
repirattq tOO
KlfllJieiIo PnellllOllia,Un
Myrobterom /fproe Lepro!Y
Myroburom rubfrruli1>il
PIIfIIIlOIlia
(ommon opjIO't!lliltit mitrobe
Most all'S in Unittd State O(QJr in immigrant! from Afrita
.'"
IIItidtotr 'MY Iirjl in HIVilfKll'd patitnts
IilintriD gonorrl1oeve Gonorrhta and OIhtr !BUilliy transmintd Ii !'IIdomt!riWi,
Most torOmoo taUll' of potUmooia il patiffilJ.
Some sptdts arepart oftheoormalimt ftora
neonatll infection
IiliJifflo mmingiridJ Menil91i1 il dlildrffi
I'MuI11lXlli PneIlllOllia, otitis mtdia,lIII'oinis, biammia,ffidoc.Jrditis
Some sptdts are part of the oormalimt ftora
Pirt ofoormal IIolillora il LWft" trait
Pirt ofoormal IIolillora il GI tratl PrortrlS mirobilil Un inftctions
un skin
ricterrJii Rody Moon!ail spotltd fM!
Food poisoring
Common opjIO't!lliltit mitrobe
A(qrirtdfrom tid:: bite
A(qrirftl from ilfKll'd aninil prodoos; raw uodffi:ooked
mutordlitkffi
5rap/ly/OCM (ljrtUs PIINIIOIIia, food poisoning. inpWlj<\ WOIIIIk, biaemria,
tQIIK shodr 1)'IKtomt,
Some il! part oftheoormilimt nora
5rfllplococCU5 pot'umooia, ffiIIourditi otitis
....
Some irfpart of the oormil host ftora
anti-infective drug may be used to treat bacterial, fun-
gal, viral, or parasitic infections. The most frequent
term used to describe an anti-infective drug is antibi-
otic. Technically, antibiotic refers to a natural substance
produced by bacteria that can kill other bacteria. In
clinical practice, howevtr, the terms antibacterial, anti-
infective, antimicrobial, and antibiotic are often used
interchangeably.
\Vith more than 300 anti-infective drugs available, it is
helpful to group these drugs into classes that have similar
properties. Two means of grouping are widely used: chemi-
ca! classes and pharmacologic classes.
Chemical class names such as aminoglycosides, fluoro-
quinolones, and sulfonamides refer to the fundamental
chemical structure of the anti-infectives. Anti-infectives
belonging to the same che'mical class usually share similar
antibacte'rial properties and adverse effects. Although
chemical names are often long and difficult to pronounce,
placing drugs into chemical classes will assist the student
in mentally organizing these drugs into distinct therapeu-
tic groups.
Pharmacologic classes are used to group anti-infectives
by the'ir mechanism of ([etian. Examples include cell wall in-
hibitors, protein synthesis inhibitors, folic acid inhibitors,
and reverse transcriptase inhibitors. These' classifications
are used in this textbook, where appropriate.
34.4 Actions of Drugs
The primary goal of antimicrobial therapy is to assist the'
body'. defenses in eliminating a pathosen. Medication. that
accomplish this goal by killing bacteria are called bacteriocidal.
Some drugs do not kill the bacteria but instead slow their
growth, allowing the body's natural dt'fenses to eliminate'
the microorganisms. Thesegrowth-slowing drugs are called
balteriostati(.
Bacterial cells have distinct anatomic and physiologic dif-
fe'rences compared to human cells. Bacteria have ce'll walls,
use different biochemical pathways, and contain certain en-
zymes that human cells lack. Antibiotics exert selectiw toxi-
city on bacte'rial cells by targeting these' unique' differences.
Through this selective action, pathogens can be killed or
their growth seve'rely hampered without major effects on
hwnan cells. Of course, there are limits to this selective' tox-
icity, dc>pending on the specific antibiotic and the dose em-
ployt'd, and adverse effects can be' expected from all
anti-infectives. The basic mechanisms of action of antimi-
crobial drugs are shown in Figure' 34.1.
LibraryPirate
RNA synthssis
i'lhibit"..:
(hopttr)( Drug' lor iIx!l'flalln/ealoo, 481
eel willi synlhuis
inhObitof8:
Cs rbopen ......
Cephalo&pori ....
I"" ...... zid
PIInicilins

Rifampi'l
P",tein synthesis
i'lhibit"..:

\
DNA oynthuis
-----'It--I inhibitof8:
m .

A'Tlinoglycoside&
Ollo.ampheoic:ol
Oindamycin
t
Li>ezclid
Macrolides
S:reptogf8mins
Tetracyclines
,. Flgure34.1 Mechanisms of action of antimicrobial drugs
34.5 Acquired Resistance
Microorganisms haw the ability to replicate extremely rap-
idly. Forexample, under ideal conditions E. coli can produce
a million cells every 20 minutes. During this rapid replica-
tion, bacteria make frequent errors while duplicating their
genetic code. These mutations occur spontaneously and ran-
domly throughout the bacterial chromosome. Although
most mutations are harmful 10 the organism, mUlations oc-
casionally result in a bacterial cell thai has reproductive ad-
vantages over its neighbors. The mutated bacteriwn may be
able to survive in harsher conditions or perhaps grow fasler
than surrounding cells. Mutations that are of particular im-
portance to tho ... conf .. r drug r .. _inance
to a microorganism.
Antibiotics help promote the development of drug-resistant
bacterial strains. Killing populations of bacteria that are sen-
sitive to the drug leaves behind those microbes thai possess
mutations that made them insensitive to the effects of the an-
tibiotic. These drug-resistant bacteria are then free to grow,
unrestrained by their neighbors that were killed by the an-
tibiotic, and the patient develops an infection that is resistant
to conventional drug thernpy. This phenomenon,
is illustrnted in ,. Figure 34.2. Bacteria may pass the
resistance gene to other bacteria through conjugation, the
transfer of small pieces of circular DNA called plasmid!.
It is importalll to understand that the antibiotic did nOI
errore Ihe mutation that caused bacteria to becomt resis-
tant. The mutation occurred randomly. The role that the
antibiotic plays in resistance is to kill the surrounding cells
thai were susceptible to the drug, leaving the mutated ones
plenty of room to divide and infect the host. It is the bacte-
ria that have become resistant, not the patient. An individ-
ual with an infection thai is resistant to certain antibacterial
agents can transmit the resistant bacteria to others.
Thewidespread and sometimes Wlwarranted useof antibi-
oticshas led to a large number of resistant bacterial strains. At
least 60% of Staphylococcus aureus infections are now resis-
lant to penicillin, and r""i_mot strains of Entl'rOl"OCl1I' /aI'''''!;',
Enterococcus [oecium, and Pseudomonru oerllginosa be-
rome major clinical problems. The longer an antibiotic is
usedin the population and the more often it is prescribed, the
la.rger the percentage of resistant straifl.'l. Infections ac-
quired in a hospital or other health care setting, called
nosocomial infrctions, are often resistant to common antibi-
otics. Resistant nosocomial infections are especiallr trou-
blesome in critical care lUlits, where seriously ill patients
are often treated with high amounts of antibiotics. Two
particularly serious resistant infections are those caused by
methicillinresistanl St<lphylococcus allreu, (MRSA) and
vanwmycin-resistant enterococci (VRE).
LibraryPirate
482 UnitS Thl'lmmu""Syst""'
, I Anlibiotic I
1.loI8d:ion
2. Anbbiotic kills all organis .....
excepllhe .... islanl one.
3. Resistanl organism lhet
remained has rapidly divided
10 infect the clienl. Anlibiotic
is no longer eliectiV'll.
,. FlgureJ4.2 Acquired resistance
Health care providers play important roles in delaying the
emergence of resistance. The following are five principles
recommended by the CDC:
Prevent infections whenever possible. It is always easier
to prevent an infection, than to treat one. lIDs includes
teaching the patient the importance of getting
inununizations.
Use the right drug for the infection. Infectionsshould be
cultured so that the offending organism can be identified
and the correct drug chosen (see Section 34.6).
Restrict the use of antibiotics to those conditions
deemed medically necessary. Antibiotics should only be
prescribed when there is a clear rationale for their use.
Advise the patient to take anti-infectives for the full
length of therapy, even if symptoms disappear before the
regimen is finished. Prematurely stopping antibiotic
therapy allows some pathogens to survive, thus
promoting the development of resistant strains.
Prevent transmission of the pathogen by using proper
infection control procedures. lIDs includes the use of
standard precautions and teaching patients methods of
proper hygiene for preventing transmission in the home
and community settings.
In most cases, antibiotics are given when there is clear ev-
idence of bacterial infection. Some patients, however, re-
ceive antibiotics to prevent an infection, a practice called
prophylactic use, or chemoprophylaxis. Examples of patients
who might receive prophylactic antibiotics include those
who have a suppressed immune system, those who have ex-
perienced deep pWlcture wounds such as from dog bites, or
those who have prosthetic heart valves and are about to have
medical or dental procedures.
34.6 Selection of an
Effective Antibiotic
The selection of an antibiotic that will be effective against a
specific pathogen is an important task of the health care
provider. Selecting an incorrect drug will delay proper treat-
ment, giving the microorganisJJ1S more time to invade.
Prescribing ineffective antibiotics also promotes the devel-
opment of resistance, and may cause unnecessary adverse
effects in the patient.
Ideall y, laboratory tests should be conducted to identify the
specific pathogen prior to beginning anti-infective therapy.
I m:l}' inch](le of urine,
fluid, sputwn, blood, or purulent drainage for microorgan-
isms. Organisms isolated from the specimens are grown in the
laboratory and identified. After identification, the laboratory
tests several different antibiotics to determine which is most
effective against the infecting microorganism. This process of
growing the pathogen and identifying the most effective an-
tibiotic is called rultul! and semitiYity ((&51 !tsting.
Because antibiotic therapy alters the composition of in-
fected fluids, samples should be collected prior to starting
pharmacotherapy. However, laboratory testing and identifi-
cation may take several days and, in the case of viruses, sev-
eral weeks. If the infection is severe, therapy is often begun
with a broadspectrum antibiotic, one that is effective against a
wide variety of different microbial species. After laboratory
testing is completed, the drug may be changed to a narrow
spectrum antibiotic, one that is effective agairtst a smaller group
of microbes oronlythe isolated species. In general, narrow-
spectrum antibiotics have less effect on normal host flora,
thus causing fewer side t'ifects. For mild infections, labora
tory identification is not always necessary; skilled health
care providers are often able to make an accurate diagnosis
I>,..",d on pMient .<isn.< sympTom.<.
In most cases, antibacterial therapy is best conducted us-
ing a single drug. Combining two antibiotics may actually
decrease each drug's efficacy, a phenomenon known as
mTfagonism. If incorrect combinations are prescribed, the
use of multiple antibiotics also has the potential to promote
resistance. Multidrug therapy is warranted, however, if sev-
eTal different organisms are causing the patient's infection
or if the infection is 00 severe that therapy must be started
before laboratory tests have been completed. Multidrug
therapy is clearly warranted in the treatment of tuberculosis
or in patients infected with HIY.
One common adverse effect of anti -infective therapy is the
appearance of secondary infections, known as superinftions,
LibraryPirate
which occur when microorganisms normally present in the
body are destroyed. These normal microorganisms, or host
flori, inhabit the skin and the upper respiratory, genitourinary,
and intestinal tracts. Some of these organisms serve a useful
purpose by producing antibacterial substances and by com-
peting with pathogenic organisms for space and nutrients.
Removal of host flora by an antibiotic gives the remaining mi-
ccoorgani,lll.'l an opportunity to grow, allowing foc ovec-
growth of pathogenic microbes. Host flora themselves can
cause disease if allowed to proliferate without oontrol, or if
they establish colonies in abnormal locations. For example
E. coli is part of the host flora in the colon but can become a
serious pathogen if it enters the urinary tract. Host flora may
also beoome pathogenic if the patient's immune system be-
oomes suppressed. Microbes that become pathogenic when
the inunune system is suppressed are called opportunistic or-
ganisms. Viruses such as the herpes virus, and fungi are exam-
ples of opportunistic organisms that exist on the human body
but may beoome pathogenic if normal flora are suppressed.
Superinfection should be suspected if a new infection ap-
pears while the patient is receiving anti-infective therapy.
Signs and symptoms of a superinfection commonly include
diarrhea, bladder pain, painful urination, or abnormal vagi-
nal discharges. Broad-spectrum antibiotics are more likely
to cause superinfections because they kill so many different
species of microorganisms.
34.7 Host Factors
The most important factor in st'lt'cting an appropriatt' an-
tibiotic is to be certain that the microbe is sensitive to theef-
fecls of the drug. However, the nurse must also take into
account certain host factors that can influence the success of
antibacterial chemotherapy.
The primary goal of antibiotic therapy is to kill enough
bacteria, orto slow the growth of the infection, so that natu-
ral body defenses can overcome the invading agt'nt. Unless an
infection is highly localized, the antibiotic alone may not be
enough: The patient's immune system and phagocytic cells
will be needed to completely rid the body of the infectious
agent. Patients with suppressed immune systems may require
aggressive antibiotic therapy with bacteriocidal agents. These
patients include those with AIDS and those being treated
with inununosuppressive or antineoplastic drugs. Because
therapy is more successful when the number of microbes is
small, antibiotics maybe given on a prophylactic basis to pa-
tients whose white blood cell (WBC) count is extremely low.
Local conditions at the infection site should be consid-
ered when selecting an antibiotic because factors that hin-
der the drug from reaching microbes will limit therapeutic
success. Infections of the central nervous system are partic-
ularly difficult to treat because many drugs cannot cross the
blood- brain barrier. Injury or inflammation can cause tis-
sues to become acidic or anaerobic and to have poor circu-
lation. Excessive pus formation or hematomas can block
drugs from reaching their targets. Although most bacteria
are extracellular in nature, pathogens such as
Mycobacteri,lm tlIbercu/osis, salmonella, toxoplasma, and
'hop1fll4 Drug,fo<Sx!e,latlnf<'Ctlo", 483
listeria may reside intracellularly and thus be difficult for
anti-infectives to reach in high concentrations. Considera-
tion of these factors may necessitate a change in the route of
drug administration or the selection of a more effective an-
tibiotic specific for the local conditions.
Severe allergic reactions to antibiotics, while not oom-
mon, may be fatal. The nurse's initial patient assessment
must include a thorough drug history and a dcocciption of
any reactions to those drugs. A previous acute allergic inci-
dent is highly predictive of future hypersensitivity. If severe
allergy to an anti-infective is established, it is best to avoid
all drugs in the same chemical class. Because the patient may
have been exposed to an antibiotic unknowingly, through
food products or molds, allergic reactions can occur with-
out previous incident. Penicillins are the class of antibacte-
rials having the highest incidence of allergic reactions;
between 0.7% and 4% of all patients who receive them ex-
hibit some degree of hypersensitivity.
Other host factors to be considered are age, pregnancy
status,and genetics. The very young and the very old are of-
ten unable to readily metabolize or excrete antibiotics; thus,
doses are generally decreased. Some antibiotics cross the
placenta. For example, tetracyclines taken by the mother
can cause teeth discoloration in the newborn; aminoglyco-
sides can affect the infant's hearing. The benefits of antibi-
otic use in pregnant or lactating women must be carefully
weighed against the potential risks to the fetus and neonate.
Lastly, some patients have a genetic absence of certain en-
zymes used to metabolize antibioties. For example, patients
with a deficiency of the enzyme gluoose-6-phosphate dehy-
drogenase should not receive sulfonamides, chlorampheni-
col, or nalidixic acid because their erythrocytes may
rupture.
ANTIBACTERIAL AGENTS
Antibacterial agents are derived from a large number of
chemical classes. Although drugs within a class have simi-
larities in their mechanisms and spectrum of activity, each
is slightly different, and learning the differences and ther-
apeutic applications among antibacterial agents can be
challenging. Basic nursing assessments and interventions
TREATING THE DIVERSE PATIENT
Hispanic Cultural Beliefs and Antibacterials
emain grwps,oo al innm b'f ,n
ara il hot ,nd roId.ln i hNhIl)' hot ind oil irl' in hllalKf;whtn ,n
inb;lIaOO' oc:rul5, dloN\t
lilltlltl all' cblsifrd II fithtf hot or wkhl WflL For fJIImplt.!OII' throaund
di.lrThN n hot distases;wkk, upper Jl'IjIil1liOl)' ilfooions. arthritis.
i nd rhtumati!m all' wnsideml wkl 1iIoN1fI. T,aditiooallrWlIII'nt in su:h aj.
IUJl'I is 10 res10ft' the body'l hllara thlOO9h the iCkition 0< subtrUon of herbs,
foods.o< rntdit.rtions that all' cblsified is wr hot or wkl. To 11M i hot dw\t,

i hot mtdia.t, but is itslOOl Usilg aa'Ulmilophffi with
make it rooItr.
LibraryPirate
484 UnitS Thl'lmmuneSyu"",
apply to all antibiotic therapies; however, the nurse should
individualize the plan of care based on the patient's con-
dition, the infection, and the antibacterial agent pre-
scribed.
Penicillins
Although not the first anti-infecthe discovered, penicillin
was the first mass-produced antibiotic. Isobted from Ihe
fungus Penicillium in 1941, the drug quickly became a mir-
acle product by preven ting thousands of deaths from infec-
tions. The penicillins are listed in Table 34.2.
34.8 Pharmacotherapy
with Penicillins
Penicillins kill bacteria by disrupting their cell walls. Many
bacterial cell walls contain a substance called penicillin binding
prattin that serves as a receptor for penicillin. Upon binding,
penicillin weakens the cell wall and allows water to enter,
thus killing the organism. Human cells do not contain cell
walls; therefore, the actions of the penicillins are specific to
bacterial cells. Gram-positive bacteria are the most com-
monlyaffected by the penicillins, including streptococci and
staphylococci. Penicillins are indicated for the treatmem of
!ABLE 34 21 Penicillins
pneumonia; meningitis; skin, bone, and joint infections;
stomach infections; blood and valve infections; gas gan-
grene; tetanus; anthrax; and sickle-cell anemia in infants.
The portion of the chemical structure of penicillin that
is responsible for its antibacterial activity is called the brta-
I.<tam.ing. Some secrete"" enzyme, ""lied beta-I.d .......
or penic: illinasr, which splits the beta-Iactam ring. This structural
change allows these bacteria to beoome resistant to the effects
of most penicillins. Since their disoovery, large nwnbersofre-
sistant bacterial strains have emerged that limit the therapeu-
tic usefulness of the penicillins. The action of penicillinase is
illustrated in - Figure 34.3. Other classes of antibiotics also
oontain the beta-lactam ring, including the cephalosporin&,
carbapenems, and monobactams.
Chemical modifications to the natural penicillin mole-
cule produced drugs offering several advantages. They in-
dude the following;
Perricil/inare-resisrarrr penicillins: Oxacillin and
cloxacillin (Cloxapen) are examples of drugs that are
effective against penicillinase-producing hacteria. These
are sometimes called antistaphyloooccal penicillins.
Broad-spectrum penicillins: Ampicillin (Principen) and
amoxicillin (Amoxil, Trimox) are effective against a wide
range of microorganisms and are called broad-spectrum
Drug Route and Adult DoSf' (max dose whj>ffl Indicated) Advflrse EffKIS
NATURAL PENICILLINS
G btnzathiM (Bidlli1)
G procaint (WUlin)
Q prnidlin G sodiumlpot.mium
pmiciltin V (Pm-'ftor K. 'ftortids., VrMiIlin-KJ
PENICILUNASERESISTANT
doudlin (Cloxaprn)
didoxadlin
nakilin
oxadllil
BROAD-SPECTRUM (AMINOPENICILLlNS)
. morid lin (AnwilTrimox)
(Augmm:in)
ampidlin (Prindpm)
(Sprctrobid)
1M; 11 milioo uriu asa!oi1gtr dolt (mal:1.4 milioo lIlits/da,)
1M;600,0-11 milim (max: t8 milioo uritslda,)
1M/IV; 1- 14 million divided MI'1 "-6 h (mal : 80 milion urilsJday)
PO; 125-150 mg qid (mal:71 glday)
PO; mg bid
PO;m- 5OOmgqid
PO; 150 1119- 1 g qid (max: 12 glda, )
PO; 150 1119- 1 g qid (max: 11 g/da,)
PO; 150-500 mg .. "Y 6 h (max: t,750 mg/<b, )
PO;150 0/ 500 mg tabIrl (u(h with 115 mg dol'l uanil: .dd) 8- 11 h
POIlVJIM;15O-S00 mg M!Y 6 h (max: 4 glday PO 0114 glday IV/1M)
PO;400-8OO mg bid
EXTENOEOSPECTRUM {ANTIPSEUOOMONALJ
Ylbtnid lin (Grodin)
sodum
wob.Klam (Zosyn)
ticardlin (rKa')
PO;381-764 mg qid
1M; 1-4 g (mal:14 glda,)
IV;B75gqidOW'rlOmin
1M; 1- 1 g qid (max:14g1da,)
i/QJh, dIorrilN, I!4IlfO, fMr,
.towsi/ltSS
Aoaplwlaxis rnnpiOmt indudina
aogiotdrnla, drtulitort ?lam ind
cardiac a!lt!!; nrphrotollkity
LibraryPirate
o
O
II /S,/CH,
J. C- C- NH- CH- CH C,
\\//H. II I CH,
C - N- CH- COOH

Il-La.dam ring
'hop1fll4 Drug,/o<Sx!e.lalllll<'Ctlo", 485
Penicillin G; p-Isctam ring givea
antibiotic
- ,
I
I Resistant bacteria: Penicillin *lactam ...
G

o
O
II /S,/CH,
!. C- C-NH- CH- HC C,
\\IIH. II I CH,
O= C N- CH- COOH
I H
OH
,. Figure 34.3 Action of penicillinase
penicillins. These are somt'times referred to as
aminopeniciUins .
l'xtmded-spectrum penicillins: Carbenicillin (Geocillin)
and piperacillin are effective against even more microbial
species than the aminopenicillins, including PseudomOIltl5,
Enterobacter, Klebsiella, and Bacteroides jragilis.
Several drugs are available that inhibit the bacterial beta-
lactamase enzyme. When combined with a penicillin, these
agents protect the penicillin molecule from destruction, ex-
tending its spectrum of activity. The three beta-lactamase in-
hibitors, davulanate, sulbaclam, and t3wooctam, are available
only in fixed-dose rombinatioJ15 with spedfl' penkilliJl5.
These include Augmentin (amo;ricillin plus davulanate), Ti-
mentin (ticarcillin plus davulanate), Unasyn (ampicillin plus
sulbactaml.and Zosyn (piperacillin plus tazobactam).
In gemral, the adverse effects of penicillins are minor;
they are one of the safest dasses of antibiotics. TIlls has con-
tributed to their widespread use for more than 60 years. Al-
lergy to penicillin is the most common advt'1'Se effect.
Common symptoms of penicillin allergy include rash, pru-
ritus, and fever. Incidence of anaphylaxis ranges from 0.04%
to 2%. Allergy to one penicillin increases the risk of allergy
to other drugs in the same class. Other less common adverst'
effects of the penicillins include skin rashes and lowered red
blood cell (RBC), WBe, or platelet counts.
See Nursing Process Focus: Patients ReceivingAntibacte-
rial Therapy on page 496 for the Nursing Process applied to
all antibacterials.
Cephalosporins
Isolated shortly after the pt'nicillins, the cephalosporins
constitute the largest antibiotic class. The cephalosporins
p-Laclam ring broken. antibiotic activity is toat
act by essentially the same mechanism as the penicillins and
have similar pharmacologic properties.
34.9 Pharmacotherapy
with Cephalosporins
The primary therapeutic use of the cephalosporins is for
gram -negative infections and for patients who cannot toler-
ate the less expensive penicillins. More than 20
cephalosporins are available, all having similar sowtding
names that can challenge t'Ven the best memory. Selection of
a specific cephalosporin is first based on the sensitivity of
the pathogen, and secondly on possible adverse effects.
Doses for the cephalosporins are listed in Table 34. 3.
Like the penicillins, many cephalosporins contain a beta-
ring IhM i< ""-"pnn<ihle fnr Their
ity. The cephalosporins are bacteriocidal and act by
attaching to penicillin-binding proteins to inhibit bacterial
cell-wall synthesis. They are classified by their
but there are not always clear distinctions among the gent'r-
ations. For example, cefdinir is considered either a third- or
a fourth-generation drug, depending on the reference
source. The following generalizations may be made regard-
ing the generations:
First-generation cephalosporins are the most effective
drugs in this class against gram- positive organisms
including 51aphylococci and streptococci. They are
sometimes drugs of choice fo r these organisms. Bacteria
that produce beta lactamase will usually be resistant to
these drugs.
Second-generation cephalosporins are more potent, are
more resistant to beta lactamase, and exhibit a broader
spectrum against gram-negative organisms than the
LibraryPirate
"


t

486 UnitS TtelmmuOI'S)"tl'm
..... Prototype Drug I Penicillin G Sodium/Potassium
Therapeutic (lass: Antibacterial Pharmacologic (lass: Cell wall ilhibitor; natural peniallin
ACTIONS AND USES
Simi!.r 10 penic:ilin V, penicillin G is <I drug of dioe <lgaimt pnw-
moc:oai"nd Of'9iInisms thai do 001 produu ptnic:illinm ind art'
shown to lit su lC!ptibie by (&5 ttlling. k is also a medication of choiu for gon-
orrllta and S)'phiil UUIN by Wl<tpliblt mains. Pmic:illin G is milablt
llltr a potmilm or SGdilm llltrt' is no difirrt'n(f llitraptutiully betwem
lilt two wits.
Only 15-10%0f an oral d= of penic:illin G is ablOlbed. of its low
oral absorption,prnic:min G is often givtn by lh! IV or 1M roottl. Penic:illin Vand
amoxic:illin art' m:lR' stablt in ,tid and art' UIfd wlltn or,1I ptnic:illin thtrapy is
desirt'd. Prnic:illinas!-prodlKing orglnisms inacti'ffit both ptnicillin G and
penicillin V. Prnic:ilin G beru:alhilll' (8ic:illin) and ptnicillin G prouilll' (Wytillin)
Art' OCIing pl .... """1 <.Ok< oftht drug.
ADMINISTRATION ALERTS
Afttr .... telill administration, oblffi'l' for alltrgic rt'actions for
30 minut6,tspffially following tilt fim dost.
00 oot mix ptnic:illin ind aminogly(osoo in tiMo wme inlla_om soIu-
lion. GiV!' IV n:edicatiom 1 hour to inter.Jnions.
Prt'gnalKY 8
PHARMACOKINETICS
Il1wtRapid
30-60 min PO; 1 S- lO min 1M
10-60 min

..... Prototype Drug I Cefotaxlme (Claforan)
ADVERSE EFFECTS
PrniciUin G hiS ffW Ifflous adYerst effects. OianbN,nlUS!'a, vomiting art'
tiMo most (ammon adYene tfl"ecu ind tan (aUS!' smous oompli:atiom in {hil-
dlt'll ind oldtr i dum. Pain it tht injrnion miy oc:cur, ,nd !lI ptrinrectiom
art' poI5iblt.Anaphylnis tilt most W'rious ,dvtrSt tffect.
Contrai nd italions: The only contraindiution is to a drug in tht
ptnic:illin daIS. 8eo:.JUS!' penic:illin G is er<reted flIensivtly by tile tht
drug should lit UIfd with caution in with W"/ert' .... al
INTERACTIONS
J)ug-J)ug: G may dKiNlf the of oral rontoopliva.
taken with this rnMitiIioo will d@aNlfthei!blorptionofplidlin.
l'ou!Sium.sparilg diurMiG adminisrelldwith
G poli5!iOOl.
Lab Ttsts: Pl'ltidlil G may ij"lt poIitiu (rombs' tfII and Ial!.! positiVI! .linary or
W'l 00I prOieilll.
Ik<rbaVFood: Urtnown
Trtalmtnt ofDt rdow: Tlltll' 00 sptcifK tlNtment for O"ItrWs.t.
RtI'tr III MyMIsIrtgR fur a MnJnq I'rortl! Foot! spKlIIi: 111M <tug.
Therapeutic (lass: Antibacterial Pharmacologic (lass: Cell wall ilhibitor;first -generation tephalosporin
Aal0NS AND USES
(tWtaumt is a ttird"9flll'ration with i broad sptclnJm of activ-
it"; 'gainst olljanisms. k is tfftniV!' 19ainst many bitlt'rial
hiV!' df"/tloped rt'Sistanu to generation <I nd
10 othtr tLmfl Ii anti-infectim. (tfotaIimt txhibits bamrioc:idal inivity t.,r
inhibiting (tll-WllIs)'lllhtsis. k is prt'S(ri bed for W'riom inftions of tilt lowtr
respiratory UiKI. (fnllal ntrYOUS S)'Stffll, genitourinary sysltm, bonts. <lnd
joints. k ilia)' also lit UIfd for blood infKtionssum as bittf ll'lll ia or Sfptic:t mia .
lil:e many otht r {fphalosporilll, trfotn illll' is not alnorbed from tilt GI tract
and must IItgiven by tilt 1M or IV IOUte.
ADMINISTRATION ALERTS
IMinjeo:tiomdffp intOi lalljt malS to prt"lent iojuryto
sunounding tMutI.
Prt'gnalKY 8
PHARMACOKINETICS
Il1set: 30 min (lM);S min (IV)

1 h
Duration: Unknown
ADVERSE EFFECTS
For most {ffotuillll' ind tht othtr art' wft medila-
tions. tilt IMn (ammon tffl,ikbough S)'mptorm
ma, indlllk only, minor rilh and iUhing. Anaphylam poIlbit. Glff!'trd
Iidt ffirm YKh as dianhei, I'Omiting. and nau IN may O(rur. Sane patienu fI-
ptritlKt mmidmblt pain at injtdion
Contrai nd ications: The only comraindication is 10 a drug in the
tepha Iosporin das (tWtaume is U(rt'ted ertt nsivtly by tht kidntyl,
Ihould lit UIN with uution in with Sfftll' rt'N1 disNst.
INTERACTIONS
J)ug- J)ug: l'robenKid UI.I\O'! dmNlrd relIal flimination of {efolaxiR and may
rtIUt io {tphalo:lporin toxi:itJ Akohol iltflam with {ffotallime to proiKe a
dsulfwam-il:e rYllion. Cefolaxime iuratn with HSoIJDllo (ikl\f an i (INIf in
platrlet inhibiticn
Lab Ttsts: Livfr fIMion test yakIfs may iKrused; may give a poIitft (rombs'
test i nd Ib eIevationI of W'l 00I or Irinary Ufainiw lewis.
Ik<rbaVFood: lJnI;nown
Trtatmtnt ofDt rdow: Thert' is 00 SptCifK Irt'atment for O"ItrWs.t.
RtI'tr II MytmbrgXI fur a MnJnq I'rortl! Foot! spKlIIi: 111M <tug.
LibraryPirate
'hoplfll( Drug' fo< !lxtl'llallolealOll' 487
TABLE34.3 I Cephalosporins
",,"
FIRST-GENERATION
Route and Adult Dose (max dose where loolcall'd) Advel"5e Effects
madroxil
ma/din (AAl:tt KtIzoI)
aphaluil (Ktfttx)
,phOOi!ll' ('kW()
SECOND-GENERATION
mador (CtdOl)
PO; 500 1119- 19 O!II' IOtwotimel/day (mad gfoHY)
1V1IM;250 mg-2 9 tid (max: 12 glday)
[JQrriIN,QImmilaluanpng. (olii'll,
ro5ll. or i"jtcrion sir/\ /XII or rogm
rQndidoJis
PO; 250- 500 1119 "d
PO; 250- 500 1119 tl'l'r)' 6 h or 500 1119- 1 9 Mf'! 12 h (max:. gfoH,)
IXudomrnlbranous (olili oepI!rotoxidty

(tfolmn (CtfOtln)
a'foxilil (Mdoxin)
PO;25O- 500 1119 lid (max:2 gld.y)
IV/1M; 1- 2 9 f'leI} 12 h (max:6 gld.y)
IV/1M: 1-2 9 f'leI} 6-8 h (miX: 12 gfday)
a'Iprozil (Ctflil)
a'I!roximt (Ctftio, ZNa'f)
PO; 250- 500 1119 O!II' to two time/day (miX: 1 glday)
PO;lSO- 500 1119 bid (max: 191oHy)
THIRO-GENERATKlN
a'ldinr (Omnktf)
a'ItiIDml (Speara(tf)
a'fuimt (Suprax)

Q (tfOtlxime (Clafonn)
a'IpDdoxint (vantil)
(ForuI, b1ir:d)
rntibulm (Ctdax)
rntiMximt(Ctfizox)
rntriaxo!ll'(Rocrphio)
FOURTH-GENERATlOtl
1M{1V: 750 1119- 1.5 9 Mry 8 h (mad g/day)
PO; lOO 1119 bid ( ..... :600 mg/di)l)
po;.oo 1119 bid for 10 oH)'I (mn:&)) mgloH,)
PO; .00 mgloHy or 200 mg bid (max: 800 mg/oHy)
IV/1M; 1-2 9 12 h; 16 g/day in IWO 10 fotrdiloided Ibsfs (max: 12 gld.y)
IV/1M; 1-2 9 bid-tid (mil: 12 g/day)
PO; 200 1119 Mf'/12 h for 10oH)'I (miX:&)) mgloHy)
IV/1M; 1-2 mg Mf'! 8-12 h (max:6g1oH,)
PO; .00 mgloHy fOliO oH)'I (max: 0100 mgld.y)
IV/1M; 1- 2 9 8-12 h, upto 2 9 4 h (max: 12 gldl1)
IV/1M; 1-2 9 12- 24 h (miX:. g/day)
9 12 h for" 7- 10 d.y, (mad gldi)l)
Irolin ammon .d'lml' ltOousod'/ml'
-
first-generation drugs. The second-generation agents
have largely been replaced by third-generation
cephalosporin<;.
Third-generation cephalosporins exhibit an even
broader spectrum against gram-negative bacteria than
the second-generation agents. They generally have a
longer duration of action, and are resistant to beta
lactamase. These cephalosporins are sometimes drugs of
choice against infections by Pseudomonas, Klebsiella,
Neisseria, Salmonel/a, Protells, and H. influenza.
Fourth-generation cephalosporin<; are effective against
organisms that have developed resistance to earlier
cephalosporins. Third- and fourth-generation agents are
capable of entering the cerebrospinal fluid (CSF) to treat
eNS infections.
In general, the cephalosporins are safe drugs, with adverse
effects similar to those of the penicillins. Allergic reactions
are the most frequenl adverse effect. Skin rashes are a com-
mon sign of allergy, and may appear several days following
the initiation of therapy. The nurse must be aware that 5% to
1000t the patients who are allergic to penicillin are also al-
lergic to the cephalosporin<;. Cephalosporins are contraindi-
cated for patients who have previously experienced a sewre
aUergic reaction to a penicillin. Despite this illcidmce of
cross hypersensitivity, the cephalosporins offer a reasonable
alternative for many patients who are unable to take peni-
cillin In addition to allergy and rash, GI complaints are
common adverse effects of cephalosporins. Earlier genera-
tion cephalosporins caused kidney toxicity, but this adverse
effect is diminished with the newer drugs in this
Nursing Process Focus: Patients Receiving Antibacte-
rial Therapyon page 496 for the Nursing Process applied to
all antibacterials.
Tetracyclines
The first tetracyclines were extracted from Streptomyces soil
microorganisms in 1948. The five tetracyclines are effective


,


LibraryPirate
488 UnitS Immune SY"'-""
TABLE i4 41 T"tracyclinti!s
Drug
demtdoqdint(Dtdomym)
doxyqdinr (Vbramym,OII1rrs)
minoqdinr(MilHKin, 01hrB)
Q ltlri()'dinr (Stmydn. odtm)

Routeand Adult Dose (max dose where Indicated)
PO; 150 mg Mry 6 h or 300 mg 11 h (mad. glday)
POny; 100 mg bid 00 day I, thrn loomglday (mal:lOO mg/day)
POnV;1OO mgu do51' foIowrd by 100 mg bid
m9 bid-"d (rnu:2 9/day)
Adverse Effects
IIlmiri"9. 0bd0mlM/(Jllmpi"9./linlmrt,
diarrM4 mild p!wlroraOdry. fI1fh, cflzinru,
stingill9fOOmirtg Vrirll fDliml oppIrorkm
Aniphylaxi; gcondary infe<!iom.l!epi!loloxidtL
afoljatiYr
IV; 100 mg. fdlowrd by SO nl9MfY 12 h
against a large number of and
grnnqXlsitive organisms and have one of the broadest spec-
trruns of any dar.s of antibiotics. The tetracyclines are listed
in Table 34.4.
34.10 Pharmacotherapy
with Tetracyclines
Tetracyclines act by inhibiting bacterial protein synthesis. By
binding to bacterial ribosome, which differs in structure
from a human ribosome, the tetracyclines slow microbial
growth and exert a bacteriostatic effect. AU tetracyclines
have the same spectrwn of activity and exhibit similar ad-
verse effects. Doxycycline (Vibramycin, others) and minocy-
Jitr Prototype Drug I Tetracycline (SumYCIn, others)
cline (Minocin, others) have longer durations of actions and
are more lipid soluble, permitting them to enter the CSF.
The widespre:.d use of tetracyclines in the 1950s and 1960s
resulted in the emergence of a large number of resistant bac-
terial strains that now limit their theT3peutic utility. Therare
drugs of choice for only a few diseases: Rocky Mountain spot-
ted fever, typhus, cholera, Lyme disease, peptic ulcers caused
by Helicobacter pylori, and chlamydial infections. Drugs in
this class are occasionally used for the treatment of acnevul-
garis, for which they are given topicaUyor PO at low doses.
Tetracyclines exhibit few serious adverse effects. Gastric
distress is relatively common with tetracyclines, however,
and patients will tend to take tetracyclines with food. Be-
cause these drugs bind metal iOIl<; such as cakiwn and iron,
Therapeutic Class: Antibacterial Pharmacologic Cia ss: Tetracycline; protein synthesis inhibitor
ACTIONS AND USES
Tetmydilll' i9iiost , broad raogr gram-
ntgzotivt olganisms, illCluding ChkJmydiD, Ri<ktftli4l, and My<cp/DfIIlD. Its use
hiS ilKft'aifd {f>I t r thr past drude due to its effKlivtnl'ls iljiinst H. py/oIi in
lhr trutrneol of uker dMm. Tttracydiot isgm orally, though it Ma
soon hall-lijf !hit may rrquiR' four prr day. Topiul ind
oral prrjlruions i R' i'liilable for treating icnr.An 1M pll'piratioo i saYililablr;
injrctions may (aIM local irritation and lit Htremtly painfUl.
ADMINISTRATION ALERTS
oral drug with full gLm of water to dtUl'aIt tIOph.!gea1 aod GI
initllioo.
aotac:idund Il'troK)'dilll' 110 3 houlHjIrt
Intilipidrmic:,,-lIillran2hoursbefoR'or afw temqdior.
PR'goancy category 0
PHARMACOKINETICS
1l1'51't: 1- 2 h
Peak:2-4 h

Duration: 12 h
ADVERSE EFFECTS
kiog i broad-spKIrum antibiotic:. tttracyclilll' M i tt ndeocy to affKt vagillill,
oral, and intlstinal flora and caU\e wPf(infe<tions. Temcydine irrifates !he GI
II"IKOU and may ColU\e ni UIN, romitiog, tpiljistric: bum iog, and dia niIe.J. Diar-
rhN may tllOll9h !OUUst discontinuatioo 01 thrrapy.Olhrr common
side effKls in(1ude discoloration 01 thr tffih and pOOt<MnsitiYity.
Contraindications: Tetracydinr (ontraindimed in patients with hypmtnsi-
tili!)' 10 drugs in eLm. Thr drug should not lit used during tht \fcond half
of prrgnaocy, in childrt n 8 )'I'ars or indio jItients with 1f'IM' Il'oal or
hrjltic: impairlMnt.
INTERACTIONS
1Wg- 1Wg: Mil; jroIiKII.ion liIiIIi"ll'S,aod
antadd:! IftIlKf lht abIorplioo and If IOOIIMis of
with the mtgI (olestipoi and (OOItsiyrallliof, 1Mfir,' dKlNIing lhf
oforal romKtptim.
lab 115ls: May inlrfR the UrN nitrogfo 18lMjJ,
aIpaftiIlf MIlinOlranlfmlf lAST), ........... aminOlrilllll'trillf wn, MIl)'W. biin.tlin,
and alaint p/IoIpIIaliIIf.
JIiorbaVhod: OdiIy irltrfmo with lfUilJdlll' ablorplion.
l INIment of Om dose: Thfre 110 sprcifK trutmeot for OYl'rdo5I'.
1Itl(er.!:l MnlniJl'rIKtsIi FooII'ipt(/It 1rI1M.:tug.
LibraryPirate
tetracyclines SllOUld not be taken with milk or iron supple-
ments. Calcium and iron can decrease the drug's absorption
by as much as 50%. Direct exposure to sunlight can result in
severe photosensitivity during therapy. Unless suffering
from a life-threatening infection, patients younger than 8
y""'" of nol given ... th""" druB"
may cause permanent yellow-brown dis<:oloration of the
permanent teeth in young children. Tetracydines also affect
fetal bone growth and teeth dewlopment and are pregnancy
category D agents; therefore, they should be avoided during
pregnancy. Because of the drugs' broad spectrum, the risk
for superinfection is relatively high and the nurse should be
observant for signs of a secondary infection. When admin-
istered parente.rally or in high doses, certain tetracyclines
can cause hepatotoxicity, especially in patients with pre-
existing liver disease. Because outdated tetracycline mayde-
teriorate and become nephrotoxic, WUlSed prescriptions
should be discarded promptly.
The newest of the tetracydines is tigecydine (Tygacil), ap-
proved in 2005. Tigecydine is indicated for drug-resistant
intra-abdominal infections and complicated skin and skin-
structure infect ions, especially those caused by MRSA. Nau-
sea and vomiting may be severe with this drug. Tigecycline
is available by IV infusion.
See Nursing Process Focus: Patients Receiving Antibacte-
rial Therapy on page 496 for the Nursing Process applied to
all antibacterials.
Macrolides
Erythromycin (E-mycin, Erythrocin), the first macrolide
antibiotic, was isolated from Streptvmyces in a soil sample in
1952. Macrolides are considered safe alternatives to peni-
cillin, although. they are drugs of choice for relath'ely few
infections.
34.11 Pharmacotherapy
with Macrolides
The macrolides inhibit protein synthesis by binding to the
bacterial ribosome. At low doses, this inhibition produces a
bacteriostatic effect. At higher doses, and in susceptible
species, macrolides may be oocteriocidal. Macrolides are ef-
fective against most gram-positive bacteria and many gram-
negative species. Common indications include tht'
treatment of whooping cough, Legionnaires' disease, and
infections by streptococcus, H. influenZ<l, and Mycoplasma
pneumoniar. Drugs in this class are used against bactt'ria re-
TABLE 34.S Macrolides
'''"pltr l4 Drug. fo< 8OC: I .... I.llnfe(Uon' 489
AVOIDING M EDI CATION ERRORS
Mr. Johnson is for. snM' inftion and dehydr.-
tion.D.Jring tilt initi.l Mr. Johnson about
Itrgits and Il'poru being alltrgic to ',pirin, sulfa, "Id ragMtd.
Followinq a history .J nd physiu I exa mination,tht primary physician oroft"!
trimethoprim-sulfaml'thomolt (Ba<lrim) DS. Whm tilt medication alljye
from tJ\e phUJllaq, it is in a unit-dose padygt.1t is.J IaI1jl' tabltt (ontaining
160mg oftrimethoprimand 800 mgofsuKamethoxarole.TIIf' IIJI"W' bruk! t!le
tablet in halt for sw.JBowing.and gim Mr.JohnlOn his first!losr with a
Ia I1jI' gla IS of water. What should tht nursr haYe diflerrmly?
5to'Apptllll/lOfllllhtJUl}9t'imiamm:
siding inside host cells, such as Listeria, Chlamydia, Neisse-
ria, and Legionella. Clarithromycin is one of several antibi-
otics used to treat peptic ulcer disease, due to its activity
against H. pylori (chapter 4(00). The macrolides are listed
in Tablt' 34.5.
The newer macrolides are synthesized from erythromy-
cin. Although their spectrums of activity are similar, these
drugs have longer half-lives and cause less gastric irritation
than erythromycin. Forexample, azithromycin (Zithromax,
Z-Pak) has such an extt'flded half-life that it is administered
for only 5 days, ratherthan the 10 days required for most an-
tibiotics. The shorter duration of therapy is thought to in-
Cft'ase patient adherence.
The macrolides exhibit few serious advt't"Se etfecl5. Mild GI
upset, diarrhea, and abdominal pain are the most frequent
adverst' etfects. Because macrolides are broad-spectrum
agents,superinfections may occur. Like most of the older an-
tibiotics, macrolide-resistant strains are becoming more
common. Other than prior allergic reactions to macrolides,
there are no contra indications to therapy.
See Nursing Process Focus: Patients Receiving Antibacte-
rial Therapyon page 496 for the Nursing Process applied to
all antibacterials.
Aminoglycosides
The first aminoglycoside, streptomycin, was named after
Streptomyces griseus, the soil organism from which it was
isolated in 1942. Although. more toxic than otht'r antibiotic
classes, aminoglycosides have important therapeutic appli-
cations for the treatment of aerobic gram-negatiw bactt'ria,
mycobacteria, and some protowans. The aminoglycosides
are listed in Table 34.6.
"n"
Route and Adult Dose {max dose where Indlcatedl
azithrom,m (1ittromal,Z-Pak)
darithromydn 16i.11il)
diitl"romym (Dynab.K)
ft)'Ibrorny<in (Hotydn, Erythrodn)
I
PO; 500 mg for _dose, thm 250 mglday for 4 days
PO;M-5OOmgbid
PO;500mglday
PO;M-SOOmgbidor m mgtid
LibraryPirate
490 UnitS The Immune SY"'-""
..
Prototype Drug
I
Erythromycin (f -Mycm, frythrocm)
Therapeutic ( lass: Antibacterial Pharmacologic ( lass: Macrolide;protein synthesis inhibitor
ACTtONS AND USES ADVERSE EFFECTS
Erythrom)'(in is by 1I0mac:h acid is tills formulattd <II cOiIItd, TIiI' molt frtqUtnt adYersr rflem from tr)1hromyr:in
tablmorcapsulr1 that diuolvr in tlil'small cramping,and vomiting,<lhhoogh are rJreiy mough to wadis-
plication is for patimlS who <I ll' un.JbIt to penicillins or who mJY hol Y!' rominunion of tlil'rapy. COIKurll'llt administration with food rtdtns thI'st
a ptnicillin-resisbm inleo:tion. k has a sptdrum to that oI!hr ptnicilli os l)'IIlpioms. TIM- molt aMM dfd is htpatoioJicity c.Jutd bytheesto-
and is rfle.:tivr <l gainll mon bacteria.1t is a prmmd drug lall' sak (lloIone) of tlil' drug. Hearing Iosl, venigo,and diuilll'Sl may be 9pt-
for infections by BllrrimJIQ pmuJIis (whooping cough) and Corynroocufium ritncrd whl'n using high doles, particularly in older addIS and in thoJol' with
dip/rdlfriat. impaired hI'p;rtir: or
ADMINISTRATION ALERTS
Contraindications: Erythromyr:in is rontraindiuted in patienu with hyptnen-

Adminisll'f oral drug on an r mpty stomach with a fUll glass ofwater.
to drugs in the macrolide dill,and fort"-taking terferudine,.ntem-

mied.
izoIe,or cisapridt.

Do not giYl'with or immediall'ly befoll' or after fruit juices.
INTERACTIONS

PIl'9n.J1K)' category 8
i)ug- i)ug: Ane\llwticJ,azolro oiflticonwnll may "lfr.I(tto YIIII'
l'fllll druij Ifvm 0( erytIvOOlycin to 1M and rfIW " tolDdtJ. Ihg n mcll
with qcIosporine, incrMilg tht risk for It may iraNSI' iIIf !ffecll 0(
wilifann.Thr(l)fl()Jfffl\ UJoI' 0( fl)'thJOnin with Iov.!ruiin not
PHARMACOKINETICS f!(0IIlIIfIICIfd becaIIIo! may OONIoI' tht risk 01 mid! toIicity. Ethanol U\oI' may
I h dtoaUlol' tht abIorptioo 0( erythrorny<in.
Peak:Hh Lab Te ts: IIIa'f "tmlnwithAST ...-.:t gi"ll'
15- 2 h
. m
Duralion:Unknown
MIll 0(
of Derdolf: is no Ipt{ifK tlNtment iJr
Rmr II MyMfihlga for MnJrtg l'reiI fools spt(itt III!tiJ ItiJ9.
TABLE 14 61 Aminoglycosides
Drug
amibdn lAmikinJ
Route and Adult Dose (max dose where Indicated)
1M; S.0-75 mg..tg is a loacting 0J\0I' , then 7.5 mg/bj bid
Adverw Effects

dio,,1wl, tfniM, 60rirm
gmUnici1 (Garamycin,OIhm)
unamycin (Kanlln)
1M; 15- 2.0 mgIkg iU loacling lbIoI',then H mgIkg bid- tid
1M; S.0- 75 mgIkg bid-tid
n!:DlJp!oxidlY ilt'mliije ototoxicitv,
superjnk<!ions
neom)\in

PO;4-11 g!day in divided
PO; 75-11.5 mglt9 in three dolt!
!Ill'p1omycin 1M;1Smg/bjupto 1 ga!i
(NebcinJ IM/tM; 1 mgIkg tid (max:S mg/bj/day)
hdkJ common adverse tfltru;lIII1aIiliDg. indiute s.ffious admlol' tflem.
34.12 Pharmacotherapy
with Aminoglycosides
Aminoglycosides are bacteriocidal and act by inhibiting
bacterial protein synthesis. They are normally reserved for
serious systemic infections caused by aerobic gram-negative
organisms, including those caused by E. coli, Serratia, Pro-
teus, Klebsiella, and Pseudomonas. They are sometimes ad-
ministered concurrently with a penicillin, cephalosporin, or
vancomycin for t reatment of enterococcal infections. When
used for systemic bacterial infections, aminoglycosides are
given parenterally because they are poorly absorbed from
the Gl tract. They are occasionally given orally for their lo-
cal effect on the GI tract to sterilize the bowel prior to in-
testinal surgery. Neomycin is available for topical infections
of the skin, eyes, and ears. Paromomycin (Humatin) is
given orally for the treatment of parasitic infections. Once
widely used, streptomycin is now usually restricted to the
treatment of tuberculosis because of the emergence of a
large number of strains resistant to the antibiotic. The
nun;e should note the differences in spelling of some
druSS_uch as -mycin ven;us -micin- which reflect the
different organisms from which the drugs were originally
isolated.
LibraryPirate
Chopltr l4 Drug' fo< 8K' .... I.II"fe<Uon' 491
Prototype Drug I Gentamicin (Garamyclfl, others)
Therapeutic CI ass: Antibacterial Pharmacologic Cia ss: Aminoglycoside; protein synthesis inhibitor
ACTIONS AND USES
Gtnumicin is a u'Uillly for
!MoIlS urinal)', respiruOI)', IItf'IOJUS, or GI inftaions whtnltss tOllic ,ntibiotiu
... <omr.inditated. Activity includes fnr",obomr, . (oIi,Kkl"ifilQ, Citm<UY,
Pstuc/omona5, QOO 5motia. Gentamicin is tffliY!' against, lew gl<1 m1lOsitift
b,cteria, including WIlle mains of methiciUinffsisunt QUftUS
(MRSA).1t is ohm used in {ombimion with other antibiotiu.A topiul formu-
lation (Genoptic) is '\\Iilablt for infffiions of
ADMINISTRATION ALERTS
For 1M administration, gi-n into
Use only 1M and IV drug IOlutions that 'R' rand coIoMss or )'1'1-
Iow.Oisurd dis<oIo.-M IOknions OI"thoS!' th.Jt (onuin particulate maner.
Wnhhold til!> drug ifth!> peak S!'rum In"ellieu1l<rfe normal range of
5- 10m<g/mL
PlI'9n.ncyc.ilegOl)'(
PHARMACOKINETICS
Onset :Rapid

Half-life: 3 .... h
Duration: 8-I 2 h
The clinical applications of the aminoglycosides are lim-
ited by their potential to cause serious adwrse effects. The
degret' and types of potential toxicity are similar for all
drugs in this class. Of greatest concern are their effects on
the inner ear and the kidneys. Damage to the inner ear, or
ototoxicity, is recognized by hearing impairment, dizziness,
loss of balance, persistent headache, and ringing in the ears.
Because permanent deafness may occur, aminoglycosides
are usually discontinued when symptoms of hearing im-
pairment first appear. Aminoglycoside nephrotoxicity may
be severe, affecting up to 26% of patients receiving these an-
tibiotics. Nephrotoxicity is recognized by abnormal urinary
function tests, such as elevated senun creatinine or BUN.
Nephrotoxicity is usually reversible.
See Nursing Process Focus: Patients Receiving Antibacte-
rial Therapy on page 496 for the Nursing Process applied to
all antibacterials.
Fluoroquinolones
Ruoroquinolones were once reserved only for UTIs because
of their toxicity. Development of safer drugs in this class be-
gan in the late 1980s and has continued to the pre:rent day.
Newer fluoroquinolones have a broad spectrwn of activity
and are used for a variety of infections. The fluoro-
quinolones are listed in Table 34. 7.
ADVERSE EFFECTS
Ruh, nausra, vomiting. and fatigue 'R' the most effKls. As
with .r <Main mlly
<lin prod", loss of hNfing 01" b.I:oIK. , which may bt<orn. pMn.nrm with
continued 1M. Tinnilu!, vertigo, an d penistent he.td.Jchri are rally of oto-
toxirit)o. Nephrotoxirit)o is of partirul.tr <on{ern to patinlts with kid-
and may limit Signs of mi"'M
iull(tion incUde oliguria, proteinuria, ,nd rlt\\lted BUN .nd <rutininr boeIs.
Rtsisull(e to genu micin is incR'i ling. and some (IOU ft'Sisull(e <lmong .. mino-
glycolidts has II'portM.
Contraindimions: Genumicin is contraindic.itM in patients with
tNit)' to drugs in iminogl)':o:s.ide <taSI. Drug the"Pl' must monitorM
<af"ully in palitnts with impaiR'<i renal fUnction, or thOl!' with
lI!>aring loll.
INTERACTIONS
Drug-Drug: 1M rill; of otot(l[idty ilKlNlfl ffthf patientis<ll"rI'Iltlytaki19
iIIIttootHidn B, fwlllMlidf, alpirin, blirnmnide, ethauynic iOd, rilplatin, 01
panrnolll)'<i1. Croamnt U!f with iIIIphotHidn B, <.Jp-fOIII)'{in, <ilplatin,
B, 01 '/olIIComy<i1 inoUlfl riIII of nephrotm:idty.
liI b 11'Sts: Gfntamil:in may inmasl' value! of folowilg: IoffiIm biirubin, IfIIIIII
uMiniM, IfllllllIacLltI' deII)'IIrogfna;r nD!), BUN, AS1; 01 All: may dKr&N valutol
[01 IoIowing:SfI\Il1 <akium,IOIium,OI
HerlI<iVFood: Unknown
lrNlment of Overdose: is 110 tre.tlmtnt for OY!'rdosr.
III ftt Ie MyMJ"/ngfJI for Q MJrJi"'ll'rrKt .. fDan 1p11< Ie rIrtJ dfU9.
34. 13 Pharmacotherapy
with Fluoroquinolones
Although the first drug in this class, nalidi..-uc acid (Neg-
Gram), was approved by the FDA in 1962, it had a narrow
spectrum of activity, and its use was restricted to UTi s.
Nalidi..-uc acid is still used for the pharmacotherapy of UTI,
although it is not a preferred drug for this infection. Since
then, four generations of fluoroquinolones have become
available. All fiuoroquinolones have activity against gram-
negative pathogens; the newer ones are significantl), more
effective against gram-positive microbes, such as st3phylo-
cocci, streptococci, and enterococci .
The fiuoroquinolones are bacteriocidal and affect DNA
synthesis by inhibiting two bacterial enzymes: DNA gyrase
and topoisomerase IV. These antibiotics are infrequently
first-line drugs, although they are extensively used as alter-
natives to other antibiotics. Clinical applications include in-
fections of the respiratory, GI, and genitourinary tracts, and
some skin and soft-tissue infections. The most widel), used
drug in this class, ciprofloxacin (Cipro), is an agent of choice
for the postexposure prophylaxis of &cillus anthracis, the
organism respoll'iible for causing anthrax_ Moxifloxacin
(Awlox) is a newer drug that is highly effective against
anaerobes. Recent studies suggest that some fluoro-
quinolones may be effect h-e against M. tuberculosis.
LibraryPirate
492 UnitS The Immune SY""m
TABLE i4 71 FluoroquinolonlO!s
Drug Route and Adul t Dose (max dose where Indicated) AdVl'l'seEffecb
FIRST GENERATION
dnoxadn
naidixic:uid (NtgGrim)
SECOND GENERATION
Q dproftwdn(("pro)
norIIoxicin (NorOlin)
oIIoJOOn (Aoxin)
THIRD GENERATION
PO;lSO- SOO mg bid-qid
thtriP1; I 9 qid
PO;Chronil: SOO mg " d
PO;2S0- 7S0 mg bid
PO;400 mg 01800 mg dolly
PO;200-400 mg bid (max;8O(I mg/da,)
M1IIIiring, rash,hrodht,

sire, /0(0/ burring, uinJr19 rorrwa/ irriloril/ll
(op/IlIIO/rrirJ
,wphyli1!is. tm:bn !IJptll'( . \Uooinfwiorn,
P!t!!dO!!lt!lltmous
ptrip!Iml nl'uroDalhy, hepalOllJl(idty
Ievolloxidn (L"iquin)
FOURTH GENERATION
OrOP' (0.196 ophO,.h";" ""luliun);Cko dd,.. 141<1 2, .. ," d"", in NoJ, .rr ... tod.,.
emf 21l0ii'i;011 doI)'i 3- 7, one !top in urn up to fool time/diy
PO;25O-S00 mgfdoly [mal: 750 III9Id,,)
gmlifloXidn (Firti'le)
moxifIoLJdn (AI'rIox)
PO;110 Ill9lday (max:320 mg/d,,)
POflV;400 mgfda, (mix;400 mgfd.ly)
A major advantage of the fluoroquinolones is that most
are well absorbed orally and may be adntinistt'red t'ither
once or twice a day. Although they may be taken with food,
they should not be taken concurrently with multivitamins
or mineral supplements because calcium, magnesium, iron,
or zinc ions can reduce the absorption of some fluoro-
quinolones by as much as 90%.
Fluoroquinolones are well tolerated by most patients, with
nausea, vomiting, and diarrhea being the most conunon ad-
verse effects. The most serious adverse effects are dysrhyth-
mias (gatifloxacin and moxifloxacin) and potential
hepatotoxicity. Central nervous system effects such as dizzi -
ness,headache, and sleep disturbances affect 1% to B% of pa-
tients. Most recently, fiuoroquinolones have been associated
with an increased risk of tendonitis and tendon rupture, par-
ticularly of the Achilles tendon. The risk of tendon rupture is
increased in patients over age 60 and those receiving concur-
rent corticosteroids. Because animal studies have 6Uggested
that fluoroquinolones affect cartilagt' these
drugs al't'not approved for children underage lB. Use in preg-
nancy or in lactating patients should bt' avoided.
Set' Nursing Process Focus; Patients Receiving Antibacte-
rial Therapy on page 496 for the Nursing Process applied to
all antibacterials.
Sulfonamides
Sulfonamides are older drugs that have been prescribed for
a variety of infections over the past 70 years. Although their
use has declined, sulfonamides are still useful in treating
susceptible UTis. The sulfonamides are listed in Table 34.B.
34.14 Pharmacotherapy
with Sulfonamides
-
The discovery of the sulfonamides in the 1930s heralded a
new era in the treatmentof infectious disease. With their wide
spectrum of activity against both gram-positive and gram-
negative bacteria, the sulfonamides significantly reduced
mortality from susceptible microbes and earned their discov-
ert'!' a Nobt'l Prize in Medicine. Sulfonamides are bacteriosta-
tic and active against a broad spec1nun of microorganisms.
Sulfonamides suppress bacterial growth by inhibiting the
synthesis offolic acid, or folate. These drugs are sometimes
merred to as folic acid inhibitors. In human physiology, folic
acid is a B-complex vitamin that is essential during periods
of rapid growth, especially during childhood and preg-
nancy. Bactt'ria also require this substance during periods of
rapid cell division and growth.
Although initially very effective, sE'Veral factors led to a sig-
nificant decline in the use of sulfonamides. Tht'ir widespread
availability for over 60 years resulted in a substantial numbt'r
of resistant strains. The discoVt'ry of the penicillins,
cephalosporins, and macrolides gave physicians larger
choices of safer agents. Approval of the combination :tntibi-
otic sulfamethoxazole--trimethoprim (Bactrim, Septra,
TMP-SMZ) marked a resurgence in the use of sulfonamides
in treating UTis. In communities with high resistance rates,
however, TMP-SMZ is no longen drug of first choice, unless
C&S testing determines it to be thE- most effective drug forthe
specific pathogen. Sulfonamides are also prescribed for the
treatment of Plleumocysris carin;; pnewnonia and 6higella
infections of the small bowel. Sulfasalazine (Azulfidine) is a
LibraryPirate
'hoplfll( Drug' fo< !lxrl'llallnlealOll' 493
..
Prototype Drug I ClprofloxaCIn (e/pro)
Therapeutic (lass: Antibacterial Pharmacologic ( lass: Ruoroquinolone,:bacterial DNA synthesis inhibitor
ACTIONS AND USES ADVERSE EFFECTS
Ciprol\olOl(in, . wa, approl'fd in 1987 .nd Gprofloucin i, toierMN by most patierlll, .nd adYme all'
is mOSI widely drug in this "'ISS. By inhibiting gy- un<omnon. vomiting. and dia rrbN may oc:rur in as many <I , 10%01 p.a--
.. dproflomin DNA II'p.i[ Moll' riflm tiffiu. Ciprofloudn may be administtll'd with food 10 diminish <I m rie GI rI-
' g<linn gram-OOl.rtiW' thIn org.nilm it is pll'sc:ribed for UTI. ,i- patient >hoold howt-W'l, taktthis drug with antacim or mineral
nusitis, pnwmonia, >kin, boot and joint innuions, innctiou, di. rrlIed,' nd ,ill(e drug .b>orption will be Some Ilitien15l1'port
tain e)'!' inffi tions. As of 2007, FDA 1I'(0mmendN thai ciprol\omin no photolllXic:ity, headac:he, i nd diuiness. The FDA hi , is5Ued <I blac:k 1m wi/ning
Iongtr be USfd to 1II'.t gonorrlrea. TIlt drug is rapidly .bIorbed aile.- oral admin- thai rofloucin m.y calM tendon inflammation or ruplUII'.Arty complaints of
ismtion and is distribuled to most body li,rue,. O .. in!llll'OOUS, ophth.lmic. difficulty with w.lking or pain in the fool or leg ,hould br Il' porled immttiatefy.
.nd olic: formulations 'll'i'I.iLlble.An t Xlended form of the drug. Pro-
Contraindi u tions: (iprol\olOl(in is rontraindiulN in Ililients with
quin XII, is administem:l foronly 3 rIa)'S and is appru;ed lor bladder inil'l:tions.
,ilivilyto drugl in the flooroquinolonedass. The drug should be discontiftutd
ADMINISTRATION ALERTS
the p.Uent v:ptritnc:t l p.in or inflammation of a tendon, as II'Ildon ruplUIl'I

AdminiSltr at lean 4 hours brfoll' . muids.nd ferlOUllUlfate .
haYl' bttn Il'plrtN.
INTERACTIONS
DrurOrug: (rocullall m iniltr.tion with willfann may incrNlf iIIl!iroagwn
Ii'lUk in bleNiIg. ThilO:ul may incrNlf lhfop/IyIine k>wk lS--J09ro.
PHARMACOKINETICS
Mudcb, ftmltll .. If.to. ar>d ... ,/IIf. 1f dfo' ........ ob5orption of dprol1.xodn.
Onset:Rapid
l.i b Ti5II: GjRIIooon mIY incrrnf UUfS of ill,.IST, serum milinine. ar>d 8I.Jt.
PNk:I - 2h Herba Hood: GprofkI:iKil can incrN" 'ifMllfvel! of CilffPilf: caflNlf

IhorMI bf' rflui:ted 10 prMII
Duration: 12 h
talhymlia.Dairy procluot15 fI' ooum-Iortififd .... mrpticn of
ciprolloJaCil.
Treatment of OYerdole: Tberr is 00 for
IItI'tf rc M)MJ1l1ng/IJ1 for Q NlJrl/JII) I'rrxm fjKlIHpKlIc rc Ilris drug.
TABLE 34.8 1 Sulfonamides
"n"

Route and Adult Dose (1T\aI( dose where IndIcated)
Opnhalmi:; 1-3 of 100,15%,or m lOknioo into lower
conjunaivil QC fYl'IY 2- 3 h
Adverw Effects
NilUItll, IIIfll.
p/roffMmiririry,
IUlfaduine (MiuoIUfoo) PO; loadilg 00..,:2-4 g
Miin!enanc:e 00..,: 2-4 glday il It .. to dividl'd doltS
ANpbyfaxk Slurn! Iobnwo
wndrom(, blood dVKlilias
IUminin! tAAa!i< rmrosis
(FiIIllidar)
1U1f ... (Azulficinc:1

PO; lliblHWfftIy (,00 mg IliIidOline.2' mg p)'lWntlhamine)
1'0; 1 2 gld.ly in IoIrdividod do ... (Jllilx:8 glday)
Q trifMIhoprim-llfIfafMthoxazole (Saclrim, Sfptra)
PO; 2-4 g follo.oml by 1-1 g qid (mil: 12 glday)
PO; 160 mg TMP,BOO mg!IMZ bid
sulfonamide with anti-inflammalory properties that is pre-
scribed for rheumaloid arthritis and ulcerative colitis.
Sulfonamides are classified by their route of administra-
tion: systemic or topical. Systemic agents, such as sulfisox-
azole (Gantrisin) and TMP-SMZ, are readily absorbed
when given orally and excreted rapidly by the kidneys.
Other sulfonamides, including sulfadiazine (Microsulfon),
are used only for lopical infections. The topical sulfon-
amides are not preferred drugs because many patients are
allergic to substances containing sulfur. One drug in this
class,sulfadoxine-pyrimethamine (Fansidar) has an excep-
tionally long half-life and is occasionally prescribed for
malarial prophylaxis.
In general, the sulfonamides are safe drugs; however,
some adverse effects may be serious. Adverse effects include
the formation of crystals in the urine, hypersensitivity reac-
tio ns, nausea, and vomiting. Allhough not common,poten-
tially fatal blood abnormalities, such as aplastic anemia,
acutt hemolytic anemia, and agranulocytosis can occur.
Nursing Process Focus: Patients Receiving Antibacte-
rial Therapyon page 496 for the Nursing Process applied to
all antibacterials.



,


"


,
,
,


0
"

,
"
,
LibraryPirate
494 UnitS The Immune SY"'-""
.... Prototype Drug I Trlmethoprlm-Sulfamethoxazole (Bactrlm, Septra)
Therapeutic (lass: Antibacterial Pharmacologic (lass: Sulfonamide;folicacid inhibitor
ACTIONS AND USES
Tht fiXl'd-dose combinalion of suifameioourolt (SMl) with tht anliinirai!'
uimethoprim (TMP) is molt Irrqurmly for tht plwrmac:othtrapy of
tract infKtions. k is allO approftd for tht U"Nlment of PntumocyJtil
plltlJmonia,shigdia inftions oItht slllilll boweI,and for acute
of chronic: bronchitis. Oral and IV prt parations afl' a'/ililablt.
Both SMl and TMP art inhibitors of bacterial mmbolism of folic: acid.
Thtir aaion is kill isachif!'d by futd rombi
mion thin would lit achR-vtd with ffllie-r drug ustd Btuuse hu
mans obtain thf pfl'CUrlOrl of folile in thfir diets and can 1M prrformtd fotale,
tlltse seiKtm for boaerid metabolism.Anotlltr advintqof
tilt combination is thai rleYrlopmem of is lower thin is obserYtd
wlltn fflht-r of tilt aqenu is ustd alone.
ADMINISTRATION ALERTS
Administel" oral with a lull glass ofwater.
(
PHARMACOKINETICS
10-60 min
Pt-ak: 1-4 h

Duration:Unknown
34.15 Miscellaneous Antibacterials
Some antiinfectiv .... cannot be srouped into d........", or the
class is too small to warrant st'paratt' discussion. That is not
to diminish their importance in medicine, beamse somt' of
the miscellaneous antiinfectives are critical drugs fo r spe
cific infections. The miscellaneous antibiotics are listed in
Table 34.9.
Qindamycin (Cleocin) is effective against both gram-
positive and gram-negative bacteria and is considered to be
appropriate treatment when less toxic alternatives are not ef-
fective options. Susc:eptible bacte-ria include Fusobacterium
and Clostridium perfringens. Clindamycin is sometimes tht'
drug of choic:e for oral infections caused by bacteroides. It is
contraindicated in patients with a history of hypersensitivity
to clindamycin or lincomycin, regional enteritis, or ulcera
tive colitis. Indications for clindamycin are limited because
some patients de.t'lop antibiotic-associated pseudomem.
branous colitis (AAPMC), the most severe adverse effect of
this drug. Se-rious adverse effects such as diarrhea, rashes, dif-
ficulty breathing, itching, or difficulty swallowing should bt'
reported to the health care provider inunediately.
Metronidazole (Flagyl ) is another older anti infective
that is eifectiveagainst anaerobes that aTe common causes of
ADVERSE EFFECTS
NaulN and yomiting an' most fn'lp'nl adwrSI' efferu ofTMPSMZ therap)'.
HyptrstnlitNity is rrlariYdy (ommorJ and Uiually IIIiInifflu as lIOn rllh, it(hirg.
and few. This mtdiution !hould be used caUliwliy i1 patient! with Pfl'""uilting
si rau)'!tliluria,oliguria,ind nonalfaikrn' h"e bfflJ fl'porttdPt,
riodic: tabor-alo f\'aluation of thf blood is ulllilly peri:Jrmtd to early
of agranulocytOlis or thromboqtopeniol. Dur to the for photosen\itivity,
tht patitnt !hould i YOid din'd IlIllight during thtrap)'.
Contraindi(ations: TMPSMZ isconmindic:.i ttd in palitnu with hypersensitiv
ity to dllJ9S in tilt !Ulfonamidt (taIS. Patitnts with rnegalobbnic:
anemiol due 10 fobtt dtrKiency should not fl'Cem this drug. Prtolnut womI'n
it term ind nursing should not tike this drug bec.iIM sulfonamide!
llUy uou the piacema and art' fan'ttd in milk and may Wile
TrimethQPrim rifcrt'i \eS pomsium eJCfl'Iion i nd is comraindilaltd in Pitients
with hyperlilemia.
INTERACTIONS
I)ug-l)ug: TMPSMl tIltelfem of lfai n imaglUln. ThN rNjI
may incJNse mfIhotfl'U1I' tolidty. By dMNsi'lll tilt hfparic metabolism of
TMP>Mlmay IilIIII' 10xicirJ TMPSMZ flfma
IpifQg fen on rIIf IK'pIwoo and lboukl lit IMd with GlllOOn with IlKh ill
Ipironolao:OOf 10 prI"fflII
Lab lets: lktnown
ootlJlo talmduring ihHap)',ooII5l
dlfC1\'d t., tilt IwaIth tart' proridfr.
l lNtment of Imrdose: Tilt rt'nal elimination of trimrthoprim can be in
by acidification oftht urilll'.1f signl of bone marrow oo:ur
during high..:!ose thtrap)', S to 1S mg oIltuoovorin should br gi!'n
P.M II MyturhIgKI fur MIsIftiJ I'rt5.I fooIl spffiIt 111M <tug.
abscesses, gangrene, diabetic skin ulcers, and deep wound
infections. A relatively new usc is for the treatment of H. py-
lori infections of the stomach associated with peptic ulcer
disease (chapter 4(00). Metronidazole is one of only a few
drugs that have dual activity against both bactt'ria and mul
ticellular parasites; it is a prototype for the anti protozoal
medications in chapter 3SOO.\Vb.en metronidazole is given
orally, adverse effects are generally minor, tht' most com
mon being nausea, dry mouth, and headache. High doses
can produce nt'urotoxicity.
Quinupristinldalfopristin (Synercid) is a oombination
drug that is the first in a newer class of antibiotics called
streptogramins. This drug is primarily indicated for treat
mt'nt of vancomycinresistant Enterococcus faecium infec
tions.1t is contraindicated in patients with hypersensitivity
to the drug and should be used cautiously in patients with
renal or hepatic dysfunction. Hepatotoxicity is the most se
rious adverse effect of this drug. The patient should be ad
vised to report significant adverse effects immediately,
including irritation, pain, or burning at the IV infusion sitt',
joint and muscle pain, rash, diarrhea, or vomiting.
Linezolid (Zyvox) issignificant as the first drug in a newer
class of antibiotics called the oxazolidinones. This drug is as
LibraryPirate
TABLE 14 91 Selected Miscellaneous Antibacterials
Drug Route and Adult Dose (max dose where Indicated) Effects
IVI\M;O.5-2.0 9 biO-"d (mu:: 8 glday) Neulta, 1OOiting, dlorrllH,rtnh, fMr.iIsomti4 (fUJb

dWoimpbmkol POllY; 50 Jt9I\g c;d NoulIa, IOfIIring. lQrrlIH
6oum:lillis IliOQ11lQt1il tIsIllI: IJIaI:l:W
drprrnIon oJpL!k a!lf!!!ii
clndamydn (Oeodn) PO;lSHSOmgqid Ne/llftl, 1OOiting, lQrrlIH,rtHh
Anan/rtIiiNI IlIprrilfraioM r;urfw;mg

iUplorTI)'tin (Cubitin) 1Y;.mgi'l;goncumy 24 h for7-14dlys iWlulta, riarrfn, (0R51ipotion. ht.vdhf
6"anbwlilli< IIIm
fra
ipm rrrrona!by
t2im
tlUpI'netn (mw) IVr1M; 1 gfdaV NeulIa,riarrfn,lIlIIdhl
DItIIdommll!!i!ll1!l

fosfomydn IMonwol) PO; 1-11 SKhft in 3-4 Ol of water II a sir9f dcM NeUlIf, flarrhet!, IIt poh IIttIdtxhl

Imlptlltm-<itastJtin IPrinwinJ IV; mg tid-qid [max:. gfday) NdulIf, 1OfMing. dlorrllH,pdn III inJtctkmitt, hIdacht
ao,utlrtlillis IliJ::udllmmlb[iIllllIiUtlilb
lincornydn (lincocin) PO;SOOmgticl-"(max.:8 gilby) Nc!/IltO, 1OOiting. dlorrllH
Anal!!rflaldi iYl!ttillS!io!!1, arm!
pSftJdomemblanous roIiti1, blood dywlSias
lioooid (lyyox) PO; 600 mg bid (moD:: 1,200 mglday) NeulIf,flarrfn,lIlIIdhl
!UmffctiOrK Il'..tI.Idommlbr.!1lOllS (oIi!:i1.
blood dyscmias
mtrOptIItI"ft (Mmml/V) 1V;1-2gtid NoUlIf, 1Ornirfng. l<!rrlIH,pdn hIdacht
DStOdornmlb!J!l!I:!!i ",,Ii!.
l<ilwl:!
-
IMIllmamlnt (M.vidtLlmint,
PO; I 9 bid (Hipral or "d ("""nd$mint) NeUlI/t _ring. dlorrllH,/flCfftlJMurFIay IJIgtIIC'J
Hiprtl,UI6)
Anal!!rflald!.mm1uria
IMlronicLuolt PO; 7.S mglkg tm)' 6 h (max:4 g/iU,) Dillmru,htrJdocht, ollOfexiQ, aMJnirrd pdn, trlftali:
IV Ioaifng 15 mgi'l;g
1M aid 1II1II5fIl. infraiom
IV maintCMOO: dtJt; 7 S mg/kg fmJ 6 h (1IIil: 4 gfd.J)')

nitroliranloin (ftJJdintin, PO;50-100mg qid (max: 7 mgA!JIday) NoUlIO, IOfIIdng, ilDrtlliflf
MaoocIantin)
Ilr:nalil: IlI:mIlil
pnPIIOO!!i!b. Slrunrlohmon 1)'lIIkOOlt
-;;;;;il-dalfopristin {Smerddl IV: 7 S mg/tg infustd O'm min "try 8 h Pain and inl/lmmtJOOn ot iIjeaionshr. myo/lfo,
arrhrlllgil, ditmJJ
coIttb
ltIitlram)'dn PO; SOO mg/da'J NdUlIf, 1OIMing. dlorrllH
flS!il!liZ!l!l!ilKfi hMat .... ""kiI atl!r!:!!:mYi
nncornyrn IV; 500 mgc;dar I gbid NeUIfII,IOOiti"9
PO; 125--500mgrvtfJ6h
ManhyijN, IIlQHi!ftaigm IlI:pIrp!griri,., g!!plgrjriTt
ltd-INn
IrQ/ia Inci<ate common dl"tcts;.IIll!kdni!.a Inckatts stIIouSiclwtnttflu.
LibraryPirate
496 UnitS lhelmmulleSyslem
NURSING PROCESS FOCUS PATIENTS R,eElVING ANTIDAa'RIAl TH'RAPY
Assessment
Bntliu assessmnt prior to administration:
Understand the rwon the drug his bffiJ in order to for
It...r. po:uli< dl ... l>.
Obllin I (Omplele heakh hinD!)' indudi ng lII'urofogic,
hepatK or Iml ,lIIeI the PQ15ibility of ple9nancy.Oblain , elrug hilw!),
illduding , Ilergies, illdudi ng 5pf(ifK ructions to QJlft"llt p=riplioo ,nd
OlC druql, httbal pll'p'r"ions,and akohollM. alert to PQslibledrug
imf r.ldionl.
liglll ind symptoml of inieuioll oolingiocation,(haraamtia,
or 1I1Ienc:e of d rai naljt Ind (ha roKler of drainlljt, durl tioo, i nd
preelKe or ab\m:e of ftl'eror pain.
Enwte appropriate labm to!), findingl if.g.,CBC, C&S, hep'tic: Ind renal
function nudid
Assfss_nt throughout administration:
for rleilfd therapt utic: efftcll (f.g., htd Siglll a nd symptOllll of
inftction alldfel'l'l).
CominUl' ptriodic IOOllitOting of(BC, hepati( Ind fUnction, C&S,
pt, kand trough drug
for adYerSI' nalMa, vomiting. abOOmin,1 (ramping. diarrhei,
dizzi nes and poolOlellliti"lity. wrt dia rrbe.J, elpt(ially rontaining
mu<u<, blood,or pIII;y<'llowing of ",Itt. or doo;.OO dK,.,><ed uri .... output or
darkentd urine should be Il'porttd immediately.
Potential Nursing Diagnoses
Inftction
P,io Ilfl;itM to infffiionJ
Hyperthermia
MOen! Knowltdgt (drug theraP'()
Rill! for Inju!)' (Il'littd 10 Id"lflSl' drug tffws)
Rilk for Dl'lio:iellt FluidVoume (IfIattd to ieYer,dii nhea (lU\fd by
drug tffem)
Rilk for Nonrompliall(f (Il'Iattd to drug effects, ritlio:ieot
knowledge, or (Olt of medic:ation)
Planning: Patient Goals and Expected Outcomes
The palient will:
ExptritlKf lherapeutic (e.C).,diminilhtd Siglll and Iymptoml ofinfectioo,dem.1td ft'ler).
Se /rte from, or minimal,arlYer\e efltus.
VerbaliRo all uodelstandiog of lhe drug's UIf, adYerse tffeds, . nd Il'quill'd ptff.lutions.
Dl'roon Illite proper !elf-administration of the medicilion (t .g., dOSl', liming. when to notify provider).
Implementation
Interventions and (Rationales)
Ensuring thtraptutk tfftctl:
CominUl' .lSflSments J I de(ribtd t arlier for thtrapeutic tfft(1\. (Diminished
fl'l'l'l, p'in,orliglll and Iymptomlof infection lhould begin alter taking the filii
Ou.nd (ominUl' to health (Ill' proYider should be 1I0tifitd
and Siglll of inffition rt'lllain after 1 days or !"Iltire (OUrSI' ofthe drug has bffiJ
taken .nd Siglll of infedion are Itill pIl'Sf01.)
Minimizing Jdft llt effKts:
CominUl'to roonitor vital siglll.lmmediatel)o Il'pOn changes
illiewi of (OlI\(iouIlII'SS (lOC), or kbrile Il'izUll's to the health w e provider.
(mmhoold begio to diminish within 1 10 3 days after starting the drug. II
(olltirutd kvtr may be a sign of wclI\flling infedion, Idvellt drug tfftm,or
.mibiotk Il'Sistanct.)
CominUl'to roonitor ptriodic lab work: hepatic: and Il'nal function lests,(B(,
urinalylis, C& S. and pNk J nd trough (Many. nlibacterills 'Il' htpilic
Ind/or rt naltoQ(. Ptriodil: C&S tesll may beordertd if ink(tiolll ,re Sf'II'Il' or
all' slow to 10 (ollfirm appropriate therapy. Drug IM-k will be monitolfd
with drugs with known adYerse tfftm.)
Patient and Family Education
Tei ch me pl tiem to Il'pon a ft'ler that riots oot diminilh below
100'1' within 1 days; ilKll'asing liglll Ind Iymplomlof infection; or
symptoms thai remain pIl'S!"Ilt after taking the tnlirt(oulSl'of the
drug.
TeICh me plliem to 1101 SlOp aotib,J{tffial when "fffiing bentr" bUI
to take thet ntill'(oulltof Intibacteriatdo 1I0t!ha1l' doSI'I with
other family members with limilir sympIOI1ll;.nd rttum to the
healch (all' prwider if symptoml not ll'IoIvOO alter I"nlill'
r""N' of I ...... py.
Tea(h me p.tiem to immedialely Il'pon I ft'ler that riots 001
diminilh below 100'1'; febrile Sl' izull's; . nd (hangel in behavior or
UX to the he.1th (Ill' provider.
IlIItnJct the p'tient 011 the nffif for ptriodic: lib work.
LibraryPirate
C""pltr l4 Drug' fo< 8K' .... I.II"fe(Uon' 497
NURSING PROCESS FOCUS PATIENTS RECEIVING ANTIBACTERIAL THERAPY (conrlnuPd)
Impl ementation
Interventi ons and (Rati onales) Pati ent and Family Education
Monitorfor h)'pl'l' lI' n,itivity <l nd allergic ruuion',tspKialiy with lilt firs! th!o patitnt to immtdialeiy It'pOn any
of any to monilor for up to 2 Wffn.fter (ompleting pa nKularfy of face, tongut. or lips; unKari.J; llulhing;
antibmerial therapy. (Anaph)olactic l'I'actions <11'1' panicularfy with tilt sylKopt; wi-ftzing; th roat tightnes; or diffiruky brl'lthing.
fint doll' of an antib.Ktt rial.PMI-lIlt, rtYdu.J1 drug Ievek, dl!ptndtnt on It ngth

Instruct the patitnt with known <I a to wry a
of half may dl!wytd
walle! idtmitKation card or WNr idtntification itwt'lry
indicating allerg,.
ContinII!' to monitor for IItparic, andlor ototoxicity.lAmibam ria k that al'l' Teach th!o patitnt to immtdiateiy It'pon any naust<l;wmiting;
htpatic, rroal,orototoxic It'quil'l' flt'querlt monitoring to pl'l"lt'nt effects. of skin or sciera; <I bdominal pain; I ight or w)'"(oIortd
Auid will plt"/em drug ,(QJmulation in stools; diminilhtd or darVning ofuril'l!'; ringing,
humming, or buuing in e<l n; ,nd d iuines or I'I'rtigo.

Advise the to ilKl'I' all' fluid intlu to 2 to II per day.
Continuo to monitor for dollllillologic clkru induding 0' P'Jrplish skin , ... h,

tllo potiont to woo, .u",,,, ,,,.nd prottiYtdothing for !lin
blineB, i nd sunburning.lmmrdiateiy It'pOn Itftlt' r.JIsIIes,tspKialiy mociattd v:posure ,nd to tinning heds.lmmediateiy I'I' port 'OY !!'"Ieit'
with blinering. (Tetr<lt),:line, IUif0na midts, <I nd may caust sunburn or rashts.
,igniflC.l nt dermatoiogic efftcts including Stt'lens- Joilnson ,yncllOlIII'.
Suf'l\{reens and (Iothing should he used for <l ntib.Kteria.k that cause
photosensitiYity.)

Monitorfor diarmu may indicate the pI'I'SI'lKeof

Instruct the patient to It'pOn any diarmu that inCft'i!!'S in
antibioticmociattd psrudomembral'"llM mlitis,or AAPM(, a superinfection flf<lUl'lK)', amount.or (ont.i", mucus, blood,or pm.
caused by (fostridiumdifficiJt .)

Instruct the patient to {onluk the health care PlO'Iider hefolt' tlking
amidiarrheal drugs, which <ould caUIl' I'I'ttmion of hannrul bacttria.

Teach tilt patient to inclt'i ll' the intake ofd<iiry prockJm with
such as buttmnilk,to help I'I'Stort' <l nd
maintain ool'Tllill

Monitor for deYeIopment of !llperinfections, e.g., AAPMC, or rungal or yeall

Teach tilt patitnt to oiulft brch.ngel in stool whill' in
inre.:tions. (Su ptrinre.:tions with opportunistic organisms may occur when mouth, whitish thickvagin<l l discharge, itching in urogenitalalt'a,
normil host IIora alt'diminishrd or killed by the antibuterial.) blistering itchy rish"nd to report !e"!'ere diarrhe<l "
dtscribtd earlier.

Teach tilt patient infection (OMIOI muSUI'I'S such "ilt'qll!'nt hand
washing, allowing for adequate drying .fIl'r bathing, and to in(lt'.t!!'
live-<ukure-rich dairy foods.
Monitorfor signitKant GI fffeas .. inciuding naust., wmiting. ,nd abdominal pain

Teach tilt patient to take drug with food or milk but to awid acidic
the drug with food or milk to 61 efftcts. foods and or ca rbonatt d drinn.
(M.arr, .rrlibiulu ''''d>_i.n..t wilh .iyrrir ... rrl GI dr .... b.Fuud III milk rr .. ,

Teach th!o patitnt to oiulft brcominuing signs of improYl'lnent in
impair of 10l1li' antibiotics such as but if paliem
infmion.
complialKe with drug rtgimen can he ensurm with lesll'ntd 61 with
a snack and continII!' to monitor for thtrapeutic riferu.)
Monitorlor signs <l nd symptom! of neurotC\llicity, t.g.,diuiness,drowsines,

Instruct the patient to It'pOrt in(lt'asing
!l'Vtlt' hud<i{he,manges in LOC.and seizult'!.(Penicillins, (ephalosporins, in hehavior or LOC,or seizult'!.
sulfonamidts, arninogl)\:osidts, <I nd fluoroqJiooiones hal\' an increastd risk of

Caution the patient that drowsinell may OCQJr and to he cautious
neurotC\llicity. Plt'vious seizult' dilOroer,or head injurit! may this riskJ
with driving orother <l ctiYitits It'quiring mentilalertnelS umil the
effml of the drug alt' known.

Monitor for signs <I nd symptom! of blood dysuuias, e .g.,low-gradt

Teach tilt patient to I'I'pOIt ,ny Iow-<lrade sort' throal,rashes,
bleeding. bruising. ,nd significant fatigue. (Penicillin dminoglymiidts, a nd bruising or ilKl'I"std bleeding, i nd unusllill fatigue or shortnell of
lIuoroquinolone! may blood dYStrasia! with reulting de.:1'I'a\tS in RBU, alter taking an <l Mibiotic for <I prolonged period.
monitoring ofCBC may he required.)
(Continued)
LibraryPirate
498 UnitS Immune SY"'-""
NURSING PROCESS FOCUS PATIENTS RECEIVING ANTIBACTERIAL THERAPY (Conllnlild)
Implementation
Interventi ons and (Rati onales)
Monitor for dnelopmfm of red-man Iyndromf in pilDenn
Mom),:in. Repon any Ycjnifiumly IallJf 'R'a of reddening wc:h i1llrunk, lItad
or IIKk, limm, or gknNI arfa tlpffially ij with blood
prfSSUR'Or t.l(h)Urdiil. (Val\{omyon tr,oJll'llfnsitiviij IM1 aJSr the rf lraltof
IallJf ,moonn of histaminr.lf , Ycjnifiunl .UN iI irwolvtd, modilation from
hilumine may calM hypoltnwn and R'fltxtathymdiil.Giving IV drip mOlt'
mwly rna)' prtYem ordeuull' tilt tilt syncirollltJ
E(G ifindured in p.!tierru on peniciliins.(SoIllt
preparations of penicillin lIIiIy lit based in SGdium or potassium salts and rna)'
calM and hyptrkaiemia.)
Monitor patients on fUoroquinolones for leg or IIttl pain,ordiffKUtty walking.
(Fluoroquinolones hiYl' IItm moc:iated with tendinitiland tendon ruptuR',
tspecially of \ht, Achillts tendonJ
Aslffi lor tile possibility of pmjnancy or in pilliems PR'l(ribtd
Itlracydint ami biotin. (Teuatydines affta fml bont growth a nd teeth
dt-itlopmtnl,(aUling ptrmantnl yellowish-brown staining of teethJ
Women of child-buring igt taking ptnicillin .Jntibiotics should lUan
,ktlllil1iYl' form of birth coonollO prt'lem pmjoancy.1 Penic:illins may reduu
lilt ell"fdiYl'fles of oral cooUJceptive!..)
Patimt understanding of drug thrrapy:
USt opportunities during adminiluation of IIII'dic:.i1ionsand during i SmSmtnU
10 discuS! tilt ratiolliie for drug therapy, desired Iheraprutic outeo mrs, most
commoo rifll, paramtters for when 10 c,lIlhe (1ft'
arod IN'Cl'lwry monitoring or pR'(.Iutions.(Using time during nursing tall'
IItlps to optimizt and reinfon:r uy teaching
Patimt selfadministration of drug therapy;
When administering mediutions,instruct lilt family, or caR'9iYl'l in
properstH-adm inimation IoIIowtd I:, return demonstration. (proptr
Jdminisuation in(1N1fS lilt of Iht drug.)
Patient and Famil y Educati on
Inl1loo the p.!tienl to immediately R'pon unusual flushing.
I'IpKiillly inwlving i large body arN;dizziness;dyspnu; or

Ttach the patiem to promptly R'port all)' palpitations or
Instroo thf p.!tienl to imllll'diately R'port any signifium or
inmo.tsing I-ftl, leg or calf pain,ordiffirukywalking to tile
proidtr.
AdYiII'women who aR' or atttmpting 10
bt<01lll' pR'gllinlto adYiIe llitir heakh caR' plll\lider btioR'
any tttratyclint anribiotK.
Ttach wollltn ofchild-btaring igt on oral contrac:epti!'S to consuk
tlltir lItalth taR' providtr about binh romrol akematiYl'S ij penic:illin
antibiotiu aR' used.
The famii)\ or shook! lit abitto stare the R'i50n for
lilt drug;appropriatt clost ind sclitduling;wlw adYI'rsr to
obll'n'l' for and wlltn to R'port; ,nd the amic:ip.!ted lenglh of
mttlic,tion therapy.
Ttach the patiem to tau the IIII'dic:.Jtion as follows:
(omplete the emiR' coorll' oftlltrapy unless otherwise inltructtd
Avoid ortliminate akohol. XJlIII'anlibiotiu (r.g.,crphalolporins)
Will' sig nific:anl R'adio os whtn taken with akohol and J kohol
iMR'aSI'IadYl'I"II' GI rffm of \ht, antibJcterial.
Tau tht drug with food or milk but awid acidic: IItYl'l"ages.lf
instllKled to tau Iht drug on an tnlp!y stomach, uu with a full
glmofw<ller.
Takt tht medication as !pated throughout each day as
feasible.
00 not tau letracydilN' with milk products, iron-<omaining
pR'pararions IlJ(h as mukivitimios,or with antrddl.
IMll'all' O'Itrall fluid im<luwhiit taking lilt anlibacterial drug.
Di<urd ootdartd medi<ations no Iongo. in us . R .......
medic:int cabinet twic:f i )'Nrfor old
Evaluation of Outcome Criteri a
Evaluate lilt of drug therapy by (onfirming patient goals and txptatd OUIrome\ hoM been mt! (see "Planning').
LibraryPirate
effective as vancomycin MRSA infeclions. Linezo]id
isadministtred intravenouslyororal]y.MoM patients can be
conVtrled from IV to oral routes in aboUi 5 days. Linezolid
is contr:r.iOOio.ted in palients with hypt'f"Sel1SitivilY to the
drug and in pregnancy, and shoukll:>e used with caution in
palients who have hypertension. Cautious use is also neces-
sar y in patients taking serotonin reuptake inhibitors, be-
cause the drugs can interact, causing a hypertensive crisis.
Linezolid can cause thrombocytopenia. The patient should
be advised to report ser ious adverse effects such as
diarrhea, headachc, nausea, vomiting, rash, diuiness, or
fever to the health care provider immediately.
Vancomycin (Vancocin) is an antibiotic usuaJly reserved
for severe infections from gram-positiw organisms such as
S. allF"ru$ aOO S"epTcw pmwrrwniae. It is often used af-
tet"bacteria haV(' become resistant to othet",safer antibiolics.
Vancomycin is the most effectiV(' drug for treating MRSA
infections. Because of the drug's ototoxicity, hearing must
be evaluated frequently throughout the course of therapy.
Vancomycin o.n also cause nephroto.ucity, leading to ure-
mia. Peak and trough levels are drawn after doses have
been administered. A reaction that can occur with rapid IV
administration is known as red-man and results as
large amounts of hi stamine are released in the body. Symp-
toms indude hypotension with flwhing and a red Tash most
often of the face, neck, trunk, or upper body. Other signifi-
cant side effects include superinfections, generalized tin-
gling after IV administration, chills, fever, skin rash, hives,
hearing loss, and nausea.
Daptomycin (Cubkin) is the fint in a newer class of an-
tibiotics called the C)"clic Lipopeptides.. ]t is approved for the
treatment of serious skin and skin-structure in(<<tions such
as major abscesses, postsurgical skin-wound infections. and
infected ukers caused by S. IlIiTeIlS, pY0gc7lts,
StreplOaXClI$ ago/actille, and E. laeealis. The most frequent
adverse effects are GI distress, injection site reactions, fever,
headache, dizziness, insomnia, and rash.
]mipenem-cilastatin (Primaxin), Htapenem (Invanz),
and meropenem (Merrem IV) belong to a newer class of an-
libiotics called carbapermru. These drugs baCleriocidai
anti h:rw: (If 'hI': hm...-les' 3nl;micmh;31 (If
any class of antibiotics. Of the carbapenems,
imipenem has the broadest antimicrobial spectrum and is
the mO:'lt widely prescribed drug in this small dass.
Imipenem is always administered in a fued_dose combina-
tion with cilastatin, which increases the serum levels of the
antibiotic. Meropenem is approved only for peritonitis and
bacterial meningitiS. Ertapenem has a narrower spectrum
but longer half-life than the other carbapenems. It is ap-
proved for the treatment of st'riollS abdominopelvic and
skin infections, commWlity-acquired pneumonia, and
complicated UTI. All the carbapenems exhibit a low inci-
dence of effects. Diarrhea, nausea, rashes, and
thrombophlebitis at injection sites frequent ad-
verse effects.
In 2((, the FDA awTO\oo telithrom)Un (Ketek), the first in
a class of antibiotics knownas the hroIides, for respiratory in-
fections. Its indio.tiorli include acute bacterial e:urbation of
duunic bronchitis, acute bacterial sinusitis, and commWlity_
acquired pneumonia due toS. pnellt,",niae. TeLithromycin is an
oral drug. and its oommon adverse effects are diarrhea,
nausea, and headache. Bec:ause of the drug's recent applQV:ll,
resistance is not yet a dinic.U problem.
TUBERCULOSIS
Tuberculosis (TS) is a highly contagious infection caused by
the organism MycoboCfcri,,,,, wbcrclliosis. The incidence is
staggering: More than 1.8 billion people, or 32% of the
world population, ue believed to be infected. It is treated
with multiph.' anti_infectives for a prolonged period. The
antitubercuJar agents are li sted in Table 34.10.
34. 16 Pharmacotherapy
of Tuberculosis
Although M. tuberrniosis typically invades the lung, it may
tr"vd tu uti",. lJuUy I!arti<.ulady 00'''', via tI", lIluuU
or lymphat ic system. M. tuberculosis aCliv.ates the body's im-
mune defenses, which attempt to isolate the pathogens by cre-
ating a wall around them. The slow-growing
usually become dormant, existing inside cavities called
tubrrdn. Theymay remain dormant during an entire lifetime,
or beconK' reactivated if the patient's inunul1t' resporu;e be_
comes suppressed. Because of the immune suppression ch:lT_
aCleristic of AIDS, the incidence ofTB greatly increased from
t985to 1992;as many as 2O%0fall AIDS patienlSdevelopac_
tive tubt'rculosis infections. The overall incidence ofTS, how-
evl'l",hasbeendecLining in the Vnited States since t992, due to
the improved pharmacotherapyofHIV-AlDS.
Drug therapy ofTB differs from that of most other inf_
tions. MJ'Wbacteria have a cell wall that is resistant to pene_
tration by anti_infectiV(' drugs. For medications to reach the
microorganisms isolated in the tubercles, therapy must con-
tinue for 6 to 12 months. Although the patient may not be
infectiow this t'ntire time and may have no symptoms, it is
critical that therapy continue for the entire period. Some
patients develop multidrug- resistant infections aOO require
therapy for as long as 24 months.
A secoOO distinguishing fea ture of pharmacotherapy for
tuberculosis is that at least two. and sonletimes fouror more,
antibiotics are administered concur rently. During the 6_ 10
24-month treatment period, different combinations of
drugs may be used.. Multiple drug therapy is necessary be-
cause tht' mycobacteria grow slowly, and resistance is com-
mon. Using multiple drugs in different combinations during
the long treatment period lowers the potential for resistance
and increases therapeuti c success. Although many different
drug combinations are used, a typical regimen for patients
with no complicating factors includes the following:
_IniTial pharr. 2 months of daily therapy with isoniazid,
rifampin (Rifadin, Rimactane), pyrazinamide ( PZA),
and ethambutol ( Myambutol ). lf laboratory test results
sbow that the strain is sensitive to the rlrSt drugs,
ethambutol is dropped from Ihe
LibraryPirate
SOO ThelmmurwSysum
TABLE3410 Antituberculosis Drugs
Drug Route and Adult Dose dose wnere Indicated) Adverse Effects
FIRST-lINE AGENTS
tlhambutol (Myambutol) PO; lH5 m9fday (nw: 1,600 mg for dolily lhtrolPY) KJmiring, heodoI:/It, rillirlru
Wis
Q Isoniazid (tlH,Hydmid) lit,nlTB NIlUiM, Klmiting, diIIrrIIH, rpigmf//r poi"
PO;300 mgld.y or 900 IIHJ IWKf 'IIftkIy for 6-9 mortm
Rmllbtlill !lllliI:
.I.ctln TB
tml9!plidtv blood dyKruja!
S mgltglday 300 mg/dar. W glltn tr1 DOT.
15 mgitgor900mgtwKf wmly
p)'minamidt (PIA) PO; 15 mCJik9tid-qid (max:l glday) iOOl't1li!m !trUmllriuxje( fIIlh

hcmokdcanrml.
rifalrulin (M1lobutin) PO;300 mg 000 daily or5 mgftglday (Toc Klmiring, t/igG!rrif: Qoorrxio
actilt TB) (max:1OO mglday)
/lawler/ft. dilJrriw, (fQmping, Ofllllgf' dilioltxorilfl
rifampin (Rlladin. pony; 600 mglday iI a 900 mglWKf 'll'eekiy for
unlit !wel!tQlldrt1!1l
4monlhs
ttll.ll filbltt
h!r.od .twU!
(Priftinj PO;600 mg a Wfft. for 1 rno;11Iffi OIKU Wfft. foc mo
com(jnation of PO;' (f Wfig(j!l\l1211b ocfllOffl i'ldMduaI drugs)
with Isoniazid and rifampin
SECONDLINE AGENTS
.miUcin(.I.mikilJ IV/lM;5-7.s rngIl:g.sa Io;Idi'lg doIt;then 7.> mgrtg bid
.mlncr.alk)'lk add (lWrj PO; 150 mgr1lgld".ln 14 equalydivlded doses Glll'lloItJD!'Ifl, QrIOrblQ, dhrhfD, fMr
Hyw}r!l!ilivity i'lhibition ohitamin 8.1i fblOlIl!"on

caprtOIl1)'cin 1M; Iglda1 (nol to 20 mgr\gld.yl for 6O-120da)'S, then I 9 sir,
IWOIOthl'tttmest...1c

dprofloudn (Gprol pony; 150- 750 mg bid
PO; 2SO mg 12 h roc 2 wk:owl!'(lUW 10 500 mgf'/fIY {)rowrinru,
12h(maxlg1d1)'l
pm;1:I!Im OOlil:lllll
(Trt(oJlorsq PO;05-1.0gld.lydivilltd E'Iff'! S-11 h (max: II)1.m in KJmiring, ,/igmrir diorrlrto
!hrH to fourdivided doItll
(Qm:ldliaOI
bnolm)Kin (Kintrl'lj IM;5- 75mgr1lgbid-tid (SHlabldU)
oIIoMdn (FIoxil) PO; 2IJO.4OO IIHJ bid (SH 34.n
1I1!p1(1111)'cin 1M; 15 mgIkg!4l to 1 gldayas. Y!I\Iltoow lil!ImO, sire,drow!irlru

Anlphylub QlQ!qrjrj'Y nmfgurv! CN5lkgrmjoo io
i11Ii1D!1 !l:ili:iWI[Xdl:ll[Qli2D f rlrfulivo> da:mutw
rwy/lrot@ehy
11m oomroon tffoos;.I!l!!mi!i!l!I. indicolte SKiouI idwrse ftlem.
LibraryPirate
'hoplfll( Drug' fo< !lxrl'llall"lealOll' SOl
.... Prototype Drug I Isoniazid (INH)
Therapeutic (l ass: Antituberrulosis drug Pharmacologic (lass: MY'olic inhibitor
ACTtONS AND USES
Isoniuid is I drug ofchoicr forilit irl'aDnl'mof M/UlHrruJosil
of hiI!' ,hown it 10 I wpeOOr 111ft!)' profileand to bt rht most
fifrnivl', 'ingle drug for ttll' infKtion. Tilt drug am by inhibiting lilt ,ymlitsis
of myo:olic:.cicls, whim all ffifmial mmponenuol mytObaal'rial {I'll wall,.1i is
bmerioc:idal for .ctiftly organisms bul baClfriostalic: for dOllna nl my-
cob.Kttria. II is ,!'leuivl' for M. l!ibtrrulmis.l,oniillid may bt used .Ione for
chemoprophyluis, or in combilloltion with otnt r amitubtltulosis drugs for
oKtil'l'di'!'''f.
ADMINISTRATION ALERTS
Gi!' on an I'mpry ,lolNch, 1 hour Ilrer or 2 hours btioll' muts.
For 1M adminimalion,ldmini"erdeep IM,and rolale lirts.
Pll'9n,lIIcy mtgory (
PHARMACOKINETICS
Onset:lOmin
PNk: l - 1h
Halllifr:l-4h
6 8 h
]
ADVERSE EFFECTS
mort common Idvrl!!' dfrm of isoniazid art' numbneu ofl11t hands .nd
11'fI. fiSh, Ind An FDA bIoKk boJi warning for isoniuid states
andlOlnelilDf"! latal hepatitis hill btl'n rt'pOotd with this drug. AlthoUiJ! rut ,
hl'palctoxic:ity uSIYII)' OC{Ur! in Ihl' fir!t 1 to 1 monlhs 01 thmpy bu may
presl'm alaO)' tirnedurilg trWrnenl Thr nul!!' shoukJ bt alto br
dn, !.ri:)lIt, I'Imttd hepatic I' I!l)'DIf!, Of loss of Hrpati: et"Il)'IIIe test;
a", UlUIIy ptrbnned monlhly dJring Ihtrap)' to idrmify uri)' htpalolouar,.
Contr.indimions: Isoniazid is conmindic:,utd in patient; with hypernnsitiv-
il)' 10 tK drug and in pllient; with Sf'I!'re IItpatic: impainnl'nt.
INTERAalONS
Drug-Orug: AhrnirmKonDining an1iCid! IDilui:l not be idmiimrN
(oncUllllltly becaw 11111 CMl dPoNlol' tht absorptioo of isonialid. Whfn dlUftwn
is lilten w!th I HH, Qd; 0( <oordination or pI)'Chotic!NClionl III.!)' lI"'iult Drinijng
akoholllillllN H ilKlNloel tht rill: ofllfpalotOIicty.isonialid rna, ilKlNlf \elUI"I
IHeh Il p/lenytoil MId (.JrbMniIlrpint.
lib TI'5!S:isoniillid III.!)' OONlf vaIutIll.IST MId ALl
Herba liFood: Food inlerffrt'l tht Iblorption 01 iIooiiIlid. Foods (OIIliining
I)'r.!mft III.!)' inelNlt iIoriazid 10lict!J
Treatment of OVl' rdOst: Isoniazid O'/!'rdose II\a)' bt fatal. TfNlmenl is
S)'mptomalic. Pyridoxine (vi(.Jmin BJ may bt infrMd in a doll' fqwl to thu of
the i IOniazid OY!'!dose to prt'fem seizull'5 nd 10 cOllea metabolic: a<idOl is. Thr
dost rnay bt IfVI'ral timl' l until thl' paliem lI'9'Iins (on!iousntss.
I Hfrtfli1M)M!rlmgfJIIDrQNUrlI"lI'nm3/OOl1lpKlKli1lmllrlJ9. )

Continuation phase: 4 months of therapy with isoniazid
and rifampin, twoto thret' times per wet'k.
There are two broad calegories of antitubercular agents.
One category consists of primary, first -line drugs, which are
generally the most effective and best tolerated by patients.
Secondary(second-line) drugs, more toxic and less effective
than the first-line agents, are used when resistance develops.
Infections due to multidrug-resistant M. tuberculosis can be
rapidlyfataland can cause serious public health problems in
some communities.
A third feature of antitubercular therapy is thai drugs are
extensively used for preventing the disease in addition to
treating it. Chemoprophylaxis is initiated for close contacts
of recently infected tuberculosis patients or for those who
susceptible to infections they immunosup_
pressed. Therapy usually begins immediately after a patient
receives a positive tuberculin test. Patients with immuno-
suppression, such as those with AIDS or those receiving im-
munosuppressant drugs, may receive chemoprophyla:us
with drugs. A short-term therapy of 2
months, consisting of a combination lreatment with isoni-
azid (INH) and pyrazinamide (PZA), is approved for tuber-
culosis prophylaxis in HlV-positive patients.
Two other types of Il1)II:Obacteria infect humans.
Mycoooch!:rium leprae is responsible for leprosy, a disease
rarely seen in the United States. M. leprae is treated with
multiple drugs, usually beginning wilh dapsone (DDS).
Mycobacterium avium complex (MAC) causes an infection
of the lungs, most conunonly observed in AIDS patients.
The most effective drugs against MAC are the macrolides
azithromycin (Zithromax) and darithromycin (Biaxin).
Nursing Process Focus: Patients ReceivingAntituber-
culosis Drugs on page 502 for specific teaching points.
COMPLEMENTARY AND A LTERNATIVE T HERAPIES
Antibacterial Properties of Goldenseal
Goldmeal (Hydrtnlis mnodmsil) war oner .. rommon pl.tnt found in woods
in Ill' t astern and micJw!.rtern Unitl'd SliItes.Aml'liun Indiafl! UItd !he rool
for i varitryof rnedic:inal applic:alionr. inekldifl\l wound lItalino.diuresis.lnd
WNI'S forinfLIrned tyI'S.ln It nt )'I'al"l, lilt planl liar bten hilrmttdlo IINr
atinction.ln particular, goidtnsl'al wu Il'pootd to mask till' appeilfin<f of
drugs in tnt urineof pati!'nt; waming to hide drug abUll'.This (laim hils sineI'
bl'l'n prol'l'd lallf.
Tir root; ind ltiVI'S of goidtnreal art' dritd Ind ...... ilible u apsuil'S,
tablets, lIIiI'I's, and tinc:tull'5. Onl' of tht primary mivl' ingmlients ;, gold-
is h)drastine, whic:h is rt'pOIttd 10 hm antibacterial and amilUngal
propmil'S. Wht n ulI'd topic:111y or gokltnsl'il is diirned to bt of 'HUe
in bam rial and IUngal skin infections and oral conditions such is gin-
givitis Ind thrush.AI anf)'I'W.sh,itcan roothl' inflirned ...
for fIOIt PfOpie. it is mnrraindic:lltd in plfgn.!1K)' and hypertension.

i

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"



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502 UnitS Immune Sy"'-""
NURSING PROCESS FOCUS PATIENTS R'CEIVINGANTITU.'RCUlOSIS DRUGS
Assessment
Bilstline assess ment prior to administration:
Understand rNlOn tht drug hil been prfnriilfd in order to asSf'lS for
therapMil ffierts.
Obtain a (ompietr hillory induding
Ijaltrointestin.1 IlrptlK or rtrwl dismr,.nd thr p0>sibility of
PIf9Oi1IK)'. OIJlain a drug hiltory induding allf"lifs, ilKludinglpfCific INCtions
to druqs.(urrmt prrsc:ription and OTC drugs, Ilrrbal and aloohol
=. alen to pollibledrug imt ractions.
Asst lS ligns and Iymptoms of infMion Mting symptoms, dJration,or
all)' IfffOt for colKurrmt inftions, panirularl)o HIV.
Enwtt appropriatr laboratory findings (t.g.,CBC,AfS C&S, and ft'nal
function \Iudifs).
AsstsslMnt thlll ughout administ ration:
AsSffi for therapeutic: tfffO:t\ (t.g., diminilhtd signs iI nd symptoms of
inffO:tion, fewor, NSt sputum
production, radiogri phic: tviritlKt of improving inftion).
ContinUl' ptriodil roonitoring ofCBC, and IItpatil and ft'IIiIllulKtion.
AsSffi for ffiem: n aUlfa, vomiting. abdominil l (ramping. diarrlltil,
dizlines p.1rtllhtsias, tinnitus, vuti4]o, blurred vimn, (hinges in
islul (olor 1fIlI<I', and in(ft'asing fil tigut.E)-r vision (uoge.suridtn
or ilKrNsing numbnes or tingling in otft'mitifs,rir<lNlrd lItaring or
tinnitus, i nd intft'.N in bruiling or bleeding should bot immfdiatrly
""',,"
Infenion
fatigUl'
Potent ial Nur sing Di agnoses
ImbalalKrd Nutrition, lfss than Body Rtquift'rntrlil (ft'latfd to fatigUl',
ildYtnt drug dftas)
Dr/ic:imt Know\edgt (drug tlltrilp)'. inftion (ontrol mrillurH)
Risle for NOIKompiialKt (ft'latfd to drug tll"KII. rltrKirm
knowlr<lqt, ltnqth of trNtrntnt ft'quirtd, or (ost of mfdilation)
Risle for Scx:i.lllsoiation (ft'latfd to disfalf,ltngth of tlN1ment)
Planning: Pati e nt Goals and Expected Outcomes
will:
thernptUtil: tifKtS di minisMd signs and symptoms of infection, rlr<ft'ased a nd fatigue, inaust<l appetit"t J.
Sr mr from, or expMtn(f minimal. arlYmr rffrru.
an undermndinq of tilt druq'1 Ulf, ad\'elSr ffieru, i nd requirtd prtUutions.
proptr of thr milation (f-9,dOlf, timing. wlltn to notify provider).
Impl ementat ion
Interventi ons and (Rati onales)
Ensuring tht ril peut ic tfftds:
ContinUl' il lSrmllf nts ill de [riilfd tarlirr for thflapeutil ffie[lI. (Diminished
ft Yel,(OlI9h, sputum, and othrrsignsand s)'lllptoms ofinfKtion should
Mtrd)
RKognill' that tubrruJlosii tft'atmrm rtqJirtslong-tfim (om plialKt and mall)'
for (Nonromplian(f thf rille to thf
family and (ommuniry and prorootfS dfwolopment
of rHistam otginisms. Monitoring o/drug administration may rfquirtcl to
fll\Uft' is contillll'd)
Minimizing ildft Bf efft-Cts:
CominUl'to monitor vital sounrk,and spurum production
qJality.lmmiatfly rtport undiminishrd frl'fl,ilKft'i lfl in sputum production,
in idftmitious brtath sounds to thf hNlth (ire
pKlYider.(IIKft'asingsigns of infwion may signify drug
MOOHIIpli.llKr with drug
CominUl'to monitor ptriodil lab work: hfpatic: and ft'nal function tHIS. (Stand
spurum (uituft' for ArB. (Antituberrulosil drugs htpatil i ndfor rtOil I toxic:.
Periodil C!lS test; may if infe(\ions aft' IfI'M' or all'!iaw to r60M
to mnfinn appropriatr therapy.Orug ItYl'k will bot monitoft'd on drugs with
kna.vn rffKts.)
Pat ient Educat ionfDischarge Planning
TN(h to nolstop drugs whu"fet'ling bttttr"but to
(ontinUl' plfl[riilfd ofthffilpy;rIo not shaft' dasH with otlltr
family mrmbm with limilar symptoms;ilnd return to pKlYider ij
tifflts dMlop to ensurt drug thtrapy iI mainlilinfd.
Disruss with tilt patient (OOwnlilbout family membotrs who
h.M similar l)'IIIptoms or may net'd prophylidil how
to lllanagf to hdp
TN(h to promptly rtpOn a fl"lfl that dars not diminish
btIow l00'f;(ominutd symptoms ofdilr.N (t.g,night Iwt'illing.
faDgUf};or in(ft'.N in sputum prodlKtion to thf (ift' pro'Iirltr.
Inltrumllt patirm on tht neN for ptriodil lab work.
LibraryPirate
Cloiop"')' Drugl InfealOOI 50l
NURSING PROCESS FOCUS PATIENTS RECEIVING ANTITUBERCULOSIS DRUGS (COIllhuro)
Impl ementation
Interventi ons and (Rationales)
Conrinut 10 moni\Ol'!of heJNtK, OfOtoxicity. tAmiwbl!lOllosis dfV9S
thit all' hepatir.ll'roal, 01 olDtoxic fttq.Itlll mooitoring to pll'Ytfll
rfffm. llKIl'lIing ftuid intakr win pll'W'm drug KruUtioo in
'""""-J
MonitOl" lor Ind symptorm ofllfllrolr.:kity, p.lrtir:ulaitt prriphtral oIIId
optic: nNlOpm.y. (HwrotoDily oIIId periphtral nMitis.1I! .dYtMtfftS 01
.ntiluberorlosis drugs. Vrtlmin BalNy bf 0Idered 10 deut.st It.e risk of
periphelll ntUropitb): )
MonitOl" blood in p.llifnts tamg iloOniuid.{bonioilid may inmiM'
giIlCOM' IMIs.DwbttK patitnts m.y II!qUft! a in !Mir antidwbtiX drug
routine.)
MonitOl" II"II'IM)' rooUM in patitnb taoog isoniazid.{foods high in lyTamint (in
inttraCt the drug Ind (i1M p.llpitations,lImhin!l-and hyptrte'lsioR.)
'alitnts uking riflmpin shook! bf (iUliontd thlt drug may tlllTllKdy IUds
(Inri, Slli'B,urirlf) is IIIrmitss bot mly suin 10ft,
hj'drophiil: (OIl!'" knses 01' dodringJ
IIKWrigt infl!.:tion (ootrol mmul'tS ba5HI on tht alent 01 ant
and follow tst.bWrtd protocol in ho\Ptlilrd p.ltitnts.(lJlft<tion (OIllroi
mtn.lrn pIl'ffilt 11"_ mnsmis.sioR. Sptcific isoI.tioP plt(i\/\ions or 1M of
spt<illizrd 1I\IIk5111i1Y lit rtqtrirtd b- hOlpitarllrd patient.}
Pat in t undtmalMfing 01 dnrg tht rapy:
lIIf opportunities IiJring adminiruuion of mtdications md <kIring MsasoltnlS
10 dinw ruion.1I- for dlU9 thellpMic OUI(OIIIts, most
(ommonly oIMrwd Irtwrw tfft<b, JNr'i!ldm lor wfHon 10 (lin tht health (ill'
nt<HSlI'/ monitorill9 or prtCiutions. (lhing during
n!Mg till! htlpslO optimizt ind Itiniofct kty Itadling 11I!ii.)
Patint inistrl tion of drug IhtrlP-':
WIltn ildmiMlering medicatXII'lS, instruct 1M lamilY, orcartgim in
proptr sfll-administration tt<hniques followed by rttum dtmonstlltion.
(Proper .!minis union will ilKltast lilt tft'tctiventss of tilt drugJ
Patient Education/Di scharge Pl anning
Too the p.ltienl to report Muse., vomiting, )'tIlowing 01 skin Of
$(im,i1ix1onWnll pain, light 01 cIiy-<oioIl'd llooft. diminished urin,
outpul,darl:r!ring of urW, mgin!l- humming. 01 buzzing in Nn,lnd
diniMss Of 'ItItigo
Advist tire patitntto ilKll'Hf fUel inlakt 10 2 10 II ptr liiy.nd 10
tlim"alt.1I Hoho! use.
Instruct 1M patitnt to Il'pOrt dmnm, all.linm, numbnnl Of
tingling in ptl"iphml txtrmitits,and mion (hangtS.Eye pain, lrutt
blurring of OIlossof eIOI seflSt, Ind suddtn 01' irKl8sillg
numbntsS 01 tingIiIIg in trlltmi\in should bf rtporttd imllltd"littly.
ElI(wr. thf JNtitnt 10 ill(ll'lM' tilt inukr of ri\.imin B. ril:h bock
(t.g.. fortifitd (tl8h, biW with skin on, balWlnll,.lI-an mtlu"
bfins) and discuss l'ilimin B.lUppltmtnts with tht htilrll
urtpml'idtr.
Too thf diabrtk pllitnt to gllKW' frtqumtly. rtpOrting
any (onsisttnt tlNations to 1M htaith till' pnMdtr.
Advist drr patitnt taking iIoniarid to ;wold foock (ontaining lylilIlW.
such M .gt<lchmt.smoktd pklStd fisIr,btft iII1d rfd win!',
biMIIa5, Ind cho<oIa!t Ind 10 rtPOII '-LKht. p.llpiutionl,.
U(hyCiiW,Of M immtdiiuly.
tilt patitnl to ((Insult: drr tyt (ill! pllWidK btIo!t using
h)'llrophilir: (ontact 1t1lStS. Considtr wtaring nonwhillt ciodling or 1M
uodtl"9lrmtnl) if Swtilting is elltmiYf.
tilt p.ltienlidtlJlollt inftion (ootid and hygitne mtlSUltS
wc:h M frequent hand w.shing,. (O'Itring tilt mouth whtn (OIIg rung GI
sneexillg, and proptr disposal of loOiltd tissues.
TIll' patitntlollllily.or (MtgMr ihould bf able 10 "Itt the ftaSOl'l !of
the drug;lppr9piWlt <lnd sdltduling;wlw 10
oIMrn fI:n oIIId 10 1tpDft;lnd 1M anoopattd Imgth of
mfd'Kation thtrapy.
Too Ihf pdtienl 1o t.rkr lh mt<Iialion oIIlolk7ln:
Compltlt!M etltill! (WISt 01 liltrlpy unitss othtrwist inSIruCltd.
TIll' duration 01 tht requirfd thtf.py may 1M! II-ngthy but it is
nt<t!.lll)' to plt'l'trlt KtM inftction.
Bimil\llt alcohol whi\tOll these mtdiutions. Thtst dnql (aIM
!ic}nifiCllnlltKtiom when takm with .kolJoL
Tlkrwdrug with foodormiD:butlwid
imtructtd to tht drug on.n t RIply slolllKh, I fun
gYss of walt!.
Take thf nwdk.tion M _Iy spac:td IhroughOllt tfCh liiy M
fmibll-.
Inatast OtrlU Huid intake while uking thne dfV9S.
Evaluation of Outcome Criteria
hallloJlt tM tlkti'ft'lll'li of drug \btrapy by mnfirming th.Jt JNlifnl 90"11 iII1d 9pK1td Olll(OIIltS 111'11' bttn mel (_"Planning").
5tr TIIl* rXihqs
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504 UnitS The Immune SY"'-""
r
tr
Chapter REVIEW
KEY CONCEPTS
The numbered key concepts provide a succinct summary of the important points from the corresponding numbered section
within the chapter. If any of these points are not dear, refer to the numbered section within the chapter for review.
34.1 Pathogens are organisms that cause disease due to their
ability to divide rapidly or secrete toxins.
34.2 Bacteria are described by their shape (bacilli, cocci, or
spirilla), their ability to utilize oxygen (aerobic or anaer-
0bic)' and by their staining characteristics (gram posi -
tive or gram negative).
34J Anti-infective drugs are classified by their chemical
structures (e.g., aminoglycoside, fluoroquinolone) or by
their mechanism of action (e. g., cell -wall inhibitor, folic
add inhibitor ).
34A Anti-infective drugs act by affecting the target organ-
ism's unique structure, metabolism, or life cycle and may
be bacteriocidal or
34.5 Acquired resistance occurs when a pathogen acquires a
gene for oocterial resistance, either through mutation or
from another microbe. Resistance results in loss of an-
tibiotic effectiveness and is worsened by the overpre-
scribing of these agents.
34.6 Careful seleaion of the correct antibiotic, through the
use of culture and sensitivity testing, is essential for ef-
fective pharmacotherapy and to limit adwrse effects. Su-
perinfections may ocrur during antibiotic therapy if too
many host flora are killed.
34.7 Host factors such as immune system status, local condi -
tions at the infection site, allergic reactions, age, and ge-
netics influence the choice of antibiotic.
34,8 Penicillins, which kill bacteria by disrupting the cell wall,
are most effective against gram-positiw bacteria. Aller-
gies occur most frequently with the penicillins.
34.9 The cephaJosporins are similar in structure and function
to the penicillins and are one of the most widely pre-
NCLEX-RN REVIEW QUESTIONS
D Superinfections are an adH'rse effect common to all antibi-
otic therapy. The best description of a superinfection is:
1. an initial infection so overwhelming that it requires
multiple antimicrobial ag<.'nts to treat successfully.
2. bacterial resistance that creates infections diflkult to
treat and often resistant to multiple drugs.
3. infections requiring high-dose antimicrobial therapy
with increased chance of organ toxicity.
4. the overgrowth of normal body flora or of
opportunistic organisms no longer held in check by
normal, beneficial flora.
scribed ami -infectiw classes. CTOS.'i sensitivity may exist
with the penicillins in some patients.
34.10 Tetracyclines have some of the broadest spectrums of
any antibiotic class. They are drugs of choice for Rocky
Mountain spotted fever, typhus, cholera, Lyme disease,
peptic ulcers caused by Helicobacter pywri, and chlamy-
dial infections.
34.11 The macrolides are safe alternatives to penicillin. They
are effectiw against most gram-positive bacteria and
many gram-negative species.
34.12 The aminoglycosides are narrow-spectrum drugs, most
commonly prescribed for infections by aerobic, gram-
negatiw bacteria. They haw the potential to cause seri -
ous adwrse effects such as ototoxicity, nephrotoxicity,
and neuromuscular blockade.
34. 13 The use of fluoroquinolones has expanded far beyond
their initial role in treating urinary tract infections. All
fluoroquinolones have activity against gram-negative
pathogens, and newer drugs in the class have activity
against gram-positive microbes.
34. 14 Resistance has limited the usefulness of once widely pre-
scribed sulfonamides to urinary tract infections and a
few other spedfic infections.
34. 15 A number of miscellaneous antioocterials have specific
indications, distinct antioocterial mechanisms, and re-
lated nursing care.
34. 16 Multiple drug therapies are needed in the treatment of
tuberrulosis, since the complex microbes are slow grow-
ing and commonly develop drug resistance.
D A patient has been discllarged with a prescription for
penicillin. Discharge instructions include that:
1. penicillins can be taken ... hile breast-feeding.
2. the entire prescription Illll'lt be flllished.
3. all penidllinscan be taken without regard to eating.
4. some possiblesideeffects indudt'abdominal pain and
constipation.
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o A patient has been prescribed tetracycline. When provid-
ing information regarding this drug, the nurse would be
wrrect in stating that tetracycline:
I. is classified as a narro..-spectrWll antibiotic and only
treats a few infections.
2. is used to treat a wide wriety of disease processes.
3. has been identified to be safe during pregnancy.
4. is contraindicated in cMdren younger than 8 years.
o Teaching for a patient reu'iving a prescription for
ciprofloxacin (Cipro) should include (Select aU that
apply):
I. Report unwual heeL lower leg or calf pain or difficulty
walking.
2. Amid taking the medicine with milk products and
antacids.
3. Linlit vitamin C, both dietary and oral vitamin forms.
4. Take her pill with an antihistamine to avoid side effects.
D A patient has been diagnosed with tuberculosis. While his
medicine is being administered, he asks questions regard-
CRITICAL THINKING QUESTIONS
1. An IS-year-old woman comes to a clinic for prenatal care.
She is 8 weeks pregnant. She is healthy and takes no other
medication other than low-dose tetracycline for acne.
What is a priorily of care for this patient?
2. A 32-rear-old patient has a diagnosis of otitis external and
the health care provider has ordered erythromycin Po.
This patient has a history of hepatitis B, allergies to sulfa
and penicillin, and mild hypertension. Should the nurse
give the erythromycin!
'hopttrl4 Drug. fo< Sx!e,lallnl<'Ctlom 505
ing his treatment. What teaching should the nurse supply
to this patient! (Select all that apply. )
1. "It is critical to continue therapy for at least 6 to 12
months."
2. K"fuu or more drugs may be used to prevent resistance."
3. "These drugs may be used to prevent tuberculosis also."
4. "No special preoJutions are required"
5. "After I month of treatment, the medication will be
discontinued.."
o A 32-year-old female has been st arted on ampicillin for a
severe urI. Before sending her home with this prescrip-
tion, the nurse will:
I. teach her to wear SUJ\SCreens.
2. askher about oral contraceptive use and recommend an
altematr.l' method for the duration of the ampicillin

3. 3""""" for hooring lou.
4. recommend taking the pill with some antacid to prevmt
GI upset.
J. A 66-year-old hospitalized patient has MRSA in a celluli-
tis of the lower extremity and is on gentamicin N. What is
a priority for the nurse to monitor in this patient!
See Appwdix D forall5wers and mtiol1aies for all activiries.
EXPLORE aQ,ll!Iitilng!tlr------,
MyMlrsil1gl(i! is )'OIJ ! one stop lOr onI"Je ehapter reVIew mill<'!lial:! and
resourtes. Prepilrt tor SI.OXer.s witI1 additiooal practice
Ques!loos, Imenu:t"". assignments ood actI";mes, well links, anima1ions
aoo videos. and "","I
Reolster I'Dl' access code from Ihe Irool til \lOUr booII al

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DRUGS AT A GLANCE
ANTIFUNGAL DRUGS flD9tSM
Drugs for Systemic Fungallnfec:t1ons PIlIJ' 5/8
Q omphom;dn B (FungjZCJnf',o""'''i
""",
O fluconazolf'rD/RucQn) Jll9f51J
Drugs for Fungal Infections
jIIlIJt514
o nynorin iM)"".ralin,Nynop,o/hfo",
P1m
ANTI PROTOZOAN DRUGS p!JJt515
rxugs J!IlII515
O (hloroquiM/Ara/lII} jIIlIJt5J/J
Antiprotozoan Drugs p!JIJt516
Q mtlro"d/u'o"IFlQgyIJ ptJIJ(5U
ANTHELMINTIC DRUGS po!JtSIl
fllll}t52J
KEY TERMS
iIlale f'I1J' 51]
derm.rtophytit filii}' 'jQJ
dywntery JIIlT517
frgosterol JIIlI1'5IJJ
erythro()1intigf m
Drugs for Fungal,
Protozoan, and
Helminthic Infections
LEARNING OUTCOMES
After reading this chapter, the Jludenllhould be db/e 10:
1. Compar e and contranthe pharmacotherapy of superficial and systemic:
fungal infections.
2. Identify the types of patients who are at greatest risk for acquiring
serious fungallnfeCllons.
3. Identify protozoan and helminthic Infedians that may benefit from
pharmacotherapy.
4. 8tplain how an understanding of the Plasmodium life cycle is
to the effective pharmacotherapy of malaria.
S. Describe the nurse's role In the pharmacologic management offungal,
protozoan, and helminthic in fectioni.
6. of the claSSol!'i shown in Drugs ata Glance, know repreSoentative
examples, and explain their mechanism of drug action, primary actions,
and Important adverse effects.
7. Use the nursing process to care for patients receiving drug therapy for
fungal, protozoan,and helminthic infections.
fungi fIIJIJ''j()J
helmimh P'11d1J
miliary pogt m
pogt515
mytlSI'S pogtsaJ
polyene fllJlJ'515
protOIOil fllJlT5r5
1Nst pogt'j()J
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F
ungi, protozoans, and multicell ular parasites are more
complex than bacteria. Because of structural and func-
tional differences, most antibacterial drugs are ineffective
against fungi. Although there are fewe r medications to
treat these types of infections, the avai lable drugs are usu-
all y effective.
35.1 Characteristics of Fungi
Fungi aresingle-celled or multicellular organisms whose pri-
mary role on the planet is to serve as decomposers of dead
plants and animals, rt'turning tht'ir elements to the soil for
recycling. Fungi include mushrooms, yeasts, and molds. Al-
though 100,000 to 200,<x>o species exist in soil, air, and wa-
ter, only 3bout 50 are associated with disease in humans. A
few species of fungi grow as part of the normal hosl flora
on the mouth, and urogenital tract. YfiI.to, which in-
clude the common pathogen Candida aiMeans, are unicel-
lular fWlgi.
Most exposure to pathogenic fungi occurs through inhala-
tion offungal spores orby handling contaminated soil. Thus,
many fungal infections involve respiratory lracl, the skin, hair,
and nails. In additions, the lungs serve as a route for invasive
fungi to enler the body and infecl internal organs. An addi-
tional common source offWlgal infections, especially of the
mouth or vagina, is overgrowth of normal flora.
Unlike bacteria, which grow rapidly to overwhelm hosts'
defenses, fungi grow slowly, and infections may progress for
many months before symptoms develop. Fungi cause dis-
ease by replication; only a few secrete toxins like some bac-
tt'rial species. \Vith a few exceptions (such as athlete's foot),
fungal infections are not readilytransmil1ed Ihrough casual
contac1. i n addition to causing infections, fungal spores may
TABLE 35.1 I Fungal Pathogli!ns
OIoplfl n Drug. for fungal ProIOZO.n..nd Helminthic: Infection, 507
ITi8!!er a hypt'rsensitivity response in susceptible patients,
resulting in allergies to mold or mildew.
The hwnan body is remarkably resistant to infection by
these organisms, and patients with healthy immWle syslems
experience few serious fungal diseases. Patients who have a
suppressed immune syslem, however, such as those infected
with HIV, may experience frequent fungal infections, some
of which may require aggressive pharmacotherapy.
The species of pathogenic fungi thai attack a person with a
healthy IDunWle syslem are somewhal distinct from those that
infect patients who are immunooompromised. Patients with
intact inunWle defenses are affiicted with community-acquired
infections such as sporotrichosis, biastvmycosis, hislOpirumosis,
and roa:idioidomycosis. OpporlWlistic fungal infections ac-
quired in a nosocomial setting are more likely to be candidiasis,
aspergillosis, crypttxoccosis, and mucormycosis. Table 35.1 lists
the most conunon fungi thai cause disease in hwnallS.
PHARMFACT5
Fungal, Protozoan, and Hli!lminthic Disli!ases
Ninety penrnt of human lung,l iofedioos .ue(,)16rd by jUII ' few
-.
or all human rung,l ime.:liorn.,86%arr "used by ullldido oIbK..r . 1III'
sond moSI common (1.3%) is c,used by sprOe of AlptI9i/fU5.
Fungi mill' 9%01 nosocomial infrctions.
Approxima!l'iy 300 to SOO million ml's of malari. ocrur wortdwidetach
an rstimaltd 2.7 million denhs dO!' to thr dill'_.
Chaogas'dill'asr,,,used by most lignm{anl
c,ulI'ofhran disNsr in sam South Amrriun countrifs.lt inl"tcts 16
million peoplr ,nnually.
AI(Qri51umbriroidrs is thr mon common inmtin.l hrlminthic infection,
,fleeting 1 billion proplr worldwide.
Name of Fungus
SYSTEMIC
Disease and Prtmary Organ System Affi'CIed
Aspenjlu, fun.y,rw, orhm
BIosromyrrs dmOQrilidi.
Cilr111idoiJlliam,oihrfs
fsKddioidfs immiriJ
UyplOaKM ntOforlOQO!
Iinop/lllll"lQ(llpsuiarum
Pr!twnocy;ri. (Qrni (Pnromory;ti5 jral'M)
SUPERFICIAL
Cilr111idoiJlljrar;,oihrfs
Epidfrrooph)'fOlllloc:W!IIm

SporolMx I(/im(kii
Trichophyron sprOO
oppon ... i'Ii<; most <0II"fJl0I"iy .fftru lung but spre.od 10 ochtr orgon.
SIiInomyul\is;brgios in thr ILngland sprr.od! lOothl'r orgaos
lIIO\I (OIllmoo oppn ... isl:ic fillgal infruim; may affKl Of.lrty an, OI9'n
Cocddioidomycosi!: in thr lunqs and !plf.od! 10 OIhI'r organs
(rypto{Ouosis; opporturillic; brgill in thr luogIM is thr most common cause 01 meriogilis in AIDS
Hi>!oplumosil: bfgins in thf spruds 10 othrrO"9ilOS
I'Mrimoqsri5pn1'11000g;oppor1II1i11ic;primariy catlll'S pnI'IIOoni, cillir kJng bul "n sprr.d 10 ochl'rorgan!"
skin, n,iis, 01",1 <aViJ:, (thrulh), vacjru
foOl (1m pl'dis),jod ildt (tiOf.l m.ris)"ndothl'r!kin disonIm
Rilgworm cil(,Jlp (liOOl c.Jpitis)
I
SporouidIosis; prinarily afirCIIW1 ,nd nodfs
All'K1i I(,JIp,skin,and nal!
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508 UnitS ThelmmuneSysI""
35.2 Classification of Mycoses
Fungal infections are calltd myISU A simple and useful
method o( classifying mycoses is to consider them as either
superficial or systemic.
Superficilli mycoses affect the so::alp, skin, nails, and mu-
cous membranes s uch as the or.lll cavit y and vagina. In mOlit
cases, the fungus invades only the surface layers o( t hese Il'-
gions. Mycoses of this type are often trealed with topical
drugs beatuse the incidence of adverse effeclS is much lower
using this route of administr.lltion. Superficial fungal infec
lions are sometimes Cl lIed der...,tIIjIb)'lk.
Systemic mycoses are those affecting internal organs,
Iypically the lungs, brain. and digestive organs. Although
much less common than superficial mycoses, systemi c
fungal infections affect multiple body syuems and are
sometimes (atallo pati.ents with suppressed immune sys
lem . Mycoses of this Iype rjuire aggr<$$ive oral or par-
enteral medications that produce more adverse effects
than the topical agents.
Historically, the antifungal drugs used for superficial in
fections were distinct from those prescribed for sys
temic infections. In recent years, this distinction has
bl urred, some of the newer ant ifungal agents may be used
for either superficial or systemic infections. Furthermore,
some superficial infections may be treated with oral, rather
than topical, agents. For example, nail infections are super-
ficial, but are often treated with or:i.l antifungal drugs. This
therapeutic division between s uperficial and systemic my-
coses is still useful, however, since it separales the pharma-
cotherapy of relativel y benign infections (supetfici:i.l ) from
those that may be life threatening (sys temic).
TABLE 15.2
Drugs for SystemiC Mycoses
35.3 Mechanism of Action
of Antifungal Drugs
Biologically, fungi are classified as their ceUuLar
structure and metabolic pathways are more similar to those
of hwnans than to bacteria. Anti- infectives that ire effica-
cious against ooderia are ineffectiw in treating mycoses be-
cause of these diffell'oces in physiology. Thus, an mlirely
differmt set of agmts is ne1ed to eliminate fungal infections.
One important difference between fungal cdls and hu.
man ceUs is the steroid used in constructing plasma mem-
branes. Whereas cholesterol is essential for animal cell
membranes,ergctft"Oi is present in fungi. The largest class of
antifungal drugs, the azoles, inhibits ergosterol biosynthesis,
cauo;ing the fun gal plasma membrane to become porous or
leaky. Amphotericin B ( Fungizooe). terbinafine (lamisil ),
and nystatin (Myrostatin) also act by this mechanism.
Some antifung:i.l.s take advantage of enzymatic differences
between fungi and humans. For example, in fungi, f1ucyto-
sine (Ancobon) iii converted to the toxic antimet abolite S
fluorouracil, which inhibits both DNA and RNA synthesis
in the pathogen. Humans do not have the enzyme necessary
for this conversion. Indeed, 5-l1uorouracil itself is a com_
mon antineoplastic drug (chapter ) :;00).
DRUGS FOR SYSTEMIC FUNGAL
INFECTIONS
Systemic or invasive fungal disease may require intensive
pharmacotherapy for extended periods. Amphotericin B
"'"'
Route and Adult DoW' (max do5e where indicated)
......... E_
O .nphotman B

AmBI-.MIphotN,FungiIJ::Jnto) 2-4 b (Il0l1 t.S
Neo/wt!!i!i!!J: !!m fllW lNDiWm, eriK i!m!
tlJmboa!oorrij lo'kppcniI .!ltJfJ'lpMmk jIld
.-
lOOIRlungili (bull) t'I; Ioidilg dow 100 mg 011 dar Ilotlowtd I,,- Mi,.1I1ngi< rttiMs sudlas
""""'"
u!pOfl.ngin [Clnc\dis) t'l;70nIIJ i1fuwdcrm I hOllIli,
iIlused b I:id 10/ 10 iii)'! rhl!:mOOphltli!is
""""'"
(Antobon) PO; SO-ISO mgi\9 in dividtd WS NQUltll, htmht
12!iSi!:I: rmat tlllU.
.-
miufingin (MJtmiM] t'I; ISO IIlIJ/k4IlIir 0'lI'l1 h for 1M f6ndid11 inlKtion; HtadXht,_,lIlIII.pNtliliJ
SO IV _ t h for Ctm.idG PfOPh)laJis
lMIefIii !.Ktions.litliri!!!!
'AIde ... 1O! s)'SItfIIiI: inIt<!ionlm iIckIcW" tabIf 15.3.
halirJindim._ "'""" lndiMtI...wr """" .. efIfiu.
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(Abelcet, AmBisome, Amphotec, Fungiwne) and flucona-
zole (Diflucan) are drugs of choice. Selected systemic anti-
fungal drugs are listed in Table 35.2.
35.4 Pharmacotherapy
of Systemic Fungal Diseases
Because human immune defenses provide a formidable bar-
rier to fimgi, serious fWIgal infections are rarely encoun-
tered in persons with healthy body defenses. The AIDS
epidemic, however, has resulted in the frequent cli n ical oc-
currence of previously rare myooses, such as cryptococcosis
and coccidioidomycosis. Opportunistic flUlgal disease in
AIDS patients spurred the development of several new
OIoplfl n Drug. for fungal Protozo.n..nd Helminthic: Infection, 509
drugs for systemic fungal infections over the past 20 years.
Others who may experience systemic mycoses include those
patients receiving prolonged therapy with corticosteroids,
experiencing extensive burns, receiving antineoplastic
agents, having indwelling vascular catheters, or having re-
cently received organ transplants. Systemic antifungal drugs
have little or no antibacterial activity, and pharmacotherapy
is sometimes continued for several months.
There are relatively few drugs available for treating sys-
temic myooses. Amphotericin B has been the preferred drug
for systemic fWIgal infections since the 1%0s; however, this
medication can cause a number of serious side effects. The
newer awle drugs such as itraconazole are considerably safer
and have become drugs of choice for less sewre infections.
..,. Prototype Drug I AmphoteriCin B (Funglzone, others)
Therapeutic (lass: Antifungal (S)"5Iemictype) Pharmacologic (lass: Polyene
ACTIONS AND USES
Amphotffic:in B has. broad spKtrUm of .uiity and is . gainS! most of
fungi pathogenic: kI it is prdtrttd drug klr moot sys-
tt mic: rny<ose.1t may .Iso bI' II prophylactic: .ntilung,1 t her.p)' tol
p'tienn with immunosuppmsion. k .ds b)' binding to t rgost eroI in fun-
gal {t llmtmbr,nes, (lusing them to PfITIINbie or Ie,k.
photericin B is oot .bsorbl'd from theGI too.it is norm,11y given b)' IV infusion.
Topic,1 pll'pmtions lit ,v,il,ble for supn-fic:iil m)'(<MI. Sever.!1 momhs of
mily br Ifquired for a complete CUll'. Relislolnce to 'mpho-
ttricin B is not common.
To B, theoriginoll drug molecule !wI
formul,ted with molecults:
Liposomal.mphotericin B (AmBisomt): consist; of (Iosfd sphtric.J 1 mi-
(les.Amphotericin B in inttgrilttd imo the lipid
Amphotericin B lipid {ompl9 (Abeled): (om,ins 'mphoteric:in B (om-
pined with two phospholipids in, 1:1 ratio
Amphotericin B (holtstt rylsulfut (omplex (Amphotec): conl;1I> of , 001-
Ioidal suspenlion of amphott ricin B in, 1:1 ratiowith the lipid
in mic:roscopk dislc-s/l,ptd partic:1es
The princip.1 acilllnt'9t of the lipid formullltions is reduced nephrotoxic:ity
. nd lesl infusion-rel,ted fmor.nd chills. The rtdllud toxi<ity is brlieved to br
dot to the plum. \mob of the drug.
ADMINISTRATION ALERTS
mol)' Il'sult if the medication
is infused too rapidly.
Administer Pfl"medication to help the risk of infusion
Withhold the drug if the BUN mteds 40 rTI9IdL or uutinine rises
.bow.-l mg/dL
Pregn.ncymegoryB
PHARMACOKINETICS (IV)
Onset:I-2h

Halflife: 24-48 h
Duration: 20 h
ADVERSE EFFECTS
Amphotericin B un procItn fIl'qutm and serious oJdverno riftas.
patienu develop ieer ard <hilk, Omiting, tht btgin-
ning oIthmp)', whic:h subsidt., {ontinUH.Phlebitisis oommon dur-
ing IV III'phrolOJirity is in80%ofthepatitnu
IoIking this drug ,nd t\fCtroiytt imbilllnces wc:h ., hypob lemii flfqtltntly DC-
(ur. (.n:liac h)1lOleOlion,and dysrhythmill 'Il' ,mpho-
tericin B (In UI/Ie ototoxicity, the should .!Isns for huring loss, erligo,
unste,dy gait, or rinnitus.
Contraindi Citionl: The rontr,indic.Jtion is to the drug.
(,ution must br when using .mphotericin Bin patients with l"1'li.1 im-
pairmem.
INTERAalONS
8 inlHiKtS with manyOOiql.(r.oonfllthfl"apy with
drll9l that r" N flllctioo, well 011 amirlogl)'(osidn. irKwny<in, or Glrbo!Utin
is oot lKomlllHldfd.l.I\.! with (ortiarswoids, Ikfletil musdf thiazd@
miIY 1l)lIOkilfmia.l!st with di lJOlin inaNSes tilt risk of digoxil toxicity in
p<fiefll> with prH1i1ting h)l101:ak>miil.
l.i b lests:.I.mphotericin 8 miIY incJuIo ......." 01 tilt IfIUIR GNtinint,
olUralilll' phoIphoJllSe, BlMj, aminotransferN (AS n,.Jnd ,Ian .....
aminotransffrllf (AlJ]; Ny 'IilIoes lor IfIUIR potas1ilnl, 1ilki1lm,.Jnd
..........
HerlIaVFood:
lINIment for O"ferdose: may It"IUk in (lrdiort-spiratoty alll'lt.No
specffit: thtrip)' is mil.!bIt;p.nimllart tll'attd lymptomatic.Jlly.
IIfI'8" /l) M)Nu1l1ngK1l A>r Q Nt!1li1l/j I'rIKm for11S lpt(1/{ /l) lin drrii}
LibraryPirate
510 U,*S Thelmm ...... Syu"""
NURSING PROCESS FOCUS PATIENTS RECEIVING ANTIFUNGAL DRUGS
Bllrlinf I55fSS.,tnt prior 10 .dmini5tl'lllion:
Undel'ltand the luwn doug has befn plf:S(ribfd in 111M to b
the!apeutic tffKts.
Obuin a Mtol}
pir.tOfY, hepatM: or rfIIII diWiW, ind me possibi6ty of Obui n I
drug hislOly induding inciJdil'lg spifK to drugs,arnm
pm{riplioo .IIId or( dNg5, hffNl plrpirJDons, and limhoIlM. Be aIen to
poisibil drug intrf'a{tiorl1.
AsItSS signs Id of (Ulltnt inffaion noting Ioution,
dIIr.lcttmoo, 01' ib!.mc:f of mirJClel
4JrJtion,.meI plmlKl' Of aMcrof ifwrOf pain.
o &ilwtt ipptOpNtf 1ibor.lID/Y (t.g.,CB<,tltctrolyttt, urilll/r!i!.,
(&5), hepatM:.meI Il'IIillunc:tion studiH).
lIn.in b.m1Wle wrightlnd vital blood prtUUll' 100 p,iIst.
bHISmfnt throughout id.,inistrillion:
.t.s1tSl for the!apeutir: df1S ('4-, diminishtd signs I 00 i)'IlIpiOIns of
in{t jon IIId fmr) .
CominUf ptriocIic monitoring of(BC,eIedJoIyt:e, hepatir:ind 1l'f1.11 fuoction,

ContinUf to monitor Yiul blood pltlSUlf Mel pulst, in
p,ltitn1:5 011 IV Itilun9iis.
AsItSS for fffe(u; ftlUSU, cri mping,diarrllfa,
m.lwi5t,musdtcrampill9 ",in, chills,
tinnilln, lkMing,Wn rash, urtiuN. Sfizull'S"h)'pOfmsion,and
tlf(tro!yw imbibnc:e ..
dIInge in IMlof conSdouiMSl (lOC),
diminilhtd lRIe 0UIpYf,0I" sInAcI lit Il'pCInfil
Potenlhl l NUl'$il"l9 01"9n05"
InfKtion (0lITtf( or risk for(OIIoull'f1t inft<tionl
Pain (reiatfil 10 infKtion)
Ifypt!thtrmia

RisUor In;"" (Mated to drug rfftsI
Risl for Ilflicimt f\JidVolumr (Iflated to Rft( diarmn ciUIfd
drug rifi5)
Ristfor DtaNstd Cardiac o.np.., 11IfftKtM! fisSIle Pfrlusioft (ttlattd 10
.mrl"lo!' antilull!lMs!
o Risk for Noncomplianc:t (rflned to adYfl"lo!'dNg tffKts, dtficitflt knowltdgt,

Planning: Patient Go.ls and Expected Outcomes
Tht p.nifnt wit;
u,erifnc:t theriptuticrifts (e.g..diminishtd signs and srmptoms ofinfKtion,6totastd fMd.
Be Irn fi-om,OftXperiencr minirnal,.dw!w dI"Kb.
Ytrbalizt, I oodmtancfllg of tht drug's IISf, MIYmt rlJfm,IOO prtuw-.
Dtmonstl1l1i! proptr wjf-lllmini5tr.tion ofdlf mtdiurioft (e.g,dOlt, timing, whtn to notify plO"tidtf).
Implementation
Interventions and (Rationales)
hl,ring effHtI:
ContinUf deoibtd tarlitr to..thmpeutic t ffro:ts. (DiminiWd
signs .oo Iymptormof infMioo shook! bt nottd)
Minillizing Iclftne effects:
CominUf monitomg of Vitai ligns,npt(J,1Iy blood pIl'llIlIf IIId
pulst,aOO ItSpintory IIId depth in pIlimu on IV .rwilongals.
1m mtdiateIJ Il'port dylthythmias, iOOf.1ing pulmonary
irfpottmion, or tachyurdi.J.(urdiomuAr Ibnonn.tlitif! Ill' poisiblt
idvtl"lo!' of IV antifuRgiIs. (ardiac ind alsesmrnl mtISl bt
monitoll'd dosrIy to obstfYf lor MIYmt tffKts.)
Patient and family EduItlon
1Nm patieftt on that IofWrII months of lreollrMnt IlIiY bt
"'" p.nienton iDpKal .miluncj;Jls to <ompIelI! Iht rntitt CDIII"\o!'
of thtrapy a nd notify Iht IwIdI (.lit providtr if symptoms 11m oot Il'IOI\JM
nstru<t tilt pMiml on Iht IIHdfor freqUfllt monitoring.Expllin tilt
I1tioniil for monitoring uwd.
LibraryPirate
OIopltl n Drug. for fungal Protozoan,.OO Helminthic: Inlectloo, 511
NURSING PROCESS FOCUS PATIENTS RECEIVING ANTIFUNGAL DRUGS (Conllnued)
Impl ementation
Interventi ons and (Rati onales) Pati ent and Family Educati on
ContinUl' to monitor prriodic: lab !!1Ii1 fUnction (Be, Tta(h tht j)<Ititnt about thl' nffil forfrequent lab telling.llon oral
uri (UIN!! and I('n 5itivity, and lewis. (Antilull9'lk aft' antifull9'lk at hOlll!',inlU1J(\ thl' !)alient on br periodic lab work.
htpatic . nd II'nal toxic.nd labs be monitoft'd IIfQUI'Iltiy. Pfflodic: (&5
tesll be ifinfl!diom !e''lf or slow to It'IoIYt to(onlirm
appropiUtt thl'rapy is being particularly when giml
IV, rtIiIy cal/\(' imb.ilancfi, tspf(ially hypokalemia .nd
hypomagOl'll'Olia,and t lt1:trol)1t II'placemt nt may be I"ftdfd)

Wtigh tht !)atitnt d.ily and !!pOrt a weight gain of 1 kg or moll' in a 14-

patitm liking oral amifUngal drugs at hOlll!' Migh I('Hdaily,
hour prriod.MNIUII' output in the hospitalized patitot.(Daily 0011)0 at wmetimeof day, and ft'(oro along with blood
weight is an auurut measulI'of fluid .tatu nd like. into ac:(ount intakt. pI"r'SUII' and rtII'alUft'rtII'nK Hoi!, the poalient rtporl5ignifiunt
OUIput.and inll'nsiblt gain or rdema II\a)' indicate wtight gain.
rt nal dysfunction.)
Monitor for h)1ltllto.itivity.nd allergic: lI'actions,t-!pt(ially with tht fir;t

patitm to promptly ft'pon any (hilk, natJll'il, tll'mor;.or
dol!' of IV anlifungal.CominUl' to monitor the poatient throughout therapy. hNdac:he.
(Anaphybctic: IN(\ion.aft' ind all' moll (ommon with the first IV
inlulion.A trst-doI!' of a Imall.moum gi\'ell WwIy may be gi\'ell btioll'
main infUsion. Pll'rtll'dicuion, inckiding i mip)"fdiu, i ntihistaminrs. and
antitrtll'tKs rtIiIy be SoIry to pm!'nt ft'ac:tions.)
[nsulI'adtqune h)dration in JlaIients on oral or IVantilungak.(Antilull9'll Tea(h tht j)<Ititnt to incrul(' fluid inlike to 1l perday ilon oral
dtugla!! lI'oal toxic: and adtquatt hydration hl'lplto pft'!'Ot It'OiII antifull9'lk. Explain the rationalt for IV f\Jid hydrillion in
effecK) poatients on IV intilull9'lk.
ContinUl' to monitor for s.igns of0101OlCicity. (Antifungal. ilia)' calnt Teach tht j)<Ititnt to immrdiatt ly report any ringing.humming.or buuing
olotOlCicity and lfQuill' f!!quent monitoring to pI"r!'nt dtru.) in dizzint ll; or vtrtigo.
Continue to monitol for he patK toool)'; e.g., jaundice, ROO pain, darkent<:! Tmh the piltient to Itport jny of
uriOl',diminished uriOl' in !)atients on IV or oral .kin or !(Im,abdominal pain, light or day..:olortd \look,or darktning of
antifungaltlltrapy. (Amilull9'lk may (il/\(' IItpatic toxicity and lfqUill'
flfQutnt monitoring to preY!'nt advtlll' . )
Monitor tilt IV frtqUl'ndy for any signs 019tra'/ilSition or

patiem to immtdiatt ly II'port any !)ain, buming.or ft'dnm at
.ntifungal medication is irritlling to !'in . UI!' a the lite of tilt prripherallV. Explain tht rationale lor all tquipmtot UIl'd.
if pos5ibleor freqUl'lltly monitor tilt IV 5itt.lnfusion pump.
mint be used to tn.UIl' the properdosagt rate and pft'Yffit t x<fiSWt flow
ratd

Monitor blood gluc:ol(' in pa!itm. taking may Teach the diabetic patient to moft' mqUl'ntly,lI'porting any
in(lI'iI.t gluc:O\f Diabttic: patienu may lfQuift' a (hangt in their (onlilttm elevations to the hl'akh (ill' proYidef.
antidiabttic: drug routiOl'.)
Monitor for .ignificant GlI'fIKIl,including oaUll'i, wmiting.and abdominal Tei(h tht j)<Ititm to toilet thl' drug with food or milk but to avoid ac:idic
poain or cramping. Give thl' drug with food or milk to Iood!and or caroonattd drinkl.
dfem. (Food 01 milk II\a)' dtclNlI' 61 effects but an antiemetic may also be
ij oaul!'a is
Monitor for .ign. ind .ymptollll of !fInclary infl!dion in topical olIN. of

Tta(h tht j)<Ititnt to Itport any inUUling II'dnes.,IOII'OI'I5 or pain,or
fUngal inre.:tion, t.g. a!hlett'. foot H sylttmic: adverst oottd, inclN.ing drainagt' from afie<1td .itt.
(ht.:k tht drug dol(' or administration roote tilt !)alient is
itching with !(ratching may b.(\M.J ill'il,lI'IUlting in a
!fInclary bacterial inre.:tion that may lfqUilt .dditiollil antibacterial
therapy. Topical drug amounts all' ulWlly in.uflKitmly absorbed to
Iysttmic
(conrlnued)
LibraryPirate
512 UnitS ThelmmuOI'SY'tem
NURSING PROCESS FOCUS PATIENTS RECEIVING ANTIFUNGAL DRUGS (conlinuM)
Implementlltion
Interventi ons li nd (Rlitionli les)
Patient understanding of drug therapy:
Use adminismtion ofmeciutions aocl ruring
aIIf S>meOU 10 disaru the miJnalr for drug therap)', desirro theraprutic:
ootOlltll'S, most oommon advme efftm. parametm fOrwhen 10Glil the
heahh (')re aO)' lIf(ess:a1)' monitoring orpreuutioM.(lking tint
ruring rming (')re helps 100ptimilr alii reinloru keytuc:hing areas.)
Patient self'il dministration of drug therapy:
When ildministering mrdiutions, inltruct the patient. lamily,or wr<jivrr in
proper II'Ifadmin istration tKh niques. (Proper administration will inc:rei II'
the of the drug.)
Pliti ent li nd Flimil y Educliti on
The or c:art'9i!'r Ihoukl bf ablr to nate the INIon for tllf
drug;appropriate doll' aocl !<lIfruling;what ad''IW rffrdllO obII'M' for
and when to report; ind the length of mediution thmpy.
Teach the patient 10 take oral or IOpic:al i ntilungal medication ill 101101'15:
Complete the mtire ofthffilpy unless otlle!will' in\Uuc:ted.
Se!'ral months 01 oral therapy mily lit rtquirro to adequately treat the
inlrdion.
Avoid or eliminate akohol whilr on oral amilungals toal'Oid hepatic:
c:ompliutions.
oral antifunlj.llloungts (troches) in mouth or rinse with liquids
alter meals aocl at bedtime.lf dentures are worn, lit/Oil'
using thrdrug aocl Irav!' out OYl'fIIight. Swilh the liquid drug arouocl
mouth aocl hold in the mouth at Irast 1 minute\ brioll' expKlOrating.
Do not swallow unless inSlruc:ted todo soand do not rinll' the mouth
with water afterwards.
Do not!M oxdusive when topic:ill i milunljills aft'
a thin, iaymo theafler:ted aIN.
Allow aflKled skin aft'aI to air dl)' and ww IooII'-fining aocl
"breilthable 1 a brio: c:lothelto allow adequate Gently dean s.t
all'lS with mild SI)lP <l oci water and avoid I'igoIOUl !<rubbing.
Evaiulition of Outcome Criterill
[vawte the elfrdi!'lIeSs of drug thmpy by c:onfirming that goals and expec:ted outc:omes ha!' bffil met
SH JHfor lisltidr0g5 rcwNchrhtst
Although rarely used as monotherapy, flucytosine (An-
cobon) is sometimes combined with amphotericin B in the
pharmacotherapy of st'Vere candidiasis. Flucytosine can
cause immunosuppression and liver toxicity, and resistance
has become a major problem.
A newer class of antifungals called echinocandins has been
added to the treatment options for systemic mycoses. The
first drug in this class, caspofungin, has become an impor-
tant alternative to amphotericin B in the treatment of as-
pergillosis. Approved in 2006, anidulafungin (Eraxis) is
approved for invasive candidiasis. The echinoc::andins are
less nephrotoxic than amphotericin B and have fewer seri-
ous adverse effects.
AZOlES
The azole drugs consist of two different chemical classes,
the imidazoles and the triazoles.Azole antifungal drugs in-
terfere with the biosynthesis of ergosterol, which is essen-
tial for fimgal cell membranes. Depleting fungal cells of
ergosterol impairs their growth. The awle drugs are listed
in Table 35.3.
35.5 Pharmacotherapy
with the Azole Antifungal.
The awle class is the largest and most versatile group of an-
tifungals. These agents have a broad spectrum and are used
to treat nearly any systemic, cutaneous, or superficial fungal
infection. Ruconazole (Diflucan), itraconawle (Sporanox),
ketoconawle (Niwral), and voriconawle (Vfend) are used
for both systemic and topical infections. The remainder of
the awles are prescribed for superficial infections.
Ketoconawle is available only orally, and is the most he-
patotoxic of the awles.ltraconawle has begun to replace ke-
toconazole in the therapy of systemic mycoses because it is
less hepatotoxic and may be given either orally or intra-
venously.lt also has a broader spectrum of activity than the
other systemic azoles. Clotrimazole (Mycelex, others) is a
preferred drug for superficial fungal infections of the skin,
vagina, and mouth.
The syuemic awle drugs have a spectrwn of activity sim-
ilar to that of amphotericin B, are considerably less toxic,
and have the major advantage that they can be adminis-
tered orally. Because of these characteristics,awles have re-
placed amphotericin B in the pharmacotherapy of less
LibraryPirate
IlIapurn Drug' 10< Helminthic: Inll'Ctlom 513
TABLE 35.3 AzoleAntifungals
"n"
Route and Adult Oose (max d05i' where Indicated) AdwfSe Effects
butocooazolt (Fmlsm) 1 iw!ic.JICf introwagillily btd:ilM ICf 3 diI)" Oril l i nd par!nt!rai routes:
dotrimazoi!, (fflII('ur, Gynt.\.otrinil. 'bpilill:ipply bid lor 4 wk;kf va911i1 myalfS, illlffi I appIi<ator
MyIM,OIhm) bdtint for 1 di)'s I'omilif/i
'bpilill;ipply bid lor 4 wk i oal2!r!:lixil blood !!!:S<miaI
Q (DiflOOln) POIIV;lOO-400 mg on !Ii)' 1, then 100-10) mgldilyfor H wk
(Sporanox) PO; 200 1119i!li)'; may to 200 mg bit (max: 400 mgldily)
(tim) PO;200400 mgldily
i PPIy OII(t Cf twitr daily 10 iff tllrd all'a Topltil route:
mkonazolt Mooillat, (roo:, otllffl) bid lor wk Dryir1ll ofJiin,5!irlgirrq
oxitonilat (Oxiltat) dilily in the 2 rno
DpIIimtion lirt, pruriM, urrimrio, (mr 1
dfflnQriD'1
!ft1.lcon.uoit (Ertaao) 'bpi1ill;29b uum bid/Of 4 wk
Ug lI:IimIlalMlxfllt!l1
IUkonazoit ritritt (Exeldern) apply Of lWitr dilily rOf 2 wk
tmonazolt (lbOzoI) 1 iw!ic.JICf intmaogillily btd:ilM IOf 3- 1wl:.
lioo:oniZOlt('hgism) I iw!ic.J1Of intmagillily btd:ilM fOf I dily
IV;' mg/bj MIY 12 h 00 dily 1,lhen 4 mg,'bj MIY 12 h; may
II'dlKUO 3 mg/bj fflf'I12 h if oot loIffltfd
inciutt ammoo id>Imt striOUSaIMlR
.... Prototype Drug I Fluconazole (Dlf/ucan)
Therapeutic (lass: Antifungal Pha rmacologic (lass: Inhibitor of fungal cell membrane synthesis;arole
ACTtONS AND USES
Likt otlltr uole, lluc:onarolt ill!:> by interfrring with tht of trgos-
tt rol. Fluc:onilOlt,OOW!'I't\ offen le'Ieral advintl9l'S oYer other systemic: anti-
fungals.1t is rapidly and (omplttt ly i blOrbM when gil'fll orally, and it iI
pirtic:ularl)o aganst (tndidQ aibironl. Unlikt itrac:onalOlt (SporallO.1)
i nd Utoconn* is ablt to penttratt IIIOlt mml-
br ....... to rn<:h inft<tion, in t .... CNS, baM, <'l"', met,.nd lI',pi lory
,,"'-
A major disadvantl9l'01 ftUiOrwOIt is IIIIrrow spt<trum of ai-
tivity. A1thoogh it is against ComfIdD aibironl, it may oot be dfctift
against non- oRliam CoriMa spt<it!, whic:h i{((lunt for a lignifium
i 9l' of fungll inftions.
ADMINISTRATION ALERTS
Do not miJ IV AlKon.uolt with other drugs.
Pregnant)' uttgOl'1 (
PHARMACOKINETICS
On5t"t :Unknown

Halflife:2o...SOh
Duration: Unknown
ADVERSE EFFECTS
FIUloniz* laUlel 1M strious tfiriU. NaUl!'a, yomitiog. and dilnhe.J
all" at high doles. Unlikt is rart wlft flu.
lonaz*, although patimu with hepatic: should lit monitorM care-
fully. Sttnns- JohnlOn lyndromr has bern II'portM in ()ititms with
im 1IIJ000uppresmn.
Contr.indi mions: fluronazott is lontraindkaled in Pititntl with
tivity III tilt drug. with (isapridt is rontraindic:ated. BltalM
most d tilt drug is mll'1ed by tht kidntyS, it should be used cautiously in
tiffits with prNJisting kidney dilfillt.
INTERACTIONS
Drug-Orug: Uf of willfarin ilKlNSfd rill: forblHOOg.
HypogI)"(fmia mnimll'd(OIKulIl'Iltiywith ooainorat
h)tlOl#fmc, n:Wng iflburiclt. fhItonazoIt ImIi may be dKrNIfd with
lonurnnt rilampit or dmmdiMo !/Sf. fhto fflffil of ffn1Ml)l, or
may bepiolongN with lOOOIrlaU olIirini!lrililn
Lib Tflts:YaiIlfS for AST,AI.,Mld illiillinP phosphat.l\i' may beilmud.
HerbaliFood: Unknown
T real mr nt of Onrdosr: Thtre is no SptrifK tll'i tmenl for am:lOlt. Di.t lysis (,J n
lit Ul!'d to Iowt-r the strum drug
RPM Ie M}M!rl/ngIJ1 fr1f D Nlmifll) Pn:m:I FOOII lpKlk Ie drrii}
LibraryPirate
I




;,


t

514 UnitS ThelmmuneSystem
serious systemic fungal infections. Topical formulations are
available for superficial mycoses, although they may also be
given by the oral route for these infections.
The most common adverse effects of the systemic azoles
are nausea and vomiting; seVere nausea may require dose re-
duction or the concurrent administration of an antiemetic.
Anaphylaxis and rash have been reported. Fatal drug-
induced hepatitis has occurred with ketoconawle, though
the incidence is rare and has not been reported with the
other systemic azoles. Azoles may affect glycemic control in
diabetic patients. Various reproductive abnormalities have
been reported with systemic awles, including menstrual ir-
regularities, gynecomastia in men, and a decline in testos-
terone levels. Decreased libido and temporary sterility in
men are other potential side effects. The awles should be
used with caution in patients.
DRUGS FOR SUPERFICIAL
FUNGAL INFECTIONS
Superficial mycoses are generally not severe and p.11ients are
often treated with topical agents. Selected agents used to
treat superficial mycoses are listed in Table 35.4.
35.6 Superficial Fungal Infections
Superficial fungal infections of the hair, scalp, nails, and the
mucous membranes of the mouth and vagina are rarely
medical emergencies. Infections of the nails and skin, for ex-
ample, may be ongoing for months or even years before a
TABLE 35.4 .
Selected Drugs for Superficial Mycoses*
patient seeks treatment. Unlike systemic fungal infections,
superficial infections may occur in any patient, not just
those who have suppressed immune systems. For example,
about 75% of all adult women experience vulvovaginal can-
didiasis at least once in their lifetime. Athlete's foot (tinea
pedis) and jock itch (tinea cruris) are two commonly expe-
rienced skin mycoses.
Antifungal drugs applied topically are much safer than
their systemic counterparts because penetration into the
deeper layers of the skin or mucous membranes is poor,and
only small amounts are absorbed into the circulation. Ad-
verse effects are generally minor and limited to the region
being treated. Burning or stinging at the site of application,
drying of the skin, rash, or contact dermatitis are the most
frequent side effects from the topical agents.
Manymedications for superficial mycoses areavailable as
over-the-counter (OTC) creams, gels, powders, and oint-
ments.lfthe infection has grown into the deeper skin layers,
oral antifWlgal drug therapy may be indicated. Extensive su-
perficial mycoses may be treated with both oral and topical
antifungal agents to ensure that the infection is eliminated
from deeper skin or mucous membrane layers.
Selection of a particular antifungal agent is based on the
location of the infection and characteristics of the lesion.
Griseofulvin (Fulvicin) is an inexpensive, older agent given
by the oral route that is indicated for mycoses of the hair,
skin, and nails that have not responded to conventional top-
ical preparations. ltraconazole (Sporanox) and terbinafine
(Lamisil) are oral prepar:ations that have the advantage of
accumulating in nail beds, allowing them to remain active
many months after therapy is discontinued. Miconawle and
Oru, Rout .. and Adult Dn<P do,," wh ...... lndlralPd) AdVPr ... I'ff ....
butmafinl> lMffitax) daily for4 wk for tiDl'aI Orying of 5kiJ, llingir.g llm/IOOn opplkorion fire,
ddopirox atam, (loprox)
Ul'am bid )( 4 for
pruriM, (0011"
or (l'ffiIoK)
iHqutltonail x >l8wks foron)'(hornyc:ostI
(g!i!tSlfll():iDI
(OIjlterbinafntl neutropenQ (0Ij( Tflbinafnt)
griItofUvin lFulvidn) PO;SOOmg 1li00li1! 01331>-175 mg dailyfor
and OIl)'(homylle
(Naftinl apply <Ttam daily 01 gel bid for 4 wk for tiDl'aI
Q Il)'statin:topicil po:IWRr (Mymstatil, PO;SOO,lro-l,OOO,OOO unilltid
Hystop);oral (Nilstat);(,Jp!IR
Intravaginal; 1- 1 tablttl daily for 1 wk
(Bio-Statin); aum, ointmffit (M)'(OS1iItil,
Hystu )
terbinafnt daily orbid )(
PO;150mgdaily x 6- 12wkforonyd\omy(ostI
tolnaftur nfll(\iI) bid for 4-6 wk
oodrcyItnil: uid daily
GordodIom,olhm)
drugs for wperfKiaI ilfffiioosafl' induded in 1SJ.
Irdi6 (011)1lI0II strious t/feds.
LibraryPirate
OIoplfl n Drug. for fungal Protozo.n, . nd Helminthic: Infection, 51 5
Prototype Drug I Nystatin (Mycostatm,Nystop,others)
CI ass: Topical antifungal Pllarmacologic Class: Polyene
ACTIONS AND USES
binds to sterols in tilt fUngal It.kagt ofinna
ctlkJlar I I tht mtmbrant betOIlltl W!'iIkenftl.Ahhough it btlongs to
tht limt chtmical dall., .mphotffic:in B, tilt poIYi!flt s, is availablt
in a willtmriety of formul ations, inWding (fUm, powdn,
.nd lounge. Too toU: lor j).Irenteral administration, nystatin is primarily "'td
topically for undida infrctions of tilt vagina, skin,.nd mooth.1t may . Iso bt
use;! orally to tft'.t candidiasis 01 tht inttstint, betalU it mvrls through tht GI
too without bting absOlbtd.
ADMJNJSTRATION ALERTS
Apply with a swab to tht affrctftl.1N in infants.nd children,as swishing
is difliruk Of impouiblt.
For oral candidiasis, tilt drug should btswishftl intht mouth for atfeastl
min"t ...
PJl'9nanq ((oral pl"I'j).Iruions) or A (topica l pl"I'p.rations)
PHARMACOKINETICS
Onset:Rapid
PNk: Unkna.vn
Halflift : Unkna.vn
Duration: 6--11 h
clotrimazole are aTC drugs of choice for vulvovaginal can-
dida infections, although several other medications are
equally effective. Some of the therapies for vulvovaginal
candidiasis require only a single dose. Tolnaftate and unde-
cylenic acid are frequently used to treat athlete's foot and
jock itch.
PROTOZOAN INFECTIONS
are single-celled organisms that inhabit water, soil,
and animal hosts. Although only a few of the more than
20,000 species cause disease in humans, they cause signifi-
cant morbidity and mortality in Africa, South America,
Central America, and Asia. Travelers to these continenl5
may acquire these infections overseas and bring them back
to the United States and Canada. These parasites often
thrive in conditions where sanitation and personal hygiene
are poor and population density is high. In addition, proto-
zoan infections often occur in patients who are immwlO-
comprom.ised, such as those in the advanced stages of AIDS
or who are receiving antineoplastic drugs. Agents for malar-
ial infections are listed in Table 35.5.
35.7 Pharmacotherapy of Malaria
Drug therapy of protozoan infections is difficult because of
the parasites' complicated life cycles, during which they may
ADVERSE EFFECTS
Wht n topica lly, nyst.tin producn Itw tffl>cts otlltr than mioor
skin irritation. Therr is 01 high inc:idenc:f of contact cltrmatitis, I"I'latftl to tilt
found in somtoftht formuloitions.Wht n gWfnorally,it may calU
diarrfln,r.aulu,nd vomiting.
Contraindi mions: Ihf on Iy comra indication is hypmfnsitiYil)' to tht drug.
INTERACTIONS
Dru;rDrug: Unknown
l.i bTe ts: Unmown
HerbaVFood: Unmown
Tl"fatment of OYerdose: TheI"I' is no !pfCiflC trutment 101 OW'idosr.
111'1'8" III M)NUIlIn9I for Q Millirrq I'rrKnJ fooJs J{lt(tk III rIr/s drr!/)
change fo rm and travel to infect distant organs. \I/hen faced
with adverse conditions, protozoans can form cysts that al-
low the pathogen to survive in harsh environments, and in-
fect other hosts. When cysts occur inside the host, the
parasite is often resistant to pharmacotherapy. W"ith few ex-
ceptions, antibiotic, antifungal, and antiviral drugs are inef-
fective against protozoans.
Malaria is caused by four species of the protozoan
Plasmodium. Although rare in the United States and
Canada, malaria is the second most common fatal infectious
disease in the world, with 300 to 500 million cases occurring
alUluaily.
Malaria begins with a bite from an infected female
Anopheles mosquito, which is the carrier for the parasite.
Once inside the human host, Plasmodium multiplies in the
liver and transforms into progeny called mel"Oloites. About t4
to 25 days after the initial infection, the merozoites are re-
leased into the blood. The merozoites infect red blood cells,
which eventually rupture, releasing more merozoites, and
causing severe fever and chills. This phase is called the
rrythrocyticstagf of the infection. Plasmodium can remain in a
latent state in body tissues for extended periods.
may occur months, or even years, after the initial infection.
The life cycle of Plasmodium is shown in - Figure 35. t.
Pharmacotherapy of malaria attempts to interrupt the
complex life cycle of Plasmodium. Although successful early
in the course of the disease, therapy becomes increasingly
LibraryPirate
516 UnitS ThelmmuneSyst"",
TABlE3S.S I
S@I@cted Drugs for Malaria
Drug Route and Adult Dose (max dose where Indlcatedl Adverse Effects
ICoartml PO; 4lableu twier daily for 31Wyswith food ftwI,orlhm/gi4
m)'f!9o._o
1tI1lI:I'>HIIiri'ti1l Qr RroInna.!tinn
alO\QQllOlltand progwrillMaiarone) POIol prophy\alis; 1 t.JbIt'lIlily llirling 1- 2 IIIys btkn uavd, Nometl, I'Omifing, abdomind pDin, diooIIfo.
aoll [OQlinuiog ,fief rtlUm IImxht, myII/giQ
PO IoIlrl'ilmmt;. labltlsJlIIy 1013 d.ys HMrootri.!,m:I1'l!I'!!Wn
o dKIroqUfM' IAr.llffij PO;600 mg dolt. thm 300 rogIwk /JaIjSetl, IJIJddiarrhto; mwldlll"9f\,
IrJdrmyd"joroqufM' IPiaqumin For acute anads:PO;620 mg iritial dose,lhffi 110 mgal6, 18,
MJdiflg btJrrfII ri5ion, p/IorJphobio IJIJd diffiruJry

paoge 743 101 the Prototypt and 28h
","'PO
Forprophylaxii: PO;310 II'Ig Itlrti'lg 2wt bdoR lIam and
I!mIo!v!k anemia il P<ltimtl with GOPOdelic:itnOC
rlillil
[ootinuilg H wt frAlowing rtum
meft<:qJilll'lLviaml PO; 250 mg OIICU wffl: for 4 v.k, tllm 150 mg VomitiIJ!l. IlIIUlIQ, m)'lllgio. dilzirll'U,

Treatmml: 1,250 mg asa 5iogle dost AVbkKk,llraIMirdia I!:molis
prillliqufM' For acule mad:s:PO; 15 mglday for 2 wk Vomitifl9, rnrullQ, m)'lllgio.lItododrI:
For prophyIaxii: PO; 1 5 mglday foIlowilg Il'lIITl 10114 d.ys

p)'rillltlilamiIll'IDaraprim) PO; mg on. WfH for 10wk
quinifM'IQuilamm) ForoKUiUnads:PO:650mgtid X 3days
Forprophylaxid15mgbid X 6wk
11m indilite (OOIITIOII oJdom's! effects; !IIderIiriog indiYtes serious adtmse
difficult as the parasite enters different stages of its life cycle.
Goals of antimalarial therapy include the following:
Prevention of the disease: Prevention of malaria is the
best therapeutic option, because the disease is very
difficult to treat after it has been acquired. The Centers
for Disease Control and Prevention (CDC)
recommends that travelers to infested areas receive
prophylactic antimalarial drugs prior to and during
their visit, and for I week after leaving. Chloroquine
(Aralen) is the drug of choice, unless travel is to a
region known to have a high incidence of chloroquine-
resistant strains.
Treatment of acute anacks: Drugs are used to interrupt
the erythrocytic stage and eliminate the merowites from
red blood cells. Treatment is most successful if begun
immediately after symptoms are re.:ognized.
Olloroquine (Aralen) is the classic antimalarial for
treating the acute stage, although resistance has become
a major clinical problem. Other medications are
prescribed in regions of the world where chloroquine
resistance is prevalent.
IImoIvIk il!!m!ia !:l flIiE'lldeOOmll
'hmiri"'J, "'U"4 myolgio. fIbdomiMi p<Ji>
Mrgaloblalli<aormy IClltoprny
l!!!mlboMooenia
Vomitifl9, IlIIIIlI<I,
Godlooism I'l'rtigCl frut visual
hlli!!l:thmnia (oma,urdiO'mruiar
ro!!w N[jQuloCYUl'jil
Prevention of relapse: Drugs are given \0 eliminate the
latent forms of Plasmodium residing in the liver.
Primaquine phosphate is one of the few drugs able to
eliminate hepatic cysts and achieve a total cure.
In 2009, the FDA approved the use of a filled dose combi-
nation of artemetherllwllefantrine (Coartem) to treat acute,
uncomplicated malaria infections. Artemether is prepared
from substances obtained from the Chinese herb Ntemisa
annua, which had been known to have antimalarial proper-
ties for overa thousand years. Lumefantrineex\ends the half-
life of the combination drug. Coartem is significant because
it is very effective and offers an additional option fo r treating
chloroquine-resistant infections. This drug is approved for
treatment, not prevention, of malaria.
35.8 Pharmacotherapy
of Nonmalarial Protozoan Infections
Although infection by Plasmodium is the most significant
protowan disease worldwide, infections caused by other
protowans affect significant numbers of poople in endemic
LibraryPirate
o Int.ded mNquito
bOtft petaOn.
f) Plumocl"'n
tr ..... IOw...
o "rGzoi,. <IiYide
Ineide MpelOC)1N.
o MtrGZoil ......
........
"",",-
....... -
and chiII..
o MlrozoitM _r
r.cI blood oeII.
..
...., ..

to ,_It cycIto.
FlgureJ5.1 Life cycle of PklsmodlUm
T REATING THE D IVERSE PATIENT
G6PD DQficiQncy and Antimalarials
o
G6PO dtfU.orq iI ciIordfr
bind .. lQ900f AIrUi.l.meiicans lIId ..
1laiUns, FiIipino1, lIId nw-.It iI the IIIOIt (1)lIIII"IOII fII-
l)mf drio!a, in OIIff..oo miIioIl ptopIt k iI bfJr.wI tIYt
.. 1tW1!d blood" inrm-

mNboiIm oflld bIoodoAsMld nwyUlMiMt
driO!nly ii pIIitnt lhoo.Ild betesled btbe IINtmenI is iiliitrd.
dwt shcUd beMided bJ with Ci6P06ebncy 1M
laoquimeilltiJioOl.llAfoNmides,lIId
areas. These infections include amebiasis, toxoplasmosis, gi-
ardiasis, crypto$poridiosis. trichomoniasis. trypanosomia-
sis, and leishrrumiasis. can invade nearly any
tissue in the body. For example, Plasmodia prefer erythro-
cytes, Giardia the colon. and &IlIl11loeba travels to the liver.
Like Plasmodium infections. the nonmalarial protozoan
infections occur more frequently in areas where public
sanitation is poor and population density is high. Drink-
ing water may not be disinfected before consumption and
Illay [,t: wilh rrom I"ullall wa,It:.
In such regions, parasitic infections are endemic and con-
tribute significantly to mortality, espedaUy in children,
who are often more susceptible to the pathogens. Several
of these infections occur in severely immunocompro--
mised patients, Each of the organisms has unique differ-
Oi>plfl n Drug. 10< Protozoon. Helminthic infection. 517
ences in its distribution pattern and physiology. Descrip-
tions of common protozoan Infections are
giVl'll in Table 35.6.
One such protozoon infection, amebiasis, more
than 50 million people and causes 100,000 deaths world-
wide. Caused by the protozoon EnramO<'oo hmo/yrica, ame_
biasis is common in Africa, Latin America, and Asia.
Although primarily a disease of the large intestine. where il
causes uk.ers, E. histolytic" can invade the li\'er and create ab-
SCC5.'ies. The primary symptom of amebiasis is amebic
il)ntff)', a severe form of diarrhea, Drugs wOO to treat ame-
biasis include those that actdirectlyon amoebas in theintes-
tine and those that are administered for their systemic effects
on Ihe liver and other organ$. Drugs for amebiasis and other
nonmalarial protozoan infections are li sted in Table 35.7.
Although several treatment options are available,
metronidazole (Ragyl) has been the traditional drug of
choice for nonmalarial protozoan infections. In 2005.
tinidazole (Tindamax) was approved by the FDA for treat_
ment of trichomoniasis. giardiasis. and amebiasis. This drug
is very similar to metronida.1.ol e but has a longerdur3tion of
action that allows for less frequent dosing,
DRUGS FOR HElMINTHIC INFECTIONS
Helminths consist of various species of par.l.sitic worms. which
have more oomplex an.atomy, physiology, and life cycles than
the protozoons. Diseases due k) these pathogens affect more
than 2 billion people worldwide, and are quite common in
LibraryPirate
518 UnitS Immune SY"'-""
NURSING PROCESS FOCUS PATIENTS RECEIVING PHARMACOTHERAPY FOR PROTOZOAN
OR HELMINTHIC INFECTIONS
Assessment
Bilstline assess mf nt pri or to administrati on:
Understand tht drug Iws bffir pre(riilfd in order to U:1E'15 for
thtrapeutic: riff,cts.
Obtain a (omplete health hiltory indudi ng lII'urologk,
I!"Ipiratory,hepatic or It'IIiII dill'all', and tht poSlibilil)' of
a drug history induding inck.oding sptCifK rN<tions to drugs,
(ulTfIlt pn'scription and OlC drugs, htlbal plt'plrations,ind akohol USl'. Be
aim to possibllo drug inttfoKtiolll.
AsII'IS and symptoms of (urrt nt infer:tion and IISI'IS family IIIl'IIltlm
or living in the homt.
Obtain a travel history, noting dates of travel and nott when (ulKm
symptoms Slarred in to (i.t., i lter travdl.
Enwtt appropriate !.ooratory and diagnostic: tfSt findings (t.g., (Be, C& S,
fal ova and hepatic: and rrnal function studie, ECG U
appropriate).
Assessment thro ughout administration:
AsII'IS for fiftcB (e.g.,diminished diarrhei, chills. kl'tf,
muscllo pain).
Cominut periodic monitoring ofCBC,hepatk and rf nal fundion,C8tS, fecal
OI/a and parasites.ind ECG as ippropriille.
AsII'IS for admSl' riff,m: naUll'a, vomiting.abdominal cramping. inut'lling
dia rrhN, drowsi dizrillfS pafl'l!OOias, mttallit tastt, darken td uriIII',
dysrhythmias, a nd palpilollion diarrhea, especially (ontain ing
mIKUS, blood,or pus;)'!llowing of sclera orskin;oietfl'iII'd urine output;
numbllf"U of lI'izufl's; dysmythmias; hypotffision; a nd
should br rtpOnM
Diarrhea

Pot entilll Nursing Dillgno5es
DerICient FiJidVoiJlIII:' (related to diarrhN, wmiting)
Fatigut
Imbalanced Nutrition, Than BodyRequifl'lllffill
Pain (fI'lattd to diarrhea, abdominal mmping. muscle pain)
Impaired Skin Integrity (fI' lattd to diarrhei)
Dmcient Knowledge (fI'Iated drug thtraP'1)
Plll nning: Patient GOlll s li nd Expected Outcomes
The patient will:
Uperitfl{f tfffi:1I (e.g.,diminished signs and symptoms ofinfffiion,oietfl'all'd ft'l er i nd
Be mf from, or experience minimal,adYerse tfftcts.
Verbalizto an understandinQ of the drurt s UII', adYerJe riff,cts, i nd rtquifl'd pttc.lutions.
proper II'Ifadministration of the mtd"Kation k g .. timing. when to notify provider).
Implementati on
Interventi ons and Rati onil ies Pllti ent li nd Family Educll ti on
----t--
Ensuring theril peutic efffcts:
Cominut iSmSmtnll i sdfStriilfd earlier forthmpeutit riff,(\s.
(Diminished pain,diarritta,orsigns of inkction should begin SCIOlI
after tlking the fint doll' and (ontinut to Thf heahh ptovidtr
should be notified ij signs 01 init(tion remain after 1 days or ij the ffitifl'
roUIll' has takffi and signs ofinfffiion ill' still pl!"II'nl)
TNCh the patiffit to IfIIM i fem that does not diminish below l00"F
within 1 days, signs and symptoms of inkction, Of )"Il1ptoms
that It'IIlain prt"ll'llt alter taking thf (OUIII' of the drug.
Minimizing ildft rse effects:
TNCh the patient to not stop the antibacterial when "kfling better" but to
take tht entirt (OUIII' of the antibaafrial;do oot shall' dom with other
mtmbtn with similar symptoms;ind f1'tum to the ptovidtr if
symptoms oot IfSCIlvtd after thef ntifl' rourSl' ofthtrapy.
--+=
Cominut to monitor vital cspcci.Jllytemperaturt iffever iI prtll'nt.
Rfpon undiminished ft'leror(hange in level of connNllfSs to Ihe heakh
calt' ptoIIidtr (mer should begin to diminish within 1 to 1
!bys aftef <uning the may he i sign of
fifKtt, or amibiotic ffSistana.)
Teach tilt patient to rtpOn a fC'/Cf t1wt dots not diminish
below l00"F, or per parameten, or (hanges in behavior or LOC to tht hfakh
ufI'provider.
LibraryPirate
o..pur n Drug' lor ProtOZOI", Ind Helminthic: Inlec:Uorn 519
NURSING PROCESS FOCUS PATIENTS RECEIVING PHARMACOTHERAPY FOR PROTOZOAN
OR HELMINTHIC INFEalONS (Conllnued)
Implementation
Interventi ons and Rati onales Patient and Family Educliti on
(ontinUl' to monitor periodic: lab "Id fUnction In\!roo tht poatitnt on the nffil for periodic: lab work.Provide a kit and
EeG, C&S, and fKilI ova and poarasites.(Hepatic: and poanirularr,. inslnICIions for homt 1M ifftcal sptdmem requiiM
with IV Ihmp)', br monitortd to MI'!'IIt
is Stilted or if in an
(&$ ttsU orftc.1 oya and tests rna)' brordtred if infections
rmtrgtrK' OI'l'IWhflming infffiion with s.ig nifK.!nt body-widt
or arr slow to II'IOM- to confinn appropriall' EeG roonitorillC)
S)'mptoms),u 5QOIl U ft asibly and ihertafll'f as ordertd b)- the
mol, he required with Willi' antimalarial drugs.)
hulth carr pmridef.

Manitor for a nd allergic: rractions, fijlfCially with first few Ttuh tilt patient to immtdiattly rrpon any itming.ralhts, s'ftlling.
doles of any dOl 9 tlNlment (Ana phyiactic: a pm partirularr,. of tollC)UI' or S)'lI(opt,
panicularr,. with tilt first doll'.As parasites dit, dianhe., wheezing. throat tightnffi,or diffKUIty brrathing. Rtport signifiunt
abdominal pain,or mills may occur.) in abdominal pain,diarrhu,dlills,orfeverto tilt lItalth Wt
providtr.
(ontinUl' to monitor for hepa\K or rtnal toxicity.(FrtqUeni monitoring is Ttuh tilt patient to rrpon any naUlI'a, YOIIIiting. )'I'llowing of
to prrl'l'llt MY!'1It Ni"KU.lnmoasillC) lkJid intlu will prt'l'I'Ilt dlll9 skin or sdtra,abdominal pain, li9ht or cla)'-colored Itook, diminished uriIII'
accumulation in outpul,or dlrkening of urint ,.
Ad'IiII' tilt patientto fluid intau to 2 co II perday. 1M
should bU"loidtd or t-iiminattd.

Manitorfor significant GI naIMa, wmiting. and abdominal tilt patient to tlU tht drug with food or milk but to avoid "idic
poain or (lampillC).GiY!'drug with food or milk to (;1 tfferts. foods, he\'trlges or wbonattd and akohol 1M, i n
(An may he conliderrd if naUIN is UII', rsperiall, patitnuon mtlroniduole.
in poatitnts on metronidazoif,may calM a dilulfiranrlikt rraction with
ocessiY!' na!Mil, l'OIIliting.and possiblt
Manitorfor signs and Iymptoms of nftJrologic Ttuh tilt patient to rill' from l,ill9 or sitting to stlndillC) toavoid
drowlilll'ss,and htadac:ht--and tniUrt' patitnt 8t uutious with tiMo dizzineslor falls and to awid driving or othtr activities mt ntal
tIde!Iy who he at incft'iIItd rille for diuinessand falb. (ltach the alfflnffi or physical coordination until tllteffectsof tlltdrug aft' known.
patient to rill' from or sittillC) to ,tandillC) gradually ifdiuiness ocrurs.)
InstrOO tht hospitlliztd to call for a5Sistancf prior to gtning out of
bed or atlmlpting to walk

Manitor and ECG as indicattd in on anlimalari.tl trratmtnl. Ttach tilt patient to promptl)' rrport any palpitations or
(SoIM antimalarials may calM II,srhythmias a nd hypol\'nsionJ

Manitorfor signs and symptoms ofballl' marrow and blood - tilt patient to rrpon any I O'N--gr.JdIo fIowrs, IOrr thlNt,rashes,
dyscrasias, t .g.,Iow-grade ie--ft'rs, bltecling. ing. or s.ignifunt fatigUl'. bruilillC) or bltecling. unuswl fat9Je,or shonnes ofblNth,
(80lIl' marrow wppres.sion rna)' blood dyscrasias with aftt r takillC) drug thecap)' for a prolongtd ptriod.
decrrases in ROCs, WBCs, a ndlor piateltn. Periodic monitoring of (Be may he

A,II'Ss tilt poalient's Itlllil panners for infffiion and tIN! rurrmt pannm Hal'f tilt patient ootif)' II' lWl for iSsessrrteclt and tlNlment
to avoid reinfffiion.(Tht infeaion mol, he rt introdlKtd b,the nonlft'attd
saualpoartnec.)

Ttach gtOeral hygitne to pft'l'ffit reinfestation with poarasites. Ttach tilt patient and family or urrgivtr h)9ier11' mt asulfSand t ll(ourq
(Familie with)'OllllC) mildrm should practic:t thOl"OUllh handwas/ling. Y!'terinary iSsessrrteclt offamily pets. if as)'mptomatK.
proptrdispoNl of diapm,and nolif)' or childurr pro'/iders of
infection.Assess for famil, ptts who wry infffiion and also requirt
traYl'ltrs should !(rupulous h)9ient,
esptcially in dIo\'tloping countries.)
Patint understanding of drug the rap,:
till' owonunities durillC) administration of during Tilt family, or should he ablt to stitt tilt for the
as II'Ssmenu to disC\J5S tht for dlll9 therapy, desirrd iherapNIic drug;appropriatt doll' and \(heduling;what aMIIt effec:U to obll'lVl' for
mon obll'lVtd poaramtttrs forwht n and to ft'port;and tilt anticipoattd ItllC)th of mtdic:.Jtion therap,.
to call tilt health cart' plOl'ider,and any nKesSllI"j monitorillC) or
precaUlions.(Using timt rurillC) rursillC) Iltlps to optimizt and
ke)' tt achillC) areasJ
(Continued)
LibraryPirate
520 Unit; ThelmmuneSyu,-""
NURSING PROCESS FOCUS PATIENTS RECEIVING PHARMACOTHERAPY FOR PROTOZOAN
OR HELMINTHIC INFECTIONS (Conrlnued)
Implementation
Interventi ons and Rati onales
Patimt selfadministration of drug therapy:
When mtdiutiool, inrnuc:t lamily, or in
Propel' inimition IoIIowfd by return demonstration.
(Propel' administration 01 drug.)
Patient and Family Educati on
TfoKh patimt to take the medication as follows:
Complett ( OUIW of therapy unbs inllnKled.
Awid or rliminuf akohol.Somt IIII' diutions
signiliunt taken with akohol and akohol in{ful!1
61 t ll ts 01 many drug;.
Takt thedrug with lood or milk but avoid oKidit instOKted
to t.!kt the drug 00 an empty stomach, take with a IuliglaSl oIwatt'l.
Takt the mrdituioo al SPited thlOllljhout t ilh day as Ifasibit.
oel"aU lkJid intakt whiit taking tilt drug.
Disurd outdattd IIII'diutions or no Iongrr in 1M. Review
ubillfl IWKr i forold medications.
Evaluation of Outcome Criteria
Evaluue the l'IiliftOl'SS 01 drug therapy by {oofinning thu patient goalund aplrd outeDl1lI'S met (ste Planning").
5tI' iIlt/e:3H, 35.7, IiIltid1i(llUlwhich rfItst ooflinglKliom .
.... Prototype Drug I ChloroqUine (Am/en)
Therapeutic (lass: Antimalarial agent Pharmacologic (lass: Heme complexing agent
ACTIONS AND USES
Devdoptd to rountt'lthe high inr:iden(tof malaria among Amt riun lOldit rs in
the P ilie I !lands during World Wi r II, (hloroquinr hi s bffiJ the prototype mtd-
ication for tht pro and UN1mt nt of malaria for thi n 60 is
in the t rythnxytit ltagt, but hn no mivity against latt m
Pll15trIIIdium. Both mioroquilK' and the do\eI)' hydroxychloJOqJiO!'
(Plaqwnii) also UIfd oll-lalltl for the trutllll' m 01 rbtumatit .nd inflam-
matory arsortiell, ilKluding upus t rythr matOlUs and rhfumatoid arthritis.
in thelood \\K\I01ts olPfoJt1llldiwn l!'Siding in red
blood crill. in tht u(uoies, it is brlieYed to the of
whim thm build; to tOlit IMoIs within the parasitt.
{an tht high of patients in tht in Itss
tllan 48 houll.1t also is ulrd to pmmr malaria by bfing 2 week;
eotORon (oolillJiog to6weKs oftt.r the
patient it<lV1'l.Ahhough {hloJOqJiO!' isa drug of moice. many other
i"lailabit, al rt'limnr:e to ehloroquint is {ommon.
ADMINISTRATION ALERTS
Pediatrit dosagt should bt IItraIM{hildren all' sus(ep-
tibit to aft rdOlf.
II administrating 1M, injtct into i i nd aspirate prior to injt-
ing medication btuult ofils irritating effts to tht tissues.
Plf90anq Ulegory (
PHARMACOKINETICS
1At'\et: 8- 1Dh
Pf,ak:3-4 h
15- 2 days
Duration: Variabit (stYeral diYS to
ADVERSE EFFECTS
ChloroquilK' txIlibin ftw serious .dvt lX' r1itm at low to Mau-
IN and diarrhei may oc{ur. At higher rIoIft, (NS and cardiomrular toric:ity may
lit obstrYl'd. S)'IIlptoms ilKludf {oofusion, (oovulliolll, rtflOfl, hy-
potension, and dysrhythmin. (hloroquint u n U IM tOliti!)" inr:luding.
blulrt'd yision, photophobia, and difliruity focusing.
Contrainditations: u n minal tOliti!)" it {OIl-
mindicattd in p.lIiton with orl'iswl rlfld dlang!1.k is also
contraindiuted in patients with rt'oal impairment i nd in !hOlt with
IiliYit-; to tht drug.
INTERACTIONS
1)ug- I)ug: Antacidland taxati"ll!l aUnintnl and
deauif {hkfoquillf atr.crptioo and mUll not tit 9i\opo withi1 4 hoIn of 00 0!hK
mayallo in!ml:n with tilt MpOOIf to rabifl 00111'.
lab Tell!: lktnowo
IlerbaVFoo:l: Uotncwn
l INiment 01 OYl!rdose: OY!'rdose may bt fatal. S)'mptomuit trfatmeot may
inr:1ucIe anticonvukanu and mOpl!'SlOll for shock. Ammonium chloride may
lit used toidify the uriO!' to hasten ellrWoo of
R#rt 10 MyMlsJflqr' (Of tmbtiJ I're!I FooIl sp1(/tI( 10 1M iJ'ug.
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OIoplfl n Drug' for fungal Protozo.",.nd Helminthic: Infection, 52 1
TABLE 35.6 1 Selected Protozoan Infections
Name of Disease and
Protozoan Specle(s) Description Source of Infection
AmdNsis Primarily infffi' tht I.vgl' int eIIin to c.JUliJg 5oMI! diall'hu; rommooly tri'/ek to tiN' Ii to form fffilI-<ontaminattct water
fIIranoebo hiJto/yli(D
iM11t\; rardy trMis to other OC9im sud! as tiN' brain, lungl,lX kidllt1
CryptolplXidOli! lolffiltiN' GtUling diarrhti; oftm Iffil in immUllO(ompromilrd pa1ientl fffilI-<ontaminattct water;

hllllilosand other anima!l
Giardiasis lofffiltiN' intellints,GtUling maiablorptioo, pain fffilI-<ontaminattct water
GiorrlQ II!mb6o
Malaria InIKt, ltd bbxI (d, fa.;5OIIIe i'lsmodQ tiN' andotiH'r offnnaif,Anop/ItIt5
i'll1OOil1ll11variou! !pKitI)
tislUl's. mosquito
1_
iovadt any 019'10; c.JUs.tl a fatal io inmmoc:ompromiltd patimt! CongI'naal cal
klIopIosmo gondii
'm
Trichomoniasis Common STD that caUIe vagiritis in urethriti! in malts Trammis!ion !hrOlJljh !t.IIIil
TOOIomI:nn ragilUll"rs
(OIIta(\ with iofffitct lkJids
Trypanosooiasis TiH' Ammo form dilriSl') DI aUlOOOmK 9i09ii;tiN' Afric.Jo of 00;t (Ammo)
TrypDl105IImQ f!lIli (Ammo)
form sidUlt llj QUIe CNS deprmioo IXtset!e fly (Nric.Jn)
TrypIIl1OSOmQ bf!KellAfriYn)
areas lacking high standards of sanitation. Helminthic infec-
tions in the United States and Canada are neither oommon
nor filtal. although drug therapy nuy be indicated.. Drugs
used to treat these infections, the antht'lmintics, are listed in
Tablt' JS.8.
35.9 Pharmacotherapy
of Helminthic Infections
Ht'lminths are classified as roundworms (nematodes), flukes
(trematodes), or tapeworms (cestooes). The most common
TABLE 35 71 Selected Drugs for Nonmalarial Protozoan Infections
Drug Route and Adult Dose (max dose where Indicated) Adverse Effects
iockqJinot (Yodm:in) PO; 63H50 mg tid for 20 dayi (mill: 2 g1day j NlWl#II, K>miring, htadQcM, tlnirlflS
!&:!Iofrision neur2lYt!rt
Q mttronidizol!, (FbgyI) 1'0;2,1)-750 mg tid lIilline5l, mera' rront,

tramiml kutooerit
rifunimox (l.Jmpit) 1'0;8-10 ffi9Il.IJ tllrel' tokutinWday for 90-110 lID II\. dilzioru,. hlDiIhf, noolftllmrb'riIg
wi!!! !!!l:aliia I!!!egnia
paromom,un lHumatinj 1'0; 25- 15 m9fkg in !hrel' dvidl'd do!el for 5- 1 0 NIWlN, K>miring, htadQcM, dQffM, ol!domilol 0IIlIpI
I!Ig1axi>ilX
pl'fltamidine (Peotam, 1'1' 11M; 4 rng./k9lday for 14-11 days; infu!e am 60 min (rug" brmdiolpo5m, rnlUIl4 rmrrxiIl
NebuPl'nt j
ll'ulioorria byoodvrnria abKmQr pain at iniraioo lhr
hlDOtmlion
sodilltl stboghKonate 1M; 20 tngtWday NQlJltQ, IIIOfaiQ, (Ojjgo\ !iIblrema /lllin
(PtntOltam)
f&i !!Il!;rajia!
tinidazoll' (Tilliamax) PO;ljardiali\: >0 mgik9 io dole (max: 2 g);ammasis: AniUliQ, mero'rront, QOO rJaJJeII
2 g/diy for 1- , da)'5
Rrdllbwlllt::llllllilm: Irui!lllrliol
/ralt5 indic.Jte (OOT1lOlladYml' indicates lI'riousarNl'!"SI' I'ffI'ru.
LibraryPirate
522 UnitS Thl'lmmuneSyu"",
.... Prototype Drug I Metronidazole (Flagyl)
Therapeutic (lass: Anti-infe<:tive,antiprotozoan Pharmacologic (lass: Agent that disrupts nucleic add synthesis
ACTIONS AND USES
Mttronidaz* is prototypr drug for mostlOlln! 01 am!'biasil, bting
aljainst both and IliIgtS 01 tht diSN!e. Reistam
forms 01 E. hislolyrKQ 11m not yet u a dinical problem with
nidaz* thtrap)'. Melronidazolt is a drug 01 lor two protoro.n in-
fKlicm:giardiasis and trichomoniasis.
Metronidazole is unique among antiprotOlOan drugs in that it aka has an-
tibiotic actiYity aljainst bacteria and thus is!Hed to mat a numbtl"of
I6piratory, bone, !kin, and eNS infections. T apical forms of IIII'troniduoie (Mtt-
UIfd to 1O\..J{U,a disu!e charmer-
ized by skin rNdening and hyperpLuil 01 !ehai:eous glanrk, particularly
around n= and bee. Off-label lM5 indude pharm"ommp)' of
psNCiom!'mbraoo!H cotitis and Crohn's Helidaoc: is a combination drug
containing bismuth,and that is used to
H.p}k>ri infection modated with prptic uker
ADMINISTRATION ALERTS
The "tended-release form must bf swallowed and taken on an
empty slOmac:h.
rirring the fim trimester 01 prtgnanq.
Prtgnancy(a\fgOl)' 8
PHARMACOKINETICS (POI
()Jset:Rapid
Pt'.k:l - lh
.... 8 h
Duration:Unknown
helminth disease worldwide is ascariasis, which is caused by
the roundwoml Ascaris lumbriroides. In the United States, this
worm ismostcommon in the Southeast, and primarily infects
children aged 3 to 8 years, since this group is most likely to be
TABLE 35.8 1 Selected Drugs for Helminthic Infections
ADVERSE EFFECTS
Ahhough adRiII' efferu occur relatiYely most are not serio!H
enough to CiU!e diKontinuation of most rommon
of metroniclazolt art anortxia, naUleil, diarrllta, dizzinelS, and headac:ht. Dry-
ness of tk mouth and an unpltuanl mttlilic taste may
though rart, metronidazole (In (lU!e bolll' marrow !Upplt-ISion.
Contraindications: Mttronidaz* is rontraindicated in f)ititnu with tri-
dJomon ia!is during tilt first trillll'"lter 01 prtgnanq and thole with hypelll'nsi-
ti'lityto tilt drug.Metronidazolt (I n marrow !UpprtlSion;thus, it is
rontraindicated lor f)it itnll with blood dl'l'ri lias.
INTERACTIONS
Drug-Drug: MEtronidazoIt iueram with oral antiroagulanll to poIaltiar:e
h)'poprothrornbilfnN. In arnbination with akohol, II" oW! ltII'dications that may
<DIUin akrtlol, lMrOIIilazolro may eIictt a dsUftram JNOion. ln palierlll taking
lithium, thf drug may flf'liltlithium
lab T15u: Mtuonidazolro may dKJNII' '/iUs for AST and ALI
IlerbaVForxi:iJnknown
Treatment ofOYerdose: There is 00 sprcifK tlNtllll'l1t for
HmfIlMyMfimgKt IIIr /UJhlgl'IIXe\lkXIIIIpKlIII.1I UIIIIfI!9.
exposed to contaminated soil without proper hand washing.
Enteriobiasis, an infection by the pinworm Enterobius vermic-
ularis, is the most common helminth infection in the United
States. For ascariasis, oral mebendawle (Vermox) for 3 days is
Dru, Route and Adult Dose (max dose where tndtcatedl Adverw Effects
al bfnduolt (Abtnza) PO:oIOO mg bidwith (IIIiIJ:800llII}iday) Abootmd 6rfrillKoon rtm,oMomiro/ p4f1, rnrult4
--.

ivffinKiin (SIromKlol) PO: 150-200 as. single .me rm, prorirus, "oms, orrhrulgi<!, lymp/IoiItoop:!fhy
allerg!!ior inflamllliltm:
Q mtbtndarole(Vermox) PO: 100 mgas i 100 mg bid for 1 days AbdroriroI di<! rrIifo, fIJ5h

pruiquantrl (Bitriddr) PO;S mgibl as a IiIglt doIr::, or i5mglkg tid Headache, dlJiflfl.!, fflQ/Qili, ftllJ, oMrmirro/ poi!

p)'ranlel (Antiminth, Ascarrl, PirX, PO: 11 IiIgit .me(max:l g) NoIllM, lerJfIII1UI. diorrlifo, fWl"! r
Pinworm GJpleu)

Irdia indiYte rommon advme tffem:.I!l!!mi!i!!!I. indiYtts 5oeIioui adve-If tffem.
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the standard treatment. Phannacothernpy of emerobiasis in-
cludes a single dose of mebendazole, albendazole (Albenza)
or pyrantel (Antiminth, karel, Pin-X, Pinworm Caplets).
like helminths have several stages in their life
cycle, which include immature and mature forms. Typically,
the immature forms of helminths enter the body through
the skin or the digestive tract. Most attach to Ihe human in-
testinal Iract, although "",me species form cyst. in .keletaJ
muscle or in organs such as the liver.
Not all helminthic infections require pharmacotherapy,
because the adult parasites often die without reinfecting the
host. When the infestation is severe or complications occur,
pharmacotherapy is initiated. Complications caused byex-
tensive infestat ions may include physical obstruction in the
L IFESPAN CONSIDERATIONS
Childhood Play Areas and Parasitic Infections
PirM'Ormsand IOOndwormsall'moll'oommonlysft'n in(hiliRn bruusf many
of thtir hygielll' and pby habits 10 the trammission ind reinfeu-
liln wonm. lnllnKI pall'llUand family mtmhe!\ about to prevmt
to and sprud of helmimhs. dlildl!1l (oma ha nd washing tffil-
nique. fill phuizirog under the niils and wishing befell' ind
after lIIing the toilet lb:ouragt pIKing ha rKk in mouth and biting naik.Do not
allow dJild to sc:rmh the anal ill'i. Make SUft' that dlildl!1l WNr shaH when
playingOUllidt.Awid UIol' ofsandbom, which(.!n he auelfd by dogs or LID;
keep ooYeft'd ....-he-n oot in lM. Cltin!f all fruits and "ffIjttabies he-
fomNting.(hangediapm fll'quently and dispolf d proprrtj(oulofchildft'n's
ft'idI). Do not dow (hildl!1lto swim in pools thm llow diaptred dJildrtn. Dis-
(USS whoIt-fIImily partiallartj in households with )OII1g
(hildl!1l, lllflllber hasan infliln.
Prototype Drug I Mebendazole (Vermox)
IlIiplfl n Drugs for fungal Protozo.n..nd Helminthic: Infections 523
intestine, malabsorption, increased risk for secondary bac-
terial infections, and severe fatigue. Pharmacotherapy is tar-
geted at killing the parasites locally in the intestine and
systemically in the tissues and organs they have invaded.
Someanthelmintics havea broad spectrum and are effective
against multiple organisms, whereas others are specific fora
certain species. Resistance has not yet become a clinical
problem with anthdmin.tia.
LIFESPAN CONSIDERATIONS
Parasitic Infections in Children
Many paruitk among(hildl!1l, with IIitilllil ratH
highesl among dlildft'n Its! than S public health libl,!he mOSI
rommoniy diagoolfd intfllin,1 p,ruitf is Gardia. GiardiaUs lalHaft' moc:i-
uti! with swimming in oontaminattl! watfrways or drinking (ontiminattl!
groond 'ftll ia (ontaminattl! diapen in (hiki-caft' mti ngs, and drink-
ing watf!" or ronwming raw fruit; or Yegetotblts during
Giordio inre.:tilm miY alia be difliruk 10 becalM lloolsprtillll'ns do
not always (ontain lhe lWoI or pa althoogh llool ,migm sprtiIK
to Gilmia isavailablt.
(hildft'll from (OUnlnn ouuillt of Unittl! State alia a
high of parasitir: infection. Up 10 1 S% of forfign-bom idopted (h i1d1!1l i Il'
Il'pOntl! 10 hi!' Giordio lamb/it!. Emrironmtnts in which hal'
Iwing. pa rtiruli rIy orphanagtS, often plOl'ide favor! bit (onditilm in-
re.:tious The (DC ft'(omllll'llds that adopttl!
undergo of at !fall 11001 !.Implt, ,nd thlft stoolsimp1t5
Gisymploms rvilltnU' has shown that in (ommu-
nitie wherto helmimh in/e(\ions aft' (Ommon. in !he U nitm Stale or
poor nutritional lIaM.a n!'mia,a nd impaired growth a nd Itaming in
IHUIt
Therapeutic Class: Drugforworm infections Pharmacologic Class: Antihelmintic
ACTIONS AND USES
is lhe most willtly pft'sc:ribed in the United
is UlI'd in the of a wiclt range of hflminth inftionl,induding tlicM
('!IMd by roundworm (Al(orn) and pinworm (Enrlrolri<nis). As a broad-
sprttrum drug. it is particularly akwblt in mill'd helmimh imfltiom, which
a (ommon in aft'iI having poor an itatiln. k is iga inst both adult
ind IalYilstage of k is poorly ablorbtd aflfr oral
tiln, which allows it 10 II'lain high (onU'lltroitions in the imHtilll'. For pinworm
infe(tions,a is uswlly inie(\ions loon!f(\J-
of therapy.
ADMINISTRATION ALERTS
Thedrug is mOil eifliYe whrn dJewfd ,nd with a farty

PHARMACOKINETICS
Onsrt:Unknown


Duration: Unknown
ADVERSE EFFECTS
BfloilM 10 littlt of drug is a bsorbtd, mtbtnduole dots not gtlll'liIlly (ilM
mious systemic siclt rifrm. A; lilt worms dif, IOmt abdominal pain,
sion,and diarrllea may he uptriencrd
Contr aindi (ations: on Iy (Omri indic:atiln is to the drug.
INTERACTIONS
Dru;rDrug: UrboImmpiIll' and p/IM)1oin (0)11 ilKffiR tilt mttaboIism of
...... "".
libTI'S1S:Unmown
HI'IiIi VFood: foods rna, inrrNlf the abIorption of the drug.
of ThM' is 00 !pf(iIK tft'itment for .
fit'" ru M7N,mlng/!ll for Q Nom/nq I'rIKm foal< 1pf<1Ic ru mrs druq.
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S14 Unit, Tho Immu,,",Syst"'"
Chapter REVIEW

KEY CONCEPTS
The nu mbered key concepts provide a succinct summary of the important points from the corresponding numbered section
wIthIn the If any of these points are not dear, refer to the numbered section wilhin the chapter for review.
15.1 Fungi have more complex physiology than bacteria and are
unafft'ded by most antibiotics. Most serimu; fungal illfe<>
tions occur in patients with suppressed immune defenses.
Hl l'unVI InfectIons are classified as superfkL11 (affoctl ng
hair, skin, nalls. and mucous membranes) or systemic
focting internal organs).
153 Antifungal medications act by disrupting aspects of
growth or lIletabolism that 3fe unique to these organ isms.
HA SystemIc mycoses affect Internal organs and may require
prolonged and aggressive drug therapy. Amphotericin B
(Fungiwne) is the traditional drug of choice for serious
fungal infections.
15.5 The awle class of antIfungal drugs has become widely
used In the pharmacoth erapy of both systemic and super-
fkial mycoses owing to a favorable safety profile.
15.6 Antifungal drugs to treat superficial mycoses may be given
topIcally or orally. They exhibIt few serious sIde effocts
and are effective In InfectIons of the sltln. nails,
and mucous membranes.
NCLEX RNO REVIEW QUESTIONS
D A p.1tient has been diagnosed with a fungal nail infection.
The health care provider has preSl:ribed fluconawle (Di -
fluC:III ). The nurse will include which of the following in
her patIent educmlonl
1. Drug therapy will be for a very short time, proOObly 2 to
4 wet'ks.
2. Carefully i/\Sped all intramuscular injection sites for
btulslng.
3. Notify the provider should you comedown .... ith
symptoms of a bacterial infection.
4. limit fluid intake to approximately 1,000 mUday.
D A patient is given a prescription for quinine (Quinamm)
for treatment of malaria. Prior to beginning therapy, the
p.1tiem wiU need to:
I . sign a consent form for taking this medication.
2. have an ECG done.
3. stop all ot her medications for 24 hours.
4. beadmitled to an ICU for the first 24 hours of therapy.
3,5.7 Malaria is the most common protozoan disease and re-
quires multidrug therapy owing to th e complicated life
cycle of the paras ite. Drugs may be administered for pro-
phylaxis. and therapy for acute attacks and preventIon of
reklpses.
35.S Treatment of non-Plasmodium prot owan disease re-
quires a different set of medications from those used for
maLuia. Other protowan diseases that may be indications
for pharmacotherapy Include ameblnsls. toxoplasmosIs,
gIardiasis, cryptosporldlosis, trI cho mo niasis, trypanoso-
miasis, and leishmaniasis.
3S.9 Helminths are pa.rasitic worms that cause significant dis-
ease In certain regIons of the world. The goals of pharma_
cot herapy are to kill the parasItes to dlsrupl
their life cycle.
o A patient returned from South America, where
malaria was contracted. A drug the nurse expects to see
used is.:
1. proguanll (P;lludrlne).
2. penicillin {AmpIcillin}.
3. ri:l<1triptan {Maxalt}.
4. chloroquine {Aralen}.
U The nurse Is providIng community education about pin-
worm. roundworms. VVhkh of Ih" foll owing shol1ld
be included in this teaching? (Select all that apply. )
1. Hand washing is very important in preventing the
spread of pinworms and rounm.urms.
2. Play habits contribute to the transmission ofpinwor/ll<;
and roundworms.
3. It is important that children wear shoes when pklying
outside.
4. Children should not beallowed to play in open
sandboxes.
S. Once the child has had lMJTOIS, reinfestatlon cannot

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o A patient, age )2, is staned on metronidazole (Flagyl ) for
treatment of a trichomonas vaginal infection, Whileshe is
on this medir;ation, she must amid:
I. caffeine.
2. addle juices.
3. antacids.
4. oIoohol
CRITICAL THINKING QUESTIONS
1. A nurse iscaring for a severely immunO$1.1ppressed patient
who is on IV amphotericin B (Fungizone). The nU!"l;e un-
derstands that this medication is highly toxic to the pa-
tient. What are three priority mmlng assessment areas for
patients on this medication!
2. A young female patient recent ly diagnosed with Insulin-
dependent diabetes has been g[\'t'f) a prescription for
metronidazole (Flagyl) for a vaginal yeast InfectIon. Iden-
tify priority teaching for this patient.
ct.Ipc...n Helminthic InlKtlons 525
o Metronidazole (FL1gyl ) is being used to treat a patient's
Gflmlill/mnblill inftion, a protozoal infection of the in-
testines. Which of the following are appropriate to teach
this patient! (Select all that apply_)
I. Metronidazole may leave a metaUk taste in the mouth.
2. The urine may turn dark. amber brown while 00 the
medication.
)_ The metronidazole may bt discontinued once the
diarrhea subsides, to minimize adYerSeeffects.
4. Taking the metronidazole with food reduces GI upset.
5. OuTent sexual partnel5 do Il()I: require treatment for
this [nCedion.
3. A patient is traveling to Africa for J months and is re-
questing a prescription for Malarone to prevent malaria.
What premedication assessment must be doll<' for this
patient!
Su Apptlldix D for UlUWI'TS lind mtionalts for till lutil'iritJ.
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DRUGS AT A GLANCE
DRUGS FOR HIV-AIDS fIlIJt519
Nudeotlde ReYEni'
Inhibitors fIlIJt $J(J
Q zidol'lJdine IRelrovir,AZT! fJIJII/511
Nonnudeoslde Reer1e Transalpuse
Inhibitors f1IlI}t5j}
o fftNirtnz (5llSliva/ jIIXJI m
Protease Inhibitors p!JIJt5Jl
o Iopino";, with rifOlIO>'i, /KolflroJ
fIIJi1511
FuslonlnhlbltoD Pt1II5JlJ
DRUGS FOR HERPESVI RUSES fIlIJt jJ&
Q acyckNir(Zovirax) p!JIJt5J9
DRUGS FOR INFlUENZAVIRUSES p!J9t54IJ
DRUGS FOR HEPATITI S VIRUSES paJt S4IJ
Interferons Jlll9t54}
KEY TERMS
immune def1tiencysyrdrome (AIDS)
JllXJ'5l&
antimroviral (JlJlJd18
,.psid paqr517
CD4 l'fCfptor fllXJ'518
p!XJ'54J
highly actin therapy (HMRT)
,.,."
Drugs for Viral Infect ions
LEARNING OUTCOMES
After froding this chapter, the student should be able to:
,. [)@scribethe major
2. Identify viral infections that benefit from pharmacotherapy.
3. Explain the purpose and expected outcomes of HIV pharmacotherapy.
4. Explain the advantages of HAART in the pharmacotherapy of HIV
infection.
S. Describe the nurw's role in the pharmacologic of
reclllving antiretrovlral and antiviral drugs.
6. Foreach ofthll classes listed In Orugs at a GlanCll,know reprl!Sentattvll
drugs, and explain the mechanism of drug action, prirnaryactlons,and
important adVllrsll Ilffllcts.
7. USIl thll nUl"$ing proceu to care for patillnts rllClliving drug thllrapyfor
viral Infections.
HIV-AIDS fllXT5l1J
human immuoodencifnC)' virus IHIVJ fIIXT 5l1J
influellU fllJlJ'540
fllJlJ'517
latint phasf (If HI V infKtionj fIIJIJ' 519
Pf9Ylation fIIXT 541
protNlli fllJlJ'5l1J
fllXT518
yiraiload fllJlJ'519
f irion fllJlJ'517
yirus {JIJ1t 5lJ
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V
iruses are tiny Infectious "gents capable of causing dis-
ease In humans lind otherorg.nlsrns.After Infecting an
organism, viruses use host enzymes and cellular structures
to replicate. Although the number of antiviral drugs has in-
creased dramatically In recent years bec.au1(' of resean::h into
the AIDS remain the IeMt effective of all
the antHnfectivfI drug dassn.
36.1 Characteristics of Viruses
V"1III\e are nonliving agents INt infect bac(eria, plants, and
animals. Virll.'ie5 contain none of the cellular organelles nec
essary for self-survivallhat are present in li ving organisms.
In facl, the slructureof viruses is quilt primitive compareil
with thaI of even the simplest (til. Surrounded bya protec.
tive protein coat, or r;ap!.id,;Io virus possesses only a few dozen
genes, either in the form of ribonucleic add ( RNA) or de-
oxyribonucleic acid (DNA). that contain the neocess.ary in-
formation needed for viral repllation. Some viruses also
have a lipid envelope that surrounds the capsid. The viral
envelope contains glycoprotein and protein spikes" that are
recognized as foreign by the host's immunesystem,and trig-
ger body defenses to remove the invader. A mature infective
particle is called a yir-ion. ,. Figure 36.1 shows the bask struc-
ture of the hrnnan immunodeficiency virus (HIV).
Although nonliving and structurally simple, viruses are
capable of remarkable feats. They in(oct their host by locat-
ing and entering a target cell and then using the machinery
inside that cell to replicate. Thus, are irlUacfiularpM<1-
sitts: They must inside a host cell to cause infoction. Viri-
ons do, however, bring along a few enzymes that assist the
pathogen in dupliating its gentl ic material, inserting ilS
sen ... into the Ilo..t's chron"lOOnu, nowly
formed virions. These unique viral enzymes $Ometimes
serve as important targets for antiviral drug action.
,. F1gun36.1 StJUctureofHfII
CIIopltlK 527
The host organism and cell are often very specific; it may
be a single species of plant, bacteria, or animal, or even a sin_
gle type of cell within that species. Most often viruses infect
only one species, although cases have been documented in
whidl viruo;es mutated and crossed species, as is likely the
case for HIY.
Many viral infections,such as the rhinoviruses that cause
the oommon oold, are self-limiting and require 00 medical
intervention. Although symptoms may be annoying, they
resolve in 7 10 10 days, and the virus causes 00 permanent
effects if the patient is otherwise he;>lthy. Some viral infeo:;-
tioru., however, require drUS thuilPf to prevcntthe infoon
or to alleviate symptoms. For example, HI V is uniformly fa.
tal if left untreated. The hepatitis B virus can cause perma.
nent liver damage and increase a patient's risk of
hepatoo::eUular carciooma. Although not life Ihrt3tening in
most patients, herpesviru!K'S can cause significant pain and,
in the case of ocular herpes, pennanent disability.
Antiviral phannaootherapy em be extremely challenging
because of the rapid mutation rate of viruses, which can
quickly render drugs ineffoctive. AI$O complkating therapy
is the intracellular nature of the virus, whkh makes it diffi.
cult to I!liminale the pathogen without giving excessively
high doses of drugs that injure normal cells. Antiviral drugs
have narrow spectrums of activity, usually limited to one
specific virus. The three basic strategies used for antiviral
pharmacotherapy are as follows:
Prevent viral infections through the administration of
vaccines (chapter 3:ZOO).
Treat active infections with dr ugs such as ilcyclovir
( Zovirax) that interrupt an aspect of the virus's
replication C)"de.
For long-term infections, use drugs t h.:lt booS( the
patien!"s immune response {LmmUnOSlimulantsJ $0
that the virus remains in latency wilh the patient
symptom free.
PHARMFACTS
Viral Infections
85\110 of Idulls hnor serologic Mden<:e of by
HSV1.
About.5 million infected with guiUI htJllts-Ontof
1M of tile toul.doitKmt.nd
(;rnit.l Ilerpts is men [ommon in WOnItn th.n in men. .nd in Afriun
Amtrium th.n in other ethnic gJOUpi.
About900,OOO living HIV inftions,and
.bout 010,000 ntw infection L OUIJr N<h )'tar.
Roughly ntw HIV infectiom occur in mu;tllt largest rish . tfgOry
is mtn who Lee with othtr men.
or the lIN HIV infections in WOmtn, 7S"'.J1! ..:quiffd thl'OUgh
htttrosnuallDl1ll<t
5R:t tilt btgiooing oltilt AIDS tpi:ltmic, II"IO!t tlwtl20 milon people

LibraryPirate
528 UnitS ThelmmuneSyu,-""
HIV-AIDS
Acquired defkiencysyndrome (AIDS) is characterized by pro-
found immunosuppression that leads to opportunistic in-
fections and malignancies not commonly found in patients
with health), immune defenses. Antiretroviral drugs slow
the growth of the causati,"e agent for AIDS, the human immuno
deficiency irus (HIV), by severul different mechanisms. Resis-
tance to these drugs is a major clinical problem, and a
pharmacologic cure for HIY-AIDS is not yet achievable.
36.2 Replication of HIV
Infection with HIV occurs by exposure to contaminated
body fluids, most commonly blood or semen. Transmission
may occur through sexual activity (oral, anal, or vaginal) or
through contact of infected fluids with broken skin, mucous
membranes, or needle sticks. Newborns can receive the
virus during birth or from breast-feeding.
Shortly after entry into the body, the virus attaches to its
preferred target- the CD4 receptor on T4 (helper) lympho-
cytes. During this early stage, structural proteins on the sur-
face of HIV fuse with the CD4 receptor. The virus uncoats,
and the genetic material of HIV, single-stranded RNA, en-
ters the cell. After entering the host cell, the RNA strands are
converted to DNA by the viral The
viral DNA enters the nucleus oftheT4lymphocyte, where it
becomes incorporated into the host's DNA. It may remain
in the DNA for many years before it becomes activated to
begin producing more viral particles. The new virions even-
tually bud from the host cell and enter the bloodstream. The
new virions, however, are not yet infectious. As a fmal step,
the viral enzyme protease deaves some of the proteins associ-
ated with the HIV DNA. enabling the virion to infect other
T4 0""" i>uuclillg UU.UTh, Ih ...
recognizes that the cell is infected and kills the T4 lympho-
cyte. Unfortunately, it is too late; an HIV-infected patient
may produce as many as 10 billion new virions t'Very day,
and the patient's devastated immune system is unable to re-
move them. Knowledge of the replication cycle of HIV is
critical to understanding the pharmacotherapy of HIV-
AIDS, as shown in .. Figure 36.2.
Only a few viruses such as HIV are able to use reverse
transcriptase to construct DNA from RNA; no bacteria,
plants,or animals are able to perform this unique metabolic
function.AU living organisms make RNA from DNA. Because
of their "backward" or reverse synthesis, these viruses are
called retroviruses, and drugs used to treat HIV infections are
called antiretroirals. Progression of HIV to AIDS is character-
ized by gradual destruction of the immune system, as mea-
sured by the decline in the nwnber of CD4 T-lymphocytes.
Unfortunately, the CD4 T-lymphocyte is the primary cell
coordinating the immune response. When the CD4 T-cell
count falls below a certai n level, the patient begins to expe-
o Viral DNA enters tho nucleus
and is iocorporaled iolo
.. Figure 36.2 Replication of HIV
host chromoSOlTllls. II ..
transcribed iolo mANA
and mo ... ';ral RNA, which

Cytopl .... m
o Viral
o Virus aliachN 10 ",copl or on hosfs
plasma membrana. ks core d""ni&gmles,
and';ral ANA enlers the cytoplasm .
LibraryPirate
rience opportunistk bacterial, fungal, and viral inflions,
and certain malignancies. A point is reached at which the
patient is unable to mount any immune defenses. and death
ensues.
36.3 General Principles of HIV
Pharmacotherapy
Thewidespread appe.mnce ofHIV infection in 1981 created
enormous chalJengesfor public health and an unpredented
need for the development of new antiviral drugs. HIV-AIDS
is rullike any other infectious disease because it is most often
sexuaUy tronsmitted, is uniformly fatal, and demands a COlI-
tinuous supply of new drugs for patient survival. The chal-
lenges of HIV-AIOS have remlled in the development of
about 20 new antirelfoviral drugs. Unfortunately. the initial
hopes of curing H IV-AI OS through antiretroviral therapy or
vaccines have not bft'fl realized; nOlle of these drugs pro-
duce> a cure for this disease. Stopping antiretrovinJ therapy
almost always results in a rapid rebound in HIV replication.
HIV mutates extremtiy rapidly, and resistant strains develop
!;() quickly that the crtation of novel approaches to antiretro-
viral drug therapy must remain an ongoing process.
Although phamlacotherapy for HIV-AIDS has not pro-
duced a cure, il has rnulted in a nwnberof therapeutic suc-
cesses. For example, many patients with HIV infection are
able to live symptom free with the disease for a longer time
because of mediations. Furthermore, the transmission of
the virus from an HIV_infected another to her newborn has
been reduced dramu iaUy (see Section 36.7). AlOllg with
better patient education and prevention, successes in phar-
macotherapy have produced a 70% decline in the death rate
due to HIV-AIDS in the United States. Unfortunately, this
decline has not been observed in African countries, where
antiviral drugs are not as readily available, largely because of
their high cost. It is estimated that as many as 25 million
Africans have mV-AIDS, including more than one third of
the entire adult population in several nations.
After HIV incorporates ilS viral DNA into the nucleus of
the T4 lymphocyte, it may remain dormant for seV('ral
months to many years. During this chronic Lalffi1 pa-
tients are asymptomatic and may not even realiu they are
infected. Once diagllOSis is established, however. a dedsion
must be made as to when to begin pharmacotherapy. The
advantage of beginning during the asymptomatic stage is
that the viral load or burden can be reduced. Presumably,
early treatment will delay the onset of acute symptoms and
the development of AIDS. Early therapy is especially critical
for infants younger than 12 months, because the progres-
sion to AIDS can be ra pidly fatal for these children.
Unfortunately, thedecision to begin treatment during the
asymptomatic phase has some negative consequences.
Drugs for HIV-AIDSare expensive; treatme nt with some of
the newer agents COliS more than $20,000 per )'E'ar. 1'best>
drugs produce 11 number of unoomfortable and potentially
serious adverSf effeas that lower the quality of life for the
patient. Therapy ov('f many years promotes viral resistance;
thus, when the acute stage evenluaUy develops, the drugs
OIIpttr36 Oru9,forVlr.llnfKtl"", 529
may no longer be effective. Bause of these consequences,
curTfnt protocols call for deferring treatment in adult
asyn:plomatic patients who have CD4 T-cell counts greater
than 350 celWmd_.
The decisiOll to begin therapy during the acute phase is
much easier because the severe symptoms of AIDS can rapidly
lead kI death. Thus, therapy is nearly always initiated during
this phasewhen the CD4 T-cell count falli below 200 cells/mel
or wnenAlOS-defining symptoms beoome apparent.
The therapeutic goals for the phannacotherapy of HIV-
AIDS include the following:
Reduce HIV-related morbidity and prolong
Improve the qualit y of life
Restore and preserve immunologic function
maximum supprc"ion of viral load
Prevent the transmission from mother to child in HI V-
iniected pregllillnt patients
T\'"O laboratory tests used to guide phannacothenpy are
CD4 T-cell count and measurement of the amount
of HI V RNA in the plasma. The number ofCD4 T-cells is an
important indicator of immune function and predicts the
li kelihood of opportunistic disease; however, it does not in-
diane bow rapidly HIV is replicating. Vililioad is determined
by measuring the amount of HIV RNA in the blood. The
HIVRNA level is an estimate how rapidly the virus i> repli-
cating and is considered a more accurate predictor of cl ini-
cal outcome than CD4 ceO counts. These telts are
IWrformed every J to 6 months to assess the degree of suc-
cess of antiretroviral therapy.
At onepoint, physicians recommended the routint useof
stru<lured treatment interruptions (STIs): periods during
whidl all antiretroviral drugs were withdrawn. This tech-
believed to reduce adverse effects, increase the pa-
tient's qualityoflife, and diminish the potential for resistant
HIV strains. Research studies, however, have questioned the
effectivene!S of STls; indeed, some data suggest that this
strategy actually promotes drug resislance and hastens dis-
eru.e progression. In all cases, viral load increases when drug
therapy is discontinued.
Tli! Qestion: WIwt t.crJn infl_ f pttIOIIlI bot IrSttdforllY inP.dionl
Study: two IeUnI Itudie tIIu mmined Ite
lining of HIV tnting .,.d variablrs moc:iattd with tilting.
tNt INny ptOPlt Wlit to untillitt irto lilt
!DUM of tilt inietlion, when trUlment options af!' 1m t/fr(tivr. Fao:IOII
assoc:iattd with wliting indudtd minority 910UPS and ml'n.ln a high
shoolnud,.,.pprolimattiy 2396 of stucitnrs who eftl had 56 hadbeoen
ttsttd for HIV.
II unDj I mpIicatiom.: Moots Ihrdd Itad! p.lMn15 JIw, inpo:rt;lna of
HH inftttiHI.Fo!thostwho 11M had unplO4Kttd sex,1Ir IIUfI'I:
ilin IIDey roIr II HH IleStilg,npKYiy M!IOI'Illdol5ms..
SruE AlllllltlfyMaWlyIll>ftl)"Rtpqr (OCS/nIftIII,wr N09,
""'-'"
!
i
i



I

;1


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S]O UnitS TtelmmuOI'S)"tl'm
36.4 Classification of Drugs
for HIV-AIDS
Antiretroviral drugs target spe<:ific phases of the HIV replica-
tion cycle. The standard pharmacotherapy for HIV-AIDS in-
cludes aggressive treatment with multiple drugs concurrently,
a regimen called highlyactiwantiretroviralthfrilpy(HAART1. The goal
ofHAARfis toreducethe plasma HIVRNA to its lowest pos-
sible level. It must be Wlderstood, however, that HIV is har-
bored in Jocationsother than the blood, such aslymph nodes.;
TABLE 36. 1 Antiretroviral Drugs for HIV-AIDS
therefore, elimination of the virus from the b!ood is not a
cure. The simultaneous use of drugs from several classes re-
duces the probability that HIV will beoome resistant to treat-
ment. Antiretroviral therapy must be continued for the
lifetime of the patient. These drugs are listed in Table 36.1.
HIV-AIDS antiretrovirals are classified into Ihe following
groups, based on their me<:hanisms of action:
Nucleoside reverse transcriptase inhibitor (NRTI)
Nonnucleoside reverse transcriptase inhibitor (NNRTI)
Drug Route and Adult Dose (max dose where Indicated) Adverse Effects
REVERSE TRANSCRIPTASE INHIBITORS
dtiaYirdillf IRecri,tor)
Q d"ilYirrnzlSullin)

PO;400 mg tid (mil: 1)00 mgld.ly)
PO; 600 mg/days (max: 600 mglday)
PO:1OO mg bid (max:400 mg/day)
III'Yir.pi"" (Vlr.m,,,,,) 1'0;100 mgld.,. In< 14 rby<;th ... in<""'" tohid
NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS
abaulir (Ilagen)
(\'"00,001)
mltridtabillf ([moo)
IamivLdot (Epi'li",lTQ
lIawdot 00)
tftlOfiwi (Vill'adj
o 1ido'I00i1lf (AlT, Rt,tnwir)
PROTEASE INH BITORS
aliUnavi
darunavir (Pluistaj
fMamprmavir (Lniva)
ildinawi ]Crilivin)
o IopinaYir/ritor\lYir (Kaltlra)
IIflfinawf lViraapt)
ritor\lYir (Norvir)

tpranaYir
PO;loo mg bid (1IIi1:600 mg/day)
PO;l1Hoomgbid
PO;loo mg/day ]1IIi1: 100 rngIday)
PO; 150 mg bid (mal :100 mgfday)
PO;.o mg bid (max:80 mg/day)
PO;loo mg/day
PO;1OO mg h (1,100 mgfday);ifte- 1 mo If\/)' rftb.:r to 100 mg
Mf'/4 h (600 mg/day) IV; H mg/bj Mf'/ 4 h (1,,00 rngIday)
PO;400mg/day
PO;6OO mg taken with ritooavi" 100 mg bid
PO; 700-1,400 mg bid i1 with mg ritonavir bid
lmoll:1,8OO rngIday)
PO;800mgtid
PO;400/1oo mg (3 tlplUiflor 5 mL of llIIpfnsion) to
S33f1ll mg (4 tlpl\Jl's or 6.S mLl bid. wIIh (onaJlfl"llt d"IVRnzor

PO;750mgtid
PO;6OO mg bid (mal: 11,000 mg/day)
PO; 1 g tid (rnal:l glday)
PO; 500 mg taken with 100 mg of ritor\lYir bid
FUSION AND INTEGRASE INHIBITORS
toMirrm(fuuon)
llliravm: (SMntry)

SlDwtaotOUs;90 mg bid
PO; 151l-6OOmg bid (1IIi1: 1)00 mgld.ly)
PO;400 mg bid (1IIi1:800 mglday)
Rash, 1'tWj: mllIlM, dmllfO, I
h!f5!besja brojupqjd!y 5!fyf0\ lob(!oo IYn!U!!If
CNSlOli!:ity fdavirmzl

roll!
Bonf mar!pW IUWI'oon OMma MINDY
gramAI!MQpmy Jaqk addQlk witb 5!N1oubl'.J
!I&OIoxidIY Dftip/lffill !INON1hy
!la\'Udiot1 paOOl'lrtis f lami'ludi!!)
1IoiIw, obdmJirJI pan,
Aotmia ItukoDtnia,wP '/fin thrombolil, panWtilis.
IvmMooDj!lby b!IDgrrbagjc m(ml
floci"naYir) yl'diicalffl!lmuoni ) tluonWCYlOPfIlia
(!!Quinal'ir), paomopmia I !<lgl.inaYir)
PIIin ill irrjKrion Jill' (fflrNirridt),
rDMII,dUrhifJ, /1fi11,!0IIIJh,
tflzinru, III J.\ uPPff
m#lJtory mra inflcrkm
]!rpato/l!):jdty mvoyrdjal jnfitjon h)'!ff'lNllitjyjty
!If'II!U!!I!'Oja thrpmbgcytpomy nfphCOWljdty
ImfU'linid!:) myopathY lraktQ@l'ir)
LibraryPirate
Protease inhibitor (PI)
Nucleotide reverse transcriptase inhibitor (NtRTI )
Fusion (entry) inhibitor
HIV integrase inhibitor
last (hII' da""""
that act by unique me.:hanisms. Tenofovir (Viread) is a
NtRTI that is structurally similar to adenosine monophos-
phate (AMP). After metabolism, tenofovir is incorporated
into viral DNA in a manner similar to the NRTIs. Enfuvir-
tide ( Fuzeon) blocks the fusion of the HIV virion to the CD4
receptor. Raltegravir (Isentress) blocks HIV integrase and
prevents HIV from inserting its genes into WJ..infected DNA.
Research into HIV-AIDS is constantly evolving as cliniciaru;
strive to determine the most effectiw combinations of anti-
retroviral agents. Pharmacotherapeutic reginlC1lS are often
different for patients who are receiving these drugs for the first
time (trt'3tmem lIaryt) versus patients who have been taking
antiretrovirals for months or years (treatment experienced).
Current clinical guidelines suggest that trt'3tment-narve
patients receive one of the following therapies:
1.A ritonavir-boosted protease inhibitor plus two
NRTIs or
CNptfll& Oru9.lorvlr.tlnIKtlom 531
2.A nonnucleoside reverse transcriptase inhibitor plus
two NRTIs
Treatment failures commonly occur during antiretroviral
therapy. The primary factors responsible for treatment fail-
ure are inability to tolerate the adverse effects of the medica-
tions, nonadherence to the complex drug therapy regimen,
emergence of resistant HIV strains, and genetic variability
among p.1tients. Pharmacologic options available for pa-
tient> with treatment failure are limited. Higher doses are
generally not indicated, because they lead to an increased
incidence of serious side effects. Ideally, the patient is
switched to at least two drugs from different chemical
classes that they have not yet received, but this option is not
always possible because there are so few drug classes avail-
able to treat HIV-AlDS. The therapyofHIV is rapidlyevolv-
ing; thus the nurse should consult current medical reference
sources for the latest treatment guidelines.
Drug manufacturers have responded to the need for sim-
pler treatment regimeru; by combining several medications
into single capsule or tablet. For example, one of the newer
therapies combines three HIV -AIDS drugs, manufactured by
two different companies. Atripla combines efuvirenz, emtric-
it.1bine, and tenofovir into a fixed-dose tablet. Approved by
Therapeutic (lass: Antiretroviral Pharmacologic (lass: Nudeoside reverse transcriptase inhibitor (NRTI)
ACTIONS AND USES
lidovudint WIS first dil(_m1 in the 196O!, and itl antNiral auiYity was
prior to thl AIDS it ih)Tllidint,
ont of tht four nudtolid! building bloc:h of DNA.A; tht
tnzynlt bfgins to S)'IItheilll' viral DNA, it mi5l.krnly UIrI zidovudint U Ont of
thtmKltoIidt .. illMd in(om-
bination with other .mirl lrovirall for both symptomuic:.nd uymptomuic:
as U for prophylnil in HIV-upoIt d
health taft' WOrRrs (I SKtion 16.6). An importlm indic:.uion iI rmlKlion of
tht rilll of tranlOliuion HIV from an HIY-politil'f mothtr to herftlus.
of the dllJ9l' widtlprNd 1M sinft' bfginning of the AIDS t pi-
resilt,nt HIV IlrailS h,1'f bfiornt (ommon. Most trtatment
do not ilKlude zidovudin! u df119 of first moKf dUf to tht potl'fltial for reil-
Combinuion prodKu (ontaining zidowdint indude Combivir (zidoYU-
dint and limivudint) T riziYir (zidoYudint, IimiYudint, ,nd abamir).
ADMINISTRATION ALERTS
an I mpt, stom"h, with
!!!Ioid with fruit
PregnalK)' uttgory C
PHARMACOKINETICS (POI
Onsrt:Unknown
Pfak: l- lh
Halflift: I h
Duration: Unknown
ADVERSE EFFECTS
Zidovudint has tht pottnri,1 for miolH tift"! and hal FDA
bla.c:k w,mingl. Thf df119 can Sf'Itfl' htmatologK tOlicity at high

may blood translusions.l.actic: ac:ido!is hepatomtgal,> with
Itf'tolis repontd, inc:luding a few fatal Prolongtd hu
iI.ooated with m)'Op'thy nd nT)'OIitil. Many patitnts htigUf
and 9! ltI".rlll'd weakntls, anorui" a nd diarrhe Htadadie will wr
in najority of patil'nll taking zidol'Jdilll', and 1nOft' IfriouI CNS t fftc15 hal'f
bec-n I!porlt d
Contraindications: H)'perItnlitivity to the dlUl iI the only k
shooJd lit USN with cauti:m in with 'lII'01i, or
INTERACTI ONS
DrurrDIIII: lidcwdilll' ill!ra(lS with man, d"u}I. ConrurJl'llt mnw ilion wth
otIm dujs that dep"fll bone mallOW lunnion, 'ilKh ao; ljIIICidoW, inil'rlflon a.a.
ftiK)1OlilM'. or yiIai5tiIf \holM! be awidfd dUO' to
immUflflllJlPle\sion. TIl! folowilMj druglmay i"uMI' 1M rill; of All toli!itr.

val poiuOd.LM with otIltI inti"l uovirai iMJi'Illl may IiIUII' laniu (iOOIis RlfYeI"l

La b Tl5Is: MNn (orpIII(I.Uf v.l!umt may be iooUlfd durilMj zidowdilll' therip"!.
WBC anj 11gb may d!aut 1M to lIfOOoptria and illi'mia, r!SpKliveIJ
HerbaliFood: LMwith(jution with hf!baI St..Iohn\ '11M,
which lIay(jkMa dMMe inaltil@!ro'liralmity.
Treatment of OYerdolr: Therr iI no 5pt(ifK tll'.ument for
IItIlr to M',NrJlJIrIgIQ/ for Q NrJlJ/fII} I'rtml foM lpt(1k to rli HIrug.
LibraryPirate
532 UnitS Thl'lmmuneSyu"",
the FDA in only 3 months, the once-daily tablet simplifies
treatment and is expected to improve patient compliance.
REVERSE TRANSCRIPTASE INHIBITORS
(NRTls, NNRTls, AND NtRTls)
Reverse transcriptase inhibitors are drugs that are struc-
turally similar to nudeosides, the building blocks of DNA.
This class includes non nucleoside reverse transcriptase in-
hibitors, which bind directly to the viral enzyme reverse
transcriptase and inhibit its function, and nucleotide re-
verse trall5Criptase inhibitors.
36.S Pharmacotherapy with Reverse
Transcriptase Inhibitors
One of the early steps in HIV infection is the synthesis of vi
ral DNA from the viral RNA inside the T41ynlphocyte us-
ing the enzyme reverse transcriptase. Because reverse
transcriptase is a viral enzyme not found in human cells, it
has been possible to design drugs capable of selectively in
hihiting viml rerlielrinn.
Viral DNA synthesis requires building blocks known as
lIucleosides. The NRTIs and NtRTIs chemically resemble
naturally occurring nucleosides. Thus, as reverse transcrip-
tase uses these drugs to build DNA, the viral DNA chain is
prevented from lengthening. The "unfinished" viral DNA
...
Prototype Drug
I
EfaVirenz (Sustlva)
chain is unable to be inserted into the host chromosome and
HIV is Wlable to continue its replication cycle.
A second mechanism for inhibiting reverse transcriptase
targets the enzyme's function. Drugs in the NNRTI dass act
by binding near the active site, causing a structural change
in the enzyme molecule. The enzyme can no longer bind
nucleosides and is un:lble to construct viral DNA.
Although there are differences in their phamlacokinetic
and toxicity profiles, no single NRTI or NNRTI offers a dear
therapeutic advantage over any other. Choice of drugs de-
pends on patient response and the experience of the clinician.
Because some of these drugs, such as zidovudine (Retrovir,
All), have been U'ied consistently for more than 25 )'l'ars, the
potential for resistance must be considered when selecting
the specific agent. There is a high degree of croslHesistance
among the NlITis. The NlITls and NNRTIs are nearly always
U'ied in multidrugcombinations in HAART.
As a class, the NRTIs are well tolerated, although nausea,
vomiting, diarrhea, headache, and fatigue are common dur-
ing the first few weeks of therapy. After prolonged therapy
with NRTIs, inhibition of mitochondrial fimction can cause
varioU'i organ abnonnalities, blood disorders, lactic acidosis,
lipod)'!:rrnphy, in which fur redidrihuTed in
specific areas in the body. Areas such as the face, arms, and
legs tend to lose fat, whereas the abdomen, breasts, and base
of the neck (buffalo hump) accumulate excessive fat deposits.
The NNRTIs are also generally well tolerated and exhibit
few serious adverse effects. The adverse effects from these
Therapeutic (lass: AntiretroYiral Pharmacologic (lass: Nonnudeoside reYerse transcriptase inhibitor (NNRTI)
AalONS AND USES ADVERSE EFFECTS
is gil'fl orally in oombimion with other antirwu;irals in thr 1rN!- in a! leoH! SO% of the patients whr-n fint initi-
mrmofHIVinftion.Thrdrug ambyinhibiting hasthr oiling thrra py, in(kiding sJrrp disordrB, nightmarrs, a bilit)' to
advantlgr ofomr-dailydoling and penl'lration imoCSF.Hnilt'lll. isa mnummt, and <!elusions. Ymptoms gradually diminish afitr J--4
drug for thr initial thrrapy of HIV infrr:lion. WffD of therap)'.likr other drugs in this ruh is (ommon and musl bt
Rrsistlncr ran drftIop rapidly to NNRTls and (1O!:s among drugs camully to plrl'!'nt!he of I>Mf"r blistl"ling ordrsqua-
in this dm(an orrur.High-fat muls inaNlI' thrabsorption by u mIKhas5O'lb mation.
and may "use toxic:it)'.Atripia is i fixed-dosr combination of three
Contraindi(ations: Ef,virenz is a known trratogl"ll in laboratory animals and
ral drugs: rmm.:iu binr. ,nd !rnofOYir.
rrust IlOl bt giftn to prrgnan! patienn. Patients in thr (hild-btaring
ADMINISTRATION ALERTS
!hould btadvill'd !o usr methods of birth (ontrol to avoid prtgnanq.

Administer on an ffilPty stomam.
INTERACTIONS

Administer al btrll:imr to limit rfftru. l)ug-l)ug: Palifm who mfdicatioollMaboliNd by thr

Prtgnanq category (
INI"I- soch ill PIIfnotwibitJI-mayrequill' p8iodic:
of plasma IHH; MliIKllIM)' irKrNIt thr incidenl:. of \l'illR\..
faWfII l un de!rNst IfIIIIIIIHH; of!1If foIowing:sUlins, rMhiIIone.lf!lralile.
and YkiOOlIllarwl biodrn. ThfOlS ...... MeetfKl! of if
PHARMACOKINETICS
thr patifnt tal;es psydlol:ropic: 00J1I or ronsume\ akohol. L.wIs of warfarin may
il1setRapid
fid\erillUNll'
Pf,ak:3- 5h
Lab Tl5l1: [/.wift'llZ maygMo filllf...posi!iw for thr plNlKtofroaoluana.lt
51- 76 h
1M)' irKrNIteOlm \\1m.
Dur.lllion:24 h
lk>rbaVFood: St..km won may <aUIf a dKlI'U i1 In!i"ftroWal
ofDrrdosr: is 00 sprdfK tlN!men! O'Iridoll'.
Rtftf 111 MyMl5/nqR ror MnJnq I'rlXt5.I fooIj sp/II( 1II1M /J'ug.
LibraryPirate
drugs, however, are different from those of the NRTIs. Rash
is common, and liver toxicity is possible, increasing the risk
of drug--drug interactions. Efuvirenz (Sustiva) exhibits a
high incidence ofCNS effects such as dizziness, sleep disor-
LIFESPAN CONSIDERATIONS
Psychosociallssu"s with Antir"troviral
Drug Compliance
Ont kf, 10 an is
pll'Kribed medication plan. Drug rompiialKf is diffiruk for most peoplt oo{f
thty frrl writ patifntl may ill' mon pront to for various lI'.HOIIl
Ma ny factors "n mharKf thf probabilil)' that the patirm will adhm to tll'at-
IIIl'IIt.For rumplt, a multidiKiplillilY allfSllIIl'IIt (an \(1!'t'O p.ltirntl for dIo-
pll'nion, akohol or drug aoolol', or negatiW' attitudes,.nd intt'M'ntion I ran ill'
initiatrd to tht imp.!{l on {OmplialKf. Eduration at an appropnatt
k-Iel is nsrmiallO tht patitnt "n understand tht dilol'alol' prom! as 'MI111
thr rolr medicatiorrs pliy in IKUring a oukomr. Developing trull
and oprn communication bttwrrrl the p.ltirntand call' proYicIrf is
nsrmial to improving thr {!worr-s of drug rompliaort and to lI'arhing com-
mon theraprutic goals.
o..p!tr]& Orug,lorvr,.lInfectlo,,, sn
ders, and fatigue, but these symptoms are rare in patients
taking nevirapine (Vimmune). Unlike some other anti-
retrovirals that nt'Satively affect lipid metabolism, nevirar-
ine actually improves the lipid profIles of many patients by
increasing HDL It'Vels.
PROTEASE INHIBITORS
Drugs in the protease inhibitor class block the viral enzyme
protease, which is responsible for the final assembly of the
HIV virions. They have become key drugs in the pharma-
cotherapy of HIV infection.
36.6 Pharmacotherapy
with Protease Inhibitors
Near the end of its replication cycle, HIV has assembled all
the necessary molecular components to create new virions.
HIV RNA has been synthesized lISing the metabolic ma-
chinery of the host cell, and the structural and regulatory
proteins of HIV are ready to be packaged into a new virion.
Prototype Drug I Loplnavlr With Rltonavlr (Kaletra)
Th@rapeutic(lass: Antiretroviral Pharmacologic (lass: Protease inhibitor
ACTIONS AND USES
Kalem is I combination drug (ontaining two protfillr inhibitors: Iopinavir and
ritoNvir.lopinavir is Iht acbvt of (ombination. Tht
smalilmoum of ritonavir inhibit! hrpatir bll'akdo'Ml 1M prr-
mitting ItIUm Irw-iloflopinnirto by 1lIOII' than l00-fold. k halan n-
trnded haH-liftthat allows for OIlU'-or dosing.
to !wI bI'en rrponrd in patirnlS trutrd with
olher protNIoI' inhibitors prior to Kalrlra looapy. K.ilrtra is I drug of (hoirr for
tht initial therapy of HIV infro:tion.
ADMINISTRATION ALERTS
oral solution fonn lhould ukrn with food 10 rnhalKf absorption.
Tablets may bt takrn with orwithout food.
PlI'9ni lKYutegoryC
PHARMACOKINETICS
Onset:Rapid


Duration: 12 h
ADVERSE EFFECTS
Kairul is 'MIl tolrratrd by molt patirnts, Ind the most II'pOrtrd
prGblrm K dianile . and elleru art common, inckJdirog
oaum, wmiting..d)'lpepsia,and abdomillil pain. Hyprrglyrrmia hal been re-
ponrd Ind Kalttra may WJIoI' or WOIWll!)'IIIplom! of diabetrs mellitus. A
lipodystropll)' Iyndrome may O(cur lhat is moc:iated with hypel9l){rmia Ind
fat lI'distribution. l'an(lI'atitis is 1 though potrmially fatal,adYtrw
Contraindications: l'atirnts with impainnrm, thoW' with pre-
existing firal hepatitis, should ill' mooitOll'<!. Htpatic rlll)'m!'
should br regulartyffalWlrd in t:hr!oI' patirnts to jlll'Vrm PI-
tirnts with diaill'tes should monitored II'lJIlarl)o bruulol' K.iltm may uar-
fflIatr this condition.BII'III ferding is{oomindicatrd dUl' 10 potrntial risk
of transmitting HIV 10 thr nrwbom .
INTERACTIONS
Dnq-Drug: l(fina'lir metMfI)' mmbolinod by htpaticl'lll)'meI,and augsthal
IIIdfI90 lIfpa!k mftabolism II\a1 in!mct with K.1Iw.I. that II\a1l1'rtKt 1M

riIaqIin, riIabIlin, phfn)'loin, and OOamazePOf. Drugs thai II\a1 irmast ""'ill 0(
I(fin.wir in<Iudf aIOOIeuI;in, dHa'o'i"diOf, and rilooavi.
Siatim shoUd not br _nillerl'd with Katelra duI' 10 an iooNsed rill; for
1Il)'OpiI!hy. Conruntnt 1M of rifampin may lower thf !lffrtinrl!2; of Kalwa.
lilHlmtl'lling ltf\rI1)1Irnial rna, ouurifKatmilll\fd{onamrl\)'
";!h pi""""",,.and many antidy<rhytlu,i< OI)Mn.KaIoualllO)l
iooNSt ef1K1161Oda1ed with s.e4Ktivf loI'IOIorin rflllllal:l inhibitors
triq(ir antid!pressMlts,ancI p/IfnoJhiazinrs.
Lib Tests: 1ot.Ji dloItstaoi rna, inaNlf.
HerbaVFood: antietroviral iK\ivityand iI
coouaioticatfd.
Treatmtnt of ImrdOSf: Theil' is 00 spe<ifK IlI'almrnl for OYerdosr.
1II!(pf Ie M)Nurllllgm Ibr Q Nurlifll} I'nxtl.! fm Jjlt{1k Ie rNs
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534 UnitS Thl'lmmuneSyu"",
NURSING PROCESS FOCUS PATIENTS RECEIVING PHARMACOTHERAPY FOR HIV-AIOS
Assessment
Bil st line aSSfssment prior to administration:
Understand rt illOn the drug !ws bffiJ pr&ribtd in order 10 for
tOOilpMK
Obtain a (omplete hillory ilKludi ng lII'urologic,
rnpif.tlllJ,hep.Jtir: or rt'IIal dilulI',ancl the pos,ibiliryof prtgn'IIC)'.Obtain
i drug induding allergits,induding sptCifK fN(tions to drugs,
rurrfllt prl'sc:ription and Ole drugs, he!bal plfpafations,and akohol USf.
alen 10 pollible drug intffauions.
klffi signs and symptoms of infe<tion OO1ing
(!wracteristKs,ind prl'lfll cr or absflKt offewr or pain.
[valuate appropriate laboratory findings {t.g., (B( (D4 (ou HIV RNA
iII.Jy,(ullUlf and [(&5) for any (OII(Ufrt'llt inftctions, and
Ifn.J1 function IeYeis, 5e11Jm and gIIKOIr).
Potential Nursing Diagnoses
Inftction
Activity IntoltralKf
Fatigut
"',;",
Imbalanced Nutrition,l.tss Than Body i!fquirl'llll'nu
Oeficitnt FluidVoume
Oiarmra
ImpaiR'd OrallNKus Membranrs
ImpaiR'd Skin Intrgril)'
Insomnia
SocialllOi.Jtion
Confusion [iKute or (hronic:)
IlII'fieur.e Therapl'lltic: Regimen M ul.Jgtment (lfi.Jtfd to (ompieJ
medic:.Jtion Ifgimen and dill',u rrmment)
(lr,fiOtnt KnowIedgt (reIattd 10 diseast proo:fIS, tranmlissiln, and drug thmP'll
Hopelessness
Spiritual DistR'SS
for InjJry, Risk for Falk (lfi.Jtrd to adw"ll' drug ordill',u)
foruregil'ff Role Strain
--+-=
Asstssment throughout administration:
klffi lOr rIt1iR'd tooapeutic: rfiem (e.g., (D4 (ounts and HIV RNA
l\'IIIilin within i (ctptable limits,able tOilltend to normal ADu, i blfllcr of
signs and symplOms of (OII(urlfnt inftions).
Continue periodic monitoring ofCBC,hepati( and rf llil function,CD4 ind
HIV RNA kwIs,lI'rum amylase, ind gluc:=.
klfss for idYmt efito:n: BIIIISH, vomiting. anom:ia, abdominal (ramping.
diarrllu, filligu-, drowsiness, ciuinm, mental chi II9fI, inlOmnia, dtkrsiJns,
musc:1e or joint pair, ir;potflllion, S)TKOpt, and
Sterr diant.e.J, jarrdic:t, rIttR'.J ltd uriIII' rutput or darUntd
iiiIII', blistering rash on body or oral mlKous membraIII'!, arulr
abdomillil pain, and iOOl'Ming mentJl or bffiavioral (!w1l9f1 or deaNltd
IrYtI of (onsOousnen (lOC) shruk! lit reportfd
Planning: Patient Goals and Expected Outcomes
Tht patifllt will:
ExptritlKt therapl'll\K tffttts (e.g., CD4 (OOnll and HIV RNA aSIi)'! within i ((tptable limits, absrlKe of \igns and symptoms of (onrurre nt infection, able 10
maintain ADu).
Br fnor from, or uperienre minimal, arhomr tfftcts.
VerlJalizlo an undemanding of the drug's Ulf, adYellr tffNts, a nd rtquilfd plffiutions.
o.monm.", proper !d/-admini.lrllion of tho modiulion .. , timing, when to notify hu kh "'''' pro.idor).
Implementation
Interventions and (R!ltionales)
Ensuring t fft ds:
ContilU' tilrnmtnts as tb:ribtd e.rlierlorthmpeuti: ek:mainteIWlKe
d normalor iOOl'illing appetite,iOOl'illing fl"lf19'J' 1M! and ability 10
maimairt ADLs, (1)4 (lJlIIS and HIV RNAuli)'l within.l(uptablt linils and
ru biliztd. and maintainilll) thtraprutic rrgimen. (Drugs wil lit R'qUiR'd Iong-
tl'llll and hiYf many potential aU;!1"II' tffetts, makilg a<iteR'OO' to 1ht
modic.niJn rtgimendiflirult. Jht, htaltb (,llf provickr shook! lit notilitd if
ffYl'l and signs and symptOllll of (0IKUIfnt infto:tiom ilKlfillf, eJ(flWt
fa. is pmtnt,or adYmt tffetu pliler adlitll'rn with drug thtrapy ill risk.)
Patient and Family Educ!ltion
Te.l(h the 001 nop the drug rtgimen whtn "feeling bffier"but to
continue to mfdiutions;do oot shalf dOlI'S with othtB;and
R'lUm to tht provider if adYl'l"ll' rfit<ll make rompiiance with R'9imf n
diffiruk 10 continue.
LibraryPirate
CNpttrlo6 Dru9,lorVlrallnlec:dom 535
NURSING PROCESS FOCUS PATIENTS RECEIVING PHARMACOTHERAPY FOR HIVAIDS (continued)
Impl ementation
Interventions and (Rationales) Patient and Family Educati on
Minimizing ad'ftrse effed:s;
Continue to monitor vital signs,npecially if is Tea{h the family, or ""t<jwmo immtdiatei)' repln that
Immtdiately report in{reasing or vomiting, r/yIpne. , enM 101'f,or per in behavior or of
t"lr,urdia,diuinffi, I)'IICOpt,{hange in bfilavior, . nd letharw or lO( 10 {on!liouso!'Ss; shorlrlffi 10 !Ninlain Ir;dr.tion or
tilt lItakh ml' plll'/idef. (lntreasing !1pffially wlltn ac:(omp;lnied by nutrition; or diuilltS5 nd faiming to the he a hh care prO'lidl"!.
worsl' ning be sign of wol1!1ling aderll' drug
f flem,ordrug l!"IistllKl'.j
Continue to monitor periodic: lab wor\I;;hl'p;ltic: and rtoal fUnction um, CBe.

InstllKt thl' p.tiem on tilt r--t for prriodK bb work,(orrNting iny
C04 (ounl5, HIV C&S if(onrulll'nt symptoms with OI'l'd for possible labs (I'.g., sl'rum if the p;ltitm is
ulf<l for the lR'atml'nt ofHIV illI' having upper abdominal p;lin).AdYM lab pmorlOl'I ofHIV status.
I"I'nal tolN:. BoIM.'!N1TOW wpprtSmn and It'IIlking blood
dysc:riIsiH, partic:Ulillly anemia .nd ltukoptnia,all' abo .amS!' tffts and
will k monitorrd by eBe Lipid Icvds ICrum .mylase will k
to asses for p;ln{lI'atitis and Im-b chl'dtd for h)"lll'rgl)'lemia.j
Monitorfor ind ililergic: lI'"tions,tspttially with tilt first Tm h tht p;ltitnt to immtdiately itthing;r.shes; 1'M'1Iing,
of.ny or proteom inhibitor. Cootinul' to monitor the p;lrtirularly of f"f, tongue,or lips; urtiuria; fkJshing;diniOl'II; l)'IIropl';
p;lti!1lt as IIffiItd bastd on tilt drug usrd or tilt patieni's{ondition. wl-ftzing; throat tightOl'ls;ordiflic:ull)' brNthing.
(Anaphy\olaic: I"I'<lctionsarf polsiblt,panic:ularly with zakitabiot.
milY not .lwil)"! bt prtdiuilblt, cilution fll'quent monitoring
art to l'OIUrt prompt trNtm!"Illj
Continue to monitor for IItpatit and II'IIiII toxitities.(AntirtirOOrab <l nd

Tm h tht p;ltitm to immtdiatt ly any naUSN, vomiting. yellowing of
inhibitors m.y be hepatic: ilnd lI'IIil toxic: ilnd fll'qUtnt lkin or !Iltr.,dbdomin.1 p.in, light or clay-{oiored llools,ilnd diminishrd
monitoring to pll"<'tnt fkJid intalct will pll"<'tnt output or dlrkt ning of urillt.
drug icrumulilUon in kidnl')"i.)
AdI'M thl' patient to Auid intillet to 2 to II ptr day.
Continue to monitor for dermatoiogic: tffts ilKluding ft'd or purplish skin

Tt ath tht p;ltitm to inlpffi oral cavity at 1t.1I a day and maintain
ralh, blisters,or skin, induding oral muc:ous ml'mbr'III'I . .wm oral II'9IJbr denull'tiIm1. Maintain good oral h)'gient .nd mouth with
murous membriln!1 for signs of ltomatitis, i ldrug tffffil or plilin water or IOknion ill PlI'I(rib!1l by tilt hukh call' provider after
immunosuppl!"lmn may Il'IUk in thl' amgrowth of oral fIora.lmmtdiateiy protfl til'l'(lothing for sun fllpOsure and immrdiatei)' repln
lilShts. !'Spttially ilSlCKiattd with blilll' ring. (Thesl' drugs may any signific:.m rashes or sunbumtd apptaralKl'.
caUSI' Ygnifiunt dermatoiogit eflem inc:ludingllomatitis,.nd
Stel'l'Ol-.Iohnson s)'lldlOll"lt, iI pottotiilily fillil ronditionJ

Monitor for signs <I nd symptoms of nturoioxic:ity, e.g., d

InstllKt thl' patiem or cilll'givrrto immrdiateiy ilKft'asing
ml' ntal insomnia, delusions, change in headac:ht, drowsinffi, WOIll'IIing insomnia, numbnts I of hands,
LOC,.nd H IV-AIDS drugs UIM periphl'lill OI'uropathy and ffft or ilnd changn in IIth .... ior or LOt
h. 1'l' .drr ..... dftct>.)
Caution p;ltitm th.lt drowsin!1s may O(rul.nd to becautious driving
orotlltr oKtWitits IIII'ntal.ltnOl'ls until efftct> of drug illI'
known.
Caution p;lt itm to beautious whtn in cootac:t with hl' at or rold as
numbOl'lI from periplltr<ll otUropath)' may murile
temperiltuft' diffic:ult

ElKourqsftp h)'gm mt.lUr6,f.g., I!"Itful rootin!1 befOll' b!1l and
avoiding largr mtab within 1 or 2 houn of sleep. HiY!' the patient (OIIIUk
with the he.alth ifinsomni. u"' .. dayti ..... or
(ontinues.
Monitorfor signs <l nd symptoms of blood dyscrasias, I' .g., tow.grade Teach thf p;ltitnt to <lny lowiJrade ft'/!1I,IOft'
bletding. bruising. and signiflGlnt (BOllI' II\jrrow lUppll'lsion may bruising or incl"l'asrd bltl' ding, and ulR/IUal fatigueor shortrolofbl"l'ath,
O(rur ilnd may CalM blood dyscrasia! with clec:lI'all'l in !'SprOaIIy aftl"! taking drug for <I prolonged period.
plateltts.Pt riodit monitoring ofC8( will lit
(commued)
LibraryPirate
NURSING PROCESS FOCUS PATIENTS RECEIVING PHARMACOTHERAPY FOR HIV-AIOS {COnltluPd}
Implementation
Interw ntlons and (Rati onales)
Monitorfor signifiunt GI effis, YOIIlirillg. abdominll l
!)liin Ofcnmping. "Id as pH guidtlinfi:Some
rtqUi,udministr.uion on ,ft tmptystomadl. some wit!J food 01 milk.
AdcIiIion.lI p/"'_oIogK Iftatmtnt may bt IIKtslafJ to fimit mM GI
Ni"Hts. Emull' nutrition.oo {,1liiie: nab.-. (.I.dwfw GI fifKh oft
cornman to most iIltitttroWals uld protme
,dminimation guidflillH bffoft' with OIwithout food
0Imil.)
MonilOrfor symptoms of !)li1Kft'ltiIis induing ItYeIt IbdomNi piin,
I\aIMa, I'Omiting,.nd abdominal dislmtian.(5omt ,nIiIl'troviril drugs IIKh
IS didlllOSior ntl, UUIt piIl(ll'Ititis. Strum Irnylalt Ind !Mis should
bt monitorrd pHiodiully.'
Monitor blood gb:OSt in uking 'ntiret1Ovir.I!. (Thtst drugs may
Wist h)'p('rgtycmli.J.1Mbrtic piOOn may lfCJJill" dwll\Jf in thtir
inticbbtti< dNg lOUTiorj
En<mngt infKtion COmrollnd 900II hygitlll' lIII'aIUftS bastd on thf Htffll
ofisust condition, and follow tsttblishrd protocol in hospiulizrd
plItitlll5.(Thtst drugsdtcll'ilf the It\teI ofHIY iniraion but do not CUII' m"
dilfiSt.Exalltftt hygient mtisurts wililimit tilt chilMt foI stoondary
inftiom in lilt immunommpromisel paliHrt.)
Pat ient and Family Education
1Nch tilt patient to!.lkt the drug with food 01 milk l 'PPlOpMt or \(I
ukt drug on in empty stomadJ with, ill gins of Wilter.Arroid IC_ Ioods
and IImks, wiml mllYUIIIt S!omid! upstt.
Enr:our'9t the p,\itnt \(I try snwll, frequmt meals,.midl N, be bttttr
tolfratrd Nn ffwrr,laIgtr mNk.Hi\Jhnloric foods ,nd wppltlllflltil
IImr'9ts (e.g.,Boost 01 Emure) may help ,dd ulorits Ind
wpp/y iddimnalllJids.klist thf plItimt in dittary
consultation if IIiUSti OIdiirrhu makes lnainuining intilkt

Instruct the !)lititnt 10 !!port!Mr, _ .bdom ...... 1 paW\, fliustl,
I'Omiting"nd alxlominal <inrntion
TtJCh tilt GllbttK patient to tHt gkloose molt Il'pOItiIlll
(onmlenl flmlioMlo the heillth Ull' pIO"fidK
Tor;h tilt plItitm .. lrdian oontrol.nd hl9ienf IIlUSUfH wdI
.S frtqJtnt Mlidiog (rowded indoor pLtces..nd adeqllilt
IIIItritioo.nd if WlIl'rdy immunCKompromilfd.
PllaKe ibstinmct 01 itlwiYS ust b.uritf piotK1ian IiJring KlMty.
Do not shalt nffifIH with otht'Hnd do not donate bIoo:I.
--+-
Pnmdt rtsOUlUS 10, mrdicJl.nd tmOtiona! support. (irNtmtnt requiltS it Adwisr tile !)lititnt about community rtsOUKe5 ,nd support
multidis<iplinif)" iPPro.adL) ___ wilh IS IIffiIrd.
Patimt ulderstanding of drug thenp-,:
Use o,portuni1ies durillll ildminismtion of mtdiutions ,nd during
mmllll'nU to dil<lIn rationale foI drug 161')', dt!ftdthffilpeuti<
OU(!;omH, most <OIIl1nOll adYtrst tffiects, alld pirametm for whtn to uD
the em i ny nKfWf)" monitorill!l 01 plt<autions.
(Using timf 6.mg IIJBing Uft' hdps to optinm ind key tor;hing

Piltimt n lfilciminiltr. iOll of dtllg therapr.
Whtn .dministtring mediutiom,."struct tilt p.atifl1l, bmiiy,or Ull'9ivtr in
Propel" foIlowrd bt' Il'tumdtmon\\fMn.
(Proprr idmirmb1Iion incll"lfI tilt of thtdrugJ
The pititnt, family,Of {.regioItf should be .ble to ltaft tht for tilt
drug;i1J11lrt111rWtf dose ind KhtOJling;wlwt tffHts kl obII'M" lor
.and when to rtpOrt;ilnd tilt length of mtd"1UIIion thera",.
Tor;h tilt p.atitnt til ukt tilt mtdiutian
Complttt the mtn COUM of otherwise ill$truct!d. The
duration of tilt rtqllirrd thtlolPYI1WJ be quitt length, but it is
10 prt'Ifnt infrction.Do not llOp mrdiutian ";'m
starting to fre/ bent '.
Eliminm akohol.mile on mtdiutions.TIIfIf dlUCJS calM
lignifiu nlll"ctions wlltn ullt n willi akohoL
Tau me drug willi food or milk but amd acidic btver.IIJH. K illStJuctrd
to ukt rill' drug OIl n tm pr, stOlllidl, takf with a fun gIas.! of Wilier.
Tau me mtdiutioft ' I fftIlly lpiCed throughout fach Iii, IS feMlle.

Evaluation of Outcome Criteria
thf of drug tIItrap)o by ronfinning thl! patimtgoals.Ind ,,",0 mt!: (lft,1'Ianningl .
Str TobW I fllf alitlXdfIJ lJlla .mi:hrhm 1U1inftilrzr m
LibraryPirate
As the newly formed virions bud from the host cell and are
released into the surrounding extracellular fluid, one final
step remains before the HIV is mature: A long polypeptide
chain must be cleaved by the enzyme protease to produce
the final HIV proteins. The enzyme performing this step is
HIV protease.
The protease inhibitors (PIs) attach to the active site of
HIV protease, thus the final maturation of the
virions. The vi rions are noninfectious without this final
step. \'/hen combined with other antiretroviral drug classes,
the PIs are capable oflowering plasma levels of HI V RNA to
an wldo1ectabl", range. Sin"" their development in 199:;, the
protease inhibit ors have become essential drugs in the
ment of HlV-AIDS.
The Pis are metabolized in the liver and have the poten-
tial to interact with many different drugs. In general, they
are well tolerated, with GI complaints being the most com-
mon side effects. Various lipid abnormalities have been re-
ported, including elevated cholesterol and triglyceride
levels, and abdominal obesity. Cross resistance among the
various PIs has been reported.
All PIs have equivalent effectiveness and exhibit a similar
range of adverse effects. The Panel on Antiretroviral Guide-
lines for Adults and Adolescents reconUllends the use of
atazanavir, fosampren.1Vir, or lopinavir as preferred drugs
for the initial treatment of HIY. The initial choice of protease
inhibitor usuall), includes low doses of ritonavir. Addition of
small amoWlts of ritonavir allows less frequent dosing inter-
vals and increases the plasma concentration of the primary
protease inhibitor. This is known as ritonavir boosting.
36.7 Prevention of HIV Infection
Early in the history of the AIDS epidemic, scientists were op-
timistic that the spread of HIV infection would be
by the development of an effective vaccine. After all, scientists
had totally eradicated the smallpox virus as a hwnan threat
and have essentially controlled major viral infections such as
measles and mwnps. Such a vaccine could be given in
hood, offering lifetime protection against the fllal disease.
After decades of research, scientists are still far from de-
veloping a vaccine to prevent AIDS.A few HIV vaccines are
currently in clinical trials, but none is expected to cause a
major impact on the HIV epidemic. At best, the HIV VaC-
cines produced thus far only boost the immWle response;
they are unable to prevent the infection or its fata l conse-
quences. Although the immlUle response boost may help a
patient already infected with the virus to better control the
disease, it does not prevent new infections.
PREVENTION OF PERINATAL TRANSMISSION OF HIV
One of the most tragic of the AIDS epidemic is
transmission of the virus from a mother to her child during
pregnancy, delivery, or breast-feeding. Newborns with HIV
rna)' succumb 10 the infection within weeks, or symptoms
maybe delayed for months or years. The prognosis for these
children is generally poor; thus, the best approach to deal-
ing with HIV infections in neonates is prevention.
o..p!tr]& ONg,lorVI,. lInlectlo,,, 537
In 1994, clinical trials determined that perinatal trans-
mission of HIV could be markedly reduced through phar-
macotherapy. The risk of transmission may be reduced
approximately 70% using the following regimen:
- Oral administration of zidovudine to the mother,
beginning at week 14 of gestation and continuing to
week 34 of gestation.
- Intravenous administration of zidovudine to the mother
during labor.
_ Oral administration of zidovudine to the newborn for 6
weeks following delivery. (HIV i, estubli,hed in
infants by age 1 to 2 weeks; starting antiretroviral
therapy more than 48 hours after birth is ineffective in
preventing the infection. )
This original regimen to prevent perinatal transmission
has been supported by subsequent research and remains es-
sentially unchanged. The specific drugs chosen depend on
whether the mother is treatment experienced prior to the
pregnancy and on the results of resistance studies. To date,
there does not appear to be an increased incidence of con-
genital abnormalities or malignancies among the children
born to women receiving this regimen. If the HIV infection
is diagnosed earlier than week 14 of pregnancy, the patient
is usually placed on HAART combination therapy, with zi-
dovudine as one of the drugs in the regimen.
POSTEXPOSURE PROPHYLAXIS OF HIV INFECTION
FOLLOWING OCCUPATIONAL EXPOSURE
Since the start of the AIDS epidemic, nurses and other health
care workers have been concerned about acquiring the infec-
tion from their HIV-A1DS patients. Fortunately, if proper
precautions are observed, the disease is mrely transmitted
from patient to caregiver. Accidents have occurred,
in which health care workers have acquired the infection by
exposure to the blood or bod)' fluids of an HlVinfected pa
tient. Approximately 56 cases of patiem.to-health-care-
worker transmission have been docwnented in the United
States following occupational exposure. Although the risk is
very small, the question remains, Can HIV transmission be
prevented after accidental occupational exposure to HIV?
The answer is a qualified yes.
The success of postexposure prophylaxis (PEP) therapy
following HIV exposure is difficult to assess beause of the
lack of controlled studies and the small nwnber of cases.
Enough data have been accumulated, however, to demon-
strate that PEP is successful in certain circumstances. For pre-
vention to be most successful, PEP should be started within
24 to 36 hours after exposure to a patient who is known to be
HIV positive. The exposed health care professional should
receive a HIV RNA level as soon as possibleafterex_
posure and subsequent follow-up testing as reconunended.
If the HIV status of the patient is unknown, PEP is de-
cided case by case, based on the type of exposure and the
likelihood that the blood or body fluid contained HIY. In
some cases, PEP is initiated for a few days, Wltil the patient
can be tested. PEP should be initiated only if the exposure
LibraryPirate
538 UnitS The Immune SY"'-""
was sufficiently severe and the source fluid is known, or
strongly suspected, to contain HIY. Using PEP outside es-
tablished guidelines is both expensive and dangerous; the
antiretrovirais used for PEP therapy produce adverse ef-
fects in more than half the patients. The basi, PEP treat-
ment includes one of the following regimens, conducted
over a 4-week period:
Zidovudine and lamivudine or
Zidovudine and emtricitabine or
Lamivudine and tenofovir or
Tenofovir and emtricitabine
If the accidental HIV exposure was particui.uly severe,
and the source is a symptomatic HIV-infected person with
a high viral load, a third drug may be added to the regimen
(Iopinavir boosted with ritonavir). Adding a third drug in-
creases the risk for adverse effects and has not been proved
to be more successful than a two-drug regimen.
HERPESVIRUSES
Herpessimplex viruses (HSVs) are a family of DNA viruses
that cause repeated blister-like lesions on the skin, genitals,
and other mucosal surfaces. Antiviral drugs can lower the
frequency of acute herpes episodes and diminish the inten-
sity of acute disease. These drugs are listed in Table 36.2.
36.8 Pharmacotherapy
of Herpesvirus Infections
Herpesviruses are usually acquired through direct physical
contact with an infected person, but they may also be trans-
TABLE 36.2 1 Drugs for Herpesviruses
LIFESPAN CONSIDERATIONS
HIV in thlil Pediatric and Geriatric Populations
(hildll'n infemd with the HIV viM appw to dtYelop opportunistic (ondi-
tions u a mlKh mOIl' rapid than do <l dult;.The )'OUngI'r the age at whith
the (hild Hquill'lthe HIV firus, thr JIOOItI" the progllOlis tMel! to lit. Like
adult;,(hi kJl!"n all' also tll'attd with (ombination thr ra py. although not a II a n-
till'tlOiral meditations can lit ustd in ptdiatric p<ltienn. Proplr;la<tit tll'<lt-
IIlI'm <lgiinn P. plIl'IImonia is <llso suntd tufy in the tll'atmrnt
Il'gimrll, bfta!M Il'spiratory infffiions all' 000 <I 11M of dtath in)'OUng
dJildll'n. Tile (<lll'gil'!'u of the child must lit ablr to handle the mtd-
Kation Il'gimrn and also must he awall' of thr Nrlys)'IIIptOlllsofopponunis-
titdisri16.
The diagnosis of the geriatric patiem m<ly lit delajotd btuIM HIV is often not
susprctrd in this populuiJn. The gffl<itri: patient who has be<0IM inftl:ted
with the HIV inn may lit irss than willing to diKJ,u <laivities that <Ill' {onsid-
md high-risk bthavJlU. The gfflatiK palienfs I"ftd for <lmill'llOiral tfNl-
IIlI'nt depenck on thr (04 (ount The older aduk ma)' hal'!' gll'<llI'r diffi:ulty
handing the rigorous lf9imrn of the tft'atment The physiologic {hangl'S <I 00-
ciattd with <lgng ilKft'.N the pos of drug mity in this population. The
sodal faaoo must <1110 bt oonsidtll'd. btuIM these patients may lit rlYing
he the primary(aIl'lilRr d a dis.JbIed !pJUse.The ability of <I pa-
tient to lit <l(tivl' is not detennined .;thell'fOll', it is I'!'ry impor-
tam to strrss!6\loll aaiit)o pft'autions to pIl"/rnt Ipft'ad of the HIV fiM.
mitted from infected mothers to their newborns, sometimes
resulting in severe eNS disease. The herpesvirus family in-
cludes the following:
HSV-l primarily causes infections of the eye, mouth,
lips, although the incidence of genital infections is
increasing.
HSV-2 causes genital infections.
DN, Route and Adult COse {max dose where Indlcatedl Adverse Effects
SYSTEMIC AGENTS
Q oK)'dlWi (lO'li"axj
ddofcwi I'mtide)
famddoYir (ramlir)
foIamet lFolGllir)
(CytIWrnt')
'fai<l(ydlWi ('hkll'J)
TOPICAL AGENTS
doc:osanoilAbrm)
idoxmlH' ([lrndid.lk!plrx)
PO; 400 mg lid
IV:" - to mg"'g .. MY 8 h 10< 7- 14.uy<
1V;5 mgi1o;g ()II(e wMIy for 2 wk
PO; SOO mg lid fo< 7 dayslmax: 1:;00 mglda)')
IV;0-60 mgl\g infwdO'f1'l" 1- 2 h tid {max: 180 mgl'gldl1)
PO;1 gtid
IV; 5 mgJ1o;g nfusrd IWrr 1 h bid
PO; 1.0 g tid (max:] g/day)
TOjiul; 1 0% lJI'am applied to {old lOll' up to fi.". timel/day for 10 days
1 drop in 00 MIl hall" cUing hoo.n <lnd 1 hr
dumg the night
pmddcwi (()malirl e'/rry 2 lor 4 days
NQlIlfo,lI1miring.diorrhM, irfOOhe,pllnooo
ifiecrioo fire! (ptnflftfllJ O9fIIrl"J
&mflg. or sUrgn; at fill! of oppirrxion.
-- PhoIophobia,k@op;Ithy,andtdffi\aofC'lrid}
(lKularagen!51
triftmne lViroptic:) ___ 'c.:: drop in 00 MIl 2 h dll"ing waking hoo.n (max:9 ctopsI ,="' ='_L __ _
Irdis inditate{Oll1mon s.ffious elfem.
LibraryPirate
Cytomegalovirus (CMV) affects multiple body systems
in immunosuppressed patients.
Varicella-zoster vilUs (VZV) causes shingles (zoster) and
chicken pox (varicella).
Epstein- Barr virus (EBV) results in mononucleosis and
a fonn of cancer known as Burkitt's lymphoma.
Herpesvirus-6 causes roseola in children and hepatitis or
encephalitis in immunosuppressed patients.
Following its initial entrance into the patient, HSV may
remain in a latent, asymptomatic state in gangli.1 for many
years. Immunosuppression, physical challenges, or emo-
tional stress can promott' active replication of the virus and
appearance of the charncteristic lesions. Complications in-
clude secondary infections of nongenital tissues.
The phamlacologic goals for the management of herpes
infections are twofold: to relieve acute symptoms and to
prevent recurrences. It should bt' noted that the antiviral
drugs used to treat herpesviruses do not cure patients; tht'
virus remains in for the remainder of their lives.
Initial HSV-! and HSV-2 infections are usually treated
with oral antiviral therapy for 5 to 10 days. The most com-
monly prescribed antivirals for HSV and VZV incJudt' acy-
clovir (Zovirax), famcicJovir (Famvir), and valacyclovir
(Valtrex). Topical forms of several antivirals areavailable for
Prototype Drug I Acyclovir (ZOVlrax)
Chaptfll& OrugslorVlr.llnlectlorn 539
application to herpes lesions, although therare not a. efIee-
tivt' as the oral forms. In immunocompromised IV
acyclovir may be indicated.
RecurrenT herpes lesions are usually mild and often re-
quire no drug treatment. If drug therapy is initiated within
24 hours after recurrent symptoms first appear, the length of
the acute episodt' may be shortened. Patients who experi-
ence particularly severe or frequent recurrences (more than
six episodes per year) may bfnefil from low doses of pro-
phybcticantiviral therapy. Prophylactic therapy mayalso be
of benefit to immunocompromised patients, such a; those
receiving antineoplastic therapy or those with AIDS.
Herpes ofthety\' is the most common infectious cause of
cormal blindness in the United Sl:!tes. Ocular herpes causes
a painful, inflamed lesion on the eyelid or surface of the eye.
Prompt treatment with antiviral drugs prewnts permanent
tissue destruction. As with genital herpes, once patients ac-
ocular herpes, they often experience recurrences,
which may occur years after the initial symptoms. Ocular
herpes is t reated with local application of drops or oint-
ment. Trifiuridine (Viroptic), and idoxuridine (Dendrid,
Herplex) are available in ophthalmic formulations. Oral
acyclovir is used when topical drops or ointments are con-
trairxlicated. Uncomplicated ocular herpes usually
after 1 to 2 weeks of pharmacotherapy.
Therapeutic (lass: Antiviral for he!pesviruses Pharmacotogic CLass: Nucleoside analog
ACTtONS AND USES ADVERSE EFFECTS
by fDA in H8l 0lIl' of finl is lim-
itt<! 10 pliarmac:Ollierap)' for for which it is I drug of dIoic:f.1t is
moSI 'gainll HSV-l and HSV-2, fffKtiYl' only at high
(MV a nd varierlla lOIter. By viral DNA s)'rllhesis,acyclovir dr-
(INSfS duration Ind ltl'frit)' of aMf tpilodrs. Whtn giftn for pro-
phylaris. it ml Y dKrNl!' frequeoq of herprs but it does not
<Urt tho pal;' nt It is "".ilobk .,. 5% oinl"",nl for opplic:.nion to .<lM: lesions.
in oral form for nd u an IV for episodes. kuUS!' of in shon
half-life,acydOYir is somftimes .dminillmd orally up 10 fiY! times i day.
ADMINISTRATION ALERTS
When gil'l'ft 1V,!ht dng may "US!' painful inflammation of vesl!'k 'I th!'
Sitf of infusion.
Adminil!fr around !hI (lock, eI'l'ft if SitfP is inttrrupted.
Adminil!rrwith food.
PlI'9nilK)' "'t9ocy (
PHARMACOKINETICS (PO)
Onst1: Unkna.vn

Halflife: l.5- S h
Duration: 4-8 h
Therr.rr ffW f JfrcU to aqdovir whtn it is topically or
ora .lleph rotoxicity is possible whtn th!' mt<!ic:ation is givtn IV. ha I
10 Ih!' drug. panic:ularl)o in patients with HIV-AIDS.
Conmindimions: Aqdovir is (onmindic:.JIt<! in patitnll"';th h)'ptntnsitiY-
ity toau!jS in !his dass.
INTERACTtON5
(rorunenl !til' of acydoW willi ntp/IrotoIK agt'IIu Ihould bf a'I<IiCfd.
ProbfnKid liftlNll'l MJ(lo'Iir millalion, and 1idowtint INY (Olll'io! iKlNIfd
dlO'IM1ru and lellIgy.
l.i b Ti5lS: YilutS f(f tidrIty IuocIion lfII\stidt ol'l BUN am !MIm aYinirlf mi)"
irK_.
HerbaHood: Unknown
Treatment of OYerdos@: TherrisoosprcifKtrratmtntforOY!'rdosr.
IItftt to M}Mmlnqm for Q Mmi"ll'rlxm fooJ5lp1k to rlrls dr>Jq.
LibraryPirate
540 UnitS The Immune SY""m
INflUENZA
Infl uenza is a viral infection characterized by acute symptoms
that include sore throat, sneezing, coughing, fever, and
chills. The infectious viral particles are easily spread via air-
borne droplets. In immwlOsuppressed patients, an in-
fluenza infection may be fatal. In 1919, a worldwide
outbreak of influenza killed an estimated 10 million people.
Influenza viruses are designated with the letters A, B, or C.
Type A has been responsible for several serious pandemics
throughout history. The RNA-containing influenza viruses
should not beconfused with Haemophilus injllumzae, which
is a bacteriwn that causes respiratory disease.
36.9 Pharmacotherapy of Influenza
The best approach to influenza infection is prevention
through annual vaccination. Thosewho benefit greatly from
vaccinations include residents of long-term care facilities,
those with chronic cardiopulmonary disease, children ages 5
and younger, pregnant women in their second or third
trimester during the peak flu season,and healthyadults older
65. Influe""" i. "'.0 reconunended for
health care workers whoare involved in the direct care of pa-
tients at high risk for acquiring influenza, including HIY-
infected patients. Depending on the stage of the disease,
HIV-positive patit'nts may also benefit from vaccination.
Adequate immunity is achieved about 2 weeks aftervaccina -
tion and lasts for several months up to a year. Additional de-
tails on vaccines are presented in chapter 32(X).
Antivirals may be used to prevent influenza or decrease
the severity of acute symptoms. Amantadine (Symmelrel)
has been available to prevent and treat influenza for many
Chemoprophylaxis with amantadine or rimanladine
(flumadine) is indicated for Wlvaccinated individuals dur-
inga confirmed outbreak of influenza typeA. Therapywith
these antivirals is sometimes started concurrently with vac-
cination; tht' antiviral offers protection during the 2 weeks
bt'fore therapeutic antibody titers are achieved from the
vaccine. Because of the expense and possible adverst' effects
of these drugs, tht')' are generally reserved for patit'nts who
are at greatest risk for the severe complications of influt'nza.
Antivirais for influenza are listed in Tablt' 36.3.
TABLE I Drugs for Influenza
Tht' nt'uroaminidase inhibitors wt're introduced in 1999
to treat active infiut'nza infections. If given within 48 hours
of the onset of symptoms, oseltamivir (Tamiflu) and
Iu Ill" nUfmai 7
day duration of influenza symptoms to 5 days. Oseltamivir
is given orally, wht'reas zanamivir is inhaled. Becaust' these
agents are expensiw and produce only modest results, pre-
vention through vaccination remains the best aitt'rnatiw.
It is important to understand that these antivirals are not
effectivt' against the common cold virus. About 200 differ-
t'fIt viruses, including rhinoviruses, cause symptoms identi-
fied with tht' common cold. Despite considerable attempts
to develop drugs to prevent this annoying infection, success
has not yet bet'n achieved. There are drugs, however, that
may reliew symptoms of the common cold, and these are
presented in chapter 3800.
VIRAL HEPATITIS
Yiral hepatitis is a common infection caused by a nwnber of
differt'nl viruses. Although each virus has its own unique
dinical features, all hepatitis viruses cause inflanunation
and necrosis 01 liver cells. Symptoms 01 hepatitis may be
acute or chronic. Acute symptoms include fever, chills, fa-
tigue, anorexia, nausea, and vomiting. Chronic hepatitis
may result in prolonged futigue, jaundice, liver cirrhosis,
and ultimately hepatic failure.
36.10 Pharmacotherapy
of Viral Hepatitis
HEPATITIS A
Hepatitis A virus (HAY) is spread by tht' oral- fecal route
and causes epidemics in regions of the world having poor
sanitation. Outbreaks in the United States are most often
sporadic events caused by the ,onsumption of contami-
nated food.
Although approximately 20% of HAY-infected patients
require some hospitalization for symptoms related to the in-
fection' most recover without pharmacotherapy and de-
wlop lifelong immunity to the virus. Fatalities due to
chronic disease are rare, and only a small nwnbt'r of patients
Drug Routeand Adult Dose (max dose where Indicated) Adverse Effects
INFWENZA PROPHYLAXIS
Jmantadinr (Synmeutll
rimantadinr (ALrnadinr)
po; 100 mg bid (ma1:400
PO; 100 mg bid (mal:lOO "'9Idiy)
INFWENZA TREATMENTT: NEURDAMINIDASE INHIBITORS
osekamivir(Tamifluj PO; 75 mg bid foI 5 days
I.ouwmivi (Rtltnza) inhalJtiooIIday foI5 days
leutoomia hall!KiDiljrm oWCP!U!jc byoO!emjon urinary
"""'"
LibraryPirate
develop severe liver failure. Thus, HAY is normally consid-
ered an acute disease, having no significant chronic form.
This makes HAY very difft'rent from hepatitis B or C.
like aU forms of hepatitis, the best treatment for HAY is
prevention. HAY vaccine (Havri:l:, YAQTA) has been avail-
able since 1995. It is indicated for children living in commu-
nities or states with high infection rates, travelers to
countries with high HAY infection rates, men who have sex
with men, and illegal drug ust'rs. \Vhen a boostt'r is given 6
to 12 months after the initial dose, close to 100% immunity
is obtained. The average length of protection is appro:u-
matel), 5 to 8 years, although protection may last 20 years or
longer in some patients. Tht' availability of the HAY vaccint'
has led to a dramatic drop in the rate of this infection in the
United States.
Prophyla:us or postexposure treatment for a patient re-
cently exposed to HAY includes hepatitis A inununoglobu-
lins (HAIg), a concentrated solution of antibodies. HAIg is
administered as prophylaxis for patients traveling to en-
demic areas and to dose personal contacts of infected pa-
tients to prevent transmission of the virus. A single 1M dose
of HAlg can provide passive protection and prophyla..us for
about 3 months. It is estimated that the immunoglobulins
are 85% effective at preventing HAY in patients exposed to
the virus.
Therapy for acute HAY infection is symptomatic. No spe-
cific drugs are indiClted; in otht'rwise healthy adults, the in-
fection is self-limiting.
HEPATITISB
Hepatitis B virus (HBY) in the United States is transmitted
printmily through e."(posure to contaminated blood and bod)'
fluids. Major risk factors for HBY infection include injected
drug abuse, sex with an HBY-infected partner, and sex be-
tween men. Health Clre workers are at risk because of acciden-
tal aposure to HBY-contaminated needles or body fluids. In
many regions of the world, the primary mode of transmission
of HBY is by the perinatal route and from child to child.
Treatment of acute HBY infection is symptomatic, be-
cause no specific tht'rap), is available. Ninety percent of
acute HBV infections resolve with complete recovery and do
not progress to chronic disease. lifelong immunity to HBY
is usuall), acquired following resolution of the infection.
Symptomsof chronic HBY may develop as long as ]0
following exposure. HBY has a much greater probability of
progression to chronic hepatitis and a greater mortality rate
than does HAY. The final stage of the infection is hepatic cir-
rhosis. In addition, chronic HBV infections are associated
with an increased risk of hepatocellular carcinoma.
As with HAY, tht' best treatment for HBY infection is
prevention through inununization. Traditionally, HBY vac-
cine (Recombivax HB, Engerix-B) has been indiClted for
health care workers and others routinely exposed to blood
and body fluids. However, universal vaccination of all chil-
dren is now recommended, and some states require HBV
vaccination prior to entr), into school. Three doses of the
vaccine provide up to 90% of patients with protection
against HBV following exposure to the virus. A combina-
Chopt .. )!; Oru9.lorVlrallnlectlom 541
tion vaccine is available that provides immunity to both
HAY and HBY (Twinrix).
For someone who has been recently exposed to the HBY,
therapy with hepmitis B immunoglobulins (HBlg) ma), be
initiated. Indications for HBIg therapy include probable ex-
posure to HBY through the perinatal, sexual, or parenteral
routes, or exposurt' of an infant to a caregiver with HBY.
HBlg is administered as soon as possible after suspected ex"
posure to HBY.
Once chronic hepatitis becomes active, pharmacotherapy
is indicated with drugs listed in Table 36.4. The two hasic
strategies for eliminating HBV are to give antivirals that
stop viral replication, or to administer immullomodulators
that boost body defenses. Three different tht'rapies are ap-
proved fo r chronic HBV pharmacotherapy:
e /nTerferon alfa: Thirty percent to forty percent of patients
respond to 4 months of therapy. Five to ten percent of
these patients relapse after completion of therap)'.
e Lamivudine (Epivir): Twenty-five percent to forty-five
percent of patients respond to therapy, which lasts] year
or longer. Emergence of resistant viral strains is
bewming a clinical problem.
e Adefovir (Hespera): Approximately 50% of patients
respond to 48 weeks of therapy. The drug is new, and
long-term studies are in progress.
In 2005 the FDA approved entecavir (Baraclude) for
chronic HBY. Earlydata suggest entecavir is as effective as or
mort' effective than lamivudine. Tenofovir (Viread), a med-
ication used to treat HIV, was approved in 2008 to treat
chronic hepatitis B infections (see Table 36.1 ). Early results
suggest that tenofovir may have equal or greater effective-
ness as adefovir. Entecavir and tenofovir offer new treat
ment options for patients who have developed resistance to
oldt'r medications.
HEPATITIS C AND OTHER HEPATITIS VIRUSES
The hepatitis C, D, E, and G viruses are sometimes referred
to as non A- non B viruses. Of the non A- non B viruses,
hepatitis C "". the clinic:\] imporhnce.
Transmitted primarily through exposure to infected
blood or bod)'fluids, hepatitis C virus (HCY) is more com-
mon than HBY. Approximately half of aU HlY-AIDS pa-
tients are coinfected with HCY. About 70% of patients
infected with HCV proceed to chronic hepatitis, and up to
30% may develop end-stagt' cirrhosis. HCV is the most
common ClUse of liver transplants.
Unlike with HAY and HBY, no vaccine is available to pre-
vent hepatitis C. In addition, postexposure prophylaxis of
HAC with immunoglobulins is not recommended because
its effectiveness has not been demonstrated.
Current pharmacotherapy for chronic HCY infection in-
cludes several types of interferon and the antiviral ribavirin.
Combination therapy has been found to produce a moresus-
tained viral suppression than monotherapy with either agent.
Conunercially available interferons for hepatitis include both
the regular and pegylated formulations. P!qylation is a process
LibraryPirate
542 UnitS The Immune SY"'-""
TABLE 36.4 1 Drugs for Hepatitis
DN,
INTERFERONS
Rouleand Adult Dose (mall dose where Indicated) Adverse Effects
i1ttrfioroo oIHoIto;n.l
i1ttrltroo .",
Q inll'rfmfl altt.2b A)
oIH,-201 I j
Pf9intffimn iH,-2b (PEG-lntlOO)
SlbartantOlJl;911K9 for 24 wi;
S!bcutantOlllJ1M;l milhn ... thltt for-l8w1!
SlbartantOlllJ1M;l
SdKutintOlJl; 180 IIK9 of 1 wk fOl48 wk
f1r1ikr myoIgio, fariquf, I1todoch(,
alriUJia,dDrI!ta
throrrbxytoprnia,wicid!:
id!:at"OII
SdKutintOlJl; 1 rnt9fkgIwk for monOlhffiP'1; 15 g/bj/Wk
whtnlj'lffiwilhrWiirin
NONINTERFERONS;COMBINATIONS
lIItfO'lir dpiYmi (Htp\e'oI) 1'0; 10 mglday
ffittc.lVr (BariWdt) 1'0;05 mgld.Jr.l mgld.J,.!SoI 00Ie for patimn with
hilltf)' oi'lami'lOOirll' rtlisLJrKl'
,(srhm'4 ht<!docht, dilliMl'l,
n<mldimJrOOOCPl (1omirudl"l/!J
NffilltlloxKjty and 1KIk: 'tidosis (i!d!;foli(
lamivucint (Epivr HBV) 1'0: ISO mg bid
Ii I
ribalirin alf;t.2b
(Inlrd A):CombinatiOll ulled Robtuoo
ribalim:PO;fi'I!' to lOO-mg ups*sd.Jily
inttrltron aHrlb:SubrutiOOlUl; 1 milion units,

tttiwdine (T)'lK.JJ
that attaches polyrthylene glycol (PEG) to an interferon to
extend its duration of action, thus allowing it to be adminis-
tered less frequently. Whereas standard interferon formula-
tions must be administered three times per week, pegy\ated
wrsions require only one dose per week. The PEG molecule
is inert and does not influence antiviral 3l:tivity. Additional
information on interferons used for other indications may be
found in chapter 3200.
NURSING PROCESS FOCUS PATIENTS RECEIVING ANTIVIRAL PHARMACOTHERAPY FOR HERPESVIRUS
INFECTIONS
Assessment
Bilst line asessmrnt prior to administration:
Undrotand rtillOn drug hi! bffir pr&ribtd in order to aslfS:i for
therapeutic tffem.
Obtiin a tomplete health hillory indudi fIIj immuniLIticrn, Il'spiratory.
neurologic, htpatic: or Il'nal possibility of Pll'9nilncy.Obtlin
,drug history indudifllj spedfK rN(tions to drugs,
(Ul!ffit pmtription ,nd OlC drugs, hmlal akohol
,It" to possiblt drug intffiKtions.
AsIfS:i and symptoms of tUIll'M infection noting
dWri{\frinks,.nd prtSl'II(tor .bmKe offewor or pain.
Enwtt ,ppropriate laboratory findings (e.g., CB( ,nd rmal
function lIudies, firal tulrures).
Asstssment throughout administration:
AsIfS:i for therapl'lltic: (t .g., diminished or ab!ftltt of signs
and lymptomlofhrrpeliM iofettion and without Iymploms of
tOlKurrmt inftions).
CominUl' periodi< monitorifllj ofCBC,and htpati< and renal function.
AsIfS:i for adverst vomiting,.diallhtil, anorniil,
Dwtnd urint OUIput 01 rlarl:entd
urine. incll"std bruising or intINsifllj symptoms of
inft(tions should be Il'pontd
Potential Nursing Diagnoses
lnfffiion
lmp,ill'd Oralll'lJo)us Membranes
lmpaill'd Skin lmtgril)'
FatMJie
Activity Imoleranct
SCKialllOlition
Oefi<iem Kmwltrlg!' (relattd to proc:6S, and drug
therapy)
Risk for FkJid Volullll' (Il'Iatl'd to diIN process or oidl'ern drug
",<><lion.)
Risk for Imb:alancrd Nutrition, Thiln Body iltquill'l11tnts (Il'latl'd to
proms 01 aamJl' drug Il'adionsj
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NURSING PROCESS FOCUS PATIENTS RECEIVING ANTIVIRAL PHARMACOTHERAPY FOR HERPESVIRUS
INFECTIONS (Conlflluea')
Planning: Patient Goals and Expected Out comes

ExperitrKt ItImJPtUIic tffb (e.g.diministlf'il 01 of sigm 1M symptoms ofinitdion,/II:IIf to mlintain rUrition 1M h)dRtion).
from,OIflptMnu' iCIftrw tfftru.
Vt!b.llizt in undtrmnclirlg of tlltdrug's 1M, iltmse tftects, Ind preuutions.
DmIonslrille proprr of tilt medil<ltion timing, when kl notify proUr).
Implementat ion
Interventions and (Ratio nal es)
lMuring tMuptUtlc effem:
Continue 6sesmenls 6 decribN t,rlitr IortherlptW: tlftru:
cl"Im inishing signs of origRal inffaion, l1li inle narn of lIOfIIlil . pPflitt.1Id
l\Jid inll\:t, and inU"usillg ellel9Y 1twI.(I)rug effu 1liiy flO! be
oin.m.bit.GrDwI impromnmt should be noted Ind tfw,
patient shOllld be eocourqd 10(omil'l\lf fiting meditation.)
Mi nimizing aCMm effects:
Continue III monitor vila! fl'port irKfI'ilYng ftlft,
cl"lUiness,.hNdKhe,or diminishtd UriM output to tht Wf pnMdtt
wflrn i{(Dmpanied b)' worwning symptom!,.
1liiy be iI\ign ofWOBtning OIIIMfWdrug tfftmJ
Continue kll!lOflitor ptriodic lab worHlK,llep.atk .lIld fI'IIll functiOll
and vira) ruIturfs.(AntMraI drugs m.l1 be toxK 10 tfw, he- .nd kidnrys.
Blood dys<161ls due to bone milltlW ItIpIIIm ion, partiwlarly
tIIIOmbocytoptnia, is an tdftnttffed and is monitortd by (Be.)
Continue III monitor for heopni( and _tOJkitit!.. (HepatM; ilnd fl'1IiII
trIoIyour Ind frtqutfll 10 prmnt
rfttm.lnuming Auid ifIIakt mlY pfl'Wllt drug aCl:lrmuiltion in kiclnfrs.)
Monitorfor signs.nd symptoms of nflllOl<lOOty, PlrtKulirly in paOmuoo
r'i iI(1(1oftt e.g., drowsiness. IIfmOB, hudi<1w. (l)llfuIioll,
dlinges in I.OC. ind p,lritnt Solftty ,nd 1Ia'fe the patient rise
sbNly from IJing or sitting It sllnding. (kydoyir, wht n gMn IV.
may be 1IfOOI1I)lic.)

lignifK.lflll,rigut,.nd inclNWng signs ofillftctioll. (Ront mlllOW
suppl"ffiion /IIi)' OCGJr ind aIM dKrNsts in RBCs, WBCs"otndlOl plattlm.
PfI'iodic monitoring ofCBC will be fI'qIIifI'd)
Monitorforsignificant GI efftm, induding IlilMi, 'fOfIIiting,lnd diirrhN.
acltquilt nutrition Ind caloric tfiecBar.
common and tfw, pitient m.,-.iso h.M tlfB, . g. moW!
SCRS. Milinllining idf<lllilt nutrition .nd Iirids is tsstntilho hti 6ng.)
Pati ent and Family Educati on
Turn tht INtitm III not <iw:0II00U!' drug rtqimtn bette(
on! to uke the fill (oolltof mecflUtioll.
[Moorq ilCItqullf nutrition, IfflIs as impmtrnent is
Mol
Tuch tht INtitnt, p!OIIIpIIy fI'IIOfI fI:omthat t1Cr('Ik
1 0 1 'f, 01 per pirJmtlm; iII, biIiry 10 mainuin hydr Mion or l1li1 tiTian: 01
diuintss to 1M helkh proidtr.
ImlJu(t the p,ltitnt on the Iftd for ptrildc: lab work,(orrNting illIJ
symptoms we tfw, nml for pcruiblt Lib! (e.g., iKrNsf'd brui5ing or
bIetodingl.
Tuch tht INtiefll to fl'port 'IIJ nausu, vomiting.)'fIlowing of
lkin OIlderll, abdominll p,lin.light 01 dI)'--cobtd stool!,or diminished
urW output ordalttning of..w.
Advise the Jlltitnt to m.iroin ftuid intake II 21t 3l perday.
IrtStnKttht p,ltitnt, f.mi1',:01 to inCIMSJg
dlllWsintu, uernon,coriusion,ordlan9ts in lOC.
<.&ilion the patitnt thit drowsintss mly 000If Ind to be uutious with
drivillll or O!btr hwrdoul ac:tiritirs unli1lM ellrcts of me drug art
--.
Ifdlzzillfls ooo.s,. rise hom I or litting position to sunding
InsUlJ(t the JNtitm to fl'port ."Iow-grac:lt 101'1' Jhn:r"t, rashes.
bNising or biffllin;.Gf unUSUil fil9Jt or shortntsl of bfl"tlI,
tsptcially if on drug thelillY for. prolongtti ptOOd.
Turn tht III avoid ioodland bt'ftligc'!,.urilonattd drinks,1II"
flI<fSIiYriy hoi; orcoid fooxIs.nd wflich ma1 CilIIIf mouth
irritition.
Encourq patirnt to try small, frtqU!'!lt muls, which 1lIIY be bettfl'
toitllttd than LlIQfI' mu!s. HiQh-<alorio:foodl and IUIIIlIemtntal
bntBges help.dd .dcitiooal calories.nc! supply addilioooll IUds..
Allisllhe patitnt in obtaining. diemy<onlllltition II rwdf'd if nlUIN or
liinhel makes lIliinuining inukr difficult.
(Continued)
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544 UnitS The Immune SY"'-""
NURSING PROCESS FOCUS PATIENTS RECEIVING ANTIVIRAL PHARMACOTHERAPY FOR HERPESVIRUS
INFEalONS (Continued)
Impl .. mentation
Interventions Zlnd (Rationales)
n(OlJragt infKlioo ronlrollnd good hygitne mealUll'S baIfd on
oondition, and fol low Ht.lbliWd prouxol in hOlpitalire:l piltiffi ts.
(Antiviral drugs tho! IMI of infectiGn but do nOl cure tho!
me.uull!! will limit ihechancf for Iondar, infrctions in
lhe immunocompromisfd piIIitnt.lnfKlion control mNwre
disem transmission.)
MainLlin h)llralion during aoc:ydo ... ir lherapy. H)IIration may bf oniertd in
lhe immedialf tn- and postadministrllion Pfriods.Monitor intake and
ootput in thf hospitalized p.nitnt (k)'Clovir may bf nephrotoxK and
Idtqwtf hydration is fS!ellu.llo PleY!'llt IdvffU fffial tffrcts.)
Patimt understanding of drug therapy:
Usf opportunities during idministration of medKations Ind during
... f-I.mems to di<cuI< "tiollOt. lot druglt.mp)\ do-si"d thff.peutK
oot{omes, most comlOOn for when to ull thf
heakh (1ft' any nKflWr, monitoring or prKautions.(Using
limf ruring nUBing Wf helpslo optimizf and key 1N(hing
aR'as.)
Patimt selfadministration of drug therapy:
When idministfring inSifIKI the or clR'gil'r
in thf plOpfl5elf-administraiion Ieo:hniqws followed by II'tum
ritlOOnstration. (Proper administration will implO'/f the f ffectiveflfS s of the
- ... >
Patient and Family Education
Tfaoc: h the pillient idtqwtf inftction conlrol and hygiffit mfi 5UrH 5U(h as
frtqUtnl hind washing. of dll'ssing material. and
arltqwte nutrition and if CUITtll!ly immuMCOmpmmisNi.
The pillient mI)' nerd to lit isolated illmpitilorft'lThlin it homeduring pNk
traflllllis!ion ptriods, lemng to IOriaI isolation. AscmJin if the pilUtnl hu
Nistancf Milabit if a proIorged pmoo ofhomebuld stalUS
Tfaoc:h the pillienllo practKf abstinence or to 1M barrier protfdion during
oKtivity mil if gtnital 001 HSV infruions
may bf traosmitted eY!'n in Ihf i symptomatK period.HaI'!' the patient
oomuk with their heakh !arf proYidfr aboot therap)'.
Tfaoc:h the pillienl on oral aoc:ydovirto oral imake prior to LIking
oral aq<loYir and inclNlI' fluids to II pfrday thfOl.l9hoot therapy.
The piltienl, should lItabie to stlte the INIOn for the
drug; .ppropr;.tedole .nd "'lfduling;wh" .dvt". fffMU to obr.rve for
ilnd when to I"fport;and lhf amKipated length of medKition therapy.
Tfaoc: h the piIIitntto:
Complttf thf {OUIIe of theraPl' unll'sl otherwilf instrudN.
Take the medi4:ation i S1'l'fl1y Spilled thfOl.l9hOUl mh day aliNsibll'.
_rail fluid int.lkt.
If using oimmfnll orcreams, wash hands well btfm applying and
in afifr appiKition.1f family or (aR'gil'l'rl administfr the med ic:i Of,
glol'l'S \hoold bf worn.
Evaluatio n of Outcome Criteria
Evaluate the effe<tivflll'lS ofdrug !herap)' by confinning that patient goals Ind fllpf(lfd ootoomes h.m (sef"Planning1 .
.".. TGbIt J6.1tlJlg Ii!! Iidft!1Jj rowhChrhe!l nllIingaaiom op{iy.
t }.( Chapter REVIEW
KEY CONCEPTS
Thf numbered key concepts provide a succinct summary of the important points from the corresponding numbered section
within the chapter. If any of these points are not clear, refer to the numbered section within the ch.apter for review.
36.1 Vi= are nonliving intracellular parasites that require
host organelles to replicate. Some viral infections are
st'lf-Iimiting, whereas others benefit from pharma-
wllJ.,rapy.
36.2 HN targets the T4lymphocyte, using reverse transcrip-
tase to ntake viral DNA. The result is gradual destruction
of the immunf system.
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36.3 Antiretrovlral drugs used in the treatment of HI Y-AIDS
do not cure the disease, but they do help many patients
live longer. Phanmt'otherapy may be Initiated In the
acute (symptomatic) or chroniC (asymptomatic) phase
of HI V infection.
16.4 Drugs from !lYe drug classes are used In various combi-
nations in tbe pharmacotberapy of Hl Y-AlDS. The nu-
cleotide reverse tranS(:riptas<> inhibitors and th ... fusion
Inhibitors hnve retently befn dlS(:overed.
36.S Tbe reverse transcript ase inhibitors block HIV replica-
tion at the level of the rewrse transcrlptase enzyme.
include the NRTIs.. NNRTls, and the NtRTIs.
16.6 The protease inhibitors inhibit the final of the
HIV virion. They are alwll)'s used In romblnatlon with
other antiret rovira1s.
NCLEX-RN. REVIEW QUESTIONS
o When the patient Isstartedon antlretrovlral drugs for HIV.
nursing education should indudewhkh of the following!
I. This drug wiD ture the dist'ase over time.
2. Thlsdrug wW not cure thedlsease but may extend the
life elpectant')'.
3. This type of drug will be llS('([ prior tovacdnes.
4. This drug is readily available aU over tile world for
treatment
o The nurse understands thai the laboratory tests must
be a5&.'!iSed. while a is on drug thenpy for HIV-
AIDS (Selt'('t aU that apply.)
I . Csc.
2. clotting factors..
3. HIVRNA.
4. CD4lymphocyte count.
5. BUN.
g When providing patient and famUy education for the
nucleoside reverM' trnnscriptase inhibitor drugs for
HIV.AIDS, the nurse would teU the patient to take the
medication:
I. on an empty stomach.
2. on a full stomach.
3. with apple juice 10 decrease the taste.
4. with orange juke 10 increase absorption.
o A patient is concerned about contracting influenza. The
best response by the nurse would be:
l. "After receiving tile vacdnation you will be protected in
about 2
2. "If you have an exposure. two drugs. O!icltamivir
{TamifIu) orzanamivir {RL'Ienz.a) are nowavailable to
help prevent the disease or 10 shorten itsduration."
36.1 The risk of perinatal transmission o( HIV am be
markedly reduced by implementing drug therapy of the
mother during and the newborn following
birth. Postexposure prophylaxiS of HI V infection is de-
signed to pre"ent the accidental transmission of the
virus to health art workers.
36.& Pbarmacotherapy can lessen acute herpes
simplex infections and prolong the latent period of the
disease.
36.9 Drugs are available 10 prevent and to tren influenza in-
fections. Vaccination Is the best choice, as drugs are rel-
influenza symptoms
36.10 Hepatitis A and 8 are best treated through immuniza
tion. Newer drugs for HBV and liBC have led to thera
pies for chronic hepatitis.
3. "You need to bevacdn:ttedonly If you are older
than 50.
4. Infectious particles are not easRy spread. and you
C1n mit 10 be vaccinated until there is an increase In the
popu1ation."
U A patient is started on efavlrenz (SustlV1). a nonnudeo
side rt>\ers.t' transcriptase inhibitor (NNRTI) drug (or
HIV. The patient should be taught :
l. tlUs drug wlU cure Ihe disease over time.
2. tbere are few notable adwrse effects of this drug but be
C1ulioosabout I2k\ng it with citrus or mRkbased
",," ....
3. nervous system l.'fJects such as dizliness, difficulty
thinking dearly, a.- nightmares nuyoo:ur but tend to
Improve after 3-4 .... -eek.i.
4. thedrugshould betaken with a high-fat meal to delay
absorption and prolollgeffect.
o A patient has been d iagnosed with berpes zoster and h3S
be<.'n Slaned on oral acyclovir (ZDvirax). Thenursewill be
sure to Include patient teaching Instructions to: (Select all
tbat apply.)
l. il'ltreastfluid intake up to 2 Lper day.
2. report any di2ziness, tremors, or oonfusion.
3. decrease the amount of ftuids taken 50 that the drug am
be Il1On' concentrated.
4. only take the drug when having tbe most itching or pain
from the outbreak.
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546 Unit, Thl'tmmu""sym'm
CRITICAL THINKING QUESTIONS
1. Tht' patit'nt is 72-year-old woman who lives in an as-
sisted living community. Tht' nurse advises tht' patient of
the Importance of receiving an amantldlne (Symmetrel)
Injection. What is the rationale supporting this recom-
mend.1tlonl How could the nurse assist the patient In
complying with this recommt'ndation!
!. A newly diagnosed HIV_positive pa!it'n! has been put on
zldovudlne {Retrovlr}. Identify prioritIes of nursing care
for this patient.
3. A ht'a1th care provider has ordt'Tt'd acyclovir (Zovirax) as
an IV bolus to be infused over 15 minuU's. Tht' patit'n! is
seriously ill with a systemIc herpesvirus Infeo::tlon. and the
heallh care provider wanu the patient to huve Immediate
access to the medication. What is the nurse's best response!
See Appendix D for answers aud rtltionaies for all activities.
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fllWUfCll .. Prepale 101 SlJCC8SS with alJditioooi 1fCtiX"-&tyIe
questloos. Imenu:tNe assignmen!S mel aCIMties. web IIi<.s. animations
and videos. and more!
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www.""" ..... gkilcom.
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DRUGS AT A GLANCE
AlKYLATI NGAGENTS plllJr551
Nitrogen Mustards paJt 555
Q cydopho<phamkk (eyr"".n) pi1J' 556
Nitrosoureas I""Fm
ANTIMETABOLITES p11l1,,5J
FoHcAdd Antagonists p m
'" mf'thorruou /Rht um<J!ra, TraaN}
fII11' 557
PyrimldineAnal ogs fIIlIJ' m
PurineAnalogs 1'11'1<'555
ANTITUMOR ANTIBIOTICS paJt554
Q dorotubkin (Mriall1ycin) poJr5'i&
NATURAL PRODUCTS pDt}' 558
Vln t.l Alkaloids JlIlIJr559
'" vincrisriM (Oocovin) JllX!' 56IJ
fIIl1'559
Topol somerase Inhibitors fII11'559
p 559
HORMONE AND HORMONE ANTAGONISTS fIIlIJ' 559
GlurocortkoldslCortkosterolds f1l1"56IJ
Estrogens Estrogen Antagonists paJt 56IJ
Q rall10xjfen paJt 56]
Androgens Androgen Antagonists paJt561
BIOLOGIC RESPONSE MODIFIERS P!XT 56J
KEYTERMS
adjUYilnt memoth<Ipy plJ/}r55(J
. Ikyl.l i ln paJtm
alopfdil p<q m
aromatas. inhibitor pajI' 561
{amptothfdn f1XJd59
can{l'Ifmlinomii fJI1J' >I/J
dlemotherapy jlIlIJd 49
Drugs for Neoplasia
LEARNING OUTCOMES
Arrer reoding mis ,hapler, rhe should be able to:
1. Explain differencM between normal celis and cancer celis.
2. Identity factors associat ed with an increased risk of cancer.
3. lif" styl"f .. ctor . .... oc .. t"d with a ,-,.duc"d ri.k of acquiring
cancer.
4. Identity the three primary therapies for cancer.
5. Explain the significance of growth fraction and the cell cycle to the
success of chemotherapy.
6. Describe the nurse's role in the pharmacologic management of cancer.
7. Explain how combination therapy and special dosing protocols
increase the effectiveness of chemotherapy.
8. Describe the general adverse effects of chemotherapeutic agents.
9. For each of t he drug clasws listed in Drugsat a Glance, know
representative drugs,and explain t heir mechanism of drug action,
primary actions, and important adverse effects.
10. Cat egorize ant icancer drugs bawd on their classification and
mechanism of action.
11 . Use the nursing process to care for patients who are receiving
antineoplastic medications as part of t heir t reat ment of cancer.
emetic potential jIQ}' 55<
growthf .. <tion puq< m
metastuis jIQ}' 5#J
mucOli tis {I/1Id5]
ni dir fIIlIJ' m
n@Opl.nm fllXT54Il
palli.nion fIIlIJ' 55(J
ta .. M 1'"'1"" 9
topoilomeril.1 fIIlIJ' 559
tumor fI1IJ' 54lJ
nsicant fI1IJ'5jJ
vinca alkabids fIIXT 559
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"

..



S48 UIIIIS The Immu"," S)"t""'
(
<lIneer Is one of the most feared diseues In society for <lI
number of reiuons.lt is often silent, producing no
syl'l'lfJ(onu !.ntil It is far itdvanced. It $OI1letlmes requires
painful <lind dsfi9U"log sUfgery.lt may strike at an early <lIge,
even during childhood, to deprive people of a normal life
span. Perhaps worst of <lI1I, the medical treatment of c<llncer
often cannot offer II cure,and progression to death Is some
times slow, painful, and psychologl(,!11y difficult for patients
<lind their loved ones.
Despite Its feared status, many successes h<llve been made
In the dlll9nosls, understi)ndiog, <lind treatment of c<llncer.
Some types of cancer <lire now ruritble, and ther3ples may
pI'OIIlde the patient a longer, symptom-lTee chapter
eumloes the role of drugs in the tre<lltment of cancer.Med-
IGltlons used to treatthis dsease are Gllied onticoncer drugs,
ontintop/ostics, or cancer agents.
37.1 Characteristics of Cancer
Cancer, or wcinom., is a disease characterized by abnomlal,
uncontrolled cell division. Cell division is a normal process
occurring extensively in most body tissues from conception
to bte childhood. At wine point in time, however, suppres-
wr genes responsible for cell growth stop this rapid division.
This may result in a total lack of replication, in the case of
muso::le cel ls and perhaps brain cells. In other cells, genes
controlling replkation can be turned on whtn it bKomes
nf'(:ess.ary to replace worn-out ails, as in the case of blood
cells and the mucosa of the digestive tra".
Cancer is thought to result from damage to the gerll'S con-
trolling cell growth. Once damaged, the cell is no longer re-
sponsive to normal chemical signals checking iu growth.
The cancer cells lose their normal functions, divide rapidly,
and invade surrounding cells. The abnormal cells often
travel to distant sites where tht>y populate new tumors, a
process called metutoHis. "" Figure 37.] illustrates wme
acteristks of UflCe1' cells.
TUIJIOt is defined as a swelling, abnormal mlargement, or
mass. The word neopImn is often used inttrchangeably with
tumor. Tumors may be solid masses, l uch as long or breast
cancer, or they may be widely disseminated in the blood,
such as leukemia. Tumon are named according to their tis-
sue of origin, generally with the suffu: oma. Table 37.1 de-
scribes common types of twnors.
37.2 Causes of Cancer
Numeroos factors have been found to cause cancer or to be
associated with a higher risk for acquiringthedise:tSe. These
facton are known as cllrcinogul5.
to.hny chemi cal carcinogens have been identified. For ex-
ampll', chemicals in tobacco smokl' are responsible for
about one third of aU canar in IN- United States. Some
dll'lllicals, such as asbestos and beruml', haw been associ-
ated with a hilther incidern:e of uncer in the workplace. In
B __ r u..g ....
- Figure 11. ' Invasion and metUti)sis by cancer
some cases, the site of the cancer may be distant from the en-
try location, as with bladder canar caused by the inhalation
of certain industrial chemkals. Some known chemical car-
cinogens are listed in Table 37.2.
A nwnbl'l' of physical factors are alw associated with can-
cer. For example, exposure to largl' amounts ofx.rays is as-
50Cialed with a higher risk of leukemia. Ultraviolet (LN)
light from the sun is a known ClIw;eof skin cancer.
It is estimated that are aSiOCiated with about t5%
of all human cancen. Examples include hl'rpes simplex
types I and II , Epstein-Barr. human papillomavirus (HPV).
cytomegalovirus, and human T-Iymphotrophic viruses.
Factors that suppress the irrunune system, such as HIV or
drugs given after transplant surgery, may encourage the
growth of cancer cells.
PHARMFACTS
Canal!r
It is _!!won 1,400,000 lIN Ci/lCrf (ISH oaur
with _!halt Wi,OOO de.tta l.soo ,",*00 lily).
Unc<'l'is the dIiri 00It of t.,. in dJidrm
.,.1<
hubrnia is tilt IMst COI'MIOII dlild!Iood <MKtI' jllll is W
OIItMIIrlh rI II (ll'(tIS OCcvrMg brkn 20.
lung GJnm hj\ the hightst mortJlity ratt: It is repOMilH lot of.H
(llKfr deaths.
PlOItatf (jlKfr is tilt SKOnd ltading (aJSf of (llKfr deuh in TIl<'I'l.
Ihf hightst survrval Iorcancm of thr prostatr, tntis,and
thyroid. Tilt lawnt Sollrviv.l ritH for piOO'Ntic.nd lil!f cancm.
Among ethnic groups,Afriun.l.Jnerum hill'!' tilt hightst incidrrn rllts
i1nwll'f Iype! of t"'-ofthe lulllj, brNm,.1111
1990, tIIis gip bmllIlInowing.
Although b.un _ is predomNm in women (SOIId in (llKtr
dtathsl,jmost 2,000 1IIm_ diIgnostdwidt !lit disosr f.idl
s-P:fftar FIJMdRgl"1 AlW/(ftCRl!' 5IPIJ ltIOI(IrMW_JJIfJ,
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TABLE 37.1 I Classification and Naming of Tumors
Name Description Examples
BffiilJl tumor
Cardnoma
Slow growiog; ob I OOIlMiSLlIIzr ind rartly rrquile d1Jg Ul' .. ummt
tpithtlial tissUl';mO\l(ommon I)'pt of ntOpIism;,WII
... picly.nd m."<ta<izg
and lpom.1,olleoma,mmingioma
MaIi!Jlint ml'lallOllW, mlal (til WOOOllli,
odMo<irOllOllli, htp>.ortilular aui ........
TtiangimuK braillt!'fl! gbma 91011 (til in tIM' brail,ijlinil (ord, pilll'al gland,posterior
piRitary rttini
LN:emia
Lymphomo
Mali9:lant tumor
.,-
bIood-foming ttisin marrow; may or cMlnK
mlUf
MytiocytK Iymphot)'liclfllkemia
dilta\e, IymphoblistK lymphoma
Malignant mtlallOllla Growsrapidi)\ to and i1 duth if!llUNtfti
of conllKtiv! 15Ut; IJOWI utr!'fl!tiy Ii piIIy ind tarly wltoma,fiblOlarmrno, Kapoli's WUomi,
Djosarmma in tIM' pI'tqtIs.ion oftlitoNaII'
H.2 I Agents Associated with an Increased
-.... Risk of Cancer
Agent T'ypeofcancel
" ...
""'
... ,
Skin arod ILng
-..

. -
lPuhmi
Hoti lung and niSil
PtII)'cydK aromatK IrJdflKilrbon! lungandlkin
Tobi(m 1ID1la1l(6 luog;hudarodoM

""'
Some cancers have a strong genetic componem. The fact
that close relatives may acquire the same type of canc:er sug-
gests that certain genes may predispose close relatives to the
oondition. These abnormal genes interact with chemical,
physical, and biologic agents to promote cancer formation.
Other genes, called tmnor suppressor genes, may inhibit the
formation oftwnors. !fthese suppressor genes are damaged,
cancer may result. Damage to the suppressor gene p53 is asso-
ciated with cancers ofthe breast, lung, brain. oolon, and bone.
Although the development of cancer has a genetic com-
ponent, it is also greatly influenced by factor.; in the e nviron-
ment. Maintaining or adopting healthy lifestyle habits can
reduce the risk of acquiring cancer. Following proper nutri-
tion, avoiding chemical and physical risks, and maintaining
a regular schedule of health checkups em help prevent can-
cer from developing into a fatal disease. The following are
lifestyle factors regarding cancer prevention or diagnosis
that should be used by the nurre when teaching patients
about cancer prevention:
Fliminate tooocco use and exposure to secondhand smoke.
limit or eliminate alcoholic beverage use.
Maintain a healthy diet low in fat and high in fresh
vegetables and fruit.
Choose most foods from plant sources; increase fiber in
the diet.
COMPLEMENTARY AND A LTERNATIVE T HERAPIES
Selenium's Role in Cancer Prevention
is an that is to maintain litakhy
immulll' function.1t is a vitll antioxidant. combilll'd with
tamin E. k protml tilt 1'I1l'III b)' prrftnting tilt formation of free
r.JdKal!, which can dimaqr the body.
Selenium (an he found in lII!'at andgr.Jilll,Brazil nun, broc:-
brown rK.,dJi!), product g.rlie, IIIOI .... .nd onionL 1M .mount 01
II'ltnium in food, howt'l'l'r,hua dirt'(\ corrt'lnion to thell'ltnium contt'nt 01
loil of muth Aml'riun farmland illow in rt'luking in
II'ltnium-dtikitnt produtf. Low ditta!), intake of II'ltnium il assoc:iotfti
with incrt'.J1I'd of II'IIml (ill(fB, including lung. (olort'ml skin,
and prol1ate. IUppltlll!'mation has in ilKrt'aII'd nitural
killtr (til activity. and studits show its promilt as protection agailllt prostate
and (oloreml (inCfB,6pially among smokeI'!.
Exercise regularly and maintain body weight within
recommended guidelines.
Self-examine your body monthly for abnormal lumps
and skin lesions.
. Avoid chronic or prolonged exposure to direct sunlight
and/or wearing protective clothing or sunscreen.
Have periodic diagnostic testing performed at
recommended intervals:
Women should have periodic mammograms, as
directed by their health care provider.
Men should have annual prostate exams after age 50.
Both m.n and women receive a
colonoscopy, according to the schedule recommended
by the health care provider.
\I/omen who are sexually or ha\'e reached age 18
should have an annual Pap test and pelvic e:umination.
37.3 Chemotherapy of Cancer:
Cure, Control, and Palliation
Pharmacotherapy of cancer is sometimes simply referred to
as Because drugs are transported through the
blood, chemotherapy has the potential to reach cancer cells
in virtually any location. Certain drugs are able to cross the
LibraryPirate
550 UnitS Thl'lmmuneSystem
blood-brain barrier to reach brain tumors. Others are in-
stilled directly into body cavities such as the urinary bladder
to bring the highest dose possible to the cancer cells without
producing systemic adverse effects. Otemotherapy has three
general goals: cure, control, or palliation.
When diagnosed with cancer, the primary goal desired by
most patients is to achieve a complete cure; permanent re-
moval of all cancer cells from the body. The possibility for
cure is much greater if a cancer is identified and treated in
its early stages, when the tumor is small and localized to a
well-defined region. Indeed, the 5-year survival rates for
nearly all Iype' of cancer hali increa,ed in Ihe palil two
decades due 10 improved detection and more effective ther-
apies. Examples in which chemotherapy has been used suc-
cessfully as curative treatments include Hodgkin's
lymphoma, certain leukemias, and choriocarcinoma.
\'/hen cancer has progressed and cure is not possible, a
second goal of chemotherapy is to oontrol or manage the
disease. Although the cancer is not eliminated, preventing
the growth and spread of the tumor may extend the patient's
life. Essentially, the cancer is managed as a chronic disease,
such as hypertension or diabetes.
In its advanced stages, cure or control of the cancer may not
be achievable. For these patients, chemotherapy is used as
palliation. Chemotherapy drugs are administered to reduce the
size of the tumor, easing the severity of pain and other tumor
symptoms, thus improving the quality of life. Examples of
advanced cancen; for which palliation is frequently used in-
dude osteosarcoma, pancreatic cancer, and Kaposi's sarcoma.
O!.emotherapy may be used alone or in oombination with
other treatment modalities such as surgeryor radiation ther-
Teloph ...... II.
ID
phesa 01 cell cycle
o AIkyieling egents
,
, ,
, "
o Anlitumot anlibiolics

o HotmOOII inhibitofS
\
#
'.'
,'.
'.'
Anaphase
FlgureJ7.2 Antineoplastic agents and the cell cycle
-- .
apy. Surgery is especially useful for removing solid tumon;
that are localized. Surgery lowen; the number of cancer cells
in the body so that radiation therapy and pharmaootherapy
can be more successful. Surgery is not an option for tumon;
of blood cells or when it would not be expected to extend a
patient's life span or to impro'e the quality of life.
Approximately 50% of p.1tients with cancer receive radi-
ation therapy as part of their treatment. Radiation therapy
is most successful and produces the fewest adverse effects
for cancen; that are localized, when high doses of ionizing
radiation can be aimed directly at the twnor and be con-
fined to a ,mall area. Radiation treatment. arc frequently
prescribed postoperatively to kill cancer cells that may re-
main following an operntion. Radiation is sometimes given
as palliation for inoperable cancers to shrink the size of a tu-
mor that may be pressing on vital organs, and 10 relieve
pain, difficulty breathing, or difficulty swallowing.
Adjuvant rnemotherapy is the administration of antineo-
plastic drugs after surgery or radiation therapy. The pur-
pose of adjuvant chemotherapy is to rid the body of any
cancerous cells that were not removed during the surgery
or to treat any microscopic metastases that may be devel-
oping. In a few cases, drugs are given as chemoprophylaxis
with the goal of preventing cancer from occurring in pa-
tients at high risk for developing tumors. For example,
some patients who have had a primary breast cancer re-
moved may receive tamoxifen, even if there is no evidence
of metastases, because there is a high likelihood that the
disea ... will recur. Chemoprophylaxi6 of cancer is uncom
mon, be,ause most of these drugs have potentially serious
adverse effects.
o Bleomycin
o ElDpDSjde
o Paditaxel
I MITOSIS I
LibraryPirate
37.4 Growth Fraction and Success
of Chemotherapy
Although cancers grow rnpidly, not all cells in a tumor are
replicating at any given time. Becmse antineoplastic agents
Benerally more effective cells are
the percentage of tumor cells dividing at the time of
chemothernpy is critical.
Both normal and cancerous cells go through a sequence
of events known as the cell cycle, illustrated in .. Figure 37.2.
Cells spend most of their lifetime in the phase. Although
sometimes called theresting stage, the Go is the phaseduring
which cells conduct their everyday activities such as metab-
olism, impulse conduction, cont raction, or secretion. If the
cell receives a signal to divide, it leaves and enters the G,
phase, during which it synthesizes the RNA, proteins, and
other components needed to duplicate its DNA during the
S phase. Following duplication of its DNA, the cell enters the
premitotic phase, or G,. Following mitosis in the M phase,
the cell re-enters its resting Go phase, where it may remain
for extended periods, depending on the specific tissue and
surrounding cellular signals.
The actions of manyof the antineoplastic agents are specific
to certain phases of the cell cycle, whereas others are mostly in-
dependent of the cell cycle. For example, mitotic inhibitors
such as vincristine (Oncovin) affect the M phase, which in-
cludes prophase, metaphase, anaphase, and telophase. An-
timetabolites such as fluorouracil (S-FU, Adrucil, Carac,
Efudex) are most effective during the S phase. The effects of
alkylating agents sud! as cyclophosphamide (Cytoxan) are
generally independent of the phases of the cell cycle. Some of
these agents are shown in Figure 37.2.
The growth fract ion i> a measure of the number of cells un-
dergoing mitosis in a tissue. It is a ratio of the number of
replicating cells to number of resting cells. Antineoplas-
tic drugs are much more toxic to tissues and tumors with
high growth fractions. For example, solid tumors such as
breast and llUlg cancer generally have a low growth frac-
tion; thus, they are less sensitive to antineoplastic agents.
Certain leukemias and lymphomas have a high growth frac-
tion and therefore have a greater antineoplastic success
rate. Because certain normal tissues, such as hair follicles,
bone marrow, and the gastrointestinal (GI ) epithelium also
have a high growth fraction, they are sensitive to the effects
of the antineoplastics.
37.5 Achieving a Total Cancer Cure
To cure a patient, it isbelieved that every single cancer cell in
a tumor must be eliminated from the body. Leaving even a
single malignant cell could result in regrowth of the tumor.
Eliminating every cancer cell, however, is a verydifficult task.
A1; an example, consider that a small, I-cm breast tumor
may already contain I billion cancer cells before itcan bede-
tected on a manual examination. A drug that could kill 99%
of these cells would be considered a very effective drug, in-
deed. Yet even with this fantastic achiewment, 10 million
cancer cells would remain, anyone of which could poten-
(110" .. 31 Drug' for Neap!",,", 55 1
tially cause the tumor to return and kill the patient. The re-
lationship between cell kill and chemotherapy is shown in
.. Figure 37.3.
It is likely that no antineoplastic drug (or combination of
drug;) will kill 100% of the twnorcells. The large burden of
canc.r cells, however, nt"}' be lowered sufficiently to permit
the patient's immune system to control or eliminate the re-
maining cancer cells. Because the immune system is able to
eliminate only a relatively small number of cancer cells, it is
imperative that as many cancerous cells as possible elim-
inatoo during treatment. This example reinforces the need
to diagnose and treat tumors at an early stage when the
number of cancer cells is smaller.
Primary tumor
1,0(0,000,000 cells
Reduced tumor
99'1' . kill
10,000.000 ""Is
Ao<Iuoed tumor
99.9'1'. kill
1.000,000 cells
.. Figure 37J Cell kill and chemotherapy
T ""Ia
''''''''''ng
remaining
cancer cells
LibraryPirate
552 UnIIS The Immune Sy>lI'm
37.6 Special Pharmacotherapy
Protocols and Strat egies
for Cancer Chemotherapy
Because of their nlpid a U division, tumor ceUs express a high
mutation r,!.Ie. This causes the tumor to change and become
moll' heurogenous as it grows, essentiaUy becoming a mass
of o.r different clones with different growth rates
and phYSiologic properties. An antineoplastic drug may kill
onlya small portion of the tumor, leaving some clones unaf-
fected. Complicating the chances for a cure is that canar cells
often develop resistance to antineoplastic drugs. Thus, a ther-
apythat was very successful in reducing the tumor mass at the
start of rnemOlherapy may become less effective over time.
The tumor becomes k) treatment.
A number of treatment strategies have bt>en found 10 in-
crease t he effectiveness of anticancer drugs. In most uses
multiple drugs from different antineopLa5l ic (Lasses
given duringa of chemotherapy_ The use of mulliple
drugs affects dlffer.ent stages of the cancer cell's life cycle,
and attacks the I';I((OUS clones within the tumor via several
mechani sms of action, thus increasing the percenlage of
cell kill. Combination chemotherapy al.so allows lower
of each individual agent, thus reducing toxidtyand
slowlllg the development of resistance. Examples of combi-
nation therapi es include cydophosphamide_methoUeltalt_
Huorouracil (CMF) for bll'ast cancel" and cyt:lophospilamide-
domrubicin-vi ncristine (mY) lOr lung cancrr. Each type of
cancel" has it5 own individual protocol , which is rontinuaily
being refined and revised based on current research.
Specific dosing schedules, or protocols., have beffi found
to increase the effectiveness of the antineoplastic agents. For
example, some of the anticancer drugs all' gil'('n as a single
dose or perhaps se"eral doses ol'('r a few days. A few weeks
may pass before the next series of doses begins. This gives
normal cells time to recover from the adverse effects of the
and tumor ceUs that may not have been repli-
catmg at the first dose to begin dividing and De-
come sensitive to the next round of chemothrrapy.
optimum dosing schedule must be delayed
the sufficiently recol'('rs from the drug toxici -
Ues, Hpecially bone marrow suppressio n. The specifK dos-
ing schedule depends on the type of tumor, stage of thoe
disease, and the patient's overall condition.
37.7 Toxicity of Antineoplastic Agents
Although ca.ncer cells are dearly abnormal in many ways,
much of their physiology is identical to that of normal cell s.
TABLE 37.3 Adverse Effects of Antineoplastic Drugs
Blood ToxicIty
AnmU(lDwlfdbloocl (fII(M{1
llI*aprnilwiltlltlOptl'lM (kIwwhft blood 1 __ )
1Iva!DKytoptllil 0. JUleId auII)
Because it is difficult to kill cancer cells seltxtively without
profoundly affecting normal a lis, aU anticanar drugs have
the potential to cause serious toxicity. Thesedrugs are often
pushed to their maximum possible dosages, so that the
greatest twnor kill can be obtained. Such high dosages al-
w:ays result in adverR effects in the Tabl e 37.3 Iist5
typical adverse effect5 of anticancer drugs.
Normal cells that are replicating are most susceptible to
adverse effects. Hair follicles are damaged, resulting in hair
loss or aloprcia. The epit helial lining of the digestive tr.lct
commonly becomes inflamed, a condition known as
mu,.,.iti . CoI).';equen,n of include painful wcel ... _
!ions., .difficulty eating or swallowing, Gl bleeding, intestinal
mfecbons, or severe diarrhea. The vomiting center in the
is triggerrd by many antineoplasties, r!.'Sulling in
slgruflClnt nausea and vomiti ng. Because of this effect, an_
tineoplastics are sometimes classified by their rmtlie polrnlial.
Before starting therapy with the highest t'I11etic polentia]
agent5, pati ents may be pret reated with antiemetic drugs
such as odansetron (Zofn.n), prochlorperazine (Com-
pazine), metoclopramide ( Reglan, others), or
(Ativan) (chapter 4100).
Stem ceUs in the bone marrow may be destroyoo by anti_
ntoplasties, causing anemia, leukopenia, and thrombocy_
topenia. These adverse effects are dose limiting and the ones
that most often cause discontinuation or delays of
chemotherapy. Sevrre bone marrow suppression is a con-
traindication to therapy with most antintoplastics. Efforts
to minimize bone marrow toxicity may include bone mar_
row tramplantation, platelet infusions. or therapy with
s uch as epoetin alra or granulocyte colony_
sllmulatlllg factor (G-CSF), filgrast im ( Neupogen), or
sargramostim (leukine) (chapter 2SOO). The administra_
tionofG-CSFsoften prel'('nt5 or shortens the time period of
neutropenia, thus towermg the risk of opportunistic infec_
tions and allowing the patient to maintain an optimum dos-
ing schedule.
Each antineopJasticdrughas a documented nadir, the low_
est point to which the erythrocyte, neutrophil , or platelet
count is depressed by the drug. Although chemotherapy de-
creases all types of white blood ceUs (leukopenia), neu_
trophil s are the type most affected. The nurse can calculate
the. absolule neutrophil count (ANC) by multiplying the
white blood ceU count by the percentage of neutrophils.
This value can be obtained by reading the patient's com_
plete blood count (COC) with differential. If the ANC falls
below 500Jmm" the risk of infection increases. Many
times, patients who 3re significantly neutropenic will be
placed in reverse isolation to protect them from exposure
LibraryPirate
to an infection from members or health care
providers. If a neutropenk develops a fever. antibi-
otics are indicatt'"d.
When pos.siblt'", art'" given locaUy by topi-
cal application or through dired instillation into a tumor
si tt'" 10 minimize s)'$lt'"mk 10000city. Most ant im!oIJlast ics,
ho ..... l.'Vt' r, must be adminiSlt'"recl intr;lvmously. Many anti-
.... ... ,,>/>ifi ...... ... Ii .... "t .. iOt!.,,,b lhal
st'I"ious tiSliue injury if Ihey from an artet"y or vt'"in
during an infusion or injection. Extravas;ltion from an in-
jection site can produce .severe tissue. and net"ve damage,
local infection, and even loss of a limb.ibpid treatment of
ext ravasation is necessary to limit t iss ue (];Image, and cer-
tain antineoplastics have spt'"dfi( antidotes. For l'JGlmple,
extr:avasation of carmustine ( BiCNU, Gliadei) is treated
with injections of equal parIS of sodium bicarbonate and
normal saline into the extravasation si le. Before adminis-
tering intravenous a ntineoplastk agents, the nurse should
know the emt'"rgt'"m:y trutmt'"nt for extravasation. Centr:al
lines (subclavian vein) should he used with vesicants when-
ever poSliible. Antineoplastk.s with the strongest vesicant
activity include busulfan, carmustine, dacarbazine, dactin-
omydn, dauno rubicin, idarubidn, mechlorethamine, mit-
omycin, plicamycin, streptolocin, vinblastine, vincristine,
and vinorelbine.
Cancer survivors face several possible long-term con-
sequences from chemother:apy. Some antineoplastics,
particularly the alkyl3ting agents, affe-ct the gonads and
have been a ..... ciat..d with infertility in both male fe-
male patients. A second conctrn for long-term SUrviWTS is
tht'" induction of .secondary malignanci es caused by the an-
ti neoplastic agents. These secondary tumors may occur
decades aftet" chemotherapy was admi nistered. Al-
though many different sec.oocbry malignancies have been
reported, the most rommon is acute nonlymphocytk
leukt'"mia. 1 n most nses, the immediate benefits of using an-
tineoplastia to ( urt'" a 0II"Ket" far outweigh SIl\OlU risk of
developing a .secondary malignancy.
37.8 Classification
of Antineoplastic Drugs
Drugs used in caI"Kef chemotherapy come from di,et"se phar-
macologic and crn-mica! classes. Antineoplastics have been
extracted from plants and bacteria, well as created entirely
in the laboratory. Some of the drug classes attack ceUular
macromolecules, such as DNA and proteins. whereas others
poison vital mt'"labolic pathways of rapidly growingceUs. The
common theme among all the antineoplastic agents is that
they kill or at least stop the growth of cancer cells.
Classification of the vanoU5 anhneoplastl cs IS quite van-
ablt'" because some of these drugs kill cancer ceUs by several
difft'"rellt mechanisms and have characteristics from more
than ont'" class. Furthermore. trn- medlanisms by which
some antinooplastics act not rompletely understood. A
simplt'" method of dassifying this romplex group of drugs
includes tht'" following six categories:
CIIopltll1 DruglforNeoplal.la 553
. Alkyl.ating agents
Antimetabolites
Antitumor antibiotics
Honnones and hormone antagonists
Natural products
Biologk respornt'" modifit'"rs and monoclonal
antibodies
Miscellaneous antineoplastk drugs
ALKYLATING AGENTS
The rlnt alkylating agents, the nitrogen musta rds, were de-
veloped in secrecy as chemkal warfare agents dur ing
World War II. Although tht'" drugs in this dass have quite
different cht'"mical structur<'"S, all share the common char-
acter istic of forming bonds Of linbges with DNA, a
process called alkylition. Figure 37.4 illustrates the process
of alkylation.
37.9 Pharmacotherapy
with Alkylating Agents
Alkylation changes shape of the DNA double helix and
prevents tht'" nucleic acid from rompleting normal ceU divi-
.ion. E"ch :ill<ytating agent allaches to DNA in a difft'"rent
manner; howt'"ver, ooUecti vl'iytrn- alkylating agents have the
t'"ffed of inducing cell death, or at slowing replica-
tion of tumor ct'"Us. Al though the process of alkylation oc-
curs indt'"pt'"ndt'"ntly of the.:ell cycle, the killing action does
nol occur until the affected ( ell allempts to divide. The alley-
lating agents havt'" a broad spe<:uum and ate used
many types of II\OIlignandes. They are some of the most
widely prescribed antineopla'llic drugs. These agents are
listed in Tablt'" 37.4.
Blood cells are panicularly st'"nsitive to alkylating agents,
and bone marrow suppression is the primary dose-limiting
adverseeffed of drugs in thi s d ass. Within(];lys after admin-
istr:ation, the numbers of erythrocytes, leukocytes, and
platelets begin to declint', reaching a nadir at 6 to 10 days.
Epitht'"lial cells lining the GI are also (];Imaged, r<'"S ult-
ing in nausea, vomiting, and diarrhu. is expected
from most of the alkylating agt'"nl5. The nitrosoureas and
mechlorethamint'" are strong vesicants. Appro.'timately 5%
of the patients trt'"att'"d with alkylating agents develop acute
nonlymphocytic leukemia 4 years or more after chemother-
apy has been completed.
ANTI METABOLITES
Antimetabolites art'" antineoplastic drugs lhat chemically re-
M'mble essential building blocks of ceUs. These drugs inter-
ferewith aspects of the nutrienl or nudeic add metabol ism
of rapidly growing tumor cel ls.
LibraryPirate
SS4 UnitS The Immune SY""m
K-".a:--l
...
..,...Iink beIwoeo DNA strands
o " Alkyla.ting ItQOOI
(a) Al<ylBtion oocuring during Go
( .... sling) phase 01 cell cycle
Flgurel7.4 Mechanism of action of the alkylatlng agents
37.10 Pharmacotherapy
with Antimetabolites
Rapidly growing cancer cells require large quantities of
nutrients to construct cellular proteins and nucleic acids.
Antimetabolite drugs are structurally similar to these nu-
trients, but they do not perform the same functions as
their natuml counterparts. When cancer cells attempt to
synthesize proteins, RNA. or DNA using the antimetabo-
lites, metabolic pathways are disrupted and the cancer
cells die or their growth is slowed. The three classes of an-
timetabolites are the folic acid analogs, the purine
analogs, and the pyrimidine analogs. These agents are
prescribed for leukemias and solid tumors and are listed
in Table 37.5.
The purine and pyrimidine analogs are structuraUysimi-
lar to the natural building blocks of DNA and RNA. For ex-
ample, the pyrimidine analog fluorouracil (5-FU, Adrucil,
Came, Efudex) is able to block the formation of thymidy-
late, an essential chemical needed to make DNA, and is used
in treating various solid tumors. After becoming activated
and incorporated into DNA. cytarabine (Cytosar, Cytosine
(b) Slrand braaks occuring
when DNA ntpIicat6S
during S pha.se 01 eel cycle
arabinoside, Depot-Cyt ) blocks DNA synthesis and is an
important drug in treating acute myelocytic leukemia. Ap-
proved in 2005 clof:uabine (Clolar) is a purine antimetabo-
lite that was the first new drug approved for pediatric acute
leukemia in over a decade. Methotrexate (Rheumatrex,
Trex.aU) and the newer drugs pemetrexed (Alimta) and
pralatrexate (Folotyn) resemble folic acid, a natural B vita-
min. Figure 37.5 illustrates the structural similarities of
some of these antimetabolites to their natural counterparts.
Bone marrow toxicity is the principal dose-limiting ad-
vt'rse effect of many drugs in this class. Some also cause se-
rious Gl toxicity, including ulcerations of the mucosa.
Mercaptopurine and thioguanine can cause hepatotoxicity,
including cholestatic jawtdice.
ANTITUMOR ANTIBIOTICS
Antitumor antibiotics are drugs obtained from bacteria that
have the ability to kill cancer cells. Although not widely
used, therare very effective against certain tumors. The an-
titwnor antibiotics are listed in Table 37.6.
LibraryPirate
TABLE 37 41 Alkylating Agents
Drug
NITROGEN MUSTARDS
bmdamllltillt (Trt.nda)
cNoramllWl (INmn)
" cydop/lo$ph.amkk: (Cytoxan)
tUnmuUinr (ErBcytl
ifOlfDide (!fee)
rMhloftth.imillt (Mu5UI'gIm)
mtlph.liln (Alman)
NITROSOUREAS
afmllSlint (BiCHU,GIacStI)
Iomustilt (CtrHU,(CNU)
urtptozOOn (ZaIlO5al)
RouU! and Adult Dow (max dose where Indica ted)
1Y;90-I20 mg/rrtl sd!fdule)
PO; initiill doseO. H1 mglkg/dly; Ma1nltnaTKt dost;4-1 0 mg/d.ly
PO; InitiiII dose 1-S mg/doly; Malnttnanct clost; I- SlIIg/kg t'VflY 7- 10
PO; 1( mglkgldiJ 10 four diYidfd doStj
IV; 11 IJ/rrtl/day for S oon!lll:ivt dayi
1 ind8c1i18-di1ycydt
PO;6mg/diyfor 2- 1wk
1Y;1OOmg/rrtlMrY'wk
PO; no rngImI asa dost
IV; 500 mg/rrtI for S
MISCELLANEOUS ALKYLATING AGENTS
buitJfan (Myltfilll)
Qmopatin
cispQtin
!Yc<1rb.izine (OTl( -Oomt)
(8oxatiftJ
proGIrb.izillt (ManjaM)
IemOzoionide (lemodir)
Ihiotq:y (llioPu. TSI',I,)
PO; (-8 mglday
IV; 360 mg/rrtI 0I'lCt t'lfry (wk
1Y;20mg/mi/daylor 5
1Y;2 ..... 5mg/kg/dly for 10days
1V;8Smg/rrtI for 2 hfor l wk
PO; 2 ..... mgItIJ/diy for 1 wk
PO; 150 mg/rrtl/day for 5 oonstrutiYe diys
I ..... wk
Antlmetabolites
Drug
FOLIC ACID ANTAGONISTS

ptnIttrtud (Allmu)
praialrt:late (Fdot)'n)
PYRIMIDINE ANALOGS
Qptdtibint (Xtb:Ll)
C)Uribilt (Cyt()S;Jf, Cytosine inbinosidt,

ftoxwidine (ruDR)
(Sru,Ad'ud,(.arac, Ehde!)
gmcitabine (Gtrnz,JrJ
PURINE ANALOGS
c1mblM (ltustatin)
cIofalabint (OoLII)
ftudarabile (Fludal'i)
mtraplOflUritIf' (6oMp, Purinethol)
neIiIrabft (Manon)
ptnlOSlatin
lhioguariM (6oTG, labIad)
Route and Adult Dose (max dose where Indicated)
PO; 10-30 IlI!Vdayfor 5 days
1V; 5OO mgJrrtI on day 1 d um
30 mgfm/ mli'lstertd Mf ]- 5 minutes
PO; 2,500 for 2 wk
IV; 100 mgJrrtI au contillUOUSinfusion (Wff 24 h
mg/kIJ/diy IS I conti'lllous
IV; 12 for consl/tiw da)'5
IV; 1,Im mgJmI fflf'/ 1 wk lor 1 wIo:
IV;O.09 mg/rrtllU1 as it Infusion
IV; mg/ml/day am 2 hours for 5 dayl
IV; 25 mglm'/day for 5 COI1SKllli'fI! days
PO; B mglkgfday
1V;1.500 mg/mi 1,1,'00 S,lfpeatfdt'lfry 21 days
IV; (mg/mi t'lfry othfr Wftk
PO; 2 m4fkghlay
IIQria incicatt common idl'l'Bf tfferu; unOO1ining imkates strious acIYme effKtl.
Adwrse Effects

Ittt1dochf. doptciD, Iftendon
Bone marrpw S!,u)[I!fW (neytrpproia
iprmia tbmmbootpprflial SO'rrrOi'''fj
djarrhta.S!mm-Joh!lS9!l
!m!tpme. hrnl!!!lhaqiH'ntifi1. Q'JmO!liry
.y neum!91iW (wboolarn dsPlatin
mliplarioJ otgtsgkjtx !rkrJatin)
hypmmsjliyity readiom (ildudinq
anaplryltrkl nmhl!!!oxidty
Adverse Effe<ts
N/ruJtO, KIffliring. stomoritis, aoomda,If1Ih,
lleada:he,aIoptda
Soot!!ll!OW )lI!I!ms!on !!!WI!DQnja antroit
Iml!o<ytowUl. S<!m flaW yqniting and
!lUrtv berutgtgprity m.[Osjth Q'dmgoary
larkitr h'fl!mt!lSjtivjtIrNctions !Including
!It!I!!t!!!:idty(qwaIW
ftuorour.tdl tbiarabiM cI.ldrllintl
LibraryPirate

I


,
i
Ii
SS6 UnitS Tte lmmu""Sysll'm
Prototype Drug I Cyclophosphamide (Cytoxan)
Therapeutic (lass: Antineoplastic Pha rmacologic Class: Alkylathg agent; nitrogen mustard
ACTIONS AND USES
iu {OInlMni)' pr.,,,ribod nit""!,,n mumm_h i!-"IM ,Iono.
or in (OInbinatioo with a widt '/iIriet)o of in,kiding
Hodgkin'l diINl!, Iymphom., m)'eloma, brust and OY.rian
caMrI'. C)'Ilophol.,h.midt.m by . tlathinglO DNA.nd diwPling replitation.
pa"irubrl)' in .. djyiding (ells.1t is 0111' of only. fM .ntiurw drugs thaI
art well ablOlbtC when giYell orally.
is powerful imm"nOlupprel.lnt. While this is (0000-
el!<! .n adYent effect during ufI(er (ht lMther. py, the drug is UIM to
immriooolly taUII' immunDIupprNion for the prophyluis of organ I .. nlpbnt
rt'jtction and 10 tft'at!l'V!'rt' mrumatoid ."hlitis.oo systemic: lupus rrythe-
m'IO"1I (SLE).
ADMINISTRATION ALERTS
DiMe prior tolV oldministration.
Mooitor pbtelet (ount prior to 1M oldministration;if low, hold doll'.
To noid GI upifl. take with mNls or djyidt doses.
Prt'gnancy catrgory C
PHARMACOKINETICS (PO)
OnV'!: Unmnwn
ADVERSE EFFECTS
eon.. ma","" is a lifHhrutoning ,,,,,,,," ruction Ihu
oc:ruB during days 9-14 of therapy; the patitm is at dangelOlH rille for !I'\'frt'
inftdion and Ifpm during this periodlhrombocytoptnia is (Ollmon, though
leIS Srftll' than with m.ny other alkylaling Igfflts. Nausu, vom Iing. iloolI'';',
ilnd diarrht. art' frt'qUfml)' experitMm Cydophosphamidt ('IIII'S rnmible
i iope(ia, .khough the hair may II' grow with a difltoll'nt rolor or tnUlIl'.
mmOOlitts of qdophosphamidt m.y UlIIl' hemonh.gic: qsritis if the urint
btromes (OMenmtM; p.titnts should be advilfd to maint.in hgh Huid inti!.?
during drug mayausr sterility in ,.titms.Unli!.?
other nitrogen mum rds, tydophospha mide dlibits little ntlJlttOXic:ity.
Contrainditations: is (oolr.iOOiuted in p,tHonts with hy-
ptr5ellsitivity to the drug i nd for those who . clift inirtlions or
00111' marrow.
INTERACTIONS
I)ug- l)ug: UlfdtorlCllffllly wim
wil irtr&JIf tfwo rilk of infK1ions .nd fll"tfwof dffllopnmt of nropIa\nIs. Thin an
ill!lN!l'd <lIarn of bone miIfltIW (oDdly if cyttoplolphallidt UIfd <OOOI"ll'Iltly
with allopIIinoi. Thert is an iKreud rill! of bIKoding if Ijvfn wim .ntkO.tgUIant>.
KUIfd (ooumntlywim digolin,IkNIfd!l'lllm IMIo;
with inlUin may Ieold to hl"POlhtfmi.l. Ptrenobartital, pOOl)1oin. (f qhcOUflKOOI
IINk:l h
tfwo bl'l. Thiazidf dilJlliG inoUll' 1M
Halflif!: H l h
Lab Tl5ts: Serum Lric: add ImII may Blood (fli {OUn6 williillinilh duI' to
,-,' C'C'fuC" :IO
C
":: _______________ ./ bonr marrow rMttioos tofllldNig,mumps,anO (lilHaiin liin
001 (PPO) ft IIIpJNfSSfd. PAP smNB may fjtf falll' p<>!itim.
Normal mlltabolile
Folic acid

Melholrax.ate
IkorbaVFoo:t: StJem'l won mayiMIN!e iMlOIit
Trt'iltment ofOmdo5e: There is 00 spt<ifll trt'.tment for
RtrI>r III MyMnJrtgR for /UsJrti} I'ror.mfooll SjIK/II( 1II1M 1tIig.
0
0
"":J
,-<X'>
oJ... ,
H,NA N N ......
I
"'
,
GUlln;"" U-acil
,
0
",:X'

"
,,,J... , ,> oJ..,
"
,
Thioguan .... Auorouradl
figure 37.5 Structural similarities between anlimelaboilles and their natural counterparts
LibraryPirate
p,. Prototype Drug I Methotrexate (Rheumatrex. Trexall)
Therapeuti c (l ass: Antineoplastic Pharmacologic (lass: Antimetabolite, folic acid analog
ACTIONS AND USES
is ,n ,ntimrubolitt iIV,ibble by tht or.Jl ,nd in-
tratheul routH. By blockilg the S)'Ilthtlis of folic acid (vitimin BJ, mttootl6-
itt inhibiu replication, partirubrly in rapidl)o dividing (tlls.1t is pR'ICrilltd a loot
or in oombinuion with othtr for ChorOOKinooy, o;ttogeni( san:oma,
IeukemioH, head and otdulKtB,brtmun:inoma,and lung CiKinoma.ln id-
dition to its role as in ant"metabolite, hil poWl'rlul immunOlUp-
pll'ssant thit "n lit Ulfdto rhtum,toid arthritis,uktr.Jlivt colitis,
upus,and psoriasis that OR to wfer lII!'dications.
ADMINISTRATION ALERTS
Avoid !kin todrug.
Avoid inhaling drug j)lrlicles.
Dilute prior to IV
Pregninquttgor;X
PHARMACOKINETICS
Onstt: Variable
P!ak: 1--4 h PO;O.5-l h IMlIV
Halflif!: 1--4 h
Duration: Unknown
IV;OlS-<l5 uri!/bj MfY4-7 ria)"!
ADVERSE EFFECTS
has many advern effect!, lOme ofwhich (oIn lit threatening.
The FD.' hal iulitd I) bbck boJ wimings regarding the U\l' of metootIWII'.
The drug (oIn uuse falil boot marrow toxiciry it high doses. HemonlJige ,nd
bru6inj olten obstMd rb to low pbtelet (OUntl. Nausea, wmitilllj, ind
aOOIl'Xi ill' (ommon, and GI uktr,tioo may resuk in sffious intrstinal bleed-
ing. Severe and potenti,lIy faul d!rmitologic ructions indud! Stelt'ns-
Johnscn syndromt and dt rmatitis. Although lilt, pulrmnuy
toxi(it, ilKluding Iife..thruttning pIl!"Umonitis has bten
Contr aindi utions: The USt of mtthotrHite i s an antiOfOpb;tic is
cittd il thrombocytoptnia, antmia,l!"Ukopeoia, COlKUITI'nt of
hepatttoxK htmatopoietK wpprrswnts, ikooolilm, or lactation.
Metoolll'ute is ttritogenic and is contraindicated in preJoant patitrts. Pi-
tiffits with ikooolism or other chronic lil'l'l disme should oot rt<eM-
methotl6,te. ImmunOlUPPll's\td p.1Iitnu or toose with blood dyscmias
should not methotrexatt.
INTERACTIONS
Dru;Hrug: 800e mallow wppressaoBsuth or radiMn
the!apyma, UUII' ioofNd IIIett!; th! patil>nt will a lawn dol>! of
(orKIIJfI"l UIf wiII1 HS.IJ[Io; may INd to Ift'fIf IIIIIhoIrmtf
.l.lpiin IOiY omtioo of incrNIfd 1>1'1" l1li
IM>ilaed llIlKity.CoooI"rootadminiltration with ivl'orai iJ((inI may i1
dKrufd antibody fflpoI1lf DI incrNIfd idWllf rations to th! Q(OO!.
Ll b Ti5U: S!rum uric: Kid levels may i1UMI'.1!Iood <DII"tI wil iiminilh Ib to
bone IIIIIfOW wppreslion.
HerbaHood: Food !ho">ool iblption of IIIiI'f
irK_ th! rille
Treatment ofOverdoSf: l.!"Uc:a.orin (folinic acid},i rtduted form offolic ltid. is
adminiswed with methottemt to "ll'saJI'" normal cells, or to pro-
ttct a91inlt se-Yl'lt' boot marrow damage. k is most tifectil'l' if idministtred is
soon 011 alter overdole il discovmd.ln addition, the uriOl' may lit
to Pro\e(t the kidotyS from tolicity.
111m 10 M)MJ1l1nqm for Q NlJIlifll} I'rrxm forus lpf(1t 10 rln
daninornym (Actinomydo-D, (OII1II'getI)
dalllOlUbidn (Ctrubidot)
IV; SOO IIKglday Itt a miDnum of 5 ria)"!
1V;*-60 mglm'lday Itt 3-5 days
dalllOlUbidn (DaunoXomt )
I;) domnDcin (Adriam)'<h)
doxonJIim &actt)

idanDdn(ldamydn)
mitanydn (Mutimyan)
mitoxantrorlt (tlovi mront)
IV; I mglm' MfY2 wk
1V;60-75 rnglm' is i dose at 21-day inltrVals,or lOmglm'
on Nm of lconseu.w! days (OYI:tOta! dose
550mglm')
IV; 20 mgIm' MIY 1 wk
IV; 100-120 rnglm' is i dose
1V;8- 12 rngIm' Irlay for 1 ria)"!
IV; 2 rngIm' IDje dose
IV; 11 rngIm'ldayfor 1 days
r


,


"
LibraryPirate
558 UnitS The Immune SY""m
37.11 Pharmacotherapy
with Antitumor Antibiotics
A number of substances isolated from microorganisms have
been found to pos.ser.s antitumor properties. These chemi-
cals are more cytotoxic than traditional antibiotics, and
their use is limited to treating a few specific types of cancer.
For example, the only indication for idarubicin (Idamycin)
is acute myelogenous leukemia. Breast carcinoma is the only
approved use for epirubicin (Ellence).
The antitumor antibiotics bind to DNA and affect its
function by a mechanism similar to that of the alkylating
agents. Thus, their general actions and side effects are simi-
lar to those of the alkylating agents. Unlike the alkylating
agents, however, all the antitumor antibiotics must be ad
ministered intravenously or through direct instillation via a
catheter into a body cavity.
As with other antineoplastics, a major dose-limiting ad-
verse effect of drugs in this clar.s is bone marrowsuppression.
..... Prototype Drug I Doxorubicin (Adrlamycm)
Doxorubicin, daunorubicin, epirubicin, and idarubicin are
all closely related in structure, and cardiac toxicity is a major
limiting adverseeffecl. Cardiotoxicitymayoccur within min-
utes of administration, or be delayed for months or years af-
ter chE'lJ1otherapy has been completed.
NATURAL PRODUCTS
(PLANT EXTRACTS AND ALKALOIDS)
Plants have been a valuable source for antineoplastic drugs.
These natural products act by preventing the division of
cancer cells.
37.12 Pharmacotherapy
with Natural Products
Agents with antineoplastic activity have been isolated from
a number of plants, including the common periwinkle
Therapeutic (lass: Antineoplastic Pha rmacologic ( lass: Antitumor antibiotic
ACTIONS AND USES
Domrubicinattuhfi to DNA,diltoning ir>doublt Ittlicll
ing oolTllill DNA and RNA iI adminiltt ll'd only by IV infusion. Dox-
orubicin ill blNd-spKUUm cytotoxic: .Jmibiotic, precribtd for solid tumors of
tilt lung. and for various ltuktmias.Jnd lymphomas.
h iI slnKNrally similar todaunorubicin. Domrubic:in ilont of tilt most tfitdi"l'l'
singlt olI}l'fll>against \Olid tumors.
A novtl deliYery IIII'thod has 1Ifton dtftloptd for both domrubic:in and
daunorubicin. Tilt drug is in small lipid ml, or mide, Gliled
liposmnn. Tilt liposomal mic:1t iI dtsigned to open Ind tilt antitumor
antibiotic:wlltn it a (fll.TIII>goal is todtlmr a higlltr (Onrtntril-
tion of drug to tilt cells, thus sparing normJI (tlls.An
uge iI that domrubic:in has a half-lifr of 50 to 60 haun, which is
about twiu that of rIoxorubicin. Doxorubicin liposom.J 1 is for
USt in patienl> with Kaposi's saKoma, refractory OII.J rYn tumors, and
mukipk myeloma.
ADMINISTRATION ALERTS
(an calM pain Ind ntensiYe tillll!' darnagt'. Skin
(ontl(\ or UtriIvasation should bt umed immediatfly with loul ict
parks to II'duc:t ablorption ofthtdnrg.
For infJnts and (hildrt n, (oncentration and of IV infusion with
tilt health GIll' provider.
Avoid !kin (Ontld with dnrg.1f ocam, wash thoroughly with
soap and wattr.
PrtgllallQ category D
PHARMACOKINETICS
Onsd: Rapid
Peak:Unknown
Halflife: 17- 32 h
Duration: Unknown
ADVERSE EFFECTS
TIll> man clost-limiting tffed of doJ:Olllbicin is rardiotOllicity.
,\artt inrkidt dysrhythmias; dtlayed t ffrcts mly indudt
IItln man, of tht .Jntiunrt r drugs, doJ:orubicin may profoundly
Iowfr blood (tll (ounts. .Jnd vomiting (ommon and oftt n
Jntiemttir therapy. though rf"lersiblt, hair Ion occurs in most
JMt myflogtnous Itukemia, mly
occur 1- 3 )'I'ars following therapy.
(ontraindi(ations: Domnrbic:in is (ontraindicated in patienl> who im-
lIlIoosuppresed orwho haw tlltdrug.
INTERACTIONS
I)ug-l)ug: If digoxin lakin (OIKUlI!ntly,paliI>n( Il'IIImt5goxin Ir>v/'kwil
may INdio im.MI plalmadNooa> of
ihona:i1 and deuMfd p/Ii'Il)1oil may iNdtodeuMfd
ph@nytoillffll, and seizin may amI" ff
mtlGlpIOpOm. "ton <OO( ..... tIy.tktwith .......... 1 ""I' ioawoo .......
ihona:i1 to ooxolloon toxidty.
Lab T151>: )frum uric: idd JfId illpMlite aminotm\llJR lAS n ""'eIs may
inmast.8iood<ell (ounl> wil diminilh due to boor> marrow IlWrI'iion.
IIerbaVFo!XI: rmn IN JIIoIYfnl\alKf thtMltitllnor tMlyof
IIns woo IN1 dKrNIe the etlKtiveness of ikD:lfltlir:i1.
TINlment of The primary r=k of doJ:orubic:in O"/trdosagt iI im-
lIlIoosuppresion. Tl"Ntmerlt indudts prophylactic antimicrobials, plateIM
mnsfusions, symptomatic Utiltllll'nt of lIIKositis,.Jnd possibly IItmopoietic:
growth f.J(\or(G'(sF. (".',I.(SF).
Rtftr III MyMIsJrIgKI fDf Q MnInq PreIS fooIl spffiIt IIIIM ItrJ9.
LibraryPirate
(Vinca rosea), Pacific yew (Taxu! baccatll), mandrake ( May
apple), and the shrub Camptlltheca acuminata. Although
structurally very different, medications in this class have the
common ability to affect cell division; thus, some of them
are called mitotic inhibitors. The plant extracts, or natural
products, are listed in Table 37.7.
The mGl alkaloids, vincristine (Oncovin) and vinblastine
(Velban),are two older drugs derived from more than 100 al -
kaloids isolated from the periwinkle plant. The medicinal
properties of this plant were described in folklore in several
regions of the world long before their antineoplastic proper-
ties were discovered. Despite being derived from the same
plant, vincristine, vinblastine, and the semisynthetic vinorel-
bine (Navelbine) e:iliibit different effects and toxicity profIles.
Vincristine is a common component of regimens for treating
pediatric leukemias, lymphomas, and solid tumors. The use
of vinblastine has declined because of the development of
newer and more effective agenl5, but it has traditionally b:n
used to treat Hodgkin's disease and testicular twnors.
The which include paclitaxt'l (Taxo!) and doc-
etaxel (Taxotere), were originally isolated from the bark of
the Pacific yew, an evergreen found in forests throughout
the western United States. More than 19 different taxane al-
kaloids have been isolated from the yew tree, and several
others are being investigated for potential antineoplastic ac-
tivity. Like the vinca alkaloids, the taxanes are mitotic in-
hibitors. Paclitaxel is approved for metastatic ovarian and
breast cancer and for Kaposi's sarcoma; however, off-label
uses include many other cancers. A semisynthetic product
of paclitaxel, docetaxd, is daimed to have greater antitumor
properties with lower toxicity. Bone marrow toxicity is usu-
ally the dose-limiting factor for the ta.unes.
American Indians described uses of the May apple or wild
mandrake (Podophyllum pe/tatum) long before pharmacol-
ogists isolated podophyllotoxin, the primary active ingredi-
ent in the plant.As a botanical, podophyllum has been used
as an antidote for snakebites, as a cathartic, and as a topical
'1101'1,,37 Drugs(D<f\IeopLHIa 559
treatment for warl5. Teniposide (Vumon) and etoposide
(VePesid) are semisynthetic producl5 of podophyllotoxin.
These agents act by inhibiting topoisomerase l, an enzyme that
helps repair DNA damage. By binding in a complex with
topoisomerase and DNA, these antineoplastics cause strand
breaks that accumulate and permanently damage the twnor
DNA. Etoposide is approved for refractory testicular carci-
noma, small-cell carcinoma of the llUlg, and choriocarci -
noma. Teniposide is approved only for refractory acute
lymphoblastic leukemia in children. Bone marrow toxicity
is the primary dose-limiting adverse effect.
More recently, isolated topoisomerase I inhibitors include
topotecan (Hycamtin) and irinotecan (Camptosar). These
agenl5 are called umptothecins because they were first isolated
from Camptotheca acuminata, a tree native to China. The
camptothecins are administered only intravenously, and
their indications are limited. Topotecan is approved for
metastatic ovarian cancer and small-cell lung cancer after
failure of initial chemotherapy. Irinotecan is indicated for
metastatic cancer of the colon or rectum. As with many
other cytotoxic natural products, bone marrow suppression
is the dose-limiting to:ticity for the camptothecins.
HORMONES AND HORMONE ANTAGONISTS
Use of hormones or their antagonists as antineoplastic agents
is a strategy used to slow the growth of hormone-dependent
twnors. Endocrine, or hormonal therapy, is limited to treat-
ing hormone-sensitive tumors of the breast or prostate.
37. 13 Pharmacotherapy with
Hormones and Hormone Antagonists
A number of hormones are used in cancer chemotherapy,
including glucocorticoids, progestins, estrogens, and andro-
gens. In addition, several hormone antagonists have been
TABLE 37 7. Natural Products with Antineoplastic ActiVity
"n"
VINCA ALKALOIDS

Q Iinainile(OIKO'!'inj
"tinorelbint IN.rlelbintJ
TAXANES
Route and Adult Dose (max dose where Indicated)
lwk
IV; 1.4 mgtm' 1 wk (maM;2 mg/m')
iY;10fll9lm'MIllwk
mtaRl(laxOiert ) 1 1V;60-100mglm'MlYlwk
paditaxti (Taml) IV; 1l5- 175 mglm' MIY 1 wk
TOPOISOMERASE INHIBITORS
60p0sid!,
irinolKiin (Camplosar)
lerIiposide (Vumon)
topoll'(.Jn
W;Sl)..l00 mgfml/day fo!)!bys
1V;1l5f119/m' MIl lwkfoc4wk
IV; 165 fll9/m' MIl 3-4 days/or 4 wk
IV; 1.5 nM}/m'lday fo! > days
Adverse Effects
LibraryPirate
560 UnitS Thl'lmmu""Syst""'
.... Prototype Drug I Vincristine (Oncovm)
Therapeutic (lass: Antineoplastic Pharmacologic (lass: Vinca alkaloid, mitotic inhibitor,natural product
ACTIONS AND USES
Vinuistine is a (M-phalr) agtm that kills unm by pre-
\'eIlting their abilit)' to complrte mitosis. k this action by inhibiting mi-
crotubulr formation in thr mitotic spindlt.Akhough ilKmline must be giYen
intral'l'llously, it mlljor adn ntoll}!' is that it taUSeI minimal immunosupplft-
sion. k has a wider" spK\rum of diniul oKlwit)' than vinblastint, and is UlWIIy
preaibtd in mmbination with other for thr trNtmffit of
Hodgkin's and non-Hodgkin's lymphomas, iruumias, Kaposi's !-armma, Wilms'
bladder ultinoma,and breast umnoma.
ADMINISTRATION ALERTS
Extransation may r=k in Ifrious tissur Stop injtction imrnedi-
ff eJ:llil'/awion I)(rurHnlhppl, local heat and injea
as ordmd Oblfl'/e litt for sloughing.
A..,id whic.h y" y",. inildtioll .00 lon ... 1 <i"'HJr>.
PI!gIlaIK)' category 0
PHARMACOKINET1CS
Onlet: Unknown
Peak: Unknown
Half lifr:ll1- m h
Durat ion: 7ct.ys
found to exhibit antitwnor activity. The mechanism ofhor-
mone antineoplastic activity is largely unknown. It is likely,
however, that these antitumor properties are independent of
their normal hormone mechanisms because the doses uti
lized in cancer chemotherapy are magnitudes larger than
the amount normally present in the body. Onl), the antitu-
mor properties of these hormones are diKussed in this sec-
tion; for other indications and actions, the student should
refer to other chapters in this text. The antirumor hormones
and hormone antagonists listed in Table 37.8.
In general, the hormones and hormone antagonists act by
blocking substances essential for tumor growth. Because
these agents are not cytotoxic, they produce few of the de-
bilitating adverse effects seen with other antineoplastics.
They can, however, produce significant adverse effects when
given at high doses for prolonged periods. Because they
rarel), produce cancer cures when used singly, these agents
are normally given for palliation.
GlUCOCORTICOIDS (CORTICOSTEROIDS)
The primary glucocorticoids used in chemotherapy are dex-
amethasone and prednisone (Deltasone, others). Because of
the natural abilityof glucocortiooids to suppress cell division
in l),mphocytes, the principal value of these agents is in the
treatment of lymphomas, Hodgkin's disease, and leukemias.
They are sometimes given as adjuncts to chemotherapy to
ADVERSE EFFECTS
lhr most Irrious dose-limiting effects of in{mtilll' relate to ner\OUl
S)'ltffll toxicity. Children all' partirularty Symptoms include 111mb-
111'11 and tingling in the mUl{Ular IoSI of neuralll'flrm, and
p,in. StYerr mnstipation is com man a nd paralytic ileus lIYy lXtur in young chil-
dlt'll.Rt'YI'fSiblr alopecia OCQJrs in most patients.
Contraindi{a\jons: Vincristine is during pl!gnalK)' and lacta-
tion. Caution should II!' u sed whrn til' uing patients with hrp.atic im piinnent or
obstnJctiYl' jaundice.
INTERACTIONS
I)ug-l)ug: cona.mntl1wilh .. bffOll' IiIKlil!inI' mayalM
inmudoontoDdty IfOIIIdaryto deo"mfd IrfpaticdHrollKfof lilKliltile.
OoxorOOicir or pIedriIone Ina)' iOOfH bont marrow toIi!ity. (aki:.m dr.JrnfI
trIu<.kto!, '''d)" i ... ,,,,,,, .iooM ..... ".n .... lioo in ,ot>. WrKIUll'Il1 "",with <irJwin
may rifaNW' digoxin IMII. 'MIfn Wraisti ... is Ij"ll'll wi!h metho!rRate, tIw pMnl
may nooIlo'ItfI 00\.eI 0( methotrr1ille. 't'iraistiIf may dKJN!I' SI'I1III p\lfnytoin
ievrll, OIirg to inaUlfd seiZin actMt,.
tab T1511: Sfrum uric:>Kid If'II'II mayilKJN!I'.
HerbaVFoIXI: Unknown
l lNtment of Overdose: l);erdoW' with vincmtint may {.1U1e life-thll'att ning
l)TllptOms or duth. Symptoms a II' "tensions of tht dtugl adYerse effls. Su p-
trUlment lIYy idministration ofleucol'Orin (folinic oKidj.
Rmr II MyMnIIIgKt for MIsJrtq I're\l" fooIl spI(/II( II WI iJ"IJ9.
reduce nausea, weight loss, and tissue inflammation caused
by other antineoplastics. Prolonged use can result in symp-
toms of Cushing's disease (chapter 43OC .
GONADAL HORMONES
Gonadal hormones are used to treat twnors that oontain
specific hormone receptors. Two androgens, fluoxymes-
terone (Halotestin) and testolactone (TesIac), are used for
palliative therapy for advanced breast cancer in post-
menopausal women. The estrogens ethinyl estradiol and di-
ethylstilbestrol (DES) are used to treat metastatic breast
cancer and prostate cancer. The progestins medroxyproges-
terone and megestrol (Megace) are used to treat advanced
endometrial cancer. Leuprolide (Lupron) is similar to go-
nadotropin releasing hormone (GnRH), and is used for ad-
vanced prostate cancer when other therapies have failed.AIso
similar to GnRH is histrelin (Vantas), a drug approved in
2006. Approved for advanced prostate cancer, histrelin is an
implant that is inserted subcutaneousl),in the ilUler aspect of
the upper arm to release the hormone over 12 months.
ANTI ESTROGENS
The anti estrogens are used to treat tumors that are depen-
dent on estrogen for their growth. Tamoxifen (Soltamox),
LibraryPirate
TABLE 37.8 1 Hormone and Hormone Antagonists Used for Neoplasia
""'9
HORMONES
dwmmlOlll'jDeudron.oIhtrs)
S1il>tmol)
tltioyl tllradiol (El othml
ftuoxyJllffimHll' jH
mtdrOX)'l!ltl9ffitro III' DqIo-Proffii)
706forth/, Prototype Drug
!mOO1

prtdrilOlll' pilje 471
for Prototype Drug 1JoxOO)

te5lOltmHll' IAnan,HistmHll', Ttsu!d,
DNtffi,othtrs) 719
Prototype Drug boxOO)
HORMONE ANTAGONISTS
anastrorok(Arimid9j
bitJlutamitk
dt9amix (Firmaqon)
UtmtstiUIt
ftutamitk (Eulain)
lulwstrint
gostI'Hn (ZoIadtx)
hilt!!!in (Yantil)
ItUOlOit (Ftmara)
Ia.prdidt VOOur)
(tilincton)
raloxh (Evisti)
O timoxnen
ttmifmt(fareton)
triptorl'lin (TmstI)
Route and Adult Dose (mn dOle where Indicated)
PO;O.lS bid-qid
PO;f tr .. lmmt of pro!lalt <1M .... mg polli.tion
1- I,lIM}Iday
PO;ft{ uutmmt 01 blffil (olfKtl, 1 mg tiel for 2- 11llOltlnjlor
piliation of UIK!'!; 0.15-3
PO;10mgtid
1M;400-1.OOlmgql wk
PO;40- 160 mg bid--qid

PO;l,Omgqid
lM;lOO-400mg M!Y 1-4wk
PO;1 mglday
PO;50lII9Iday
StD:Ulilll'OUl; 240 mgloadilg doll' followtd Il)' 80 mg
18""
PO;2, Ill9lday ift ... a IMal
PO;250mgtid
1M;2S0mgooa
StD:utilll'ously;3.6 mg "try
1 implant "'Ill mo (501119)
PO;2.SlIM}Iday
Subrutalll'OUlly; 1 mglday
PO;lOO IJI9fday for thm ISO
PO;60 1119 daily
PO; 10- 10 mg OR!' to two (morning and Mning)
PO;&OlII9Iday
1M;17SmgOOO' monthly
'1101'1,,37 Drug'(D<f\IeopLHIa 561
Adverse effects
We'qllrgoifl,momflio.abdJmif"IQl
di5lflHion.lwtllrl'f14 ftIlhif14 dQrrlIeG.

(ItlflmtrOlII',ltIlo/Q(/Ontj
Thrombophlrbitis. mUld!: wallioo
(prf!bMnr deumrI[Ia\Ollr) gru:gwolk
broatp!mjcih lll'm&ronr Ifllpliqporl


Qffhtnio.l!QUJfQ
HyprorositiYity runions (induding
!Npby!axhl tblPmbq!b1rbki> (HE
htoalOuo:ility
(flularri4el !Utial dyllunnion (QOX!!in.
nilutMtidP. uo:idlY
-
which is the most widely used drug for breast cancer,
toremifene (Fareston). and raloxifene (Evista) are called
selective estrogen-receptor modifiers (SERMs). These
drugs block estrogen receptors on breast cancer c('Us but
have an estrogen-stimulating effect on some nonbreast tis-
sues. The progestogenic effects have positive actions on
bone mineral density and improve lipid profiles (increase
HDL and lower LDL).
to estradiol. Aromatase inhibitors can reduce plasma estrogen
levels by as much as 95% and are used in postmenopausal
women with advanced breast cancer whose disease has pro-
gressed beyond tamoxifen therapy.
The antiestrogen class also includes anastrozole (Arim-
idex}.letrol.Ole (Femara). and exemestane (Aromasin). which
are called These antiestrogens block the en-
zyme aromat:tSe, which normally converts adrenal androgen
ANDROGEN ANTAGONISTS
Hormone inhibitors also include the antiandrogens bicalu-
tamide (Casodex), nilutamide (Nilandron). and flutamide
(Eulexin). These agents are prescribed for advanced prostate
cancer. which is strongly dependent on androgens for growth.
LibraryPirate
S62 UnitS Thl'lmmu""Syst""'
LIFESPAN CONSIDERATIONS
- -
Chemotherapy in Elderly Patients
Thr oIdtr lruk population hasa higher mon of unw II I
R'wk of I gR'ltrr mumulation of (')Kinogrnic efm:u O'/rr and
in that hepuicdlll9
.ctivity(P-450J is dK1N1fd by 30'11i in healthyoldtr adults, mulling
in dernilfd metabolism of drugs. TIll' glomerular filtration rate also dt
Jl'Suhing in !'X(1Mion of dlUlJS from the Redoced
hematopoietic nem (rll mm and ability to mobililr these celb from
tht bone marrow rna)' !low R'ClIvrry (Chalta etal., 1994J.MyrlolUpprrssion is
mOll'{ommon and moR' SfflR' in oIdtr .dulu.
Include the following points whrn tra{hing older .rulu ind thtir caR"
givrB about
Older adulu I"t{ejying {hrmotherapy drugs may uprrirlKe greutr
IOIicity from oormal rIo!ts.lmtllKt thr patirm to monitor and R'port
bftding or bruising and to i wid aspirin products.
Bf{ollIIf older adulu olrrn haYrdefir:irm nutritional intalct,te.ch
patirnt and (,)lf9ivm about hralthy food choices,and thr
patirnt', ability to foods and mediutiom. Nutritional
wpplrmenu may lit
Constipation may ocarrdut to I in riiminuion. [ncoorilge tilt
patirnt to drink adequate !krichand to incrule dietary filltr by using
grainland
.., Prototype Drug I Tamoxlfen
BIOLOGIC RESPONSE MODIFIERS
Biologic response modifirrs (BRMs) alter body dd'enses to
enhance the destruction of cancer cells. BRMs include inter-
ft'rons, interleukins, and certain other cytokines. Some of
the BRMs are immunostimulants.
37.14 Pharmacotherapy
with Biologic Response Modifiers,
Immune Therapies, and
Miscellaneous Antineoplastics
Biologic response modifiers and inununt' therapies are med"
ications that stimulate tht' body's immune system to rid the
body of tumor cells. The immWlOstimuiants are less toxic than
most other classes of antinooplastics. These agents, along with
somt' miscellaneous antineoplastics, are listed in Table 37.9.
Types of drugs within thissubdass include the following:
e Interferons: Natural proteins produced byT cells in
response to viral infection and other biologic stimuli .
Interferons bind to specific rect'ptors on CllnCer cell
membranes and suppress ct'll division, enhance the
phagocytic activity of macrophages, and promote the
cytotoxic activity ofT lymphocytes. Peginterferon alfa-
2a ( Pegasys) and interferon alfa-2b (Intron-A) are
approved to treat hairy cell leukemia, chronic
Therapeutic (lass: Antineoplastic Pha rma(ologi( (lass: Hormonal agent, estrogen receptor blo{ker
Aal0NS AND USES
Timouit>n is an oral anliestrogen thit is i ptmrred drug for tR'aring mewta-
tic blNlt UIK('I.1t is effliYr i gainn brun tumor crils that requiR' estrogen
for thrir glOWlh, which known as receptor ([HI POlitivr
bloch estrogen fl'U'pton on brean u nm (elk, but tamOlifro actually twilles
l"t{eptoB in other pam 01 thr body, in t)'piul
effects!UCh al rrduU'd Jnd ilKrralfd mineral den!ity 01
A uniqut 01 tamoxifu is that it is the only antineoplastic thit is ap.
p<OKi for prophyl .. is of bR'iI' for high. ri<k pnirnu who Olf II risk of
drYrIoping thr lridition, it is approved as adjunaiYr therapy in
women following lIY5If{tomy the potemial foruncerin throppo-
sitt brt ill
ADMINISTRATION ALERTS
Give with food orfluick to drr:R'all' GI irritllion.
OonoHMhor{wdrug.
Awid antl{ick for 1- 2 h following PO dOlaljf oitlmoxifen.
Plf9nancy category 0
PHARMACOKINETICS
Unknown
Peak:
Half lift':
Duration: Unknown
ADVERSE EFFECTS
Othrr than n"UIN and vomiting, tamoxifen rmie serious toxicity. Of
colI(em,howeYl'l,is theassoci.Jtion of tamOliit>n thtrapy with an inausKI risk
of endometrial (alKrr and thromboembolic dile<llr, induding strokes and pul
morw ry emboli. Hot lias !krid nlion, j nd vagini I dischjrgei i It relatiW'ly
common. TamOlifen initial "tumor liaR'" - an idiosyncratic in
but this is an l'lpKtKl thrrapwtic M'n1. Hyptrtenlion and KlemJ
ocarr in lbout 1('% 01 patient> taking tilt drug
Canlr"; ndi<dlion>: (olll,.iooo..l"" 10 lilt u,", of 14,oolil. " in<.lude . n1ic.o-
agulant therapy, prMJiliing mdomnrial hyprrpl.lIia, history of thromboem
boIi! diINle, "nd lactation. Prrautionl shoold lit ob!l'lVfd in
p"tirnt; with blood dilordtB, dilrurbanU'S, hyprrukrmia,
Jnd hypen:oolrslrrolrmia.
INTERACTIONS
Drug-Drug: NlKuagWnt; tM (ooo.mnriy with tamoIfIi>n rna, iootR the
rill; of blHding. (oocUrmlt !III' with C)'IotoDr: may ill(lNII' thr rill: of
wi. tIKINIl'
IabTflU: >MIn (lkium ImIIIfIi)' OONlf.
IlerbaVForxl: Unknown
Trmtment of ImrdOlf: Stizurrs, neurotoxicity, and dysrhythmial rna)' our
with The patient is tR'aifd s)'Illptomatiuliy.
IIt/i>r 111 MyMnIngR fot MnJrIg 1'rf'55 Foon lpK/It 1II1M atJg.
LibraryPirate
(1101'10137 Drug,fD<Neopla," 563
leukemia, Kapsoi's sarcoma, and chronic
hepatitis B or C
Monoclonal antibodies (MA&): Engineered to attack only
one specific type of tumor cell, unlike interferoru and
interleukiru, which are considered general
immwlOstinmlants. Once the MAB binds to its target cell,
the cancer cell rues, or is marked for destruction by other
cells of the immWle response. For example, trastuzwnab
. lnterleukin-2: Activates cytotoxic T lymphocytes and
promotes other actions of the immune response.
Marketed as aldesleukin (Proleukin). this drug is
indicated for metastatic rena] cell carcinoma.
TABLE 37.9 1 SC!IC!ctC!d Biologic RC!5pon5C! ModifiC!r5 and Mi5cC!lIaneou5 Antineopla5tic5

triolid! (TrisfflJI)
(Ebpn)
bo:arot_ (lugretioJ
hydroxyull'ol (Hydr61)
iote-fffllO.!Itr 1 (RofI>roo-A.lotroo A)
(w 454 for tilt Pltlloty]N' Drug
tm<X>1
ilabtpilmt(lKffilpril)
ImmilOk (Errjamisvl)
mitoufIt (l)'soho)
PEG-L-
asparolginalt)
romidtpsil (lstodax)
'IOrinostit (loIinu)
IdMrooKJOO (1orneta)
MONOCLONAL ANTIBODIES
aimtWlllloib (Camp.!th]
btYadzumab (Amlio)
bortnomib ('kk.Jdt)
wuxinab (&binD:)
e-\oIioib (TaKt'loI)
gefninib(rnsa)
9fflItuzumab ozogamidn (Mylota'lj)
ibril!lIlornab tiuxetio (Zt'lillin)
imalioiJ (Gitt'lKj
Idl"'lilib [Ty .... b)
ofatumllllilb(Arll'lri)
p.!ZOp.!nib (Votriffit)
ritlilin.Jb(Ri!uun)
Ilinitinib (Suttnt)
sorafmib (Neuvir)
tositumomab (Bt'Dir)
trutuzumib (IIffi:tplio)
Route and Aduh (mall where Indicated)
1'0;65 mglrn'/day
1V;0.15 mg/k9lday [max:60 dolts]
IV; 100 i l1enwlionil
1'0; l00-400III9Im'fdq;topical; 1% gtI applitd to 0lIl' to

1'O;20-lOmg/day
S!t>anaotOUsl\M; 2- 3 for ltukrmia; to
36 milion for Kaposrs 5ita:Jrna
1V;40mlJ/m'infllltdamlh"tf'! lwk
I'O;SO mg tid for 3 days
1'0; 1- & glday givtn in to foor dividtd doIts;may
to
1V;1,500 Mf114 dars
IV; 14 mlJ/m'admioistl'R'd 0'/ff4 hroo ditrs 1, B,and 15
1'0;400 mg ona diily
1V;4
1V;3-lOIII9Iday
IV;S m9Ib;i MI)' 14 days
IV; 1.3 wMIy for 2wk
1V;400 mglm' 1 h;tIItn (ooti_ with 250 mg/rn' O'/ff
1 h Wl'ekIy
1'0; 150 mg/day
1'0;150-500 Ill9lday
1V;911191m'for2h
lV;lSO 1II9Im' of rituxinab is infwd foIOWl'd by 5 mG of
unlin in a 10-llio IV push
1'O;400-600lII9Iday
PO; 1,250 my15 .. bh:,,)," .. un d.,. 1 II> 21
cmtilllOlllly in combinition with
1V;300 mg initial dos/, foIOWl'd by 2,00l mg wMIy for 7 dolts
1'0;800 mg ona diily
1V;375 mlJ/m'/day ua (ootinllOUl iofusion
1'0; SO mg ona daily for 4 Wffb followtd by 1 Wl'dts off
1'0;400 mg bid
1V;450 mg 60 min
1V;4 a dos/,;tIItn 1 mgltg"tf'! 1 wk
Adverw Effects
IiIIIJJe4 aHIftXiQ, rolh,
a/cpi4 (MQIOfmt)
Boor IDa]!9WMlD!Olioo (ol'ullgpmy m!IDia
thrombocy!oprri.!) gym and
hyprorosili'li!v
!fiOkm (i"tdydjnganapbyWbl NouNliik
fJ\IIj!JtjNsr bl'mQlrof P!'W\lljrgasr)
hYDQ!lr1l2idi\ll) (bmrO!tOcl, hroatOlOJ:iQg
(JINraojrusr bfiin ditmaqr

/iQlJIfO, (IIIfmllWmob),
QoorrxiQ, III Jh, stomaliliJ, ft'll'r, {hils
Boo!: IDa!NW !!.OPm1ioo (ntlItroproia
seym: niu!!:i and
LibraryPirate
564 UnitS Thelmmull<'S),,'I'm
(Herceptin) binds to specific proteins on breast cancer
cells (called HERl proteins) and induces cell death.
Alemtuzumab (Campath) binds to a protein known
as CD52, which is presem on the surface ofB and
T lymphocytes, monocytes, and other white blood cells,
and is used to treat chronic lymphocytic leukemia. The
key point about MABs is that the tumor crlls must
possess the specific protein receptor; otherwise, the MAE
will be ineffective.1bis is illustrated in PhannacothETapy
lUustrated 37.1.ln the treatment of rhewnatoid arthritis
and severe psoriasis, MASs are used to dampen overactive
inflammatory crlls.
\'/hen given concurrently with other antineoplastics,
biologic response modifiers help limit the severe immu-
effects caused by other agents. Additional
information on the biologic response modifiers, a drug pro-
totype for interferon alfa-2b, and nursing considerations for
this class of drugs can be found in chapter 3200.
Certain anticancer drugs act through mechanisms other
than those previously described. For example, asparaginase
(El<;par) deprives cancer cells of asparagine, an essential amino
acid. It is used to treat acute lymphocytic leukemia. Mitotane
(Lysodren), similar to the insecticide DDT, poisons cancer ceUs
by forming links to proteins, and is used for advam:ed adreno-
oortical cancer. Two of the newer antineopJastics, inmtinib
(Gleevec) and sorafenib (Nexavar), inhibit the enzyme tyrosine
kinase in tumor crUs. Lenalidomide (Revlimid) is an angiogen-
esis inhibitor that prevents the formation of new blood vessels
that are vital to the growth of new twnors. Approved in late
2008, plerixafor (Mowbil) is classified asa hematopoietic stem
cell mobilizer. The mobilized stem ceUsare then collected from
the bkxxl for subsequent autologous transplantation in pa-
tients with non-Hodgkin's lymphoma and multiple myeloma.
PHARMACOTHERAPY ILLUSTRATED
37.1 Monoclonal Antibodies and Cancer Cells
Adminis ter
MAB
I
.-. '"",,,,,
TU"TIOI" celie die die to

fixation, or induction of
apoptosia.
Exampln:
Rituzimab (Rituxan)
Alemtoromab
I
NOITTIIII cella 1\& .... no
IU"TIOI"-apec;fic antigena
of their auof...,....
TU"TIOI" cell s with
tumor-apecific antig-ens.
The anliQ"" p,,,,,ent is
diff""",t for """" tYP" of

Monoclonal antbod ....
(MAB) ""' crMted for
"""" speci fic type of
tumor antigen.
Adminis ter
MAB
5 TU"TIOI" cells stop 9rtlWins
due to inhibition of 9rowth
factor m<:eptore.
........'
Cetu>.imab (Erbitux)
T .... tuz:umab
LibraryPirate
'1101'1,,37 Drug'(D< f\IeopLHIa 565
NURSING PROCESS FOCUS PATIENTS RECEIVING ANTINEaPLASTIC THERAPY
Assessment
Baseline aSSr5!ment priorto admini stration:
o Undtr>tind Il'ason drug has prec:ribfd in ordtr to use. for
tlltraptUtic:
o Obtain 1 (ompittt history irKluding
rtspiratol1, or rt llil dutom, Ind tht bility of p!f9nalK y. Obtain
a drug history ilKluding alitrgifs, ilKluding spr<ifK Il'actions to drugs,
(urrent p=:ription and OK pll' p"arions,and akohol ulI'.Be
alert to drug interactions.
o signs and .ymptoms of rulll'llt inffitions and for history of
lO.ll'r or pox.
o Obtain an imrruniurion history,rsptdally It(ffi t momion, with
vauintl,particularfy varic:tlb.
o Evaluate approp riatt Iaboratol1 findings (t.g., C &, plattitt (ount, urinalysis,
htpatic i nd Il'nallulKtion studifs, uric acid. tleuro!ytts, gl!KolI').
o AslI'Ss findings from otlltr diagnostic tn ll to planntd typtof
antineoplastic: thefap)' (e.g., ludiology, cardiac testing, ECG, EMG).
o Obtain N5tline and vital the level tht
of pain. Assn , dttp tt ndon Il'flexrs (OTR,).
Assellment thro ughout administration:
o AslI'Ss for dtsired therapMic rilecll (t.g., indicator>of trmrnem ilium or
palliation SIKh as growth in solid tumon, organIbodY"'pedfk
MRlfCT sun demonmates diminished tumor load without rneti.tasis,able
to Mtffid to nomul ADu,.!bll'lKeof sign, of (onrurrent inie(!ions).
o Continue monitoring of lab war!: (e.g., CBC, absolute ntutrophil
count [AHCL plattlet count, urinalysis. htpatic: and Il' nallulKtion
uric gllKose). (AN( = Totil WBC (ount multiplifd by
total pmentageof nwtrophils [stgsplus b,nd.t e.g.,WBC 5000 X (0.4S
II'gmenttd nNtrophiis + 0.05 Nndrd neutrophilsJ = 5000 X O.S = ANC
oflSOOJ
o Continue to monitor finding, from diagnosti< trsu to pbnntd
of i minroplastic (e.g., audiology, (.I rdial: I\'StinQ. ECG, EMG).
o A.lI'Ss for the of nause, or pain.
o AslI'Ss DTIb,and ECG as ,pffifk to typt of antinropbstic drugs given.
o Continue daily weighlland repln any Might gain or 10" of mol"!' than 1 kg
in 14hour>.
o btu ilr adYmt effffls: lliUlN, wmiting. anomia, alKbmiial cramping.
diarrhu , fatigue, diuiness, dysrhythmias, angina, dyspnea,
musc:1e or joim pall'Slhrsias, diminished or absent deep tendon rffbes.
bni.ing,and blttding.ftytrmtedng
pararneteB b)' tilt
urine output or hematuria, el(tuiYe bruising or bIffiIing. rrspiratory distrrss,
andd)'lfhythmia, or an.jna shoukl be rtpOrIrd inmediattly.
Potential Nursing Diagnoses
o InlNtion
o Activity IntolewKe
o Fatigue
o Anxiety
o ImNlanctd Nutrition,lffi Than Body Requill' menll
o Der,dffit Fluid Volume
o Oiarrhea
o Impaill'd Oral MuWJS Membrann
o Impairrd Skin Integrity
o Pain (ac:uteol(hronic)
o Scx:ia llsolation
o lnelfectift Therapeutic: Rtgirnm Managernent (rtlated to (omplu
mtdication and disNse trtatrnem)
o DerKitnt Knowltdge (Il'lattd to dilNlI' pl'Xn , and drug tooap)'l
o HoptIes!lltll
o SpiritlQlOistrrss
o Risk for D!'!:lNsed Cardiac: Output (rtbttd to efftct
o Risk for Injury, Risk for Falls (rtbted to adverse drug or dill'm)
o Risk for Call'gi!'r Role Strain
Planning: Patient Goals and Expected Outcomes
patient will:
upt"rir-rKt thera peul:ic tfffcts k g., Il'duction i n tumor flY" or dt (Il'.md progrnsion of abnormal cell growth, abll' IKt of signs i nd symptoms of (OlKUmnt
inlenion, able to mai main ADU).
Bf!lft from, or nperiflKt tffts.
o an undfr>tanding ofthedrug's UII'"dvelll' and rrqJill'd precautions.
o Demon!lrate proper seIf .. administration 01 tilt medication (e.g.,doII', timing.. wht n to notify provider).
{Continued}
LibraryPirate
566 UnitS ThelmmuoeSysum
NURSING PROCESS FOCUS PATIENTS RECEIVING ANTINEOPLASTIC THERAPY (CorrtlrlUed)
Implementilltion
Interverrtlons and (Ratlerrales) Patient and Family Educat ion
--+-
Ensuring Iherilpeul k effech :
Continut ill5mmtnts ilsdecribed earlier for therapeutic eiffc15:
radicJgraphic fYidtnc:e ofdiminisi'lfd tumor production of
ilbnormal cell growth. of signs of infection,
ilnd food and ftuid intake,nausN Ind 'oOmiting cOl'ltl'Ol1ed, .nd to
maint.in ,mpubif ItveIs of AOIJ.(Antineoplistic drugs do not hal't
imrMdiately oIMrnbif J!Win and I!'IUIts will !If mtilsured limt.
Thee drugs han many potentiill tfFlS.)
Minimizing il dft J!f effects: (ienffalCIIft
Cominut to monitor vital signs. Report incJNsing ttmptrarurr thit mreds
(t.9-, th,", tt mptf.IUIl'SOI.'I" l00S'F or any tempmrurr ()I/er
101F) to the oncology proYider.Avoid tlking rrctJltemperaturrs.
(I ncft'asing fI.'I"I Iow-grlde tt mper atuft's m.y lit sig n of inftion.
ImmlJflosuPPll'Ssion mi y infKlions to occur il nd dil5eminatt
61 tndothelial cells aft' affKted b)' chemotiltrapy and ft'dill muona may be
d.l1IIiIgtd if rt<l<ll ttm ptraturts art ustdJ
o Continut to lib work:(O( ANC, pllteict hepatic ind
ft'JI II fundion tests, eifclrolytes, and urinalysis. (Bone marrow
supprtSsion with I!'IUking blood dysunias is an opKIed idYfrIf" effKl
and will be monitorrd b)' AOC,(BC, and counn.)
for all t!'Sting ilnd trNtmt nts
inform ilion on the tllpKltd COUJlt of dJemothm py: rrqJill'l1II'nts lor
inYilliY!! lints (t.g . ptripherall'eJSus ilCetSl ports). initial infusion or
dosing. I.eqUl'llCY 01 treatments, nlustl control, hydration and
nutrition needs, IJ!qtIfnt lib testing.on!tl of iliopecia,tf(hnique !Of
managing fatigtlf, nutrition and lkJid I'ftds, follow-up appointl1ll'nts, in-
hoIpital W1US outpatient dinic and how to INCh oncology teil m,
wring off.nouJ!.lnl'Ol\'t tilt family and ....... in informnion

TNCh the patient to take temptr.ltuft' tl'r)' 4 hours if symptoms indicatt a
netd (e.g . ill(rrased body warmth,general maliiSf,iflhatgy).lncUdt
instructions on when tocall the oncology telm if 1ft' ell(tede<i.
InslnKtthe p.lOtntthat ilmipyrttiu art not to !If used units! explkitly
by the oncology provider. (Antip)'ll'Iics may mask the symptoms
of an infl'(!ion,allowing rapid disll'Jllinuion of tht inff(tion.)
o Teach the patient 01 the need for Irtquf", lab work. HaY!! tilt patient ilifrt
I<tb pmonnel ofchemotht r.lPY ust.
If pt"riphtral ninlate!lled for phlfbotomy, KJUpulous cifilnsing of the
prior to stide and prolongtd pressurt may be Il'lJIill'd If a
C-__ used, Krupulous cicansing of the pon is rtqUirtd.
Continut to monitor nutritio ... 1 and fluid intlke.(Naultii .nd I'Omiting all' antiemtlic: the"py during of drugs with high and
rommon tfFfcts ilnd usually Il'lJIill' ilntitmetic therapy to man.. morlmte mtlic potential. If the patient has had prmous tll'atment with
lliHJry consulution may be rrCJIirrd to optimum nutrition.) thecht mothtrapy rrl}imen,as\f"$s the fIIl'11t of naUlfllnd I'Omiting and
whkh intiemttjcr Iwd tht molt succm in prtI.'I"lting naultl.
Continut to forthe PJl'ltnct of pain and pKlYide for adtquate
medication./Pilin may I!'IUk from disNst or advtr\f"drug tIlKU.
In advanced disease, pain medication is not Withheld.ASSffi possible dl\Jl}"
related caUStS for in and trell the UUIf ...men possibif.)
PJO'Iie1e for rtst.(Fatigut related to anemia Ind adY!!JIf drug
tflKls is common,tspf(ially around the nadir and immediately after:
o Encourilge incrr.std nuid inlilkt,up to II perday, taken in f.eqUl'llt vull
Jmounts.
Enrouragesmallhigh-<alorit, nutriem-denst meals rlthtr thin large,
i nirrqUl'nt IlINls. Nutrition.1 su ppifmenn such iI S U tVury, or En surt
l1'l/I'1 help boost Cilloric im!kt.
Awlid spicy, highly scented foodS,ind uctssmly hot or cold Ioodiduring
ptriods of naulta. Small of Cilrbonated !'Specially gingtr aif,
may provide ft'lief.1f GI efiKis predominatt (e.g, diarrhea), mid high
roughaqe foods.
o Encourage f.eqUl'llt oral t: rinSf mouth, tspecially abr tating; USf
lip balm;and 'l'Oid moutliwdsh, ...mkh m be drying to Iht
mucosi.
EnCOUr.lgf tht to Itek pain ll'Iil'fwiltn nffiled. Teach til!< patient,
family, and ull'9mr that abselKeof plin is a goal in tht tll'atment of
advanced disNse and pain medication should not be withheld.
Teach the patient tht importalKe of daily routifll'l throughout the
diy.Encouragt JI'It whtntvtr fatigutocrurs.
Fatigut may continut ifteHell (ouml ft'IUm to normal ilnd miy ptrmt for
hll'll transportnion needs if fatigueallem ability to driYt.
___ "--""" ="' ,,, 1 to lOCiallfrmts IS netded.
Itl!fal )'faJ! alter themothtrapy.)
LibraryPirate
'1101'1,,37 Drug'(D<f\IeopLHIa 567
NURSING PROCESS FOCUS PATIENTS RECEIVING ANTINEOPLASTIC THERAPY (Continued)
Implementation
Interventi ons and (Rati onales) Patient and Family Educati on

Protttt patient from inlKtion: t. 9. frequent hand w uh ing befD<t o Ttach family, and (.I regiel" inre.:tion control mtalUfl'S u
patient (.Ifl';maimaining IUlJpulous inlKtion comrol mUlUfl'! for alllY follow!:
linrsor \'eIIOIIS puncture; tlKouraging patitm to mainuin daily o o\void uowriM indoor pb.c:H.
hl'lient mmures to limit t rttlllilillora;and lor,ymptomlol
o Awid known in/euionlor)'Ollng childlt'll who haY!' a
opponuniltK inftttionland I{quiring tarly Ueatlll!'nt or prop/lylaJil.
higher rilk of having i n infect ion.
pbc:6 patient! at high riIk lor inlKtion. ProphyOOic
o Cook food allowing orcaregmr 10 prr palt' raw
with intifungll and anribac:ttrial mouth riOllS,ind
foods.nd 10 dtan up:pati.nt should not ,onIUm. r ..... fruit! or
isolation may be l!qtJirtdJ
vtgmblts.
o Repon all)' and ,ymptoms olinftttion!lKh as:wourm with
It'dnel or draina9t, ill(lt'asing toIJ9h,ill(rming latigU!', whitt pauhes
00 oral murouslII!'mbranrs or whitt and ildlyvaginal discharge,or itdJY
blilter-likt veliclts on skin.
o I'rovidt lor tmOliollill suppon for family, and (.Irtgmr. (Can't! o ElI(ourag. family,and cartgmr 10 di!WI1 {OlI(rllll or
rf"IUkl in profound . motionallt'l roOOlirom all inrolY!'d. EnWUri9f quetionl ind 10 sm approprim spiritual or !O<ial support mltsilt'd
di=ion of ,olUm appropriatt It'I. rra II lor !O<ia I support or spirilwl
o AI5f11 finan,ial (01I(em\ and providt approprialt .ooal lffi'ic:.lt'lerral u
asliS!iIl(.,and ,1IIlnl patient or family for dilufI! that may It'quilt'
n. tdtd.
m.ntal
Minimizing adft l!f ffl"Kl s: Specific to Drug rherapy
o Monitor DrRs, neurologic lIatus, and 1tY!'! 01 UDO. lA/ky/mil19 o Ttlth patient to be cautious walking or tllks
agmn!lKh as c,dophoIphamideand norurol produa amnlClpa!lia!lKh rrquiring mra df,nerity. Promptly repon all)' lignifK.l nt d iffiru Ity with
as vinailtine ha .... neurologic advmr .fft<ll.Changes llliy occur in orRs df,xt. rity, or duminfl! whtn I. rrying out ADLJ or when walking.
that alt' not notiltabit 10 the patitm in t arly ltages but llliy alfm dmeril)'
o E()(ouragt increal.d intakeoffluid! and modtrate fib.r in diet if
or wlltn walkingJ
constipation iI t ift" It'laitd to deul'lltd therapy may
lit lI'quilt'd if (Onstipation is IfYtre 10 straining during dtlation.
o Monitor(.lrdiolral(Ular ItaM i()(luding ECG, and blt'ath IOUnm, o Ttllh tiMo Pitient about nw:! for flt'quent monilOring of "rdiil IUM.
prl'ltllteof tdtma,and or mflt-wall pain.lA/ky/mil19agmflllKh Immtdiateiy repln any lhest-wall pain.angina,
cydophoophami df" antitumor QIIfibodies !lKh II dolOrubicin, na/uroJ longtltion, or dizzinell.
prodrxr oninroplll5lia !lKh as vinlriltine, i nd hormont and hofTrlOM
onloganim mh is tamoxif. n haY!' mdiomrular ad-mit eifls !lKh
and effttts on tho cardiil conduction

Monitor respirnor; SUM indudiog breath sourKb Ind pulmonary function o Teich tilt: Plitient ibout nffll for fll'qU!'nl monitoriog of respirator;
t6 11. Wkylatil19 ogmfl IlKh is cyciophoophamidf" antimHoboiirl'5 sum i lIaM.lm mtdiat. 1y repon all)' Ch6 t pa in. dyspnei,lung longetion, or
mtlootlt'ute, onriwmor omibodil! !lKh doJOlU bicin, fIIlwroi produa
onOOeoplmria s ",h as vinailli lit, and bioIogk mpomt modifiers !lKh 1\
o Ttlth tiMo patient pulmonary h)'9ienr mtaSUJtl !lKh II fluid
inttrl"uon alphi-2 hal'f Jtlpiratory ad-;.B!' effls !lKh a\ interllitial
intakt to moisten II'Spiruory aowdtd indoor placfl and
pnrumonitis.)
proplt with known II'Spiratory dileasr,and avoiding Ulfol room or body
which llliy be an irritation to tho Jtlpiratory tract.
-
o Monitor hepatic and It'ndl staMand for urinary trill dysfuoclion. o Teach lilt: patient 10 immiattly repon any naulta, )'dlowing of
drug I may (.IU If significant hepatic and fl'na Itoxicity. lkin or scltra,ibdominal pain, light or llay--cololt'd urine
A/kyloringogmB IUdJ II may (.11M htmorrhagic 01 urin. , or suprapubic pain or blood in urine.

o Advile patient to fluid intakt to 1 to II perday.
o Monitor for ototoxicity.!A1ky/IriIg agmn s",h a\ I)'(lophospha mide and o Ttlth tiMo patient iboot ntt<I for periodic monitoring
onrmtrobolill! !lKh as mflootlHalt llliy (.IUIt otoUcil)',affKtiog hearing. Immtdiateiy repln any diuillfl!, Vtnigo. naIMa It'lated to motion,
balancr,or both.) buuing.ringing.or humming in t m.

Monitorfor orulartoUcity.(l/ormontond honnontanlagonisn !lKh is o TtlCh tiMo patient about nw:! for ptriodic mm.lmmtdiattly
tamoxifrn may ocular toxicil)'.) It'pon all)' bkJrmf vilion,.yt pain,or or other vilual disturba()(6
immtdiat. ly.
o E()(ouragt patitnt to wur when in bright light.
(Continued)
LibraryPirate
568 UnU The Immune System
NURSING PROCESS FOCUS PATIENTS RECEIVING ANTINEOPLASTIC THERAPY (Corlflnvtti)
Implementation
Interventi o ns and (Ra tionales)
MonilOrfor MllNloiogic IOllicity. (N1)"lti!9119l1'1U IS
(){lophosphirniM ma, causr lignfunl U R'actions indJdill!l
StMM-Johnsonsyndromt.)
Monitorfor 1!U:00itis. {AnMplnn.: drugs IIIiI'I calM sigrlilkilnl l!U:osilis
ltiated 10 tfffft5 on 111.,..,. dividill!l GI tncioIhtliill [thJ
Monitorfor and i1lr.qK 19ttiom.. (AnIiMOplIln.: drugs
may YIM IrfpmtnWvity and llIr19i1: inckJdill!l
arwphylallis.Bfause ructions mry not bt prtdirub!t.Q\ftion aM
frf!Jlffll monitoring <If! mfntiallO mIllR' prompt UfiltmtIIlJ
Bt lWalt of polil:its and plllllJR'llfloIted 10
IntincottlastK Idministmion.!pillfliflagtmCfll. aM Itquirtd cWfWWOrk
btfo!t womng with or gm.,g AI IV infusions wi be gitfl
via monilortd pIlII!p.1V push drugs mily utim a push--jIuH ttd'l.iqIt.A11
spills will bt managed N OSHA and p!01lXols.liIJ9tI spills may
HAZMAT intmmtion.(lnttmM t<kJutiln prognmSilR'
priof to administering vnicMJlS ilM othel (htmothmp)' drugs.'lI:IltCtion
ohhe pmonnfl, iIIId others inI'otffil in the
aM administriltion of chemotherilJl1 is
Patimt uldefltanding of drug thenpy:
Use opportUnities during adminisuiltion of lMdic:atiom 1M during
ISsmml'ntS to diicUSSl1Ilioroalr for drug llImp)', dtsftd thtraPfUlic:
outcomes, most comtnOll tiru, pililmettrs for when to an the
heilth UR' III)' mooitoring 01 prtUutions..(Usill!l
timt Wriog em helps 10 optimize ilnd ltinfortt I:ty INch ing
lR'asJ
P. timt stlfldminllIlMion of dnt, thtrlPJ:
When ildministering meGutiolll"inwuct the p.ltimt c.JIlI'giver in
PIOpfI Ie K-m inistrllion Ie< hniques IoIIowfd rtI\Jm MmollSlfation IS
I'ftdfd. (PlOptr adminismtion wiI Male the riflivmes drugs.)
Pa t ient a nd Fa mily Ed ucati o n
Tum tilt p.lDentlO R'\IOI'tany unUSUiI 10 skin,
I1IWs. ()' sunoom.ikt i PPfII1l00' promptly. RfIlOrt any purplish-ml
blisttlill!l fWl,Of pMill!l skin.
kICh the p.lDent 10 inspt(l mouth at IrlSt once oWy 1M regWI
Mnt.ll wms.Miintain good onl tryqitnt and rinse mouth with plain
watel 01 iOUion Ifttl eatill!l. Use and ilntifunrJal mouth
rinses and do not rinse mouth with Willtt' iftel usinQ, kfoid txHSMiy hot
()'cold foods.
kICh tilt p.lDent 10 ill'Oid high-lOUghilgt foods, spier foods,carool\lltd
Ind acidi.: bMrage,ilkohol, and uffHlt.HdiantIt.J is Ifftl!'. drug
therapy mry bf requirtd.lmtlWdiattl1ltpOfI excHSM dia nbti,
rspecially lit (ootlm IIIIKlII Of blood.
kICh tilt p.lDent 10 R'\IOI'tany itching, rashts,orlwtlling,
p.lfli.:ulariy offace, 10fIl1Jf. or i ps; unif:aria; fUsIWIg; diumss; I)'IKOPf;
whttzillg; thron tightlltls; or difflOJky brtathillg.
PIIlYide tht filmil"and ul!'giver rdocition ilM IUppofl when
gimg chemolhtfilflJ
The fimiiy. ()' UregMor UIouId bf able tostatt tilt ItISOll for the
dost Ind sd!e!kJlinq;whil adverw tltKb (0 obstm 10,
ilnd whm to rtpoft; ilnd the ilnticipated length of mediution theril""
PlIlYiden:plicit iltSUUctions b the filmily,Of UII'gMor 00 lhe
fOIItine to IoIow for illy ilntineoplastic drugs used it home. Entourage the
IN' of c.almdars iol lKOrdill!l drugs and doses ustd;ilnd pmide
inlormnion on handl'1Il9 a liquid spill and on plGpfI' disposal oflny UIIIMd
drug. (Consult local pliarmiICifs,. as many will accept unusrd drugs lor
propel disposal. Chemothtrap)' should IIf'IItI be llushed down the
poortd in I drlin.Of thrown IW"I in the msh.)
Evaluation of Outcome Criteria
the of drug tMapy by (OfIfirmillg tltill patimt goals Ind eJjlKttdOlJlClKl'lellwve bten (sH,1'I,nning1.
SrI' l1l*I17.1 rIrrIIHjI 17.'111 b /hfjl1wtKltl1lNlIIIMf 1KIiInI:"".
LibraryPirate
(lIopltll7 569
Chapter REVIEW
KEY CONCEPTS
The numbered key concepts provide 3 succinct summary of the important points from the corresponding numbered section
within the chapter. If any of these points are not clear, refer to the numbered section within the chapter for review.
37.1 Cancer is characterized by rapid, uncontroUed growth of
cells that eventuaUy invade normal tissues and metastasize.
37.2 The causes of cancer may be chemical, physical, or bio-
logic. Many environmental and lifestyle factors are asso-
ciated with a higher risk of cancer.
17J Cancer may be treated using surgery, radiation therapy,
and drugs. Chemothernpy may be used for cure, pallia-
tion, or prophylaxis.
37A The growth fraction, the percentage of cancer ceUs un-
dergoing mitosis at any given time, is a major factor de-
termining success of chemotherapy. Antineoplastks are
more effective against cells that are rnpidly dividing.
H.S "Ib achieve a totat cure, every malignant cell must be re-
movW or kiUed through surgery, radiation, or drugs, or
by the patient's immune system.
37.6 Use of multiple drugs and special dosing protocols are
strntegies that allow for lower doses, fewer side effects,
and greater success of chemotherapy.
17.7 Serious toxicity, including bone marrow suppression,
severe nausea, vomiting, and diarrhea, limits therapy
with most antineoplastic agents. Long-term conse-
quences of chemotherapy include possible infertility
and an increased risk for secondary tumors.
37.a aasses of antineoplastic drugs include a1kylating agents,
antimetabolites, hormoneslhormone antagonists, natu-
NCLEX-RN" REVIEW QUESTIONS
D A patient undergoing cancer chemothernpy asks the nurst'
why she is taking three different antineoplastics. What is
the nurse's best response!
1. "Your cancer was very advanced and therefore requires
more medications."
2. "Each drug attacks the cancer cells in a different way,
increasing the eifectivellt'SS of the therapy."
3. "Se\.eral drugs areprescribed to find the right drug for
your
4. "One dntg will cancel oUi the side elfeas of the other."
D The nuTS(' understands the effective treatment methoo
for the nausea and vomiting that accompany chemother -
apy is to:
I. administer an oral antiemetic when the patient
complains of nausea and vomiting.
raJ products, biologic response modifiers, and misceUa-
neollS ant ineoplastics.
37.9 Alkylating agents have a broad spectrum of activity and
act by changing the structure of DNA in cancer cells.
Their use is limited because they can cause significant
bone 1Th1rrow suppression.
37.10 Antimetabolites act by disrupting critical pathways in
cancer cell s, such as folate metabolism or DNA synthe-
sis. The three types of antimetabolites are purine
analogs, pyrinlidine analogs, and folate inhibitors.
37.11 Due to their cytotoxicity, a few antibiotics are used to
treat cancer by inhibiting cell growth. They have a nar-
row spectrum of clinical activity.
37.12 Some plant extracts have been isolated that kill cancer
cells by preventing ceU division. These include the vinca
alkaloids, taxane:s, topoisomerase inhibitors, and camp-
tothecins.
37.13 Some hormones and hormone antagonists are antineo-
plastic agents that are effective against reproductive-
related twnors such as those of the breast, prostate, or
uterus. They are less cytotoxic than other antineoplastics.
37.14 Biologic response modifiers and some additional anti-
neoplastic drugs have been found to be effective against
tumors by stimulating or assisting the patient's immune
system. These include interferons, interleukins, and
monoclonal antibodies.
2. administer an antiemetic by 1M injection when the
patient complains of nausea and vomiting.
3. administer an antiemetic prior to tile antineoplastic
medication.
4. push fluids prior to administering the antineoplastic
medication.
o Which of the following statements by a patient undergo-
ing antineoplastic thernpy would be of concern to the
nurse? (Select all that apply.)
I. uI haw attended a meeting of a cancersupporl group."
2. "My husband and I are planning a short trip next week"
3. "I am eating six small meals plll'i I\\oU protein shakes
a day."
4. "I am taking my lS-month-oid granddaughter to the
pediatrician next for her baby
5. "I am going to go shopping at the mall next week."
LibraryPirate
D To monitor for the presence of bone marrow suppression,
the nurse evaiu.ltes the results of the:
I. BUN;and serum creatinine.
2. serum electrolytes.
l. CDC.
4. bonescan.
o A 2-yl'.lr-old patienlis receiving vlncrlstlne (Oncovln) for
Wilms' tumor. Whkh of the foUowing symptoms should
be reponed to the heal th are
1. DimRea
2. DimInished bov.\>I sounds
l. Stomatitis
4._
CRITICAL THINKING QUESTIONS
1. A patient is newly diagnosed with cancer and is .lbout to
start chemotherapy. identify the teaching priorities for this
patient.
2. ClIemotherapy mediations often cause neutropenia in
cancel' pIItierlls. What would be a priority for the nurse to
teach a patierlt who Is receiving chemotherapy at
1. A nurse Is takJrlg chemothel'apy iV medkat lon to a pa
tient'S room and the IV bag suddenly leaks solution (ap.
proximately 50 ml ) on the floor. What action should the

Sa "ppmila D foranswns and f'Il,ionaks for aU activitia.
o Thl' nurse nOies that t he patient has reached his -nadir."
This means that:
I. thepatient is rtaiving the highest dose possible of the
chemotherapy.
2. the patient is experiencing bone marrow $uppnssion
and his blood oountJ an at their lowest point
l . the patient haspraktd on his chemotherapy ltwl and
should be going home in a f"" d3)'S.
4. the patient is uperiencingt"l:tremt depresdon and wiD
be having a psyt.hlatrk consult.


Is YW' one _ I1lI' 0'*'1: d'll!PItr mIew materials and
Ie&WICH. Plllpae lor MIh ua .. w-st'p16 Practice
QlII$b1s, Interl/;1llle aid aCIMIics, web tlnks, lIIi'mtlon!
arid and morll
IICI:tJiII c:odIIlrom 1h81rm1 of)QIr DOOIr lit
www.mrllll.linilkitcam.
LibraryPirate
(HAPTER 38
CHAPTER 39
U NIT 6
l he Respiratory
System
Drugs for Allergic Rhinitis and the (ommon (old
Drugs for Asthma and Other Pulmonary Disorders
LibraryPirate
DRUGS AT A GLANCE
Hf RKIPTOR ANTAGONISTS (ANTIHI STAMINES)
",,,,
o
,.,,,,
INTRANASAL CORTICOSTEROIDS ,-,511
<;) flu/mOtIf IfJMcose V"IImyst olhmJ
""w
MASHUl STABILIZERS f1J1I/56J
DECOMGSTANTS pq5MJ
.;)
ANTlTUSSIYES ,.w
Q (l:W.I)'fI1,IIobinmm.
olhm) pillJt511
EXPKTORANTSANDMU{OLYTI !3 1'11'584
KEY TERMS
ilHeIJI'Il fIIJ1t 574
.nff1k minim ,.514
.nlossi'll5 JIIlIJ'5&J
Drugs for Allergic Rhinitis
and the Common Cold
LEARNING OUTCOMES
Aher readiflt} this chopter, rhe sWdent $hould be obiI' 10;
1. identify major of the Uppf!f n>5piratory t ract.
2. Describe common causes and symptoms of allergic rhinitis.
3. Differentiate between H, and Hl histamine receptors.
4. Compill'e and contraSl tile oral and Inlfa.nasal decongestants.
S. Discuss the pharmaootherapyof cough.
6. Describe the role of i'KpectOfanlS and mucolytks In uNtlng bfonchlal
congestion .
7. Fofeach of the classes listed In Drugs at a Glance,know reprewlltative
drugs. and explain I t.-ir meChanism of drug action, primary actions on
Ihe rfspiratory system. ;lnd Important adverse effects.
8. Use the nursing to call! for patients who are receiving
pharfTliloCotherapy for i\lliergic rhinitis and the common cold.
mlKllJl:i:5 JIIlIF J!5
felloW (ongetiln ptIJt 1II1
LibraryPirate
T
he respiratory system is one of the most important organ
systems; a mere 5 to 6 minutes without breathing may
result in death. When functioning properly, this system pro-
vides the body with the oxygen critical for all cells to carryon
normal activities. The respi ratory system also provides a
means by which the body can rid itself of excess acids and
bases,a topic presented in chapter 31 co .This chapter exam-
ines drugs used to treat conditions associated with the upper
respiratory tract: allergic rhinitis, nasal congestion, and
cough. Chapter 3900 presents the pharmacotherapy of
asthma and chronic obstructive pulmonary disease, condi-
tions that affect the lower respiratory tract.
38.1 Physiology olthe Upper
Respiratory Tract
Knowledge of the basic anatomy and physiology of the up-
per respiratory tract ( URT) is necessary to underst.and the
of thM reginn. The
URT consists of the nose, nasal cavity, pharynx, and
paranasal sinuses. These passageways warm, humidify, and
dean the air before it enters the lWlgs. This process is some-
times referred to as the "air conditioning" function of the
respiratory system. The basic structures of the upper respi-
ratory tract are shown in .. Figure 38.1.
InI ... ",.
"""""
Vestibule
Hard palme
a.alaM!y
.. Flgure.J8.1 The respl.atory system
'"",If,31 Drug< for AlIe.glc Rhlnltl' and the Common Cold 573
The URT traps particulate matter and many pathogens,
preventing them from being carried to bronchioles and
alveoli, where they could access the capillaries of the sys-
temic circulation. The mucous membrane of the URT is
lined with ciliated epithelium, which tmps and "sweeps" the
pathogens and particulate matter posteriorly, where it is
swallowed when the person coughs or dears the throat.
The nasal mucosa is a dynamic structure, richly supplied
with vascular tissue that is under the control of the auto-
nomic nervous system. Activation of the sympathetic ner-
vous system constricts arterioles in the nose, reducing the
thickness of the mucosal layer. This serves to widen the air-
way and allow more air to enter. Parasympathetic activation
has the opposite effect: arterioles dilate and more mucus is
produced. Thisdifference becomes important fordrugs that
affect the autonomic nervous system. For example, admin-
istration of a sympathomimetic will shrink the nasal mu-
cosa, relieving the nas.al stuffiness associated with the
common cold (Section 38.5). Parasympathetic agents will
cause increased blood flow to the nose, with increased nasal
stuffiness and a nmny nose as side effects.
The nasal mucosa is a first line of immune defense. Up to
:10 'lU:1orl of [lro<"luced :1ond fluid
rich with immunoglobuliru that are able to neutralize air-
borne pathogens. The mucosa also contains various body
defense cells that can activate complement or engulf mi-
crobes. Mast cells, which contain histamine, also line the
nasal mucosa, and these playa major role in causing the
symptoms of allergic rhinitis.
11I.L\;':i:t--- Laryngopharynx
Sourt:e RIce, Medical Terminology with Human Anatomy, srh ro.,p.l9l, Cl lOO5. Reprlllroo /;)i permls5lcxl ofl\>Qf5a1 fdocarJoo. tic, Uppe' SaddIe RIver, NJ.
LibraryPirate
ALLERGIC RHINITIS
or hay fovtr, is inflammatkln of the nasal mu-
(<= due to exposure to altergens. Although not tife threat-
ening, allergic rhinitis is a condition affe<:ling minion<; of
patients, and pharmacotherapy is frtquentl y n.ecessary 10
wnlrol symptoms and 10 prevent seoondarycomplications.
38.2 Pharmacotherapy
of Allergic Rhinitis
Symptoms of allergic rhinitis resemble thoSt" of the com-
mon cold: eyes, snet'ling, oongestion, posl-
na.loa] drip, and ilchingofthe throat. In addi tion 10 the acute
symptoms, polenti31 complications of allergic rhinitis in-
d ude loss of taste or smell, sinusitis, chronic cough, hoarse-
ness, and middle ear infections in chil dren.
As with other allergies. the cause of allt"rgic rhinitis is ex-
posure to an antigen. An antigen, also cal led an allergen, may
be defined as anything thaI is recognized as foreign by the
body's immune defenses. The specifk allergen responsible
for a patient's allergic rhinitis is often difficult 10 pinpoint;
however, the most common ngents are pollens from weeds,
grasses, and trees; mold spores; dust mites: certain foods;
and animal dander. Chemical fumes, tobacco smoke, or air
pollutants such as OlOne are nonallergenic factors that may
worsen symptoms. In addition, there isa strong genetic pre
di,p06ition to allergK
Some patients eJ:perience symptoms of allergic rhinitis
only at specifi c t imes of the year, when pollen levels are at
high le"els in the environment. These per iods are typically
in the spring and fall when piants and trees are blooming,
thus the name alJergk rhinitis. Obviously, t he
"blooming" season changes with the geographic location,
and with each spies of plant. The51:' patients may need
pharmacotherapy for only a few months during the year.
Other patients, however, are affiiaed with a1lrrgk rhinitis
throughout the year because they are cOfllinuoulilyexposed
to indoor allergens, such as dust mites, animal dander, or
mold. This variation is called ptfennia/ allergic rhinitis.
These patients may requi re cont inuous phannacolherapy.
It is oft en not clear whether a person is exprriencing sea-
sonal or perennial allergic rhinitis. P:itients withst"asonal al-
lergies may also be to some of the perennial
aUrrgens. It is also common for one all ergen to
the patient to another. For example, during ragweed season,
a patient may become hyper-responsive to other allergens
such as mold spores or animal dander. The body's response
and the symptoms of a llergic rhinitis are the $lime, howewr,
regard less of the specifi c allergen( s) . Allergy testing can help
to pinpoint the specific allergens producing the symptoms.
The fundamental pathophysiology responsible for allergic
rhinitis is inflammation of the mucous membranes in the
nose, throat,and airways. The nasal InUCO$3 is rich with mast
ceUs (a type of connective t issue ceU) and basophils (a type
of leukocyte), which rtoognile environmental agents as they
try to e nter the body. with allrrgic rhinitis contain
greater numbers of Inast cells. An immedillte hypersensitivity
response releases histamine a nd other inflammatory media_
tors from the mast cells and basophils, producing sneering,
itchy nasal membranes, and watery eyes. A delayed hypers-en_
silivily reaction also occurs <I to 8 hours after the initial ex_
p<>Oure,caus.ins amtinuous inflammation of the mucosa and
adding to the chronic nasal congestion expuienced by these
patients. Beause histamine is released during an allergic re_
sponse, many signs and symploms of allergy are similar 10
those of inflammation (chapter ) )00). The pathophf$iol -
ogy of aUergic rhinitis is illustrated in Figure 38.2.
The therapeutic goals of t reating allergic rhinitis are to
prevent its occurrence and to relieve symploms. Thus, drugs
used to treat allergic rhinitis may thus be grouped into two
basic categocies: preventers and relievers. Prewlllm are
used foc prophylaxis and include antihistamines, intranasal
corticosteroids, and mast cell stabilizers. Rrliel'Cfs are used
to provide immediate, though temporary, reliefforacute al.
lergy symptoms once they have occurred. Relievers include
the oral and intranasal decongestants, usually drugs from
the sympathomimetic class. In addition to treating allergic
rhinitis with drugs, the nurse should help patients identify
sources of the aUergy and recommend approprbte inter_
ventions. These may include removing pel s from the home
"" ....
containing
histamine
Bnmgoite
fo< .... rgy
AlIe'll' pI_ cell
reIe_ -.IIergy"
-\

Pelt"" binds to
allergy anlibociw,
CItU5lIOI hist ........
.......
Figure lB.2 A1ler!lIC mtnllt s
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environment, cleaning moldy surfaces, using microfilters on
air conditioning Wlits, and cleaning dust mites out of bed"
ding, carpet, or couches.
H, -Receptor Antagonists/Antihistamines
Antihistamines block the actions of histamine at the H, re-
ceptor. They are widely used as over-the-coWlter (OTC)
remedies for relief of allergy symptoms, motion sickness,
and insomnia. Theseagents are listed in Table 38.1.
38.3 Treating Allergic Rhinitis
with H,-Receptor Antagonists
Histamine is a chemical mediator of inflammation that is
responsible for many of the symptoms of allergic rhinitis.
"When released from mast cells and basophils, histamine
reaches its receptors to cause itching, increased mucus se-
cretion, and nasal congestion. In more severe allergic states,
histamine release may cause bronchoconstriction, edema,
hypotension, and other symptoms of anaphylaxis. The his-
tamine receptors responsible for allergic symptoms are
called H, Il'(fPtors. The other major histamine receptor, H" is
found in the gastric mucosa and is responsible for peptic ul-
cers (chapter 4()00).
Antihistamines an drugs that selectively block the actions
of histamine at the H, receptor, thus alleviating allergic
TABLE 38.' HI -Receptor Antagonists
Clllplfr 31 Drug<; for All<>rglc Rhlnltl. the Common Cold 575
symptoms. Because the term antihistamine is nonspecific
and does not indicate which of the two histamine receptors
are affected, H,-receptor antagonist is a more accurate
name. In clinical practice, as well as in this text, the two
terms are used interchangeably.
The most frequent therapeutic use of antihistamines is
for the treatment of allergies. These medications provide
symptomatic relief from the characteristic sneezing, runny
nose, and itching of the eyes, nose, and throat of allergic
rhinitis. Antihistamines are often combined with deconges-
tants and antitussives in OTC cold and sinus medicines.
Common OTC antihistamine combinations used to treat
allergies are listed in Table 38.2.Antihistamines are most ef-
fective when taken prophylactically to prevent allergic
symptoms; their effectiwness in reversing allergic symp-
toms is limited. Theireffectiveness may diminish with long-
term use.
In addition to producing their antihistamine etfects,
these drugs also cause typical anticholinergic effects. Anti-
cholinergic effects are responsible for certain beneficial ef-
fects of the antihistamines, such as drying of mucous
membranes, which results in less nasal congestion and
tearing.
A large number of H,-receptor antagonists are available
as medications. They all have the same basic mechanism of
action and are equally effective in treating allergic rhinitis
and other mild allergies. Adverse effects are similar but
"n"
Routeand Adult Dose (max dose v.tlere Indicated) Adverse EifKt5
FIR5T-GENERATION AGENTS
alflutillt (,l.sttlin)
bromphtriramillt othffi)
d"kIrp/Iffii"imi"lf ((blor-T linetoo, 01hffl)
(lavist)
qproheptadilll'
(Dri nran
dud"orphtriramillt (DmrIor, PoIidfi,
PoLiramilll')
diMnlrfdrilal! (Dramamile)
Q tip/lffih)'1hmillt (Bmodryl,OIhffi)
prometlwillt
triprolidilll' (Zymilt)
SECOND-GENERATION AGENTS
miizilt(qml)
(Oarilltxj
iexom!adilll' (ldltgra)
(X)'lin
Ioratatillt (OariIin)
oIopatadilll' (Patanalf)
Intranilil; 2 !pia)'! (It! IIOIIril bid
PO; 4-8 mg tid-"d (max: 40 Jll9/day)
PO; H mg tid-"d (max:24 Jll9/day)
PO; 1.34-2.68 mg bid (max:8.04 mg/day)
PO; 4-20 mg tid 01 "d (max: 0.5 m9Iday)
PO;6mg bid
PO; 2 mg Mry Hh (max: 12
PO; 50- 100 mg Mry 4-6 hr
PO; 25- 50 mg to four timrl daily (Jnax:lOO Jll9/day)
PO; 12.5- 25 mglda, (max: 100 Jll9/day)
PO; 2.S mg bid ortid (max: 10
PO; 5- 10 mglda, (max: 10 mgfday)
PO; 5 mglday (mad mglday)
PO; 60 mg bid or 100 mg
PO; 5 mg n tabltt or 2tmpocrnj
PO; 10 mglday
Intrallilil; 1 !pia)'! (It! IIOIIril bid
Dry moolh, IIetldlKiIt, dirzjrltlS,
II'rmlion, l/icttning of bIoodiioI ftCII'!illl!\.

Dry moolh, IIetldlKiIt, dilzirIm,
II'rmlion,rlJJi'f1
ParadOJ(ital hyprorosilil'ity
JI'!itjom,hyOOll'nSOO
5

,


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"


f.

S76 Un'" Tte ResplfOlo<y
TABLE 38.2 Selected OTC Antihistamine Combinations
Brand Name Antihistamine
Adiftd Coidand AI dIIorp/Iffiiamilr
dIIorphtni'amilr
8tnidryl AllergyfCold Glplets diphtrtlydl"DirM'
ChIorTrimeton dIIorp/Iffiiamilr
ChikRnl Cold and brompheniramiM
Sulbftd PE Sinusnd Alltrgy dIIorp/Iffii'Jmilr
Sulbftd PE Cold diphtrtlydl"DirM'
tJvi51 dtmaSliM
Triamiri( CoIdfAlItqf dIIorp/Iffii'amilr
TyIffioI dIIorp/Iffii'amilr
TyIffioI PM GtkapI diphtrtlydl"DirM'
differ in among various antihistamines. The
older, drugs the to cause sig-
nificant drowsiness, which can bea limiting adverse effect in
some patients. After a few doses, tolerance generally devel-
ops to this sedative action. The newer, second-generation
agents have less tendency to cause sedation. Alcohol and
other CNS depressants should be used with caution when
taking antihistamines, because their sedating effects may be
additive, even for the second-generation agents. Some pa-
DecongMlant Analgesic
p/IffiyIqtlriM
p/IffiyIqtlriM
p/IffiyIqtlriM

p/IffiyIqtlriM
p/IffiyIqtlriM
p/IffiyIqtlriM
p/IffiyIqtlriM
p/IffiyIqtlriM
tients exhibit CNS stimulation, which can cause insomnia,
nervousness, and tremors.
Anticholinergic adverse effects are also common in some
patients. These include excessive drying of mucous mem-
branes, which can lead to dry mouth,and urinary hesitancy,
an effect that is troublesome for patients with prostatic hy-
pertrophy. Some antihistamines produce morepronolUlced
anticholinergic effects than others. Diphenhydramine and
clemastine prod uce the greatest incidence of anticholinergic
..,. Prototype Drug I Diphenhydramine (Benadryl, others)
Therapeutic (lass: Drug to Ireat allergies P ha rma(ol 0 9 i ( (I ass: H I-re<:eptor antagon is!; ani ihistamin e
ACTtONS AND USES
Diphmhydramint is a H,-rmplor Jmagonisl whole primary
usr is 10 tft'<II milor s,mptorm of and Ihr (ommon (old wc:h as
ing. runny tNring of thr r)'I'I. is (ombined
with n Jnalgtsi<, dKongestam, or txpf(loranl in OK (Old and!kJ produru.
DiphmhydramiM isJkoadminislerro lopicallyto IR'<II ruhes,and IMIlV forms
milable for allergic: rmliofll. Othrr indiutiom for diphfOhy-
dramiM indude farkifllOn'l diINlr, motion inlOmnia.
ADMINISTRATION ALERTS
isan inC"N1e:i rilkof anaphy\.lcti[ lhock whrn Ihis drug is adminis
tmd parrmrwlly.
Whon .dministorirog IV, injro rolo of 25 mgfmin to tho .iskol
,hod.
1M, injKt drt"p into J largr mUlde 10 tislUl'
irritltion.
PR'gnallQ C
PHARMACOKINETICS

1-4 h

Duration:4- 7h
ADVERSE EFFECTS
H,"R'(eplor antlgonisn. 5lKh u diphrnh)'draminr GlUS!' Yg"
niflUnt dfOWlinesl, although Ihis ulually diminishe with Iong1emI US!'. O,:u
Iionall" par. dal:iul CNS stimulation and rnitability will he 1lIMMd. r<llher
than drowlinffi. Excitllion is moR' frequent in [hildrm than adfu. A mKholin
tl9ic: effKts 5lKh a\ dry mooth, tac:hprdia, and mild hypolmsion O(QJr in
IOmI' patirnu. Diphmh)'d ram iM may causr phollXffilitjyiry.
Contrai nd ications: H yperll'nlitivity 10 Ihr drug. prollalic: hyprnrophy, nJ rrow
Jnglr gf.Juo:oma, Jnd Gl obllruction JR' (onmindiuliofll of US!'. The drug
mould he ule:i uutiously in palirnu with asthmJ or
INTERACTIONS
Drug-Drug: u.. with CNSdopr=ll\tl """ ;><akohot or opioidI wi. """" in<JNSf<i
Ioed.!lioo. 0tIw orc mid ]llfllill"ationI may ioo&JIt antio:hoIiM"riI: Plftm.IMO
inhibitoo mayGIIMa h)1lf!1M1i"ll' aM.
Lab Test!: IlrIJlIhcUd br d&on!OOfd iIIlNst 4 day5 prior to lki n ifill;
O!hfrwi\.!, te\II may
Ik>rbaVFoo:l: filii')' [auII' OON5fd aOOdIoilll'rgK fll'KtI.
TrNtment Onrdo!l' may GlUSr fflhrr CNS drp=ion or mita
lion."Jhm is no IR'UmI'nl forOYelllo!l'.
Rmr III MyMnhIIJR for MIsJfIg Procell fixIIl !pf!(1/1( IIIIM auq.
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side effects, whereas the second-generation agents---lorata-
dine, desloratadine, and fexofenadine---produce the least.
Although most antihistamines are given orally, two are
availablt' by the intranasal routt'. Azelastint' (Aslt'lin) is ap-
proved for nonallt'rgic rhinitis and is as safe and efft'ctive as
the oral antihistamines. Although a first-gt'nt'ration agt'nt,
azelastine causes less drowsiness than others in its class be-
cause it is applit'd locally to the nasal mucosa, and limited
systt'mic absorption occurs. Olopatadine (Patanase) is a
second-generation antihistamine approved in 2008 for al-
lergic rhinitis.
In addition to allergic rhinitis, antihistamines have been
used to treat a number of other disorders. These include tht'
following:
Vertigo and motion sicknfSS: Nausea ft'sulting from
vertigo or motion sickness responds well to
antihistamines. These drugs act by suppressing the
vomiting center in tht' medulla and depressing neurons
of the vestibular apparatus of the ilUlt'r t'ar. To bt'
effective, they must be taken prior to the onset of
symptoms. Medizine (Antiwrt) and dimenhydrinate
(Dramamine) are two common antihistamines used for
this purpose. The pharmacotherapy of nausea is
discussed in chapter 4100 .
Parkinson's disease: Drugs with significant
anticholint'rgic actions are used to treat mild forms of
Parkinson's disease. They are also used to treat the
tremor and certain other adverse effects of conventional
antipsychotic drugs. Because diphenhydramine exhibits
greater anticholinergic action, it is sometimes used to
treat these conditions. The pharmacotherupyof
Parkinson's disease is discussed in chaptt'r 2000.
("",If,31 Drug>; fo, Allergic Rhlnltl' aJld the Common Cold 577
Insomnia: Many patients become drowsy after taking
first-gent'ration antihistamines. OTe sleep aids usually
includt' antihistamines such as diphenhydramint' and
doxylamine (Unisont Sleep Tabs). Aftt'r a few days,
patients will becomt' tolerant to tht' drowsiness
produced by thest' drugs: thus. they should bt' used for 2
weeks or less.
Urticaria and other !kin rruhes: Urticaria or hives is
oftt'n caused by the release of histamine; thus, the
condition responds wt'll to H,-rect'ptor antagonists.
Symptomatic treatment may include any of tht' first- or
second-generation agt'nts, either using oral drugs or
topical creams or lotions.
Intranasal (ortieosteroids
Corticosteroids, also known as glucocorticoids, may bt' ap-
plied directly to tht' nasal mucosa to prevt'nt symptoms of
allergic rhinitis. They havt' largely replaced antihistamines
as preft'rred drugs for tht' treatment of perennial allergic
rhinitis. These drugs are listed in Table 38.3.
38.4 Treating Allergic Rhinitis
with Intranasal Corticosteroids
The importance of the corticosteroids in treating severt' in
flammation was presented in chapter 3300. Although cor-
ticosteroids are very effective, their use as systemic tht'rapy is
limited by potentially st'rious adwrse effects. Intranasal cor-
ticosteroids, however, produce virtually no serious advt'rse
effects. Because of their effectiveness and safety, the in
tranasal corticosteroids art' often first-line drugs in the
treatment of allergic rhinitis. Some of the corticosteroids are
.... Prototype Drug I Flutlcasone (Flonase, Veramyst, others)
Therapeutic (lass: Drug for allergic rhinitis Pha rmacologic (lass: Intranasal (ortiC05leroid
ACTlONS AND USES
Fknkasont is typiul of tlMo intrarw..J1 mrtKostt roitis!Md to nut Jl-
Itr<jK rhinitis. Tlltr,Pl' UllUIIy begin I with two Ip,a}'S io N(h oostril, twiu daily.
.lOd to 001' ptrday.Flutiu!OOI' am to local iolbmm,-
tioo io tilt mal thUI mallluffiOl'lI.
ADMINISTRATION ALERTS
IOIlIlKl tht p,tM<m to ""wily follow tilt for 1M providtd by
tlMo manufa{\uftl" .

PHARMACOKINETICS
Onset:Unknown

Halflifdh
Duration: 11- 24 h
ADVERSE EFFECTS
AdYel"5t rlffi:u of fkni<a!OOI' i Swallowing large amounu tht
10, 1)"I\I1mic: (ortKolleroid ,dvmr tfftru. Halal irrimion
uris oc:rur in a !In.JlIrumoo of patitnts.
Contr aindi w ions: TIMo only (ontlainal(.Jtion to flutiu!OOI' i I prior
tivity to the drug. ronic:olleroich (ao mask lignl of ioftion. patitnts
with knowo bmtrial, fungal. 0' pmlitic: inn(1ions (rlptCialiyof tilt rts-
pi,atorytrad) lhould oot It iYr intraoal.ll (ortKoltrroids.
INTERACTIONS
D"'!l-Drug: ""-niOOl "'" or on inWII>UI dKongomnti.{J ..... thtrilkof
n.JI.Il ilrimion (I bl@tdng.lMwim ritOMifst.U:i dru9
plasma nutiG!loM
lib Testl:UoUlc!m
Herba VFood: 1M with Cilk'tion wi!llliurice. wIid1l11irf poifOtioft iIIf 01'
(0!Iic:0III'I00I.
l,m ment of OerdOlt: Tberr is 00 lptCifK 10, OY!'HIoIr.
III!ftr 10 M)M!!J1ngm (of Q M!flilJ,l PIoct1! fOOIIlpKlk 10 rIi'l
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578 U"IU n..lle\.plruorySystem
NURSING PROCESS FOCUS PATIENTS RECEIVING ANTIHISTAMINE THERAPY
Anes5ment
BI5t1ift t tiStnmut prior to administrMion:
UOOerstalld the tilt dNg his betn preaibed ill otder to for
thmpMK
Obuio history including piMM histofy of symptoms
Ind a\soonion to took, or frwironmmloili HpOWfI'S; nisting
ca!d'Mrmcula(, ft'Spiratofy, lItpatic,ltnal. or nMOIogic
PJOIt.ltK h)'ptftlOphy or diffi<ulty with urinition; pmtI1<t of r-r Of actM
inIKtiom; pregnancy or brea\t -lffiIing; or smoking. Obuin
dlUlj history, noting the t)'pe of aclvrlSe ItKlion or .nrrgy to
Iny mf<licaliorts.
H symptolll'l are of lIN for any ItCrnt ciwongH in dirt
so.I pi, cosmttia,lotions, r rIYironment, or rHtnt urptt ooning. polrticularly
in infants and young childrrn.
Obuin bmline vitll signs. All ECG rnaJ 1M! Ofdfled for p"itnts with.
history of CinflK concfitions.
"pPfOpMe findings (e.g.. (8(, hepatK reJljj bbs).
bltss.ment throughout .d.,lnmr .. ion:
desired rffts (e.g.,ciKrNsed nas.! (OrgHtion
ciKN!ased fre Waltring or itmill9l .
Conrinur prriodK moniforing of(BC,1nd l!Oai IS
IpProprW;te.
AslHll'it.Ji signl,tsprciilly pubr rltt ind mythm.
AsIHl!Of adwrw rffKti:diuilltll, dro.....mm, dry IIIOUIb, bklntd vision,
or headachr. any inuming confusion, mUl(lr
wuknHS, tidryuldia. palpitations, hypottMioft, SyMOpr,dysp1U,
pulmonary congestiorl, urinary retention,.nd sudden r,e pain or
uoorod lights.
Potential Nursing Oi_gnoses
IntftectM Aifw" (lrmnct
IntffectM BN!atlling P, UM!
CMturbfd SftpP.ntmtlNtedtoadversedlU!!fll'tcts)

OtfKifflt {drug
Risk fof In;..y, Risk for Falk to drug rlftctsl
PJ.nning: Puient Go.ls and Expected Outcomes

rffKts nalill (Ongmion and Aching).
Br frtr from,or minimal. aclmst
an undMtanding of the drug's IIIl', adwBt tfftcts.and r!I:FIirtd preuutions.
Dtmonstntt proprr seIf __ inistration of tilt med'otion (t.g..dosr, timing. when to' notify
Implementation
E II.rin 9 thtr, peutlc effects:
Cominllf iSStsSments described earlitr fof thtfapMK tfleets.
(lmprwtll'lrnt in srmptomsof alltlgy should bf9in .fttr t.lking tilt first
drm ,nd (ontinur to imprtJl't .TM htahh calt prv>'idtf should 1M! notified if
symptolll'l connnul' 10 incfNlt,tsp(cially l illYOlI'tml'flt
_ 1
For trtatmtnt O'f ItISOflollI.allergies, dlUlj tlltripy should be n.lled btIott
the beginning of a!W;i appearilllCtof symptoms.
(Btginning drug therapy bHort histamine irKrNse will
rt!UIt in grrattr tbmptutic tfftcts. drug IhrraP'l' afttr illttgy
symptoms'lI! It'lful doses IM!fort marked imp_t
of symptoms is oottd.)
Mlnhnlzing ,dftrse ffferts:
En SUIt patient safgy, in oIdtf adu Obstrn fOf dizzintss..
MonitOI imbWtion the tffts of the dlUlj Ire known. (DrowsiIltss or
dizmtsS from O'rtflonatK hypounsion may occur tht risk of
falls.Orowsillffi tmds to diminish om sf'l'tfal dosts..l
read! the p.uient to suwlement dlUlj therapywith llOop/llrrrlKo!ogK
mtiSum such a\ incrt.sed lkJid iIIuk! to Iiquefy . nc! assist to mobiflZt
rTJ.JCUS to reduct p;lOIUft to allr!gens wr-
.Idvise tilt pitient to uny. WIllet idrntifolion un:! or wur rnt<iul
idrmiflution jrw!ky ind iuting .ny signioo nt olIlrrgies or illi ph,ty,am.
TeICh tile p.uient to begin taking the drug before allrlg1 ItlSOO brgins Of
It possible otpptar,nceofsymptoms for tfftcts.
InstnKt tilt patitnt to Cililor assisulICt prior 10 grtting out of bed or
10 walk to iYOid drmng orO'thtr KliYitits rt<pJiring
ment.aI.1et1ntss or phy!K.l (OOfdioation until the effects of the d IUIj
.... ".
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(""'lfr 31 Drugs for AIlerglcRhlnltl, and I"" Common Cold 579
NURSING PROCESS FOCUS PATIENTS RECEIVING ANTIHISTAMINE THERAPY (Continued)
Implementation
Interventi ons and (Rati onales) Pati ent and Family Educati on
Continue to monitor ratt and rhythm fOr patitnn InstllK\ tht palitm to immtdiattly rt'port diuinffi, palpitations,or
with Histing urdiac EC(rt may bt ordmd ptriodiully for j)atitrru sync:opt.
with history ofdysrhythmias.(Histamint a rolt in cardiac conduction 0
Ttach tht j)atitnt, family, or cart'9ivrr how to monitor pulst and blood
and when bIockrd by antihimminr!;,1IIdY calII<' tttsrrr,thmias in patients
Pf1'S5Urt' " appropriatt. Ensure the r UI!' and functioning of any
with history of urdiac di5elI!'.)
home !,(!uiplMm obtaintd
Continue to monitor ptriodic: hej)atic and rualfunction in
0
InstllKt Iht patitm on the netd to rtrurn periodieally for lab woll
""timts on long t.rm anlihi>1Ominr u", or th",. with. pn:viou> history of
htpatie or renal impairmffil (Htpatie tOllicity is a pott ntial adYl'lW tffffi of
rrul function will inhibit drug HCIt'tion and
prolong rifNn.)
Monitor for pmistenl dry cough, ilKrt'asing cough 1!'I'I'rit)<,incINsing InstllKtthr patitm to promptly rt'port any change in tht or
congestion, or (A ntihillamifl!'l art' ustd with tx1rt'11lI' caution in frequtncy of cough. Any cough accomj)a nied by , Ihortnffi of brt nh,
j)atitnts with Histing rt'spirnory dMur, including COPD. Thidcmtd mucus incINsing (ongrstion, mtst pain shoukl lit rt'porttd immediatt ly.
is a pottntial adYl'lW drtH} tlFect.A change in the of the cough may 0
Encour<lgr the patitnt 10 incrNsr fluid intake to in liqJifying mUCDUI
indie"t incrt'asing allergic: mpons,", disNl!' plIXf"Is,or
I!'Cretions i nd to NIt dry mouth tfftm.
rtspiratory infrction and should bt rt'ported immrdialrly.)
MOOS for (NS tiferu including nervousfl!'lS, iMomnia,
0
Innlu(\ thr Piltirm, to report in<re.J!ingleth<lrgy,
hNdacht, 1rt'ft101""l, fatigue, or wt'aknes. RtpO/t 1fYert' or any disorientation, confusion, chaogrs in behavior or mood,agitation or
disoritnlalion orconlusion (e NS dtprrssant effKtS such as aggrffiion, skJrrrd speech,or mJia immtdi.ltti}o.
fatigue,or mild art common.Paraonic:a1 tnitemenl
InstllKt tht palitm to avoid or tliminatt akohol consumption whilton
ItKh as nmousnrll, or insomni.l may in
antihistamilltl.
chiklrt'ft.Akohoi consumption incrt'astI tht eNS dtprt'lsant rfleet> and
lhould bt avoidtd.)
If ustd for j)aUtnl safety on awakening.AI'Oid using Caution the patitnt about polliblt morning ordaytimr !leepines and 10
for mort thin 1 Wl'rks and consuk the health cart' Otr<M caution with activitil's requiring menial altrtfl!'lsor physical
proI'icIrr if insomnia continurs. (Morniog or daytimr dro'Mifl!'ls, a coordination until daytimt tffrcts of drug art' known.Do not kffp the
"han90\'ef" occur in IOI1lI' j)atitnts laking antihistamine for mrdiution al tilt btdside 10 ol'ffilosagr from ocQJrring if
ind imj)air oormal i citiYitirs.Patitms may btc:OI1ll' toltrim to additional doltS art' taken whtn Do nottakt the mtdieation
drowsinminducing tffrcts within 1 conQJlI\'Ittly with ikohol.
AsltIs for change"! in visual acuity, blurred vision, lassof ptriphtral fision, InstllKt patitm to rt'port any fiswl rnangrs or pain
sing rainbow halos around lighu,irutt f)'t pain,or iny ofthese
symptomsac:comj)anitd naul!'a and vomiting arod rt'port immrdiatd-,-.
imriocular prt'>5Urt' in paritms with narrow-anglt glaUComi
may occur with imihistamine.)
AsltIs for urinary rt'tention, in malts 0'lrl400rwith i history of
0
InstllKt patitm to immtdiattly rt'port inability to l'Oid,ind
prostatic Ityptrtroplt)<. (Antihistamine may causr urinary bladder pressurt' or pain.
0
Monitor for GI rffKtl.(NaUIN,
0
Tmh tht p;ltitnt to takt the mtdieation with food or milk. Report
(onstipation, or diarrlrra may ocrur and art treatrd symptomatically.) significant (t.C)., n<lusea with VOOIitiog,diarrlrra) to tht
health provider.
Monitor for anlichoiintrgic:fflaltd adYenr tffrcts including dry mouth,
0
Ttach tht j)atitnlto incrt'al!' lkJid intau orltKk on hard candy to reiiewo
Ihic:kened mlKUl, nasal drynffi, blurred vision,and ht adacht. (Mild mouth and rrspiralory Ifact drynes.E=:il!' caulion if bkJrred vision
antic:holinrlllic: tfftcn art' common and art' trt'i ted I)Imptomalieally. normal ictivities and report signirKilnl viswl disturbance is
Significant synt ptom s as listtd prtl'iously art' rt'pontd immrdiattiy.) listtd
Patint understanding or drug therapy:
UI!' opponunitits during administration of mrdic:ationsand during Thr patitm shoukl bI' able to staU the rt'ason for the dlllCj,ippropriate
'" ""''''''''''' 10 dim", Iht ,arinnat. for dnHJ rlMilPd th"'p"'ttir
<rhNlulilll]. whit .r!. ...... ..ti"I'<1S In nb< ....... fotand wh." rn
moll common tflKts, parametm for wlltn to ull thr rtportthem.
hNlth cart' ptoYider, a nd a ny fl!'(ffiary monitoriog or prt'(iUlions. (Using
lil1ll'during nursing urt' helps 10 oplimireand reinfolU' key Iraching

(Continued)
LibraryPirate
580 Unit, TheR"'PIrotorySY'!em
NURSING PROCESS FOCUS PATIENTS RECEIVING ANTIHISTAMINE THERAPY (Continued)
Implementlltion
Interventi ons li nd (Rlitionliles)
Patient selfil dministration of drug thuapy:
Whtn ildministmng tht mtdiution, instruct piltitm, or
megrm in tilt proper Sl'1fadministration of drug, t.g., take tht drug IItfoll'
allergySl'ilson or bebll' symptoms illl' Sl'Vtll'.(Proper administriltion will
inc:ll'ilSI' tilt eifedmnes of tilt drugJ
Pllti ent li nd Fli mil y Educllti on
piltitnl and or Ull'9iftr should lit il ble to discuss appropriatt
dosing il nd adminismtion fIffiIs.
Evaiulition of Outcome Criterill
Enwtt tilt eifedil'!'nes of drug thmp)' by confirming that patient 9'lils and tlptCted (]IJ\(OI"11fS hal'!' bet-n rutt
5ft Tab//> J8J flit /t)wNd/ dIN mrlqlXlitm
TABL[ 38.3 I Intrilnasill Corticosteroids
Drug
bfdmI!,thalOllf (BffilnaSl' NJ.Qml
p.l9I' 600kt tht Prototypt Drug
Route and Adult Dose (max dose where Indlcatl'Cl)
1 spray in IIOSIril bid-qid
Adverse
Tromimlrmi1l
snmifH},oro:t)'fll'l.!
""'"
budtsooidt IRhiloc:ort Aqu.i)
OOtIOOKR (Omnaris)
Intranalill;2 sprays in NCh noruil bid
Intranalill:2 spaysOlKe daly (max200 rrKglday)
Hyproortidsm (only ij lamt amoonu
a(CwDowrdl
flurisolidt (Nnalidt, Malarell sprays in NCh noruil bid;may ioowo! totid ij!Wdtd
Q ftUtilil1Olll' (RonaSl', VtrilmySl,OIhm) Intranalill; 1 spray in urn II05IriI aue (VrrilmySl) or twice (flonast)
momtlillOlll' INaIOOO:) !plaYs in NCh nostril/day
triamdooiOlM' aatooidt (NuiI(O/t AQ) Intranalill;2 sprays in u ch nostril daily
also administered by inhaler for the treatment of asthma
(chapter 3<)00).
\I/hcn spntycd onto the nasal mucoo", corticosteroids de
CreaSe the secretion of inflammatory mediators, reduce tis
sUe edema, and cause a mild vasoconstriction. They are
administered with a metered spray device that delivers a
consistent dose of drug per spray. All have equal effective
ness. Unlike with the sympathomimetics (Section 38.5),
benefits are not immediate; 2 to 3 weeks may be required to
achieve peak response. Because of this delayed effect, in
tranasal corticosteroids are most effective when taken in ad
vance of the allergen expooure.
\I/hen corticosteroids are administered correctly, their ac
tion is limited to the nasal passages. The most frequently reo
ported adwrse effect is an intense burning sensation in the
nose that occurs immediately after spraying. Excessive dry
ing of the nasal mucosa may occur, leading to epistaxis.
For patients who do not respond to intranasal cortico
steroids, intranasal cromolyn (NasaiCrom) is an alternative.
Because it inhibits the release of histamine from mast cells,
cromolyn is called a mast cell stabilizer. Most effective when
giwn prior to ailergen exposure, cromolyn has ft'W advent' ef
fects, and was recemly approved as an OTC drug for the treat-
ment of allergy and cold symptoms. Further discussion on
the mast cell stabilizers is presented in chapter 3<)00, because
asthma is a second indication for drugs in this class. Othcral
terno1lives to the intranasal corticosteroids in treating allergies
include montelukast (Singulair) and omalizumab (Xolair).
Decongestants
Decongestants are drugs that relieve nasal congestion. They
are administered by either the oral or intranasal routes and
are often combined with antihistamines in the pharma.
cotherapy of allergies or the common cold. Doses for the
nasal decongestants are listed in Table 38.4.
38.S Treating Nasal Congestion
with Decongestants
Most decongestants are sympathomimetics: agents that ac
tivate the sympo1lhetic nervous system. Sympathomimetics
with a1pha adrenergic activity are effective at relieving the
nasal congestion associated with the conunon cold or aller-
gic rhinitis when given by either the oral or intranasal route.
The intranasal preparations such as oxymetawline (Afrin,
LibraryPirate
'"",If,31 Drug< fo, Allergic Rhlnltls and the Common Cold 581
TABLE 38 41 Nasal Decongestants
On"
Route and Adult Dose (max dose where Indicated) AdwI'5l! Effect,
SYMPATHOMIMETICS
knlaMloJI (0.1,%);1- 3 !pIa)'5/rmuit oot more f'tqumtly min
JlWZing, 0Idr)nm, htodQcM
IIiphazolint: (lmiw:) urn nOllrii h PO: fIfrlI:lIIIW, in>OO1/1i4 hfadtxht, tty mourh
Q Ol}'meljzdirt (,11m 12 Inlrarwl (0.05%);1-3 ooSlnl bid forup 10 3- 5 days l1uiulasal; rtbor.n:I (on!lmion
Hto-S)TItphriot 11 HOII",othtrs)
Q: mitJlion Iiml9f1h,
[Amn InllaMloJI (0.1%); 1-3 dlllp5 or ijKi)"l Nm 34 h, diffi cUly in voiding, Yo! 5lKOOIuiction
Hto-S)TItphriot 4- 6 HIHI",OIhtrs)
.-
(Actifed, Sudaftd. PO;60 mg 4-611 (rnn:l40 fn9/day)
.. ,"'"
1f:uihydroldiot (Tyziw:) InllaMloJI; 14 drop! or !play! flDllril MIl 3 h
xyIomrtllOliot IOtrivin) InllaMloJI (0.1%); 1-1 nostri bid (mn:thrrt dwsIday)
ANTICHOLINERGIC
ipritropiJm Nilil ijKay;1 spray! in Nm flDllrillhrrtto fOIl" limrsJday upto 4 da)"l Tronlifnr nQSQ/ irrirooon, baniIg, WfZing. Of
CorrbiI'mt)
IIQIia ilKkatr ammon idl'!'1>I' rIIetts;l!!l!t!!l!!i!!9intkatts
others) art' availablt' ore as sprays or drops, and produce
an effective response within minutes.
Intranasal sympathomimetics produce few systemic ef-
fects because almost none of the drug is absorbed into the
circulation. The most serious, limiting side effect of the in
tranasal preparations is rebound (ongfstion, a condition charac-
terized by hypersecretion of mucus and worsening nasal
congestion once the drug effects wear off. This can lead to a
cycle of increased drug use as the condition worsens. Be-
cause of this rebound congestion, intranasal sympath-
omimetics should be used for no longer than 3 to 5 days.
Patients with aUergic rhinitis who develop to the
effects of decongestants should be gradually switched to in-
tranasal corticosteroids because they do not cause rebound
congestion.
When administered orally, sympathomimetics do not
produce rebound congestion. Their onset of action by this
route, however, is much slower than when administered in-
tranasally, and they are less effectiw at relieving severe con-
gestion. The possibility of systemic adverse effects is also
greater with the orul drugs. Potential adverse effects include
hypertension and CNS stimulation that may lead to insom-
nia and anxiety.
Prior to 2000, pseudoephedrine was the most conunon
decongestant included in oral OTC cold and allergy med-
icines. Pseudoephedrine, however, is the starting chemical
for the illegal synthesis of methamphetamine by drug traf
fickers. Although still OTC, pharmacists are required to
dynru, rough, htodtxht
lkiroao: !!!rnl!m. worstni!!!l oIlIirrow ... ggr
"""'"
monitor distribution of pseudoephedrine by kt'eping a log
of patient names and address, checking the photo identi-
fication of the buyer, and limiting the quantities of the
drug that are sold at one time. It should be noted that
these precautions are not being taken because pseu-
doephedrine itself is a dangerous drug, but to limit the
availability of the drug to illicit makers of methamphet-
amine. Manufacturers have reformulated their OTC cold
medicines to contain phenylephrine rather than pseu-
doephedrine. A drug prototype feature for phenylephrine
is included in chapter 1300.
B<'C3USe the sympathomimetic< relieve only con_
gestion, they are often combined with antihistamines to
control sneezing and tearing. It is interesting to note that
some OTC drugs having the same basic nante (Neo-
Synephrine,Afrin,andVicks) may contain different sympa-
thomimetics. For example, Neo-Synephrine decongestants
with 12-hour duration contain the drug oxymetawline;
Neo-Synephrine preparations that last 4 to 6 hours contain
phenylephrine.
One anticholinergic, ipratropium (Atrovent), is used as a
decongestant. Given by the intranasal route, ipratropium
has no serious adverse effects. Its actions are limited to de-
creasing rhinorrhea; it does not stop the sneezing, postnasal
drip, or itchy throat or eyes characteristic of allergic rhinitis
or the common cold. A more conunon indication for ipra-
tropium is in the pharmacotherapy of asthma, and a proto-
type feature for this drug may be found in chapter 3900.
LibraryPirate
"'" Prototype Drug I Oxymetazohne (Afrm, others)
Therapeutic Class: Nasal decongestant Pharmacologic Class: Sympathomimetic
ACTIONS AND USES
Ct.ymmzolint..ai .. tHalpha_.d""'"'9i< intt..<ympott..ti<
ThisQum arterioles in to (OMtrict, Ihus drying Iht
mlKOUS mffllbranes. Relief from n.ml (ongtStion CKwr; within miMtS ,lnd
last! for 10 or moft' is .dministert'd with a mererrd spray
devKe or by IW.iI drops.
LIl) is also available al drops. It QUIH moron-
miction of !'S5tk in the eye and is used to rednHI and proYidlo ft'li.t"
from drynHsand minor
ADMINISTRATION ALERTS
Walh hands (aft'full)' dtet" administration to anisocoria (blurTfd
mion intqWlity of PIlpil
Plf9naocy rnegory C
PHARMACOKINETICS
IAtset:S- l0min
Peak:Unknown
Unknown
Duration:6- 10h
H OME & COMMUNITY C ONSIDERATIONS
Dextromethorphan and Drug Abuse
Dutromt thorphan (DXM), a nonnmori( (ough luppft'mnt available ore
has ,1110 gained tht R'putation and popularity as a halludnogenit drug
that is . buSfd for lhe psy<hotropic effKts it plOYides.!t is known by namH
SlKh al "DXM:'DM: llobo: and -Vtl'let. ' DillooariYf ane-sthl'"lia tffKts,
wileR' the user e.per;'n(el Itotling ' out of body: .J R' similar to ket.mint
((h.pttr 19(0) and the illtgalwbstaoc:t PCP.These .t"fKU "peri-
en(ed b, USfB alter largtr-th.n-normal dOlf"S aR' taken and m. , 1m up
to 6 hOUB. EJu.-nR'nljth (ough IyrUpl with del:tromethorphan art the
most frequently .bused.
OlC rough meditations aft' wmly available and whffi taken in I!(om-
mtnded doses, ootromethorphan is a lalto and tife(tive rough suppmsant
The shook! be.Jwareof the potential for abuse ofOXM and shook! (oun-
sel patients to avoid t lfding tile R'o:ommt nded dose.Of ponirular (oo'm
'R' (oogh meditations (ontl ining OXM and antihistaminH or dKongl'stanll.
While ttkeom-lirge dos6 to the
of DXM, add itiorY lantihistamint or dto:ongtStant doses may signifiumly in-
(lNse IhI' risks ofdmromethorphan abuse. Nurses ploy a vital role in
ing p.tienn with wratt inforTlliltion about thl' dangen of .Jbusing
induding those aviilable Olt
COMMON COLD
The common cold is a viral infection of the upper respira-
tory tract that produces a characteristic array of annoying
symptoms. It is fortunate that the disorder is self-limiting,
because there is no cure or effective prevention for colds.
Therapies used to relieve symptoms include some of the
ADVERSE EFFECTS
Rebound is romlMll when o<ymtWoli .. is used In, Ion<jt, tNn 1
to 5 days. Minor stinging and dryness in IhI' IW.iI mlKosa beflperienced.
Systtmit .t"ftm arl' unlikely, unless. 1o"1l' amounl of the is
!Wiliowfd.
Contraindimions: Pat;'nts with Ihyroid disorder;, hypentnsion, or
he.n disNst should 1M sympathomimttit5 only 00 the dirl'dion of their
heakh carl' pw;idtr.
INTERACTIONS
I)ug-l)ug: tIo diiYIly imporunt interaaions 0(01; bKaust ibsorption of
QI)'IMaldill' illinitfd.
Lab Tem: lktoown
IlerballFoo:l: IJSI' with caution with herbII <II St. won tIwt
ilavr propI'I1itI: of mono;ull .... OxWIf inhlJitor;.
Treatmt nt ofDYtrdose: Thtrl' is no 5ptdfK trl'iltmtnt lor O'ItrdoSl'.
RM IIIMylUIlrrgXltlN Mn/n9l'rrx:mFoollsprdtt III fMltriq.
AVOIDING MEDICATION ERRORS
A 42-)'I'iIr-<l1d woman is admitted to the mediullIoor for obstrntion <l iter
sufft ring \e'lffilfrmured ribs and SKOndal)' to SI'YM' (oughing
from .rutt bronc:h itis. knzonllate (Tffialon PMts) I 00 mg tid is ordered. Tht
brings in tht meditition and the p.tient sta1e-s 1 don'llhink I (an take
th.n.My(oughing is so bad,l don't Ihink I un swallow it."Tht rlJrn pundurl'"l
IhI' ptrlt with a sterile ntedlt to triable tht pot;'m to swallow thl' liquid in-
sm. Tht patiem uperienlf1signifiunt respiratory distrHl after
IhI' med K.i t ion a nd thl' rlJllt (alk forthe MltrgelKy reponse tea m. What tr-
lOr did the nurit make and what shook! NVt betn difleremly?

same drugs classes used for allergic rhinitis, including anti-
histamines and decongestants. A few additional drugs, such
as those that suppress cough and loosen bronchial secre-
tions, are used for symptomatic treatment.
Antitussives
Antitussives are drugs used to dampen the cough reflex.
They are of value in treating coughs due to allergies or the
common -cold.
38.6 Pharmacotherapy
with Antitussives
Cough is a natural reflex mechanism that serves to forcibly
remove excess secretions and foreign material from the res-
piratory system. In diseases such as emphysema and bron-
LibraryPirate
chitis, or when liquids have been aspiruted into the bronchi,
it is not desirable to suppress the normal cough rellex. Dry,
hacking, nonproductive cough, however, can be irritating to
the membranes of the throat and can deprive a patient of
much-needed rest. It is these types of conditions in which
therapy with medications that control cough, known as
antitussiwl, may be warrunted. Antitussives are classified as
opioid or nonopioid and are listed in Table 38.5.
Opioids, the most effective antitussives, act by raising the
cough threshold in the eNS. Codeine and hydrocodone are
the most frequently used opioid antitussives. Doses needed
TABLE 38 S! Selected Antitussives and Expectorants
(""'1f.31 Drug' for Allergic Rhlnltl. and the Common Cold 583
to suppress the cough reflex are very low; thus, there is min-
imal potential for dependence. Most opioid cough mhtures
are classified as Schedule III, IV, orV drugs, and are reserved
for more serious cough conditions. Though not conunon,
overdose from opioid cough remedies may cause significant
respirutory depression. Care must be taken when using these
medications in patients with asthma, because bronchooon-
striction may occur. Opioids may be combined with other
agents such as antihistamines, decongestants, and nonopi-
oid antitussives in the therapy of severe cold or flu symp-
toms. Some of these combinations are listed in Table 38.6.
On"
Route and Adult Dose [max dose where Indicated) Adverse effectl
ANTTTUSSIVES: OPIOIDS
rodtilM'
I1ydrocodont combi ntd wilh
(lIyrocIin, otlltrs)
ANTITUSSIVES: NONOPIOIDS

Q dtllltmttholphan [Dtbym,

EXPEC10RANT
guaifmtsjn (MlKilM'l,

MUCOLYTIC

MlKomyst)
po; 10-20 mg h pm (max: 120 mg/24 h)
PO; llablu or > mL h 011 ntl'lItd [max:30 mUday or 6
ubltu/di1)
PO; 100 mg tid pm (max:600 mg/day)
po; 10- 20 mg 4 h or 10 m9 h (max: 110 mg/da,)
PO; 200-400 mg f'/!f14 h (max: 2.4 glday)
rflNSe PO;600-1,200 mg Mry 12 h (mB: 2,400 mglday)
MOl; Inhalation: 1- 10 mL of 20% solution Mry 4-6 h Of 2- 10 mL of
10% 101100 Mry h
KmiIi/ii romtipDrkII. coofusion, dilmrn,.
""''''"
Stizuft\:,!!aOO,dia orr
!iepmlioo Wtre IOmoolroce
Pa(jdoxi(jl rujlatOO trl'mor; cuOOprja jQlOmnia
/leQdllCM, Glupm
(l>IS depression. paradoxiYl mitalion, rtspimort
'"""'"
I
l"JrowIillffi, /leQdllCM, Glupm

I
Un!llt=M oOOr, fIOl!5tQ
SI"WI' oaus!,F()d )'limning brpncbo'jNl/D
TABLE 38.6 ! Selected Opioid Combination Drugs for Severe Cold Symptoms
Trade Name Oplold Nonoplold Active Ingredients
Ambtn)"l Cou91 Syrup codrillt bromodip/lffihydramillt
S)TI4l codrillt ulciLm iodm
CodamilitSyrup
h,.._

Codioo, 011 Syrup
h,.._
guanffirlin
Codimal DH
h,.._

Hycodan
h,.._
homauopilM'
HycomiM Compoood
h,.._

HycoillSS bptctOfanl
h,.._
guanffirlin
HovahislilM' 011 codrillt

"".
_ ...
A-C guanffirlin
S)TI4l
h,.._

TUllionn
h_
cbiorp/lffii,amilM'
LibraryPirate
584 UnU The R"'I'I tOfY Syst'-""
The most frequently used nonopioid antitussive is dex-
tromethorphan, which is available in arc cold and fiu
medications. Dextromethorphan is chemically similar to
the opioids, and also acts on the eNS to raise the cough
threshold. Though it does not have the same level of abuse
potential as the opioids, in large amounts dextromethor-
phan symptoms of abuse include slurred speech, dizziness,
drowsiness, euphoria, and lack of motor coordination.
Benwnatate (Tessalon) is a nonopioid antitussive that acts
by a different mechanism. ChemicaUy related to the local
anesthetic tetracaine (Pontocaine), benzonatate suppresses
the cough refie)! by anesthetizing stretch receptors in the
lungs. If chewed, the drug can cause the side effect of numb-
ing the mouth and pharynx. Adverse effects are uncommon,
but may include sedation, nausea, headache, and dizziness.
COMPLEMENTARY AND A LTERNATIVE T HERAPIES
Horehound for Rllspiratory Disorders
1m bttn ultd uan YfKf theafKitnt fwptilnsand
wal popularwithAmMran IOOilns.ln toaid ina num-
ber of rtSpir,I\Qry dilonlen including asthma, brondlim, whooping cough. and
infections IlKh as tub!'KUlosis. HOIll!"lpi"tory um inciudt bowfl disonle-r;,
jiluOOict, ilnd wouOO htaliog.
Ani'Il' ingreditntl are found thftll.lghout the fIowtring plant
chit! conrututnt is a bitter IUbltllI(t calltd morrubirm thilt ItimulatHlt-
crelions. Formulations indudt tta, drifd or fresh ieilftS, and liquid mliKtI.
hu an txptCtorant action whtn utatill9 midi a nd isi 110 avililable
as rough drops. k is daimtd to norm, l !t{l!"Iions to iht lung and othtr
organs.
Expectorants and Mucolyti(l
Several drugs are available to control excess mucus produc-
tion. Expectorants increase bronchial secretions, and mu-
colytics help loosen thick bronchial secretions. These agents
are listed in Table 38.5.
38.7 Pharmacotherapy with
Expectorants and Mucolytics
Expl!Ctorants are drugs that reduce the thickness or viscosity of
"",rel;on., Ihu . incr .. a . ing mllc". flow Ihal ClIn
then be removed more easily by coughing. The most effec-
tive OTC expectorant is guaifenesin (Mucinex, Robitussin,
The Quntion: Are medications in trMing children with chronic
cough?
The S tudr. Rtll'aKiIeB eumi!lfd the tlisting datab.Jm fur tvidenc:f t!wt
anlitussim, ilntihistamines, or other mtdic.ition 1 could redtn
oonsptciflC cough in ptdiltric poalimls undtr 15. The ltudy fouOO no
evidmU' for using medications fur the symptomatic relitl of rough in th is
populition. Itrffied th,t if mtdic.uionlare lJII'd. the health
care provider should follow up ,00 stop tht mtdic.itions ifthfl!" is 00
tift<! 011 the rough within a designattd timt framt.
Nursing Implk"ions: MurlfS should INch piltitntl toobtain tht ,d'/icf of
their pediatrician btfure lreating tht ir children with orc cold ilOO fkJ
drugs for nOlllptCiflC rough >ymptoml.
5otm:l1II1111j. All &GI:mII W.1l
(h& 1l'J(1
.... Prototype Drug I Dextromethorphan (De/sym, Rob/tussln, others)
Therapeutic (lass: Cough suppressant Pharmacologic (lass: Drug for increasing cough threshold
ACTIONS AND USES
DtlIlOIIIfIhorphan isa oooopioiddrug that is a complnmt in many orc 1I'YI'ft'
coldand Au pl!"p.afationl.lt ismil,ble in a largt fa rit\1olformulations, inWd-
ing tablets,liquid-filltd ca pluies, lounges, ilOO liquids. k !ws , rapid onll'! of oJ(-
lion,usuallywithin 15 to 30 minuttl.likr codtint, it am in mtdulla,lhough
it licks tht anaigfsic and tuphoric tiffm 01 t!lf opioids ind doH oot produ<t
dtptndtnct. Patitnts whOII' cough is oot rtlie\'fd by dutromtthorp!wn ilfter
therapy lhould II'f their hr.llth providtr.
ADMINISTRATION ALERTS
Awid pulmonal)' initants, IIKh as vnoking or other Iulllt"l,btcaUll' thfst
agents miy cit<realt drug
Pregnancy rnegory C
PHARMACOKINETICS

f'eak:Unknown
Unknown

ADVERSE EFFECTS
At dose, aderst tiftds rut to dextlOlllflhorphan rare. Diui-
IM'II, drowsilM'ls, ilnd GI Upltl occur in !OIIle In iibull' lituations, the
drug can caUll' CNS toxicity with a Mde variHy including IUlTI'd
IptfCh, ataua, hyptrexdtlbility, rtIpiratoty dtprellion, lI'izures, {lima,
and toxic psydmis.
Contraindica\ions: Dmromtthorp!wn is cOlltr,iOOiUltd in lreillmtm 01
chroniccoughdUl' in althma, IIIIOking,
indernph)"ll'llla.Suppl!"lling reIIex is 001 in thf2patitntl.
INTERACTIONS
l)ug-l)ug: IlnMj inlfliCliJnl with dutrOlll@ihorphaniKkIde!nitation,
ir,'polfnsioo, and Ir,"pp)m:ia whi>n UIfd C(OOlfflltly with MAO i"lhibitori.lIst
with aImhot, opioids, or other 015 dfpreSMlts may r!!Ut in IfIIalion.
Lab Tets: lklkoown
Ik>rbaVFoo:l: Grip!fniI;:ie! can liill> SfI\Itn iefIs of d!J:uomKhorpllan ind <aII1f
1OJIidty.
Trfatment Thert is no lptCifK lreUmtnt loroverdoll'.
IIt/i>r 111 MyMnlngRfot MnJrrgI'rf'55 FoonlpKl/t IrIIM <hg.
LibraryPirate
others). Like dextromethorphan, guaifenesin produces few
adverse effects and is a common ingredient in many OTe
multisymptom cold and flu preparations. It is most effect ive
in treating dry, nonproductive cough, but may also be of
benefit for patients with productive cough. Nonprescription
cough and cold products (including those containing guaifen-
esin) should not be used in ,hildren under 4 years of age.
Acetykysteine (Mucomyst) is one of the few drugs avail-
able to directly loosen thick, viscous bronchial secretions.
Drugs of this type, which are caUed mu(olytics, break down
the chemical structure of mucus molecules. The mucus be-
comes thinner, and can be removed more easily by cough-
ing. Acetylcysteine is delivered by the inhalation route and is
(""'lfr 31 Drug<; for Allergic Rhinitis , lid lhe Common Cold 585
not available OTC. It is used in patients who have cystic fi-
brosis, chronic bronchitis, or other diseases that produce
large amounts of thick bronchial secretions. Mucomyst can
trigger brochospasm and has an offensive odor resembling
rotten eggs. A second mucolytic, dornase alfa (Pulmozyme),
is approved for maintenance therapy in the management of
thick bronchial secretions. Dornase alfa breaks down DNA
molecules in the mucus, causing it to become less viscous.
Acetykysteine (Acetadote) is also administered by the
oral or IV route to patients who have received an overdose
of acetaminophen. Its use in the pharmacotherapy of aceta-
minophen toxicity is presented in chapter 3JOO.
NURSING PROCESS FOCUS PATIENTS RECEIVING SYMPTOMATIC COLD RELlEF: ANTITUSSIVE, NASAL
DECONGESTANT, AND EXPECTORANT THERAPY
Assessment
Baselinr assrssmtnt priorto administration:
Undtrnand thr INson dlll9M presc:ribtd in orlltr to mesior
tlltrapwtic:
Obtain a (omplttt ill(klding previous histOf)' i nd of
mdionl(ular,mpiratOf)', rmal diseall';
pregnaocy or brea II-!<Iing; al(ohol lIII'; or smoking.
Obtain a drug history, ill(luding al!tlllie,wITI'm pll'I<Tiption and OK
htrbal prej)arnions,ulirill!',nic:otill!',and akohol lIII'.Bt altn to p,miblt
drug imfractions.
Obtain b.1l1'1inn ital signs.
['/<Iluateapprop.utt laboratory findill9l (e.g.,CBC,hej)abr: and rt llillabs).
AutlSmrnt throughout ildministration:
ASlI'Ssior dtlired Ihtripwtic: effeo:n (r .g., (0119 h, in(lNsed
in murus,(!tarer na\ill j)alSagtl).
AslI'Ss vitalligns, rspeo:iall)' pulll' IlIte and rhythm in j)atitnn with rxisting
urdiat dise.N.
ASlI'Ssior t ffls: dill.iness, blurrro vision, hNlbc:ht,
and t pistaxis. Rt porl ilny increasing tath)'lardia,
j)alpititionl, I)'1I(0pt, dyspll!' i , pul mona ry (ongestion, or (onrusion.
Potential Nursing Diagnoses
Airway (!taralKf
Inclfffiivt Bre<llhing Panem
Disturbed Slet>p i'anfm to advfl"ll' drug tfflom)
DefKitnt Knowltdge (drug therapy)
Risk lor Injury to advfl"ll' drug tfflom)
Planning: Patient Goal. and Expected Outcome.
Tht will:
uptritrKt therapwtic: tfflS (t.g.,de<reiSfd nasal (ongetion and drainage, ilKreiltd NSt in oplorating m!KUS, thinll!'r lI'm'tions).
from,or adVfl"ll' tffKII.
Vfrbalizt an undtmanding olthtdrug's UII', advel"ll' tffrru. and reqJirro precautions.
Demonmatf oilhe meditation (f.g.,doII', timing, wht n to notif)' proI'idtr).
Implementation
Interventi ons and (Rational es)
Ensuring thtrilptutic riftds:
ContinU!' iIIltllmMII as dtscribM t arliu lor the rapwtic: tffls.Kough is
diminished, le(rttions are ihinll!'r and rail' is ill(reastd, llisal
j)aSsaqts are brr<llh sounds are dNr.lmproftment in othtfsigns
and rommon rold should begin aitfr tiking the first doll'.
health Wt plOl'idtr should br notifitd symptoms
respiratOf)' worstns or if ft-m is prestmJ
Plltient and Family Education
Tea(h tilt patient to wppltmtnt drug therapy with nonphamumlogic:
mmor6!lKh as ill(reastd Iklid intakt 10 liqJtfy and aslist to mobilizt
murusand to moisten tilt respiratory IToK!.
Instruct tht to(ontaa tht htahh care providtr symptoms WOIItn
or iffev!>r is prtll'nt or ilKrealing.
(Continued!
LibraryPirate
NURSING PROCESS FOCUS PATIENTS RECEIVING SYMPTOMATIC COLD RELlEF: ANTITUSSIVE, NASAL
DECONGESTANT, AND EXPEOORANT THERAPY (COll tlnue.:1)
Implementation
Interventions a nd (Rationales) Pati ent and Fllmily Educa tion
Minilllwng illiftne rffb:
[nSUlt patitnt fill older JduIts.Obsfflt lor diainm. iIIllnKt the palitnt t.Hi1i for fililtance prior to getting out ofbed O!'
(Oltllninen or diz.zinm l1li)' Olwr; inu,,;ning mk of lab. in older wall aIone"nd to mlid drioring Of ,ctM\irs
._,
melltal or eooIinnion until the efFects of thf dlll9 11ft
.... ".
Cominut 10 moniflll vitil signs,tspiilly pulse r.le MId rhythm for P'litnlS 1n11nK1 the pilitntlo immtdii ttly !!pOll d iaiMlI, palpit.tions, or
taking MtongrsuMS. incbfing rwwl dKOngetlnlS.
""'.,.
miY C.IM OO)'C.olnii and drsrhythmiil in patitnts with
Tech lilt f.mily,1II aregim howlO moNtO!' p.l1st.nd blood
of c diINSofJ
,ppropNle. E_ the proper 1M ard funclioning of, ny
borne equipmtfll obtiined.
Monitorfor pminul d!y(ough. cough SoMrity,ilKlNsing InllnKt the patitntlD rrpon ptOIIIptIy anr (hinge in tilt or
congeslion,1II cIysjlnu. {Some of thtst drugs.r.! Ultd with QUlion or are cougitAff'/ cough by shonnessofbr.!illh,
contraindic.ted in patitnts with emting incUling COPD. inmuill!llDfl9nliorl, det piin lllouk1 be immrdi.!tly.
.&. in lilt !ofYeriry of the (DI,IIjh m.ly indiultwonflling diseillt
Encouril9f tile pilient to ill(rtHe fluid intlb 10 illlist in liquifying mucous
PfO(tlSlII iI mot! Itrious mpiralJ' should be teported
sretiolll,nd to moislen tilt upper mpiratory IRCt
immeciiltelyJ
k;sm tile colDr ,nd comiltmcr of anr upedDfJttd spuIIIm. InII!U<l the patitnt 10 anr sigmnt cilangto in the
thicknesl, IItmoptyRs, or of sputum IIIiY indicatf i Itrious mmisttrKy,lH quantiry of flputOrutd mucus to tilt hulthQte prowidrr.
inftion and Wluld be immedwttl,oJ
Monitorfor GI tfFts. the pitielll: to like or Qpsules with Teil(h lilt patitnt 10 tale lilt mediC<1tiott with .dditionailluicl or food.
, fulgLm ofwatrr.fTaking wdrucj with additional ftuichor food may anJsigniOOnt GI S)'!IIptoml I\aUSU with wrMing, diilrrhu)
dKltiIt GI adenttflts.) to tht hNlth carf p!OVider.
the pititnt deu now before lISWIg nilliliprilf$ ilnd 10 tilt patitnllO deilr fW\iIl pill'ges. then adm"iswthe
waijl S mirotes befolt using iI stCond spray if OIderfd.1f rwsal dKongtltlnl sprIJ . .&.fter a w..iling ptriad of S 10 10 mirlllttS, UIt
cortKQ!;lrroich or mast cfilu bilizm It also ordrrrd, IIIf , MtOll9fltant idditionallpiay if ordtred or 10 low with addition,l nasal sprays 'I
nalil SptI)' fin(, Iollowed in 5 10 10 minUTes by Ihtgl.m:orticoid. 5jli1 out O!dtttd. An, tII.t drains into the mouth should be I9f: cut lind not
, ny!'X(!'Slliquiddrug that m, y dfJin into lhf rroUTiL (Ourill!llfll' n'lIl sw,11owed.
pillil9fl befoft the fWlil and the MI of\Wo
lhe paOentlO limit IMof dKOngeslinl rwwllpr. )'I to ) 10 5 dm.
10 IXIfIItricllocalwlltinnd 11IUl0li win,lIow tilt If"!' 10
unltllotbefwistonlered by 1M provicler,to , widtebound
teach higbtr into pilligfS.UsingMtongrslMlt spray brloltother
win optf1 rwlillllUCOU,iIIowing lilt other drug to r.!iCh molt W
m(J(QII.SwailowVJg additiorwl dtulj mar risk ofsystrmil:
efft<tlj
EnOltDge tile Ult of dtulj preparations whfn pMoIiblt. tilt patitnllO COII$ideHymptoms wilen sffiting OK (Ijld temrdies
(Multisyslem mmulilions inQ'ti5t the mk of .dftrlt tffects . .&.dditional .nd choose jXtpir.tions bastd 011 runt. symptoms.
drugs not in mulWst PrepaOOolll shoold bf noidtd.)
InIInJU the patitnt that multirst cold tmlt<i'lHcontaining
rrusl bf ulzfl in prtKriIIfd doses tuwid aauminophrn
O'ftI'dose.rd
Patient ulderstanding of thenP'1:
1kt opportunities during ,dministration of rnedicatiom and during TlIf patitntsllould be ilblt to stall' the ItlllOn for the druq..pproprialf
illltllllll'ntI co diirusl the miorwlt for drug thfr.lPY, deRd thtr.!peutK do!.r a rd sdltduling, and wllilt adl<mf riffcll to obstM' lor and when to
OOKorrJe, most (Cfl'IIIIOfI ac!Yrrw pifimt tfn for when to ulltht
hfa Ith QIt prow and ,ny nrcesSit} moniloring or pR'Colutionl.. (Using
time ckrring nuMlg Ute IItIpI to leinmf Izy INCh inIj
, teasj
LibraryPirate
C"",lfr 31 Drug< for Allergic Rhinitis and the Common Cold 587
NURSING PROCESS FOCUS PATIENTS RECEIVING SYMPTOMATIC COLD RELlEF:ANTITUSSIVE, NASAL
DECONGESTANT, AND EXPECTORANT THERAPY (eontInUffl)
Implementation
Interventions and (Rationales)
Patint selfadministntion of drug therilPY:
mtdiulion, iostOKt the puirm.
in lhe proper oltht drug. e.g., take thedrug btIore
alle19Y IUlon or before Iymptoms art' !e"'re. (Proper adminiltration will
the tffeo:ti'leoeu of the drug.)
Patient and Family Education
The !)atitnt and fam iIy art' i ble to discuss appropriale dosing
and administralion ntfds. induding:
u,ugir supprtS.S<Jllfl:Cough syrups Ihould be IwallaMd withoot wuer
i nd allowflf to (OU the throat for soothing foilaWl'd by
ilKll'iIStd fluid intake 30 10 60 minutes laltr.
&ptcraran/!::S)TUps should be tal!rn with a IuligliSs of liquid and
ilKrt'aIfd fluid intake Ihroughout tht clay 10 mist in thinning mucul for
Nit of tlpeuoration.
Nasal NiSal pdSsagI'S should re(leared t, blowing.
follaMd by the OiIal'pray.
Evaluation of Outcome Criteria
Evaluate the tfrectil'l'lltsl ofdrug therapy by (onfinning that !)atitm goaisand H pKle<t oU\(omtS h",'f met 1="Planning").
5tf T6Ne: 3"-3, 38.4, 3H , .J.!.6 f,.. a liM of dfl!lJI re which rIIoIllJIIsing aailJllupply.
KEY CONCEPTS
The numbered key concepts provide a succinct summary of the important points from the corresponding numbered section
within the chapter. If any of these points are not clear, refer to the numbered section within the chapter for review.
38. 1 The upper respiratory tract humidifies and cleans incom
ing air. The nasal mucosa is richly supplied with vascular
ti5sue and i5 the lim line of immunologic defense.
38.2 Allergic rhinitis is a disorder characterized by sneezing,
watery eyes,and nasal congestion. Pharmacotherapy is tar
geted at preVl'ming the disorder, or relieving its symptoms.
38.3 Antihistamines, or H, receptor anmgonists, can provide
relief from the symptoms of allergic rhinitis. Major side
effects include drowsiness and anticholinergic effects such
as dry mouth. Newer drugs in this class are nonsedating.
38.4 Intranasal corticosteroids have become drugs of choice in
treating allergic rhinitis due to their high efficacy and wide
margin of safety. For maximum effectiveness, they must
be administered 2 to 3 weeks prior to allergen exposure.
38.5 The most commonly used decongestants are oral and in
tranasal sympathomimetics that alleviate the nasal con
gestion asso,iatoo with allergic rhinitis and the common
cold. Intmnasal drugs are more but should be
used for only 3 to 5 days due to rebound congestion.
38.6 Antitussives are effective at relieving cough due to the
common cold. Opioids are used for severe cough. Nono
pioids such as dextromethorphan are used for mild or
mooerate cough.
38.7 Expectorant s promote mucus secretion, IlliIking it thin
ner and easier to remove by coughing. Mucolytics directly
break down mucus molecules.
LibraryPirate
588 Un'" Thl'R"'!'I tOfySystem
NCLEX-RNO REVIEW QUESTIONS
D The patient has been prescribed o)(ymetazoHne (Afrin).
The nurse understands that:
I. the serious side effect is ft.Wund collgt'Slion.
2. theaver;lgeusel.sfor IOdays.
3. thl.sdrug should not be used In conjunction with
antihistamines.
4. this isan OTC drug and maybe used as needed for
congestion.
o A patient Is prescribed an corticosteroid for al-
rhinitis. The nurse's would (Selel:l
all that apply. )
l. there no known effects.
2. tMspray Is a consls1ent dose.
J. it could take 2 to 4 weeks before ImptoVl'ment in
symptoms is noticed.
4. it iscontraindic:t1ed to usesaline Ilasal sprays with this
medicine.
5. the medication can be used any time symptoms
increase.
D A patient's history includes taking a first-generation H,-
re.;eptor Considering this history, the nurse
assesses for which of the following findings!
1. A history of heart disease
2. Anyrecent weight g.1in
3. A history of respiratory illnes.o;.es
4. A hlSioryofpeptic ulcer
CRITICAL THINKING QUESTIONS
1. A 74-year-old male Informs the nurse that he I.s
taking diphendydramille {Benadryll to reduce seasonal al-
lergy symptoms. This patient has a bistory of an enlarged
prostate and mild glaucoma (controlled by medication).
Whal Is the nurse's response!
2. A 65-year-old has bronchitis and has been cough-
ing for several days. Of the two medications,
denromethorphan and codeine, which is the drug of
choice for this patient! Why!
3. A67 -year-old patient has allergic rhinitis and always carries
a handkerchiefin his pocket because he has nasal discharge
nearly every day. Sometimes his nose is stuffy and dry. The
health care provider prescribes fluticasone (Flonase). He is
to take one spray intranasally at bedtime. The patient starts
o v.lben teaching patients how to self-administer intranasal
corticosteroids, which of the following must be included?
(5ele(;t all that apply.)
1. Prime device prior to Inltl31 we.
2. Clear nose before administration.
3. Clear nose after administration.
4. SWallow that drains into the mouth.
5. Spit 0111 anyexces5 thM drolns Into tbe mouth.
D Prior to administration of antlbistamines. the nurse u-
sesses for.
I . prostatic hypertrophy.
2. Itching.
3. dryskin.
4. increased restlessness.
o Which of the following is the hfl advice that the nurse
can give a patient with viral rhinitis who intends to pur_
chase an OTC comblnallon cold remedy!
1. Dosages in these remedies provide precise dosing for
each symptom tlJ.1t you areexperien<:ing.
2. Theseagents are best used in conjun<:tion with an
antiblotl<:.
3. II Is safer to use a lingle-agent preparntlon If you are
only experiencing one symptont
4. Since these agents are awilable over the counter, it is safe
to use any of them as long as needed.
to lake flutlcasone and a week later call s the provider's of-
fice and talks to the nurse. He says, "This Flonase is not
helping me."What is the nurse's best response!
St:e Appendix D for answers and rtltionll/u for 1111 activilies.
EXPLORE
is yoor aM SlOp fOf onHne review matflfWS.,d
resoo fWS. I'f!lllille b succuss Mth additional practicy
qUflSliDns, Interacttle assiQlVllCn13 and actl\iltles, 101m tln<.s . mhmtims
and .ideos. and moIyl
t::OIle from me Iront of yoor OOOk at
www.myn..w.gkilcam.
LibraryPirate
DRUGS AT A GLANCE
BRONCHODILATORS fI1IJ' 592
Beta-Adrene-gkAgonlsts J1OIF591
Q /'SI'rn'mI} J1OIJ' 59S
Antlchollnwglcs plllJt594
o jprarropjum (ombMnl)
"",,,
Methylxanthlnes jllJlJt595
ANTI -INFLAMMATORY AGENTS ptJIJt595
Cortkosterolds 1"l1'595
Q b/><:lomnha.otIf' AQ OIar)

l eukotrlene Modifiers fIIXF 599
Mast Cell Stabilizers jlIJIJUi XJ
o zafirlukast (Accolate) fI1IJ'6IJ1
KEYTERMS
ar, 1
il!thma fllXY 591
bronmospivn jIIJIJt 591
duonic bronchitis J'I'Il' 6(J1
chronic obnlll(\iv. pul lllDnar"/ dis"lf (COPD J
",,@
Drugs for Asthma and Other
Pulmonary Disorders
LEARNING OUTCOMES
Afrer reading this chapter, the sNdent should be able /0:
1. Identity anatomical structures asKICiated with the lower respiratory
uact and t heir functions.
2. Explain how the autonomic nervous system regulates airflow in the
lower respiratory tract,and how t his process can be modified with drugs.
3. Comparelhe advantages and di5advantages of using the inhalation
route of administration for pulmonary drugs.
4. Describe the types of devices used to deliver aerosol therapies via the
inhalation route.
5. Compare and contrast the pharmacotherapy of acute and chronic
asthma.
6. Describe the nurse's role in the pharmacologic treatment of lower
Il'spiratory tract disorders.
7. For each of the classes lined in Drugsat a Glance, know representative
drugs,and explain thei r mechanism of drug action, primary actions on
the respiratory system,and important effects.
8. Use the nursing process to care for patients who are receiving
pharmacotherapy for lower respiratory traa disorders.
drypowd inhal .. iDPl j _m
p!JIJt6IJ 1
leukotrienl5 p!JIJt 599
metereddos. inhaler (MOl) p!JIJt 591
mM,ixanthin. _ 59>
n, buli, p!JIJt
perfusi on pa]'5'XJ
stat UI m hmatirus p!JIJt 59]
ventilatiln p!JIJt 5'XJ
LibraryPirate
590 Unit,
T
he flow of oxygen, carbon dioxide, and other ga5es in
and out of the human body is dynamic and in constant
flux.Minute-by-minute control of the airways is necessary to
bring an abundant supply of essential gases to the pul-
monary capillaries and to rid the body of some of its most
toxic waste products. Any restriction in this dynamic flow,
even for brief periods, may result in serious consequences.
This chapter examines drugs u5ed in the pharmacotherapy
of two primary pulmonary disorders-asthma and chronic
obstructive pulmon .. ry diseue.
39.1 Physiology of the Lower
Respiratory Tract
The primary function of the respiratory system is to bring
oxygen into the body and to remove carbon dioxide. The
process by which gases are exchanged is called respiration.
The basic structures of the lower respiratory tract are shown
in Figure 39.1.
Venti lation is the proc5S of moving air into and out of the
lungs.As the diaphrngm contracts and lowers in position, it
creates a negative pressure that draws air into the lungs, and
inspirntion occurs. During expiration, the diaphragm re-
hxes and air leaves the lungs passively, with no energy ex-
penditure required. Ventilation is a purely mechanical
process that occurs approximately 12 to 18 times per minute
in adults, a rale delennined by neurons in the brainstem.
This rate may be modified bya number offactors, induding
emotions, fever, stress, the pH of the blood, and certain
medications.
The bronchial tret' ends in dilated sacs called alveoli,
which have no smooth muscle but are abundantly rich in
Trachea
capillaries. An extremely thin membrnne in the alveoli sep-
arates the airway from the pulmonary capillaries, allowing
gases to readily move between the internal environment of
the blood and the inspired air. As oxygen crosses this mem-
brane, it is exchanged for carbon dioxide, a cellular waste
product that travels from the blood to the air. The lung is
richly supplied with blood. Blood flow through the lungs is
called prrfusion. The process of gas exchange is shown in
Figure 39.1.
39.2 Bronchiolar Smooth Muscle
Bronchioles are muscular, elastic structures whose diameter,
or lumen, varies with the contraction or relaxation of
smooth musde. Bronchodilation opens the lumen, allowing
air 10 enter the lungs more freely, thus increasing the supply
of oxygen to the body's tissues. Bronchoconstriction doses
the lumen, resulting in less airflow. Bronchodilation and
bronchoconstriction are largely regulated by the two
branches of the autonomic nervous system.
The sympathetic branch activates beta,-adrenergic
receptors, which causes bronchiolar smooth muscle to
relax, the airway diameter to increase, and
bronchodilation to occur.
The parasympathetic branch causes bronchiolar smooth
muscle to contract, the airway diameter to narrow, and
bronchocOIutrictionto occur.
Drugs that enhance bronchodilation will cause the patient
to breathe easier. Drugs that stimulate betaradrenergi' re-
ceptors, commonly called bronchodilators, are some of the
most frequently prescribed drugs for treating pulmonary
disorders. On the other hand, drugs that cause bronchocon-
striction maycause breathing to become labored and the pa-
tientto become short of breath .
Expired air
Left lung
Diaphragm
.. Flgurel9.' The lower respiratory tract
Left primary bronchus
""-"' blood circulated
back to the heart
LibraryPirate
39.3 Administration of Pulmonary
Drugs via Inhalation
The respiratory system offers a rapid and efficient mecha-
nism for delivering drugs. The enormous surface area of the
bronchioles and alveoli, and the rich blood supply to these
areas, results in an almost instantaneous onset of action for
inhaled substances.
Medications are delivered to the respiratory system by
aerosol therapy. An aermol is a suspension of minute liquid
droplets or fine solid particles suspended in a gas. The ma-
jor advantage of aerosol therapy is that it delivers pul-
monary drugs to their immediate site of action, thus
reducing systemic side effects. To produce an equivalent
therapeutic action, an oral drug would have to be given at
higher doses, and be distributed to all body tissues. Aerosol
therapy can give inunediate relief for bron(hospasl1\ an acute
condition during which the bronchiolar smooth muscle
rapidly contracts, leaving the patient gasping for breath.
Drugs may also be given to loosen viscous mucus in the
bronchial tree.
It should be clearly understood that agents delivered by
inhalation have the potential to produce sysremic effects be-
cause of absorption across the pulmonary capillaries. For
example, anesthetics such as nitrous oxide and halothane
(Fluothane) are delivered via the inhalation route and are
rapidly distributed tocause CNSdepression (chapter 1900).
Solvents such as paint thinners and glues are sometimes in-
t"ntionally i.nhaled and.:an.:ause ..,rious adver.., df""ts on
the nervous system and even death. In general, however,
drugs administered by the inhalation route for respiratory
conditions produce minimal systemic toxicity.
Several devices are used to deliver drugs via the inhalation
route. Nrbulilt'B are small machines that vaporize a liquid
medication into a fine mist that can be inhaled, using a face
mask or handheld device. !fthe drug is a solid, it may be ad-
ministered using a dr,powderinhale-r(DPI}. A DPI is a small de-
vice that is activated by the process of inhalation to deliver a
fine powder directly to the bronchial tree. Turbuhaler and
Rotahaler are types of DPIs. Meterrd-doSf inhalers (MDls) are a
Drugs /0, ... ,m"", and Oth<>' Pulmonary O""rders 591
third type of device commonly used to deliver respiratory
MDIs use a propellant to deliver a measured dose of
to the lungs during each breath. The patient times the
inhalation to the puffs of drug emitted from the MD!.
Therearedisadvantages to administering aerosol therapy.
The precise dose received by the patient is difficult to mea-
sure because it depends on the patient's breathing pattern
and the correct use of the inhaler device. Even under opti -
mal conditions, only 10% to 50% of the drug actually
reaches the lower respiratory tract. Patients must be care-
fully instructed on the correct use of these devices. Swallow-
ing medication that has been deposited in the oral cavity
maycause systemic adverse effects if the drug is absorbed in
the GI tract. In addilion, patients should rinse their mouth
thoroughly following drug use to reduce the potential for
absorption of the drug across the oral mucosa. Three devices
used to deliver respiratory drugs are shown in ,.. Figure 39.2.
ASTHMA
Asthma is a chronic pulmonary disease with inflammatory
and bronchospasm components. Drugs may be given to de-
crease the frequency of asthmatic attacks or to terminate at-
tacks in progress.
PHARMFACT5
Ast hma
Asthma is resplnsiblto [0, mOK than I.S million emrlge'KY drpanrnrnt
flits and more than 500,000 hospitalizations
iIIore than S,5OO patiems die of asthma N(h
Till' inddrna of asthma has bten dramatically ifl(reasing e>Kh yr.
lilSO in all age,grnde-r,and f1hnic groups. The liIil'ofifl(ft'lIr has
Iftn among Afriun AlIII'riuns.
Till' highest inddenc:f of asthma is in patients )'JUnger than <Igr 18; from
7lI. to ]()% of(hildrrn haYe the disNsf.
lnadults,asthm<l islS% morl'(ommon in women than in IIII'n.ln
mildren,hOWfYl'f, alFrru twicr.Js many boys asgirls.
,.. Flgure39.2 [)@vlcesusedtodellverresplratorydrugs:(a) metered-dose Inhaler;(b) nebulizer with face mask;(c) dry powder
Inhaler
Source: fWxwn friKarkJ/l/PH College.
LibraryPirate
592 Unit,
39.4 Pathophysiology of Asthma
Asthma is one of the most common chronic conditions in the
United States, affecting 20 million Americans. Although the
disorder can affect a person of any age, asthma is often con-
sidered a pediatric disease. Characterized by acute bron-
chospasm, asthma can cause intense breathlessness,
coughing, and gasping for air. Along with bronchoconstric-
tion, an acute inflammatory response stimulates histamine
secretion, which increases mucus and edema in the airways.
As in allergic rhinitis, the airway becomes hyper-responsive
to allergens. Both bronchospasm and inflammation con-
tributeto airway obstruction, as illustrated in Figure 39.3.
The patient with asthma can present with acute or
chronic symptoms. Intervals between symptoms may vary
from days to weeks to months. Some patients experience
asthma when exposed to specitk triggers, such as those
listed in Table 39.1. Others experience the disorder on exer-
tion, a condition called exercile-illduced asthma. Status asth-
matirus is a severe, prolonged form of asthma unresponsive
to drug treatment that may lead to respiratory failure.
Because asthma has both a bronchoconstriction compo-
nent and an inflammation component, pharmacotherapy of
the disease focuses on one or both of these mechanisms. The
goals of drug therapy are twofold: to terminate acute bron-
chospasmsin progress and to reduc thefrequellcyof astluna
I NORMAL BRONCHIOLE I
attacks. Different medications are needed to achieve each of
these goals.
Beta -Ad renergic Agoni sts
Beia,-adrenergic agonists (or simply beta agonists) are ef-
fective bronchodilators for the management of asthma and
other pulmonary diseases. They are drugs of choice for the
treatment of acute bronchoconstriction. These drugs are
listed in Table 39.2.
39.5 Treating Acute Asthma
with BetaAdrenergic Agonists
Beta-adrenergic agonisl5 are drugs that activate the sympa-
thetic nervous system, which relaxes bronchial smooth
muscle resulting in bronchodilation. Beta-agonist medica-
tions may act on either beta, receptors, which are located
primarily in the heart, or on beta, receptors, which are lo-
cated in smooth muscle of the I=g, uterus, and other or-
gans. Beta agonists that activate both beta, and beta,
receptors are called nonselective bronchodilators. Beta a80-
nists that activate only the beta, receptors are called selective
agents. The selective beta,-adrenergic agonists have largely
replaced the older, nonselective agents such as epinephrine
Mucous m9l11brane
Smooth muscle
(b) InAammatory calls
and debris fill the
airway
(c) Smoolh muscle
contraction
constricts the airway
,.. FlgureJ9.3 Changes tn the bronchioles durln9 an asthma allack:(a) Normal bronchlole;(b} the Inflammatory component plugs
the alrway;(c) bronchoconstrlctlon narrows the airway
LibraryPirate
TABLE 39.1 I Common Triggers of Asthma
Cause Sources
Ai'pjlutaou
-.-
....
lirrousand 11M .. o:Iidts
fI.mtI from duning lkJids or soMnU

"-
Polito from trfe,lJlIStI, and WffiIs
Animal dander
Housthoid dUll
"Od
Chtmitalsand food DnI9s. indudng alpiin, and brtJ
""'"

Food ald induding monosodium
1M SG), shrllfuh, and dairy produru
Potspi'uory infffiions Baw,rial, viril

Emotional
umill' io dry,(oId
and isoproterenol (Isuprel) for asthma pharmacotherapy
becaur.e they produce fewer cardiac side effects.
Beta agonists are bronchodilators that relax bronchial
smooth muscle. thus widening the airway and making
breathing easier for the patient. Although quite effective
at relieving bronchospasm. beta agonists have no anti-
inflammatory proputies; thus, other drug classes are re-
quired to control tht inflammatory component of chronic
asthma.
A practical method for classifying beta-adrenergic ago-
nists for asthma is by their duration of action. Short-acting
agents such as pirbuterol (Maxair) have a rapid onset of ac-
tion. usually several minutes. Short-acting beta agonists are
Ihe most freq1lently pTI"criheti tim" for ahorting or termi_
nating an acute asthma attack. For this reason, they are
sometimes referred to as reSCII" agents. Their effects, how-
ever, last only 2 to 6 hours so the use of short-acting agents
is generally limited to as-needed (pm) management of
acute episodes.
Intermediate duration beta agonists such as a1buterol
(Proven til) and levalbuterol (Xopenex) have therapeutic ef-
fects that last approximately 8 hours. while long-acting
agents such as salmeterol (Serevent) last up to 12 hours.
These agents have a relatively slow onset of action. The in-
tennediate and longacting agents are used in combination
with inhaled corticosteroids for the prophylaxis of moder-
ate to severe, persistent asthma. The specific drug chosen for
pharmacotherapy is dependent on the pattern of symptoms
experienced by the patient.
In 2005, the U.S. Food and Drug Administration
(USDA) issued a public health advisory regarding an in-
Drug' lor Asthma and Other Pulmonary O""rd .... s 593
crea.<e in deaths among persons taking long-acting beta,
agonists (LABAs). Because LABAs are not to
abort an asthma attack, taking a LABA instead of a short-
acting beta agonist could result in lUlrelieved bron-
chospasm and subsequent death. The LABAs ale also
delivered via handheld inhalers and patients may assume
they have the same actions as the short-acting agents. Pa-
tients must be warned of the inherent dangers of taking
LAB.o\s during an acute episode.
Beta-adrenergic agonists are available in oral, inhaled.
and parenteral fornmlations. \'lhen taken for respiratory
conditions. inhalation is by far the most common route. In-
haled beta agonists produce minimal systemic toxicity be-
caust only small amounts of the drugs are absorbed. When
given orally, a longer duration of action is achieved, but sys-
temic adwrse effects are more frequently experienced. Sys-
temic effects may include some activation of beta, re.:eptors
in the heart, which could cause an angina attack or a dys-
rhythmia in patients with cardiac impairment. With
chronic use, tolerance may develop to the bronchodilation
effect and the duration of action will become shorter.
Should this occur, the dose of beta, agonist may need to be
increased, or a second drug may be added to the th=peu-
tic regimen. Increased use of a beta agonist over a period of
hours or days is an indication that the patient's condition is
rapidly deteriorating, and medical attention should be
sought immediately.
Nursing Process Focus: Patients Receiving Adrenergic
(Sympathomimetic) Therapy, page 134 in chapter 1300, for
the complete Nursing Process applied to caring for patients
receiving beta-adrenergic agonists (sympathomimetics).
H OME & COMMUNITY CONSIDERATI ONS
------------ -- - -
Asthma Management in the Schools
Appmimilely 9 million {hildren )'OUllgl'lthin agt 18 asthm. lit-
5Ug9I'It that asthma a((ouou lor 14 m ilIOO misled "hool dlfl ta{h
misstd workdays Iofp,ill'Ots, making thisdM.Ncwoftlit
most romrooo (i!MS for sdml and work absmlffism.l n i typita I dall of 30
(hileRn. two students sulI!'r from asthmatic attl{b N(h )'NI whilt at "hooL
{aoMtlum whilt 9p1'ritnciog sh:Jrtntss

.I5silling smoolslO asthma O"Ianagtllltnt programs ha, btc:OIlll'
t ilt ixU! of fNl.'lal agenc:its and dozens of profes>ional and p,itieot
idYtcacy groups. Man-, "hools adopting asthma manigtmeot as
pan of a "hool lItakh program. xhools with programs
hm "asthmi-fritndly" wdI as allowing students !O WI)'
i nd Idminister asthmi mrd italioos. Additiona "hoJis rou-
tineljo maintlin a {OPY of tht studmt's asthma action plan from tht
or health {i If PfOllider. The rolt of tht is to review tilt plan, deter-
mint tht llffiIs,and be that the student ha,
,I{<elsto quic:k-relief i sthma mrdiutioOl. Tht optimal plan lor _h l1Udem is
{ill' by cast, with input from tht student. p,iIl'OB, heakh
pfOlld ..... aod "hooi permitttd to {arry tilt
inha'er and as nttdrd. The nufll' ofttn ktepS a b.JdlJP IUppIy
of tilt student's mtdiutioo. For youngtl dJ a IUpl'fYised health
maybedeie9attd to admioister tilt


,


"
LibraryPirate
594 Unit, TheR"'PImorySY'!em
TABLE 39.2 1 Bronchodilators
Drug Route and Adult Dose (max dose where Indicated) Adverse Effects
BETA AGONISTS/SYMPA.THOMIMETICS
albuttrol (PrIl'Imti, Ymlolin, 2 inllalatioos Ml'/4-6 h as nrtdtd (ma1: 11 inhaiatiomldayl
HeiUim: 115- S mg 4-8 hasnffiltd
IItodiKhf,dilzinw;, rmoo,
ltMrooct
ridrtyroia.dysrhythmi.Jt hYDoQ!!fl1ia.
hypmly(m1ia. paradoxical bronm!XOl!lIrigion
PO; 2- 4 m9lid- qid (max: 12 mglday)
arformoltrol (8rOYan)
Ionnottrol (kmit Pfrforomi51)
I!Irnr tabs:8 mg MIY 12 h (max: 32 miVday dividtdl
HeIPulim; 1 S III(g daily (max: 30 mc:glda,)
12 meg inllalitioo M!Y 12 h (ma1:14 mc:gIday)
HeiUiztr:lO 111(9 bid (mu:40 nKiVda,)
HeiUiztf;0.63 mg tid-"d
2 inllalatioos q 4-6 h
pirbuterol (Muair)
Q !aimtlmll(SmI'mI)
tm..nalinr
2 itllalollioos "d (mil: 12 inhaliliomlliay)
inhalations bid or 1 pc:II\'dft' dilkus bid
PO;l5-S mglid (mil: 1S mgIda,)
SlbwtJnrous; 2SO meg (IrUY til' I'rpNtrd in IS nin)
inh,iatiom(lOO m'9lspr.y) M!Y 4-6 h
A.NTlCHOLINERGICS
Q ipratropiJm ithalaliool qid (mil: 12 inhalations/day)
Nrbulim: 500 meg h urftdlod
1 CipstH irhalrdlliay tiotropiLm (Spiriwl
METHYLXANTHINES
aminophyllilt
othm)
po; 380 mgIda, in diridtd dosrs M!Y 6-8 h (ma1: 918 m glut)
PO:300-600 mgld.y i1 d'lidrd dcMs(nw:900 mglday)
IiHItII5I!tS\ Nl'mol\ dirlirlflj, htodiKhe, 00UIf4
Imlirilli
Anticholinergics
Although beta agonists are drugs of choice for treating acute
asthma, anticholinergics are alternatiw bronchodilators.
Only two anticholinergics are commonly used for pul -
monary disease, and these agents are listed in Table J9.1.
39.6 Treating Chronic Asthma
with Anticholinergics
Although shortacting beta agonists are drugs of choice for
treating acute bronchospasm. anticholinergics (also called
cholinergic blockers or antagonists) are alternative bron
chodiJators. Anticholinergics block the parasympathetic
nervous system. Because the parasympathetic response is
largely the opposile of the sympathetic response, blocking
the parasympathetic nt'rvous system results in actions sim-
ilar to those of stimulating the sympathetic nervous system
(chapter 1JOO). lt is predictable, then, that anticholinergic
drugs would cause bronchodilation and have potential ap
plications in the pharmacotherapy of asthma and COPD.
Although anticholint'rgics such as atropine have been
available for many decades, drugs in this class exhibit many
Tidrmroia. dysrhythmi.J\ hyDO!tllSion idnm,
cirwialory filure r@ralorurml
adverse effects when administered by the oral or parenteral
routes. However, the rel.1lively recent discovery of anti-
cholinergics that am be delivered by inhalation led to the
approval of two important drugs in this class for asthma:
ipralropium (Atrovent) and tiotropirun (Spiriva).
Ipratropium (Atrovent) is the most common anticholin-
ergic prescribed for the pharmacolherapy of chronic ob-
structive pulmonary disease (COPD) and asthma. It has a
slower onset of action than most beta agonists and pro-
duces a less intense bronchodibtion. However, combining
ipratropium with a beta agonist produces a greater and
more prolonged bronchodilation than using either drug
separately. Taking advantage of this increased effect, Com-
bivent is a mixture of ipralropium and albuterol in a single
MDi canister. Tiotropium (Spiriva) is a newer anticholin-
ergic for COPD thai has a longt'r duration of action than
ipratropium.
The inhaled anticholinergics are safe medications. Tht'
wide range of anticholinergic adverse effects observed
when drugs in this class are administered systemically
rarely occur by inhalation. Dry mouth, gastrointestinal
(GI) distress, ht'adache, and anxiety are the most common
patienl complaints.
LibraryPirate
Drug' lor A,mma and Other Pulmonary O""rd .... , 595
p,. Prototype Drug I Salmeterol (Serevenr)
Therapeuti c (lass: Bronchodilator Pha rmacologic (lass: Betapldrenergic agonist
ACTIONS AND USES
Salmrtrrol isa LABA by <ele.:tivrly binding to brta,-,drmt rgic
tOB in bronchi, llmooth IlUldt to U!lll' bronchoditation.lu ll-hour duration
of iKtion is longer than that of many other bronchodilatOB, thus making it best
wited for the rna nagemell of chronic althma. When tiktn 31>-60 minuc!"! prior
to phylic.J I activity, it u n plt"ll'llt brondmpasm. Salmetfltll is
<1110 iPPIV>'f<I for Ifllucing broncho!pasm in patifnu with COPD. 8euust sil-
mell'rot liUS 1 S- 25 minJ!!"! to Kt. it should be UII'd to terminatt iMt
bronmospasm.
ADMINISTRATION ALERTS
The Propl'l !III' of the metmd-dol!' inhaltr is importlnt to the elftiY!'
delivtry of thedrug. and instruct tht patifnt in Propl'I usr.
Pregnancy uttgory (
PHARMACOKINETICS
Onsrt: lO-20min
P!ak: 2h
Half lil!: 3-4 h
Duration: Up to 12 h
The complete nursing process applied to patients receiv-
ing anticholinergics is presented in Nursing Process Focus:
Patients Re.::eivingAnticholinergic Therapy, on page 145 in
chapter 1300.
For additional nursing considerations, please refer to
Nursing Process FOUlS: Patients Receiving Bronchodilator
Therapy, on page 59:.
Methylxanthines
The ntethylxanthines were considered drugs of choice for
treating asthnta 30 rears ago. Now they are primarily re-
,erved for the long-term management of per,j,tent a,thma
that is unresponsive to beta agonists or inhaled cortico-
steroids. These agents are shown in Table 39.2.
39.7 Treating Chronic Asthma
with Methylxanthines
The mrthylxanthines, theophyUine (Theo-Dur, others) and
aminophylline (Truphylline), are bronchodilators chemically
related to caffeine. The methylxanthines are infrequently pre-
scribed because they have a narrow safety margin, especially
with prolonged use.Adverseefftcts such as nausea, vomiting,
and CNS stimulation occur frequently, and dysrhythmias
may be observed at high doses. Like caffeine, methylxan-
thines can cause nervousness and iru;omnia. These drugs also
have significant interactioru; with nwnerous other drugs.
Methylxanthines are administered by the PO or IV
routes, rather than by inhalation. Having been largely re-
ADVERSE EFFECTS
Seriou:! Idvrnl' elfe.:u from wlmetMlI uncommon. Some p,tifml uptri-
erl(f he.Hbc:hes,thro,t irrimion, nrlVOUSlM'U,l nd rt5tir!5l1!'15. BrulM
01 ii, pottntial to causr !am)'(ardia, patifnts with hun disul!' should bf mon-
itolfll regularly. S,ll1IEteroi hiS a bbc:k box Wilming that LABk mly ilDf<lll'
the rislof dmhs.
Contraindi cations: Salmetl'l'Ol!III' is cOIltrairodiutrd in patifnts with hyper-
srmitml)' to tilt drug and in patitnU Hptriencing uutr bronchosp"!III la
slionfl-Icting drug should be UII'd).Caution should be UII'd whtn umilg pa-
tiMu with dysrhythmia!, hypertension, hu n or Il'izUItS.
INTERACTIONS
Drug-Orug: (rorurrent U\I' with bIoclal wil 1M bfondlo!ilalion I'fIK1
ofsalmtlfll.
La b Ti5IS: rna, {aU\I' hypobIi'mia.
HerbaHood: a!collHIdtn may {aU\I'

Treatment of IMrdosr: OY!'rdoII' ltSuhl in an Haggtratro sympathetic ICUva-
tio n,u.lling dylrhythmial, hypokalfmia,'rod hyptrgl)ocrmia.ln seY!'rt mrs,ad-
ministmion of , urdioll'le.:tive bftI-adrf lll'rgic antagonist may be lI!'(esary.
IItI'tf rc M}NurJlIIgKJI fr1r Q NurlIrrtj I'rrlm.! fooJs Jpl(1k RHIIIs drug.
placrd by safer and more effective drugs, theophylline is
curnntly used primarily for the long-term oral prophylaxis
of asthma that is unresponsive to beta agonists or inhaled
corticosteroids.
Corticosteroids
Inhaled corticosteroids (lCS) are used for the long-term
prevention of asthmatic attacks. Oral corticosteroids may be
used for the short-term management of acute severe
asthma. These drugs are listed in Table 39.3.
39.8 Prophylaxis of Asthma
with Corticosteroids
Corticosteroids, also known as gJucocorticoids, are the most
potent natural anti-inflammatory substances known. Be-
cause asthma has a major inflammatory component, it
should not be surprising that drugs in this class playa ma-
jor role in the management of this disorder. Corticor.teroids
dampen the activation of inflammatory cells and increase
the production of anti-inflanunatory mediators. Mucus
production and edema is diminished, thus reducing airway
obstruction. Although cortioosteroids are not bronchodila-
tors, they sensitize the bronchial smooth muscle to be more
responsive to beta-agonist stimulation. In addition, they re-
duce the bronchial hyper-responsiveness to allergens that is
responsible for trigguing some asthma attacks. In the phar-
macotherapy of asthma, corticosteroids may be giwn sys-
temicaUy or by inhalation.


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"
LibraryPirate
.... Prototype Drug I Ipratroplum (Atrovent, Comblvent)
Therap!! utic (lass: Bronchodilator Pharmacologic (lass: Anticholinergic
ACTIONS AND USES
Ipruropium is an ,nticholinergic agenl tMI is rleliYerrd b)' thr inhalation ,lnd
inmllilsal routH. inhalalion form is to and preYellt the
brondiospasm that is dlilruristic of althma and (OI'D. Whrn (ombined with
(Combirent), it is a prrfmed drug for liming bromflospums due to
(OI'D, ilKluding bronchitis and Although it h.n nOI reuived FDA
approval for trt'almrnt of mhma, it is prrs{ribrd off-labrl for thr disordrr.
Ipruropium is an altrrlliltm- 10 slion-<Kting brta agonist!. <lnd for pMiconl5 n-
periffidng mhma rloKmmiom.1t is wmelimes (ombinl'd with brta
agonist! or ronKOIIeroidIlO plOl'irle additm- brondJodilation.
Whrn adminislrrrd vi, inMI,tion, ipratropirm un bron-
(hospasm within ,!ltrr administration, although may takt
1- 1 lioun.BrolKhociil,tion action may (ontinlll' for up 10 6 houn.
Tht nalal spray formulation of iprauopium is 'pprumlfor the relief of runny
n= associated with the rommon ooId and allrllIK rhinitis. Thr dlll\l inhibits
n.nallfCretions but dot-I not h.M rlecoo9l'slant <Ktion.Treatmt nl is limited to

ADMINISTRATION ALERTS
Tht proper of the metered-doSl' inhaltr (MOO is imporuntto the ef-
futiYl' drlm-IY oldrug. OWm!and instnKt tht patitnt in proper uS!'.
Wait2- 3 minutes bel'oYl'rn OOsagll.
Al'Oid (on\ad with vision may oc(ur.
category 8
PHARMACOKINETICS
On5d: S- ISmin

Halllilr: 1.S-2 h
Duration:34ih
TABLE 39 3 1 Anti-Inflammatory Drugs for Asthma
ADVERSE EFFECTS
Bffi!M Yl'ry little is ablOrbed from the lungs. ipratropium prodKes ftw 1)'1-
tf mK adYI'ne of thr upper re!piratary trm may re\Uk in
WJgh, drying of the llilsal m!Kosa, or hoanenl'll.1t prodlKfS a bitter IaItt,
whidl may be relieed by riming the mouth afler UII'.
Contraindications: Iprauopium is (ontraindicated in patitnts with hyptnensi-
twiry 10 soya lecithin or relatrd food products sum as soybfan and peanut. Soya
IKithin is usrd as <I propellant in the inhaltr.
INTERACTIONS
Drug-Drug: LMwlth othfrdllJ1l in rmdallw as atropill! marlNd

lab 115Is: Unl;oown
IlerballFoo:1: Unknown
of with ipr"ropilm dots nat occur beu!M
try linlt of thr drug is ab!orbed when giYl'o b)' arlOlOl.
Rtfer Ie MyMnbJqQ I'Dr MnJrtiJ /'ro(eIS fool! spK/II( Ie 1M
DN, Route and Adult Dose (max do\e where Indicated) MverS(' Effects
INHALED CORTICOSTEROIOS"
o lII'domrthalOOr (Bfconu AQ,Qvar)
IHIdtlOOicie (Pulmirortl
dOOonicie (Atw,sro)
f1urisolicle (AeroBidl
f1utiulOlll' (ROYI'Ilt) palJl'
PrototyprDrug boxOO)
momrlillOlll'(Almanl'l)
(Mni(ort)
MAST CELL STABILIZERS
avmoIyn (Intal)
nedooomiisodilm (lilalle)
LEUKOTRIENE MODIFIERS
montrlubst (Singwir)
o afirlwl! (A((oIitr)
lilruton (1y11o)
MIX; 1-1 inhalations tid-qid (max: 20 inhalatiomlday)
1- 2 inhalatiOlll (200 Ijd (max:800 IIKglday)
inhal"ion; 1-2 inMlitKm/day (l204i40 IIKgl
MIX; 2- 1 inhalations bid- tid (max: 12 inhalatiomlday)
MOl (<< IIKg):2 inh,latiom bid (mn : 10 inMlitionllda,)
OPI; 1 inhal"ion daily (mn:2 irhalations diily)
MIX; 2 irhal" ions tid- qid (mn: 16 inhal"ions/day)
MOl; I irhalation qid
MOl; 2 irhalations qid
PO; 10 mglda, in moing
PO; 20 mg bid I h lII'forf IX 2 h IIINls
PO; 1)00 mg bid
"F dOSI'I at' systrmic: (ortkomroids, rdrt to d1apter 0 0110.
Ildio"indi<J1< <OIII1TIOO..mn. indi<JI .... riouIld ...... tfltcl .
rty rnwrh, WIJ9II, SlIfe drool
Orpo/Iarynge,1 oodidm hyproortidW
hyW'imlitiYitY!f1jooS
NatMfJ, YlftJing, OQfIIlllingintJ. rlnr
unjitllSQIlf roste
Anaphylaxis a!'!Qionkma, brond!o!palm
LibraryPirate
IlI>pltll9 0rug51o, Asthma and Other Pulmonary O""rd .... , 597
NURSING PROCESS FOCUS PATIENTS RECEIVING BRONCHODILATORTH"RAPV
Assessment
Basrlinr a,srssmt nt priorto administration:
Under>tlnd reason the drug has bn presc:ribtd in ollimo uses fo,
ther.J ptUlic: e1fls.
Obtain a (omplttt heakh including previous of symptoms
and .J 10 stasom. foods, or cnvironmt ntal O;POlures; existing
re-spiratory, hf patic. or ntUrologic: gla lKom.J;
prostatic: hypmroph)' ordiffirull)' with urination; or mra
inleuions; P't9"' IK1 or brmt -feeding; akollal or YIIo1:ing. Obtain a
drug noting the t)'pt of lI'action to any

If asthma s)'l11ptoms Ut 01 new for .J ny lI'!!'nt (liangf'S in
soaps including laundry or (osmetiu,iotions,
or lI'<ent {arptl {INning in young (hildll'n) th.Jt
may (omlatt with of symptoms.
Obtain vital signs, Mting respirator)' rate and dtpth.
Asses pulmon.ll)' function with pNk t lpirlloryflow mell'r.
and/or anfrial blood gam to
['/<Iluate appropriatf laboratory (e.g., C8(, hepatic and renal labs).
Assess)'mptonHf lated effects on rating. sleep, and activit)' Itvrl.
ASSf llmrnt thro ughout ildministration:
Asses for dtsired therapNtic: efle.:u (r.g., inc: re.J sed NSt of breathing.
implO'lfment in pulmonal)' function nudies, improved signs of peripheral
D.l)'9l'Iluion and activit)' IMIs, maimrnancfof normal rating
and sleep periods).
Continue periodic: monitoring of pulmonary function with PUM orimeter,
peak o piruor)' flow andlor a,terial blood appropriatt .
Asses vitalsigns, rspecially respirator)' rate and bruth
sound!, noting prrsen!!' of sounds, .J nd any mUQJI prodlKtion.
Asses for advel'>r rlfects:diuilH'sl, toKhycardia, palpitllions, blurred vision,
or headac:hf. Rt port immediately .J ny (onfusion, tJoc: hlUroia,
hypotension. synrope, dyspnN. or increasing pulmona I)'
(ongrnion.
Potential Nursing Diagnoses
Impaill'd GiIs Uc:hange
. lnrIfiMTr>sue F'fllusion
Allliely (rtlattd to diffirulty in breathing)
Siefp to drug
ktiYity Intoltranc:e (1I'lattdto diseasr or inrffKtil'fdrug thmp)' )
DerKitnt Knowledge (drug therilp)')
Planning: Patient Goal s and Expected Outcomes
Thr patitm will:
uperience tlltr. ptutic: effects k g., of bll'athing, im in pulmonary function lIudits, ablt to rxptritnc:r Mrmal sletp .J nd N1ing
periods, .J nd to (jfry out ADl.s to a ItY!'I appropriate for (ondition).
8(' free from, or rxptritnc:r adVtrse efferu.
Vt rIHIlize an undtr>tanding ofthedrug's 1M, advtrse t fferu, and IfqJired precautions.
DmIOnstratr Propl'l of tht medication (t.g.,dose. timing. when to notif)' provider).
Implementation
Interventions and (Rationales)
Ensu,ing the,.peutic dfects:
Continue as dtsc;ribtd t .J rlitr lor tlltra ptUlic: tffects. (In(lNSI'd
t oN of bll'athing; lessened adY!'ntitious breath sounds; impJOVtd signs of
tislUl' oxygenation; and normal .J ppeUte, t illing.and sleep patlffiI s should
hukh Wl' providtr IMuId be notifltd symptoms wornn,
f'Sptwlly ilrrspirator, invo/vemt nt in(lNsrs or fel'fl is plrsenl)
Patient and Family Education
Tu(h the patient to supplement drug therap)' with nonpharm.Jroiogic:
mf.Jwr6 l1Kh as incll'ased fkJid intakf to liqJrIy and assist to mobilize
murusand to redlKfOPOSUII' to .J lltl1}flls
Advise the patient to tall, .J wallet identification uro or WNr mediul
identification jMrll)' indic:ating tht prestnc:t ol .J llhma or ,rspil1ltOI)'
(ondition, a ny signifium allergies or ana phylui!., and usr of inhaltr
therap)'.
(Continued)
LibraryPirate
598 UnU
NURSING PROCESS FOCUS PATIENTS RECEIVING BRONCHODilATOR THERAPY (conrtJued)
Implementation
Interventi ons and (Rati onales) Patient and Family Educati on

Monitor pulmOOif)' function periodically with pull!' pNk TNCh patient tht Ul!'of peak apiratOr)' IIoY.r mettr Of
flow mell'r,indlor anerial blood gasn.(PtriodK monitoring is tqUipmtrlt ordtrrd to monitor pulmonary function.
flt(eluf)' to i ISf!1 drug

patifnt 10 immftlialely It'pOn \)'I11p10f1110f dfteriofating
respirator)' llaM wc:h as r/yIpnN, breathlf!ll\eSs with
ilKrmftl andl or orthopnea.

To aron an Kute althmatK atu<k,inhaltr tOOapy !hould be at

ProideapiKit inltruction! on tht U\f ofqtJKkalting YmUS Iong-.KIing
fillt lign of respirator)' For tOOa inhatrn.TNCh patitnt to USf qtJKk--acting inhalers at earlitn
blOlKhodiiation by inhaler Oforally will be ulf<l.Long-oCliI19MO, ogarilfs posliblt appearaIKt of lymptoml.llIng-acting inhaler; or oral therapy
(l.AiI/u) Qnd /ong-ocring In>ndrodiIQ/Of! In rIOllO be UI!'d 10 abort <IIII/Curt I!IiI)' be ustd to maintain brondlOdiiation but do not dilUrd qUKk-alting
OffQck. (Arutt i lthmatic analks all' managed with qtJKk-acting inhaltll if on long-term maintenaIKt thtrapy. The)- may !lill be nettled for
brOlKhodilation wc:h.H beU, agonistl.For plt"lMting attuh,LARA!, ptriodK itt1(k\.
amKholintrgia, malt ctll Itabiliztn,and rorlKolitrOid therapy may be
wd.1t is (furial to know and rOgnizt diffelftl{t in qUKk-alting and
Iong-alting inh.ltll.)
Minimizing ildft lle e!fHts:

Continue to moo itor rrspirations, rall', dtpth, bfl'ath IOUncIs, rruus prodKtiJn.

InllnKt tht patient to immftlialtly It'pOn l)'I11ptOf1110f dl'ttriofating
inefl'aling dylpMiI, bll'ath IOUndl. Ii9:Is of ti\\ut hypoxia, anxittjo, respiratory SiaM wc:h.H iIKfI'astd dyIpnN,brmhlt!ll\eS\ with Ipttlh,
ronfusion, and detlt'aling ftroions stu:lirs. (11KINIing d)\pllN, ilKlt'ilf<l anxiety, or orthoplli'a.
idYtotitioul bfl'ath 1OUnds, timirishtd oxygtMion. Of ilKfI'asing anxifty or
ronfrllion may iladequatt drug thtrapy, WOIItfing distall' pnxm,or
repillllOf)' iliM:iJn andYlouId be immtdiattiyJ

Monitor tating iI nd Ilttp patttrns and ability to maintain functional TNCh patient to drug thtrapy with nonphannac:oIogK
ADu. PlOYide lor lalorit-rith, foork, ttlt ptriork mealUttI iIKluding:
betwrtn rating or actilrity,and iI root room fOfsftping.(Repiratory

Huid to liquefy and mistto mobilill' mucus
difficulty and fatigue mo{iatftl with hypoxi nd tlltwork
Small, frtqJent alorit-and nutritnt-.densefoods 10 prevent
may afftd i ppttite, and tht to ut dJring dyspnu and maintain
fatigue and maintain normal nutrition
AOl!.Maimaining adequate nutrition, Hum, and Ittep all'
Adtquatt rtII ptriods lletwffn tating and oKtivitiH
to IUpport optimal htalthJ
room temprrarufl' for eale ofbrtathing dJring lletp.
to illltrgtfll whert polliblt.
InllnKt thf patifnt to immftlialely rtpon any lignifiunt changf in
i ppttitt, an inability to maintain oorm al inadequatt Iltep ptriodl.
or n inability to carry out ADIJ.

Bininat\' smoking.linit 6pOIUrt to lKondhand lmoke. and linit (afieilll' TNCh patient about smoking CtssaDon programs, to al'Oid
if taking methybamhines.(CigaR'tl\' smokt irritates t nvironments with mondhand and to limit or t liminateullrifll'
R'\Pratory mu:0IJI membrafll'l. r.c:lI'asing risk of adYtrIt effll and taking brOfuhodilator thmPl'.
inertil ling blOlKhOOlllllriction. I!IiI)' iOOl'aII' risk 0/ liIdr,urdiL)

Mainlil in dOling of Iong-iCting bfOlKhodilatoll. (Rtguiar, TNCh patient the importllKeof lonsistt nt administration of
rofllisll'nt doling with ma\tallslilbilill'fs. and bfOlKhodilation Ihtrapy to prnfm KUtt allilcb.
rortKolteroid I is !lied to or limit oKutt broIKhoc:on 51riaiYl' attalksJ

Utilizt appropriate !paler betwtt n inhaltr and mouth aI appropriatt and

InllnKt tht patifnt in pI"Operul!' of IpICUI followed by
ri= mouth after using in eptri.llly afttr cortitolttrom. (Sp alfll fl'lUm-demonlllaDon.
betwrtn mHtrl'd-dol!' inhi ltllallist in thf roordination and timing of
TNCh patient to mooth aftt r tdch ulr of the and to
inhaiation and pfl'Vtnt mftlit.ition being deiiYtrl'd to bark of tht
spit out afttr rinling.
phaf)'nx.Riming tht mouth afttr the USt ofinhalm S)'StertlK
il1lorption or Ioulill'd fI'KlioM to IIKh i s ukeration.)
Patiml undtfllanding of drug thuap-,:

Usr opportunities during the administration of mftlKationl and tlrring Thf patifnt should be ablt to IUtt thf f1'ilOn for thf drug.
mtlSflII'nll to dilcuss tht rationalt for drug ther<JptUtK dolt i nd IIhfduling. and what tff11 to oIurvt for and when to
ookoflll'S, most (ommonly obl!'rvtd adYl'nf parlmetm forwhtn report them.
to call health urt ptoYider,ind any flt(tlSilf)' monitoring Of
prautionl.(Using time during nursing tart htlp> to optimizt and fl'inlout
ko)' ."'OIJ
LibraryPirate
IlI>pltll9 Oruq< /0, Mthma and Other Pulmonary Disorder, 599
NURSING PROCESS FOCUS PATIENTS RECEIVING BRONCHODILATOR THERAPY (ConrlnuwJ
Implementation
Interventi ons and (Rati onales)
Patint selfadm inistnt io n of drug tht rilPY:
Wlltn administering thr mrdiution,instllKt thr Pltirm, lamil)o,or urtgiRr
in the proptr ,rlf-adminismtion olthr drug. r.g., thedrug at first
appea,anctof symptom, before Ymptoms all' (Proper
adminiruation the tiffdiY!'nfSs of the drugsJ
Pat ient and Family
The patient the difleftll(f betwrrn quickacting and long
a(ling inhalrrsand knows when eaoc:h is to be UIfd.
InstnKt the patient in proprr administration tKhniqur1 lor inlwll'B,
lollowed by Il'tum-dffilon smtion, inc:luding:
!Ma spam ifinltrudfd betwffn the inllaltr and
_h.
Shake the inhalrr or load inhair, with tablet or powder as inllrumd
II using bronchodilator and cortKostrroid inhalen, usr the
wait 5 minu1l'5, then UII' the (ortKosteroid to
eIllUll' thilt the drug ll'iKhes dttper into bronchi.
Rinsr the mouth lIIing all)' inlwll't
Evalull tion of Outcome Criterill
oldrug therapy by mnfirming that patirnt go;Ilsand oprdfd oUKomrs hal'(' bem met Isre PianninifJ.
5rf TOOIe5J9.1 tnJ J93 ku wNd! tht5t llllingacriml<Wlr-
Inhaled corticosteroids are the preferred therapy for
preventing asthma attacks. When inhaled on a daily
ule, corticosteroids suppress inflammation without produc-
ing major adverse effects. Although symptoms will improve
in the first I to 2 weeks of therapy, 4 to 8 weeks may be
quired for maximum benefit. For patients with persistent
asthma, a long-acting beta,adrenergic agonist may be pre
s.:ribed along with the inhaled corticosteroid to obtain an
additive effect. Inhaled corticosteroids must be taken daily
to produce thei r therapeutic effect and these drugs are not
effective at terminating acute asthmatic episodes in
progress. Most patients with asthma carry an inhaler con-
taining a rapid.acting beta agonist to terminate acute at-
tacks if they occur.
For severe, unstable asthma that is unresponsive to other
treatments,systemic corticosteroids such asoral prednisone
may be prescribed. Treatment time is limited to the shortest
length possible, usually 5 to 7 days. At the end of the brief
treatment period, patients are switched to inhaled corticos-
teroids for long term management.
Inhaled cortico<teroid.< He into The circlllation
so slowly that systemic adverse effects are rarely observed.
Local side effects include hoarseness and oropharyngeal
candidiasis. If taken for longer than 10 days, systemic corti-
costeroids can produce significant adverse effects, including
adrenal gland atrophy, peptic ulcers, osteoporosis, and hy-
perglycemia. Because asthma most commonly occurs in
children, growt h retardation is a concern with the use of
these drugs. Because these effects are all dose and time de
pendent, they can be avoided by limiting systemic therapy to
less than 10 days. Other uses and adverse effects of corticos-
teroids are presented in chapters 33 and 4300.
See Nursing Process Focus: Patients Receiving Systemic
Corticosteroid Therapy, on page 674 in chapter 4300, for
the complete nursing process applied to caring for patients
receiving corticosteroids.
leukotriene Modifiers
The leukotriene modifiers are relatively new drugs used to
reduce inflammation and ease bronchoconstriction.
Leukotriene modifiers are used as alternative drugs in the
management of asthma symptoms.These drugs are listed in
Table 39.3.
39.9 Prophylaxis of Asthma
with Leukotriene Modifiers
lrukot rienl5 are mediators of the immune response that are
involved in allergic and asthmatic reactions. Although the
prefix lel/ko-implies white blood cells, these mediators are
synthesized by mast cells, as well as neutrophils, basophils,
and eosinophils. When released in the airway, leukotrienes
promote edema, infIanmlation, and bronchoconstriction.
There are currently drlle< that modify lenkotriene
function. Zileuton (Zyflo) acts by blocking Jipoxygenase, the
enzyme used to synthesize leukotrienes. The remaining two
agents in this class, zafirlukast (Accolate) and montelukast
(SinguIair), act by blocking leukotriene receptors. All three
reduce inflammation. They are not considered bronchodila
tors like the beta, agonists, although they do reduce bron
choconstridion indirectl y.
The leukotriene modi fi ers are oral medications approved
for the prophylaxis of chronic asthma. Zileuton has a more
rapid onset of action (2 hours) than the other two
leukotriene modifiers, which take as long as I week to pro
duce optimum therapeutic benefit. Because of their del3)l\'d
onset, leukotriene modifiers are ineffective in terminating
LibraryPirate
600 Unit,
.... Prototype Drug I Beclomethasone (Beconase AU ().tar)
Therapeutic (lass: Anti-inflammatory drug for asthma and allergic rhinitis Pharmacologic (lass: Inhaled corticosteroid
ACTtONS AND USES
is a cOiticmtfroid availabll-' through .IeroIGI inhalation for
asthm i (Qyar) 01 as a IW.i I !pia)' (Be{OI'Iast All) fOi alll-'rgic rhinitis. Blomttha-
HIt and otht, drug, in Ihi, dl" I '" plM""",d drug, fo, It..loog_ltno mofla9"-
men! of pmKtent asthma in both children Ind Muits. For asthma, IWG
two to thlff time prr day, USUiIIIy prOidt adeqwte proph)"luK.
ms by ",dJ,:iog inflammuion, tlltfrequency
of althmaatllcitl.k K oot a bronchodiluor and mould not lit used to tenniOite
asthmi attadu in progrffi.
ADMINISTRATION ALERTS
Do not 1M if tilt patifOt is6jleritndng an arote ilthma atI1d.
Or.1 inhalation produdsand nual spray products a'" notto beUlfd inlff-
changubly.
PlfgOolIK)' calfgOry (
PHARMACOKINETICS
()Jlft: 1--4 wIu
Peak:30-70min

Duration: Unknown
acute asthma attacks. The currt'nt role of leukotriene mod-
ifiers in the management of asthma is for persistent asthma
that cannot be controlled with inhaled corticosteroids or
short-acting beta agonists.
Few serious adverse effects are associated with the
leukotriene modifiers. Headache, cough, nasal congestion,
or GI upst'l may occur. Patients older than age 65 have been
fOlUld to experience an increased frequency of infections
when taking leukotrient' modifiers. These drugs may be
contraindicated in patients with significant hepatic dys-
fimction or in chronic alcoholics, because they are exten-
sively metabolized by the liver.
Mast Cell Stabilizers
Two mast cell stabilizers serve limited, though important,
roles in the prophylaxis of asthma. These drugs act by in-
hibiting the release of histamine from mast cells, and their
doses art' listed in Table 39.3.
39.10 Prophylaxis of Asthma
with Mast Cell Stabilizers
CrOllJulyu (lutal) amI u.,.]ucrumil (Til"J,,) ar" d"-,>ili,,d ""'
mast cell stabilizers because their action st'rves to inhibit
mast cells from rt'leasing histamine and other chemical me-
diators of inflammation. By reducing inflammation, they
are able to prevent asthma attacks. like the corticosteroids,
these agents should be taken on a daily basis because they
are not effective for terminating acute attacks. Maximum
ADVERSE EFFECTS
Inhlll-'d bKlomethaIGIif protium few synemic effll. Bffiulo!' 1111111
iroourrtl lIYy ill' swallaMd with U4:h tilt piIlitot should bl'obsmed for
<io)n. of InKo<lfroid ,,,,,icily whm '"king lilt drug for prolong'" p"riod<.lo-
cil tffll may indudt mouth,nd in tint .
As with all {ortKosteroids, It.. proptrtits of bKlolIII'tha-
1001' can muk signs of inffilions, and tilt drug is coot"indicUtd if i n oKlive in-
fenion is pl"rSfOt.A <io)nifunt prnrntlgt of puients taking bKlomflMonf
on i Iong-teno basis will deYeIop oropltJryngeal candidiasis,alUngal infection
in the to tilt Instant deposits of drug in the OIal cavity.
Contraindications: BlomethalOOI'is cootraindicated in
litivit)o to the drug. The growth of patients shoold lit manito...:! ""'-
fully btuusr inhaled Inicosteroids lIYy ...:!uce growth in lomf
childru
INTERACTIONS
I)ug-l)ug: lktoown
lab Tl5ts: lktnown
Ik-'rbaVFoo:t: Unknown
Trtatment ofOmdost:Ovtrdose dots notocrurwiltn tht dlll9 Kgiven bytht
inhalation route.
Rdrt III MyMIsJnqKI rot MIsbtq /'rtxeIJ FooIl5pf(/It: IIIIM <h9-
therapeutic benefit may take several weeks. Both cromolyn
and nedocromil are pregnancy category B and exhibit no se-
rious toxicity. The mast cell stabilizers are less effective in
preventing chronic asthma than the inhaled corticosteroids.
Cromolyn (Intal ) was the first mast stabilizer discovered.
The drug is administered via an MDI or a nebulizer, and an
intranasal form (Nasalcrom) is used in the treatment of sea-
sonal allergic rhinitis (chapter 3goo). Adverse effects in-
clude stinging or burning of the nasal mucosa, irritation of
the throat, and nasal oongestion. Although not common,
bronchospasm and anaphylaxis have been reported. Be-
cause of its short half-life (80 minutes), cromolyn must be
inhaled four to six times per day.
Nedocrom.il (Tilade) is a newer mast cell stabilizer that
has actions and uses similar to those of cromolyn. Adminis-
tered with an MDI, the drug produces adverse effects simi-
Jar to those of cromolyn, although the longer half-life of
nedocromil allows less-frequent dosing. Patients often ex-
pt>riencea bitter, unpleasant taste, which is a common cause
for discontinuation of therapy.
CHRONIC OBSTRUCTIVE
PULMONARY DISEASE
Chronic obstructive pulmona ry diseasr (COPD), is a progressive pul-
monary disorder characterized by chronic and recurrent
obstruction of airflow. The two most common examples of
conditions causing chronic pulmonary obstruction are
chronic bronchitis and emphysema.
LibraryPirate
Prototype Drug I Zafirlukast (Accolate)
Therapeutic (lass: Anti-inflammatory drug for asthma prophylaxis
ACTIONS AND USES
Zafirlubn is lI<I'I'l for r .... prnphyl .. is of d""nM: asthmi _ k r-<enl<
airway and inflammation by Jffi'II1oo in the ,ir-
ways.An .dv.ntage "fth. drug is that it isgiwon by the oral IOUte. ks rtluiv.1y
long onset of adinn m.krs it uowitable for tl'll!lination of .rut.
k is Itss tfftctiW' than inhaled corticost.roids It IlIhlllil prophylaxis.
ADMINISTRATION ALERTS
Do not UIe to rmnillit. iM. ,sthlllil alli(D.
PlI'9na lK)'mtgoryB
PHARMACOKINETICS
Onset :l wIr
Iflk: 3h
Halflife: IOh
Duration: Unknown
HOME & COMMUNITY CONSIDERATIONS
J
- -- - - --- - --- -- --------
Helping Patients Manage Asthma
Ont nonirl'miYe, inapmsiYe, and tasy-to-us. tool that (,In mist a
with m'lliging asthlllil is the peak-flow mmr. The m(ter IlINSures king (,I-
parity.nd gives I lNding.The un then be utfgorizfd on a (han to de-
tennint if the patitnt is haYing <10)' manges, rnn earl)' breathing changes.
This will allow the to seltd which Inel of tr. umen!,if be
prior to the he.kh (,I'. providtr. k In giW' an rty warning
and possibly h.lp the patitnt iwid an acutt atIk with earl)' intmemion. The
mtgOrie can be stt up with the heakh IR' proYidtr and individwlizfd for

39.11 Pharmacotherapy of COPO
COPD is a major cause of death and disability. The three
specific COPD conditions are asthma, chronic bronchitis,
and emphysema. Otronic bronchitis and emphysema are
strongly associated with smoking tobacco products (ciga-
rette smoking accounts for 85% to 90% of all cases of
nonasthmatic COPD) and,secondarily, breathing air pollu-
tants. In mronic bronmitis, excess mucus is produced in the
lower respiratory tract due to the inflammation and irrita-
tion from cigarette smoke or pollutants. The airway becomes
partially obstructed with mucus, thus resulting in the classic
signs of dyspnea and coughing. An early sign of bronchitis is
often a productive cough on awakening. Gas exchange may
be impaired; thus, wheezing and decreased exercise toler-
ance are additional clinical signs. Microbes thrive in the
mucus-rich environment, and pulmonary infections are
common. Because most patients with COPD are lifelong to-
bacco users, they often have serious comorbid cardiovascu-
lar conditions such as heart failure and hypertension.
IlIopltll9 Oruq< /0, Mthrna and Other Pulmonary DIsord..... 601
Pharmacologic (lass: Leukotriene modifier
ADVERSE EFFECTS
Zafirlukasr prod.:es few serious i dve"" tff __ is r .... """t<ommon
complaint, and ,nd dianhe. 'R' R'plnt<i by some
Contraindi cdions: Th. contraindication is 10 tht drug.
Ilfc.UIe a frw raR' castS of hepoJtic f.iklr. bffir R'plnt<i in tak-
ing zafirlubst, those with hepoJti( should tR'att<i
with raution.
INTERACTIONS
Dru;rDrug: I.M with warfaoin may OOrnf prOlhromun tiM. Erythromyc .. may
decruSl'Sl'lUm lMokof
li b Tests: bMukist may OOf<llol' IMJIl AU YiIIUfI.
HerbaVFood: Food till! rmu tMbioiII'ailabititr,thus,tMo-ug!hcQd hi' liter. on
Mlempt, stOll"liCh.
Treat mt nt of OW' rdose: Thert is no spKiIic trl'atmtm for cwrdose.
III!ftf Ie M)Nu/f IngIJf for Q Nrmlnl} I'rIKnJ fools ljIKlk ro rlrls
COPD is progressive, with the termillill beins
. rnphysern After years of chronic inflammation, the bronchi-
oles lose their elasticity, and the alveoli dilate to maximum
size to allow more air into the lungs. The patient suffers ex-
treme dyspnea from even the slightest physical activity. The
clinical distinction between chronic bronchitis and emphy-
sema is sometimes unclear, because patients may exhibit
symptoms of both conditions concurrently.
The goals of pharmacotherapy of COPD are to relieve
symptoms and avoid complications of the condition. Vari-
ous classes of drugs are used to treat infectiofl'i, control
cough, and relieve bronchospasm. Most patients receive
bronchodilators such as ipratropiwn (Atrovent), beta, ago-
nists, or inhaled corticosteroids. Both short-acting and
long-acting bronchodilators are prescribed. Mucolytics and
expectorants (chapter 3goo) are sometimes used to reduce
L tFESPA N CONStDERATtONS
Respiratory Distress Syndrome
iltspi,uOl)' syndromt (RDS) is i condition, occurring in PR'-
motu", bobics, in which rho tunlj<.'" nor producing .. rfut.m. Surf. <lilnt
forms a thin laytr on the inntr surf. of tilt IlYfoIi to raist tht surf. 1I'I'l-
sion, tlltrrby tht i Ivtol i from (oll,j)ling during filpiration.1I binh
ocam btfore tht pnfUrnocyte in the lung art matuR' trIOugh to Sl'CR'te sur-
f,{Un!,the alnoli (ollaj)Sl' and RDS results.
Surfactant mtdicnions can be deliW'rtd to tht newbom,tithtr as prophy-
lactic therap)' or is 'fSUI!' therap)' deW'lop. The two nalUlll
surflint Igtnts used for RDS aR' callactant (lnfasur!) .nd btractant
(SuMnt.). (alfactant is h'M'stt<i from (,III lung!, ind bertant from m,iuR'
mile kings. These drugs iR' i dministt rtd 4 10 6 houB,
until the titnt's condition improYf1.The only synthetic (oIiOKl'l'iI
(UOIUrf), is 00 Iongtr ustd in the U nired States bfcause it is Itss tffruiwo than
the natural surfarunts.
LibraryPirate
602 Unit, The RespmorySY'!em
the visoosity of the bronchial mucus and to aid in its re-
moval. Long-term oxygen therapy assists breathing and has
been shown to decrease mortality in patients with advanced
capo. Antibiotics may be prescribed for patients who ex-
perience multiple bouts of pulmonary infections.
Patients with COPD should not receive drugs that have
beta-adrenergic antagonist activity or otherwise cause
bronchoconstriction. Respiratory depressants such as opi -
Chapter REVIEW
KEY CONCEPTS
oids and barbiturates should be avoided. It is important to
note that none of the pbarmacotherapies offer a cure for
capo; they only treat the symptoms of a progressively
worsening disease. The most important teaching point for
the nurse is to strongly encourage smoking cessation in
these patients. Smoking cessation has been shown to slow
the progression of COPD and to result in fewer respiratory
symptoms.
The numbered key concepts provide a succinct summary of the important points from the corresponding numbered section
within the chapter. If any of these points are not dear, refer to the nWllbered section within the chapter for review.
39.1 The physiology of the respiratory system involves two
main processes. Ventilation moves air into and out of the
lungs, and perfusion allows for gas exchange across cap-
illaries.
39.2 Bronchioles are lined with smooth muscle that oontrols
the amount of air entering the lungs. Dilation and con-
striction of the airways are oontroUed by the autonomic
nervous system.
393 Inhalation isa common route of administration for pul -
monary drugs because it delivers drugs directly to the
sites of action. Nebulizers, MDIs., and DPIs are devices
used for aerosol therapies.
39..4 A.'lthma i. a chronic disea.., that ha, both inflammatory
and bronchospasm components. Drugs are used to pre-
vent asthmatic attacks and to terminate an attack in
progress.
39.5 Beta-adrenergic agonists are the most effective drugs for
relieving acute bronchospasm. These agents act by acti -
vating beta, receptors in bronchial smooth muscle to
cause bronchodilation.
39.6 The anticholinergic ipratropium is a bronchodilator oc-
casionally used as an alternative to the beta agonists in
asthma therapy.
NCLEX-RN" REVIEW QUESTIONS
D The patit'nt receives treatment for a respirntorycondition
through aerosol therapy. The nurse explains that the ma-
jor advantage of this type of therapy is that:
l. it has no systemic side effects.
2. it delivers the medication to the site of action
3. it requires no skill to use it.
4. it issafe for aJ.I patients.
39.7 Methylxanthines such as theophylline were once the
mainstay of chronic asthma pharmacotherapy. They are
less effective and produce more side effects than the beta
agonists.
39.8 Inhaled corticosteroids a.re often drugs of choice for the
long-term prophylaxis of asthma. Oral oorticosteroids
are used for the short- term therapy of Sl'vere, acute
asthma.
39.9 The leukotriene modifiers, primarily used for asthma
prophylaxis, act by reducing the inflammatory compo-
nent of asthma.
39.10 Mast cell stabilizers are safe drugs for the prophylaxis of
aMhma. Thq are I ...... dfectiw than the cortico-
steroids and are ineffective at relieving acute bron-
chospasm.
39.11 Chronic obstructive pulmonary disease (COPD) is a
progrer.sive disorder treated with multiple pulmonary
drugs. Bronchodilators, expectorants, mucolytics, an-
tibiotics,and oxygen may offer symptomatic relit'f.
D The patient is using a beta-adrenergic agonist for treatment
of asthma. The nurse teaches that the action of this drug is:
]. redudng mucus production.
2. relaxing bronchiole smooth musdt', thereby causing
bronchodilation.
3. liquefying mucus.
4. redudng cough.
LibraryPirate
o Patient teaching for patients on long-term therapy with
beta-adrenergic agonists for treatment of asthma should
include:
1. discontinuing the drug if the heart rate increases.
2. monitoring intake and output.
3. reducing the dosage of the drug ifinsomnia ocrurs.
4. notifying the health care provider if the drug no longer
seems effective.
o A 65-year-old male is prescribed ipratropiWll (Atro"ent)
for the treatment o f asthma. An appropriate nursing in-
tervention includes:
1. teaching the patient to amid caffeine in the diet.
2. assessing for an enlarged liver.
3. teaching the patient to repon an inability to urinate.
4. monitoring for development of diarrhea.
CRITICAL THINKING QUESTIONS
1. A 72-year-old male patient has recently been started on an
ipratropium (Alrovent) inhaler. What teaching is inlpor-
tant for the nurse to provide!
2. A 45-year-old patient with chronic asthma is on cortico-
steroids. What must the nurse monitor wht'n caring for
this patit'nt?
3. A 7-year-old boy with a history of asthma goes to the
health room at his elemenillry s.:hool and states that he has
increased shortness of breath and chest tightness. On as-
sessment, the school nurse notes s.:attered expiratory
wheezes throughout his upper and middle lung fields and
a decreased peak meter (Jow. The currt'nt therapeutic reg-
imen for this child includes salmeterol (Serevent ) two
puffs evt'ry 12 h, montelukast (Singulair) 5 mgfday PO in
the evening, triamcinolone {Az.Illaoort l two puffs tid, and
albuterol (Provt'ntil) two puffs every 4 h prn. Afterobserv-
o..plfll9 0rug51o, Asthma and Other Pulmonary OM,d ... , 603
II Nursi ng assessment for a patient on long-term oral corti-
costeroids would include: (Select all that apply. )
1. assessing liver function tests.
2. assessing cardiac dysrhythmias.
3. assessing for signs of peptic ulcers.
4. monitoring blood glucost' for hyperglycemia
S. assessing for changes in level of oonsciousness.
o Which of the following agents is .!!l2ll immediately help-
ful in trelting a severe acute asthma attack?
1. Bedomethasone (Qvar)
2. Zileuton {Zyflo}
3. Albuterol (Proventil, Ventolin)
4. Salmeterol (Serevent)
ing the child's technique in using the metered-dose inhaler
(MOI l, thes.:hool nurse wishes to reinforce thechild'sed-
ucation as it relates to the administration technique of his
inhaL'lnt s. What areas should be emphasized!
See Appendix D for answers and rationalel for all activitiel.
EXPlORE
Myflrsingllit I! yoor to, OtIIi rll! mapler revieW materialS
fl!SOOlceS. Prepare lor sucus. wiI!t
QUestilns. Inl(lactil1) and woo i llks, a\imatl(l1$
and _ideo:s, . nd
Regi(ller \'OUr access (:OdD Ilom IllS kont 01 ywr al
WYM.mynll"*'gIIltcom.
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TI,is page intentionally left blank
LibraryPirate
CHAPTER 40
CHAPTER 41
CHAPTER 41
Drugs for Peptic Ulcer Oisease
U NIT 7
The
Gastrointestinal
System
Drugs for Bowel Disorders and Other Gastrointestinal Conditions
Drugs for Nutritional Disorders
LibraryPirate
DRUGS AT A GLANCE
PROTON PUMP INHIBITORS 1'J'II'.10
Q omeprozole (PrlIosff) pI1Jt611
HIRECEPTOR ANTAGON ISTS pI1Jt611
Q ranllldlne(Zanlac) fl1I}'61l
ANTAODS pI1Jt61;
Q aluminum hydroxide (AlternaGEL,
others) pI1Jt616
ANTIBIOTICSFORH.PYWRI JIl'll'ri15
KEY TERMS
ilntacid fl1I}'615
antiflatulrnt (II1I'615
chirf(ells poqe6lJ8
reflUJ ftl'1l' 6lI!
gastroesophageal reflux disenf (GlRD) fX1I}t(D;
H+ ,K+ ATPalf paje611
Drugs for Peptic Ulcer
Disease
LEARNING OUTCOMES
After reading this chapter, me student should be able to:
1. Describe the major anatomic structures of the upper gastrointestinal
tract.
2 . Identify common causes,signs,and symptoms of peptic ulcer disease
and gastroesophageal reflux disease.
3 . Compare and contrast duodenal ulcers and gastric ulcers.
4 . Describe treatment goals for the pharmacotherapy of
gastroesophageal reflux disease.
S . h.J.,,,tify th" cld.sinCdtiun uf drug" u."u to l, .. "l p.,ptic uk." di""d .,.
6. Explain the pharmacologic strategies for eradicating HeUcobacterpy/ori.
7 . Describe the nurse's role in the pharmacologic management of patients
with peptic ulcer disease.
S. For each of the classes listed in Drugs at a Glance,know representative
drugs, and explain their mechanism of drug action,describe primary
actions,and identify important adverse effects.
9. Use the nursing process to care for patients who are receiving drug
therapy for peptic ulcer disease.
Hrrutptorantagonist fllKlt6ll
HelicobQCttfpy/ori ty.TJe6(1)
intri nsidactor fIIKIt{l1J
milk-alkalisyndrome puJe61S
fIIKIt(iJ7
parietal cells {!all 6al
peptic ulcer fIIKIt{l
peristalsis page (iJJ
proton pump inhibitor page611
syndrome jl!9I611
LibraryPirate
V
ery little of the food we eat is directly available to body
cells. Food must be broken down,absorbed, and chemi-
cally modified before it is in a useful form.The digestive system
performs these functions,and more. Some disorders of the di-
gestive system are mechanical in nature, providing for the
transit of substa nces through the gastrointestinal tract.Others
are metabolic, involving the secretion of digestive enzymes
and fluids, or the absorption of essential nutrients. Many signs
and symptoms of digestive disorders are nonspecific and may
be caused by any number of different pathologies.This chal>
ter examines the pharmacotherapy of two common disorders
of the upper digestive system:peptic ukerdisease (PUD) and
gastroesophageal reflux disease (GERD).
40.1 Normal Digestive Processes
The digestivt' system consists of two basic anatomic divisioru;:
tht' alimt'lltary canal and tht' accessory organs. The alimen-
Bile '"''' ------....
Hopa1ic II
"
T,an5Ve," , o , , - ~ , - ; - J -
". Flgure40.1 The digestive system
tary canal, or gastrointestinal (GIl tract, is a long, continuous,
hoUowtube that extends from tht' mouth to the anus. Tht'ac-
cessory organs of digestion include the salivary glands, liver,
gaUbladder, and pancreas. Major structures of tht' digestive
systt'lll are illustrated in ". Figure 40.1.
The inner lining of the alimentary canal is the mucosa
layer, which provides a surface area for the various acids,
bases, mucus, and enzymes to break down food. In many
parts of the alimt'ntary canal, tht' mucosa is folded and
contains deep grooves and pits. The small intestint' is lined
with tiny projections called yilli and microvilli, which pro-
vide a huge surface area for tht' absorption of food and
medications.
Substances are propelled along the GI tract by pfristal5is,
rhythmic contractions of layers of smooth muscle. The
speed at which substances move through the GJ tract is crit-
icalto the absorption of nutrients and water and for the re-
moval of wastes. If pt'ristalsis is too fast, nutrients and drugs
will not have sufficient contact with the mucosa to be ab-
sorbed. In addition, the large intestine will not have t'Ilough
time to absorb water, and diarrhea may result. Abnormally
,i
"
"
colon
colon
Source: MJMIIJII er 01. Hurr.m DI'>&I5eI: A SY'ilemk: Approac:h, 6lh ed/rial, CL006, p. H6. Reprlnred Uy permlllJoool Pro'500 frucorloo, he. Upper
SaddIeRIver,NJ.
LibraryPirate
608 Unlt7 TheGa,uoIm",tI ... ISym'm
slow transit may result in constipation or even obstructions
in the small or large intestine. Disorders of the lower diges-
tive tract are discussed in chapter 4100.
Tu i>r"ak duwn i" I!.,,,t,,d foud, larg" Ilwnu"r
of enzymes and other substances are required. Digestive en-
zymes are secreted by the salivary glands, stomach, small in-
testine, and pancreas. The liver makes bile, which is stored
in the gallbladder, lUlt il needed for lipid digestion. Because
these digestive substances are not common targets for drug
therapy, their discussion in this chapler is limited, and Ihe
student should refer to anatomy and physiology texts for ad-
ditional infonnation.
40.2 Acid Production
by the Stomach
Food passes from the esophagus to the stomach by traveling
through the lower esophageal (cardiac) sphincter. This ring
of smooth muscle usually prevents the stomach contents
from moving backward, a condition known as
fl ux. A second ring of smooth muscle, t he pyloric sphincter,
is located at the entrance to the small intestine. This sphinc_
ler regulales the flow of substances leaving the slomach.
The stomach thoroughly mixes ingest ed food and secretes
substances that promote the processes of chemical diges-
tion. Gastric glands extending deep into the mucosa of the
stomach conlain several cell types critical to digestion and
importanl to the pharmacotherapy of digestive disorders.
Ch irf (flls secrete pepsinogen, an inactive form of the enzyme
pepsin that chemically breaks down proteins. Parif tal (fils se-
crete 1 to 3 L of hydrochloric acid each day. This strong acid
PHARMFACTS
Upper Gastrointestinal Tract Disorders
AppMim.!.1y 60 to 70 million Am.rica ..... afk<trd by. dig .. tw.
dilmf.
Approxim,lt/y 10% of Americanl willapffil'lI(f a ptptic: uhr in their
liktimt.
Mo .. th,n 400,000 new ml's of ptplic: aft' diagn&led

About 6,000 proplt die anrually of ptptic rtlatrd (omplic,lions.
pl'KfM of Amtricans wfrer from daily symptoms of GERD.
helps break down food, activates pepsinogen, and kills mi-
crobes that may haw been ingested. Parietal cells also se-
crete intrinsic factor, which is essential for the absorption of
vitamin Bll (chapter 42(0) . Parietal cells are targets for
the classes of antiulcer drugs thai limit acid secretion.
The combined secretion of the chief and parietal cells,
gastric juice, is the most acidic fluid in the body, having a pH
of 1.5 to 3.5. A numbt>r of natural defenus protect thestom-
acb mucosa against this extremely acidic fluid. Certain cells
lining the surface of the stomach secrete a thick mucous
layer and bicarbonate ion to neutralize the acid. These form
such an effective protective layer that the pH al the mucos.al
surface is nearly neutral. Once they reach the duodenum,
the stomach contents are further neutralized by bicarbonate
from pancreatic and biliary secretions. These tl.1tural de-
fenses are shown in .. Figure 40.2.
1_ Gastric juice pH - 2
.. Flgure40.2 Natural defenses against stomach acid
Bicarbonate barrier
neulralizes acid .
LibraryPirate
40.3 Pathogenesis of Peptic
Ulcer Disease
An IIleer is an erosioo of the muoosa layer of the GI tract,
usually associated with acute inflammation. Although ul
cers may occur in any portion of the alimentary canal, the
duodenum is the most common site. The term peptic ulcer
refers to a lesion located in either the stomach (gastric) or
small intestine (duodenal). Peptic ulcer disease is associated
with the following risk factors:
00 ... family history of PUD
Blood group 0
Smoking tobacco
Beverages and food containing caffeine
Drugs, particularly corticosteroids and nonsteroidal
anti-inflammatory drugs (NSAIDs), including aspirin
Excessive psychologic stress
Infection with Helicobacter pylori
The primary of PUD is infection by the gram-
negative bacteriwn Htlirobttfpy/ori. Approximately 50% of
the population has H. pylori present in their stomach and
proximal smaU intesline. In lIoninfected patients, the most
common cause of PUD is drug therapy with NSAIDs. Sec-
ondaryfactors that contriblltt:to ulcer formation and subse
qut'nt inflammation include secretion of e."(cess gastric acid
and hyposecretion of adequate mucous protection.
The characteristic symptom of duodenal ulcer is a
gnawing or burning, upper abdominal pain that occurs 1
to 3 hours after a meal. The pain is worse when the stom-
ach is empty and often disappears on ingestion of food.
Night-time pain, nausea, and vomiting are uncommon. If
the erosion progJ"eSles deeper into the mucosa, bleeding
occurs and may be evident as either bright red blood in
vomit or black, tarry stools. Many duodenal ulcers heal
spontaneously, although they frequently recur after
months of remission. Long-term medical follow-up is
usually not necessary.
Gastric ulcers are less common than the duodenal type
and haw different symptoms. Although relieved by food,
pain may continue even after a meal. Loss of appetite,
known as anorexia, as well as weight loss and vomiting are
more common. Rt>missions may be infrequent or absent.
Medical follow-up of gastric ulcers should continue for
several years, because a small percentage of the erosions
become cancerous. The most severe ulcers may penetrate
the wall of the stomach and cause death. \'lhereas duode-
nal ulcers occur most frequently in males in the 30- to 50-
year age group, gastric ulcers are more common in women
uv"r 60.
Ulceration in the distal small intestine is known as
Crohn's disease, and erosions in the large intestine are
called ulcerative colitis. These diseases, together catego-
rized as inflammatory bowel disease, are discussed in
chapter 41010 .
40.4 Pathogenesis of
Gastroesophageal Reflux Disease
GlIstro!sophageal rrfl ux disease (GERD) is a common condition in
which the acidic contents of the stomach move upward into
the esophagus. This causes an intense burning (heartburn)
sometimes accompanied by belching. In severe cases, lUl-
treatoo CERD can lead to complications such as esophagi-
tis, 01" esophageal ulcers or strictures. Although most often
thought a disease of people older than age 40, GERD also
occurs in a significant percentage of infants .
The uu"", of GERD umally a weakening of the lower
esophageal sphincter. Tht' sphincter may no longer close
tightly, allowing the contents of the stomach to move up-
ward when the stomach contracts. GERD is associated with
obesity, and losing weight may eliminate the symptoms.
Other lifestyle changes that can improve GERD symptoms
include elevating the head of the bed, avoiding fatty or
acidic foods, eating smaller meals at least 3 hours before
sleep, and eliminating tobacco and alcohol use.
Bocause patients oftt'n self-treat this disorder with OTC
drugs, a thorough medication history may give clUe! to the
p .. esfnce of GERD. Many of the drugs prescribed for peptic
ulcers are also used to treat GERD, with the primary goal be-
ing to reduce gastric acid secretion. Drug classes include
antacids, H,-receptor antagonists, and proton pump in-
hi bitors. Because drugs provide only symptomatic relief,
surgfry may become necessary to eliminate the cause of
GERD in patients with persistent disease.
40.5 Pharmacotherapy of Peptic
Ulcer Disease
Before initiating pharmacotherapy, patients are usually ad-
vised to change lifestyle factors contributing to the severity
of PUD or GERD. For example, eliminating tobacco and al-
cohol ust' and reducing stress promote healing of the ulcer
and may cause it to go into remission. Avoiding certain
foods and beverages can lessen the severity of symptoms.
The gooisofPUD pharmacotherapy are to provideimme-
diate relief from symptoms, promote healing of the ul,er, and
prevent future recurrence of the disease. A wide variety of
both prescription and OTC drugs are available. Thest drugs
fall into four primary classes, plus a misceUaneous group.
The mechanisms of action of the four major drug classes for
PUD are shown in Pharmacotherapy Illustrated 40.1:
H,receptor amagonists
Proton pump inhibitors
Antacids
Antibiotics
Miscellaneous drugs
For patients on NSAIDs, the initial approach to PLlJ is to
swikh the patient to an alternative medication, such asacet-
aminophen ora selective COX-2 inhibitor. This is notalways
possible, because NSAIDs are drugs of choice for treating


,


"


,


"
LibraryPirate
610 Unlt1 Thl>Ga'i!'oIm .. tln.1 System
PHARMACOTHERAPY ILLUSTRATED
40. 1 Mechanisms of Action of Antiulcer Drugs
Pmtoopunp
,mibil""
Proton pump inhibitors to
K+ ATP ... e and
prev"'" acid ""'" bftog ....,..,ted.
prolonpump
H
2
-receptor antagoni.t. occupy
the h",tam"" reoeplOta and
pn!I_ acid .ecrelion.
cellwilh
H,,-receptor
UIc&r with H pylori
0" /\
...... .. J '-- -
Antibiotic 0 ... __ ___ + HCL - water + salt
00
o 0
Antibiot K>. emdica.l .. fi pybri. the
primary cause 01 peptic ulce ....
chronic arthritis and other disorders associated with pain
and inflammation. If discontinuation of the NSAID is not
possible, or if symptoms persist after the NSAID has been
withdrawn,antiulcer medications are indicated.
For patients with H. pylori infection, eradication of the
bacteria with antibiotics is the primary goal of pharma-
cotherapy (see Section 40.9). Treatment using only antiulcer
drugs without eradicating H. pylori results in a very high re
currence rate of PUD.
Alka line antacid. chemically coml> ....
with acido to Iow<tr .tomach pH.
PROTON PUMP INHIBITORS
Proton pump inhibitors act by blocking the enzyme respon-
sible for secreting hydrochloric acid in the stomach. They
are drugs of choice for the short-term therapy of PUD and
GERD. These agents are listed in Table 40. 1.
LibraryPirate
CNplfl40 CInJ9' /0, Peptic: Uk .... [)I, ... ", 611
TABLE 40 1 I Proton Pump Inhibitors
",,"
Route and Adult Dose (max dose where Indicated) Adverlie Effects

PO; mglday
(f't!'Ii(id) PO; 15--60 mglday
0, omtpI'amit IPri.-:) PO; 2O--ro m9 tolWO
(Protoril) 1'0;010 mglday
.,btpnlOlr (AdplltxJ pO;lOrnglday
IIQ/k! iOlkatr ammon mr;r uodelliniog iolkate strilM adYmt
40.6 Pharmacotherapy with Proton
Pump Inhibitors
Proton pump inhibitors roouce acid secretion in the stomach by
binding irreversibly to the enzyme H+, K+-ATPasf. In the pari-
etal cells of the stomach, this enzyme acts as a pump to re-
lease acid (also called H ,or protorts) onto the surface of the
GI mUCO<3. Th .. proton pump inhibitor. reduc .. acid .<'Cre_
tion to agreaterextent than the H,-receptorantagonists and
have a longer duration of action. PPls heal more than 90%
of duodenal ulcers within 4 weeks and about 90% of gastric
ulcers in 6 to 8 weeks.
Several days of proton pwnp inhibitor therapy may be
needed before patients gain relief from ulcer pain. Benefi-
cial effects continue for 3 to 5 days after the drugs have been
stopped. These drugs He used only for the short-term con
Prototype Drug I Omeprazole (P"losec)
IItOOodIf, dilJrrhto. OOIISN, 1I!!Ii. dirzirlflj
5Njoujadyerlr are rlre
trol of peptic ulcers and GERD; Th .. typical length of ther-
apy is 4 weeks. Omeprawle and lansoprawle He usoo con-
currtntly with antibiotics to eradicate H. pylori. The newer
agents esomeprawle ( Nexium) and pantoprawle ( Pro-
tonix) offer the conveni .. nce of once-a-day dosing.
All proton pwnp inhibitors have similar efficacy and ad
verse effects. Serious adverse effects from drugs in Ibis class
,mcommon. nn"""",,
and vomiting are the most frequently reported effects.
H,-RECEPTOR ANTAGONISTS
The discovery of the Hrreceptor antagonists in tht 1970s
marked a major breakthrough in the treatment of PUD.
They have since become available OTC and are widely used
Therapeutic (lass: Antiulcer drug Pharmacologic (lass: Proton pump inhibitor
ACTIONS AND USES
Ortll'p,aroit was thr fim proton pump inhibitor to II!' applVt'fd for PlJD: Both
pl"I'sc:ription and OK forms al"l' 'lIIilabit. k l"I'dum ac:id If(l"I'tion in tilt !10m-
.(h by binding to the ml)'lllr H+, K + -ATPasr.Although this agtflt
un tlU 2 hours to 1"I'.(h tht raprutic: lfoIels, its rfftcn bl1 up to 72 houn.1t is
UIN fortllt shon-term, to 8-wrrk therap)' of ac:ti!' ptptic: ukt rs and GERD.
Most patients al"l' S)'IIIptoll .firr 2 wrrks of therapy. k is wd for Ioogff pt-
riock in PiUients who (hrooic: hyperlf(l"I'tioo of gastric. .cid, condition
known as lollinger-Eni!on s)'rtdrome. k is tilt molt rfftaiYe drug for this
syodrornt. Omeprazolt is milablt only in oral fonn. Zrgffid is a combination
drug (ontlining omtprnolr and tht antacid sodium bic:arbonatt.
ADMINISTRATION ALERTS
If possiblt,administfrbefol"l' bl"l'akfast on an t mptystoma{h.
It may II!' administtrtd with antacidl.
(apsules and tablets sllould nOl II!' chewe;l,diYided, or uushtd
PlI'9
n
'OQU1tgory(
PHARMACOKINETICS
Onlt"t;0.5--l5h
Prak;5days
Halflife; O.5-1.S h
Duration; l ... 4 days
ADVERSE EFFECTS
Ad!'m tffM aft' gtntrally mioor and in{kidt htadac:ht, l\alMa, dicrrht.,
lid ilbdomina I pain.lhr main con{tm with proton pump inhibitors is that
Iong-tmn UIf has brrn moc:iatM with .n in{JNsed risk of gastric Cal(tI in
laborallry animals. of this possibility, therapy is gentraUy limitrd to 2
monthl.
Contr.indiutions; Tht on1)' rontraindic:ation is hyptl"l>l'nlitMty to thr drug.
OTC lilt is oot approvtd for patienu uncltr 18 )'I'ars of agf.
INTERACTIONS
willi diaztpam, mil"1
00II' rom! blood It'II'II of thfsf Conrufll'ntllll' with w!!l'Mil mil")'
inaNw: the liWhood of blfeding. Akohol (;lO iHJ9'aviltl' the !iIOIIIidlIlUOW atd
dKJNs.! the fifutivmm of lJMP"iIldf.
Lib mil")' i1crNst vaIut>s for
_w.
HI'IiIiI Hood; Gioiato iIId won mil")' dKJNII' the pIaIrna of
.......
Treatment of Owmlose; Theil' is 00 sprc:ific: trtatmeot for O!'Idosr.
RPI'l'r Ie M)M!rliIIgKJIlbr Q Nlmlrll} Pn:m! fOOI5 Jjlt(1/{ Ie rills
LibraryPirate
612 Unlt7 ThI' Ga'ilrolnt .. tI",,1 Sy<!'-""
TABLE40.2
H
2
-Receptor Antagonists
Dru, Route and Adult Dose (max d05l! where Indicated) Adwrse Effects
PO;300 1119 6 h 01800 mg .It OI400mg bid with food fMrrIIeG, (lmMipmiOll, MliI<xilt, faligut,
(Ptpdd, Mylointa AP I PO;lO 1119 bid 0140 mgolt
(Axid)
o rinitidilll' (lanta() PO; 11-1SO mg bidor 300 mgat
(OI'llmon tdwnt
in the treatmem of hyperacidity disorders of the GI tract.
These agents are listed in Tab)e 40.2.
40.7 Pharmacotherapy
with H
2
-Receptor Antagonists
Histamine has two types of receplOrs: HI and H,.Activation
of HI receptors produces the classic symploms of inflamma-
tion and allergy, whereas the H, receptors are responsible for
increasing acid secretion in the stomach. The
onisl! are effective at suppressing the volume and acidity of
parietal cell secretions. These drugs are used to treat the
symptoms of both PUD and GERD.
All H,.receptor antagonists have similar safety profiles:
Adverse effects are minor and rarely cause discontinuation
fOr Prototype Drug I Ranrtrdrne (Zanrac)
gynKOfflQl/iQ
!!art: Hepatitis. t+Jod d'l'l!OOi\, .naphy\a1:iI.!MrIrtlImin.
{OOfuIiooOl'
1lwiKht; MUJtq. dry fOOIJIh
P<lin OO)'Qrdia !IOOd dysqasia,

of therapy. Patients taking high doses,or those with renal or
hepatic disease may experience confusion, restlessness, hal
lucinations, or depression. The first drug in this class, cime-
tidine (Tagamet ), is used less frequently than other
H,.receptor antagonists because of numerous drug-drug
interactions (it inhibits hepatic drug-metabolizing en-
zymes) and because it must be taken up to four times a day.
Antacids should not be taken at the same time because the
absorption of the H l ' re<;eptor antagonist will be diminished .
ANTACIDS
Antacids are alkaline substances that have been used to neu-
tralize stomach acid for hundreds of years. These agents,
listed in Table 40.3, are readily available as OTC drugs.
Therapeutic (lass: Antiul cer drug Pharmacolog ic (lass: Hl-It'(l'plor antagonist
AalONS AND USES
byblodcing H, rmpton in todfill'u!' ac:id prodlK-
lion.1t hal ol higher palm')' lhan whim allows it 10 lit administt rrd
onc:t al bedtin"l!'. Adtqwtt htaling of tht ukff I.kes approxi-
4 to 8 Wffks,ahhough at high risk for PUD may (ontinue on drug
m.imo ... for prolongod po>riock 10 p ....... nt IUrrrn.li.><trK rrqJilt:
longer thmpy for healing to oc(ur.1V and 1M forms 'I! aY.ilablt for n at-
mt m of ,nM, ukm.Trit is i (ombination drug with
,nd bismum is availablt in i dissoiYing tablet form
(EFFERd=) fortlNtingGERD in (hildrenand infanrsolder mol n 1 month of agt.
ADMINISTRATION ALERT
Administer after mtakand roonitor liver and lI'n.llunaion.
Pf!gniOCY rnegory 8
PHARMACOKINETICS
I),set Unknown
Pf,ik:l- l h

DUrition: 8- 12h
ADVERSE EFFEaS
tffects art unc:ommon and mild. Rnitidint doe 001 (rol!! tht
blood-brain b.rrier 10 i ny a extt nt. so it OO!'! nOI the (onfusion
and CNS obserwd with (imetidint.Ahhough rail', 1!'\'I'fl' rrdlKtions
in number of red , nd whitt blood (l'lk ,nd all' possible;thUI, peri
odic blood count< lniy be pcrformrd High ""'y rnuk in impotolKo or 10 ..
oflibido in mt n.
Contraindirnions: Contraindicationl inc: kKit hypersmsitivity to H,.rt plor
aMt porphyrit, i nd or( administration in childl!n Ie! than 12
yursofq.
INTERACTIONS
1Wg- 1Wg: blitidM has Itw drug-d"ug il!l'I"actioos than dmttidirll'.
Raritidillf may redtn thf .t.sorptiOl'l of kMlKOIIiroIf, and
itrar:onarolt.AnIiKids Ihoo.Ml no! be gil'l'Owitllil 1 hoor ofH,-rtcfPlOl oI ntagonisrs
beao.MthfeflKriI'I'IIfII may bf di'<JNIi u to rflkKfdabsorplion.
dPaui.fI thf of raoi!icine.
Lab Tflt!: Raniti!fn> mil1inmu thf UiIfS of 1fI"000 1TN1ili1lf,.IJT,AL, too,
alaIirII' and bilNliIl k IN)'prOliu fb poIiliHosfor m]HIHI.
HerbaVFood: Absofption of vitamin 8" deprnds on ill addic: thus,
df/idfn(ymay OCtut no isalso bfUH absorbfd in ill oIddic: fmironlllfflt
l INtment is 00 Ipt(ific: tlNlmenl for OWOOI!'.
IWtf /II MyMIsIrtiJU fIJf MnbIiJ Plrxl'S.! fIlM spt{1/I( /111M ItrJg.
LibraryPirate
CNplfl40 Orug;fu'Peptk:UIc .... DI' ... '.. 613
NURSING PROCESS FOCUS PATIENTS RECEIVING DRUG THERAPY FOR PEPTIC ULCER IPUDJ
AND GASTROESOPHAGEAL REFLUX DISEASE (GERD)
Assessment
a,smment priorto admini,tration:
Undtrstmd thr INSOO the drug has bn presc:ribrd in ordrr ro mes for
rhrrapMic: t1frru.
Obtain (omplete history ill(k.iding 61. hrpatic, K'nal. or
(a,dicmsaJlar Pft'9nanc,; or b,N \I-fffiling. Obu in a drug histor,
inckiding allergies, currenr plI'ICription aod OlC drugs, hrrbal prr parations,
(aiteill!', nic:Olill!', aod akohol usr.B .. alert ro possible drug intmctions.
Obtain' hisror, of pur and symptoms, ooting any cOll<'btions
rht onsrr or pltSt lKt of any piin ItLited to meals, slftp.
positioning. 0' moc:iatt<l with orhr, medic:ations.Also nort whar mfUUII'S
hnt bn to II' lifl't tht pain (e.g., t uing).
Obtain signs aod wtight.
Evaluall' approprWtt laboratol)' findings (f.g., C Be, platf lm, titctroi)1es,
htparic: or renal fulKtion Slodie).
Assessment throughout iI dministration:
for dtsirrd thrrapMic: fitI'm (t.g., diminisht<l gamic: all'a pain.
Its=rd bloating or bekhing).
Continue periodic: monitoring of (BC,elt(trolytes, ,md hrp.ltK and
fiJoaion Llbs. Te ting for H.pyIai rna)' be nffiRd if symptoms fail to rrsotvf.
for adve!lf tlfrru: n.JIMa, wmiting.dianbea,hradoKhr,drowsines,
and dil.zinm.Sr'Rre abdominal piin,l'Omiting,roiftt"9roond or bloody
I'Omiting.or blood in \OOI or ralT)' stools !hoold be Il'pOnfd immtdiatfly.
Potential Nursing Diagnoses
AruIl'Pain
Ak .. ,t<1 Nurrition,lffi Than Body RfqJill'l1II'nn
Derl(ient KnowIl'dge (drug thl>rapy)
Risk for Health Maimf nalKf (lodjyidwl or Family;dietary ,od
liftstylechangtl)
Planning: Pilltient GOillis iIInd Expected Outcomes
Thf patirm will:
bptrielKf thrrapMic: tifls It.g.,diminished or absrnt gastric: piin,ab!elKe of related symptoms !lKh ill bloating or belching).
iIl'f from,or idvtrsr t lferu.
an undtBtaodiog ofwdrug's 1M, flfts,and II'qJill'd plfCautions.
Demonstratt proper !eIf-<l dministration ohhr mtdiytion timing. when to notify provider).
Implementilltion
Interventions and (Rationales)
Ensuring thtrilptutic effects:
--+
E lKooragt induding an ilKlNstd inrake of
)'OgUn and oc:KIop/lI1I1Honraining patitm ktepa food dial)'
noting corll'iations betwren diso:omfort or piin aod me<l lsor adjyitirs.
(Smoking ,nd akohol 1M ilKltaSfgallrK add and inirarion aod should be
eliminated.(omlating symptoms with dirtary habits rna)' ht lp to tliminate
a triggering foKtor.)
Minimizing adftlSe tffHts:
(ontinut to monitor thr pll'srlKfof 9iIItrK all'il piin.{Continutd symproms
may iodintt iOl'lfliYeness ofcUlIl'Ot drug thrrapy or thr Ol'td for testing
for
Monirorfor anylf"lfll' <lbdomioal pilin, wmiting, rolfft'-ground or blood)'
I'Omiting,or blood in stool or tarry stools report (Drugs
used rotll',t PUD <l od GERDdem,sr 9iIItrK oKidiry, making
Itss f'l'Orablr for uker dtelopl1ll'Ot bur do not heal
v:isting SorYert <l bdomioal pain 0' blood in t mrsisor \lools m<ly
indic,re a worst ning of or moll' strious (ondirions aod should be
reponed immtdiatelyJ
Pilltient and Fillmily Educilltion
ElKoorq the patient ro <ldopt a healthylih,style food choic:e
aod ilKlI'astd m-rdsr,aod to eliminatt <lkohol aod
smoking.Prafldt for dittitian (oosulration or information on smoking
(ffiation programs iIIlM'tdtd.
TNch the IHItirnr that full drug tlferu rna)' rake lI"/eIal days ro wtfn or
longer. Con>isttnr drug therapy wi II prafldt thr besr results. If 9<1stric
or pain (OnrinuforWOBtn afrflll'Vl'ral weeks of rhtraP1, the
health (a,e prafldtr >hoold be norifled.
Teach the IHItirnr rhat smlt abdominal pain orany blood in t rntsis or
stools should be r"POrted immedi.Jtt'ly to the heakh care prwider.
(Continued)
LibraryPirate
614 Unlt7 lheGa'ilrolnt..,tI""ISymrn
NURSING PROCESS FOCUS PATIENTS RECEIVING DRUG THERAPY FOR PEPTIC ULCER (PUDI
AND GASTROESOPHAGEAL REFLUX DI SEASE IGERD) (Continued)
Implementlltion
Interventi ons li nd (Rlitionliles)
Conlirue to monitor pfriodic hepatic: and rrul function trill ,nd (Be.
platrlm. ,nd rledrolyir (Aboormallrm- fUnction I..,U may indicatr
drugindlKrd adYe.n hepatic ROC. WOC.or platelets h,Ye
bffiJ noted with iong1mJl H,.recr ptor blocker iOOapy and dr<lNsrs
should bt I!poned 10 thr health ('R' providtr. UII' of anudds may
affect ritrolyir 1eW'1s.)
EnsoR' patinlt safrty. in oIdrr aduhs.ObIl'M fordiuinrss and
monitor ambuLllion unlil the rfi"Is of thr drug arr known.(Orowsinrss or
dizziness from H,reptor bIoc:urs may Q((ur. which inuralel thr risk of
falls.cMtinued dizzines!ordrowsinm may I"I'qJiR' a changr in drug
thrrap)'.j
undt rstanding of drug tht ra p-,:
lJSI' opportunitiH during administration of mediGlDons and during
mrs,mfllU 10 the r.tion.1e for drug , ...... py.dt,irtd thK.lP"'tK
ou\(omrs. most (ommon amrserfil'ltI.paramrtrrs forwhrn to ulllhr
he.kh taR' provider. ,nd a ny ne(rs sary monitoring or precautions. (Using
time during nursing (aft-' help! to optimin> and rl'in/oKe teaching
aR'asJ
stlf'il dministration of drug thrrapy:
Whrn administffing thr IIII'dimion, instruct the fam it;. or
taR'giver in the proptr oft .... druq. r.g.. ruring mning
IIlNI. (Proper administralion impl"l)Yel thr rfilil'l'llrss of thr
Pliti ent li nd Fli mil y Educlition
Instruct t .... patirnt on the need to R'lum ptriodiully for lab work.
Instruct the patirnt to u ll for assistalKr prior 10 getting out of btd or
allempling 10 walk alone,and to avoid driving or other activitirs R'qJiring
menial , Irrtnes s or physical (oordination unlilthr rlln ohhr drug aR'
""" ..
The patirnt, famit;. or taR'9iYer should lit able tostalr Ihr for thr
drug; .ppropri.N doI nd hodJling;what oct ........ ffKtlIO obll'lft for
and when 10 R'pon; and thr antic:ipaied length of medicilion thrrapy.
Tra.c:h thr totaR mording to 'ppropria!t guidrlines as
follows:
H,.rrtrptor bIoc:UB: Tau th. drug aftrr meals.Oo not laR (onrurrrntly
with amac:ids unless tht drug is milablr in a combination product IIKh
U
Proton pump inhibitoB: Tau 30 minutes btfoR' meals.lf onlN-d/ly
dosing onirrrd, in tho morning bebR' blNkfasl
Antadds may lit tiled (OIKurR'ntly. 00 oot oontinUl' takill9tho drug
bryand 1 to4 months unless dirrord by health taR' providtr.
Anta.c:ids: TaR 1 hours btfor. or aft. r IIlNls with a fUliglaS! of witer. 00
oot taR other IIII'diution s cOOOJlRmly unless ava ita bit .J S a
(OI11binat ion proO:Kt or dirrtttd to do 10 by tho health providrr.
Evaiuliti on of Outcome Criteria
E-Ialuatr the effectiveness of drug thrrap)' by (onfirming that patirnt goals and nptmd ou\(OIIII'S bet-'n mrl (1H P\anning1.
SH rli>lrl4IJ. 4IJ.l.ooo i1rridf'.llJllrl whidirirtst rNnirlgtimsopply.
LI FESPAN CONSIDERATIONS
H2 Receptors and Vitamin B' 2 in Older Adults
H,.R'(tptor blockers the Sft'tion of hydrodtiorir: a.c:id in thr stom
a.c:h. Unforwnatrly. gastric Kid rs\el1lial for R'ltasing vitamin B" in foods.
whic:h bound in a pratrin matril. By .lIting nomuh a.c:idity. thrsr drugs
can affect theabsorption of this itamin.
H,.reptor bkKurs aR' frrqurntly prrstribtd for older adults, who
more liuly to haYe plMllisting Iowt-'r vit,min 8" IfleMS or f'IfIl defKirn
ciH. Wrth aging. the ability to prod1Kr adtqWil' i mounts of hydlO(hiorir: add,
intrinsic ,nd digtstil'!' rlll)'mrs pI09R'SsiYely diminishes. Thesf
can Irad to lower absorption r.llt-S. depletion of and t"Vtmually B"
dtfKirnq. Thr nurw musl tdwN oIdrr adults taking thrsr as to thr
imporuntr of ilKkidill9 plenty of foods rich in Yiumin B" in thoir ditts, in
duding I!d meat. poultry, rllh,and tggs.
H OME & COMMUNITY CONSIDERATI ONS
Over-the-Counter Medications for GI Disorders
Many patirnts pun:hast arc medicalions bastd on infoonation obtaintd from
the mtdia. H,.reptor and proton pump inhibitoB
av,ilablr as OK medic:ations. Alth01l9h fYrrY orc mrdiution indudes an in
form,lion r;hffl,m.Jny proplr do not lhem. Soliii' do oot R'ad thom lit
(ausr lhey fffi that all or( medications aR' !.Ire, and othoB haYe dillkulty
small prim on tho information shws.Stili others may not
that they all' taking ,n OK thai m,y intrract with a prmribtd medicition. k
important to stR'S! to patirnts that orc mediGlDons may R'sult in
dnrg--drug intrractions and procItKr adYl'lSf rffeus. Patirnts should be in
mu(ttd to meck with their health carr provider if their digrstivt> S)T1IptOl11S
WOBrrI or aR' not R'lirYtd by orc products.
LibraryPirate
TABLE 40 3 Antacids
0""
and Adult (max dose Indicated) Adverse Effects
Q illlrinlJll hydroJlid!, 1'O;600lIIIjtid- qid CiJn5tipofiOfl,

ukilJll urbonitt (Titrili<. Turm) 1'0; 1-1 9 bid- tid CiJn5tipofiOfl, IIorultllCt
ukilJll with Illi9M1ilJll 1'0;1 pm (!IIoIx: 11 tabltts/day) Frql impilClion.me\ibolK
(Mylint.l GtI-<ip!, RoIiidsl b)l!fWltfIllia DI:iIIUdi
(Riopan) 1'0; 1,080 mg (5- 10 mL!Uljlffision or 1- 1 ublets) diiiy OOIlltO, K1mi1ing,
(mil: 10 t.lblm or 100 mL/day) (J(Jm{irll}
(Milk 1'0; 5-15 mL or 1- 4 ublttsai rwdtd up to foor time diiiy
mllrolrniil (wliffi
mollJll'liLm IrJdroxide with alLminLm hydroxide 1'0;1-4 ubltts pm (max: 16 tibltts/day)
giYl'n Dartnterally)
(Mailu)
IrJdfllXidlo with alLminLm hydroxide PO; 10 mL pm (!IIoIx: 110 mL1day) or 1--4 tabletl pm
with (M)'Iinti,Mulu PM,othtfS) (mn: 14 t.lblmlday)
\Odium biurbonite (AlkaSdtm, baking soda) 1'0;315 1IIIj- 1 9 to fOll' timrllday Abdcmiool til/moon, bIc hing, IIorulmcr
441 forth/, ProlOl)'prDrug box OO)
I!QIk! ammon idvmr sMousadwmr
40.8 Pharmacotherapy
with Antacids
Prior to the development of H,-receptor antagonists and
proton pump inhibitors, antacids were the mainstays of pep-
ti' ulcer and GERD pharmaootherapy. Indeed, nrony pa-
tients still use these inexpensive and readily available OTC
drugs. Although antadds may provide temporary relief
from heartburn or indigestion, they are no longer recom-
mended as the primary drug class for PUD. This is because
antadds do not promote healing of the ulcer, nor do they
help to eradicate H. pylori.
Antacids are alkaline, inorganic oompounds of alu-
minum, magnesium, sodium, or calcium. Combinations of
aluminum hydroxide and magnesiwn hydroxide, the most
common type, are capable of rapidly neutralizing stomach
acid. Chewable tablets and liquid fonnulations areavailable.
A few products combine antacids and H,-receptor blockers
into a single tablet; for example, Pepcid Complete contains
calcium carbonate, magnesiwn hydroxide, and famotidine.
Simethicone is sometimes added to antacid preparations,
because it reduces gas bubbles that cause bloating and dis-
comfort. For example, Mylanl3 contains simethicone, alu-
minum hydroxide, and magnesium hydroxide. Simethicone
is classified as an ntiflatulrnl, because it reduces gas. It also is
available by itself in OTC products such as Gas-X and My-
lanta Gas.
Self-medication with antacids issafe, when taken in doses
directed on the labels. Although antacids act within 10 to 15
minutes, their duration of action is only 2 hours; thus, they
must be taken often during the day. Antacids containing
sodium, calciwn, or magnesium can result in absorption of
these minerals to the general cin:ulation. Absorption of
antacids is clinically unimportant unless the patient is on a
ftuid
hmmli!!!mli.!
sodium-restricted diet or has diminished renal function
that could result in accumulation of these minerals. In fact,
some manufacturers adwrtise their calcium-based antacid
products as mineral supplements. Patients should follow the
label instructions carefully and keep within the recom-
mended dosage range.
Antacids containing calcium can cause constipation and
may cause or aggravate kidney stones. Administering cal-
cium carbonate antacids with milk or any items with vita-
min D can cause milk-alkali syndrome to occur. Early symptoms
are those of hypercalcemia and include headache, urinary
frequency, anorexia, nausea, and fatigue. Milk-alkali syn-
drome may result in permanent renal damage if the drug is
continued at high doses.
ANTIBIOTICS FOR H. PYLORI
The gram-negative bacteriwn H. pylori is associated with
80% of patients with duodenal ulcers and 70%0fthose with
gastric ulcers. It is also strongly associated with gastric can-
cer. To more rapidly and -completely heal peptic ulcers, com-
bination therapy with several antibiotics is used to eradicate
this bacteriwn.
40.9 Pharmacotherapy with
Combination Antibiotic Therapy
H. pylori has adapted well as a hwnan pathogen by devising
ways to neutralize the Itigh acidity surrounding it and by
making chemicals called adhesins that allow it to stick tightly
to the GI mucosa. H. pylori infections can remain active for
life, if not treated appropriately. Elimination of this orgaJtism
LibraryPirate
616 Unlt7 The Ga'i!,oInt..,tI,..1 Sy.rem
.... Prototype Drug I Aluminum Hydroxide (AlternaGEL, others)
Therapeutic (lass: Antiheartbum agent Pharmacologic (lass: Antacid
ACTIONS AND USES
Aluminum h)'droUde is an agent used lime or in combination with
other antlom. Combining aluminum (ompounds with magnesium (Mum,
Mylantl) inclN .., their efleo:ti'lenm and rtdutfS the potentill for ronnipa-
lion. U cakium-N 5ed an!.icidl that can br ,bsorbrd and cause l)'Item K d-
Irm, dJminum compounds are primary action is to
stomlch acid by rlising the pH of the nomac:h contl'l1ll. Unlike H,-
reU'ptor ,magoni.1I ,nd prolon pum p inhibiton.' uminu m antlcids do 001 If"-
duce the voiullll' of acid !e<rrtion.ihey a re mOlt used in (ombination
with other antiuktr agent! lor the lymptomatK relidolheartbum dJt to PUD
or GERD.A !e<ond aluminum "It. ,luminum carbonate (Bas.iljen, is also '\\Iii-
heartbum.
ADMINISTRATION ALERTS
Administer ,luminum Intadds" Imt 2 hOUri befono or alterother drugs
because a blOlJltion (ould be a/fted.
PR'9nalK)' category (
PHARMACOKINETICS
1Al1I:'t: 2Q--40 min
Pt-1k:30min

Duration:2 h when t,ken with food,) h when !.iken 1 h after food
aUows ulcers to heal more rapidly and remain in remission
longer. ThefoUowing antibiotics are commonly used for this
purpose:
amoxicillin (Amoxil, others)
clarithromycin (Biaxin)
metronidazol .. (Ragyl )
tetracycline (Achromycin, others)
bismuth subsalicylate (Pepto-Bismol) or ranitidine
bismuth citrate (Tritec)
Two or more antibiotics are given concurrently to increase
the effectiveness of therupy and to lower the potential for
bacterial resistance. The antibiotics are also combined with
a proton pwnp inhibitor or an H,-receptor antagonist. Bis-
muth compounds (Pepto-Bismol, Tritec) are sometimes
added to the antibiotic regimen. Although technically not
antibiotics, bismuth compounds inhibit bacterial growth
and prevent H. pylori from adhering to the gastric mucosa.
Antibiotic therapy generally continues for 7 to 14 days. Ad-
ditional information on antiinfectives can be found in
chapters 21 and 2200.
40.1 0 Miscellaneous Drugs
for Peptic Ulcer Disease
Several additional drugs are beneficial in treating PUD. Su-
cralfate (Carafate) consists of sucrose (a sugar) plus alu-
ADVERSE EFFECTS
Auminum ntadds cause constipation. At high dOl .... aluminum
protium bind with pholplutt in the GI tratl and long-term use (.In rflUk in
phosphate depletion. Tholl:' " risk ilKkidt thaW' maloourishtd, akoholiG, and
tholl:'with renal diW'aII'.
Contraindications: This drug should not be UII'd in patil'l1l1 with lUlpfded
boweIobmuction.
INTERACTIONS
[)ug- [)ug: AUnimrn (m1POUOOl !ht:Ud oot bf 00n with othfr rntduIiom, II
m., may n erlM with their olbsoIptioo.lkt with 1Odi:.m poIystyffM sulfonate may

Lab T.",: V.km f ....... op<lrin . n d oon ... , pit moy ilawst. \.or .... phosphO!.
\\Ik1e! may IiKINII'.
Ili!rballFoo:t: AUrin .... iIIUtim lNy inhibit IfIIo i!bsoIption of dtlify iron.
of DYfrdoH: There is 00 lpt"{ifK tlNtment lor
R<ftr III MrImlrl9R till MnJnq l'r!KeIS fIxrIs sp/It IIIIM /J"ug.
COMPLEMENTARY AND ALTERNATIVE T HERAPIES
Ginger's Tonic Effect s on the GI Tract
The 1M d gilger IJjngibtr offirinafs) for mtdicin.J1 PUIpOll'S dotH to
in Indil ,nd Chirw. The K1if i-.gRdienu 01 those 1M mate in spicy
ftil'/Ol" and prD}!'nt odor,lre louted i1 its IOOU or rIizornrs. k is sometimtllttn-
dordized according to its IttiYt 5Ubstanm. gilgerok Ind shooiok. k is sold in
pharrnac:i...asdrirdgingerroct 1,00> mg.and isread-
avaibble at roost groc:rry lor home cooki-.g.Gingtr is 0lIl' d best
lIudied herbs. and itappeilri to be useful lor I number con-
ditions. iu widtst UII' is for 1ft'ating nauw, iKb:ling tIwt (.Iused b)o roo-
lion Wmtsl, plf91'lK)' morning postoperative proc:tduR'l.1t has
""111 shown to stirruw appetite. promote !II1tric: incru .. peri-
lubi!. Iu! Ihown tlut girger may inhibit the efIeru of H. f1I/i
and may help heal prptit:ulc:m.ltleffrruappeilr to Item lrom dRet Itt;;'n on
I<Ither than on tlltCHi Ginger hal 00 toxic:itywhtn used at rerom-
mtndtddOle.AtIYrrII:'ellrmilKk.dtabdomirwldilCOmfortanddilrrhra.Om-
may lead to CNS inhibition d platelM aggrtgllion. and
(.Ird;;'tonK effrru Nathiw.van.iffprakolbon, to l.ettalelll-
gooi.1006; Padrin.lOO n.
minwn hydroxide (an antacid). The drug produces a thick,
gel like substance that coats the ulcer, protecting it against
further erosion and promoting healing. It does not affect the
secretion of gastric acid. Other than constipation, adverse
effects are minimal, because little of the drug is absorbed
from the GI tract.A major disadvantage of sucralfate is that
it must be taken four times daily.
LibraryPirate
Misoprostol (Cytotec) inhibits gastric acid secretion and
stimulates the production of protective mucus. Its primary use
is for the prevention of p"ptic ulcers in p.1tients taking high.
doses of NSAIDs or oorticosteroids. Diarrhea and abdominal
cramping are relatively oommon adwrse effects. Classified as
a pregnancy category X drug, misoprostol is contraindicated
during prt>gnaJIcy. In fact, misoprostol is somE1imes used to
tenninate pregnancies, as discussed in chapter 4500.
Metoclopramide (Rt>gIan) is occasionally used for the
shortterm therapy of symptomatic, PUD in patients who
Choplfl40 OnJg;Io,PeptkUIce<DI,,,,... 617
fail to respond to first line agents. It is more commonly pre
scribed to treat nausea/vomiting associated with surgery or
cancer chemotherapy. Metoclopramide is available by the
oral, 1M, or IV routes. It causes muscles in the upper intes
tine to contract, resulting in faster emptying of the stom
ach. It also blocks food from reentering the esophagus
from the stomach, which is of benefit in patients with
GERD. Adverse CNS effects such as drowsiness, fatigue,
confusion, and insomnia occur in a significant number of
patients.

- -
KEY CONCEPTS
The numbered key concepts provide a succinct summary of the important points from the oorresponding numbered section
within the chapter. If any of these points are not clear, refer to the nwnbered section within the chapter for review.
40. 1 The digestive system is responsible for breaking down
food, absorbing nutrients, and eliminating wastes.
40.2 The stomach secretes enzymes and hydrochloric acid
that accelerate the process of chemical digestion. A thick
mucus la)'l'r and bicarbonate ions protect the stomach
mucosa from the damaging effects of the acid.
40.3 Peptic ulcer disease (PUD) is caused by an erosion of the
muoosallayer of the stomach or duodenum. Gastric ul -
cers are more commonly associated with cancer and re-
quire longer follow-up.
40.4 Gastroesophageal reflux disease (GERD) results when
acidic stomach coments enter the esophagus. G ERD and
PUD are treated with similar medications.
40.5 Peptic ulcer disease is best treated by a combination of
lifestyle changes and pharmaootherapy. Treatment goals
are to eliminate infection by H. pylori, promote ulcer
healing, and prevent re;;urrence of symptoms.
NCLEX-RN" REVIEW QUESTIONS
D A woman has been using OTCantacids for relief of gastric
upset. She is on renal dialysis three times a week. The
nurse should carefully monitor the patient for the devel-
opmem of what condition?
L Hypomagnesemia
2. Hyperkalemia
3. Hypermagnesemia
4. Hyponatremia
D In the treatment of H. the nurse must recognize
that the use oftwo or more antibiotics is essemial for what
reason?
L To lowerthe potential foroocterial resistance
2. To decrease the chances of development of duodenal

40.6 Proton pump inhibitors block the enzyme H+ K+ ATPase
and are effectiv\: at redU(ing gaSlri, a(id secretion.
40.7 H,-receptor blockers slow acid secretion by the stomach
and are often drugs of choice in treating PUD and
GERD.
4005 Antacids are effective at neutralizing stomach acid and
are inexpensive OTC therapy for PUD and GERD. Al-
though they relieve symptoms, antacids do not promote
ulcer healing.
40.9 Combinations of antibiotics are administered to treat H.
pylori infections of the GI tract, the cause of many pep-
tic ulcers. A proton pump inhibitor and bismuth com-
pounds are often included in the regimen.
40.10 Sewral misce1laneousdrugs, including sucralfate, miso-
prostol, and pirenzepine are also beneficial in treating
PUD.
3. 1b increase the likelihood of eliminating redevelopment
of gastric ulcers
4. 1b decrease the cost of future drug thernpies
D Sinlethicone (Gas-X, Mylicon) may be added to some
medications or given plain in order to:
L decrease the amoum of gas associated with GI
disorders.
2. increase the acid-fighting ability of some
medicat ions.
3. prewnt constipation associated with GI drugs.
4. diarrhea associated with GI drugs.
LibraryPirate
618 Unlt7 TheGa,uoIm",tI ... t Sym'm
EI In addition to multiple antibiotics, what compound
should the nurse anticipate will be added to the regimen
for treatment of H. pylllri?
1. Antacids
2. H,-receptor antagonists
3. Bismuth oompounds
4. Vitamin Ecompounds
II The nurse assesses for which of the following risk factors
associated with pum {Select all that apply.}
1. Smoking tobacco
2. Blood group 0
3. Excessiw psychologic stress levels
4. 1)'pe II diabetes mellitus
S. Caffeine use
CRITICAL THINKING QUESTIONS
1. A patient with chronic hyperacidity of the stomach takes
aluminum hydroxide (Amphojel) on a regular basis. The
patient presents to the clinic with complaints of increas-
ing weakness. What may be the cause of this increasing
weakness?
1. Identify why nurses who work at night are at higher risk
for developing PUD.
3. A patient who is on ranitidine (Zantac) for PUD smokes
and drinks alcohol daily. What education will the nurse
provide to thi5 patient!
See Appendix D for answers and rationales forall activities.
o In taking a new patient's history, the nurse notices that he
has been taking omeprazole {Prilosec}, consistently over
the 1'<1st 6 months for treatment of epigastric pain. The
nur.;e will recommend:
1. switching to a different fonn of the drug.
2. trying a drug like cimetidine (Thgamet) or famotidine
{Pepcid}.
3. taking the drug after meals instead of before meals.
4. checking with his health care provider about his
oontinued discomfort.
EXPLORE
1s)'OOI one !IMp ItIO" Mline r..,..lew matenllIs MI1
reSOLKO!&' Plepare for with addiuMat practice
ql>llStioro>. Intaractl"" as&lg1mants and aClI ..rllos. web tkll<&. amatlcl"ll
a<ld'lideo$.8<ldmorel
RoglSlEr )'0" ar.:cess code Irom the fllJrll ,.,... book 111
www.lItj ..... slngkltcorn.
LibraryPirate
DRUGS AT A GLANCE
LAXATIVES pagt611
Bulk Forming /if 611
Q p$yNlum mucilioid (Meramuclt Olllers)
1"1"1)
Saline and Osmotic f1llt6J]
Stimulant pa;t 6]]
Stool Softener/Surfactant ".611
Herbal Agent pi1jt 611
ANTIOIARRHEALS fIIJ9IW
Opioids paJt 614
o dlpl!tnoql(Jtt with olropiflf (I.omoUI)
..
DRUGS fOR INFLAMMATORY sown DISEASf:
AND IRRITABl.E Bown SYNDROME ptJgt6JS
'" wlftJ$DkJzne (AlII1fldkW) {#/t6Jr
AHnMETICS ,.619
o (Cotnpttl.hf) pagt6JI
DRUGS fOR OBESITY pogtOf
Q sJbutromhf (Mttldb) ptl9t6Jf
PAHCREATICEHZYM(R1PlAUMlHT {IfI1t6J5
Q
OlhMJ ,.,636
KEY TERMS
anoroiam pI19t6JI
antifmttic pogt 619
bodymassindu(BMI)
Cilthilltic pqgt6}1
d'of1norH@!ItOltriggtfzone(m) ptl/t6J8
UlIlSIipation ".6]1
Drugs for Bowel Disorders
and Other Gastrointestinal
Conditions
LEARNING OUTCOMES
After reading mis the student should be able 10:
1. Identify major anatomic structures oftl'lt lower gastrointestinal tract.
2. Explain the pathogenesis of constipation and diarrhea.
3. Discuss conditions in which the pharmacotherapy of bowel disorders Is
Indicated.
4. Explain conditi ons in which the ph,umacotherllpyof nausea and
vomiting is indicllted
5, Describe the types of drugs us.ed In the short-term management of
obesity.
6. Explain the use of pancreatic enzyme replllCement In the
pnllrmiKotherllp)' of pIIncrelltitil-
7. Describe the nurse's role i"l the pnllrrnacologk management of bowel
and VOmitll"l!:lllnd other GI conditions.
8. For eiKh of the <tug classes listed In Orugs" II Glance, know
representat ive drugs, and explain the me<hanism of drug ItCt ion,
describe primary iKt ions, and identify important advene effe<b .
9, Usethe nursing process t o ale for who are receMngdrug
therapy for bowel disorders, nausea and vomiting. and other GI
conditions..
Crohn's di srasr {XIqt61S
diarrma fXJ'}t 611
rlMsis pq.1S
rntrtiu fIIIIltUIJ
mrloqfnicpotmli.ll fl7jt 0l8
inlloJlTfllatOl)" boftI (IBn) fl7jt615
irritablr bowtl syndromt nBSI fi'J9t 6lS
lautiYr fXJ'jt611
fXJ'jtOI
!lUstii fJI'1t61S
fXl}t6JS
ukefatitulliitis p;gt615
LibraryPirate
620 Unlt7 The Ga'i!,oInt..,tI,..1 System
B
owel disorders, nausea, and vomiting are among the
most common complaints for which patients seek med-
ical assistance. These nonspedfic symptoms may be caused
by a large number of infectious,metabolic,inflammatory, neo-
plastic, and neuropsychologic disorders. In addition, nausea,
vomiting, constipation, and diarrhea are the most common
adverse effects of oral medications. Although symptoms often
resolve without the need for pharmacotherapy, when severe
or prolonged, these conditions may lead to serious conse-
quences unless drug therapy is initiated. This chapter exam-
ines the pharmacotherapy of these and other conditions
associated with the gastrointestinal (GI) tract.
41 .1 Normal Function
of the Lower Digestive Tract
The lower portion of the GI tract consists of the small and
large intestines, as shown in ,. Figure 41.1. The first 10
inches of the small intestine, the duodenwn, is the site
where partially digested food from the stomach, known as
Jeiunum:
chyme, miXES with bile from the gallbladder and digestive
enzymes from the pancreas. It is sometimes considered part
of the upper GI tract of its dose proximity to the
stomach. The most common disorder of the duodenum,
peptic uict'r, was discussed in chapter 4000.
The remainder of the small intestine consists of the je-
jWlUm and ileum. The jejunum is the sitt' where most nutri-
ent absorption occurs. The ileum empties its contents into the
large intestine through the ileocecal valve. Peristalsis through
the intestines is controlled by the autonomic nervous system.
Activation of the parasympathetic division will increase peri-
stalsis and speed materials through the intestine; the sympa-
thetic division has the opposite effect. time for chyme
through tht'entire small intestine varies from 3 to 6 hours.
The large intestine, or colon, receives chymt' from the
i1ewn in a fluid state. Tht' major functions of the colon are
to reabsorb water from the waste matt'rial and to acrete the
remaining fecal maleriai from the body. The colon harbors
a substantial number of bactt'ria and fungi, the host fiora,
which servt' a useful purpose by synthesizing B-complex vi-
tamins and vitamin K. Disruption of the host flora in tht'
colon can lead to diarrhea.. With few exceptions, little reab-
sorption of nutrients occurs during the 12- to 24-hour jour-
ney through the colon.
Duodenum:
reoeOY85 chyme
I""" stomach
perlo"",, most
01 digestion
andchemic.al
absorption
"
"':,"""5
material
I"""small
inlesti""
,. Flgure41. 1 The digestive system:functlons of the smallintenine and large Intenlne (colon)
Source: Pf'a00fl fduwtion/PH CoIleqe.
LibraryPirate
''''''lfr 41 Drug, for Bowel Olsorders and 0!1>ef GmrolmesHn. 1 Coodltlorn 621
PHARMFACTS
Gastrointestinal Disorders
Uktrati'lt rolitis 1m a peak OII!H from agts 15 to 30 and anothrrfrom
aljH60toSO.
k. many <IS 40'!1. ofthOlt <Igtd 6S and older repln I"NIJrTfnl (onllipation.
Irritable bcrftl ),ndroru alftcts 10% to lO% 01 adults.
Am .... itans sptnd $ll billion 011 OftightffdKtion
products and srrvim.
Thr in(idtlKt 01 motiolsic:knm ptab from 4 to 10,and then

auoontforW'lb 01 all Qlf"lol oKutf pan(lNtitis,
akohol (OIIIUmption iU!I;ociaud with 70% 01 all drronic: panm'atitits.
About lS,*, of Americans than 1 million adults) who all.' using
Wl'ight-losssuppll'melRl oot Oft lWI'ighl
CONSTIPATION
Const ipation is a decrease in thf frequency of bowel move-
ments. Stools may become dry, hard, and difficult to evacu-
ate from the rectum without straining.
41.2 Pathophysiology
of Constipation
As waste materialtr;;vels through the large intestine, water
is reabsorbed. Reabsorption of the proper amount of water
results in stools of a normal, soft-formed consistency. If the
waste material remains in the colon for an extended period,
however, too much water will be reabsorbed, leading to
small, hard stools. Omstipation may cause abdominal dis-
tention and discomfort, and flatulence.
Constipation is not a disease, but a symptom of an un-
derlying disorder. The etiology of constipation may be re-
lated to a lack of eJ{ccise; insufficient food intake, especially
insoluble dietary fiber; diminished fluid intake; or a med-
ication regimen that includes drugs that reduce intestinal
motility. Opioids, anticholinergics, antihistamines, certain
antacids, and iron supplements are just some of the med-
ications that promote constipation. Foods that can cause
constipation include alcoholic beverages, products with a
high content of refmed white flour, dairy products, and
chocolate. In addition, certain diseases such as hypothy-
roidism, diabetes, and irritable bowel syndrome (lBS) can
cause constipation.
The normal frequmcyofbowel movements varies widely
among individuals, from two to three per day, to as few as
one per week. Patients should understand that variations in
frequency are normal, and that a daily bowel movement is
nOI a requirement for good health.
Occasional constipation is self-limiting and does not re-
quire drug therapy. lifestyle modifications that incorporate
increased dietary fiber, fluid intake, and physical activity
should be considered before drugs are utilized for constipa-
tion. Chronic, infrequent, and painful bowel movements,
accompanied by sewre straining, may justify initiation of
treatment. In its most severe form, constipation can lead to
a fecal impaction and complete obstruction of the bowel.
Comtipation occurs more frequently in older adults, be-
cause fecal transit time through the colon slows with aging;
this population also exercises less and has a higher fre-
quency of chronic disorders that cause constipation.
laxatives
laxaties are drugs that promote bowel Many are
available over the counter (OTC) for the self-treatment of
simple constipation. Doses of laXlitives are identified in
Table 41.1.
41.3 Pharmacotherapy
with Laxatives
LaXlitives promote the evacuation of the bowel, or defeca-
tion,and are widely used to prevent and Ireat constipation.
Cathartic is a related term that implies a stronger and more
complete bowel emptying. A variety of prescription and
OTC products are available, including tablet, liquid, and
suppository formulations.
Prophylactic laxative pharmacotherapy is appropriate fol-
lowing abdominal surgeries. Such treatment reduces strain-
ing or bearing down during defecation- a situation that has
the potential to precipitate increased intra"abdom.inai, in-
traocular, or blood pressure. In addition, laxatives, in con-
junction with enemas, are often given to cleanse the bowel
priO! to diagnostic or surgical procedures of the colon or
genitourinary tract. Cathartics are usually the drug of
choice preceding diagnostic procedures of the colon, ouch as
colonoscopy or bariwn enema.
The two most frequt'ntly reported adverse effects
tivesare abdominal distension and cramping. Diarrhea may
result from excessive use. When cleansing the bowel prior to
colonoscopy or purging the bowel of toxic substances or
parasites, forceful, frequent bowel movements are expected
outcomes. Care must be taken to rule out acute abdominal
pathology such as bowel obstruction prior to administra-
tion because the drugs will increase colon pressure and pos-
siblycause bowel perforation.
When taken in prescribed amOlU115, laxatives have few ad-
verse effects. These drugs are often classified into five pri-
mary groups and a miscellaneous category:
Bdk-forrning laxatives absorb water, thus adding size to
the fecal mass. These are preferred drugs for the
treatm",nt and prevt'ntion of chronic oonstipation. and
may be taken on a regular basis withoul ill effects.
Bocause of their slow onset of action, they are not used
when a rapid and complete bowt'l evacuation is
necessary.
Stool softeners or slIr/actant laxatives cause more watt'!"
and fat to be absorbed into the stools. They are most
often used to prevent constipation, especially in patients
who have undergone recent surgery.
Stimulant laxatives promote peristalsis by irritatins the
bowel mucosa. They are rapid acting and more likely to


,


"
o
,

o

;;
,
LibraryPirate
622 Unlt7 The Ga'il ,oim ... tloal SYS!<'ffi
TABLE 41.1 1 laxatives and Cathartics
DN, Route and Adult Dose (max dose where Indlcatedl Adwrse Effects
BULK FORMING
calwm poI)Urbopbil (Equaiactin,Fibmon, PO;llJfdaypm AbdomioolfrJ/nru1Jl
othfrl)
[lIlIIblllll11tl gl;UIIlUlislD ilLlKD
methrl{du&ll' (Gtnnl) PO; in 3- 10
jnwffiOOu "lid
Q psrllillll mllilloid PO; 1- 2 tIP it Sill Wiltrdaiiy pm
othfrs)
SALINE AND OSMOTIC
migorsiJm h)'ltoxidf, (Mlk DiIIm, uv"f!if1lJ
poIytthyltot glyrol (MiriYxJ PO; 17 9 in 8 01 of liquid daly for 14 da)'l
IOIiLm biphosphite (FJffi PhosphoSoda) PO; 15- 30 mlmixtd iowmr daily pm
(dys!I!ythmias, mpir.l!o!y
STIMUlANT
bililodyl (Cor!tttol. Dukolax. othrn) PO;IQ-I5mg/da, pm
GlSioroi (Emulsoil,
STOOL SOFTEN ER/SURFACTANT
(CoDtt)
I
PO; SO-SOO mg/da,
HERBAL AGENT
!trIoa/!trIoosidti (b .ul, StrIokot, othm)
I PO;8.6-171mg1da,
MISCELLANEOUS AGENTS
kJbiprOlioot PO; 14 flK9 bid
mintraloil PO;I5- 30mLbid
/tal(! tommoo iodititts strioo; i liwr!!: tlfttl!.
cause diarrhea and cramping than the bulkforming
type of laxatives. They should only be used occasionally
because they may cause laxative dependence and
depletion of fluid and electrolytes.
Saline cathartics, also called osmotic laxatives, are not
absorbed in the intestine; they pull water into the fecal
mass to create a more watery stool. These agents can
produce a bowel movement very quickly and should not
be used on a regular oosis because of the possibility of
fluid and electrolyte depletion.
Herbal agents are natural products available arc that
are widely used for self-treatment of constipation. The
most commonly used herbal laxative is senna, a potent
herb thai irritates the bowel and increases peristalsis.
Other naturalluatives include rhubarb, cascara sagrada,
aloe, flaxseed, and dandelion.
Miscellanrou5 agents include mineral oil, which acts by
lubricating the stool and the colon mucosa. The use of
mineral oil should be because it may
Abdomiool (fQmpirIIJ rDMII, filinrilg.
dQrrhto
AI!!!;! and lOIS
I Abdooiool(fQmpirIIJ dQrrhto
I!o Icious idl'tl'!!: dlts
I Abdomioolaompirli dQrrhto
It! strioo; film!!: tlftm
NMefl, di<rrl!fo, hfadoclle, dfJPhN
Allergic Wpm

Nutritional I1!]:IIIIOfia
interfere with the absorption of fat-soluble vitamins and
can cause olher potentially serious adverse effects.
Lubiprostone (Amitza) is a newer drug that increases the
secretion of intestinal fluid by activating chloride
channels in the muoosa of the large bowel. This drug is
approved for chronic idiop.1thic constipation and for the
constipation phase of irritable bowel syndrome.
DIARRHEA
When the large intestine does not reabsorb enough water
from the fecal mass, stools become watery. Diarrhra is an in-
uease in the frequen'1' and fluidity of bowel movements.
Diarrhea is not a disease but a symptom of an underlying
disorder.
41.4 Pathophysiology of Diarrhea
Like constipation, occasional diarrhea is often a self-limiting
disorder thai does not warranl Iherapy. Indeed, diar-
LibraryPirate
C"",lfr 41 Drug' for 80wel Disorder, and Otl>ef Gi nrolole';Hn. 1 Conditio", 623
Prototype Drug I Psyllium MUClliold (Metamucll, others)
Therapeutic (lass: Bulk-typelaxative Pharmacologic ( lass: Natural product
ACTIONS AND USES
P,yllilm is deri...oo from a natural prooiK1. tht 'ttm of lhe planlain plant. Like
olher bulk-funning plyllium is an illlOluhlt fibtr that is indigestiblt
and not alMrbtd from the GI trau. Whtn Liken with a wffic:itnt of
psyiliumsOftlisand tht sUeoithefml mm.Tht Lirgt r the size
oflht It ullN!5, the mOf!' the ddtcation reflex will he nimul.ntd. tills pro-
moting the pM!a9f of ,tool. Stftral Ousol psyllium may bt IItfdtd O'/!'r 110
J da)"5 to a thmptutic: The drug may he Liken as a fibtr
9Jppltllll'm.
FlI'qutOt lMof p,yllilm (7 g/dayl may UlMa small rrouuion in blood {ha-
this psyllium may bt u,t<! . , part 01 a regiment
to rtdUCt the ri,k of rol"OOary lINn
ADMINISTRATION ALERTS
Mix with ilie.J,t 8 Ol 01 water, fruitjuic:t,or milk, and admini,ter immtdi-
ak'ly.FoIIow mh doW' with an addition. 18 Ololliquid.
oldtr . duln {iorely fur polliblt . spirMion.
Pregnancy uttgory (
PHARMACOKINETICS
Dn'tt: 12- 14h
Ptak: l - Jda)"5
Halfli M:Unmown
Duration: Unknown
rhea may be considered a type of body defense, rapidly and
completely eliminating the body of toxins and pathogens.
\'lhen prolonged or severe, especially in children, diarrhea
can result in significant loss of body fl uids, and pharma-
cotherapy is indicated. Prolonged dwrrhea maylead to fluid,
acid-base, or electrolyte disorders (chapter 3100).
Diarrhea maybe caused by certain medications, infections
of the bowel, and substances such as lactose. Inflanunatory
COMPLEMENTARY AND ALTERNATIVE THERAPIES
Acidophilus for Diarrhea
liIcrobociJJw ocid:IpIriIus is i probiotk bacterium oormally found in the human
alimenLiry u nal and i, umiderrd to bt prottctil'l' flora, inhibiting
tht growth of pottmially pathogenic: !petits IlKh as Esdrtfichio di, CantRda
albirQm, H. {1fIori, and fomml/Q 1'IJ9i1o/is. Clot IllKhanism lISt<! by L i-
dcriIus 10 limit the growth olother ba{tmal IPfCits is the gtntration 01 hy-
dl"09fll ptrw:idt, whidJ is toxic to IOOst ctlls.
The primary UII' of L IKidopIrlus is to tht normaillori 01 the intts-
tint following dia"hei, particularly from antibiotic: thmpy. k has i M
shown to he tfftttiYt at shanming epirocIts 01 aMf inftiou, diarrhei (Tt it-
elbaum,lOO5).L lKido,ni1us may bt obtaint<! by drinking i (idophikJs milk or
by eiling yogurt or kefir oontaining liYt (or aaift) Thost wi,hing to
obtain from )09urt Ihould ft'ad the labtls ml'fully, btuUll' oot
all produc" {ontain i ctift {ukuft'l; froil'll )09urt (ooLlin, no actift (uituft'l.
Suppltmtou in(kidt up,ults, granules. 1lo!I's aft' oot ,tandard-
izfd, i nd tahltt dose ringt from SO to SOO mg.
ADVERSE EFFECTS
is a wit Ial0tift and raft'iy prodlKf"I adl'l' nt k Itss
o:ramping than stimulant-type and ""ul" in a 100ft' natural bowel
IIIO'/tllll'Olll Liken with in,uflkitnt it IIIil)' (,lUll' obnllKlionl in the
tsophagusor inrestiOl'.
Contraindi u tions: Plyllium should oot bt i dministertd to patient! with undi-
agOOW'd i bdominal pain,intf"ltinal obllruction,or Itul impauion.
INTERACTIONS
Drug-Drug: f'I)'II i:.m maydKr&R tfwoaborptionaodfffem ofwarfarin,.n,
wkyla!fI.
lib mol)' ioofil\o! tfwo IfIIIIO glwrlf Ilvel.
HerbaVFood: Unknown
TlNt mem of OYerdo,e: Ovmiost from plyllium is unlikely.
III'ferlOM)NurslJrgntfrxoNurslnljl'rl:>!:m
disorders such as ulcerntive colitis, Crohn's disease, and irri-
table bowel syndrome can cause episodes of intense diarrhea.
Antibiotics often cause diarrhea by killing normal intestinal
flora, thus allowing an overgrowth of opportunistic patho-
genic organisms. The primary goal in treating diarrhea is to
assess and treat the underlying condition causing the diar-
rhea. Assessing the patient's re.;:ent travels, dietary habits, im-
mune system competence, and recent drug history may
provide information about its etiology. Critically ill patients
wilh in""un" "'''1'''''''' whu =l'u"t:<I lu ''''Illy
antibiotics may have diarrhea related to pseudomembranous
colitis, a condition that may lead to shock and death.
Antidiarrheals
For mild diarrhea, OTC products are effective at returning
elimination patterns to normal. For chronic or severe cases,
the opioids are the most effective of the antidiarrheal agents.
The antidiarrheals are listed in Table 41.2.
41.5 Pharmacotherapy
with Antidiarrheals
Pharmacotherapy related to diarrhea depends on the sever-
ity of the condition and any identifiable etiologic factors. If
the cause is an infectious disease, then an antibiotic or an-
tiparasitic drug is indicated. If the cause is inflammatory in
LibraryPirate
6 24 Unlt7 TheGaslrolnt..,tI,..1 System
TABLE 41.2 1
Antidiarrh@als
DN, Routeand Adult Dose (max dose where Indicated) AdwrwEffects
OPIOIOS
camphmttd opium tilKl!ll' (mgoric:) rDMG,dilmm,ilry
diftnoxin auopi'>. (Mot. (tn) PO; 1- 2 mg afttr ... " dianbta .pim (maltS mglday)
moorh (frrIm Qlrop;,e), cmsripion
Q wilh auopiJlf [LomotiQ PO; 1-2tabs oc 10 mllid-ilid
ool)'!K jleuswi!!l
doos5ion.CHS depmsion
loptramid!, (lmodiJm) PO;4 mgasa dost, liltn 2 mg afitr mh daIThea
(max;16mg/d.y)
MISCELLANEOUS AGENTS
bismuth sailS (Ptpto--BilmoI) PO;2 tabsoc 30 mlpm (OfIIliporioo, OOIl!t4 rinrirtJf

(Saodostatinj
I SCIIV; l00-ioOO mcgld.y il lwo tofotrdiYided OOst,S
NIAAt4 di/lrrIieG,oMomillQ/ {Kin
iD II:IlID gllllgg IIiIBlIIlIIQ dllIlr: l!.1lil
.!!mi!1!il
Irdla common adl'mo! tffffis;lIIIkdi!iog, inditite strious
nature, anti-inflammatory drugs are warranted. When Ihe
diarrhea appears to be an adverse effect of pharmacotherapy,
the health care provider may discontinue the offending
medication, lower the dose, or substitute an alternative drug.
The most effective drugs for the symptomatic treatment
of diarrhea are the opioids, which can dramatically slow
peristalsis in the colon. The most common opioid antidiar-
rheals are codeine and diphenoxylale with atropine (Lo-
motil). Diphenoxylate is a Schedule V agenl Ihat acts
direct/yon the intestine to slow peristalsis, thereby allowing
more fluid and electrolyte absorption in the large intestine.
The opioids cause CNS depression at high doses, and are
generally reserved for the mort-term therapy of acute diar-
rhea because of the potential for dependence. Details on in-
dications and adverse effects of opioids may be found in
chapter 1800.
OTC drugs for diarrhea act by a nwnber of different mech-
anisms. Loperalnide (Imodiwn) is similar to meperidine but
il has no narcotic effects and is not classified as a controlled
substance. Low-dose loperamide is available OTe; higher
Prototype Drug I Dlphenoxylate With Atropine (Lomotll)
Therapeutic Class: Antidiarrheal Pharmacologic (lass:
ACTIONS AND USES
Tilt primary antidia rrilNl in glfllient in lomotil is diphenox)'late. LiR other api-
oids, slows peristalsis, lilowing iiIIII' for additional Witer
wrptionhom (olon nd solid stools. k 1m within 45 10 60 minute .1t
is for roodtrate 10 but is oot Je(omllll'fld!,d for chil-
dren. atropiot in lomoti I is oot added for its antKholinl'r9K but 10 dis-
COUr.lgt patitnts from taking too m!Kh of drug. At higher dos& tilt
dntic:holiJlfrgic: ff1fcts of atropiot may be which ilKlude dra.vsinel,
dry mouth, and is discontinutd as lOOn as tht diar-
r!'SOI\\".
ADMINISTRATION ALERT
If to )'lung childrrn, mNsurr tilt drug murately by using
tilt dropper !)ickaged with liq,Jid form of drug.
Plf9r1ancy category C
PHARMACOKINETICS
()twt 45-60 min
PmU h
Half liff;H h
Duration; l -4 h
ADVERSE EFFECTS
Unlike most has 00 analgesic: proptni... and has an n-
low pottntial foe is'MlltoltruM at normal
palitnu diuines 01' drowsinffi, a nd should oot driY<" 01' opt<-
ate muhilltr)' until tht of tilt drug known.
Contraindications; Contraindications include to drug,
obstructiW' se'ItrI' dth)d ration or imbal-
narrow angl!> glaucoma, and dianhN with psrudollll' mbranous
wlitis.
INTERACTIONS
l)ug-Drug; with atropint inlecam with oihlor (!j,
including akdlol, to prodUCt id!i1iH Ifdaticn I'I!Ien IikM with MAO m tftm,
tiphrnol)lalt may cause hy)l@Hensi wai\is.
Lab Tests; Ilipbrnox)lalt with atropilll' may iKmsIo Mn)lalol'.
IkorballFood; Unknown
Treatment ofllverdose; Dwd_with Lomotil may lit ltI'ious.Narrotic:i1ntag-
onim S!Kh as may readministl'rM to rtVl'rII' rrspiruory
within minute.
Rdtr IIIMyN/n1ngll (ora IOI!ri! d'ug.
LibraryPirate
''''''lfr 41 Drug; (Of Bowel Olsoro..fS ,00 Otl>l'f Gamolm",Hn. 1 Conditions 625
TREATING THE DIVERSE PATIENT
Cultural Remedies for Diarrhea
I!eaIu marrhl'a is in agMId rubdjo that afftds all pojUations,
lIftS hiYr um.ard-true S)TIlplOmatic: mnecies bl thr (ondition. One
prepililOO UIfd II)' propiein runyregionsof thr work! is mmltlf{h (a heapilg
tNlpOOllIuO in a gins Ii 11'.:*1 ha'II' boiled rUand
giYrn the dikrted rU to babits to ftat dianhea.1hI' bthiKI these
two is thatthl'y...m by absorbing mes Wiltr in the thus
stoppilg the dianhea.AIthrugh a wu not il NrlitrtimfS, pro-
pie Ii mall)' aftes frond mat NO"l grilted applt that had turned bruNn allM-
aI\'d symptoms.TIrst proKkes appall'ntIy rYOIYed into what today is u-n as
thr All of dirioN 1II'.wnrot apples. ballolIW lUst ball'ly ripr), and (arrots. The
urdffiying principle is th" .." pKtin in these loom is o:Uciird, prtdrc:i1g
thr same i"lll'litnt blind illlUll)' OlC dianhea rneOOlIfI.
doses are available byprescription. Other OTC treatments in-
clude bismuth subs.alicylate ( Pepto-Bismol), which acts by
binding and absorbing toxin<;. Psylliwn preparation<; may
also slow diarrhea, because they absorb mrge amounts of
fluid, which helps form bulkier stools. Probiotic supplements
containing LactobaciJlus, a nonna! inll.1bitant of the human
gut and vagina, are S<lmetimes taken to correct the altered GI
flora following a serious diarrhea episode.
41.6 Pharmacotherapy
of Inflammatory Bowel Disease
and Irritable Bowel Syndrome
bO'M' I diseall! (lBD) is charucterized by the presence of
ulcers in the distal portion of the small intestine (Crohn's disease)
or mucosal erosions in the large intestine (uktl3tiworolitis). lBD
is treated with medications from several classification<;. Over
1 million Americans are estimated to have lBD.
Symptoms of lBD range from mild to acute, and the con-
dition is often characterized by alternating periods of remis-
sion and exacerbation. The most common clinical
presentation of ulcenttive colitis is abdominal cramping with
frequent bowel movements. Severe disease may result in
weight lor.s, bloody diarrhea, high fever, and dehydration.
The patient with Crohn's disease also presents with abdomi-
nal pain, cramping, and diarrhea, which may have been pres-
ent for years before the patient sought treatment. Symptoms
of Crohn's are sometimes similar to those of ulcerative colitis.
Mild-to-moderate IBD is treated with 5-aminosalicylic acid
(5-ASA) agents. These include the sulfonamide sulfasalazine
(Azulfidine), olsalazine (Dipentwn), and mesalamine (Asacol,
Pentasa, others). Corticosteroids such as predniS<lne, methyl-
prednisolone, or hydrocortisone are used in more persistent
cases. Particularly sewre disease may require immunosuppres-
sant SIKh as :rzathioprine (lmuran) or methotrexate
{MIX). lnfliximab (Rem.icade) is a monoclonal antibody ap-
proved for Crohn's disease and ulceratiw colitis. A single infu-
sion of inlliximab carrcall'ie remission in 65% of patients with
moderate to severe Crohn's disease that may last up to 12 \Weks.
Budesonide (Entooort-EC) is a corticosteroid with inter-
esting properties that allow it to be used as a first-line ther-
apy for IBD. Entocort-EC is encapsulated to prevent signif-
ic..nt absorption in the stomach or duodenwn. The drug is
released slowly and reaches a high concentration in the ter-
minal ileum and proximal colon, the two most frequently
affected sites for lBD. Thus, the drug is in direct contact with
the GI mucosa and, in effect, it produces a topical anti-
inflammatory effect. In addition, when it is absorbed,
budesonide is almost entirely removed by first-pass metab-
olism in the liver. Thus, this drug shows few of the adverse
effects seen with the long-term use of other corticosteroids.
It is approved for mild to moderate Crohn's disease.
The introduction of biologic therapies in the btt 1990s
gave clinicians another valuable tool in the pharmacother-
apy of lBD. The tumor necrosis factor (TNF) inhibitor in-
fliximab has been shown to effectively reduce
acutt symptoms and provide maintenance therapy for both
Crohn's disease and ulcerative colitis. A second anti-TNF
dr ug. adalimumab ( Humira) , was approved in 2UU7 for
Crohn's disease. a pegylated TNF inhibitor, cer-
tolizumab pegol (Cimzia), was approved that offers dosing
at 2- to 4-week intervals. Natalizumab (Tysabri), a drug pre-
viou>ly approved for multiple sclerosis, was approved for
treating Crohn's disease in 2008. The biologic therapies are
expensive and patients experience a much higher rate of se-
rious infections due to their immwlOsupprer.sive actions.
Biologic therapies are currently recommended onl)" when
corticosteroid therapy is unable to control symptoms.
bowel syndrom! (lBS), also known as spastic colon or
mucous colitis, is a common disorder of the lower GI tract.
Symptoms include abdominal pain, bloating, excessive gas,
and colicky cramping. Bowel habits are altered, with diar-
rhea alternating with constipation, and there may be mucus
in the stool. IBS is considered a functional bowel dimrder,
meaning that the normal operation of the digesti,e tract is
without the presence of detectable organic disease.
It is not a precursor of more serious disease. Stress is often a
precipitating factor along with dietary factors.
Drugs used to treat IBS do not alter the course of the dis-
ease and, in some cases, they may actually worsen patient
symptoms. Research has not denlOnstrated that drugs are
any more effective than nonpharmacologic treatments such
as lBS support groups, relaxation therapy, or dietary changes.
There is not prototype drug for this condition. Drugs that
provide symptomatic relief for some patients include alos-
etron ( Lotronex), dig.domine (Bentyl), and hyosCYJmine
(Anaspaz, others). Tegaser<XI (Zelnorm) was once cOn<;id-
ered a prototype drug for IBS but the United States and
Canada have suspended marketing of the drug due to the po-
tential for adverse cardiovascular events. Drug therapy oflBS
is targeted at symptomatic treatment, depending on whether
constipation or diarrhea is the predominant symptom.
NAUSEA AND VOMITING
NaUIO!!l is an unpleasant, subjective sensation that is accom-
panied by weakness, diaphoresis, and hyperproduction of
saliva. It is sometimes accompanied by dizziness. Intense
nausea often leads to vomiting, or


,


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LibraryPirate
NURSING PROCESS FOCUS PATIENTS RECEIVING DRUG THERAPY FOR BOWEl DISORDERS
(CONSTIPATlON, DIARRHEA, IRRITABLE BOWEl SYNDROME)
Asseument
Buelifte .ssenmut prior to administrat ion:
Ulldentand the rtison the dtvg his been pmaibm in order to mHS /Of
thtfapevtil: riftcts.
()bQin iI cornpiett Ilulth hiSUlry indudi ng 61, Cilfdirmstut. \ Of
It'II.Il dileolSt;pmJMoln(J;or bll'olSIAffding.Obt.Jio a dOl9Mtory inWding
pmuiption and OK drugs, htfb.al pltpolrations,uiffilll',
nil:01int,ind akollol IM.at .Ilert to possible drug
Obuin i hiilOly of!)-lst irld WI'ltM S)'fllptoms,noting VItIit _ haw
bttn sucmslll.t Il'limog the symptoms (e.g., incll'.Sfd ItJicIs. fibet
dimry dI.Inqes).
llbUin bast6ntweighund vital signs.
V. Uitt i pJHOpriaft Iabor.Itory Iinclings (f-I}. (Be, dKtroI)'tts, htp.llil: or
1t'II.1 f_lion sl.).
Obt.Jin olII.bdominal (t.9-, sooods, disttntion,
prtstnct of tende-ntssL
Aslessmtnt throughollt . chninistration:
AsSHS fat- effts palttfn of elimination,
nonnal stool tonsistency and volume).
Cominut periodil: monitoring of .bdomiOiI.sstSSmfIlt tindirl!JS, rspecially
bowel sounds.
Continut Pfriodil: monitoring ofCBC,Mtro/ytrs,l nd hepatil: Ind ll'IIal
funaion labs as .Ippropriatt.

drowsiness, ind dizziMU. 5Mrt abdomillil pain, CDffft-lJOJnd or bloody
II stool orlirTYstoob shoYld be rtpOrted immtdiittly.
Potential Nursing Diagnose5
eom,ip.ltion (Il'lated to mtd'K.Ition,ditt,Ndequatt toilttirog. tit.)
[brmea (related to mtdiution, aiel, inftc.rioos,ttc.)
DtficitlltKnowleOge (drug therapy)
Riik for Deficient FtJidVolulllt (ftlattd to cilrmu,OftOlSt of lamim)
Planning: Patient Goals lind Expected Outcomes
The patient will:
up'rifnu thef<ipeutic rifern {e.g., 10 moll! norm.l of elimillition,nolrOil 11001 voIumt and tonsistency}.
Be from,Of minimal,ilcM!w efkotts.
VerlIalizf an uodmtanding of tIw, drug's 1M, a.:Iw!w tffKn.ilnd prtuutioos.
IlfmDnltr.l1f prop'r stIf-adminiitration of the (t.9-,dOlf, timing, whm to notify p!tI'ridfr).
Impiementlltion
Intervent ion5 and (Ration. lesj
E.luring theril ptlltic effectl;
If a btheCllltnl l'fl'lll*ll'OSGn be icItntified (e.g.. illMion,
food poisoning. inadequilf l\JiI inukt),CDm(ltllfUIM possilW.
(Constipation .nd dWnhti all! uswt, symplUlTlS Ii other lJIdfrtying OJIlditions
Patient a nd Family Educat ion
For rewRtr'f tonstip. tion or di.rmta, trKOllrilgt tile patitftt to mimain
dilry of (onrelatioos btt_ symptoms,foods, bel'tf.ges. IIrHS,Of
mtdiurioM to btIp Kltntify GlIIitiYf facton..
___
appropril.te lifesty\t dlinqes. Hm the pltifnt kttp it diiIY Encoufil9t t!If pnitm IW) adopt iI heiltlty &t)W ofiocmse<i dieQry
noting CDITI'btionl be!\ftfn symptoms and foods, btftri9f'l, IIJf\!, Of mlrr and fluid imale. iKrmed iMil " of YD!Jl" ,1nd txidopIilll'
{El1IIIring .moufIls of daiy ftuidl and dittary fibet (l)fltaining foods, ItIl'SS II\aIIoIgfmtnt te<hniqlltS, illOfasfd tRfCist,and
.nd inOfiSing olCtiYity i1Ssisu in encouraging normal ptriSlib: limiltd Of elimin.ted .kohol consumption ind smoting.Pn!1'idt for
activity. Smoting and (/Sf i kel' norm. 1 peristalsis and shoold be dittitian comukition Of information on smoking crswtion PI'09UrTl'S . s
limited Of elimillittd (OfItlating symptoms willi rMdicmoos Of s1ll'ls llloly
help 10 idmtly .triggmng fiKtor.OwraIl htaltby liftsty\f chMl9fl will
support IIId m)nimizt, the Iftd for drug therapy.)
foIIowappropNlt .dnWIistration guicit lines.Oo not iJdmioisltr lautiYrs ff
bowel obstruction iI possiblt.Oo not adminisitf inticflolrrhtal dl1lCJ! if
inftion ii possible. (Ciuidltlints boatt mil:ing, fluid intakt.Of
.dminisllering with meals should be followed. If bowel sounds 'II!
hnmctiYf or tht htalth CIII! plIl't'iOO befort idministtring
thtdrug.lf ink1:tion is of dianht ., ccmult with the IINlth
( .lit' pro<WicH, r befort giWlg .ntidianhN I drugs IlruUlt cItm.ntd
ptrirulsi! II1oJ)' giw tile inftaion the opponuniryto SPll' ilcU
Tt adl the p.aOOltot." tilt drug following appropriatt or
label dim:t ions, pa rtirularfy for any Ilklid inQir.t Ifquiml, for
btltll!Wlts.
InstllKt the patient tlli! dilnflt. or cOII stipation ilssociatfd with
increasing n'(/Sfa or if i(cOlllpanied by .bdominal
pain, should be Il'pOrted to the hu lth cart prtMder WOIt' liking dIug.
LibraryPirate
(""'lfr 41 Drug' for Bowel Olsorder nd Othef G:onrDl"te<Hn.1 CDl\d1l1om 627
NURSING PROCESS FOCUS PATIENTS RECEIVING DRUG THERAPY FOR BOWEL DISORDERS
(CONSTIPATION, DIARRHEA,. IRRITABLE BOWEL SYNDROME) (Conllnued)
Implementation
Interventi ons and (Rati onales)
Minimizing ad'ftrle effrcts:
ContinU!' to monitor findings.Any signirlC.l nl
or in boJwd !OUnd"or or in discomfort
or pain YIould promptly. (Any ,ignifiunt in
!GUnd auivity or inmalfd discomfon or pain may .ignal tiMo deffiopmtm
of WOMning .. eorof ad'll'fU drug
Monitorfor an, 1f'Ien' abdominal pain, or bloody
fflI!"Sis, or blood in Slool or t.my stook. abdominal pain or blood in
em!"Sis or Slook may indicale a of or miolJl
conditions should be I"!pontd immediatelyJ
patitm !.I/ety, especially in older .dults. OillerYe for dininm and
monitor ambulation unlil t iMo of the drug known.Obtlin
leYels if diuines, conlinUl'l.(Drowsifll'Sl ordiuiness from
or .ntidiarrbNls mayour and thr rille of
falk.Continued dizziness may indicate eler:trolyte
ContinU!' to monitor ptriodic hepatic and renal fUnction t6 t>,and
elearolyte Imls as function l!"Sts may indic.ill'
dfll9""ind!Ktd IItpalic t ffecK Ull' of la.utim or
(ominued diarrhN may affKt eler:trolyte
Monitor'lital partirul<llly rate. nd depth, on palil-m,
taking opioid or opiojd..rrIattd df1191. (Opioids may rHpiratory r<lle
and depth.lntervention with n.notic.flIi9Onim may nffil rd if
OCQJrs.)
Patient understanding of drug therapy:
UIl' opportunitits during admilistr.tion of mtdic.itions and durilg
a\.Il'IMIIl'IIts to dilru;, tht rationale for drug ther.py, desired therapeuti:
OUMfIIl'I, mostcommon idYrflt tifKts,parallll'im forwhen to call the
hNlth Pl(lllider,.nd any f1K!"sSiry monitorilg or prKolutions.(Using time
durilg call' htlps and key
Patient selfadministration of drug thtrilpy.
Whl-n rntdication, instllKtthr palil-m, f.mily,or
(aregm r in tiMo pIOpI'r selfadmini5lralion of thr drug, e.g., taken with
additional fluid (Propl'r .J dministration incll'asH tilt of tht
,,,,,I
Patient and Family Educati on
Te.ch the p;ltitnt that some using of discomfort 10 constipation or
dianhr. rna)' be noticed soon after beginning drug thmp)' but full
effect; may lallt tb)'l or longer. If gillric diKomfort or pain
(ontinU!' or WOI1ffl, tilt pro'lider ,hould notified.
Tea{h tht p.;Ititnt that abdominal p.in or any blood in ellll'lis or
!!ools 5hou1d immtdialely to tilt pftll/ider.
InstllKt palil-m to "II for prior to gening oot ofbed or
attempting to w. Ik alone if diuiness or drowsiness ocQJr.1'roYide
(ornmodl' or IItdp.n ne<llbjo. For hoIIII' .wid driYing or other miYi1ies
lfqUiring memal a!trtnes, or physic.i l coordin.nion until lilt effK1S of lilt
drug koown.
patil-m on tilt I"ftd to return pModic.11y for lolb woll
Tea{h tht p.;Itil-nt to like lilt drug as ordered ind oot 10 in{lNsr thedose
orfrequency un!t1S instructed to do 10 by tilt lItalth (III' provider. Arr;
df"OWlinm. dizzinHS, or dilOnrnmion should lit prompdy II'pontd to the
proYider.
pilil-nt, should lit i b!t to ,tall' tilt for tht
drug; appro pRatr dose nd scheduling; whllt effects to oblerie for
and when to II'port; .J nd the antici pattd length of medication tiMorap)'.
Te.{h p;ltitm on lautiR-s to lae tht drug .Jccording 10 appropnall'
guidelinrl,i1s follows:
All LlxatiY!' drugs: Tole the drug with additional lkJids and incrNll' fluid
intae th rooghout tilt tht inlallt of dietary
Excffilingl!rommmded doseor frequenl Ll xaliY!' 1M tiMo
risk of ad Y!'fIf .nd oonnal peristalsis oyrr !"!Suiting in
' Iwti'lr depl'ndence:
Bulkfurrrrirrg Lo .. (j .... .... tiom 1 huur 2lraurs
after thr LlxatiY!'.Powdrrro formulations should mil:rd with a fUll
glm ofliqJid and immtdiately taken,loIlowfd by an i dditional fUll
glill ofliqJid. Powders should nMI swallowfd dl)' or l'IOphllgeal
ob>lllKtion may result.
Millffill oillaxatiY!'l:Do not take n nausea is .nd do oot tallt at
bedtime to aYoid tiMo of .. piralion.
Evaluation of Outcome Criteria
Evaluatr tht rffectiYeflt!s of drug thmpy bjo ronfinning that tilt patitnt gails and outcome haY!' IIII't
5H TabIt5 H ll111d 41.1 ku I5t of drugI/O M1id! thtse fIIIffig oem oppIy.
LibraryPirate
628 Unlt7 The G. sUoInt",tlnal 5ys!,-,",
.... Prototype Drug I Sulfasalazlne (Azulfidine)
Therapeutic ( lass: Drug for inflammatory bowel disease Phannacologic ( lass: 5-aminosalkylate, sulfonamide
ACTIONS AND USES
Sulfualazinr is nora I drug with mmatol)' propertits that is approYed
10 11m mild to modtratt symptoms of colitis. is wd
to tR'at CroIln's diswt.1t is approYf<l asan in tilt phar-
of rhtumatoid and is wssifltd u a dist-..modilying
antirheumalic drug (DMARD) (chapter 4700).
SulfJwlazint inhibits mtdiaton of inflammation in tht colon !lKh u
prostaglandins and Itukotritnes.Colon baoc:ltria metabolino suHa.,laziot to 01(-
metabolitt-s,mtlalamint
is .nan IBS drug.
ADMINISTRATION ALERTS
Do not idminister this drug 10 patitnts who hnl' allergits to sulfollimide
antibiolics or fulO\trOidt (lasix).
Not approYfd forchik!R'O uodl'r q 2.
Do not crush orcM tlttrldtd-mr.m tablets.
PR'<lnancy category B
PHARMACOKINETICS
Onstl: Poorly absorbtd


Durati on:5- 10h
41.7 Pathophysiology of Nausea
and Vomiting
Vomiting is a defense mechanism used by the body to rid
self of toxic substances. Vomiting is a reflex primarily con
troUed by the vomiting center of the medulla of the brain,
which receives sensory signals from the digestive tract, the
inner ear, and the cht molKtptc.-triggerzont 1m) in the cerebral
cortex. Interestingly, the crz is not protected by the
blood- brain barrier, as is the vast majority of the brain;
thus, these neurons can directly sense the presence of toxic
substances in the blood. Once the vomiting reflex is trig
gered, wavelike contractions of the stomach quickly propel
its contents upward and out of the body.
The lreatment outcomes for nausea or vomiting should
focus on removal of the cause, whenever feasible. Nausea
and vomiling are common symptoms associated with a
wide variety of conditions such as GI infections, focxl poi -
soning, nervousness, emotional imbalances, changes in
body position ( motion sickness), and extreme pain. Other
conditions that promote nausea and vomiting are general
anesthetic agents, migraine headache, trawna 10 the head or
ADVERSE EFFECTS
The most efiKtl of suHasalaziot aR' GI-R'lated: nausea, rom
iting. dianbt J, dyspepsia, and abdominal pain. DiYidi09 tht total daily dOlt
tvl'nly throughout tilt day and using the entericooattd labirn may
adlltR'OU'. Hrad,ullt is common. Blood dyscrasia! occur infreqUtrltly dJri09
rash", art common and may a sign of a mort I!'rious
efFIsuch u 5tewns- bhnsoo syndromt. The drug may impair mJit
fMility, which revmtI when tht dlllC) is discoolirAlfd. SuHasalaziot (in caust
photostnsitMI)'.
Contraindications: is ooMraindiuted in patient! with sulfon
a mide c.- salicylate (a Ipirin or S-ASJ,) hyptntrllitiYity. Patient! with plH'urung
J ntmia, folatt, or othtr disordm should u It tilt drug with (iutian
btcau I!' it may wontrl blood dyscrasia!. Sulfasalazint should be ustd with (iU-
tion in patients with IItpatic impairmtM btcaust tht drug (in (iUSt IItpalo\OJ-
icity.Thf drug isconrraindica\l1d in palieotswith urinary obstruction and should
bt wd with (iulion in dehydrated patients becaust it may caUl!' crystalluria.
Puients with diabttfs or hypoqlycfmia shook! USt with (iutian
btcaultthe drug can incR'ut insulin I!'crrtion and worwo hypoglyctmia.
INTERACTIONS
t:rug.Drug: SlililSaWiM IOa1 'M)I';I'n bcrw IllimlW IUppmion cawd by
rnrthourulf and aso R'SUt in Ab:Iorpiion of digoxi1 1Oa1 bt
dPcR'a\.td. can displacr warfarin film its p-Olein IiII11i1g
iOONlfd anocoaojlNnt tIKI!.
Lab lktoown
IkorbaVFood: Wfasalamr IOa1 dtcmN tht absorption of.OI1 and lOtic Mid.
Trratment of OYerdose: Overdose will calllt abdominal pain, anuria, drowsi
ntss, gastric distrffi, naUIN,l!'izu rtI, and wmiting.1R'atmeol is supportM.
RtI'tf III MytmJogKl fur MIsIftiJ PrIKf'55 fiKul !pt(/II( IrIIM /trig.
abdominal organs, inner ear disorders, and diabetes. Psy-
chologic factors playa significant role, as patients often be-
come nausealed during periods of extreme stress or when
confronted with unpleasam sights, smells, or sounds.
The nausea and vomiting experienced by many women
during the first trimester of pregnancy is referred to as
morning sickness. If this condition becomes acute, with oon-
tinual vomiting, it may lead 10 hyperemesis8r1lvidarum,a sit-
uation in which the health and safety of the mother and
developing baby can become compromised. Pharmacother-
apy is initimed after other antinausea measures have proved
ineffective.
Nausea and vomiting are the most frequently listed ad-
wrseeffects for oral medications. The nurse should remem-
ber that because the vomiting center lies in the brain, nausea
and vomiting may occur with parenteral formulations as
well as wilh oral drugs. The most extreme example of Ihis
occurs with the antineoplastic drugs, most of which cause
intense nausea and vomiting regardless of the route they are
administered. The capacity of a chemotherapeutic drug to
cause vomiting is called its t metogtni c potential. Nausea and
vomiting is a common reason for patients' bckof adherence
LibraryPirate
("",If,41 Drug. for 80wel Disorder, and Otl>ef Gm ,oIntesHn.1 Condition, 629
to the therapeutic regimen and for discontinuation of drug
therapy.
When largt' amounts of fluids are vomited, dehydration
and significant wt'ight loss mal' occur. Because the contents
lost from tht' stomach are strongly acidic, vomiting mal'
in Ihe pH oflhe blood, resulling in met>.bolic
alkalosis. With excessive loss, severe acid-base disturbances
can lead to vascular collapse, resulting in death if medical
inlt'rvention is nOI initiated. Dehydration is especially dan-
gerous for infants, small children, and older adults, and is
evidenced by dry mouth, sticky saliva, and reduced urine
outpul thaI is dark yellow-orange to brown.
Antiemetics
Drugs from at least eight different classes are used to prevent
fMusea and vomiting. Many of these act by inhibiting
dopamine or serotonin receplors in the bJ"3in. The
antiemetics are listed in Table 41.3.
41.8 Pharmacotherapy
with Antiemetics
A large number of are available to and
vomiting. Selection of a particular agent depends on the ex-
perience of the health care provider and Iht' cause of the
nausea and vomiting. Patients seeking self-treatment can
fmd options OTe For example, simple
nausea and vomiting is sometimes relieved by antacids or
diphenhydramine (Benadryl). Herbal options include pep-
permint and ginger, the most popular herbal therapy for
nausea and vomiting. Relief of serious nausea or vomiting,
however, requires prescription medications. Patients receiv-
ing antineoplastic drugs may receive three or more
anti emetics concurrently to reduce the nausea and vomiting
from cht'motherapy. In fact, therapy with antineoplastic
drugs is one of the most common reasons for prescribing
antiemetic drugs.
Serotonin (5-HT,1 Antagonists
The serotonin antagonists include dolasetron (Amemet),
granisetron (Kylril, Sancuso), ondansetron (Zofran), and
palonosetron (A1oxi ). These agents are preferred drugs for
the pharmacotherapy of serious nausea and vomiting due to
antineoplastic therapy, radiation therapy, or surgical proce-
dures. They art' usually given prophylactically, just prior to
antineoplastic therapy. IV, oral, and transdermal patch
forms are available.
Antihistamines and Anticholinergic<
These agents are effective for treating simple nausea, with
some being available OTC. For example, nausea due to
motion sickness is effectively treated with anticholinergics
or antihistamines. Motion sickness is a disorder affecting a
portion of the inner ear that is associated with significant
nausea. The most common drug used for motion sickness
is scopolamine (Transderm Scop), which is usually admin-
istered as a transdermal patch. Antihistamines such as di-
mt'nhydrinate (Dramamine) and meclizine (Antivert ) are
also effective, but may cause significant drowsiness in
some p"lients. Drugs used to Ir",,1 motion sickness "re
most effective when taken 20 to 60 minutes before travel is
expected.
Antipsychotic Drugs
The major indication for phenothiazines relates to treat-
ing psychoses (chapter 17010), but they are also very ef-
fective antiemetics. The serious nausea and vomiting
associated with antineoplastic therapy is somt'limes
treated with the phenothiazines. To prevent loss of the
antiemetic medication due to vomiting, some of these
agents are available through the 1M, IV, and/or supposi -
tory routes. Nonphenothiazine anti psychotics that have
high antiemetic activity include haloperidol (Haldol) and
droperidol (Inapsine).
Corticosteroids
Dexamethasone (Deu.dron) and methylpredni,olone
(Solu-Medrol) are used to prevent chemotherapy-induced
and postsurgical nausea and vomiting. They are reserved for
the short-term therapy of acute cases because of the poten-
tial for serious adverse effects.
Other Antiemetics
Aprepitant (Emend) is the first of a new class of antit'met-
ics, the neurokinin receptor antagonists, used to prevent
nausea and vomiting following antineoplastic therapy. The
benzodiazepine lorazepam (Ativan) has the advantage of
promoting rela.ution along with having antiemetic prop-
erties. Cannabinoids are drugs that ,ontain the same active
ingredient as marijuana. Dronabinol (Marinol ) and
nabilont' (Cesamet) are given orally to produce antiemt'lic
effects and relaxation without the euphoria produced by
marijuana. Dronabinol and nabilone are Schedule II con-
trolled drugs.
On some occasions, it is desirable to srimulatetht' vomit-
ing reflex with drugs called Indications for emetics
include ingestion of poisons and owrdoses of oral drugs.
,ymp, ur.dly, ur giv"n
neously, will induce vomiting in about 15 minutes.
OBESITY
Obesity is a growing epidemic in the United States: II is es-
timated that 95 million adults are overweight or obese. This
represents 34% of the adult population over age 20. Obesity
is dosely associated with increased health risks that indude
premature death, hypertension, hyperlipidemia, diabetes
mellitus, heart disease, sleep apnea, and osteoarthritis.
LibraryPirate
6]0 Unlt7 The Ga'i!,oInt..,tI,..1 Sy.tem
TABLE 41 3 I S@I@ctedAnti@metics
Drug Route and Adult Dose (max dose where Indicated) Adverse Effects
ANTlCHOLINERGICS AND ANTIHISTAMINES
PO; SO mg h (max:lOO mgfday) dry meuth, bltJrrtd rilkI!
dimmhydrinatt (ilramamint, othffi) PO; 50-100 mg 4-6 h (mn: 400 mglday)
(!liCfIOIomiMJ
diphmtl)'i"amilH' (Btoadryl,OIhm) PO; 25--SO mg lid-qi d (mn: 300 mglday)
ICdatiQl). IrtmOf\
(Ii9C m for III!: ProtOl)'pC: Drug IJoxOOj
!!i&ur!j, hallu(iIa!mm.1!!!oooxiuJl
ImO!! (ammon in
(Ataru, Vimnl) PO;25--loo mg lid-qid
PO;25--SO mgldolY, taenl h btfo!! trav!l (mu:SO mglda,)
KopoiamiM (HyoIcint, Transdmn-Scop) Transdmnal piltdl;O.' mg 72 h
BENZODIAZEPINE
knlfpilm 158 for tilt IV; 1- 1.5 mg prior to dImIothtraP'f
Protot)'Jlt Drug boJ:OO)
(1DIIIl: <mmOII ill dlilliml
(If abw1fy(bamtiMdl.(OO\j
CANNABINOIDS
drooabilol (Marinol) po;, mglrn' 1- 3 h bffO!! admini5b'ation of dItmothffiP'f Dilmm" dlllWlinru, tlJjIhorio" QroJi4
(m.u:15mg1m')
PO; 1-2 mg bid Pjra!!!y' !i!!;:al'altd moIor (ooroila1im
""""'"
CORTICOSTEROIDS
dex.imt1ha1oot (DeYdron) PO;O.l5-4mgbid-qid Oml,
(Medro!. SoIu-Mtdrd. PO;4-48 mglday in dil'idtd dolt!
II<IU5f4 imomfia, wdium rnJ IIuid rrrtllfioo,
OIhfn)
rnpoUdwormdhf06l1g,mtmffiJol
I1boomrQ/irits,irn:mnio
!'Wi!: with
Iosl of mm
dl'W' il!'d!lOW!h jn dtUdrro ool'jjblr milkjng

NEUROKININ RECEPTOR ANTAGONIST
aprrptant (Emmel) PO; US mgl h prior to dlmlOlhtrapy rnlUlf4
hkrup
t!d!!dratioo. oo!RIlrnIIlNOO!\m. !;!!ood
p!IN!Ionia
PHENOTHIAZINE AND PHENOTHIAZINELlKE
m<:todopromidc: (R<?i>n,othc:,,1 PO; 2 1 h prior to chrmothc:f.py Dry tyt>, bIomrd ri lim, dry """,m.
(Phmilint, Tnlafon)
(J)l1lliporkl\. drt:ltlt'IifH'J5, p/IolO5RlHiriYiry
Q PO; 5- 10 mg lid-cjd
E!;tral!):ramidal
maiiooant syJI!tpm!: aqilOuosytosis
proolfIllil:iM (Phmtrgal,othm) PO; 12.,- 15 mg 4 h qid
SEROTONIN RECEPTOR ANTAGONISTS
doIi5tlrOn (Anztmet) PO; 100 mg 1 h prior to dttmotheriP'f
graniletron (Krtril, Sanrusol PO; 2 mglday I h pritoditmothtraP'f
di<lrrlilo
IV; 10 10 mil prior to chtrrothfrap)'
IlvIrIri!bmjaj QmqrumjdalwmptQmj
TrilO500mal pilldt: 1 paldt 1448 h prior to dlmlOlhtrap)'
G/ldinsron (Zolrin)
IV; 31 mg Ii,,* dose orlhrte O. I, mgItg dose 30 miMe prior
to dItmothtriP'f
palOIIO!CIron (Aloxi) PO;05 mg I h priorto dttmothtrapy
IV;OlS mg 30 mil priortodttmothtraP'f
Ito/it< irodicou <OIIIrMn .t'f.ct<;.!II!IaIiIiDg,lrodicot .. ..nou. adwr" ""'<t<.
LibraryPirate
(""'lfr 41 Drug' for 80wel Disorders and 0I1>et Ganrolme<Hn.1 Condition, 631
Prototype Drug I Prochlorperazlne (Compazme)
Therapeutic (I ass: Antiemetic Pharmacologic (lass: Phenothiazine antipsychotic
ACTIONS AND USES
PnxhlolpfruilK' jl <I phenothiazinr,<I d<ll' of drugs UIU<l11y for !>Sy.
d,oltS. The all' tilt largest group of drugs presc:ribtd for
BaUIN and OOlitinq. .nd pnxhlolpfruiOl' is tht most frequently pll'"l<ribed
JntiemHic in iu mn.Prochiorpmzill!' am by blocking rt<tpton in
the brJin, which inhibiu signals to vomiting (fmfr in tht medulla.A. an
<I ntiemetk. it is by the rmlllllUtf, wOOe absorption is rapid. It
is .110 milablt in 1M formulations.
ADMINISTRATION ALERTS
2 houn btfoll' or antacid! and .
PJ\'9nanqutegory(
PHARMACOKINETICS
Onstt : 11>-40 min 1'0;60 min Il'<IaI
Iflk: Unknown
Halflife:Unknown
Duration: H h 1'0 or rectll
41.9 Etiology of Obesity
Obesity may be simply defined as being more than 20%
above the ideal body weight. Clinically, obesity is commonly
measured by the body mass inda (8MII. BMI is determined by
dividing body weight (in kilograms) by the square of height
(in meters).
The etiology of obesity is a complex combination of ge-
netic, lifestyle, and physiologic factors. In a fewC<lses, weight
gain can be attributed to mediC<l1 conditions, the most com-
mon being hypothyroidism. Certain rare disorders of the
hypothalamus can also cause overeating. Drugs such as oor-
ticosteroids are clearly causes of weight gain.
Lifestyle choices playa key role in the development of
obesity, the two most obvious factors being diet and physi-
cal activity. The fundamental shift in obesity levels in the
past three decades has likely been due to high-fat, calorie-
dense diets combined with less physically active lifestyles.
Despite an ongoing debate on the diet, the fact re-
mains that body weight is determined by energy (calorie)
balance. Simply stated, if the number of calories consumed
equals the number of calories expended, body weight will be
maintained (balanced) at the current level. Changes in
weight are due to an energy imbalance. For example, an im-
balance of as little as 10 surplus C<llories per day can lead to
a I lb weight gain each year. While this seems insignificant,
if the imbalance persists over several decades it can lead to
obesity in older adults. Of course, this C<lkulation holds true
ADVERSE EFFECTS
Proc:hlorpmzint prodlKtS doIt-lt"Iated antic:holilK'rgic: side efftru wc:h .. dry
mouth, sed.nion, (on ,tipation, orthostatic hypotrn lion, and tac:hyu rdw. Wllto
UIfd for prolonged periods at higher dole, extr.pyramidal symptOllll
bling thOlt of Parkinson', distalt all' <I SfriotK Olll(t m.
Contraindications: Thisdrug mould not beUlfd in patientswith
it)' to in (omatolf p.tients, or in tilt prtIfII(f of profound CNS
depIl'Ilion.h is allorontraindiuted in(hiidren )'OUogerthan age 2 orwrighiog
lei thin 20 lb. Patients with narrow-angle glalKOma, balK' marrow Illppm-
sion,or hepatic orcan:li imp-aifOlfnt lhoold oot this drug.
INTERACTIONS
Drug-Drug: Prodllorptiam. ilterat:s with aIat.oI aoo other OIS dfpIl'IloIfIts to
YUII' idditi'll' stdaIion.Antalidland .arlidi.!rlOOl:lilhibitthlo ib!ptiln of
p-ochklrpHazine. 'MItn tabo with mttaboIiIm of p-odiIorpKazilf
inoNIfcLiM with tricydI: arlid@prrnanumayp-Olixtifl(rNlfdilltidiolinflgir:
.-.:IlIypoteflli'll' fflKII.
li b iests:Untnown
HerbillFood: Unknown
TfNlmem of Ovtrdose: Overdose mavresuk in seriousCNSdefjlffiiM and ex
trapyramidal signl. Patienu m<l y be with amip-an.insonilm drugs (for
91rapyram idal S)'III ptOIlll) and poIlibly a CNS Itimulant sIKh .. dextroamphet
amint.
for losing weight, but few are patient enough to wait an en-
tire year to lose a single pound.
Therefore, to lose weight one has to expend more calories
than one conswnes.Although nutritionists disagree, in terms
of weight loss, the sollrre of the calories (carbohydrates, pro-
teins, or lipids) does not matter. Of course, the source is in-
deed important in terms of overall health and wellness.
Hunger occurs when the hypothalamus reoognizes the lev-
elsof certain chemicals (gluoose) or hormones (insulin) in the
blood. Hunger is a normal physiologic response that drives
people to seek nourishment. Appetite is somewhat diffurent
than hunger. Appetite is a psychologic response that drives food
intake based on associations and memory. For example, peo-
ple often eat not because they are e:q'eriencing hunger but be-
cause it is a particular time of day, or because theyfind the act
of eating pleasurable or social. This is a key concept because
blocking hunger sensations with drugs does not guaramee
that a person will have less appetite or oonsumefewercalories.
Nonpharmaoologic strategies should always be attempted
before initiating drug therapy for obesity. This is true for two
reasons. First, drugs for treating obesity produce only mod-
est results and should be taken for only a few months. For
someone who needs to Lose 25 or more pounds, nonphar-
macologic strategies must be employed. Secondly, maintain-
ing an optimwn weight C<lnnot be accompLished by drugs
alone: Smart lifestyle choices are required. A sustainable,
healthy diet and an appropriate exercise program are essen-
tial to losing weight and maintaining optimum weight.
LibraryPirate
NURSING PROCESS FOCUS PATIENTS RECEIVING ANTIEMETIC DRUG THERAPY
Assessment
Bilstline assess mf nt prior to administrati on:
Under>tlnd the the drug has betn pre(ribed in onIer to for
therapMK tffrm.
Obtlin a complete heakh history indudi ng GI, wdioYascula or renal
pregnancy;or a drug histOl)' including
rufTl'm prf"l(ription and OK herbal preparations,
nicotine,.nd akohol tileR 10 drug
Obtain ind vitalsigns,rspedally blood Pfl'SIUIl' and pulse.
E-iilum appropriate laboratory findings (e.g., elKtrolytn, gkKose, (&,
hep-atK or renallUnction srudits).
Obtain an ibdominal aSlffimtnt (f.g.,
preell(e of tmdernrss).
l'mfIis for (oIor, and pIl'lmCfofblood.
Assessment throughout administ ration:
Aslffi for desired therapeutic (e.g., nalllN is dtclNml, no vomiting
able to Huick and ill(lNsing solids).
CominlH'to monitor i nd measure all)' f mtlis.AIIffi urine output and
maintain inlakf and output lIII'illUmntnU in the hospitalilrd
Monitor vitilsigns,fIp!'(ially blood and IfIIOIl ill)'
hypotension ormhyurdia to the health (ilft' provider.
ContinlH' periodic monitoring of abdominal findings. epteially
boweisoonds.
CominlH' periodK monitoring of eleuroly!n,gluc:OlC, (SC, and hepatic ind
It'IIal function labs 0 appropriate.
Aslffi for acIYer1t tffrns: heada(he, diuiflfl5,dry mooth, blurred
ision, and fatiglH'.(ontirued wmiting. M'I'M' with blood
preem or appearan(f, h)"pOteMion, Udl)'GIrdia, or ronfusion
should be replned
Potential Nursing Diagnoses
FluidVolumt to 'fOIlliting)
Dl'lKitm (drug
Risk for Falls to drug effects)
Planning: Patient Goa ls and Expect ed Outcomes
The will:
therapeutK eiftcts (f.g.,doomed or absell(f of na!MiI, wmiting. ability to take fluids ind food).
Be me from. or flpfritnre minimal. adY!'ne tffrru.
Vtrbalizto an understanding of the drug's UII', ad\'elle tffrru, i nd Il'quill'd preuutions.
Dtmon slrtlte proper ldf-administr.tion of the medic.tion If -9., dOl(, timing. wilen to notify provider).
Implementation
Interventi ons and (Rationales)
Ensuring tht rilpeut ic effeds:
If definitiY!' (a!Mfor the symptomlcan bt identified (e.g.,
inftetion, i.Ml1fdrug effKh),cOlTf(\ possible. (HallIN
and yomiting afl' often symptoms ofotherunderlying conditions sud! is
drug t ifl'(1\ or inffuiorn.)
Encou.a wall alllOllltoffluihorKed!Pland dtcft'illitgac:tivity 1M! whit
naull'ated; eimitatilg akohoI il1ake, smoking alii iKIwiIg intake of
and <l'iOOpIrius-<OOtaining foods after has (faled.
inteM'ntionIlIIi)' help fiIIe S)'lllptOllll rurilg Ihl' awte phu. Ensuring
idtqwte oflkids, including intril"'llOUs flWs ijnflSilry, will
m.JiltJin tI oomuilluid bai<nre. SnJJking tlnd oIkoho1 tile (atI\f gastril: irritation.)
Adminiltff 11) to 60 m inutf"l anticip-ated nauseaindlKing
or drug adminillr.!tion (f.g., d!tmother.ipy). adequate
hydruion priorto theOll\et of anticipated aft' most
effK1iW'when taken naulN O(rurs.ElllUring adequate pre/l)'dration
dtcft'asel the rilkof dehydration should wmiting O(rur.)
Pati ent and Family Educat ion
Re-.itw medications, foods, and the plssibilil)' of illnesl with the patient,
family, or (all'gr.er to help idtntif)' UUl.lliYe factors.
tk<ll'aM' noxiou Istimul i (e.g., strong odors, rapid (hange in position) that
m.Jy naUM'a orvomiting.
Encooragt the patiem to limit ph)'siullllO'/emtnt or ac:tivity ruring periods
of i Me IIiIlMii or vomiting. Enrouragf inmasing fluid imakegraduali'/, with
Kf (hipsor Imalisipsofwater.Ginger may au al a naMal antinaulu
iltvtr'ge and may bt for some
Teac:h the patient to take the il ntiffnetic ij IIiIlIIN iI
If drowsifll'is or diuillfll milY O(rur, enrourag!' the patitntto (onsider a "tria I
run" with the medication tlken in t'lffiing btfoll' btdtillll' to il\{fruin
elite!> priorto tlking ifdriving illl'quift'<i.
Teac:h the on i\homl'(hl'm01heril py to take antiemeUa prior to
dtemotheraP\' dost or routintly al ordtrrd b)' the heahh (ilft' provider.
LibraryPirate
NURSING PROCESS FOCUS PATIENTS RECEIVING ANTIEMETIC DRUG THERAPY (Conflntwdl
Implementation
Interventi ons and (Rationales) Patie nt li nd Fllmily Educlltion
Minimidlg IchotM rlfffb:

MoniWf 'riul sig"" p.lticulilfy ItIood prts.sure IIld l.b blood Tu(1I t!Ie to rise!ll)llllying 01 sittin9 to SIIoding slowly to l'IOid
prenul1' Iyinq. mting..md sundinglo&tat onhost.tic IIypottlllion.8t diuinlssorAlb.
Clutious with oIder.1iIIts who <lit at an inmastd risk for hylXltfrtlion.
Rtport any iIypottlllion,t!f)Kially usociati!d with UdlYQrdia,
immi!diatfl,.(EllCtuil'f 'fOIlIiting m.yuuse deIr)ldration and decrtrn
blood prtSIure or iWltiMtilllints, and
phrnolllW:inr or dnqs may blood
PIl!SIUI1'..)
ContinUt to rnonitor . bdomirwl olIltSSment findillgs.lmmi!diattly ftport Tudr t!Ie to report any intreolling discomfort or pain.
.oy signifi{;WI\ in bowft sooodl,.distfl'ltion,. nrw
11IItnK1 the l!wIt .bdomillill pain or ill)' blood in tmnis
or Ull!ollt in dinornfort or pain,!oMrt abdomirwl p.lin,orvomiting t!wlt is
should br I1'IIOrttd immediately to dre hNlth
mffM-ground in ncy or (onuins blood. (lncltiSing or !tI'fft
.bdomillill piin or blood in may inootf j WOfSfI'Iing of dist.stJ

n1Uft p.ltiMt saftt); in oldtf aduh ObstM fdizziMss and InstnKt the patitnt to all lor uSist'lKt priorto gttting out of btd or
monitor .mbulation until th! tflects of the drug .ft known. lIl1iin atttmpting to w i11k .1oM if dizziness Of 0111'. P JOYide iWI
IMIs if diuintss (ooonufS. (DfO'NIiness Of dizziness from tmts.is hilin neilby.m homt Ust,awid driYing or other .tMties
&hydrltion or from .dvtrst drug cfftm occur .nd Urt.1tS tht risk of rtqIIiring lllfIIul.lfrtnns Of coordination untillllf rlffru of tltf
falb.Cootinutd diuinrss may indiurteleruolytt imbalana and tltmolJte drugomknown.
Itftk should bt asltSStd.)
CorItinUt to monitor ptriodic duo/ytt,gUost 1tvtb..IId hepatic IIld 1nstfU(t tire on thr nw:Ilor labwort
1m.1 function rtll1 n netdtd.(loss of tltruulytrs IIIiI'f ocrurwith
vomiting.Abnormalliwr flllKtion ttll1may advtnot


MorWtor inukr <lnd output in thr hospitalizrd p.Jtitnt.lnitiatt IV IUd ImlnKt tire patifllt on thr netd to MthOOlcl tUds.wl food until vomitin9
rtp/M:rmflltwhtn indiatm Hold oral fluids unti aUrll! IIOmiting hll h.s cused.fnitiatt illm'nk'IItal Ul1'aItS in intalt with srlliln
(tast<! .nd then graduily Urt'!e IUd inub, beginning with smaisips of sips of wale. and dtit lIuids.
Wittror itt chips. (Continuing olil inlalt IN, WOI1m IIiIlIsta iWld 'IOflIiling.
EqlIiin thr r.tiollillf lor illY IV hydrilion lequiftd and IllY equipmtnt
resuming fluids will for without stimulating
""" llilW'a.1V lIuid replic:ml!'nt may lit lequiml iflluid loss h<lslftn
and deIr)ldration prtIfIIl)
If JII1'9I1iI'q is suspt(ttd orconlirmtd, hold thtintitmttic until COflSUIting Iftht p.lUfI'It is prt1jIlilnt.Of if prt1j1lil1'q is suspt(rtd. tt iJdr t!Ie patient to
Mth tht hellth (IR' pnwidti: (AllmJatM IntillillM. mtolIUII!S should bt with tire htllth care btfOft' tlking Ill)' antitmrtic: drug ilr
used 10 t.I!e nausea when possiblt.Tht drug's pltgnancy diss and morning sickness.
prt1jIUMY trimtSttl will bt mMldertd b, he.1th WI! proWIel befort
thr useof AOI'Idrug _ SU(h as dry and UflSWtttfl'li!d
prtl(ribingJ
ctfuboroatUts taken in smil .mounts.iVOiding noxious stm during
periods of naum,orgingtr ilf may aid in diminishing nlUst
Patient u.derslanding of drug therapy:
Ust opportlJnitiei during the idministration of mediutions and Wring The patient. fimil1.or calegiftr should lit able 10 mtt the reuon for the
.SItSSmfntslO discuss thr fuiollillf for drug desirltd therapeutic drug; . ppropriate dose .nd !Chi!duling; 'llftit . eM 1st effu to obstrvt for
outtOOlts, most common <Idverw tfftos, p.lramtters for wilen to aD the and when to reportand the .nticipattd Itngth of mi!diution theraPl'.
helrth eM!' <I oy nt(tlliry monitoring or prtUutions. liking
timt during WI! helps tooptimizt and ftinfortt kry ttM:hing
.1tiS.)
Patient of dl'1lg therapJ:
When adminislt ring the mtdic.Jtion,instnxt tht Amil1.or Tilt patient .nd flmily or are ,blf 10 disarss ,ppropMe dosing
Ciltgil'fr in tht proptt st if-administllltion of the drug.t.g.. tal:l!n with alld administr"ion IIfflk.
sma. sips of 1'lJid. (Proptr administration intl!astI the efttctiwntss of t!Ie
d ... J
Evaluation of Outcome Criteria
t!Ie tffKtivtnts.! of drug drtraPl' Il, confirming tht tht p.ltirnt go.k.nd ecptCltd ou\(omt! hll'f IIftn IIItt (Ief "lalll'ling1.
Stt' TtIbIt4U IfW.
LibraryPirate
6]4 Unlt7 TheGa,lrolnt..,tI,..1 Sy'tem
Drugs for Obesity
Despite the public's desire for effective drugs to promote
weight loss, however, there are few such drugs on the mar-
ket The approved agents produce only modest results,
41.10 Pharmacotherapy of Obesity
Because of the prevalence of obesity in society and the diffi-
culty most patients experience when following weight reduc-
tion plans for extended periods, drug manufacturers have
long sought to develop safe drugs that induce rapid and sus-
tained weight Joss, In the 1970s, amphetamine and dex-
troamphetamine (De:wdrine) were widely prescribed to
reduce appetite; however, these drugs are addictive and rarely
prescribed forthis purpose today, In the 19905, theoombina-
tion of fenfluramine and phenlennine (fen-phen) was
widely prescribed, until fenfluramine was removed from the
market for causing heart valve defects, An arc appetile sup-
pressant, phenylpropanolamine, was removed from the mar-
ket in 2000 due to an increased incidence of strokes and
adverse cardiac events. Until 2004, natural alternative
weighl-loss products contained ephedra alkaloids, but these
have bem removed from the market because of an increased
incidence of adverse cardiovascular events, Thequest to pro-
duce a hmagic pill " to lose weight has indeed been elusive,
Current pharmacologic strategies for weight manage-
ment focus on two sites of action, One strategy to reduce
weight is to block the absorption of dietary fats using drugs
called li pilS!' inhibitors, OriislM (Xenical) blocks lipid absorp-
tion in the GI tract. Unfortunately,orlistat may also decrease
absorption of other substances, including fat-soluble vita-
". Prototype Drug I Sibutramine (Mendra)++
mins and warfarin (Coumadin) , To avoid having severe GI
effects such as flatus with discharge, oily stool, abdominal
pain, and discomfort, patients should restrict their fat intake
when taking this drug, GI effects often diminish after 4
weeks of therapy, This drug produces only a very small de-
crease in weight compared with placebos,
A se.:on d strategy to reduce weight is to block parts of the
nervous system responsible for hunger with anorexiant!, also
called appetite suppressants, Until recently, sibutramine
(Meridia), a selective serotonin reuptake inhibitor (SSRI), was
the most widely prescribed appetite suppressant for the short-
term of obe..ity, In 2010, the manufa<:turer
withdrew sibutramine from the market because the drug in-
creased the risk of stroke and myocardial infarction, Twoother
SSRIs, fluoxetine ( Prozac) and sertraline (Zoloft) , produce a
small loss in weight, although they are not FDA approved ror
this indication, Phentermine, once part of the now-banned
combination offen-phen, is still avaiIableas monotherapy, al-
though it produces onlya small, transient weight loss,
All the anorexiants have the potential to produce serious
side effects; thus, their use is limited to short-term therapy,
Anorexiantsare prescribed for patients with a body mass in-
dex (BMI) of at least 30 or greater, ora BMI ofl? or greater,
with other risk factors for disease such as hyperlension, hy-
perlipidemia, or diabetes,
PANCREATIC ENZYMES
The pancr eas secretes essential digestive enzymes: Pancre-
atic juice contains carboxypeptidase, chymotrypsin, and
trypsin, which are converted 10 their active forms once they
Therapeutic (lass: Antiobesity agent;appetite suppressant Pharmacologic Class: Anorexiant;SSRI
ACTIONS AND USES
Sibutlllmine is only oIpprored for lilt trulmenl when with
a rmN-umdietand ilKn'aIfd physiul anM!)"Tht drug isolblt 10prod!Kf
a 5% ttl 10% Ion of body Wl'ight within 6-12 momht of ufatm!'nl. Patients
who hm not lost aiitaSl41bakfrilitfil'll month oflhtrapy lfqUil! an inuN,r
in OOS!'ordil(ontinWlion oh he"apy,Sibuuaminr thmpy is not
for Iongmhn 1 ym,
ADMINISTRATION ALERTS
Allow at Irolst 2 WffIu belwel'n dilcontinuing MAO iohibitonand staning
siOOtramine,
Thisdrug is not approwd for !lSI' in patients undtr ige 16.
Pl!ijnancy rnegory (
PHARMACOKINETICS
Onset: Unknown
Iflk:Uh
14-16 h
Durat ion: Unknown
++ Sibutramint was rentO'ftd from lhe marUl in Oaobtr 2010
ADVERSE EFFECTS
Sibutlllmine is gentlllily 'MIl toIera\fd, The most smous aU;tlS!' n in-
mud risk of strou <I nd III)'OUrdial infaraion. HeadM:ht,coostipali:IO, ifllOmnia,
01 00 RIOStomia tM mon common romplaims reporttd durilg
thtrapy,Wtight gain may wr <lfter k a Sditdur

Contraindications: Sibutramint is (OIllraindiuled in p;ltitnts with eating dis-
ordtrs (.J llOmOa III' rvou or bulimiaj.Jnd thole laking MAO inhibiton. Tht drug
!hoold be Ultd "';th in p;ltitnu with he.Jn diseaS!', dysrhythmias,or ,Iroke
it mayUUlt tadtyurdii.Jnd raist blood prtSlUlI',
INTERACTIONS
I)ug- l)ug: lIstwith atlH9Y lIIKkation, may<aUSf
.w,.a\ed blood iIIId erytInrny<in may ilhibit 1M
of Iibw.Ullint, (oocWlI'nt !III' with a lIICIIOiIIIiIf oIidR (MAa) or
1MIi'll' U'I1IIO nin rl'UpiiI:I' inhibitor (,SRI I rna, COlUII' Sfrotonill,oorOlll',
Lab TeslS: tktllOWll
Ik>rbaVFood: Unknown
Treatment of Overdo It : Tach)'UrdY and hypenension m.JY II'IUk from om-
dost, BetNdrene"lic blockers may be administerrd
IWfI llIMyMlIbrgKJrflJf 101M!tug.
LibraryPirate
(IIIplfr 4t Drug. fo,OoweI011o,d<'r, aooOlIll'rG. nrolm",,"n. ICoodltlom 635
Thr Qurstion: the most effKl:ift Slrilltfgies for prodKing
lustaiord Wl'ight losl?
Thr Study: Tht authon (onrb:ted I)'Itrrnatic: !!'ViM to tyPfI of
Wl'ight-Iou intrrventions that (omribute to thl' mon luarsdiJl
ou\OOIlll'S. Eight typH ofWl'"ight-lolI intt rventions
alonr, dift plus mn111' meal my..Jow-
elll'l9Y diets, weight-11m l!Il'dirations (oriistat iIInd libutramiOl'j, and
adYKr alonr.Tht most llJ((Hlful inter/Mtions Mff <I
die! andlor Wl'ight-Ioll mrdiutioOl.i)Jring thl' first 6 momhl,an
Wl'ight lois of 5 to 85 kg (5% to 9%) wiloilll'rwd.ln lrudirs
wending to 48 monlhl,a mean 1 to 6 kg (1% to 6%) of Wl'ightloll Willi
l1IiIintainrd. and fll'rtM--alonr group! HptritrKed minil1lill
Wl'ight lou.The authors (onduded that the addition ofWl'"ight-101I
medic:ations enhalKrs Wl'"ight-Io!s maintenantr.
Nursi ng Implicationl: 4Iou1d k'ac:h p-atifrrts that drug! (an be UII'd
to enhalKf weight lois, but ttr, mun be (ombinl'd with a
diet to be most tfl"KI:ift.
M.11IIru.l CiIJIrr,J.8otK/ttr, llfllorr,1I!
(lOOl). Moolei:A S)1ItmQ/t RPI1twooo
Dlrkd t /Q/f wlrh 0 Mln.tnu11 1-1N- fDI/ow.1Ip. Journal of tllt.l.merkoJn Dlfl:fIk
Mlodatlon,107(10l Il55-1767.
reach the small intestine. Three other pancreatic enzymes----
lipase, amylase, and nuclease-are secreted in their active
form but require the presence of bile for optimum activity.
Because lack of secretion will result in malabsorption disor-
ders, replacement therapy is sometimes warranted.
41.11 Pharmacotherapy
of Pancreatitis
Pancreatitis results when amylase and lipase remain in the
pancreas rather than being released into the duodenum.
The enzymes escape into the surrounding tissue, causing in-
flammation in the pancreas. Pancreatitis can be either acute
or chronic.
Acute pancreatitis usually occurs in middle-aged adults
and is often associated with gallstones in women and alco-
holism in men. Symptoms of acute pancreatitis present sud-
denly, often after eating a fatty meal or consuming excessive
amounts of alcohol. The most common symptom is a con-
tinuous sewre pain in the epigastric area thM often radiates
to the back. The patient usually recovers from the illness and
regains normal function of the pancreas. Some patients
with acute pancreatitis have recurring attacks and progress
to chronic pancreatitis.
Many patients with acute pancreatitis require only bed
rest and withholding food and fluids by mouth for a few
days for the symptoms to subside. For patients with acute
pain, meperidine (Demerol) brings effective relief. To re-
duce or neutralize gastric secretions, H,-receptor blockers
such as cimetidine (Tagamet ) or proton pump inhibitors
such as omeprawle (Prilosec) may be prescribed. To de-
crease the amount of pancreatic enzymes secreted, carbonic
anhydrase inhibitors such as acetazolamide (Diamox) or
antispasmodics such as dicyclomine (Bentyl) may be used.
In particularly severe cases, IV fluids and total parenteral
nutrition may be necessary.
The majority of chronic pancreatitis is associated with al -
coholism. Alcohol is thought to promote the formation of
insoluble proteins that occlude the pancreatic duct. Pancre-
atic juice is prevented from flowing into the duodenum and
remains in the pancreas to damage cells and cause inflam-
mation. Symptoms include chronic epigastric or left upper
quadrant pain, anore.tia, nausea, vomiting, and weight loss.
Steatorrh ra, the passing of bulky, foul-smelling fatty stools,
occurs late in the course of the disease. Chronic pancreatitis
eventually leads to pancreatic insufficiency that may neces-
sitate insulin therapy as well as replacement of pancreatic
enzymes.
Drugs prescribed ror the treatmem of acute pancreatitis
may also be used for patients with chronic pancreatitis. Opi-
oid analgesics, IV tluids, insulin, and antiemetics may be
necessary. Oral pancreatic enzyme supplementation is often
used in patients with chronic pancreatitis. Pancreatic en-
zyme supplements such as pancrelipase (Cotazym, Pan-
crease, others) or pancreatin (Ku-Zyme, Kutrase) help to
digest fats, and prewnt steatorrhea.
L IFESPAN CONSIDERATIONS
Psychosocial and Community Impacts
of Alcohol -Related Pancreatitis
Patirnll with ac:Uk' palKlNlitii most often middle aged, <lnd moll' with
chronic palKrwitis rtIMt in tiltir 50! or 601. Patitnl! whost panae-
uitil iI moc:iatro with 9'lllstonH II\a)' !fail'!' a diffrlfllt tyPf and amoum of
from ,ignifitant Olhl'rs, thl' (ommunity, and et'II from nurll'! <IS (om-
with thole who palKlNtitii mowted with akoholilm. NUIIf'
will nerd to eoxaminr thrir and anitudl's rNird to akoholism in grn-
t ral and to patifnt! with akoholiun-a5Soc:ia1ed pancrNIitii in and
will nerd to adopt atlilUdrs to htlp tht p-atifntattain goals.
Patifnt! who abull' akohol often ntfd referral to (ommunity agrlKirs to
I1IiInagr thtir addiction andlor rtI1IiIin in Family mrmbm may abo
III'I'd !ffenal to oommunity agrndrs for hl'lp in dl'aling with altered family
prom'H dUl' to thr patifm's drinking <lnd an, role they II\a)' hal'!' played in
. n.bling the !,"liMt'" .buse .kohoL
H OME & COMMUNITY CONSIDERATI ONS
Educating Patients About OTe Medications
for Bowel Disorders, Nausea, and Vomiting
dilorders, Ool!lll'a,and vomiting <l mong thf most common (om-
plaint! for which palimt! !edc medi(al (onluitation; they also
thf most (ommon (omplainu with Ol( medic:ationl Many patient!,
Hpt(ially oId!'r oldu In, do not undemand that thell' OK mrdic:ations hal'!' thf
pottntial to QUII' drug-1lrug interactionland adl'!'lIf efi"Ku.MolI of
thrsr OK mrdic:ationl with thr rnetabolilm of pA'lCl"iplion mrdic:a-
tions and Ihould be UII'd with caution in patient! with Mlarged proltatrs be-
UUII' thI')o can UU\e life..thrNtening also nerd to
thanhrsr orCs can caulr drowsiness and hypotenlion. (.JIdul ro!Koltion iI re-
quired 10 that patienll understand that (ontirued!lll' of thHf mrdic:ations
II\a)' mollk a hl'ahh dilordtr.
LibraryPirate
636 Unlt7 lheGo'ilrolnleStinalsym'm
..... Prototype Drug I Pancrelipase (Cotazym, Pancrease, others)
Therapeutic Class: Pa ncreatic enzymes Pharmacologic Class: None
ACTIONS AND USES
romains lipall', 101911', a nd 'myW of parle origin and is UIfd u
rep1.KrllM'M t/itrap)' for palirnu with illluffkirni pan(lNtK oooinr II'{Ie-
induding 111011' wilh pnrmilis and ryslk fibrosis.GiYm orally, Ihr (,)p"
sullo dislOivrs in thr ,lIblinr rnvironllM'M of IIi!o dJodenum and releasrs its
rrll)'1IIH. Thr m locally in Ihr GIUoKt and arr not absorbrd Panaeli-
pasr is milablr in powder, tablet, and upsulloformulatiolll.
On an basis, pilKrrlipall' is mOl"l' paleM lhan with
12 Ii1111'S th!o tlll)'mt activity. a Iso (omains 011 iea >I four as muc:h trypsin
andamylall'.
ADMINISTRATION ALERTS
00 IIOlUlIsh oropen r nterK-<oaled lablets.
I'owdrrformulations maybr sprinklrd on food.
GiYr h brIortor with meals,or u dirtaed bt' the hr,kh Urt
provider.
Prtgnanq calf90ry (
PHARMACOKINETICS
Ons!'!: Immediatr
Iflk: Unknown
Halflift : Unknown
Duration: Unkoown
Chapter REVIEW
- -
KEY CONCEPTS
ADVERSE EFFECTS
rtrts of unrommoo, sinct thr rnz)'llll's 001 ab-
sorbed. Thr most frtqUrnl oIiMIW tife(ts an' GI symptoms of IliUll'a, wmiting,
a nd diarrllra. Vrry hi.;h doll'! 01 moc:iated with a risk for hyptNricemia.
Contraindicationl: is (ootraindicated in patirnu allfl<JK to tht
drug or to pork produm. The delayed-nieolll' produru should not be giYm 10
pillitnu with oKUl\' pinae"'itis.
INTERACTIONS
1Wg- 1Wg: Porrnlipa;t inmru with i Ol1, whidlmay rflWi i1 dKrNSfd
absption ofiron.Nna:idI the fife(! ofparmlipu.
lab Iflls: PanoripR rna, incrNlf \eIUm or urinal)' levels of uric add.
Ik>rbiollF.w: U" ....... ,
llNtment of High of uric oI cid may oc:rur with Pa-
titnts UUled
IIeI'lr III MyMnbtgl(l W MnIrtg /'reIS Fo:us spKl/I( IIIIM <tug.
The numbered key concepts provide a succinct summary of the important poinls from the corresponding numbered section
within the chapter. If any of these points are nol dear, refer to the numbered section within the chapter for review.
41.1 The small intestine is the location for most nutrient and 41.6 Innammalory bowel disease indudes uicer.ltiw colitis
drug absorption. The large intestine is responsible for and Crohn'sdisease. Treatment indudes 5-aminosal.icylic
the reabsorption of water. acid (5-ASA) agents or corticosteroids. Drugs for irritable
'"
Constipation, the infrequent passage of hard, small
bowel syr.drome are largeled at symptomatic treatment,
stools, is a common condition caused by insufficient di -
on whether constipation or diarrhea is the pre-
etary fiber and slow motility of wasil' maleriallhrough
dominanlsymplom.
the large intestine. 41.7 Vomiting is a defense mechanism used by Ihe body to rid
41J Laxatives and cathartics are drugs given to promote
itself of toxic substances. Nausea is an uncomfortable
emptying of the large intestine by stimulating peristalsis,
feeling that may precede vomiting. Many drugs can
lubricating the fecal mass, or adding more bulk or water
cause nal:Se3 and 'omiting asside effects.
to the colon contents.
.,.
Symptomatic treatment of nausea and vomiting indudes
41A Diarrhea is an increase in the frequency and nuidity of
drugs from many differenl classes. including pheno-
bowel movements that occurs when the colon fails to re-
Ihiazines, antihistamines, antkholinergics, cannabinoids,
absorb enough water.
corticosteroids, benzodiazepines, and serotonin receptor
41 5 For simple OTC medications such as loper-
antagonists.
amide or bismuth compounds are effective. Opioids are
41.9 Obesity has become widespread in the United States and
the most effective drugs for controlling severe diarrhea.
is with multiple chroniC diseases such as hy-
LibraryPirate
("",If,41 Drug. fo, Oowel 0"",<1<>" aoo Ollie< G. nrolllle<"n. 1 Conditio", 637
pertension and heart disease. Theetiologyof obesity is a
combination of genetic, lifestyle, and physiologic fac-
tors. A sustainable diet and exercise program should be
implemented before pharmacother apy is considered.
41.10 The pharmacothernpy of obesity includes the anorexi-
ants sibutramine and the lipase inhibitor orlistat. Both
NCLEX-RNO REVIEW QUESTIONS
D In a patient with a prolonged episode of vomiting, the
nurse must assess for the development of what problem?
I. Acid-base disturbances
2. Intractable diarrhea
3. Esophageal tears
4. HypoventUation
II The nurse should educate patients to take diphenhydri-
nate (Dramamine) how long before tht")' board an air-
plane for a trip?
1. 20 to 60 minute"
2. ] 5 minutes
3. 2 hours
4. 6 hours
D The nurse assesses for one of the major precipitating fac-
tors in the development Iss, which is:
1. stress.
2. peptic ulce!>.
3. gastroesophageal reflux disease (GERD).
4. Helwhamr pyillri.
o The patient has been given a drug for treatment of nausea
and vomiting and is IIOwcomplllining of dry mouth, con-
stipation, and a rapid heart rate. What drug would cause
these side effects? (Select all that apply.)
CRITICAL THINKING QUESTIONS
1. The patient has been taking diphenoxylate with atropine
(l.omotil) for diarrhea for the past 3 days. The patient has
had diarrhea five times today. Iden tify the priorities of
nursing care.
2. The health care provider has ordered morphine and
prochlorperazine (Compazine) for a patient with postop-
erntive pain. The patient insists that she is "needle
and wants all the medication in one syringe. What is the
nurse's response?
drugs are used for the short-term management of obe-
sity but produce only modest effe.;:ts.
41.11 Pancremitis results when pancreatic enzymes are trapped
in the pancreas and not released into the duodenum. Phar-
maootherapy includes replacement enzymes and support-
ivedrugs for reduction of pain and gastric acid secretion.
J. Loperamide (immodium, Kaopectate)
2. Prochlorperazine (Compazine)
3. Peppermint
4. Diphenoxylate with atropine (l.omotil)
5. Promethazine {Phenergan}
II The patient has been prescribed sibutramine (Meridia)
for obesity. The nurse assesses for what as a possible con-
traindication? (Select all that apply.)
J. UncontroUed hypertension
2. Hepatic impairn>ent
3. Renal impairment
4. Coronaryarterydisease (CAD}
5. Bowel obstructiOll
1:1 The nurse has administered prochlorperazine (Com-
pazine) to a p.1tient for postoperative nausea. Before ad-
ministering this medication, it is essential to che\:k the
patient's:
1. pulse.
2. blood pressure.
3. IWlgsowu!s.
4. temperature.
J. A patient comes to the clinic complaining of no bowel
movement for 4 days {other than small amounts of liquid
stool}. The patient has been taking psyllium mucilloid
(Metamucil) for his constipation and wants to kllOw why
this is not working. What is the nurse's response?
See Appel1dix D for answen and ratiol1alel for all activitiel.
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DRUGS AT A GLANCE
VITAMINS pI1Jt 619
Lipid-Soluble Vitamins pI1Jt 5//
Q vltamJn A (AqUQ50/ A,. olhffs) f!I1I1t 642
Water-Soluble Vitamins fCljt6-/l
Q foN, ocld ;vge 644
MINERALS !'Jilt""
Macrominerals fOJt 648
Q lIl<lgne5Jumsulfote (MgSO.) P'X}t&19
Microminerals pagtfA8
NUTRITIONAL SUPPLEMENTS {X1IJt65IJ
Enteral Nutrition fUJf 65(J
Parenteral Nutrition plI}t651
KEY TERMS
beriberi f'Jt}t64J
pI1Jt 641
enteral nutrition JUje6S0
ergocalciferol MI641
jXIgt 640
maaomineral (major mineral) paljt648
Drugs for Nutritional
Disorders
LEARNING OUTCOMES
Aher reading this chapter, the student should be oble to:
1. Identify characteristics that differentiate vitamins from other nutrients.
2 . Describe the functions ofvitamins and minerals.
3. Compare and contrast the properties of water-soluble and fat-soluble
vitamins.
4. Identify diseases and conditions that may benefit from vitamin or
mineral pharmacotherapy.
S. Describe the nurse's role in the pharmacologic management of
nutritional disorders.
6. Compare and contrast the properties of macrominerals and trace
minerals.
7. Identify differences among oligomeric,polymeric,modular,and
specialized formulations for enteral nutrition.
8. Compare and contrast enteral and parenteral methods of providing
nutrition.
9. For each of the drug classes listed in Drug at a Glance, know
representative drugs,and explain the mechanism of drug action,
describe primary actions, and identify important adverse effects.
10. Use the nursing process to care for patients who are rece iving drug
therapy for nutritional disorders.
minfral) nf,48
parenteral nutrition {!'Jgt6'lJ
IIfllagra JVj I f,43
IIfrnicious (rnfgaloblastid anf mia 6-U
provitarnins .39
Rf(omrnfnded Diftary Anowan(f (RDA) pagt&J9
SlJJrvy mrf,44
tOOlpheroi JXI9IfY/1
total parentrral nutrition (lPN) {!'Jgt651
undernutrition n65IJ
vitamins pI1Jl6J9
LibraryPirate
T
he nutritional supplement business Is II multibillion
dollar Industry. Allhough clever marketing often leads
people to believe thaI vitamin and dietary supplements!!re
essenlial to maintain health, most people obtain all the
ne<l'ssary nutrients through ill b.1Ilanced diet, Once the
body has obtained the amounu of vltllrnins, minerals, Of
nutriefllS it needs 10 carry on metabolism, Ihe elcess is sim-
ply excreted at' nored.ln eMaln conditions, however, di-
etary supplementation Is nessary aM benefits the
patient's health. This chapter focuses on these conditions
and explores the role of vitamins, minerals, and nutritional
supplements In pharmacology.
VITAMINS
Vitamins are essential substances needed to maintain opti-
mwn wellness. Patients having a low or unbalanced dietary
intake, those who are pregnant, or those exper iencing a
may bend;t from vitamin therapy.
42.1 Role of Vitamins
in Maintaining Health
Vitarrins art'organic compounds required by the body in small
amounts for growth and for the maintenance of normal
metabolic pTOCe$St$. SiJ1(e thedisroveryofthiamine in 1911,
more than a dozen vitamins have bn identified. Bewuse sci-
enmls did n<M know the dlemical Slructures of thevitamins
when theywere they assigned letters and numbers
such as A, B'l,and C Thesenames are still widely used today.
An important characteristic of vitamins is that , wi th the
e.n:eption of vitamin D, human cells cannot synthesize
them. They,or t heir pre<:ursors known as Jl!VritJmils, must be
supplied in the diN. A seoond important characterist ic is
that if the vitamin is oot present in adequate amounts, then
the body's mebbolism will be disrupted;lnd disease will re-
sult. However, the symptoms of the deficiency am be re-
versed by administering the missing vitamin.
Vit;lmins srrve diverse and important roles. For enmple,
the B-complex vitamins arc cO<'nzymes essential tQ many
metabolic pathways. Vitamin A is a precursor of retinal, a
pigment needed for vision. Cakium metabolism is regu-
lated bya hormone that is derived from vitami n D. Without
vitamin K, abnormal prothrombin is produced, and blood
clotting is affected.
42.2 Classification of Vitamins
A simple way to classify vitamins is by their abilit y to mix
with water. Those that dissolve easily in water are called
water-soillblevitamins. wmples indudevitamin C and the
B vitamins. Those that dissolve in lipids are called Jat- or
lipid-soluble and include vitamins A, 0. E. and K.
0Iap1tl41 Orugs 10, Ofsorden 639
The difference in solubility affects the w:J)' the vitamins
art' absorbed by the gastroint estinal (GI) tract and Slored in
the body. Thewater-soluble vitamins are absorbed with Wa-
ter in the digestive tract and re:lldily dissolve in blood and
body fluids. When excess watersoluble vi tamins are ab-
sorbed, they cannot be stored for bier use and are simply ex-
creted in the urine. Because they are not stored to any
significant dt'gTte, they must be ingested daily; otherwise,
derlCiencies will quickly develop.
Fat-soluble vitamins, on the other haod, cannot be ab-
sorbed in sufficient quantity in Ihe small intestine unless
they are ingested with other lipids. Thesf vitamins can be
stored in large quantities in the liver and adipose tissue.
Should the patient nol ingest$utncient;lmounts, fat-soluble
vitamins are removed from stOl'1lge depots in the body, as
needed. Unfortlillat ely, storage may lead 10 d.a.ngerously
high levels of these vitamins if they are taken in excessive
aJnounts.
42.3 Recommended Dietary
Allowances
Bas<>d on scientific research on humans and animals, the
Food and Nutrition Board of the National Academy of Sci-
ences has established levels for the diftary intake of vita m ins
and minerals called RtcommeRdrd Dietill)' AllowaJl<ts (RDAs). The
RDA values represent the minimum amount of vi tamin or
mineral needed to prevent a deficieJ1(Y in a healthy adult.
The RDAs art' revised periodically to reflect the latest scien-
tific Current RDAs for vitamins are listed in Table
42.1 . A newer standard, the Dietary Reference Intake ( DRI )
is sometimes used to reptsenllhe optima/level of nutri ent
needed to ensure wellness.
Vitamin, minera1, or herbal supplements should never
substitute for a balanced diet. Sufficient intake of proteins.
carbohydrates. and lipids is needed for proper health. Fur-
thermore, although the label on a vitamin supplement may
indicate thaI it contains 100% of the RDA for a particular
PHARMFACTS
Vitamins, Minerals, and Nutritional
Supplements
AiIout4<m of AmrrKanllilu vililmin suppltrntrtudUy.
Thm is no diifmllCt bttwftn tilt Itruc1U1II! of illIol1Ural
vitamin and alynthttic vililmin, YtI consumetS II<IY m!l(h molt forthe

Vitamin Bu is pltlfnt only in animal pnx!!I(u.Vfgwriilns mily find
adtqu;lle amounu in (fINis, nutritional suppltments, or ytil st.
Administration of folic acid lklring pregnilllCY has betn found to reduct
birth dtfts in ntlYOUl system of the
P,tirntt who IIMr rtaivr sun lll;pOSUJl! may rd ";tlmin D
SUppImJlrru.
Yitlmm tffiInicaIIy elMO! ilKlNll! I pilirnt's tnell})' IMI.EntI9Y Coln
!If proYidld only by adding Cilkllirs frf.tm Cboh)'drilts, PfO\eim,.lIId
.,...
LibraryPirate
640 Unlt7 TheGa,uoIm",tI ... ISym'm
TABlE42 .1 1 Vitamins
'D'
VItamin Functlon(s) Moo
Common Cause(s) of Defklency

ViIlI,1 (dl, 1,0001119 RE* 8001119 RE Proloogtd dtlay dfpffl,lion, p.lrtirubrly when
rU is the main food IOUITt; II'IKft'"kdiIN!I';
dnllOlis
Bwmpi9:bioIin in mrubolk rt', aions lOnKg
qilr11XONbmin (Bul Cotnzyrnt in nudril: oXid

lido: ofinnimi( intlu offoods
/rom,nimaloric;jn
(Bol in amilo.uid ind nudric. 16Q--1&Jmc:g ,koholism, (i1Kn-, or,1 roniri(rplift
.xiii mriabolism ..
rioXin(BJ Cotnzyrnt in OIidation- rrdJaion 15-20mg 13-1Smg Proloogtd dtlay drpi'i'lllion,lI'rtirubrly
ruction, Indln (OI!l is the main food
dlronic: diarrhN; i'lff di!l'a\I': alut.olilm
p.lntolheril:.xiII (8,) CotIIl)'RIr in mrubolk rt'iaions
'''' ''''

pyridoJ:inflBJ CotIIl)'RIr in amilo ,dd
''''
1.H.6mg ,l,koholilm, oral rontrnpli..,. U!I',
RBC produaion maiablOlplion distlltl
ribo/IaYin(B,1 Cotnzyrnt in OIidatioo-frdJaion U- l.8mg 1.HJmg (OOIUmplion of mit or Inimll
ructions dlronic: diarrhN,live' Ii !l'alo!,
akoholism
ttiaminf (B,) (0ffil)'IIIt in met.lbolic: rt'.I<liom, RBC 11- 1Smg 1.0-1.1 mg ProIOIigN metal depri'l.llion, pirtiwbrlywhen
formation rU is the main food IOUITt; h)'pffihyroidilm;

C(aI(orbic:,dd) CotIIl)'RIr and antioxidant

60.., offnits
prt'IJIaoq,dlronic: innammatorydiSt.l1t, tum,
diarrhu,akoholilm

Cikium Ind phoophll. S-10mg >- 10mg low diftl" into., inodtqUlIO fXJHIlUr. to
SIIllight
,
Antioxidant IOTE** 8..,. Prffilalllity, mabblorption di!l'aItI
,
ColKlor in blood dorti'lg 65-80m{lj i'lffdi!l'aII', Iongtmn p.llfllttrl l
*RE = miooid **TE = alphiHorophrroI rquivalrnu
vitamin, the body may absorb as little as 10% to 15% of the
amount ingested. With the exception of vitamins A and D, it
is not harmful for most patients to conswne two to three
times the recommended levels of vitamins. In cases where di-
etary needs are increased, the RDAs will need adjustment
and supplements are indicated to achieve optimwn wellnes.s.
42.4 Indications for Vitamin
Pharmacotherapy
Most people who eat a normal, balanced diet obtain all the
necessary nutrients without vitamin supplementation. In-
deed, megavitamin therapy is not only expensive but also
harmful to health if taken for long periods. or
toxic levels of vitamins, has been reported for vitamins A, C,
D, E,1\;, niacin, and folic acid. In the United States, it is ac-
tually more common to observe syndromes of vitamin
excess than of vitamin deficiency. Most patients are unaware
that taking too much of a vitamin or mineral can cause se-
rious adverse effects.
IHllrition, rntain drug,lIKh as trphalo5pJrim
,nd saikyiattl
Vitamin deficiencies follow certain patterns. The following
are general characteristics of vitamin deficiency disorders:
Patients ntore commonly present with multiple vitamin
deficiencies than with a single vitamin deficiency.
Symptoms of deficiency are nOllspecific, and often do
not appear until the deficiency has been present for a
long time.
Deficiencies in the United States are most often the
result of poverty, fad diets, chronic alcohol or drug
abuse, or prolonged parenteral feeding.
Certain patients and conditions require higher levels of
vitamins. Infancy and childhood are tintes of potential defi-
ciency due to the high growth demands placed on the body.
In addition, requirements for all nutrients are increased dur-
ing pregnancy and lactation. VVith normal aging, the absorp-
tion offood diminishes and the quantity of ingested foOO is
often reduced, leading to a higher risk of vitamin deficien-
cies in older adults. Men and women can have different vita-
min and mineral needs as do persons who participate in
LibraryPirate
vigorous ext'rcise. Vitamin deficiencies in patients with
chronic liver and kidney disease are well documented.
Certain drugs have the potential to affect vitamin metab-
olism.A1cohol is known for its ability to inhibit the absorp-
tion of thiamine and folic acid: Alcohol abuse is the most
common cause of thiamine deficiency in the United States.
Folic acid levels may be reduced in patients taking phenoth-
iazines, oral contraceptives, phenytoin ( Dilantin), or barbi-
turates. Vitamin D ddiciencycan be caused by therapy with
certain anticonvulsants. Inhibition of vitamin B" absorp-
tion has been reported with a number of drugs, including
trifluoperazine (Stelazine), alcohol, and oral contraceptives.
The nurse must be aware of these drug interactions and rec-
ommend vitamin therapy when appropriate.
Lipid-Soluble Vitamin,
The lipid or fat-soluble vitamins are ablUldant in both
plant and animal foods, and are relatively stable during
cooking. Because the body stores them, it is not necessary to
ingest the recommended amoWlts on a daily basis.
42.5 Pharmacotherapy
with LipidSoluble Vitamins
Lipid-soluble vitamins are absorbed from the intestine with
dietary lipids and ale stored primarily in the liver. \'/hen
conswned in high amounts, these vitamins can accumulate
to toxic levels and produce hypervitaminosis. Because these
are available OTC, patients must be advised to carefullyfol-
low the instructions of the health care provider, or the label
directions, for proper dosage. It is not unusual to find over-
the-counter (OTC) preparations that contain 200% to 400%
of the RDA. Medications containing lipid-soluble vitamins,
and their recommended doses, are listed in Table 42.2.
Vitamin A, also known as retino/' is obtained from foods
containing Carotenes are precursors to vitamin A
that are converted to retinol in thewall of the small intestine
when absorbed. The most abundant and biologically active
carotene is beta carotene. During metabolism, each mole-
cule of beta carotene yields two molecules of vitamin A.
Good sources of dietary vitamin A include yellow and dark
leafy vegetables, butter, eggs, whole milk, and liver. Vitamin
A is used as replacement therapyfor conditions affectingab-
sorption, mobilization, or storage of vitamin A, such as
steatorrhea, severe biliary obstruction, liver cirrhosis, or to-
tal gastrectomy.
Vilamin D is actu."llly a group of chemicals sharing simi-
lar activity. Vitamin D" also known as rrgocalciferol, is ob-
taimd from fortified milk, margarine, and othel dairy
products. Vitamin D, is formed in the skin by a chemical re-
action requiring ultraviolet radiation. Vitamin D is nsed to
treat skeletal diseases that weaken the bones such as rickets,
osteomalacia (adult rickets), osteoporosis, and hypocal-
cemia. Sometimes vitamin D is helpful in treating psoriasis,
rheumatoid arthritis, and lupus vulgaris. The pharmacology
of the D vitamins and a drug prototype for the active form
of vitamin D are detailed in chapter 4600.
Vitamin E consists of about eight chemicals, called
laraplrml .. toc:opheml oonsli_
IUtes9O% of the tocopherols,and is the only one of pharma-
oologic importance. Dosage of vitamin E is sometimes
reported as milligrams of alpha-tocopherol equivalents
(TE). Vitamin E is fOWld in plant-seed oils, whole-grain ce-
reals., eggs, and certain organ meats such as liver, pancreas,
and heart.h is considered a primary antioxidant, preventing
the formation of free radicals that damage plasma mem-
beam's and other cellular structures. Deficiency in adults has
been observed only with severe malabsorption disorders;
howtwr, deficiency in premature neonates may lead to he-
molytic anemia. Patients often self-administer vitamin E be-
it is thought to be useful in preventing heart disease
and increasing sexual prowess. although research has not
TABLE 42.2
Lipid-Soluble Vitamins for Treating Nutritional Disorders
",,"
Route and Adult (max dose where IndIcated) Adverse EffeciS
o wililmin A A,o:hm) PO; 500,000 uriu/day for 3 followrd by 50,000 uniufday for Mwm tff!'I:r;olf UOOlIlIIl!OOOI rwmmmdtddosts
1 'lit; tllm 1 0,000- 2O,I)XI for 1 mo I M; 100, 000
Hg. dcleS:niul(a fitim initabilitr. righ:
for 3 doJYs folowrd by for 1 wk
drnkin
o wililmin O:cakitriol(CiI:ijtJ:, PO;015 mJglday;may br ilKlWl'd by 015 mJg/doJY rffiY 4-8 wi! Mwm tff!'I:nolf lMfalk
RocaKroI) 735 lor dialysis p.llimll Of MIl 2--4 wk fOI hypopilathyrold If

ProIotypr Orugboxoo)
H!!J!! fa!!!m
IV;05 meg tinesiwk al thr md ofdiilysis;rnay nud !4l 10 wtigtu [1m balkJdNlioD! dMytbrri'luwlrand bonr
3 m(glf"ffl timrslwk
""
E:tocophrrol POJlM;60-75 tff!'I:Il01f1i00llllll!00Olrwmmmdtddostl
(Aqwso! E, V"rtlP!us
H!!J!! dostS:rvYl!:'
I'itlmin ponWsmtanroos; 1.5-10 mg lup 10 15 rng),may br IfPratrd FtxioIIlilhir9. pan 01 irrjKtiOOll"rt
IAqwMEPHYTON) .fltr6-8 b n IIffiIrd
IV rourr mlt rm!t in !b:IRnr. hll!Q!rosion
"'"
Iro/ia inootr ammon
5

,

"
LibraryPirate
642 Unlt7 TheGa,lrolnt..,tI,..1 Sy'tem
.... Prototype Drug I Vitamin A (AquasolA, others)
Therapeutic Class: lipid-soluble'titamin Pharmacologic Class: Retinoid
ACTIONS AND USES
Vitamin A is 6!e1lrial for and particularly of rhe
bonrs,rem, and epithelial membranrs. k is for Pltlll" wound heal-
in'!. is for m.. bio<ymhesis of <lerni<k. is M. of the piglllt'llU .....
quirt<! for night vision. Yitl min A is in dNicitncy stares ud during
periods of r"ftd !lKh as pR'9nancy,loKt.lIion, or undernutrition. Night
blindnrss and slow wound healing un be In'a1td with as as
30,000 uninof vitamin O'/ef a is 1M prescribed for 61 dis-
whm absorption in small imestinr is diminished 01' I b!elli. Topical
forms all' ol'Ia iLl bll' for a.c: nr. plOriasis, and OIher skin dilordefs. of vitamin
A all' IOmttimes mtasull'll in Il'rinoid (RE}.ln
nates, up 10 500,000 unitt may be giYl'll per day for 3 days. gradually rapering
01110 10,000-20,000 uniHIday.
ADMINISTRATION ALERTS
Plfgnancy U1fgOry hr low dom
Plfgnancy U1fgOry hi dolts l bovi' tM IDA
PHARMACOKINETICS
Onstt: UnkMwn
f'eak: UnkMwn

Ouration:Unknown
always supported these claims. In addition to oral and 1M
preparations, a topical form is available 10 treat dry, cracked
skin.
Vitamin K is also a mixture of several chemicals. Vita-
min K, is fOWld in plant sources, particularly green leafy
vegetables, tomatoes, and cauliflower; and in egg yolks,
liver, and cheeses. Vitamin K, is synthesized by microbial
flora in Ihe colon. Deficiency states, caused by inadequate
TREATING THE DIVERSE PATIENT
Vitamin D and Diabetes Risk
EmeIlJing s1lJdirs and mtta analyses ha'II.' suggesrtd a link bmYffn tM deYelop-
rntnt of Type I diabe!es and viramin D riefriency. 'frramin D rIeft:imcy has aM
bern I pormtial factor il tht of chooi cond-
lions SIKh <IS heart risNlt, hi91 blood prtsllft',UIKfI; T)'pI' II diabfre, <lnd au-
Ioimrrunr !ruhipl!' >tu:Jirs <Ill' being alIIdoord 10 conmn linkl
in tht gtneral pIlII'Jlation and i n spe<i.JI popUaiions such <IS oIdrr adUts and il dif-
ferrnwhnigroups.
I'ropIt with darl<. skin hae glNrtr alllOllltS of pigrntnt mtLlrin and ha'II.'
a ability 10 prcdKevitamin Ofrom lun rxpoIull'.ln I study by tht USDA
HUlll<ln
est rates of vitamin D cll'1icimq 'Ihn comparrd with othfr AmtrDlIS. And .....
DUbetrsAssoMion halSUlgrstmrhatAfrican Americalll
IWOtines moll' IRlyIO hlYl' T)'pI' I diabfle than non-woo whiles.
Wrth strong trnerging that lII<Iintaining adequitf amctllll of viranin 0
may prMntrnlMic T)'pI' I riabms, mamin 0 IUppitmentatiM
may bf Iow-risk pre't'fIl1ion option for Type I diabeles,epa:ial)o in peo-
pi!' with a high OINSf.
ADVERSE EFFECTS
tfFeds art not obltlWd with norm.JI of vitlmin A.Acure
tion, howfm, prod!Kes serious CNS ilKUding ht ad<lrnt, irrirabilil)',
d"' .... poibio mou. long_lmn of high amrum<
UUIt! drying and scaling of tht skin, JIopia, fatigue, <Ir.orexi<l, wmiting. and

Contraindications: Vitamin A in fllCffi of tht RDA is conrraindicated in Plfg-
nam parient\" or rho!!' who lIIiIy be<ome pll'gnanl Feral harm lIIiIy Il'IUIt.
INTERACTIONS
lWg- lWg: PI'opIt takill9litamin A should iMIid raki19 ninfral oil 0100
droil'll)'ramill@,bKall\!' both deouI,,1ht iIbIorpIiJn 01 vitamin A. (000I"i8l
II\!' with isorflinoin may lI!I,*in toxicity.
Lab Tests: Vitamin A inclNlt \MIll! G1kium and BUll.
IkorbaVFoo:l:lJnknown
of OnrdoSf: is no sptcifr tlNlmenr for u;erdol!'.
RM III M'fMlIhl9Kl till MnJnq 1'roce\S Iixu! 'ipKltt 111M I'1InIn.
intake or by antibiotic deslruction of normal intestinal
flora, may result in delayed hentostasis. The body does
not have large stores of vitamin K, and a deficiency may
occur in only I to 2 weeks. Blood dotting factors II, VII ,
IX, and X depend upon vitamin K for their biosynthesis.
Vitamin K is used as a treatment for patients wi th dotting
disorders and is the antidote for warfarin (Coumadin)
overdose. It is also given to infants at birth to promote
blood clotting. Administ ration of vitamin K completely
reverses d eficiency symptoms.
Water-Soluble Vitamins
The water-soluble vitamins consist of the B-oomplex vita-
mins and vitamin C. These vitamins must be conswned on
a daily basis because they are not stored in the body.
42.6 Pharmacotherapy
with Water-Soluble Vitamins
The B-oomplexgroup of vitamins is oomprised of 12 differ-
ent substances that are grouped together because they were
[rullI [uuu-
the disease beriberi. They have very different chemical
structures and serve various metabolic functions. The B vi-
tamins are known by their chemical names as well as their
vitamin number. For example, vitamin B" is also called
cyanocobalamin. Medications containing waler-soluble vi-
tamins, and their doses, are lisled in Table 42.3.
LibraryPirate
TABLE 423 I Watti!r-Solublti! Vitamins for Trti!ating Nutritional Disordti!rs
On"
Routeand Adult Dose (maxdost' where Indicated) Adverse Effects
vitamin B,:thiamilll'
PonarirJjtioolile
PO:S 10mgfday IV mme!!ljly 1f$y!t in ,!1IaioNlNna Moosk
I1!.!mon!l!r!:!!em!l,!i! bIHdi!!g, !l!!!l
(,udioYillcular (oiaIM
'tit.Jmin B,:ribolbvin PO;HOmglday NMfll ,"KrJ haM' oor twn rf/KXr!
l'itamin B,:niadn (Nirobid, NKoIar,OII1trs) PO;ID-lOmglday Ad'ftMtffem for
IV n Mfsubcu!a1ll'OOl; 1,- 100 mg two to fiw tines/day
viramin rlltropy
High
l'itamin B,:pyridoJo:illl' POIIMJlY; 1.5-10 mglday for 1 wk;thtn may to PonorirJjtioolilt
Htsirer, IIIhtn) l.Hf1I9Iday
High ataxia
Q witamin B,:folic:Kid (FoI.Kin) POIIMJlVI!lbrutantOUl;OA-1 mgfday Ad'ftMlffem rKommrot/ed
dom

l'itamin Bu:cyalllXtlNLnin (Betain l1,CoIJa, I subcUlalltOUs; 10 fll(glday for , - 10 dar. thtn
Cynapin. othm) pig!' 4OOfortht Prototype lIXHOOfll(gimo
High thrombosis. hypokalemia,
Drugbox
OO
)
ilYmona!l fail!!!!:
vil.lmin (:aso:orbic JOO (,i,s(ortiup, POIIVllMlsubcuLJntOUI; mqfday in _ totwo Ad'ftM l ffem Qrt fll(Offlmm rKomtIIfflII8/
Vit.J(,OII1trs) dom
/Jolin """""" ...,.;""'''''''''''''
Vitamin B" or thiamine, is a precursor of an enzyme re-
sponsible for several steps in the oxidation of carbohydrates.
It is ablUldant in both plant and animal products, especially
whole-grain foods, dried beans, and peanuts. Because of the
vitamin's abundance, thiamine deficiency in the United
States is not conunon, except in alcoholics and in patients
with chronic liver disease. 1hiamine deficiency, or is
characterized by neurologic signs such as paresthesia, neu-
ralgia, and progressive loss of feeling and reflexes. With
pharmacotherapy, symptoms can be completely reversed in
the early stages of the disease; however, permanent disabil-
itycan result in patients with prolonged deficiency.
Vitamin B" or riboflavin, is a component of coenzymes
that participate in a number of different oxidation- reduction
I"C<Ictions. Riboflavin is abWldantly found in plam and meat
products, including wheat germ, eggs, cheese, fish, nuts, and
leafy vegetables. As with thiamine, deficiency of riboflavin is
most conunonly observed in alcoholics. Signs of deficiency
include corneal vascuLarization and anemia, as well as skin
abnormalities such as dermatitis and cheilosis. Most symp-
toms resoh-e by administering 25 to 100 mgldayof the vita-
min until improvement is obserwd.
Vitamin B" or niacin, is a key component of coenzymes
essential for oxidative metabolism. Niacin is synthesized
from the amino acid tryptophan and is widely distributed in
both animal and plant foexlstuifs, including beans, wheat
,\\erm, meats, nuts, and whole-,\\rain breads. Niacin defi-
do,.
f!!l!lrl
umalillia
ciency, or pellagra, is most commonly seen in alcoholics, and
in those areas of the world where corn is the primary food
source. Early symptoms include fatigue, anorexia, and dry-
ing of the skin. Advanced symptoms include three classic
signs: dermatitis, diarrhea, and dementia. Deficiency is
treated with niacin at dosages ranging from 10 to 25 mg/day.
\'/hen used to treat hyperlipidemia, niacin is given as nico-
tinic acid, and doses are much higher-up to 3 glday
(chapter 2200).
COMPLEMENTARY AND A LTERNATIVE THERAPIES
Sea Vegetables
StJ or art J form of Il"IJrine algae grow in tilt up-
P'" It.d. ofthi' O<e.ln, wh ... IUnlighl ron proo"."'. wmpb ofthcs di
bit seawel'm inc:Udt spirulina, kelp, ararne, J nd nori, many of wh ic:h
used in Asian rooking. SN 'le9!'tabirs art found in (oastallootions
throughout tilt world. Ktlp, or laminJria, is found in tilt (old watm of the
North Atbntit and P.J(ifirOmns.
Su I'f9I' labits (ootJin.J multitude of vitam ins,as WfII as prott in. Their moot
notabir nutritional asped. 110_, is thtir miooal (ootent. Plants from the
sea (ontain minerals than most other food SOUK6, induding (akium,
magnesilm, pllosphoroos, iron, potassium, Jnd all tlrmtnls.
kause the, aft' so ric:h in seawel'm an as alkalizen for tht blood,
helping to rid tht body of acid (ooditions (acidosis). Spirulina, kelp. and
are a\\lilablt in IiIpsult or 1.1 blet form, or u pan of a' grrl'ns-minon-
taining other nutritiou I
LibraryPirate
644 Unlt7 TheGa,lrolnt..,tI,..1 Sy,rem
.... Prototype Drug I Folic ACid (Folacm)
Therapeutic Class: Water-soluble vitamin Pharmacologic Class: None
ACTIONS AND USES
Folic: is administl'fl'd to rm'Be symptoJM of deficiency, whic:h most com-
monly occur; in patirnts with inadequate imakt, such as with thIOnic akohol
alxM.BecalMthis vitamin isdemo)'edat high
coole thtir food may folate dtIKirncy. Pl!9nallC)' marUdly
tilt nffil for dirtary folic: Kid; folic: acid is during pregnane)' to promote
normal fetalgrowth.BeulQ inwfficient vitamin B" mates a lack of
folic: acid, deficienc, s)'tnptDmsll'lI'mblt thoW' of vitamin B" deficiene)'. Tilt
megaloblastic alll'mi.l in folat e--defic:ient patirms, howevrr, dor5 nol
inckidr tilt smll' III'IVOUS s)'Stem symptoJM II'tn in patienn with Bu dtfi-
citney.Administration of 1 mglday of oral folic acid ofll'n IM'rws the deficirncy
symptoms within 5 to 7 d.J)'S.
ADMINISTRATION ALERTS
Pl!9nancy category A (calegory ( when laken in dolI'S above tilt RDA)
PHARMACOKINETICS
Onset Unknown
P!ak: 30-1 min
Halflife: Unknown
Duration: Unknown
HOME & COMMUNITY CONSIDERATIONS
Vitamin B9 and Neural Tube! Defects
It is now well dorumtmed that low vitamin II. (folic acid) in prtgnant
Womffi m.ly contribute 10 the formation of _fal tullt delecn in tilt feM.
Womffi S health call' plOYidm.Jll' OOW suggtSting thal)OOng women begin
taking fol ic: prior to anempting h has nol been delermined
how long a woman muntakefolic:acid prior toconception,but it is now bting
wggtSted th.Jt young womtn btgin taking tilt supplement lIIsoon .u men-
strunion btgins. To avoid poslibit OftrdOS!5, most lItahh pnwiders 11'(-
ommend taking a daily mukivitamin th.Jt mnlains folic
Vitamin I\" or pyridoxine, oonsists of sewral closely re-
lated compounds, including pyridoxine itself, pyridoxal,
and pyridoxamine. Vitamin B6 is essential for the synthesis
of heme, and is a primary coenzyme involved in the metab-
olism of amino acids. Deficiency states can result from alco-
holism, uremia, hypothyroidism, or heart failure. Certain
drugs can also cause vitamin B6 deficiency, including isoni-
azid (INH), cycloserine (Seromycin), hydralazine (Apreso-
line), oral contraceptives, and pyrazinamide (PZA). Patients
receiving these drugs may routinely receive B. supplements.
Ddj"it:ll"y "YJlJl'lull1s jllduJ" Skjll aUllufJlJalili,..;, d",ilusis,
fatigue, and irritability. Symptoms reverse after administra-
tion of about 10 to 20 mg/day for several weeks.
Vitamin &" more commonly known asfolateor folic acid,
is metabolized to tetrahydrofolate, which is for
normal DNA synthesis and for red blood cell production.
Folic acid is widely dis t ributed in plant products, especially
ADVERSE EFFECTS
Adftlll' effects during folic acid tlltraP\' are uncommon. may
flushrd following IV AIIt"lic hypmffisitivity to folic acid by tht IV
route is posliblr.
Contraindications: Folic: .Jcid is (onmindicattd in anemias other than th<M
caused by folall'deficirncy.
INTERACTIONS
I)ug- l)ug: lMliOOons may
interfmo with tllf absorp!ionoffdic: add. may aotagonizlo Hlf<lIof
kilaft thrrilpt'. Oral rontral:eptWrs, ikohol, barbitll"itrl, mrihotrrutf, and
prirridmr may GI!M foLlu drficifn:J
Lab Tl5ts: lillie: add may dKlMI'SfIUInifflll of vhmil
Ik>rbaVFooo: lJnI;ncwn
Tll'atment of OYrrdose: is 00 specific tlNlment O'IeldoSl'.
green leafy vegetables and citrus fruits. This vitamin is high-
lighted as a drug prototype in this chapter.
Vitamin B", or cyanocobalamin, is a cobalt-containing
vitamin that is a required coenzyme for a nwnber of meta-
bolic pathways. It also has important roles in cell replica-
tion, erythrocyte maturation, and myelin synthesis. Sources
include lean meat, seafood, liver, and milk. Deficiency of vi-
tamin B" results in pernicious (mtgaloblastic! n emia. This vita-
min is featured as a prototype drug in chapter 28 00.
Vitamin C, or ascorbic ocid, is the most commonly pur-
chased OTC vitamin. It is a polent antioxidanl, and serves
many functions including collagen synthesis, tissue healing,
and maintenance of bone, teeth, and epithelial Many
consumers purchase the vitamin for its ability to prevent the
common cold, a function that has not been definitively
proved. Deficiency of vitamin C, or scurvy, is caused by diets
lacking fruits and vegetables. Alcoholics, cigarette smokers,
cancer patients, and those with renal failure are at highest
risk for vitamin C deficiency. Symptoms include fatigue,
bleeding gums and other hemorrhages, gingivitis, and poor
wound healing. Symptoms can normally be reversed by the
administration of 300 to 1,000 mgldayofvitamin C forsev-
eral weeks.
MINERALS
Minerals are inorganic substances needed in small amounts
to maintain homeostasis. Minerals are as
macrominerals or microminerals; the macrominerals must
be ingested in larger amounts. A normal, balanced dil.'l will
LibraryPirate
NURSING PROCESS FOCUS PATIENTS RECEIVING VITAMIN AND MINERAL PHARMACOTHERAPY
Assessment
Baselinr assrssment priorto admini stration:
Undtrsund Il'ason tilt drug has prec:ribfd in ordtr to uses for
thtra ptUtic: (t.g., rfpialffllfnt theraPl' dtrKitlKitl, pll'l'mtativt
hNlth maimenalKe).
Obtain, lomplttf lItakh histOl)' ilKludillC) nturologic,
endocrine, rmal diINlI'.Obtain .J drug histo!)' induding allergits,
(urrent plt'l(ription and OK drugs,and htrbal pll'pilrMions, ,1001101 UII' or
smoking. Bealer! to pDlSiblt drug inttra(tions.
Obtain a history of any (urll'nt symptoms that may inditatt vit,min
defititlKitsor hyptrvitamioosis (e.g.,dry itchy skin,alopl'liI,!OR' and
gums ortongue, teodtncy to Nsily or bruising.
n.JulN or fOmiting.rnmivr fatigue).
Obtain a dieta!)' histOl)' noting of mrnti,1 viUmins, mintrals,and
nutritnts obtainfd through food wun:rs.
Note sunsuft'n UII' and the amount of sun
Obtain ball'linr "ftighund
[1'<I1u.Jte approp riatf iaborato!)' findings (e.g., (&, hepatic: and
rf nalliJO(rion studits, and iron
Assess mtnt thro ughout ildministration:
Asses for ther,peutic: effemdtptndtm on tht 1l"lOn lor tilt drug
(symptoms of dtlic:itnqo are diminishrd or ,bll'l11).
Continue monitoring of vit,1 prriodit lab alurs u appropriate.
for and promptly Il'port Omiting. f X<flSivt
filiQut, tiKhytard iii, hypotension. (onstip,tion. d rows intss,
disorientltion. hYpI'r-ll'flexia,.J nd tleurolyte imba Ia IKfS.
Pot enti i!l l Nursing Di i!lgnoses
ImbalanlN Nutrition:LfSs Th,n Body RtqJill'lIII'ms
Health MaimfnalKf to dim!)' h,bits, dtfititnt knowlrdgt)
Enh'IKN Therapeutic: Rtgimtn Maoaqrment
Defic:imt KnClWledge (drug ther.iP1)
Risk lor Inju!)' (reIatrd to drug rlfrm, h)'pfIVitamiOOlis)
Pli!lnning: Pi!lti ent GOi!ll s Expect ed Outcomes
patitm will:
tlltra ptUlic: elfects (e.g., mainteo'lKf of overall hfalth. symptoms of prrYious defititn'1 all' abll'ntl.
from,or rlpl'ritlKe idW"1I' riff(\!.
,n underst,nding oftlltdrug's effects, and rrqJirro pll'uutions.
Demonstrate propl'lll'll-.ldministration of the meditation kg.,doII', timing. whfn to notif)' provitItrl.

Interventi ons and (Rati onal es)
Ensuring thuilp.,utic "ff., cts:
II a dtfinitivt 1'lIII'of vitamin or mineral dtlic:itnqo is ideotif"ttd,rollKt tilt
delic:itlK)' using diet,!)' lOUn:fS 01 tht nutritm wlltll' possiblt.(Thedimry
history tan assist in determining tilt Will' oItllt S)'mptomsand the
adtquiKYof tilt patient'HUrmlt diet.tlaturalfood IOUIffi provide additional
nutritnts, rIIrnti,llfqUilflllenU not foond in vitamin ,nd miOl'ral
ruppiement,!ion.)
Minimizing adft rse effKts:
RMew the dietary and supplemrm histofJ to (orrtct any possibiliW
for hypervitJminosis and rIiKh.(Ex{tSsil'f intakr of vitaminl
A, C, D,E. B" niac:in, and folic: acid may Itad to toUt ellto:ts.)
Patient i!l nd Family Educliti on
Review tlltdimry histo!)' with tilt and discusl food options
lor rormting anydelic:itlKits. [n(OlJr'ge p,tient to adopt a healthy
lile\)'le of ilK ifilli'd l'<lriety in thediet.PlO'fide for dietitian (onsultation as

tilt patient and f,milyor uregiver to betOInt (ORlUOIffS:
awall' of matUting ofsuppltmeots th,t may not be lI'quirro if tht diet is
atieqUllte.PtoYide Nutational materi,ls or web-basfd refenolKfS to
Il'putablr IOUltfS as IIffiied kg., NIH Offkt 01 Dieta!)' Supplemtnts u
hrrp:f lods.ad. nih.go).
Oisrun the nrtd for nutritional rupplements if the normal diet is urwblt to
rupply these or if (e.g., pernicious aOl'lllil) Pll'Yfnt
ablorption or utiliz,tion.
Oiscourage tilt O'felllll' and ptoYide information on
adverse rlfrmand symptoms to hypmitaminosis.
(conrlrruefi)
LibraryPirate
646 Unlt7 TheGa,lrolnt..,tI,..1 Sy'tem
NURSING PROCESS FOCUS PATIENTS RECEIVING VITAMIN AND MINERAL PHARMACOTHERAPY (comlnutidj
Implementation
Interventi ons and (Rati onales)
CominUl'to monitor prriodil: lab worlc lS tffiS appropriate to
rondition [f.g.,pernic:ious anemia and 11gb and Ikt Ievcls] will help toensurt
therapeutic: art ml'l With milll'ral replac:emenl,tifiuolytes !hoold
R'tum 10 norrnallfolflsJ
Monitor lhe 1M offat--solubif vitamins. umsm intakt may INd to toxic:
fffKU.(FaHolubif vitamins art stoR'd in tIlf body and may mumulatt and
in toxic: Ievcls.Monitorlil'ff function and for symptoms suc:h as
narsta, omiting, hurbd!r, faligue,dry ,nd itchy !kin, blunN vision,or
palpitations. Rep:ln any symptoms immediatl'ly.)
AsSffi for storagr a\\lilabilit)' for Ill)' prenatal vitamins
ktpt in tht houSl'.(FoIi( <100 suppiemtntation lI'rU:tS the incidentfof
M\lroIogi< birth d./Nu.um,;'" yjnmin inn'" may h ..... dtiotPlious
rffKU on tht r1rvtloping feNS and plI'nitil vitamin USI' should II!'
monitoR'd.Poisonings with vitamins and iron all'{ommon in (hildll'nJ
[nsurt Irlrqwtt hydration if Ia 191' dosts of water -1Olublr vitamilll III' takrn.
(Water-solublr vHamilll an' not slOlI'd in the body but III' "mtN.large
( nYy (iUIC rroal cal(uli.)
Patirnt understanding of drug thrrapy:
Use opportunitit"l during administration of meditatiolll and during
alSl'lSmI'mS 10 discus slhe ralionaif for drug thr.-apy, desiR'd therapl'utic:
OO\{Oml'l, most (ommon advrrSl' effects, paramrttn for when to {ililhe
heakh (ill' I ny nKt"lwl)' monitoring or prKlutionl.(Using
timt rluring (irt helps to and reinfon:t INthing all'l!.)
Patirnt selfadministration of drug thtrapy:
When <ldministt ring the mtdic:.Jtion, illltllKt the fami 1)', or carrgmr
in the plOpl'lll'lf-administration of the drug. f.g., takrn with additional
Hum. (propl'r administration will in{lI'ast the effecti"lrnts s of the drug.)
Pati ent and Family Educati on
InslnKt the patient on tht nrN 10 rflUm prrioditaliy for labworlc.
InslnKt the patient 00110 takt IaIl1t' amoonu offat--solubif vitamins unlen
inslrumd by the health {ill' providtr.
fat-1Olublr vitamilll from naM,1 !OUl{t"I sIKh
Vitamin A:. willis, pumpkin, winttr squa!h, rbrlc grten lrafyVl'getablts,
apricou, mtats, fish, and Imr.
Vitamin O:milk and other dairy prodIKU fonified with vilamin D,oiiy fi!h
(f .g., salmon, wrdilll'S), adrquate sun flpOSUII'.
Vitamin E:Vl'geIabkoiis <lnd ml l9ilrint"l marlr from egetabkoil!, fruits
and V!'9r tabirs, nuts. and forrified (tll'll!.
Vitamin K:gft'PlJl'fgtlabits SIKh IS turnip lpinlm,{.1uliliower,
{ibbaoge and bro((oIi, and (fIlain vtgetabifoils induding !Oybt ln
olive oil.
TUlh womfn of{hildburing agt about foli< ltid and in USl'fulnt"ls in
Pll'Yfllung nruroiogi< related birth defrcl5. [Moorage the adequatr intakr
of vitamin ond Ioli< oc:id- rich foods ptiloCOrKtption.
InslnKt the patient 10 ktrp plI'nanl itamins in <I Sf(UII' location if)'OOng
childrr n arr in the houSI'hoid 10 pmoent I({idrnlll poisoning.
tilt patitntlo in{lNst fluid imakt 10 llof lkJid pI'I" rby,dil'irlrd
throughout therla)o.
The patient !hoold br Ibif to statethe II'l!On forthe drug;appropriatt doSl'
a nd nheduling; what adl'fBt to obSl'fYf for and when to II'port; and
the antic:ipattd ifngth of mNi<alion theraP'1.
The patient is abif to di!{uSl appropriate cIoling ind adminil1ralion 1II'I'ris.
Evaluation of Outcome Criteria
haluue the effKtiYtDl'I1 of drug therapy by u)nfinning thu patitnt goals.nd OUt1OmtS havt bttn md htt' Plannin().
JH ToIIk< n.t4lJ,.fl.J. &41.4 fa nliJrd'*"'1< ro..mid! rhN
provide the proper amounts of the required minerals in
most people. The primary minerals used in pharmacother-
apy are listed in Table 42.4.
42.7 Pharmacotherapy
with Minerals
Minerals are essemial substances that constitute about 4%
of the body weight and serve many diverse ftmctions. Some
are essential ions or elKtrolytes in body fluids; others are
bound to organic molecules such as hemoglobin, phospho-
lipids, or metabolic enzymes. Those minerals thai function
as critical electrolytes in the body, most notablysodiwn and
potassium, are covered in more detail in chapter 3100.
Sodium chloride and potassium chloride are featured as
drug prolotypes in that chapter.
Because minerals are needed in very small amounts for hu-
man metabolism, a balanced diet will supply the necessary
quantities for most patients.As with vitamins, patientsshould
be advised nOlto exceed recommended doses because excess
LibraryPirate
TABLE 42 41 Selected Minerals for Treating Nutritional and Electrolyte Disorders
On"
Route and Adult Dose (max dose where Indicated) Adverse Effects
dlIoride MicroK,K1or.(on,
PO; 11)-100 mEqlll in dividtd dosts Noultl!, MlmiD"1IJ dillrrlifo, abdImirrd
QIhm) (It!' paq!' 439 for ProIOl)'ll!' Drug
IV; 11>-40 mEqIll 113 al 11)-10 mEq/loo mL d
mmling

solution jmu 200-400 mEqlda,) Hypelka!tmia hYDQltoSion (oo/ulion
!!'!:!!I!l:!hmia!
!Odium bicarbonate (Itt p.iIJt 441 fa' w PO;03-2.0g/dily--ijd or 1 upol powder il j Htotkxllt,
PrOIQI)'II!' Drug box 00)
IIIJlI:mmmioi
lwilchi!l!l dySlhrthmiai.oolmonary rdema
t1triphml mma
CALCIUM SALTS
calci!lll oKrtalr (PhosLo) PO;2- 4 t.lblelSwith rad! mnl (YCh (ootain! 169 mg) rDMG, ImII'D"1Ii
calci!lll (Rwm, PO; 1- 2 9 bid-tid
Jiff!
ulci!lll dlIoridr IV;o.S- 1.0g/q3days
Oro/ roorr: obdomi!1Ol "an, lass of opptCiff!,
mIIltI!, 1'mliD'1IJ wIISlipolio!\. dry mourII,
calci!lll <itrail' PO; 1- 2 9 bid-tid
iOOfflltd IhirWllifNlion.
ulci!lllgllKonale (Kakinatt ) PO;I- 2gbid-qid
IIvmGlkmi!l
ulci!lllloKt.ltt (Cal-Lx) PO;32S mg- 13 gtid with lIII'ais
fltiw a!lOftXia (oofusion dOOythmiu
ulci!lll phosphate tribasic: PO; 1-2 9 bid-tid
IRON SALTS
ferrous fumarate PO; lOCI mg lid- qid Noultl!, rllnJlipoliiJn fit diorrlifo, abdImil!l
n:ntIUI (Fflgon,O!Iim) PO; 325-600 ""1 qid; may br lJadually iflCll'a ltd 113 650 mg "d

aJ and toitfatrd OOlfjn!, !!):1!!!:2!emia,
ferrous sulfale (It!' paq!' 401 PO; 75(1.-1,500 mglday in dose Of l'IIOlIQ
Ilmat\'!Q6i1. tAAa\Q\oxidtY, metabole
for Itw: Prototy)ll' Drug 1HJxOO) dividtddosts
....
iron dextrin (Dexfmllm,Iim) 1MI1V;00Ic t indimwlirel inddetmnilrd from a UbltQ/
W1riitioos betwffn palirnt"s and tw:moglobin
(O\il:l00mg (2 mll dirondmranwithin 24h)
MAGNESIUM
mJlt!i!lll rhlorido! (Chlormlig. SIo- Mag) PO; m - 400 NoIlltlJ, MlmiIiIlJ dillrrlifo,flu5ling
flliCjllrli!lll PO; 15 mL Of 1- 4 t.lbltlJ uptQ fOIl" Iimrs/da,
CinlllIl!I:ilia
flliCjllrli!lll oxidr PO;400-1)OO mglday in dividrd dosts
hypgltDljQll lrndQll Irl\eI )fWQjoo
[<ldal DirOlhtOO,wnkness
Go) magntsium sulfatr IEpsom saks) IVI!M;05- 3.0 g/da,
PHOSPHORUS/PHOSPHATE
phosphail'J (K Phos original PO; 25(1.-1,(00 mg/da, NoIlltlJ, MlmiIiIlJ dillrrlifo
KPhos Mf.KPhoJ 1"lMr00I,HMri-PhoJ K,
lIvDtmhosR!!atl1llia lBin,fr.Ktu!!l:,
)ko.l(JlnMral)
mulde (QIlfusion
"NO
linr oKrtalr (Galm) PO;50mgtid NMrII1tfftrurn uocommooOI
linrgllKonail' PO; 21)-100 mg (10 mgloIrnge\ may br tam. tQoI mal Qf lil
fommfOOed 00JtJ
Hiqu!q\t1; II!lUltMooliting levrt
linrRMm (Oralinr,1inrate,O!Iim) PO;IH1Omglday
I immuoolUpprnion.aotmia
IrQ/ia ammoo idvelll' striOl/ladwelll'
amounts of minerals can lead to toxicity. Mineral supple
ments are, however, indicated for certain disorders. Iron
deficiency anemia is the most common nutritional deficiency
in the world and is a common indication for iron supplements.
Women at high risk for osteoporosis are advised to consume
extra calciunl, either in their diet or as a dietary supplement.
Certain drugs affect normal mineral metabolism. For ex
ample, loop or thiazide diuretics can cause significant urinary
LibraryPirate
648 Unlt7 TheGa,uoIm",tI ... ISym'm
potassium loss. Corticosteroids and oral contraceptives are
among several classes of drugs that can promotesodium re-
tention. The uptake of iodine by the thyroid gland can be
impaired by certain oral hypoglycemics and lithium car-
bonate (Eskalith). Oral contraceptives have been reported
to lower the plasma levels of zinc and to increase those of
copper. The nurse must be aware of drug-related mineral
interactions, and recommend changes to mineral intake
when appropriate.
42.8 Pharmacotherapy
with Macrominerals
Maaomineral, (major minerals] are inorganic substances that
must be consumed daily in amolUlts of 100 mg or higher.
The macrominera]s include calcium, chlorine, magnesium,
phosphorus, potassiwn, sodium, and sulfur. Approximately
75% of the total mineral content in the body consists of cal-
cium and phosphorus salts in bony matrix. Re.:ommended
daily allowances have been established for each of Ihe
macrominerals except sulfur, as listed in Table 42.5.
Calcium is essential for nerw conduction, muscular con-
traction, ,onstru,tion of bony matrix, and h"llostasis.
Hypocalcemia occurs when serwn cakiwn fulls below 4.5
mEq/L and may be caused by inadequate intake of calcium-
containing foods, lack of vitamin D, chronic diarrhea, or de-
creased secretion of parathyroid hormone. Symptoms of
hypocalcemia involve the nervous and muscular systems.
The patient often becomes irritable and restless, and muscu-
lar twitches, crnmps, spasms, and cardiac abnormalities are
common. Prolonged hypocalcetnia may lead to fractures.
Pharmacotherapy includes calciwn compounds, which are
available in many oral salts such as calcium carbonate, cal-
cium citrate, calcium gluconate, or calcium lactate. In severe
cases, IV preparations are adminislered. Calciwn giuconate
is featured as a prototype drug for hypocalcemia and osteo-
porosis in chapler 47CiJ1O.
Phosphorus is an essential mineral, 85% of which is
bound to calcium in the form of calciwn phosphate in
bones. In addition 10 playing a role in bone structure, phos-
phorus is a component of proteins, adenosine triphosphate
(ATP), and nucleic acids. Phosphate (PO.'- ) is an impor-
TADlE 42.5 1 Macrominerals
Mln .... al
."
Function
tant buffer in the blood. Because phosphorus is a primary
component of phosphate, phosphorus balance is normally
considered the same as phosphate balance. Hypophos-
phatemia is most often observed in patients with serious
medical illnesses, especially those with kidney disorders that
cause excess phosphorus loss in the urine. Because of its
abWldance in food, the patient must be suffering from se-
wre malnutrition or an intestinal malabsorption disorder to
experience a dietary deficiency. Symptoms of hypophos-
phatemia include weakness, muscle tremor, anore.tia, weak
pulse, and bleeding abnormali ties. \'/hen serum phosphorus
levels fall below 1.5 mEq/L, phosphate supplements are usu-
ally administered. Sodiwn phosphate and potassium phos-
phate are available for treating phosphorus deficiencies.
Magnesium is the second most abundant intracellular
cation and, like potassium, it is essential for proper neuro-
muscular function. Magnesium also serves a metabolic role
in activating certain enzymes in the breakdown of carbohy-
drates and proteins. Because it produces few symptoms Wl-
til serum levels fall below 1.0 mEq/L, hypomagnesemia is
sometimes called the most common undiagnosed elec-
trolyte abnormality. Patients may experience general weak-
ness, dysrhythmias, hypertension, loss of deep tendon
reflexes, and respiratory depression--signs and symptoms
that are sometimes mistaken for hypokalemia. Pharma -
cotherapy with magnesium sulfate can quickly reverse the
symptoms of hypomagnesemia. Magnesiwn sulfate is a
CNS depressant and is sometimes given to prevent ortenni -
nate seizures associated with eclampsia. Magnesium salts
hav .. additional appli,ations as ,athartics or antadds (mag"
nesium citrate, magnesium hydroxide, and magnesium ox-
ide) and as analgesics (magnesiwn salicylate).
42.9 Pharmacotherapy
with Microminerals
The nine micromioerals, commonly called tra(f miouals, are re-
quired daily in amounts of 20 mg or less. The fact that they
are needed in such small amolUlts does not diminish their
key role in hwnan health; deficiencies in some of the trace
minerals can result in profound illness. The functions of
some of the trace minerals, such as iron and iodine, are well
<al(um
<h_
800-1)OOmg
7 ...
Forms bony matril;l!gwtf! IIfI'll' (onOJaion ,nd mU\dt(ontrauion
Major anion in bOO! ftuids;p.lr! ofgawic:add (Ha)
magllelirm Mffi:151>-4OO mg
Wornm:280-100mg
...,....
700 ..
2.0g
...
"'''
"".
lIOIeIt"blilhtd
Corauor for many mzymf!; lIt(elSary for normalllfM oonduaion and muldt (ontrKlion
Forms bony matril;p.lrt of AlP and nudtK .od!
HtCf"lSary for normal Om'! oondudion and muldt (ontraction; prindp.ll cation io i"ltriKtllu,r nuid; t5!fntial for
add-balf "nd balitOO'
Ht"lsary for normal Om'! oondudion and muldt (ontraction; prindp.ll cation in utriKtilwr fkJid; t5!fnwt for
add-balf "nd dtnrolyu balitOO'
COftlIOIII'ot of JUIlti11, B vitamir I, "nd other aitilal rnoIKultl
LibraryPirate
IlI>pltl (l Oruq< /0. Nutrnional 649
Prototype Drug I Magnesium Sulfate (MgSOJ
Therapeutic Class: Ma(lnesium supplement Pharmacologic Class: Electrolyte
ACTIONS AND USES
Sevt ll' hypom.gotsem ia (,J n ill' rapidly It'Ye!!td by the . dminim.tion of 1M or
IV m.gotlium sulfatt. P' lI'rueral formuLition s indlllk 4%, II%, 12.5%,.nd 5O'JI(,
lOuDons. H)'pOOl'9ne!1'mi. has. number of (,JUII'!, including lilt loll; of body
fluids due la di arrbN, diJretic: ther.py, or oa\09<lstrK suctioning;. nd prolong!d
p'lI'ott ral ffeeling with IOlutions.
Afttr adminismtion, magotlium sulfilt is distributed thJOlJ9hout tilt
body,.nd tffl.s.1I' aboitrvedwithin 30-60 minutts. Oral iormsof
maogntsium sulf.tt art as whtn rompitlt tv.wation of lilt
colon is delired.lu.ction as CNSdepr!"llolnt has Ird ta in o{(asion,1 UII' as an
i ntiroOYullolnl
ADMINlSTRATION ALERTS
monitor tM patitnt during IV infusion far NrI)- signs of de-
(It'aIe<i (,J rdiac: fuoction.
m'glltsium mry 6 h during pa.t nlml infusion.
When gJYill91V infusion, gil' lI'quill'd doll' O'/t r 4 h.
PlI'9n.ncymtgoryA
F PHARMACOKINETICS
h 1'0; 1 h 1M
f'eilk:Unknown
H. Iflife:Unknown
Duration: 1-4 h 1'0;30 min IV
TABLE 42.6 1 Microminerals
Tr.ce Minerai 'DA Func:don
ADVERSE EFFECTS
Patients Il'<ritinglV infusions of sulfillt rtqUirt (,J rt ful obsm.Don
to PreYl'Ot lo:lic: ity. E.rI)- signs of OI'!'rdosr indlllk flushing of the
skin, sedation. confusion, thirst,.nd mus(lr
(,JIM oruromUlQltar bIoc:bdr with repiratory par,Iysis, hNrt block,
.nd drrulillol)' rollapsr. PLism. IrYeIs should ill' monitored frt-
qumtly. Bffiull' of IhtII' pott otially fill.l i dmw t fftm, the USt of migllf-
sium sull.lt is II'ItrKted to II'"Itll' magotlium derlCitncy:
h)1lOl1li9ot\e11lia is lreattd with oral forms of IIKh as migotlium
ghKOnillt or h)droride.
Contraindi cdions: Magneium iscootraindiuted in patitnu with serious (,Jr-
diac: Or.1 adminismtion is (oolraindiutt d in paOOlI with undi'g-
nosed .bdominal pain, intestinal obstruction, or 001 impaction. Iht dlllC)
should ill' UsM in patiffits with It'ul imp.irmtnt b.iIM tilt dlllC)
m.y list to toxic: 1rYeIs.
INTERACTIONS
Drug-Drug: lJ5f with fIl'II"OIIlI/IIUar bIodHl may iocJNlf J@ijIiaICJ)'dfpm.lion
other CN, dtpil'!wnI'; may
INdtoilKlNlfd Ifdation. sam may IiKJNlfw abIorption 01" rntain
t"'raqdi ...
lib Tem:UoUlolrm
Herba VFood: MagneWn sam may deauwo W abIorption of am.
inflouiv5llKh ill mracydilf.
T rrat mt nl of Imrdos!: Strious rr-spi ralary ,nd cardiac: sian m.y reuk
from ol'ffllole. CikiJm or 91uct ptatt m.y ill' .dministt red IV iI. n

9t!fPr Ie M)M!I! IngIJ1 for Q Nlml"9 Pn:ms f/KJJ5 lpKlk Ie ,iris mlMrlI.
dmnilln
.....
0.05- 2.01119
0.1 ""9
Potentiatrl inwin.nd iI for pl{llltf gixo" mtt.boIism
Cofactor for viI.llin Bu and If'Itr.1 oxida!il'l' tnzyme
"""
ftuori Ol'
"'-

.... ng.OI'"

ltim!lll
,.

15-4.01119
lSOmc:g
Men:lO-12mg
Worntn: 10-15 mg
""1
75- 2501119
Mtn:50-70meg
Womtn: 50-55 meg
12- 151119
Cofactor for htmoglobin S)Tltheis
hfl utllCf:! tooth ROKIlR.nd .ffK!sgrowth
Corrponenl 0( thyroid hormone
Corrponenl 0( htrlUHJlobin .nd IOIIIt trIlYmrl of oxidativr Jiloljilorylation
Colan .. in ''''' .. tnZyme 0( lpid, GlrbMy<irn .. ..,d prottin ,,,,,.Il0l ,,,,
Cofactor for (trtain trIlYml:!
Antioxidant rofiKlOl for Cffiain tnl)'mts
Cofactor for {trtain trIlYml:!, indLdng larbonic nhydra,,; IIttdtrf for pI{IIItf prottin SUOOUII' , normal growth,
andwound ht.ling
established; the role of others are less completely lUlderstood.
The RDA for each ofthemicrominerals islisted in Table42.6.
sulls in iron-deficiency anemia. The pharmacology of iron
suppleme.nts is presented in chapter 2800, where ferrous
sulfate is featured as a drug prototype for anemia. Iron is an essential micromineral thai is most closelyas-
sociated with hemoglobin. Excellent sources of dietary iron
include meat, shellfIsh, nuts, and legwnes. Excess iron in the
body resulls in hemochromatosis, whereas lack of iron re-
Iodine is a trace mineral needed to synthesize thyroid hor-
mone. The most oommon source of dietary iodine is iodized
salt. When dietary intake of iodine is low, hypothyroidism
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"


t

650 UnliT
occurs and enl.oJrgement of the thyroid gland (goiter) results.
At high concentrations, iodine suppresses thyroid function.
Lugo/'s 5O/urion, a mixture cootlining 5% elemental iodine
and 10% potassium iodide, is givm to hyperthyroid pati ents
prior to thyroidectomy or during thyrotoxic crisis. Sodium
iodide acts by rapidly suppressi ng the secretion of thyroid
hormone and is indicated for patients having an acute thy-
roid ern;". Rodioacti." iodi n( (1- 1)1 ) i, siv<: n to datroy
overactive thyroid glands. Pharmacotherapeutic uses of io-
dine as a drug ('lItend beyond the treatment of thyroid dis.-
ease. Iodine " an effeaivetopical antiseptic that can be found
in creams, tincture5, and solutions.. Iodine salts such as io-
thalamate and are very dense and seT\'l' as diag-
IlO!it icmntrast agents in radiologic procedure5 ofthe urinary
and cardiovascular systems. The role of potassium iodide in
protecting the thyroid gland during acute rndiation u]>05ure
is discussed in chapter JOO.
Fluorine is a t(:lce mineral found abundantly in nature and
is best known for its benefidal effects on bones and teeth. Re-
search has validated thai adding fluoride to the water supply
in very small amounts ( I part per billion) can reduce the in-
cidence of dental caries. This effect is more pronounced in
children, because fluoride is incorporated into the enamel of
growing teeth. Concentrated fluoride solutions can also be
applied to the teeth topialUy by dental professionals. Sodium
fluoride and stannous fluoride are components of most
toothpastes and o(:l.] rinses. Because high amountsofflooride
can be quite toxi c, the use of fluoride-containing products
should be closely monitQred in children.
linc is a component of at least 100 enzymes, including al-
cohol dehydrogen3se, carbonic anhydrase, and alkaline
phosphatase. This t(:lce mine(:l.] has 11 regulatory function in
enzyme$ controDingnudek acid synthesis and is believed to
have role$ in wound healing, male fet"ti lity, bone formation,
and cel l. mediated immunity. Because symptoms of zinc de-
ficiency are often nonSpedrK, diagnosis is usually con-
firmed by a serum zinc level of less than 70 mCg/dL Zinc
sulfate, zinc acetate, and zinc gluconate are available to pre-
vent and treatdefKiency states,at dosesof 60 to 120 mg/day.
In addition, lotenges cont3ini ng zinc are available arc for
trealing sore throats and symptoms of the common cold.
NUTRITIONAL SUPPLEMENTS
The nurse will encounter many patients who are undernour-
ished. Major goals in resolving nut ritional deficiencie$ are to
identify the specific type of defici ency and supply the miss-
ing nutrients. Nutrition31 s upplement s may be needed for
short-term therapy or for the remainder of a p;ltient's life.
42.10 Etiology of Undernutrition
is the ingestion or absorption offewer nutrients
than required for nonn31 body growth and maintenance.
Successful pharm3cotherapy of this condition reli e5 on the
skills of the nurse in identifying the symptoms and causes of
the patient's undernutrition.
Causes of undernutrition r:mSe from the simple to the
complex, and include the following:
Advanced age
. HIV-AIDS
Alcoholism
Burns
- Cancer
- Chronic inflammatory bowel disease (180)
Eating disorders
GI disorders
Chronic neurologic disease such as progressive
and multiple
Surgery
Trauma
The most obvious caUSC' for undernutrition" low di etary
intake, although reasons for the in3dequat e intake must be
3.'iSessed. Patients may h3ve no resources to purchase food
and may be suffering from starv3tiOn. Oinkal depression
leads many patients to shun food. Older adult patients may
haw poorly fitting dentures or difficulty chewing or swal -
lowing after a stroke. In terminal disease, patient s may be
comatose or otherwise un3ble to take food orally. Although
the etiologies differ, patients with insuffident intake exhibit
a similar pattern of general weakness, muscle wasting, and
loss of subcutaneous fat.
When the undernutrition is caused by lack of one specific
nutrient , vitamin, or mineral , the disorder is more difficult
to diagnose. Patients may beon a fad diet lacking ooly pro-
tein or fat in their intake. Cenain digestive disorders may
lead to malabsorption of specific nutrients or vitamins. Pa-
lients may simply avoid certain foods such as green leafy
vegetables, dairy products,or meat products, which can lead
to specifi c nutritional deficieocie5. Proper pharmacother-
apy requires the expert knowledge atld assessment skills of
the nurse, and sometimes a nutrilional consul l, so that the
correct treatment can be
42.11 Enteral Nutrition
Numerous nutritional supplements are al'2iLable, and a
common method of classifying these is by t heir route
of Ildministrllrion. Products that are administered via the GI
tract, either orally or through a feeding tube,are dassified as
mter.1 nutrition. Those th3t are 3dtninistered by means of IV
infusion are called parrnttral nutrition.
When the p;ltient 's condition permits, enteral nutrition is
best provided by oral consumpti on. Oral feeding aUows n3t-
ural digestive processes to occur and requires less intense
llur,ill!! ""1[1:. It J""" IIUW"""', Idy Ull Valie"l
because it is not feasible for the heal th Clre provider to ob-
serve the patient at every meal.
Tube feeding, or enteral tube is necessary
when the p3tient has diffi culty swallowing or is otherwise
unable to take meals oral ly. An 3dvantage of tube feeding is
thai the amount of enteral nutrition the pat ient receives can
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be precisely measured and recorded. Various feeding
routes are possible. including nasogastric (nose to stom-
adl), nasoduodenal (nose to duodenum), nasojejunal (nose
to jejunum) ,gastrostomy. or is placed
rectly into the s tomach or jejunum, resptively, through a
.ursiel incision). A nasOfPltric tube may be in.erted by a
registered nurse or licensed practical nurse. The
naI and nasojejunal tubes are usually inserted by a radiolo-
gist or other physician. The gastrostomy and jejunostomy
tubes are plOKed by a surgeon or a gastl'Oentl'l'Ologist.
The particular enteral product is chosen to address the
specific nutritional needs of the patient. 8ecauseof the wide
diversity in their formulas, it is difficult to cnegorize enteral
products, and several different me!hods are used. A simple
method is to classify enteral prodUCIS ;IS oligomeric, poly-
meric, modular, or specialized formul3tions.
Oligomeric formli/ru contain lsic fonns of frf'<' amino
acids and peptide combinations th:lt require little or no
digestion, and are easily absorbed into the body. They
are usually low in fat, which allows for rapid gastric
emptying, and many of these prepal'3tions are dl'$igned
for administration directly into the intestinl'$.
Indications include partial bowel obstruction, irritable
bowd syndrome, radiation enteritis, bowd fi stul .... , and
short-bowel syndrome. Sample products include
Vivonex T.E.N., and Peptamen Liquid.
Polymaic formulas are the most common enteral
preparatioru. These products contain various mixtures
of proteins, carbohydrates. and lipids. These formulas
are used in patients who are gener-1I1y undernourished,
but have a fully functioning Gltract. Sample products
include Compleat regular. Sustacal Po",'der, and Ensure-

Modulllr formulas contain a single nutrient, prott'in,
Lipid.or carbohydrate. While not designed to serve as a
CIIop1tr 42 DrugS /0, Nut,ftloNl Olsolders 65 1
sole source of nutrition, they can be added to other
products to meet a specific nutrient deficien<:y. For
example, protein modules can be utilized to mf'<'t the
extra nitrogen needs of patients with burns or severe
t rauma. Sample products include Dsec, PoIywse,
Microlipid, and MCf Oil.
Specialiud formulations are products that contain a
specific nutrient combination for a particular condition.
Indications include a specinc disease statt's uch as
hepatic failure, renal fai lure. or a spific genetic enzyme
dt'ficiency. Sample products [n<:lude Amin-Aid, Hepatic-
Aid II, and Pulmoc.are.
42.12 Total Parenteral Nutrition
When a patient's metabolic needs are unable to be met
through t'nteral nutrition, tot. 1 p' I!'I1te ... l nutritiOl (TPN), or hy.
peralimentation, is indicated. For short-term therapy, pe-
ripht'ral win TPN may used. Because of the risk of
phlebitis, however, long-term therapy often requires central
vein TPN. Patients who have undergont' major surgery or
trauma and those who are severely undernourished are can-
didates for central vein TPN. Because tht GI tr3(t is not be-
ing utilized, patients with severe malabsorption disease may
be treated successfully with TPN.
TPN is able to provide all of a patient's nutritional needs
in a hypertonic solution containing amino acids, lipid emul_
sions, carboh)'drates (as dextrose), eltrolytes, vitamins,
0100 minerals. The particular formulation may be specific to
thedi5ease state, sud! all renal failure or hepatic failure. TPN
should be administered through an infusion pump, so that
nutrition deli-'ery can be precisely monitored. Patients in
various settings such as acute care, long-term care, and
home health care often benefit from TPN therapy.
NURSING PROCESS FOCUS PATIENTS RECEIVING ENTERAL AND PARENTERAL NUTRITION
Assessment
Btitlint aiKliment prigrtg Idminl itrlllOl'l:
Undtnttnd the lilt drug hiS bttn in ordtllD ilSSHS fol
thelilptUlic: tIIeru (t.g.. short- ollo"9'tetm undtllyu'o!l heillth

o Obtain iI complett hNlth induding
!'I1dor:rinr,hflHtit, Of Itnal distast.Obtain iI dlU9 in(kiding allergirs,
currmt pm<riplion .nd OK drugs. herbal akobol LIst.or
smoking.Be illtrt to possible drug
o Obtain. dietary noting the.bility to"t ilnd flum.
o Obtain height, vitll
o i1ppropriollt lilboratory findillgs (B(, gluclKf, BU II.
hepitiund rm.J1 funo;tion studin,. total 5ef\Im libumill,ipid
stMn iron 1rIttb).
Pot ential Nursi ng D1IIg no5es
Imbaiano;rd Nutrition: TIIIn Body
Defici!'I1t {drug the!i1pyl
Risk for Imb.ililnttd FkJidVolume
Risk for Infr(!ion
{COIIrInutdJ
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652 Unlt7 TheGaslrolnt..,tI,..1 System
NURSING PROCESS FOCUS PATIENTS RECEIVING ENTERAL AND PARENTERAL NUTRITI ON
Assessment
Assessment throughout administration:
Aslffi lOr desirtd therapeutic: rfftcts dependent on thr INson for thr drug
(r.g., weight is lipid rrmain
within normal limits).
Cominur monitoring of ligm,.nd periodit lab I'iIlue! al appropriate.
Weigh at thr same lime mh day and rrcord.
Aslffi lOr and re-pon nauIN,vomiting.

disorientation, hypJ. or hyprl9l){emia, a nd electrolyte imbalaMrs.
Potential Nursing Di agnoses
Planning: Patient Goalsllnd Expected Outcomes
Thr palient will:
ExpeMlKe therapeulic rifrcts (r.g., maimenalKr or improl'!'lllem of omall health and nutritional status).
Be frrr from,or expeMmr minimal. adl'!'rsr eift<ls.
VerlJalizlo an undemanding of thr drug's USl', adl'!'flr tffNts, a nd rtquirrd prruutions.
proper II'Ih:lminimalion 01 the mrdicalion (r.g.dOSl', timing. when to notify provider).
Implementlltion
Interventions li nd (Riltionilles)
Ensuring therapeutic effects:
Aslffi the patirm's ability to tlkI'oril nutrition and eMooragr small oral
ldings if illowed.(Supplementation with oral ldings may !If alto-:! if
rmeral or pareotrral nutrition will !If uSl'd shon ternl. [Mooragingsmall
amounts oforal imake will maintain normal saljyation and ADLs ruring tiM'
time of rrplac:eolI'nt nutritionJ
Minimizing ildftrse rffHts:
Monitor vital signs, panirul.rly temperature, throughout nutrition
all ac:{rss sitrs tuhrsitr,lVor pon sitrs)
frrqurmly for streaking, swrlting. or drainagr. Rrport a ny leI'!'!,
[hilk,malaill',or [hangrs in Inrmal status (Entrral and
pareotml nutritional rrpla[emeot [onlains high gkKose, protrin,and lipid
IOUKfI that may stlvr ilIa rrlffilOir lor infection.M(rss may also stl'le
as a poinHI-rntryfor inieuion.)
Usr mid ilSl'ptK ttchniqur with all IV tubing or bag and sile
(hangrs. Relrigeratr thr TPN IOknion until 10 mirutrs !lfloft' using
ind riIIlra emml formula in thr rrlrigerator alteropeoing. (Infusion
and ac:(rss ilrr at high risk fordtvtlopmrnt ofinieuion and must hr
monitorrd frr"",ntly. Soknions ,md mra fonnula must hr ft'frigeraltd to
inhibit baurri.llgrowth.)
Monitor blood gU!:osr Itvrls.Obsern for ofhyperglytrmia or
h)<poglyt:rmia i nd obtain u pillaI)' 91(1[OSl' irI'I'k is ordrrrd. (Blood glll[OSI'
may hr affratd ifTPNoremeralldingisstopped,tflrratr isrrdlKrd,
or is depeodem on other mrdic:.IIions tiM' patient is ta I:i ng. Supplrrnrmal
insulin, or added to thr IV IOknion,may hr ft'qJirrd)
Monitor lor signs 01 fluid ol'!'fload.(TPN is a hyprrtonic: solution and un
[ft'atf intra\\Jl(ular shifting 01 otrattilularfluid with rrsuking inaNSI' in
intrava\(ular fluid Monitoring lor iMrraSl'd pulst ralr ind qUillity, ilKrraling
blood will assist in qJiddy noting advrrst
rffKtsJ
Patient and Family Educlltion
II illowrd,eMooragr tiM' patient to maintain small, Irrquent oral intake or
hal'!' iI megil'!'r i lSill with oralllllrition and h)llration.
InstnKt thr orurrgiYer to rrport alTj
unuswl dJangrs to thrac:{rss IiR.or{hangrs in tiM' IrI'I'I of
mllS(iousness to thr iM'ahh (lire providrt
Explain Ihr rationalr lor all drrssing and rquipmeol monitoring and (hangrs.
Te.Kh appropriatr lfihniqur (asrptic: or dun) to Ihr lami or GI rrgil'l'r if
llllrition is to hr mntinurd at home, followtd by rttum demonstration umil
liM' lamily is (omfonable with the routine.
InslnKl Ihr patient on thr III'rd for frrqueot gl(l[OSI' monitoring.Tud! the
patirm, la mill', or to IfIIOn signs of h)<pergl){rmia (mrssiYe
mpious urinalion, and insati.blt hungrr) or h)'poglyt:emia (nervousness,
diuinm) promptly.
InstnKt tflr or urrgiYer in thr tKhniqlK' to monitorupillary
gUmsr, IoIlowrd by rMUrn-demonstration, ij tiM' ))aIirnt will hr on nutrition
rrplai:rmrot at home.
InstnKt thr or urrgiYer to immtdialrly rrport shonnrs! of
brrath, heart palpitations, I'M' lting, decn'aSI'd uriIII' disorientation, or
mnfusion.
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IlIopltl41 653
NURSING PROCESS FOCUS PATIENTS RECEIVING ENTERAL AND PARENTERAL NUTRITION (ContimJedJ
Implementation
Interventi ons and (Rati onales)
Monitor ren,1 lIalUS.(intae and output "tio,cIaily wfigln,and I,boratory
lIudies sIKh <IS <lnd BUN should he mOllitOlfd.)
Maintain a(ruratt feeding or TPN infusion rue with inMion pump;
m,ke "te change! gradwlly;<lnd avoid ,bruptly discontinuing TPN fffiling.
(Tht 1M of infulion pYmpl ,11ow! rontrol OY!'r ffitl'l,1 rate or
TPN infusion. Abrupt discominuuion may Will' hypogiyttmia,and a sudden
(hangt in parffiteral flow rate !an Will' fkKtuations in blood gl(l(oS!' Iewoll.)
AlstSl for appropriate ffiteral rube btIore adminiltrriog
fffiiing.!Propl'l" ruhe illSfrtion Ihoold he confirmed racliog"phiully before
any fffiiing is initiatN.COIIfinn,rion of plac:rmem by obll'lVing
(haroKtemtiaof thegaltrK or pH may he uS!'d to (Ollfinn
... -1
Patient unMrstanding of drug therapy;
US!' opportunititol during administration of during
.!S!eSS/mtts to discUlS the rationale for drug therapy, the:rapMK
OUi(omtl,mOIi (ommon ad\'el!t tiftcts, p",metm for when to ull tht
hfillth Uft' proYidtr, <l nd any lIf(ffi,Jry monitoring or precautiom.(lhing
time during nursing !are helps to optimireand reinfon:e kqtu(hing <I fNI.)
Patient self.administrilt io n of drug thf ril PY:
Whe:n administtring the mtdiution,imtruu patitont,
in the proper Sl'1f...Jdminismtion of the drug. taken with addition,1
tkliIh. (PIQptr administration.an impWlt the tf'le(tireneHOlthedrugl.)
Pati ent and Family Educati on
ImtnKt the p,titont on home therapy to'Migh daily atthe s,metime
toKh day and fl'cordAn inc:ft'all' or loll in 'Might ofol'tr 1 kg ptr 24 hou"
should he fl'ported to the health.aft' provider. Report '11)' Ntrn<l or dyspnu
immtdiattly.
Te.JCh the patitom about tht rationale for all US!'d and the for
frequent monitoring. If using homefquipment,enlUft' the proper iull(tioning
of fquipl1ll'nt and proper US!' by the family, or ufl'gi-m.
Explain the ratiolhlle for (heciing tube priorto m h iecdingto the:
family, oruregiY!'r.lfhol1ll' enteral therapy is ordtrtd, teoKh the
family, or ufI'giYl'l the appropriate ior(hecking pIoKffiIerlt
prior to fffiling.
Tht p,titont, should lit to Stilte the fI',son for the
drug; appropriate dost j nd stlieduling; what advmt diem to ob!efYl' for
and when to rt'port; <lnd theantKipatN of medication therapy.
The p,titont and or ufI'giver aft' ,bit to discussappropnate dosing and
administration nl'l'ris.
The patient, is able to appropriate
dosing. ,nd administration and mr of mtlssiltl ,nd prior to home

Evaluation of Outcome Criteria
the effectiYerltu of drug therapy by confinning that goalland fXpKted haY!' bten met
-r- -
Chapter REVIEW
KEY CONCEPTS
The numbered k")' con""pts provide a succinct summory of the importam points from the corresponding numbered """tion
within the chapter. If any of these points are not dear, refer to the numbered section within the chapter for review.
42.1 Vitamins are organic substances needed in small
amounts to promote growth and maintain health. Defi-
ciency of a vitamin will result in disease.
421 Vitamins are classified as lipid soluble (A, D, E, and K) or
water soluble (e and B complex). oflipid-
soluble vitamins are stored in the liver and adipose tissue.
42.3 Failure to meet the Recommended Dietary Allowances
(RDAs) for vitamins may result in deficiency disorders.
The RDA is the amount of a vitamin needed to prevent
symptoms of deficiency.
42.4 Vitamin therapy is indicated for conditions such as poor
nutritional intake, pregnancy, and chronic disease states.
Symptoms of dl'ficiencyare usually nonspecific and oc-
cur owr a prolonged period..
42.5 Dt'ficiencies of vitamins A, D, Eo or K are indications for
pharmacotherapy with lipidsoluble vitamins.
42.6 Dt>ficiendes of vitamins C, thiamine, niacin, riboflavin,
folic add, cyanocobalamin, or pyridoxine are indica-
tions for pharmacotherapy with water-soluble vitamins.
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654 Unlt7 TheGa,u olm",tI ... ISym>m
42.7 Minerals are inorganic substances needed in very small
amounts to maintain normal body metabolism.
42.& Pharmacotheropywith macrominerals includesagentscon-
taining calcium, magnesium, potassium, or phosphorus..
42.9 Pharmacotherapy with microminerals includes agents
containing iron, iodine, fluorine, or zinc.
42.10 Undernlllrilion may be caused by low dictary intake,
malabsorption disorders, fad diets, or wasting disorders
such as cancer or AIDS.
NCLEX-RN" REVIEW QUESTIONS
D An older adult has been diagnosed with pernicious ane-
mi3 and replacement therapy is ordered. The nurse will
3ntieipate adminislering which vit amin. and by what
lechnique?
1. B., orally in liquid fom}
2. K, via intramuscular injection
3. D, bylightbox therapy or increased sun exposure
4. B", by intramuscular injection
D The nurse is prep<lring to administer magnesium sulfate
intraVl'nously. The nurse should assess for which of the
following adverse affecls? {Select aU thai apply. }
1. Decreased liver function
2. Respiraloryfailure
3. Complele heart block
-4 . CirculatorycoUapsc
S. Increase in peripheral edema
D The nurse is assessing a p.1tient who is exhibiting general -
ired wrukness, cardiac dysrhythmias, hypertension, loss of
deep tendon reflexes, and respiratory distress. What could
be the possible cause of these symploms?
1. Hypocalcemia
2. Hypercalcemia
3. Hy}xlmagnesemia
4. Hypennagnesemia
CRITICAL THINKING QUESTIONS
1. A patient has been self-medicating "ilh vitamin B,
(niacin) for an elevated cholesterol level The patient
comes to the clinic with a severe case of roo ness and flush-
ingand is concerned about an allergic reaction. Whal is the
nurse's best response?
2. A patient complains of a constant headache for the past
seVl'rat days. The only supplements the patient has been
taking are megadoses of vitamins A, C, and E. What would
be a priority for the nurse with Ihis patient?
3. A palient presents to the health care provider with com-
plaints of severe flank pain. This patienl hasa historyofre-
nal calculi. The only medication the patient lakes is a daily
42. 11 Enleral nutrition, provided orally or through a feeding
tube, is a means of meeting a patient's complete nutri -
tional needs.
42. 12 Thtal parenteral nutrition (TPN) is a means of supply-
ing nutrilion to patients via a peripheral vein {short
lerm} or central vein (long term).
o The patienl is a long-time alcoholic. The nurse under
stands that alcoholism is the most common cause of
which vitamin deficiency?
1. Vitamin E
2. VitaminA
3. Vitamin D
4. Thiamine
II The patient is a 12-year-old child with hemophilia. The
nurse is awan' that this patient will require administra-
tion of which vitamin to improVl' the function of clolling
factors?
1. Folic acid
2. Ribollavin
3. Vitamin K
4. Vitamin A
o Tolal parenteral nulrilion (TPN) has been ordered for a
patient with gastric Olncerwho is no longer able to main-
tain oral intake. The nurse notes that the patient has a tem-
perature of [OOA
O
F. What should the nurse assess first?
1. The date the TPN WllS ordered
2. The patient's last electrolyte levels, partiwlarlygluoose
3. The introvenous accesssiteand aU N equipment and
TPN bag
4. The patient's last chest x-ray repon
multivitamin as well as vitamin C. The nurse should assess
for whal potential problem?
See Appendix D foraTl5Wl'rs arid rtltionaies for all activilies.


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CHAPTER 43
CHAPTER 44
CHAPTER4S
CHAPTER 46
UN I T 8
The Endocrine
System
Drugs for Pituita ry, Thyroid, and Adrenal Disorders
Drugs for Diabetes Mellitus
Drugs for Disorders and Conditions of the Female Reproductive System
Drugs for Disorders and Conditions of the Male Reproductive System
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DRUGS AT A GLANCE
HYPOTHALAMIC AND PITUITARY DRUGS p!XJ'6(iJ
HYPOTHALAMIC AGENTS fIIlIJ'6(iJ
Anterior Agents p]'66iJ
pIlIJtMI
THYROID DRUGS p!JIJ'66l
Th)Told Agents ptJIJ! 66]
o ItvorhyroKin. Synrhroid,
ofhoon) fllJl/' 664
AntHhyrold Agenls !"9"66J
o propylrhiouroc:iI (PTU) fX1I}t 661
ADRENAL DRUGS fXkJ' 667
Glu(ororticolds p!JIJ'6J(J
o hydrocorlisOM ((orlPt HydrocorrOM,
olh<>nl {JIJIJ' 67J
Antiadrenal Agents fX1Y 611
KEY TERMS
Addison's disuse fX1IJ'611
fX1J'657
. dr. II.lOlliu l in, .mu.n<, fII1!' 61IJ
adnono(oniu tropir honnone (ACTH( fIIl1'61O
.lntidiuretir honnone (ADH) poqt661
bualmetaboliuat e poqt661
Cushing's syndrome fIIlIJ' 6n
Drugs for Pituitary, Thyroid,
and Adrenal Disorders
LEARNING OUTCOMES
Afrer froding lhis chapter, the sNdent should be able /0:
1. [)@scribethegeneralstructureandfunctionsoftheendocrinesystem.
2. Through t he use of a specific example,explain the concept of negative
feedback in the endocrine system.
3. Cl@scribethedinicalapplicationsofthehypothalamic and pituitary
hormones.
4. Explain the pharmacotherapy of diabetes insipidus.
S. Identify the signs and symptoms of hypothyroidism and
hyperthyroidism.
6. Explain the pharmacotherapy of thyroid disorders.
7. D.!scribe the signs and symptoms of Addison's disease and Cushing's
syndrome.
8. Explain the pharmacotherapy of adrenal gland disorders.
9. Dt>scribe t he nurse's role in t he pharmacologic management of
pituitary, thyroid,and adrenal disorders.
10. Foreach of the (lasses listed in Drugs ata Glance,know representative
drugs, and explain t he mechanisms of drug action, primary actions, and
important adverse effects.
11 . Use the nursing process to care for patients who are receiving drug
t herapy for pituit ary, thyroid, and adrenal disorders.
p!l1'661
p!l1'66i
G' . ... di [1JIJ'66J
hormone fllXT 657
rnyxedf ma p!l1'66J
neurohypophysis p!l1'657
parafollirularcell s [1JIJ' tiS l
rt'l easing hormone p!l1'657
, IHr,I . ldlu",
fII1J' 659
thyroid storm fII1J'66l
globulin (TBG) p!l1' 66J
LibraryPirate
L
ike the nervous system, the endocrine system is a major
controller of homeostasis. Whereas a nerve exerts instan-
taneous control over a single muscle fiber or gland, a hor-
mone from the endocrine system may affect thousands of
cells and take as long as several days to produce an optimum
response. Hormonal balance is kept within a narrow range:
Too little or too much of a hormone produces profound
physiologic changes. This chapter examines common en-
docrine disorders a nd their pharmacotherapy. The reproduc-
tive hormones are covered in chapters 4S and 4600.
43. 1 The Endocrine System
and Homeostasis
The endocrine system oonsists of various glands that secret",
hormonn. chemical messengers released in response to a
change in the body's internal envirOIUllent. The role ofhor-
mones is to maintain the bodyin homeostasis. Forexample,
when the level of glucose in the blood rises above normal,
the pancreas secretes insulin to return glucose levels to nor-
mal. The various endocrine glands and their hormones are
illustrated in ,. Figure 43.1.
After secretion from an endocrine gland, homlOnes enter
the blood and are transported throughout the body. Some,
such as insulin and thyroid homlOne, have receptors on nearly
every cell in the body; thus., these honnones have widespread
effl!(;ts. Othen;, such as parathyroid hormone (PTH) and oxy-
tocin, have receptors on only a few specific types of cells.
In the endocrine system, it is common for one hormone
to control the sa:retion of another hormone. In addition, it
is common for the last hormone or action in the pathway to
provide feedback to turn off the secretion of the first hor-
mone. For example, as serum calcium levels fall, VfH is re-
leased; VfH causes an increase in serum calcium, which
provides feedback to the parathyroid glands to shut off PTH
secretion. This characteristic feature of endocrine homeo-
stasis is known as negative feedback. Negative feedback
helps to prevent excessive secretion of hormones thereby
limiting their physiologic responses.1t is important to un-
den;tand that when a hormone is administered as pharma-
cotherapy, it provides negative feedback in the same manner
as the normal, endogenous hormone.
43.2 The Hypothalamus
and Pituitary Gland
Two endocrine structures in the brain, the hypothalamus
and the pituitary gland, deserve special recognition because
they control many other endocrine glands. The hypothala-
mus sa:retes rrlrasing hormonfs that travel via blood vessels a
short distance to the pituitary gland. These releasing hor-
mones specify which hormone is to be released by the pitu-
itary. After secretion, the pituitary honnone travels to its
target tissues to cause its biologic effects. For example, the hy-
pothalamus secretes thyrotropin-releasing hormone (TRH)
IlIoplfl41 0nJ9' 10, Thy,oId,.nd Ad ....... 1 Ol..,rder, 657
,. Figure 43.1 The endOCrine system
source: IWr!JJfl Erumr/oiVPHCDlIge.
Pineal gland
Hypolhalam.JS
gland
that travels to the pituitary gland with the message to secrete
thyroid-stimulating hormone (TSH). TSH then travels to its
target organ, the thyroid gland, to stimulate the release of
thyroid hormone. Although the pituitary is often called the
master gland, the pituitary and hypothalamus are best visu-
a. an integratedllni!.
The pituitary gland comprises two distinct regions. The
anterior pituitary, or .denohypophysis, consists of glarldular tis-
me and secretes adrenocorticotropic hormone (ACfH),
thyroid-stimulating hormone (TSH), growth hormone, pro-
lactin, follide-stimulating hormone (FSH), and leuteinizing
hormone (LH). The posterior pituitary, or neurohypophysis,
contains rleTVOU5 tissue rather than glandular tissue. Neurons
in the posterior pituitary store antidiuretic bomlOne (ADH)
and oxytocin, which are released in response 10 nerve impulses
from the hypothalamll'i. Those hormones that affect the fe-
male reproductive truct are presented in chapter 4500. Se-
lected hormones associated with the hypothalamll'i and
pituitary gland are shown in ,. Figure 43.2.
LibraryPirate

pHuilluy
.....

Ad ..... lgland
Thyroid gland
Ii=> G"."' ........ ,GH} -/
Bone, mu.de,
ot.er
,,,.,,"' ,,,,,
......., .......
I Testo5Ieltlne I
185105
Ovari ...
,. Flgure.fl.2 Hormones associated with the hypothalamus and the pitui tary gland
Sour(/': PearsonEducaf/oo/PHCalege,
LibraryPirate
43.3 Indications for Hormone
Pharmacotherapy
The goals of hormone pharmacotherapy vary widely. In
many cases, a hormone is administered as simple replacement
tht'!"apy for patients who are unable to secrete sufficient quan-
tities of their own endogenous homlOnes. Examples of re-
placement therapy include the administration of thyroid
hormone aftt'!" the th)TOid gland has been surgically removed,
or supplying insulin to patients whose pancreas is not func-
tioning. Replacement therupy supplies the same physiologic,
low-level amoWlts of the hormone that would normally be
present in the body. Selected endocrine disorders and their
drug therapy are summarized in Table 43.1.
Some hormones used in cancer chemotherapy to shrink
the size of hormone-sensitive twnors. Examples include
testosterone for breast cancer and estrogen for testicular can-
cer. Exactly how hormones produce their antineoplastic
action is largely unkoown. Vthen hormones are used as anti-
neoplastics, their doses far e."Keed normal physiologic lewis.
Hormones are always used in combination with other anti-
neoplastic medications, as discussed in chaptt'!" 3700.
Another goal of oormonal pharmacotherapy may be to
produce an exaggerared response that is part of the normal
action of the hormone. Administering hydrocortisone to
suppress inflammation takes advantage of the normal ac-
tion of the glucocorticoids, but to a greater extent than
would normally occur in the body. Supplying estrogen or
progesterone at specific times during the menstrual cycle
can prevent ovulatiOil and pregnancy. In this example, the
patient is given natural hormones; however, they are taken
at a time when levels in the body are normally low.
Endocrine pharmacotherapy also involves the use
tihormones." These hormone antagonists block the actions
of endogenous hormones. For example, propylthiouracil
AVOtDtNG MEDt CATtON ERRORS
A Ift",","rr weigh. 2,000 9- Tbt ookr is fur
lS mg!kg.'!lay i dministerrd in twofqwll)'dividtd ooln.The
nurst administers SO mg iorlhe 10:00 a.m.oost.l'l !hit ((IIIK!
5tl'AppmdIx DfllllIIt suggtlltdlllSlll'l'.
Dopttr (I I:lr\'9' lor PRulmy. Thyrold..nd Ad....,.t OMIde" 659
(PTU) is given to block the effects of an overactive thyroid
gland (Section 43.7). Tamoxifen (Nolvadex) is given to
block the actions of estrogen in estrogen-dependent breast
(chapter 37 00).
43.4 Pharmacotherapy with Pituitary
and Hypothalamic Hormones
Of the 15 different hormones secreted by the pituitary and
the hypothalamus, onlya few are used in pharmacotherapy,
as listed in Table 43.2. There are valid reasons why they are
not widely used. Some of these hormones can be obtained
onl),from natural sources (human brains) and can be quite
expensive when used in therapeutic quantities. Further-
more, it is usually more effective to give drugs that directly
affect secretion at the target organs.
The only hypothalamic hormone used clinically is
gonadotropin-releasing hormone (GnRH). Leuprolide
(Lupron), goserelin (Zoladex), and nafarelin (Synalel) are
analogs of GnRH that are used to treat endometriosis, a
common cause of infertility (chapter 4500). Leuprolide
and goserelin are also used for the palliative treatment of ad-
vanced prostate cancer. Two pituitary hormones, prolactin
and oxytocin, affect the female reproductive system and are
discllssed in chapter 45 00. Corticotropin affects the adre-
nal 8land, and is discussed later in this chapter. Of the re-
maining, growth hormone and antidiuretic hormone have
the most clinical utility.
GROWTH HORMONE (GH) Growth hormone, or somatotropin,
stimulates the growth and metabolism of nearly every cell in
the body. Deficiency of this hormone in children can cause
short stature, a condition characterized by significantly
decrfased physical height compared with the norm of a
specific age group. Severe deficiency results in dwarfism.
Short stature is caused by many conditions other than GH
deficiency, and often a specific cause cannot be identified.
Prior to 1985, all GH was obtained by extructing the hor-
mone from human pituitary glands, which severely limited
the amoWlt available for pharmacotherapy. Human GH, so-
marolropin (Ao;; retropin, Genolropin, HWl1alrope,
is now available by the subcutaneous route in large qwntities
through recombinant DNA technology. If therapy is begun
early in life, as much as 6 inches of growth may be achieved.
GH therapy is contraindicated in patients after the epiphyses
TABLE 43.1 I Selected Endocrine Disorders and Their Pharmacotherapy
Gland Hormolll'(s) Dlwrder Drug Therapy
Adrrnal lOft9 Gl<ocortiloid! Hypmtmtion:UMiIl S)'!1dro ..
Qurorortiroirk
Piwilall Growth l/ypost(rtIion:Yl\a1 SliJture Somatmn (Protropin) and somatotropin (Gtnotropin)
Hypmtmlion:oKKIIl"ItO}Ily (adulI) Ortrrotid!' (mdosLJtin)
hormonf Hypost(rtlion:diabufS VasoprrSiin, and Iypmsil
.,...
Thyroid honnont (T, andTJ Propylthiouool( PlU), methimazolt (Taparole), and I-H 1
(olduks) Th)TOid hormont, Itoiothyroxr.t, (TJ
LibraryPirate
660 Unlt l TheEr.doal .... SyS!,-""
TABlE43 .2 1 Select"d Hypothalamic and Pituitary Ag"nts"
Drug Route and Adult Dose (max dow where Indicated) Adverse Effects
HYPOTHALAMIC AGENTS
octre01jdf, StD:UlintOUS; 1 00- 600 m(g/dily in two to fool dMdtd dose; may 1iou5ltl, I'Omirilg,dit7rhto, fluslir.g,
I switch to 1M drpcl! inj<ction , fir< 2 wht20 mg <Wry . wIc for 2 mo injt<1io. pdn, </.ekiirlUa>if
fiillfl' linin
.......
pfgYiIorunt {Somivmj StD:UI.ntOUS;40.mg Ioadng tlltn 10 mgldily
(madOmgldiY)
dilmag,!f'litrd nnloaminilt!MI!
ANTERIOR PITUITARY AGENTS
rortkotropin (ACTH) IV; 10- 25 intma1ioni1 in SOO ml OSW infUltda.'n' 8 h 50diJm and
roIYntropin (Cortrol)'ll) IIMV;015 mg Oftf 211in
lJIet.lsmnin (Inml9,lpluj StD:UI.ntOUS (:;e:l yrund okirr): 0 5 mgIkg 000' diliIy, up to Inilionfire iron de6(ffl()'oflmlkl.lJOirer,
1- 2 mglkgldily,ljl'ffi diily ontibody dm/opment helldoche, hyptrrrophy of
Ildeooidl IOmiis
HiI!Q!1!:!:(ffilY inuNlI'd intrac:rariil
somatotropin StD:UtintOUS;dostS higtly individuililrd,baltd on. mile!'! IVn or ifJirion Jirr, hyPfrylytPmi4 r./hdrjo.
Gffiotropin, H!lllittropt, IJ'OWIh obckrnilol P(jn, oom mtI6o,. headache, l:Irrahilis,
Norclitropin, tlnropin, Srrosim, hyporhyroidi5m, hyperfmlion, &J1ikt l)mpl'cml


Ii .
' j
;
TlrJrotropin (IIrJKI9ffi, thyroid- 1M15UlKutJrItOUI; 10 for 1- 3 diI)'! NaU5ltl, htododt4: Q5!henio
lIimwting hormOlll' (TSH)
Ug il:ligiIUItaIlll: lWiIlm
POSTERIOR PITUITARY AGENTS
Q InTrin.saI;O.I -<1.4 ml (lo-40nKg) in 00sts 1ItodtKhe, mua cmqmion or irrirorioo, oouseo
IV 2-4 nKg in t'M) divided doItl
:tii!fr: ilWiWiIlo 1!I!IIi Iblllmwllllli, djlllllfl;
PO; O.H . mglday
hypolHlrtmii
1M l5UbtWrItOUI; 5- 10 uriu Iqueous soknoo two to foos MlmiriIg. WVrtrrtWllm
I IV; O.HI . upTO IIIIit/min
mOil !.I( 1IoI!IIIIfIIf IIDIIlllxdnil;
*Hyporhalimk and pil!ilirY ultd in mapler 45 00.
Irdla common adl'ffSt indiciT61trious
have closed. GH agenTs are usually well tolerated, although
patients must undergo regular assessments of glucose toler-
ance and thyroid function during pharmacotherapy.
Meas"rmin (Increl" x, Iplex) is" newer "sent,"pproved in
2005, thaT has the same actions as growth hormone. Mecaser-
min is indicated for the long-term treatment of growth fail-
ure in children with severe deficiency of insulin-like groWTh
factor (lGF) or for those who have developed neuTralizing
antibodies to GH.lt is administered once daily by the subcu-
laneous roule. Adverse effects include hypoglycemia, head-
ache, dizziness, vomiting, and tonsillar hypertrophy.
Prior 10 2003, growth hormone therapy was approved only
for treaTing short stature in children who had deficiencies in
GH. The FDA, however, has now approved growth hormone
therapy to treat children with short stature who have normal
levels ofGH. The height criterion for treatment is defined as
an expected adull height of less than 5 feeT J inches for men
and 4 feet II inches for women. GH Therapy in children with
normal growth hormone levels may add I to 3 inches in
height to children af'ter4 to 6y""n; of pharmacotherapy. The
annual cost of$30,000 to $40,000 may discourage many par-
ents from seeking this therapy for their children.
Excess secretion of growth honnone in adults is known as
acromegaly. A rare disease nearly always caused by a pituitary
tumor, acromegaly sometimes requires pharmacotherapy.
Octreotide (Sandoslatin) is a synthetic growth honnone
tllltagoniSl structurally relaTed to growth honnone--inhibiting
hormone (somatostatin). In addition to inhibiting growth hor-
mone, octreotide promoles fluid and el.ectrolyte reabsorption
from theGI traer and prolongs intestinal Transit time. It has lim-
iTed applications in treating acromegaly in adults and in treat-
ing the severe diarrhea sometimes associated with meTastatic
LibraryPirate
cm:inoid tumors. Acromegaly mayaiso be treated with pq0-
somant (Somavert), a growth honnone-receptor antagonist.
ANTIDIURETIC HORMONE It is essential that the concen-
tration of fluids in the body be maintained within narrow
limits. Loss of large amowtts of water leads to dehydration,
whereas too much body fluid leads to congestion, edema,and
water intoxication. Antidiurrti( hormmr (ADH) is one of the most
important means the body uses to maintain fluid homeostasis.
As its name implies, ADH conserves water in the body.
ADH is secreted from the posterior pituitary gland when the
hypothalamus senses that plalma volume has decrealed, or
that the osmolality of the blood has become too high. ADH
acts on the collecting ducts in the kidneys to increase water
reabsorption. The increased amOlUli of water in the body
reduces senun osmolality to normal levels and ADH secre-
tion stops. ADH is also called vasopressin, because it hal the
ability to constrict blood vessels and raise blood pressure.
A deficiency in ADH results in diabete insipidus (DI), a rare
condition characterized by the production of large volumes
of very dilute urine, usually accompanied by increased
thirst. Two ADH preparations are available for the treat-
ment of diabetes insipidus: vasopressin and desmopressin
(DDAVP,5timate).
Valopressin is a synthetic homlOne that has a structure
identical with that of human ADH. l t acts on the renal col-
lecting tubules to increase their permeability to water, thus
enhancing water reabsorption. Although it acts within min-
utes, vasopressin hal a short half-life that requires it to be
administered three to four times per day. Vasopressin tan-
nate is formulated in peanut oil to increase its duration of
action. Vasopressin is llSuallygiven 1M or IV, although an in-
tranasal form is available for mild diabetes insipidus.
Desmopressin is the most common form of antidiuretic
hormone in use. Details reg3rding this drug may be found
in the Prototype Drug feature.
43.5 Normal Function
of the Thyroid Gland
The thyroid gland secretes hormones that affect nearly every
cen in the hody. Thyroid hormone io"rea."", ha .. 1 ITN'ubnl ir
rate, the baseline speed at which cells perform their func-
tions. By increasing cellular metabolism, this hormone in-
creases body temperature. Adequate secretion of thyroid
hormone is also necessary for the normal growth and devel-
opment in infants and children, including mental develop-
ment and attainment of sexual maturity. The thyroid
strongly affects cardiovascular, respiratory, gastrointestinal
(GI), and neuromuscular flUlction.
The thyroid gland has two basic types of cells, which se-
crete different homlOnes. Parafomrularcflls secrete calcitonin, a
.... Prototype Drug I Desmopressin (DDAVP, St/mate)
Therapeutic (lass: Antidiuretic hormone replacement Pharmacologic (lass: Vasopressin analog
ACTIONS AND USES
is s)'IIthetic analog of human ADH lhat aru on tilt kidllt)'S to in-
rrabsorption of water. It is USfd to (ontroltht Uti' S)'m ptom! of di-
insipidus in patitnt! who inlUfficitnt ADH mrrlion. Tht oral
is akhough naSiI spray, and parrnteral folllll
<l rt avaiiabit. k hu a ruralion of action of up to 20 wherm moprffiin
(Pitll'Ssin) hal a duration of only 2- 8
Dtsmoprrnin (mlfaction of smooth in tile "lal(uiar 1)"I1I'm,
uterus,and GI tfiK1.1t also an inO"NW' in (lotting factor VIII <lnd on
Willebrand"! factor, and is thUl indicated for tht rnanigtl1ll'nt ofbftding in Pol-
titnll with hemophilia A <lnd wn Willtbrand"s dilfaW' (typt I).An off-label 1M
for this drug is 10 (ontrol enurtlis lbed-wetting) among (hildlt'n.
ADMINISTRATION ALERTS
When IV for insipidus, desrnoplI'Ssin is givtll undi-
lutt<! oYer I minutl'.
Following in IV injection, Hum must rrltrictedand (alt'fi.dly monitored
10 prr"l'!'nt W'riOUI water intorication.
PlI'9ni llquttgoryB
PHARMACOKINETICS
IV; I h PO
Prak: IHOmin 1V;4-7h PO
Halflift:75min
Duration: lh 1V;S-lO h PO
AOVERSEEFFECTS
(an cauW'symptormofwater hNdac:ht,
and listitlllll'ss, proejll'Ssing to (OIIl'Ulsions and (orna.Otlltr in-
dUlk transitnt lItadacllt, nauW'a, mild abdominal p.ain and mmping, facwl
llulhing, hypertension, p.ain, or at injection site. Intranasal forms can
(aIM nasal (ongtltion, rhinitis,ind epistuis. Toltrancr oieYmpslO
of rlesmopmsin wilen it is administered rnorr frequtnlly than 48 hour;,
orbjotlll'lVroutt .
(ontraindi (ltions: Dtsmoprrssin is (ontraindicatl'd in p.atitnll with diabet6
insipidus that iscauW'd by 100111')' dilfiW' bmUW'thtdrug can !\rid rr-
II'ntion and o..moad It is uW'd with (aution in palitnlS with (oronary irtery dis-
N il', hyptrtensiOll,and in p.atitnts al mk for hyponallt'mia or thrombi. Young
childrrn and thtolder aduhs should trrut<! with caulion beciIM thm 11'1-
titnu <lit' mort' to wner intOlicalion and hyponatrrmw.
INTERACTIONS
Drug-Drug: lnarnfd oKtion can OU\I" with GlIbammpiIll',
nonlleroidal
GIIl o((llrwith lithium,aklilol.ht>parin,and

Li b Ti51S:Unmown
HNVFood: Unknown
Treat ment of may (,JIM W'Y!'rr Wilt r intOlication.Trrat-
mtnl ilKludei water rrstriction and osmotic diJrrtKs.
LibraryPirate
662 Unlt l The Er.docrl .... Sym'm
hormone that is involved with calciwn homeostasis
(chapter 47 00). in the gland secrete thyroid
hormone, which actually consist of two different hormones:
thyroxine {T.} and triiodothyronine {T ,}. Iodine is er.sential
for the synthesis of these hormones,and is provided through
the dietary intake of common iodized salt. The names of
these hormones refer to the number of bound iodine atoms
in each molecule,either three (T,) or four {T. }. Thyroxine is
the major hormone secreted by the thyroid gland, however,
it is converted to T, before it enters its target cells. T, is three
to five times more biologically active than T .
As it travels through the blood, thyroid hormone is at -
tached to a carrier protein, thyltlll ine-binding globulin (TBG),
which protects it from degradation. Any condition that
causes decreased amounts of plasma proteins, such as pro-
tein malnutrition or liver impairment, can lead to a larger
percentage of[reethyroid hormone, with subsequent symp-
toms of hyperthyroidism.
The secretion of thyroid homlOne is regulated by the hy-
pothalamus and anterior pituitary gland by way of a nega-
tive feedback loop, as shown in .. Figure 43.3. When blood
levels of thyroid hormone are low, the hypothalamus se-
cretes thyrotropin-releasing hormone ( TRH). Secretion of
TRH stimulates the anterior pituitary to secrete thyroid
stimulating hormone (TSH). TSH, then, stimulates the thy-
roid to produce and secrete T, and T . As blood levels of thy-
roid hormone increases, negative feedback suppresses the
secretion of TSH and TRH. High levels of iodine can also
cause a temporary decrease in thyroid activity that can last
for several weeks. One of the strongest stimuli for increased
thyroid hormone production is exposure to cold.
THYROID AGENTS
Thyroid disorders are common and drug therapy is often
indicated. The correct dose of thyroid drug is highly indi-
vidualized and requires careful, periodic adjustment. The
medications used to treat thyroid disease are listed in
Table 43.3.
PHARMFACTS
Thyroid Disorders
Hypothyroidism is 10 times mort mmmon in women;hypenhyroidism is
S to 10 times mort(ommon in women.
Tht two most (ommon thyroid disffil"l, Gram' disf.m and Hashimoto's
thyroiditis,art autoimmuflt disNm and may hal'f a gmetic:
Ontof 4,000 babits is bom without a working thyroid gland.
About lS,lXHl new m!'i of lliyrOd can(ff <1 rtdiagnOlfd f<l(h )'eolr.
Ontof ",-,Iy fil'f womm than 75 )'eolB has Hashimoto's thyroiditis.
Postpanum thyroiditis O((UB in 5% to 9%ofwomrn and may rtrul in
IutUrt pr!gnalKits.
Both hypenhyroidism and hypothyroidism can dfoo a woman's abtlityto
brcol1ll' pr!gnant and can calM miswriagtl.
anterior
Neg"" ""
, .... "
o
e


"

./
o tncreased metabolic .ate
in moot body c .. 11o
NeUlOsecretDtY
cells ot hypothalatnl5
". Flgure4J.J Feedback mechantsms of the thyrotd gland:
(1) sllmu)us;(2) releal(> ofTSH;(3) release ofthyrotd hormone;
(4) tncreal(>d BMR;(S) negallve feedback
43.6 Pharmacotherapy
of Hypothyroidism
Hypothyroidism may result from either a poorly function-
ing thyroid gland or low secretion of TSH by the pituitary
gland. The most common cause of hypothyroidism in the
United States is destruction of the thyroid gland due to
chronic autoimmWle thyroiditis, a condition known as
Hashimoto's thyroiditis. Early symptoms of hypothyroidism
in adults, or m)"ftdrmil, include general weakness, muscle
cramps, and dry skin. More severe symptoms include
slurred speech, bradycardia, weight gain, decreased sense of
taste and smell, and intolerance to cold environments. Lab
LibraryPirate
TABLE 43.3 1 Thyroid and Antithyroid Drugs
0""
Route and Adult Dose (max dose where Indicated) Adwrw Effects
THYROID AGENTS
dtsir:Gilttd th)fOid (ArInoII', 8j,). Thyroid, ThyKid
usp'othtrs)
o S)'nthroid,othn"s)
liotlrjronilt (C)'IOmrl, Trio5tJl)
lioiril IThyrdar)
ANTITHYROID AGENTS

ioddt and iodllt (LugoI'l Soh.-ion, PiIN,
Thyro.8Iod:)
PO; 11-400 mOlfday
PO;2>-75 mOJlday
IV; 100 III(g/day
PO; 125-30 mOl/day
PO;H,mgtid
PO; 250 rng tid
PO;300-450mqtid


imomnio, mfmrrod MytJ),m'rits
IlnrIMbmjal byptOernioo

Wl'i9hrgoirr,
hfadochf, fm! oomblltSJ in /ingtfJ,

o propylthiouracil (PTU)
iodide (I. Bl,lodoIopI') PO;O.s-150 mG la G or (I.-it iu
results generally reveal elevated TSH with diminished T,
and T. levels. The etiology of myxedema may include au-
toinunune disease, surgical removal of the thyroid gland, or
assressive treatment with antithyroid drugs. At high doses,
the antidysrhythmic drug amiodarone (Cordarone) can in
duce hypothyroidism in patients due to its high iodine con-
tent. Enlargement of the thyroid gland, or goiter, may he
absent or present, depending on the cause of the disease.
Hypothyroidism is treated by replacement therapy with
T, or T . The standard replacement regimen consists of
levothyroxine (T. ), although combined therapy with
levothyroxine plus liothyronine (T, ) is an option. Desic-
cated thyroid gland from beef, pork, or sheep sources (Thy-
roid USP) is an inexpensive option, although it is rarely used
because of the possibility of allergic reactions to animal pro-
tt'in. Liothyronine sodium is a short -acting synthetic form
of thyroid hormone that can be administered IV to individ-
LIFESPAN CONSIDERATI ONS
Shih Workers, Hypothyroidism,
and Drug Compliance
Many bod, proc:ffirlllKh <IS blood of certaio
honnonrl, biochemical fludwteon a 24.flour Khtd-
ule MaNn as rbyllrm. Cirtadiao thought to br 1f9-
ulated b)o daylight. Normal ciKadian C){1rs Ina)' br imflTUpttd io tholr ptOple
who 'M)flmrird mtdicatiom that mUlt br given at a sptci-
rtrd timr to t nhalKe potrmial elF! (.10 bra <OlKrm for Ihift ......nns.
for enmple. thyroid mrdiution is brll gmo at the I.lme time Nch rIa)o,
usua on .!Wakffiing. br<aul!' it (.I n disrupt slerp if later in the da,. But
for Ihift worms who Ihilt:i, <lnd awakffi at timrs,
this conlistent dosing Khtdule Giln br <I dlallenge. Advisr patients of this chal
1I'ngt. and hal' tflrm work with the (.1ft' providl'r to <I mtdica-
tion IChtdult that allows optimization of drug effNn.
uals with myxedema coma. The short duration of action al-
lows for a rapid responst' to critically ill patients.
Serwn TSH levels are used to evaluate the progress of
therapy. Because small changes in drug bioavailability can
affect thyroid function, patients should avoid switching
brands of medication once their condition has stabilized.
V-Ihen initiating therapy in older adults, the precaution is to
low and go because there is a risk for inducing
acute coronary syndromes in susceptible individuals. Re-
placement therapy for most patients is continued lifelong.
ANTITHYROID AGENTS
Medications are often used to treat the cause of hyperthy-
roidism or to relieve its distressing symptoms. The goal of an
tithyroid therapy is to lower the activity of the thyroid gland.
43.7 Pharmacotherapy
of Hyperthyroidism
Hypersecretion of thyroid hormone results in symptoms
that are the opposite ofthose caused by hypothyroidism: in-
creased body metabolism, tachycardia, weight loss, elevated
body temperature, and anxiety. The most common type of
hyperthyroidism is called Graves'dilrase. Considered an au-
toimmune disease in which the body develops antibodies
against its own thyroid gland, Graves' disease is fourto eight
times more common in women, and most often occurs be-
tween the ages of 30 and 40. Other causes of hyperthy-
roidism are adenomas of the thyroid, pituitary tumors, and
pregnancy. If the cause of the hypersecretion is found to be
a tumor, or if the disease cannot be controlled through
pharmacotherapy, surgical removal of the thyroid gland is
indicated.
LibraryPirate
664 Unlt l .... Sy<!"",
'" Prototype Drug I Levothyro)une (I..evothrOld, Synthrol(i, others)
Therapeutic (lass: Thyroid hormone Pharmacologic (lass: Thyroid hormone replacemenl
ACTIONS AND USES
lmJthyroxine a form ofT, thlt I drug of ,hoice for
tlltra py in patients with low thyroid fulKtion. Action s thole of endoge noIlS
th)oroid hormone, Ind ilKlude loss of wtight. improftd toitranU' 10 roviron-
mernal temptl1nJrl', ilKrmed xtivity,and illumed pulst rate.
To noid of ImIthyroxine highly individwlizfd for
each When gim by tilt oral route, weeks may be rtqUirtd to ob-
tain full theraptUtK btntfits. DOlts for p;ltitnts with cardi.l{
tom uswlly ilKl"Nlofd at 4-6 week intervals to mlid triggering
d),!mythmi.lsor angillil att.Kks.Strum TSH rtgUlarty monitoml tode-
tmnine whttht r the patitm m:riviog suHKitnt ItYothytOJine-high TSH
IeYeis indiott t!wt tht dos.aqeofT, rftds to he ilKrulofd.
ADMINISTRATION ALERTS
Administef the medication at the Sollnt hint el'tf)' day, in the
morning to dKlUse tht pok'nti.ll for insomnia.
cattgOry A
PHARMACOKINETICS
On""l: 3- 5 I" (ordl), 24 to (IV)
Pea k:3-.4 wk
6-7 cia)'!
Duration: wIc
Very high levels of circulating thyroid hormone may cause
thyroid darm. mre, life_thr ... Mening form ofhyp .. rthroidi.m.
If Wltreated, it is associated with mortality rates of 80% to
90%, even with treatment. Symptoms indude high fever,
cardiovascular effects (tachycardia, heart failure, angina,
MI), and eNS effects (agitation, restlessness, deliriwn, pro-
gressing to coma). Thyroid storm is treated with supportive
measures, efforts to reduce body temperature while trying to
avoid causing shivering, fluid, glucose and electrolyte re-
placement, and beta-adrenergic blockers. Antithyroid drugs
may be used to decrease thyroid hormone production.
Tht' two primary drugs for hyperthyroidism are propyl-
thiouracil (PTU) and methimazole (Tapazole). These rued
kations act by i nhibiting the incorporation of iodine atoms
into T, and T . Methimazole hasa much longer half-life that
offers the advantage of less frequent dosing, although ad-
verse effects can be more severe. Both drugs are pregnancy
cat"'!!ory D agents, but methimazole crosses the placenta
ADVERSE EFFECTS
Attlltlil peutK d=s, adl'ffSe oflewthYlOJ:ine py hhough
must he taktn to avoid OYertnoatmt nl Ad"mSl' thOSl' of hyper-
th)oroidism and inc:lude p;llpitaDoos, iOlOlllnia, weight
and intolel1lKf. Men!tnJal may OC{lJr in and
Iong-tt nn U\I' 01 ImIthyroxine !ws bft>n aslO(i.lied with osteoporosis in
women.
Contraindications: l.tfOthyroxine contraindKatfd if patient hyperSl'll-
sitive to the drug, optril'lKiog thyrotoxKosis, or sel'm
conditions or arute lIl)'ocardial inlarrtion (Mil. If gmn to p;ltitnts with
insu/frc:itncy, th)'Jllid hormone may a serious krisis; thus, the insuf-
ficiency should bt {ometed prior to of Ievothyroxine.1i should
he ulofd with (aution in with urdiac: h)optnt osion, oIdtr
and impaimi kidney function. Symptoms of mellitus ma)' bt
WOMned with of thyroid hormone dole of
dlllCJS may L.ewthyroxint has I bIad boJ warning t!wt it
illl'iftctift for wtight miudion and can bt potrotially IOIK wlltn ulofd with
drugs.
INTERACTIONS
1:nJg_1:nJg: (hoIoItJ""flli"" aoIo.mpoi dorrN<t tho """""ion of ...
(QiI(lIll'Ot mniruation of I'piIfpIIrWMIII thfriskol
W i( in!itfidflKJ Lmiltyroxi .. inmasfs tJlf ff1Kn 01 mOt, resultilg in an
illUN!fd risk 01 tw!iog.
tab Tell: tktoown
HerbaVFood: \.o)tIean IkIII" anlant formula), coctortsefd mNI, wal nuts, 0100 diftary
filfr may bind Ind d@muthoiblorptiooollM>iltyroxi .. lOdiumlromthfGl
100. token it lPiII 4 hem ift., utilg
k.roiIt)'roxiw to prMOt
ofOmdoSl': caUSl' smous th)orotOXKOSis, whKh may
not pR'Sl' m until !e'Y!'ral da)'S the OYtrdose. Trutllll' m symptomatic, U!U-
wgetfd at prevroting (Iidiao: toxicity with bttHdrtne"lK
IU(h as
RtII>r 10 MyMIsIniJD (llf MIsJfIg PrIKts5 froIl spnt: 10 1M It!!g.
more readily than propylthiouracil and is contraindicated
in pati .. ot.<.
A third antithyroid drug, sodiwn iodide-131 {Iodotope}
is a radioactive isotope that destroys overactive thyroid
glands with ionizing radiation. Shortly after oral adminis-
tration, 1-131 accumulates in the thyroid gland, where it de-
stroys follicular cells. Tht' goal of pharmacotherapy with
1- \3 I is to destroy just enough of the thyroid gland so that
levels of thyroid function return to normal. Full benefits
may take several months. Although most patients require
only a single dose, others nero multiple treatments. Small
diagnostic doses of 1-131 are used in nudear medicine to
determine the degree of iodide uptake in the thyroid gland.
Nonradioactive iodine is also available to treat other
thyroid conditions. Lugol's solution is a mixture of 5% el -
emental iodine and 10% potassium iodide that is used to
suppress thyroid function to to IS days prior to thyroidec-
tomy. Sodium iodide may be administered IV (along with
LibraryPirate
NURSING PROCESS FOCUS PATIENTS RECEIVING PHARMACOTHERAPY WITH HYPOTHALAMIC
AND PITUITARY HORMONES
AH,um, nt
Baseline prior t o lMIminiSUMlon:
lkIdenu..! 1M _ the drug Ns betn inOf!ltrto iliSm for
melJpMJ: dem [t. g.. trNtll'lftlt of diltilst (0Adiri0n wxh as
Iiibm mipOn, oIf.Jabel U5t!of fIOf\tIdxJnt-rtlitfd (ordtions sud! II

Olll"in iI t.e.kh histOly iMt.Jding
mwI blMt-lffdingJ)buin iI drucj listory
iKbIing prtSCriptiot'I illId OJ( drugs,ht!b.1I ptrp.llitiam,.
.oId lM,W wokiIg.8e.1eft to posWit drug
miu.lw, Itbontory Iindin9s {e.t. wine inc! stl\Hll OImo11liy,
urine sprm- 9J'tity, imIIl'I p!OIein, (II(, tltan!Jrrf!" gloKt. htpitK iI nil
nlYl imctioo studirsl.
Obtain heigllt viulligns.OWin u EClion pititn6
uking growtlJ hormone ilnI.gor.ists.
ASStlllllfnt t hRllghout ulmi nistr. tion:
for dnired IherilpwlK on the rusan thr drug it
givm kg.. _r, blt ifKJtue in slowed diurtSis, JtNrn to
norm,l urioe ootput and strum osmoltlity, rtturn to normal
Continue ptriodic: monitoring of urint 1M IfI'Um osmolality, urine lPf(ifK
gravity. htpatk and JeIlill function studits.
Continue monitoring viul signs.htighlilnd wtight.Monitor the ECG for
ukiog gJ<JWth hOfl'nont
oIdleSs for ildYmt flff<U: 'IMt1, 1\t.IILubf. Hypo-
Of bypertfl1!ion,tadl)umi "dysmythnVi,Of ingilll bf, rtpOfItd
immtdiatf t,.
Pot e nt ial Nursing Diagnoses
fU:I 'kIIImf
DUrrhea

SitwlioNlLow SeIf..s1mn (INttd II MigI1c,
Impairtd lIrinary EimiNtion (nortumll mmis)

Pla nni ng: Patie nt Goals a nd Expected Outcomes
Thf patitftlwil:
tbelJpMK ffff<U (t.g., height nc'tilt ftlNlI,nblr owrtinP,ciI.mii daM we wftind strUm omoIility witbin IIOIINIIimiu,teIUIft II
normll bowel fI.mion, lIOCtumil t1UM IIol:S SID\IPf).

Ymilirr In undfl\lindirlg of the dN(s
Dnnomtmf 1fI'1dminim-1rion of tile (t.g.,dost,m. .... II noIif1 pro"YicIrr).
Impl ementation
Interventions and (Rational es)
Ensuring tMrlpNtk ftfffiS:
PoritnIJ fIltinggrowflthormotlf: Monito! iOO weight II 00
visil.Repor\ Iict of groowth tothe (irt of groowth ,tiff
a jlfliod 01 grllWth m11 matt tht dffllopmtnt 01 antibodifs
again! GH.)
PatitntJ rQkinggrowflthormOllf antQgmjsn: Monitor ,"tis of strum GH.
Monitor boweIlOUrm 1M for 1 dtcrt11t in dianht,.(GH art
giwon for acromfgi t" Itwort di1nhN un respon to other drug thmpy,
and the trtatmfnt 01 portal hyptrtension.Monitoring levtlsof strum GH
and bowel iKlivitywili n , IU11t tilt'1pwtK (h,ngts.)
PotitntJ tQlirll}lII1tidilJrrti( homllNltS: for imipi.:M,
monitor urineoulpul,uriflt 100 strum osmo"lity,100 urint sptcifio: gr,vity
for In/m 10 nonnallimits. 1f gi-ltn fo, enuresis.h,'/f tilt patient,
f,mily,o, U"9Mr Rtp 1 diM)' of sIttp patWIll, noting any btd-wrlting.
(Urineoutpul,osmolilit); and SIItlifK grirty should 'twm to norm,l
W-tMg has)(owtd or slO9ptd.1
Pati ent and family EduIti on
kid! patitm. f, ...,., Of U"9Mrlo mnSlllt'oo It(ord height ind
wright wctkly.1Id bring tilt: fKb dinial visit.
Imtnxtmr pilifnt on tht nmI to l!I:um periodiully for .. b won.
Imtnxt thf pilifnt to monitor output, pmidr mnsu,ing rquipmrnt
1ftded,Ind to kffpa It(ord 01 diily"ftigbt lnd output aoo bring
rt<Droto Nch prwider
Tta(h tht ('ffgimto urp' dial) of night-timt Iip
habits Ind any btdW!'tling. Limit ollilluicis within 4110urs ofbtdtimt.
Ad'iM tIlr plritnt of tilt: drug'lcost br<;tinni"9
ability to moiinuin drug tIlmpyfo, tilt dU'iltion ol tllt trtatment
prtS(n"btd. NstSS fi lllnc:iaI {Onulm Ind providt social ItIYKf
""'" . """'"
LibraryPirate
666 Unlt l TheEr.doar .... SyS!,-""
NURSING PROCESS FOCUS PATIENTS RECEIVING PHARMACOTHERAPY WITH HYPOTHALAMIC
AND PITUITARY HORMONES (Conrlnued)
Implementation
Interventions and (Rationales)
Minimizing ild'ftBf riffCts:
Monitor for il ny [omplaims of musdt,joint,or bont !)ain,!)arlKularly in thf
or hip, or aO)'(hanqtJ in gait(Awwlar is il n a.dl'llf drug
tffKl of growth pain injoinuor(hangts in
gait should be rt porte<l promptly for follow-up evaluation.)
Monitorgl!Kolf tevm,!)artKUlarly in diabetK Replrt [onsistl'flt
tlmtions to tht hfilhh wr providlor. (GH and GH antlgonisu may caUSt
in gl!Kolf IewI. Diahftiu may altffiltiolll in their normal
rootines ifhyptrgl)'[l'f!Iia O[ruB.)
CominUl'to roonitor vital iigns,fSpfflally pullf and blood for
with wdiac: dilfast. KGI may hfordtred periodKally for patifnt>
with a histol)' of dyvhythm ia Monitor daily Wfight, output, luog sounds,
ilnd for peripheral fdtma. (Fluid rrtt mion Itlndilry to ADH may
Iud to intrililsrular voIumr and hyprrtrnsion.)
Monitor for Ygns of periphfral iso:hrmia or il ogina ind immrdiately.
(VillOOlMtriction causrd by \\Isoprffi in may caUlf mdia( or periphfral
iso:hem ia, angina, or infarnion.)
For pIItitnu takiog intranasal monitor nilsal tmlil9fS.RrPOrt
'0)' aroriarion or bletding.(longterm imranalill ADH thmpy may atilt
naIiIl irritation and ukrration.)
CominUl'to roonitor nutritional ind fluid intau.(ChronK,lfVffl' diarrhfil
tft'atmrnt with a growthhonroOf antagonist may l'fSult in
nutritional derlciu and dehydr.ltion until the diarrllea is (onffiM. Dietal)'
[oOlUkation may be
Patient undtrstanding of drug thmp-,:
lIIf opponunitifS duriog idminimation of mrdic.nions ilnd dJing
ill SfS5l111'ntslo disulIS thf riltionait for drug ther.lp)', therap!'UIK
0UK0rTII'S, most romroon adver!f rifKIs. pIIramelrB for when to ull thf
hNhhyll' any IIf(fSsal)' moritoringor p!I'GIutiom.(lIIiog iiIIII'
dJing nursiog W t helps lOoplimiil!' ilnd ft'moKr tra.c:hing illNSJ
Patimt sflfadministration of drug thtrapy:
When ildministering the mrdiution, irrmuct the family, or y rtgivfr
in lhf proper stifildministration of the drug. f.g.,during fY{'fIing muL
(Proper a.dminil1mion will inmilll' lhf riffnivrnffi of tIlr drug.)
Patient and Family Education
IMtnKt thf patifnl, family, oryrt9M-r to ft'pOIt any (hangtS in walkiog.
di\[omfon or !)ain in knefor hip joints. roOf !)ain,or(onlistt m mUl(it
!)ain oYer joint artill to tht hfilhh Wl' ptovidlor.
IMtnKt the p.atifnt on thr IIfI'd to ft'lUm periodKally for lab work.
Tra.c:h thf diabetK to monitorypillal)' IMIs
during therap)'. Replrt {onsistrnl Mvillion s in blood
gkKosr to the health (art provider.
IMtnKt p.atifnllo immrdiateiy IeplM pounding
!)alpitations,or synmpe.
T_h thf family,or how to monitor pullfand blood
appropriatr.Ensurt thr proper UII' ilnd fimctioniog of any home
rquipmrnt obtairwd.
IMtnKt p.atifnllo monitoroutpul,providlo mrallJriog rquipmtfll IS
lIffiItd,and to borp a rffilrd of daily wright and output and bring tht ft'(ord
tora.c:h provider visit
IMtnKt lhf puifnl to IeplM any !)ain,!)ain Of
rumbnffi in tOl'S or fingers,or {Iampiog whfn walkiog to the hfahh
provider.
Tra.c:h thf patitnt to Ieplrt niwl (ongtstion, irritation, in(INIf in nasill
di\[liarge,or nasal blrtding to thr health we provider.
Enc:ouragt inc:rmed fluid intabo,up to 2l per day, taun in ImjUl'nt small

Enc:ouragt high-ulo!ie. Mril'fIt-deo!f meals rillhfr than largt,
infrequent mNts.
p,l1ifnt should be ilbit 10 statr thf for
dolt ilnd I(hfduliog.and whill ildvrn.r effls to obst rve for and whl'fI to
Ieplrt thfm.
Too tht p.lli.>rU t:I laizo a.:rording blbM:
R onl1ilUte the j).Irrmml drug per !)a,ugt dirrctions and do
oot shaR thf vial but rotalr gtmly toavoid down drug.
(lift'(! high illo thf nasaiuvity rather than hack to thf
nasopharynx.Do IKt !hau thf nawl !prIY using WI ro!alfgtnlly.
any ullJlfd ft'(onllituted solutions in Nasill !prays
may be k!'pl at room but avoid tl[fSsive 8O'f.
Disurd a ny dil[oIored sokrtion Of ij !)a rtirulalt matter is prtlfl"rt
Mministff GH drugs in thf f'YtI)ing to mimK the body's natun I rhythms.
Mminisrer ilSUbanarrolJi irjKtions in the abdomen, buttoc:k. or thig/l ilft'.II.
Evaluation of Outcome Critfria
[valua1l' the efflM-III'SS of drug therap)' by [onfirmiog that j).IIitnl goals and rxpKltd outlnH'S mt!
5tf & l ,rorQIiIr!tutp III
LibraryPirate
propylthiouracil) to manage thyroid storm. Potassium io-
dide (Thyro-Block, ThyroSafe) is administered to protect
the thyroid from radiation damage following a nuclear
bioterrorist act, as discussed in chapter 300.
ADRENAL GLAND DISORDERS
Though small, the adrenal glands secrete hormones that af-
fect every body tissue. Adrenal disorders include those re-
sulting from either excess hormone secretion or deficient
hormone secretion. The specific pharmacotherapy depends
on which portion of the adrenal gland is responsible for the
abnormal secretion.
43.8 Normal Function
of the Adrenal Gland
Weighing only two-tenths of an ounce, each adrenal gland is
divided into mu major portions: an inner medulla, and an
outer cortex. The adrenal medulla secretes 75% to 80% epi-
nephrine, with the renlainder of its secretion being norepi-
nephrine. Adrenal release of t'pinephrine is triggered by
activation of the sympathetic division of the autonomic ner-
vous system. These homlOnes are described in chapter 1]00.
.... Prototype Drug I Propylthiouracil (PTU)
Dl>p1fl41 Drug; /0, 0"",<1<>" 667
The adrenal cortex secretes three classes of steroid hor-
mones: the glucororticoids, mineralocorticoids, and go-
nadocorticoids. Collectively, the glucocorticoids and
mineralocorticoids are called corticosteroid5 or adre,lO-
cortiC<lJ hormones. The terms corticosteroid and gluco-
corticoid ue often used in clinical
However, it should be Wlderstood that the term cortico-
steroid implies that a drug has both glucocorticoid and min-
eralocorticoid activity.
GONADOCORTICOIDS
The gonadocorticoids secreted by the adrenal cortex are
mostly androgens (male sex hormones), though small
amoWlts of estrogens are also produced. The amounts of
these adrenal sex hormones are far less than the levels se-
creted by the testes or ovaries. It is believed that the adrenal
gonadocorticoids contribute to the onset of puberty. The
adrenal glands also are the primary source of endogenous
estrogen in postmenopausal women. Twnors of the adrenal
cortex can cause hypersecretion of gomdocorticoids, result-
ing in hirsutism and masculinization, signs thai are more
noticeable in females than males. The physiologic effects of
androgens are detailed in chapter 4600.
Therapeutic Class: Drug for hyperthyroidism Pharmacologic Class: Antithyroid agent
ACTIONS AND USES
Prop)'lthioorlcil 10 patitnu with hypenhyroidiml. k am by in-
Itrfering with the and1, in the thyroid gland.lt j llo prt'ltnll the
(oovenion ofT, lO T I inlhe l'rge\ MSU!'S.1ts Inion lI"Iiy IItdelaytd from SM'r,1
10 U long as 6-12 indude, 1I'1urn to Mrmil thyroid func-
tion: Wfight gain, II'dKtioo in inxiety,!t1S illlOOlnii, ind !JaMr 11I1e. Br-
(,lUll' it hu " short half-life, PTU usually idmillisterrd timrs " rIajo.
Prop)'lthiourlcil the pll'ferrrd intithyroid drug for liming thyroid starm.
ADMINISTRATION ALERTS
Adminillerwith m!'"luo rrduc:r Gl
PlI'9nillqutrgoryO
PHARMACOKINETICS
Onset: 30-40 min
Iflk: 1- 1.5 h
Halflife: I- 2h
Duration: 1-4 h
ADVERSE EFFECTS
DYl'rtreatllll'llt with propykhiool"iKil prodlns s)'lllptams af hypothyroidiml.
Ruh ,nd tramitrn lwropenii Ul'the most frequent j(jYffit I'ffKlS. A small
peKrnt'9t iljrinulocytosis, which its mosl serious 1rJ..
rilKI. Periodic Iabol1ltary blood (ounts and ISH value '''' rte(rsS.J ry to rs-
ublish
Contraindi (iltions: Propyithiourj(ilshouid not lit giYen during pll'9nancy or
Ij(tltion or to p.ititnts with koown or wspeard hyplthyroidism.
INTERAalONS
Dru;rDru;!: Prop)1IIiooool MHlf'i1hf iCIionI of whidi
ill OONIfd iHj@flts potaIsiOOl
1CJIjdt, lOdium 1OIidf) and U,roKIlIcrnIJnts (0)11 naqooill' tIIf 01 tIJS

h)"pflWllliti"Oily INffion to IIIfIhimazolf, Ihf otlM>r rn<4(f mtI!yroid mfdiatm
liI b Tell: PropyIthioor.Kil mq ioofN protII"ombin titrE;nj irmR 1l'l000lMis
of iSpiIlil! aminotronlfHalf IAlTI, ilminor,amfflilSl' (ALD, and ilblilf

HerlJiIVFood: Unkncwn
Treat ment of Overdou: Dvt-rdosr will WM signs of T,e"'-
IIIfIIt indudfs a thyroid "'ropilll' far brad)Urdia, ,, OOS)'lll ptomuic: tll'iI-
IIIfIIt as III'(rssary.
LibraryPirate
668 Unlt l .... Sy<!"",
NURSING PROCESS FOCUS PATIENTS RECEIVING PHARMACOTHERAPY FOR THYROID DISORDERS,
THYROID REPLACEMENT AND ANTITHYROID DRUGS
Assessment
Bilst line Issessmtnt prior to administration:
Understand tht drug Iwl bffiI pre(ribtd in order to as:1E'15 fCH
thtrapeutic: t!ff,w (t .g, tft'atmtm of hypoill)'roidism CH hyptnh)'foidilm).
Obtain a (omple-te health hiltory indudi ng mdio'faKular, 901 ItlDin1Otinal,
htpatic,or ft'nal pft'9nancy;or brtaMffiling. Obtain a drug history
inc:luding pmcription and Ole hmlal pft'Polrations,
akohol USI', or smoking. aim to plISiblt drug imtraaioos.
Enluatt appropriatt laboratol)' findings (t.g., T" T fSH 1tveIs, (8(,
platt ltts, fltctrolyte,. gllK=, a nd lipid
Obtain baltlilll' filal signs.Obuin an KG as nffdtd.
Asstssrntnt thro ughout administration:
Aslffi for thfraJlflltic: dtptOdeot on the INIon is
bting gil'fO (f.g, T"and TSH rttum to normal modattd
symp torm of hypo-- or hyperthyroidism Nse).
CominUl' ptriadic monitoring ofT" l .. ilnd ISH ltvek;CBC; plateltts;and
gU<ose.
CominUl' monitoring vital signs, weight Monitor KG ill
"""" Aslffi for adYmr t!ff,m: nilUSN, VOln iting, diarrllt ii, tpigastrK d
skin rillh, it(hing.lltadoKlIt, umymdia, palpitatiolll,dysrhythmial,
S"M'ating. nervotJllIl'IS, tll'moJ1, in !Omnia, lItat intoleranc:t,
and CH hyptntnsion, tac:hlUrdia, 6 pt(iillly mooattd with
angina, \hoold bot II'pOntd immtdiattly.
Potential Nursing Diagnoses
Activity IntoteranU'
FatigUl'
Constipation
Knowledgf (drug tht r.lP,)
Riok for Infedion (1I'1attd to aomllfdrug effeds)
Planning' Pati .. nt Goals and Exp .. cted Outcom ...
Tilt patifot wiU:
uptril'nc:ttherapeutic: tfftcts (f.g.,demaSf in Iymptoms, th)'lOid lab studies rerum to within normallimiB).
Bt ill't from, or fxperien(f minimal, adYellt tfftcts.
Vflbalize an undemanding of tilt drug's USf, adYeIIe tiffrts, iI nd rtquill'd preuutions.
Dtmon mate proptr IeIf-adminiruation of the medication dOlf, timing, wlltn to notify pJO"tider).
Implementilltion
Interventions and (Rationill les)
Ensuring thtrilpeutic tffeds:
Pilltient iIInd Family Educill tion
----II--
Monitor signs, a ppttitf, SfOsitivity to hut or (old, 5Ieep
patttms,ilnd ADLs for II'IUrn to oonnallimiB.(l1lt patient lhould II'tum to
01011' normal ADls and ftelings ofWl'lIlIl'Is. Weight and pulst ratf all'
to oHSfIS II'sponse to drug thmpy.)
Monitor diet for iodinf<onta ining foods (e.g., iodized salt. roy sall<f, tofu,
milk, llrawberrie,. tggs). (inuf,l\ing CH dt(ft'aling normill iodint
intake may ft'IUlt in ad'lme drug fflecll.)
Monitor thyroid IulKtion \I1I!s. (RfSUhl httpdttenninethtt!fedillfOtlSof
tilt drug thtrapy and tilt IIff<I for do\ige mangel.)
Minimizing ildft rse rfftrts:
Monitor fCH II'IUm of original symptorm and II'port (onsistfnt oaurft'lKf.
IkKtuatiom in Iymptoms ma, oc(ur.Significant inat'aSfS in origin.!1
symptorm may signallUboptimalll'sulll. Dramatic oppolite t!fed i nd
hypo. or hypttthyroid !ymplOlnI may signal drug toxic:ity.)
AdYilfthe patient that tht drug will help to ltabililf thyroid hormone
Itvtls but lull t!ff(l\ maytakt a Wffkor longer toocrur.
InllnKt tilt patient to maintain (OOsistfOt doling during this initial period
to illiow ft'ac:h thtrapeutic: Itvels.
InslI\Kt the patient 10 Wl'igh ItH t'NOto thref time! per Wl'ek and to
record puhe rate.Bring tht lI'(ord of Wl'ight and puhe toeath provider
visit.
Pl\lYidediet.iry iostllKtion on foods toavoid.Provide dietitian {Onsuitation
.n nffiltd.
InllnKulit patient on tht IIff<I to II'IUm ptriadic:allyfor labwork.
TN(h the patient that lInilll dail)' ilOOUilionl may ruring
ptriod\ of Itrffi or illlIl'Is.Any signifKilnt or inc:reilling d\a09fl in pulse
rate. IIl'I'IOUlnes CH fitigut, intoltriln(e to heit CH {Old,.! nd
diant.ea or (onllipation should lit II'pOntd to tht lItilkh (aft' prOYidet
LibraryPirate
o..pltl43 I:lnJ9' /0, pnult.,y, Thy,oId, ao<l Ad", ... 1 Disorder, 6611
NURSING PROCESS FOCUS PATIENTS RECEIVING PHARMACOTHERAPY FOR THYROID DISORDERS:
THYROID REPLACEMENT AND ANTITHYROID DRUGS (Continued)
Implementation
Interventi ons and (Rati onales)
___ + patient and Family Educliti on
Monitor for signs of inlKlion, (Be aocl platelet (aunK (Antithyroid drugs
ma, talMaogranulocytomJ
Monitor symptoms in olde, adults mOIl' frequently.(Older arulu al!' moft'
Itnsitioft' to thyroid I!'pla(l'II1ent tlltrapy. Minor (hangl's i n daily thyroid
ieYels II\a)' cause <I significant mangl' in symptoms.)
-
Monitor serum gl(J(<m in patients with
should monitor capillary !ems mOIl' (Thyroid aocl antithyroid
drugs may tallll'{hangtl in gu.:osr Ie-Irls.)
[n!llft' nt !<IfN)" rspecially in older adulu. Ol!sere lor aocl
monitor ambulation until tilt rflem olthr drug aft' known. (Dizzilll'SI may
5f(oocIaf)' to (hanges in pIIl\t or blood Efircu of thyroid
hormonr on bone l\'IIlodeling II\a)' piau the at risk for
[nsul!' aocl uregiver if radiomNr iodinr is UIM (RadioactiYt
iodilll' provides Iow--Ou radi.ltion but prolonged contatt by IINlth cal!'
providers or visitors !hould iWided.)
Patint understanding of drug tht rapJ:
UII' opplnunities during administration of medicationsaocl during
.H !elsmerm to dim/U the rationale for drug theri!py, dtsirrd therapNIic
most common aclveBe rfferu, pariflK'ters for when to ulltllt
hNlth cal!' prwider,aocl any nr<ffiif)' monitoring or prruutions.(Using
oflK'during nursing urr helps to optimize and rrinfone kty teaching

Patint selfadm inistril tio n of drug tht'ilpy:
Wlltn administer'ing thr medication,ioslOKt the f,mily,or
cartgioft'r in the proper self-administration 01 the drug. e.g., tau the drug in
tilt morning at the same time Nh day.!Proper administration will ifl{lNse
tilt effKlioft'nl'lS of the drug.)
Instruct the to I!'pon I_r, SOIl' (hills, malaise, or
weakness to the lItahh (1ft' provmr.
Tea(h tilt patient aocl family or Uft'9Nrr that the lawnt doll' will
staned and graruilly in(ft'.tII'<I to fiocl the optimum ie\'el. Arr$ signirK.lot
in symptoms should Il'portl'd to tilt IINlth care provider
prompd,.
Te"h tilt diabetic patirnt to monitor "pillaf)' glueoil' iems morr
Irrqurntlyduring tlltrap,. Repon any consistent ele-lations in blood
glulOll'to tilt lItalth caft' providrt
Instruct the !)atienl tocall for mistalKe prior to 0lII of bed or
atll"nlpting to walk alone if
Assess tilt salety of the environment and distun modifK.llions that
mi)' be IIffiIed with tilt lamily "ft'9il'l'f.
Trich tilt patienno limit wotan with fjmily to I hour per day per person
until the tl!'atmenl period is Young mildrrn aocl PlI'9nant WOflK'O
should avoid (Onia(\.
Advise the patienl to ifl{lNsr fluid intau and 10 void to ,wid
irradiation 10 gonads from radiomil'i!)' in the uriIII'.
Instruct the !)alieni oot 10 and to the mouth when
<oughi"'l.AnyconllmiOlt.dti .. ..,. !hauld b< dispoord of pert .... protocol
of tilt hNkh carr provider.
The !)alieni should able 10 state the _ lor the drug. appropria!!'
doll' <lnd sdJr<krling. aocl what .lII'efie<1I tool!sere for .JocI when 10
rrponthem.
Te.J(h lilt Pitient 10 tau the drug oKcording to appropriate !IIIidelifltl, is
follows:
Tau the drug at lile lime time N(h morning to approximate normal
body ieYels.
Take tilt drug with food or i meal.
Avoid foods high in iodillt unltls approYed by tilt hrahh carf provmt
To '",IIft' a thrfopnrtic ll'lpon .. , toke It.. >am. braoo of drug 000
request lime manufoKturrr e.J{h UfIK' the drug is filled.Do nolswiuh
bliocl namts without lileapproval ofillt heihh (al!' proYider.
Evaluation of Outcome Criteria
[valuate Ihe elfettiventSs ofdrug tlltrapy by mnfinning lhat "peded ouUomes haYl' been met!1fe Planning").
LibraryPirate
670 Unit. Thl'EIIdoaI .... Sy.lem
MINERALOCORTICOIDS
Aldosterone a.:COWlts for more than 95% of the mineralooor-
ticoids secreted by the adrenals. The primary function of al-
dosterone is to regulate plasma volume by promoting sodiwn
reabsorption and potassiwn e."tcretion by the renal tubules.
When plasma volume falls, the kidney secretes renin, which
results in the production of angiotensin II. Angiotell'lin II
then causes aldosterone secretion, which promotes sodiwn
and water retention. Attempts to modify this pathway led to
the deVl'lopment of the angiotell'lin-oonVl'rting enzyme
(ACE) inhibitor class of medicatioll'l, which are often pre-
ferred drugs for treating hyperteru;ioll and heart failure
(chapters 23 and 24 00). Certain adrenal tumors cause ex-
cessive secretion of aldosterone, a condition known as hyper-
which is chm"lKterized by hypt'rtension and
hypokalemia.
GLUCOCORTlCOIDS
More than 30 glucocorticoids are secreted from the adrenal
cortex, including cortisol. corticosterone, and cortisone.
Cortisol, also called hydrocortisone, is secreted in the highest
amount,and is the most important pharmacologically. Glu-
cocorticoids affect the metabolism of nearly every cell and
prepare the body for long-term stress. The effects of gluco-
corticoids are diverse, and include the following:
_ Increasing the level of blood glucose (hyperglycemic
effect) by inhibiting insulin secretion and promoting
gluconeogenesis, the synthesis of carbohydrates from
lipid and protein sourv;es
_ Increasing the breakdown of proteins and lipids and
promoting their utilization as energy sources
_ Suppressing the inflammatory and immWle responses
(chapters 32 and 33 00)
- Increasing the sensitivity of vascular smooth muscle to
norepinephrine and angiotell'lin II
_ Increasing the breakdown of bony matrix, resulting in
bone demineralization
_ PmmOline hmnc.hnclilMinn hy making hmnc.hial
smooth muscle more responsive to sympathetic nervous
system activation
_ Influencing the CNS by affecting mood and maintaining
normal bruin excitability
43.9 Regulation of Glucocorticoid
Secretion
Control of glucocorticoid levels in the blood begins with
corticotropin-releasing factor (CRF), secreted by the hypo-
thalamus. CRF travels to the pituitary where it causes the re-
lease of hormone' (ACTH). ACfH then truvels
through the blood to reach the adrenal oortex,causingit to re-
lease gluoocortiooids. When the level of cortisol in the blood
rises, it provides negative feedback to the hypothalamus and
the pituitary to shut off further release of gluoocorticoids. This
negatiVl' feedback mechanism isshown in Figure 43.4.
Circadian rhythms 51 .......

Hypolha1am.J5

T e
Anl ... ior
Adrenal corlex
G', ""' 1
Biological ellocto
(
Negaliva
Ioodback
e
51imulalion
Nag&live !!!!!!)It-
tee<lba.d<.
,.. Flgure4J.4 Feedback control of the adrenal cortex
Lack of adequate glucocorticoid production, known as
.drtnocortic.l insufficit ncy. may be caused by either hyposecre-
tion of the adrenal cortex or inadequate secretion of
ACfH from the pituitary. Cosyntropin (Cortrosyn)
dosely resembles ACfH and is used to diagnose the cause
of the adrenocortical insufficiency. After administration of
a small dose of cosyntropin, plasma levels of cortisol are
measured to determine if the adrenal gland responded to
the stimulation. A rise in plasma cortisol level indicates
that the adrenal cortex is responsive to the ACfH chal-
lenge; the cause of the patient's adrenocortical insuffi-
ciency is likely at the level of the pituitary. Lack of cortisol
increase suggests that the adrenal gland is unreceptive to
the ACfH stimulation; the cause of the patient's adreno"
cortical insufficiency is likely at the level of the adrenal
gland.
GlUCOCORTICOIDS
The glucocorticoids are used as replacement therapy for pa-
tients with adrenocortical insufficiency and to dampen in-
flammatory and immune resporu;es. The glucocorticoids,
listed in Table 43.4, are one of the most widely prescribed
drug classes.
LibraryPirate
o..plfl4l Drug; /0, Ad""",1 DIsoro.-" 671
TABLE 43.4 1 Selected Glucocorticoids
0""
Route and Adult DoSE' (max dose where Indicated) AdverSE' Effects
SHORT ACTING
PO; 20-300 mglda, Sodumltluid
Q hydllKortilone l/yItoconone, o!htn) PO; 10-320 mglday in tlvte 10ftiii' divided doII'l
mood

IVI1M; 1,- 800 IJl9lday in to fool diYidtd dos6
weighrgoill,
(mal:2 glda,)
knNirtdwwnd
INTERMEDIATE ACTING
!N1kinq of
PO; 1-60 mg 10 fOll' lintl/day
aU!lI!hl
YRn gl.:!IKOOU OID'ppormjl
prrdrilOloM PO;,-60 mg 10 fOll' lintl/day
musd( w)S1i!IIJlMablrn.
prrdrilOlle [Ite m for!ht Drug boxOO) PO;,-60 mg 10 fOll' lintl/da,
CHF mrrn, 'IIOOffling of
"""""
[AriltOIpin. Ktnalog) PO; 448 mg 10 IWO
LONG ACTING
ooolmethillOlle 0I1Im) PO; 0.6- 7.1 mg/day
dwlMihalOlle IM;O.HlJl9lday
PO; 0.2,-9 mg bid-qid
ammon iodvmr Iffiousadoimt
43. 10 Pharmacotherapy
with Glucocorticoids
Symptoms of adrE'norortical insufficiE'ncy include hypo-
glycemia, fatigue, hypotE'nsion, incrE'ased skin pigmE'nta-
tion, and GI disturbances such anorexia, vomiting, and
diarrhea. Low plasma cortisol, accompanied by high plastrul
ACTH levels, is diagnostic, because this indicates that the
adrenal gland is not responding to ACTH stimulation.
Primary adrenocortical insufficiency, known as Addison's dis-
is quite rare and includes a deficiency of both glucocor-
ticoids and mineralocorticoids. Autoimmune destruction
of both adrenal glands is the most common cause of Addi-
son's disease. Secondaryadrenocortical insufficiency is more
common than primary and can occur when corticosteroids
are suddenly withdrawn during pharmacotherapy.
When glucocorticoids taken as medications for pro-
longed periods, they provide negative feedback to the pitu-
itary to stop secreting ACTH. Without stimulation by
ACTH, the adrenal cortex shrinks and stops secreting
endogenous glucocorticoids, a condition known as adrenal
atrophy. If the glucocorticoid medication is abruptlydiscon-
tinued, the shrunken adrenal glands will not be able to se-
crete sufficient glucocorticoids, and symptoms of acute
adrenocortical insufficiency will appear. Symptoms include
nausea, vomiting, lethargy, confusion, and coma. Immedi-
ate administration of IV therapy with hydrocortisone is es-
sential, as shock may quicldy result if symptorru remain
untreated. Acute adrenocortical insufficiency can be pre-
vented by discontinuing glucocorticoids gradually. Other
possible causes of acute adrenocortical insufficiency include
infection, trawna, and cancer. The development of adrenal
atrophy following corticosteroid administration is shown in
Pharmacotherapy Illustrated 43.1.
For chronic adrenocortical insufficiency, replacement
therapy with glucocorticoids is indicated. The goal of re-
placement therapy is to achieve the same physiologic level of
hormones in the blood that would be present if the adrenal
glands were functioning properly. Patients requiring re-
placement therapy usually must lake glucocorticoids their
entire lifetime, and concurrent therapy with a mineralocor-
ticoid such as fludrocortisone (Florinef) is necessary.
In addition to treating adrenal insufficiency, glucocorti-
coids are prescribed for a large nwnber of "nonendocrine
H
disorders. Their ability to quickly and effectively suppress
the inflammatory and immWle responses gives them
tremendous therapeutic utility to treal a diverse set of con-
ditions. Indeed, no other drug class is used for so many dif-
ferent indications. Following are the indications for
pharmacotherapy with glucocorticoids:
. Adrenal insufficiency
Allergies, including allergic rhinitis (chapter 38 00)
Asthma (chapter 39 00)
Inflammatory bowel disease, including ulcerative colitis
and Crohn's disease (chapter 41 00)
Edema associated with hepatic, neurologic, and renal
disorders
Cancer, including Hodgkin's disease, leukemias, and
lymphomas (chapter 37 00)
Transplant reje,tion prophylaxis (clJapter 32 00)
Rheumatic disorders, including rheumatoid arthritis,
ankylosing spondylitis, and bursitis (chapter 47 00)
Shock (chapter 29 00)
Skin disorders, including contact dermatitis and rashes
(chapter 48 00)
LibraryPirate
672 Unlt l Thi> Er.do<rlJW'YfSlem
PHARMACOTHERAPY ILLUSTRATED
43.1 Corticosteroids (Glucocorticoidsl and Adrenal Atrophy
1. a d"'nal glat>da
2. Ad......al gland atrophy
following cortioasloroid
... ,,'"
Gmd",,1 Discootinuation
,
3. Gmdual withdmwal ot
cortico<;teroids allows adrenal
glands \0 ""SUllie normal
tunction
More than 20 glucocorticoids are available as medications,
and choice of a particular agent depends printarily on the
pharmacokinetic properties of the drug. The duration of ac-
tion, which is often used to classify these agents, ranges from
short to long acting. Some, such as hydrocortisone, have min-
eralocorticoid activity that causes sodiwn and fluid retention;
others, such as prednisone, have no such effect. Some gluco-
corticoids are available by only one route: for example, topical
for dermal conditions or intranasal for allergic rhinitis.
Glucocorticoids interact with many drugs. Their hyper-
glycemic effects may decrease the effectiveness of antidia-
betic agents. Combining glucocorticoids with other
ulcerogenic drugs such as aspirin and other NSAIDs
Illark<:<l.ly im;r"""",,, lit" ri.-k ur uk"r ili,,,a,,,. AJmiu-
istr:ltion with non- potassium-sparing diuretics may lead to
hypocalcemia and hypokalemia.
High doses of glucocorticoids taken for prolonged pe-
riods offers a significant risk for serious adverse effects.
These adverse effects, shown in Table 43.5, can impact
nearly any body system. The following strategies are used
Sudden Discontinuation
4. Suddan wilhdmw ot
corticosteroids I .... ds 10 awe
IKire nai insufficiency
' hypot_ ion
lethargy
",,,,,Itailura
asthenia
""u"""""""'mog
to limit the incidence of serious adverse effects from
gluoocorticoids:
Keep doses to the lowest possible amount that will
achieve a thel1lpeutic effect.
Administer glucocorticoids every other day (alternate-
day dosing) to limit adrenal atrophy.
For acute conditions, give patients large amounts for a
few days and then gradually decrease the drug dose until
it is discontinued.
Give the drugs locally by inhalation, intra-articular injec-
tiorl'l, or topical applications to the skin, eyes, or ears, when
feasible, to diminish the possibility of systemic effecl'l .
43. 11 Pharmacotherapy
of Cushing's Syndrome
syndromr occurs when high levels of glucooorticoids
are present in the body over a prolonged period. Although
hypersecretion of these hormones can be due to pituitary
LibraryPirate
o..pltl43 I:lnJ9' /0, pnulu,y, Thy,oId, ao<l Ad", ... 1 Disorder, 673
TABlE415 I Adv"rs" Eff"cts of long-T"rm Glucocorticoid Th"rapy
Type of Adverse Event Description
Supprrs!ion 01 tilt Jnd io/lammatory mporlltS ilK/UltS IlJI(tplibility to ioftaions. lhrir
actions may!M II:: till' signs 01 an oillilg infection,
i'rpIi(!HtrS DtYelopmmt of ukm Q(ul',rsptdaliywhtn oombilll'd with nonsttroidil aolHnflammatory drugs (NSAIDs).
.. """"
Up to SO% of palims 00 IlHI9'tmn tllffi!11 willsuflrr a foo!ll' rut to ostropoollis .
Bthavioral d1angtS Pt)'thologit til' nin, W JlntI'/OIIIIlrn or i!1l'Ol'lt halliKNtiom and OONttd lliddal
ttndmdrs.
- -
EytdlanlJl's Cataoosand opm-anglt giaocoma modill!'d with ionq-tmn tllffi!11.
Metabolit Thn h)'IIffiJlytffilit tfka railtS serum ghKOII' and can caU\e Mobilization 01 lipids nwy uU\e
and abnormal lat ElKIrOI)'It mangtS indude h)'pocakffilii, hypobltnia. and hyptmatrrmia. ALid W!ight gail,
il)'ptllmlion,and oommoo.
Myopathy M usdt wasting UUltS Wl'akOl'lI and fatigut; mOOt oU .... or musdrs.
.... Prototype Drug I Hydrocortisone ((ortel, Hydrocortone, others)
Therapeutic Cl ass: Adrenal hormone Pharmacologic Class: Corticosteroid
ACTIONS AND USES
StllKturaliy idtmi loll with tile naturJ I oormoOl' hjdrocortisoot is a S)Tl-
thetic corticOSlrll)id that is the drug of cMKr for liming adrtnocortia I insuf-
lidenC)'. When !Md far rtplaten1ft1l therapy, it is givrn <II physioklgit doltS.
properdoliog isoKhirYfd,its rlfrmshould
dogtnous {ortitosttroitk. H)IIrocortisoot is abo iYJilabit for tile of
inflammation, allelijit disordtB, and mJny olhtr londitions.lnuNnic:ular in-
jtaions mi y br givt' n to dtcrull' inflammation in all'Itd joints.
Hydrotonilone is available in YJ diftrlt'Otlonoulations. H jdrotoniloOl' bu
(kr=b-HC, Alp/mit no, (('latOn, oillen) and oKetatt (AnUlOI
HC, Cortaid, Conti' Au-Iatd iYaiiabit as oral and oint-
1III'On. HydrotortiwlII' typiona1l' (Contl'FkJid) is an oral SUlptnsion. Hydrotor-
todium phosphate (Hydf\XortoOl' Phosphalt) and
todium I!Ktina1l' So/uumtfj for USt
(ortisOIll' (Weslron) isoniy far topital applitations.
ADMINISTRATION ALERTS
as pr&ribtd and it tilt lillll'm!fY day.
Administtrolliionoulations with food.
PlI'gnilK)'Ui<'9ot)'C
PHARMACOKINETICS
Onset: I- lh PO;20 min 1M

Halflife: 15- 2 h
Duration: 1- U days PO or 1M
ADVERSE EFFECTS
UIfd allow dom for or b)' tile topital or imranasal
routt!, Jd'itllt tflKn of h)'drocortisont art raft. ygrrs of Cushing'l
synd,allll' un dev!'lop with high dOltS or with prolongtd ulI'.lf taktn lor Iongtr
than 2 Wl'tks,hjdf\Xortisoot !hould bedisrononurd
posltSm IOIIlt milll'lalotonic:oid Jctivity,w todum and fluid rttention may be
ooted.A widt ratH}!' ofCNS Hfern hom been rtporttd, ilKUling insomnia,ilU-
iety, huda{lIe, dtpression. Card'lOYaI(ular tliecl'l mJ, in-
dude hyperlension and tathlUrdia. IlIng-ltrm therapy may resuh in peptK

Contraindimions: Hydf\Xonisone is loolrainditaltd in jlitirnu wha alt' hy-
to drug or who have known unless tilt patirnt is br-
ing with imi-iniettives. Patients with diabrtH,
OIteoporolis, Ii'm' d is9I1', or hypothyroidism shoo Id br tJNtt<l with
"ulian.
INTERACTIONS
Dru;rDrug: Barbinl'atn, phMytoi1. and may i1trNII' hPpatit lIIfIaIQiIm,
thus doofi'iing hjd!1l(ortiloM ltvftl. EstrogmI poWItiatf 1M fllKl! of
h)'dromrlisorw.l.M with OOIIIHOidaI ... ftornmalory (NSAIDS) iooUlfl
thf rMolptplit and IlKJNII' hyQ-otortilOOI'
absorptitnDl.fem and RJNII'

a dHr&u il im01llllfrelpOOll' to'/il((ooand IOIllidi.
li b Tesll:H)II!1l(orti\orM> may ilmfifl4'lum 'IikIt'i for
todilJll,lIit add, or cakium.lt may deaNIt' IoffiJO vallII5 01 potalsilm and Tilt
VFood: lII4''' ""rocortisone with WOIIiI, t.i<;Cill1, or budthorn may aM
dftitimty with dl'ooit 1M.
Treat mf m of Hjdrotonilone has no ac:ul!' tOJicil)' and dtaths art
ralt'. No IPHifK therapy is mi labl t i nd p.uirnll IrNttd symptomatitally .
.... fe' m M;rNurJlngI(1! for Q Nurllfll} Proo1! fm Jjlt(1/{ millis
LibraryPirate
NURSING PROCESS FOCUS PATIENTS RECEIVING SYSTEMIC GLUCOCORTICOID THERAPY
Assessment
Bil srlinr assrssmrnt prior to administrati on:
Undffitand the tilt drug his in order to lor
therapeutic riferu (t .g., rt plawnent theraP'J', trutment 01 spt<ifi<
ronditionl SIKh ill alier9ic 1!"IjI01I\lS).
Illtain a romplru huhh history in:ludl"f;l lepi-i1oty, neurok9<.
htpatic. or pr!9nancy; or brNlI-fredl"f;l.llKain iI rirUl h istory
indJ:Iing allei9M. current pre!(ription and OlC drug!, Ilerb.JI
alrohol iltnto inttOOiom.
llKain vitilligni and weight.
l.lhn .. lnl)' finding' ( . g.,CR(
gUeosr,li pid profile, hepatic or renallunction stud its).
Assrssment thro ughout administration:
Aslffi for therapeutic rfft(B and symptoms 01
inflammation such as or IWt'liing
CominUl' periodic monitorill9 olCBe,
profile, and hepatic or renallulKtion lIudits.
Aslffi viti I sig ns ind weight periodiu or if symptoms warram. Obt.i in
tilt Wfight daily ilnd gain 0YrI1 kg in a 24-hour period or
2 kg in 1 Wffl
Aslffi for and promptly!!"pOn B1Kts:naUIN, vomiting.symptoms
01 GI bletding (darlc or "tlrry' ItOOk, htrnatr mesis or (ofiet.ljround _is.
blood in thellool),abdominal euphOOi
or dtplt'l!ion, palpitations, tac:hyurdia, respiratol)'
ratf and dtp!h, significant gain.tdrma,
bkJITl'dvision, infectiolll.
Potentilll Nursing Dillgnoses
DrfKitnt Knowltdgt (drug !ht rapy)
Risk for Ucffi (rt lattd to fluid retfntion propenits 01
gluc:oconicoids)
Risk for I njul)' (II'Iattd to adYefS I' drug filt(u)
Ri sk for Infections (rt lattd to ad YefSI' drug el'lffu)
Risk for Impaired Skin Intf9rity (reiatl'd to drug tifrclI)
Pl anning: Plltient GOll ls and Expected Outcomes
The patient will:
UperHolKt therapeutic tfftcts (t .g., dtmilstd liglll and Iym ptom s 01 inflammation or lePOnse).
from,or experienuo minimal.ildYefSt tfltas.
In undmtar.ding of I .... drug'. u"",adven. dfrru, l r.d pr.tution .
properlfll-adminimation ol!hl' mication (e.g.d=, timing. wlltn to notify plO'/idtrl.
Impl ementllti on
Interventi ons and (Rilti onil les)
Ensuring thrril peutic dfects:
CominUl' i SmSmtnts il SdfSCribtd earlier for thl'rapeuticrifeclI.
(Diminished allergic responsr, and ilKrei std 01
begin alirr takill9 the first and rontinUl' to impl"O\'e.J
Minimizing ildft rsr effects:
CominUl'to monitor yitil blood plesurund puke.
Immediately II'pott tachymdia or BP (Wr 14OMO mm Hg.or per
par.tmelen ilS ordtrrd, to the ht ahh ure ptoYidrr. (CortKolieroick may
in(rt'iJstd blood prffiUrt, ilnd tadtjUrdia dUl' to the
retrmion 01 fuidsJ
ContinUl' to periodic lib work:CBC, tledro/yttl,gluco\!', Ie\lek,
ilnd htpatic i nd renallulKtion tfffi.(Corticostfroids affect theC8(, i nd mil y
(iiUS!' hyperg/yr:emia, hyptm i1rem ia, hyptrlipidtmia, and hypoU It mia.
Diabetics may tequirt' a in tlltir antidiabeti< ml'diution if the blood
gUeOll' remains eltvated.)
Monitorfor abdominal pain. blackor wrystook,bIood in tilt, 11001,
htmatemesis or (dretilroood rmM. riuillfSl, hypotension, if
llsociatedWith tadt)Urdia. (GI biffiill9 is an adYml' drug
Pllti ent li nd Family Educll ti on
Teach the patient to any rt'tum oIoriginal symptoms or inert'iI\!' in
inflammation, illlfrgic ft'Iporllf, or malaisl' to the hNlth Cirf
prwider.
Tl'ilCh the patient how to monitor the pIIM and blood [nsurt' tilt
proper lilt and lunctioning 01 any home equipment
tichyurdia, palpitations. or BP to heilkh ure pro'Iidtr.
In,lnKt tilt patient on the IIffiI to IfIIIm periodicallyfor labwork.
Advist tilt piltitm Iilkill9 ronicosteroids IoIl9 term to ml)' a wallet
idtmifimion (ilrd orwrar mi(ill identification ind"uull9
corticosteroid theraP'J'.
Tl'ilCh thediabeti< patient to tel tilt blood gk.lt= lrequently,
notifyill9tllt lItahh (are prwider if a consistrm Mation is nottd.
InslnKt tilt patient to immtdiately report any siglll or symptomsol GI
blttding.
Tl'ilCh the patient ro take tilt drug with bod or milkto dtcll'ilsr GI
initation.Akohol U\t should be iWidtd or eliminattd.
LibraryPirate
o..pltl (] Drug; /0, Thyroid. and .<.<1", ... 1 O""rde" 675
NURSING PROCESS FOCUS PATIENTS RECEIVING SYSTEMIC GLUCOCORTICOIDTHERAPY (Conllnued)
Implementation
Interventi ons and (Rati onales) Patient and Family Educliti on
Monitor for signs a nd Iymptoms of inreuion. (Corticosleroids rupp Il'II th!o
immune and inflammatory Il'sponm and may mask thesignl 01 inreuion.)
Instruct the patient to ,epan any signs or Iymptoms 01
inftions kg., in(ll'asing temperaturt or ftl'el, lOll' redlltll or
swtlling siteolinjury, whitt p;l\(1\es in mouth, rash).

Monitorfor osteoporosillt.g., bonedenmy testing] in patienll
on Iong-ttrm (Of!i<osttroids. E lKourage adtqwte "kium intakt, al'OidalKt
of wbonated sodas,and wflght-bearing (Corticosteroids alft
bone mttabolilm and mol)' GlIM osteoporosis i nd "'dull'!. Weight-bearing
I'J:trtM bont ind tll(ourages normal bone Il'modeling.Extesi'll'or
long-term (onlUmption 01 taroonattd sodas has bn linked to an ilKll'a5ed
riskoiostNpo!OIis.)
Monitorfor unusUilI (hangtl in mood or afreu.((ortitosttroids may mu
an ilKll'utd or drNstd mood.l'Uphoria,di'p'ffiion,or mental
inltability.)
Wtigh tht patitnt daily and It'pOn wtight9'lin or in(lming peripht ral
edema. Me.!IUft' the inti kt a nd output in the hOlpitalill'd patient. (Da
weighl is an rurate mNSUll'of fluid status <l nd tlkts intoi((ounl intlkt,
inll'nsible IolmJ
Monitoryision ptrioditali)o in patient5 on cortKosteroids.(Cortitosttroids
may mu ilKll'iI5ed imraorubr presull'and <I n ilKlN5ed risk or gbutom<l,
and may taUSt GltlramJ
Do oot stop til!- drug drug nlJst be laptll'd off if LISI'd longer
thiln 1 or 1 Wffks.(Adll'nal insulfitienq and (rM may o((ur with prolound
hypoten lion. ta(hyurdill, and othtr <l dYtr>e efi11 if drug is Itopptd
abrupti)oJ
Tu(h the patient to maintain (akium in til!-
"roonated sodas,and to do wtight-buring tlertMsai lust to four
time ptr wttk.
Tt,(h the pallmt nop,U\i1 woman to conluh with II!-r proYidI'r about til!-
nted for drug thmpy (t.g. bisphosphonate) for osttoporosis.
Ttath the famii)o,orta't"9i'1l'r to promptly It'pOn l'J:cr\si"fl' mood
swin9l0r unUIWI in mood.
Instruct the patientlowtigh leifdaily, ideally at III!- day.TII!-
patitnt should It'pOn a wtight gain of moll' lhan 1 kg (approximately lib)
in i 14--hour ptriod or more than 1 kg 4-5Ib) ptrWffk,or
in(ll'asing periphml tdtma.
Ttath the palient to maintain tyo!' txamslWitt yrarly or moll' frtqUtntl)o al
inslllK1ed by the provider.lmmediately Il'port any eyt pain, rainbow halos
around light\, diminished vision. 0' blurring and inability to fotus.
the patienl to not SlOp (orticosttroids abrupti)o and to notify tilt
(ill' pftl\lider if unable to tlkt tht for I1IOIl' than 1 dol)'
due to mnffi.
Implementation
Interventi ons and (Rati onales)
Patirnt understanding of drug tht rapJ:
1M opponuoities wring admioisuillioo of mrdic.Jtionland wring
asleSmtnlllo disnru tht ralionalt for drug therapy, dtsill'd therapNIit
0l0I1 (om obsft"vtd ffiU. pa for when
to tall the health (ill' and any ntaSSilI)' monitoring or
pll'uutiolll. (Using lime ruring riming tart helps to optimill' and rtinfon:r
ktyttathing areas.)
Patirnt stlfadm inistntion of drug thtrapy:
When admioinering thr mrditillion, illltOKt thr paliem, f,mily or mtgiYer
in til!- proptr oIdrug, f.g., with food or milk.(Proper
adminiltralion will inuulI' thr t ffecti"fl'nffi of thr drug.)
Patient and Family Educliti on
Tht fjmii)o,or rall'gim should br jblt to state the 1l'<l lOn for the
drug;appropMt doll' and sc:heduling;whilt ,d"/rBl' t lfts to obSl'lVl' for
aod wht n to Il'poI"t thtm;and length of
therapy.
Til!- and or urtgivtr all' <l ble to disc:uss appropnalr doling
and administration nttds,ilKluding:
Take drug in tht morning at the Silmr time toKh day.
Take drug with food, milk,or a medlto prtVeIlt GI upii'!.
HOlMhold measuring deWe suth iltralpoorlldilfer signifiunti)o in
sill' and amounl and should not bt UItd for pediatric: or liquid dosrs.
Evaluation of Outcome Criteria
halUiltt the rfieui\'elltll of drug th!orapy by ronfinning that patient gNlsand I'J:prded outtomrs bern met (= Planning").
5H Tabit4H forQ htliltr!ljHnwlidi rhe5t ooflillljlKtioJIl
LibraryPirate
676 Unit. Thl'ElIdoalneSym'm
(due to excessACTH) or adrenal tumors, the most common
causeofCushing'ssyndrome is long-term therapy with high
doses of systemic glucocortiooids. Signs and symptoms in-
clude adrenal atrophy. osteoporosis. hypertension. in-
creased risk of infections. delayed wound healing, acne,
peptic ulcers, general obesity, and a redistribution of fat
around the face (moon face), shoulders, and neck (buffalo
hWlll'). Muuu allU II",
patient may become psychologically dependent on the drug.
Some glucocorticoids, including hydrocortisone, also have
mineralocorticoid activity and can cause retention of
sodium and water. Because of their anti-inflammatory
properties, gluoocorticoids may mask signs of infection, and
a resulting delay in antibiotic therapy may result.
Because Cushing's syndrome has a high mortality rate,
the primary therapeutic goal is to identify and treat the
cause of the excer.s glucocorticoid secretion. If the patient is
receiving high doses of a glucocorticoid medication, gradual
discontinuation of the agent is often sufficient to rewrse the
syndrome. \\'hen the cause of the hypersecretion is an adre-
nal twnor or perhaps an ectopic tumor secreting ACTH,
surgical removal is indicated.
Chapter REVIEW
KEY CONCEPTS
MetynJpone ( Metopirone) isan antiadrenal drug used for
diagnostic purposes. A single dose is administered orally at
midnight, and blood samples are taken 8 hours later. lewIs
of ACfH and gluoocorticoids are measured to determine if
the adrenal glands responded to the inhibiting action of
metyrnpone. The drug may also be used off-label to treat
Cushing's disease.
TI,,, urug ( Nizural)
preferred drug for patients wi t h Cushing's disease who need
long-term therapy. This drug T3pidly blocks the synthesis of
gluoooorticoids, lowering serum levels. UnfortWlately, pa-
tients often develop toleT3nce to the drug and glucocorti-
coids eventually return to abnormally high levels.
Ketoconazole should not be used during pregnancy because
it has been shown to be teratogenic in animals.
Mifepristone (Mifeprex) is a steroid that occupies gluoooor-
tiooid receptors; it does not block the synthesis of gluoxorti-
ooids or decrease their amounts. Although it has antiadrenal
actions. its primary use is as an abortifacient: The drug is preg-
nancy category X and will induce abortion early in pregnancy.
None of the above drug therapies cure Cushing's disease.
Their use is temporary until the tumor can be removed or
otherwise treated with radiation Of antineoplasrics .
The numbered key concepts provide a succinct summary of the important points from the corresponding numbered section
within the chapter. If any of these points are not clear, refer to the nWllbered section within the chapter for review.
43. 1 The endocrine system maintains homeostasis by using
hormones as chemical messengers that are secreted in re-
sponse to changes in the internal environment. Negative
feedback prevents owr-responses by the endocrinesystem.
43.2 The hypothalamus secretes releasing hormones, which
direct the anterior pituitary gland to release specific hor-
mones. The posterior pituitary releases its hormones in
response to nerve signals from the hypothalamus.
43J Hormones are used in replacement therapy. as antineo-
plastics, and for their natural therapeutic effects, such as
their suppression of body defenses. Hormone blockers
are used to inhibit actions of certain hormones.
43.4 Only a few pituitary and hypothalamic hormones, in-
duding growth hormone and ACfH, have clinical ap-
plications as drugs. Growth hormone and ADH are
examples of pituitary hormones used as drugs for re-
placement therapy.
43.5 The thyroid gland secretes thyroxine (T.) and tri-
iodothyronine (T,). which control the basal metabolic
rate and affect every cell in the body.
43.6 Hypothyroidism may be treated by administering tby-
roid hormone agents, especially levothyrol ine (T. ).
43.7 Hyperthyroidism is treated by administering agents
such as the thioamides that decrease the activity of the
thyroid gland or by using radioactive iodide, which kills
overactive thyroid cells.
43.8 The adrenal oortex secretes glucocortiooids, gonadocorti -
, oids, and mineralocorticoids. The glucocortiooids mobi -
lize the body for 10llg-term stress and influence
carbohydrate, lipid, and protein metabolism in most cells.
43.9 Glucocorticoid release is stinlulated by ACfH secreted
by the pituitary. ACfH and related agents are rarely used
as medications.
43.10 Adrenocortical insufficiency may be acute or chronic.
Glucocorticoidsare prescribed for adrenocortical insuf-
ficiency, aUergies, neoplasms, and a wide variety of other
conditions.
43.11 Antiadrenal drugs may be used to treat severe CUshing's
syndrome by inhibiting corticosteroid synthesis. They
are not curative, and their use is usuaUy limited to 3
months of therapy.
LibraryPirate
NCLEX-RNO REVIEW QUESTIONS
o The nurse=gniusmat drugsfrom which of the follow-
Ing classes Cl Use illCreased risk for peptic ulcers, decreased
wound healing, and increased capillary fragility!
I. Gill(OU)niooids
2. Antidiuretic honnones
3. Growth homlOIlt'5
4. Antithyroid hormemes
o When administering hydrocortisone (Cortef, hrdroror-
tone, others), the nurse reaJglliz.es it may mask which
symptoms!
I. Signs and symptoms of infection
2. Sigrul and symptoms of heart failure
3. Hearing loss
4. Skin infections
o When hydllXortisone use is disrontinuf'd abruptty, the
nurse must assess for which side effect!
I . Development of myxedema
2.. 0lIbpse
3.
4.
o A patient who Is taking levolhyrOJ(lne (Synthrold) begins
to develop weight loss, diarrhea, and stress intolerance.
The nUTS(' should be aware thaI Ibis might be an indica-
tion ofwhu hormonal condition!
1. Addison's disease
CRITICAL THINKING QUESTIONS
1. A S-year-old girl requIres trutmenl (or diabetes Insipidus
acquired IOUowing a ase of meningitis. The child has suf-
fered serlouscompllallons Induding blindness and men-
Ial retardation. Herdiabetes Insipidus Is being lreated wilh
intranasal desmopressin, and the ,hild's mother has been
asked to help evaJu.ate the drug's effectIveness usIng urine
volumes and urine specific gravity. Discuss the changes
that would indiate that the drug is effective.
2. A 17-year-old adolescent with a hIstory of severe asthma is
admitted to the intensive care unit . He is comatose. ap-
pears mud! younger than his listed age, and has short
stature. The nurse notes that the asthma has been man-
aged with prednisone for 15 days, until 3 days ago. The pa-
tient's father is extremely anxious and says that he was
unable to refill his son's prescription for medicine until he
got his paycheck. What is the nurse's role in this situation!
2. Hyperthyroidism
3. CUshing's syndrome
4. De>dopment of acromegaly
U What preoullons should a patient who Is receiving ra-
dioactive iodine be made a .... 'areoi'! (Select aU that apply.)
I . Drink plenty tt fluids, espeda1ly thost- high in alldum.
2. A\"OId dose c:ont3ct with chOdren or prtgnanl women
for 1 v.w:k aftendminlsl ration of the drug.
3. Be aware of symptoms of tachycardia, increased
metaboU, and anxiety.
4. v-.wa mask if.round children and pregnant women.
5. Signs and .>ymptoms of hypothyroidism indude general
weakness. muscieaamp&. anddty skin.
o A patient with diabetes insipidus has stabilized but will be
discharged home on d('$mopressin (DDAVP, Stimate) by
nasal spray. When admInistering d('$IJlospress.!n intra-
nasally. aU of the IOUmring administration guidelines
should be followed EXCEPT:
I . gently rotate tbt' nasal spnty bottle bel"orespntying but
do noIwke.
2. store the bottle at room temperature but avoid uc:esslve
heat over 80" F-
3. SPIllY the nasal spray high into nasal cavity, avoiding tile
bad: tt the throat.
4. usc the spray each morning at the same time of day.
J. A 9-year-old boy has been diagnosed with growt h hor-
monedefkiency. His puents havededded to proceed with
a presalhfd regimen of somatotropin ( Humatrope).Out-
]jne the basic information the parents need to know re-
guding this regimen, side effects. and evaluation of
effectIveness.
Su Apprnd;x D for III1JWUS lind rlltionaitl {orallllctivilin
EXPLORE
fI!)'lllrsillgKi\ i!I )'WI one SIDp for onIlfIf! eIlI!'>ter l'PfIew matenalS a.ncI
llIWurces. Prepare lor SIJWISS witfl addiIiatal practice
(JleSIiom. assgmuns md a.cI;;Ijes. weD 1m. sninatioM
aod videos. and mOle!
FIeg::!ll!r 1011' Bcee!L'I alde Imm me Imm 01 'fWI bOOk al
_...." ..... gkiU ....
LibraryPirate
DRUGS AT A GLANCE
INSUUN ptJIJtfillJ
o humon .0' ",wM(HlImu/j" R.
NCNNnAj prI9Ill4l
ORAL H'l'POGLYCEMICS ptJIJt6aJ
o mtrfotm ...
G/urMUG,othmJ pr19168'J
KEY TERMS
cU,,"i: ketOiCidosis (DM) ptJIJtfJlJ

gkonHgenris ptJIJt619
IIyptIQl)'lemic tffKt piJJt619
lIypI'rovnolar t.,pKf)'temK S1iJlf (H HS) Pl'6a1
IIypofJumktfIKt ptJIJt619
Drugs for Diabetes Mellitus
LEARNING OUTCOMES
AftprrNflingthisclKJpl, rhenudMrshouldbf'ablefO:
1. Describe the endocrine and e)(()(rlne functlonsoflhe pancreas.
2. Compare and connasl type 1 and type 2diabetes mellitus.
1 . Compare and COflIIaSI types of insulin.
4. Describe tt-.e signs and symptoms of Insulin overdose and underdose.
S. Describe nurw's role in the pharmacologic of
diabel:es mellitus.
6. Identify drug used to trNt type 2 diabetes mellitus.
7 . For each afthe drug dasws listed in Drugs al a Glancl'. know
representative drug "xamples,and explain the mecMnisms of dtug
act ion, primary Ktionli,. and important otdvefW effects.
B. nursing process to care for patil!nl'l receiving drug wl3pyfor
dlabel:es mell itus.
imllin ptJIJt619
imllinauklg jIIlIJttill!
imllinlftinance ptJIJt68J
isiftsoflillgemillS ptJIJt6l'9
RtoiOds ptJI}tiW
SoIllOfJi"-"mentn ptJIJt 6a1
typf l.iabelrs ml'llitus fII1I1'6/1J
typfHiabMfS ml'l1irus fII1I1'Mi
LibraryPirate
D
iabetes is one of the leading causes of death in the u.s.
Mortalitydue to diabetes has been steadily increasing.
causing some public health officials to refer to it as an epi-
demic.Diabetes can lead to serious acute and chronic com-
plications, including heart disease,cerebrovascular accident
(eVA), blindness, kidney failure, and amputations. Because
nurses frequently care for patients with diabetes, it is imper-
ative that the di sorder, its treatment, and possible complica-
tions are well understood.
44. 1 Regulation of Blood
Glucose Levels
Located behind the stomach and between the duodenum
and spleen, the pancreas is an organ essential to both the di-
gestiveand endocrine systems. It is responsible for the secre-
tion of several enzymes into the duodenum that assist in the
chemical digestion of nutrients (chapter 4100). This is its
exocrine function. Clusters of cells in the pancreas, called
illets ofLangerhans, are responsible for its endocrine function:
the secretion of g1ur;agon and insulin.
Glucose is oneofthe body's most essential molecules. The
body prefers to use glucose as its primary energy source: The
brain relies almost e.'l:c1usively on glucose for its energy
needs. Because of this need, blood levels of glucose must re-
main relatively constant throughout the day. Although
many factors contribute to maintaining a stable serum glu-
cose level, the two pancreatic hormones play major roles:
inrulin acts to decrellse blood glucose levels, and glullgon acts
to increrue blood glucose levels ( Figure 44.1 ).
Following a meal, the pancreas recognizes the rising
serum glucose level and releases insulin. \Vithout insulin,
glucose stays in the bloodstream and is not able to enter
cells of the body. Cells may be virtually surrowtded by glu-
co.e hilt to ""e it IIntil in."lin It
be helpful to visualize insulin as a transporter or "gate-
keeper." \'/hen present, insulin swings open the gate, trans-
ALPHA CELL
Glucagon- seaeting

"
BETA CELL --'C-- -
Insoi n-
seaeting

GUcegoo-raiS85 blood glU00S8 level
Insolin-loWllTO blood glU00B8l.......t
,,,.,,'
LBng..maM
in pane""",
.. Flgure44.1 Glucagon- and Insulin-secreting cells In the
Islets of Langelhans
Source: Pearsoo fducat/oo/PHCoIlege.
OIoplfi,,", 0"'9s for DI.beles Mellitus 679
porting glucose inside cells: no insulin, no entry. Thus, in-
sulin is said to have a because its presence
causes glucose to Jell\\' the blood and serwn glucose to fall.
The physiologic actions of insulin can be summarized as
follows:
- Promotes the entry of glucose into cells
_ Provides for the storage of glucose, as glycogen
- Inhibits the breakdown of fat and glycogen
_Increases protein synthesis and inhibits glulonrogrnesis;
the production ofunew" glucose from noncarbohydrate
molecules
The pancreas also secretes glucagon, which has actions
opposite those of insulin. \I/hen levels of blood glucose fall,
glucagon is secreted. Its primary function is to maintain ad-
equate serum levels of glucose between meals. Thus,
glllUlKUJI h,.,; h,p"'gl ,mni< droll, baall'" illi pr",,,,,,,,, "all""
blood glucose to rise . .. Figure 44.2 illustrates the relation-
ships among blood glucose, insulin, and glucagon.
Blood glucose levels are usually kept within a normal
range by insulin and glucagon; however, other hormones
and drugs aln affe, t glucose metabolism. Hyperglycemic
hormones include epinephrine, thyroid hormone, growth
hormone, and glucocorticoids. Common drugs that om
raise blood glucose levels include ph,mytoin, NSAIDs, and
diuretics. Drugs with a hypoglycemic effect include alcohol,
lithium, angiotensin-converting enzyme (ACE) inhibitors,
and beta "adrenergic blockers. It is important that serum glu-
cose be periodically monitored in patients receiving medica-
tions that exhibit hypoglycemia or hypoglycemic effects.
High blood glU00B8
J
P"ncr .... )J

I
Cell. take
up glucose

(0)
Low blood glucose
Blood gluooae risM
'")
.. FlguTf 44.2 Insulln,glucagon, and blood glucose
LibraryPirate
680 Unit. The Er.do<:rr ... Sym'm
DIABETES MELLITUS
Diabetes meUitus (OM) is a metabolic disease in which
there is deficient insulin secretion or decreased sensitivity of
insulin receptors on target cells. resulting in hyperglycemia.
Worldwide. approximately 135 million people are believed
to have OM; by 2025, this nwnber is expected to have in-
creased to 300 million. The etiology of OM includes a com-
bination of genetic and environmental factors. The recent
increase in the frequency of the disease is probably the result
of trends toward more sedentary and stressful lifestyles, in-
creasing consumption of highly caloric foods with resultant
obesity, and increased longevity.
44.2 Etiology and Characteristics
of Type 1 Diabetes Mellitus
Typr I diabetfS mellitus accounts for 5% to \0% of all cases of
OM and is one of the most common diseases of childhood.
Type I OM was previously calledjuvenile-onsetdiabetes, be-
cause it is often diagnosed between the ages of II and 13.
Because approximately 25% of patients with type I OM de-
velop the disease in adulthood, this is not the most accurate
name for this disorder. This type of diabetes is also referred
to as insulin-dependent diabetes mellitus.
Type I OM results from the autoimmune destruction of
pancreatic beta crlls, resulting in a lack of insulin secretion.
The disease is thought to be an interaction of genetic, im-
munologic, and environmental factors. Because children
and siblings of those with OM have a higher risk of acquir-
ing the disorder, there is an obvious genetic component to
the disease.
The signs and symptoms of type I OM are consistent
from patient to patient, with the most diagnostic sign being
sustained hyperglycemia. Following are the typical signs
and symptoms:
Hyperglycemia-fasting blood glucose greater than 126
mgldL on at least two separate occasions
Polyuria---excessive urination
Polyphagia- increased hwtger
Polydipsia- increased thirst
Glucosuria- high lewis of glucose in the urine
Weight I",,"
Fatigue
Untreated OM produces long-term damage to arteries,
which leads to heart disease, stroke, kidney disease, and
blindness. Lack of adequate circulation to the feet may cause
gangrene of the toes, requiring amputation. Nerve degener-
ation, or neuropathy, is common, wilh symploms ranging
from tingling in the fmgers or toes to complete loss of sen-
sation of a limb. Because glucose is unable to enter ceils,
lipids are utilized as an energy source and ketoacids are pro-
ducrd as waste products. These ketoacids can give the pa-
tient's breath an acetone-like, fruity odor. More important,
high levels of ketoacids lower the pH of the blood, causing
PHARMFACT5
Diabetes Mellitus
Ofthlo 16 million Allltriuns who hal'edilbms,5 million
unawalt' thu thry thf
E,ch day, than 2,000 diagoosed with diabel!-!.
Gestational diabetn Iff!!. about 4% of all pregnant womm in tilt
United Statn 115,000
Diabms CiI!MSalmost 200,000 is siuh !tading
wuofduth.
Diabms is thf !tIding talM of blindnl'ss in adults;uth )'rar 12,000 10
24,000 ptopIt their sight beCiluW'
is I!1plMib!t for SO% of nontraumatir
56,000 imputations af"! prrformed NIh yw on with diabetn.
Diabetes is the leading CilUW' 01 disuW', mounting for
about 40% of new meso
diabrlicketoacidosis{DKA), which may progress to coma and pos-
sible death if untreated. DKA occurs primarily in patients
with Type 10M.
Insulin
Insulin first became available as a medication in 1922. Prior
to that time, type I diabetics were wtable to adequately
maintain normal blood glucose levels, experienced many
complications, and usually died at a young age. Increased
insulin availability and improvements in insulin products,
personal blood glucose monitoring devices, and the insulin
pump have made it possible for patients to maintain more
exact control of their blood glucose levels.
44.3 Pharmacotherapy with Insulin
Patients with type I OM are severely deficient in insulin
production; thus, insulin replacement therapy is required in
normal physiologic amounts. Insulin is also required for
those with type 2 diabetes who are w13ble to manage their
blood glucose levels with diet, exercise, and oral antidiabetic
agents. Among adults with diabetes in the United States,
16% take only insulin, 12% take insulin with oral agents,
57% take oral agents only, and 15% take neither insulin nor
oral medication (CDC, 2(05).
iO.<lllin .ecrelion ""ri,,_< in re_
sponse to daily activities such as eating and exercise, insulin
administration must bt' carefully planned in conjWlction
with proper meal planning and lifestyle habits. The desired
outcome of insulin thel1lpy is to prevent the long-term con-
sequences of the disordt'r by strictly maintaining blo<Xl glu-
cose levels within the normal range.
The fu ndamental principle to remember aboul insulin
therapy is that the right amount of insulin must be available
to cells when glucose is available in the blood. Administer-
ing insuli n when glucose is not available can lead to serious
hypoglycemia and coma. This situation occurs when a pa-
tient administers insulin correctly but skips a meal; the in-
sulin is availablt' to cells, but glucose is not. In another
LibraryPirate
example, the patient participates in heavy exercise. The in-
sulin may have been administered on schedule, and food
eaten, but the active muscles quickly use up all the glucose
in the blood, and the patient becomes hypoglycemic. Pa-
tients with diabetes who engage in competitive sports need
to consume food or sports drinks just prior to or during the
activity to maintain their blood sugar at normal levels.
Patients with diabetes who skip or forget their insulin
dose face equally serious consequences. Again, remember
the fundamental principle of insulin pharmacotherapy: The
right amount of insulin must be available to cells when glu-
cose is available in the blood. Without insulin present, glu-
cose from a meal can build up to high levels in the blood,
causing hyperglycemia and possible coma. Proper teaching
and planning by the nurse is essential to successful out-
comes and patient compliance with therapy.
Many types of insulin are available, differing in their
source, time of onset and peak effect, and duration of ac-
tion. Until the 19805, the source of all insulin was beef or
pork pancreas. Almost all insulin today, however, is human
insulin obtained through recombinant DNA technology be-
cause it is more effectiw, causes fewer allergies, and has a
lower incidence of resistance. Pharmacologists have modi-
fied human insulin to create certain pharmacokinetic ad-
vantage5,such as a more rapid onset of action (Hwnal og) or
a more prolonged duration of action (lanius). These mod-
ified forms are called inlulinanalogl. The different types of in-
sulin available are listed in Table 44.1.
Doses of insulin arc highly individu"lizcd for the precise
control of blood glucose levels in each patient. Some pa-
tients require two or more injections daily for proper dia-
01..,1<,4-1 0"'9' for Dial> .. MeUitu' 681
betes management. For ease of administration, two different
compatible types of insulin may be mixed, using a standard
method, to obtain the desired therapeutic effeclS. Some of
these combinatiolts are marketed in cartridges containing
premixed solutions. A long-acting insulin may be taken
daily to provide a basal blood level. and supplemented with
rapid-acting insulin given shortly before a meal. It is impor-
tant for nurses and patients to know the time of peak action
of any insulin, because that is when the risk for hypo-
adverse effects is greatest.
Because the GI tract destroys insulin, it must be given by
injection. Some patients have an insulin pump Figure
44.3). This pwnp is usually alxlominally anchored and is
programmed to release small subcutaneous doses of iltsulin
into the abdomen at predetennined intervals, with larger bo-
luses administered manually at mealtime if necessary. Most
pumps comain an alarm that soltllds to remind patients to
take their insulin. Figure 44.3 shows an insulin pump.
The primary adverse effect of insulin therapy is overtreat-
ment; iltsulin tn.1y remove too much glucose from the blood,
resulting in hypoglycemia. This occurs when a patient with
type 1 DM has more iltsulin inthe blo<Xl than is needed to bal"
ance the amolUlt of circulating blood glucose. Hypoglycemia
may occur when the insulin level peaks, during exercise, when
the patient receives too much iltsulin due to a medication er-
ror,or if the patient skips a meal. Some of the symptoms of hy-
poglycemia are the same as those of diabetic ketoacidosis.
Those that differ and help in detennirting that a patient is hy-
poglycemic include pale, cool, and moist skin, with blood glu-
rose Jess than 50 mg/dL and a sudden onset of symptoms. Left
untreated,severe hypoglycemia may result in death.
TAgLE 44.1 I Types of Insulin: Actions and Administration
AdmtntsUatlon
"n"
""""
Onset
""'.
Duration andTlmtng Compattbillty
i!IIUin (Novolog)
.'"
10020min 1- 3h 1-5h sw.:utantOOl; 5-10 min Can 9MWith NPH;draw
alpin !4l fim and
imllltlhtdy
i!IIUin lilpro lHumalog)
.'"
5-15min 1-1.5 h Hh sw.:utantOOl; 5-10 min (an 9M- with HPH;draw
lilpro upfimand
imllltlhtdy
imuin (Apidra)
.'"
15- lOmin 1 h Hh SubultantOOl; I, min (an 9M- with HPH;draw
frn and gift
imllltlhtdy
i!IIUin rtgUar lHumuin
.. ,
lD-60min 1-5 h 6-10h SubcutantOOl; 30-1 min (an miniih tlPH,lImil'
R,HowinR) btforu 1IIIIINllililt;do

1lI1J11HPH, 12h 6-14 h 16-24h SubrutantOOl; rrix (an mixwiih alpin, liIpro,
HlJIlJlil H)
,...",
or not

i!IIUin deimir llfo1mirj
"'"
."""
'-Oh 102H SubrutantOOl; 1/day Do MI mixwith any othtr
illlUlin
i!IIUin lli!ntUl)
"'"
1.1h Hoptak 102H SubrutantOOl; 1/day, Do MI mixwith any othtr
iiIIII' mil day illlUlin
LibraryPirate
682 Unlt l The ErdoallM' Sym'm
,.. Figure443 Insulin pump
500r(e: pfizer oc.
If the hypoglycemia is mild to moderate, symptoms can
be reversed bygiving food or drinks containing glucose. The
quickest way to reverse serious hypoglycemia is to give IV
glucose in a dextrose solution. The hormone glucagon is also
U5ed for the emergency treatment of severe hypoglycemia in
patients unable to take IV glucose. Glucagon (I mg) can be
given IV, 1M, or subcutaneously to reverse hypoglycemic
symptoms in 20 minutes or less, depending on the route.
Other advent' effects of insulin include localized allergic
reactions at the injection site, generalized urticaria, and
swollen lymph glands. Some patients will experience Somogyi
phenolllt'non, a rapid decrease in blood glucose, usually during
the night, wltich stimulates the release of hormones thai el-
evate blood glucose (epinephrine, cortisol, and glucagon)
resulting in a Itigh morning blood glucose level. Additional
insulin above the patient's normal dose may produce a rapid
reboWld hypoglycemia.
44.4 Etiology and Characteristics
of Type 2 Diabetes Mellitus
Type 2 meHitus is the more common form of OM, rep-
resenting 90% to 95% of people with disorder. Because type
2 OM first appears in middle-aged adults, it has been re-
ferred to as age-onset diabetes or maturity-orlset diaberes.
These are inaccurate descriptions of this disorder, however,
because increasing numbers of children are being diagnosed
with type 2 OM. Patients with type 2 OM are often asymp-
tomatic and may have the condition for years before their
diagnosis.
The primary physiologic characteristic of type 2 OM is
insulin larget cells be.:ome wlresponsive to insulin
LIFESPAN CONSIDERATIONS
Psychosocial and Cultural Impacts
on Pediatric Patients with Diabeus
For the child or who hll diabetts, art psychosocial and rul-
!utili considerations of (ompliaOC:f with mtdication and dimry regimens.
Enn if diagoosN tarly in (with lI'amtd behaviors regarding tht dimll'
p.lramtlt ri), the ell'mentary school ytari can bf difflCUk for some chikill'n
with diabttH. Social MnII weh birthday p.lrties, nip!, and after-
school snack time, whtll' SWffl trNts all' tht norm, II a physiul and
psychologic tempmion. During adoll'sctnU', when tht tn wants to rn in
with 01 peetgroop, tilt diabttic regimt n un ilfoome mIlft' difficultlt is during
this time thilt fililull' to insulin or to follow dietilry guideline bKomes iln
issue that rna)' negatiYely alFfd plI'lI'nund iulUII' health. So"", teem may
hm insulin pumps ilnd un moll' Nsily tlkt nm insulin to cOY!'r foods not
UlWIIy on tlltir diet Tht oIbility to do this helps tns f11l'1I difffft'nt from
pem.. but carrite! to l'lCel, thi! ptilctiU' un also lead to probkms. Tht nurll'
pla)'Savitill '* in eduuting tht p.ltienl and fam ily and in making ft'fffrolis to
community oIgfoc:iH thilt milY mist in ht lping the young ptrson kltp blood
sugar in control whill' prrlftYing
1111<': to in r<':c"'!'tor f1lnction. th",
pancreas produces suffici<':nt amounts of insulin but target
cells do not recognize it.
M cells be.:ome more resistant to insulin, blood glucose
levels rise and the pancreas responds by secreting even more
insulin. Eventually, the hypersecretion of insulin causes beta
cell exltaustion, and ultimately leads to beta cell death. As
type 2 OM progresses, it becomes a disorder characterized
by insufficient insulin levels as well as insulin resistance. The
activity of insulin receptors can be increased by physical ex-
ercise and lowering the level of circulating insulin. In fact,
adhering to a healthy diet and a regular exercise program
has been shown to reverse insulin resistance, and delay or
prevent the development of type 2 OM.
Many patients with type 2 OM are obese, have dyslipi-
demias, and will need a medically supervised plan to roouce
weight gradually and exercise safely. This is an important
lifestyle change for such patients; they will need to maintain
these healthy lifestyle habits for their lifetime. Patients with
poorly managed type 2 OM suffer from the same complica-
tions as patients with type 1 OM (e.g., retinopathy, neuropa-
thy, and nephropathy).
Hyperosmoiarhyperglycemicstate(HHSI is a serious, acute condi-
tion with a mortality rate of 20% to 40% that occurs in per-
sons with type 2 OM. This condition was formerly called
hyperosmolar nonketotic coma ( HNKC). HHS is caused by
insufficient circulating insulin. The onset of HHS is gradual
and is sometimes mistaken for a cerebrovascular accident.
Seen most often in older adults, the skin appears flushed,
dry, and warm. Blood gluoose levels maybe extreme and rise
above 600 mgldL. Treatment consists of fluid replacement,
corre.:tion of ele.:trolyte imbalances, and low-dose insulin
given by slow IV infusion to lower glucose levels to 250 to
300 mgldL.Although less common, HHS has a higher mor-
tality rate than diabetic ketoacidosis.
LibraryPirate
0"'9' (or Olabete, Meliltu, 683
... Prototype Drug I Human Regular Insulin (Humulm R.Novoim RJ
Therapeutic (I ass: Antidiabetic agent; pancreatic hormone Pharmacologic (lass: Short-acting hypoglycemic agent
ACTIONS AND USES
Human insulin is!Md to maintain bIoodgUcoW' within oor-
mallimits."Iht tifrds ofhuman ff9ULtr ill\Ulin al"!:to crlluLtr
uptake of gUcoSl', amino adm, and potmilm; to promotr protrin 5)'nth6is,
formation and storiljr, and fatty acid 510ragr u triglturides; ind to
(onsrrn by promoting thr utiliution 01 glucosr lor rlll'l9)' nmk,
a nd inhibiting glu<onrogrnesis. BffiuW' ff9ULt r insulin is shan "tin 9. it is most
!Md in mmbination with intrrmrdiatr or IoIlQ-actillQ in",lin to achm
24-hour gUcoW' rontrol.lndic.ilions for insulin include the following:
Asmooothet"apytolowfrbloodgkJmselnn in patirnllwith typr I diabrtes
In combination with ",al i midiabetic agrnts in patirnts with typr 2
For thefflll'rgerKy trNtmrm of diabetic ktioaddosis
For 9l'Itationai diabetts
ADMINISTRATION ALERTS
En",rr that the p;ltirnt has ",fficifnt food and is oot brio!"!
administffing insulin.
Rrgular in",lin is thr only typr ofin",lin that may be!Md for IV injection.
injKtion When thr patirnt is hospitaliml, not oor-
mally!Md b)' t he p;ltirnt when at homr.
Administer approximatrly 30 mrak w ill\Ulin will be ab-
wrbrd and available when the patirnt begins to ut

PHARMACOKINETICS
Onsrt: min subrutanrous; 15 min IV
Peak: 1-4 h lubcutanrous; min IV
Halflile:Upto 13 h
Duration:6-HI h subrutanrous;30-60 min IV
Oral Hypoglycemi<s
Type 2 DM is usually controlled with oral hypoglycemic
agents, which are prescribed after diet and exercise have
failed to reduce blood glucose to normal levels. As the dis-
ease progresses, insulin may become necessary for type 2 di-
abetics, or it may be required temporarily during times of
stress such as illness or loss.
44.S Pharmacotherapy with Oral
Hypoglycemics
The six primary groups of oral antidiabetic drugs are classi-
fied by their chemical structures and their mechanisms of ac-
tion. These include sulfonylureas, biguanides, meglitinides,
thiazolidinediones (or g1itazones), alpha-gluoosidase in-
hibitors, and incretin therapies. Therapy with oral antidia-
betic agents is not effective for persons with type 1 DM. All
oral hypoglycemia;. have in common the action of lowering
ADVERSE EFFECTS
Thr most (ommon adverW' efiro 01 ill\Ulin thrrip)' is Ifypo-
glycrmia may mult lrom taking too mum insulin, not properly timing the in-
sulin injection with food intau, or skipping i mral. Signs of
tachycardia, (onfusion, sW('ating, and drowsilll'ls.lrrittlion al injKlion
SitH may occur, induding lipohypfflrophy, thr accumulation of lat in the al"!a of
injrction. This rffKt is with rotation olinjection SitH. Wright is a
possiblr tffra.
Contraindi mions: Insulin is!Md with uution in pregnane,: !"!1IiI1 impairmrnt
or lailul"!, !tvrr, thyroid disNsr, an d among oldrr adults, childl"!n, or inlann.ln-
sulin should oot be administmd to patirnts with hypoglycflllia. Patirnts with
h)1lOkalrmia should be monitorrd ul"!lully bKiUW' insulin miy worm this
condition.
INTERACTIONS
Dru;rDrug: Thf (oIowiIg substanus may poiI!ntialf twogIy<fmic !/OO!: aIutIoI,
saiC)li!l'I, MAaI, anabok stl'l"oidI, n:lgUftthidinr. Thf loIowing subltarKll may
anligonile fffKII: conicoruroidl, thyroid 00r1llOOf, and tpiIfpImf.
Sl'l"00I ijlUClISf k>mI may inclMll'd with furwrnidf or thWidt dUMino

li b 1l'1": may ilKfflR umary Nnlylmandtlic acid {VIM I and inlffil'l"!
wi!h IivI'I" tl'IlIand tht"oo flllctioo tem.k maydKr&MlMI\ IfIIIm pomsium,
calWn,andmagneWn.
Herba VFood: Garlic, bilbMy, and girIIeng may potential! tfMo ",p09ycfrric: fffKII
inlUin.
Treat ment of Overdose: Owdoll'uuW'S hypoq1ytemia.Mild CiW'Sarr t!"!ated
with oral glucOW',and rpilodrs al"! truled with pal"!ntrralgiuugon or
inlril'Ilous glucosr.
s.... RtfI'I" III MyMlsJni}Kl (Of IIUlIng /'reII Fool! sp11Ii: 111M ttug.
Th r Question: Oors Iowrring blood lipid IeYek help to improve the
therapeutic outtomrs of diaooic patienll?
Th r Study: analyzed 12 srudirs ttYt the of
lipid-lowering drugs in with diabete. [ad! study lasted lor 3
looked at the in
diabnia nondiabetics.AIthough both groups from lipid-
Iowrring drugs (OY!'r 10'1(, irWl'rurdiOlla!ular
p;ltirnts ipprirm to brnrfit than nondiabetiu.
Implications: Nurm should Itach diabetic patirnts thr imponancf
of managing thrir blood lipid well as blood glueoW' IMis.
Slutt: CoIm,J., BIlfges, M, Lhn101 C & !<!mfIn;A.V. (1OO6).Etrll:1K111f1lfN
Ml!gllNlmml'tMr1Id/)ttJ(QM
ronUOltlt IDIIi. 8rItiIII1MdIul.iou mall Jl: 1115- 1114.
LibraryPirate
684 Unlt l TheEr.doar .... SyS!,-""
NURSING PROCESS FOCUS PATIENTS .EeElVING INSULINTHE.APY
Assessment
Bilstline assess ment prior to administrati on:
Understand rt ilson the drug hu betn pre.:ribtd in order to aslnS for
.. peuti< tff.rts ond 10 pbn forl_hing nH<k (t .g., new onS<'t of
diabttts with hypergl)'(tmia in imulin
sliding IYIt u)Y!'ri9\', trtatmenl of hyptfk.Jltmiil).
Obl,in a (Ompltlt history ilKluding
or rt n.1 distal<'; p or brt il st-fre:ling. Obtain a drug hislory
ilKluding alltrgies,rurrtnt prtKription and OT( hffiIal plt'pilmions,
akohol ust.1k ,ltn to drug interadiom.
Obliin a history of (Urrenl s)'lllplOrm,duralion ,nd Im'riI)o, ,nd olher
malf<i sigm or 5)'mplorm (t.g., parf llhtsias of hanmor fttl).A1stn fttl
,nd for polSiblt uktr.ltiorrs.
Obtain a dittl ry history induding {alorit if on a n AOA din. and the
numbtr of mI'iIls il nd m,ds perdil y.k!es fluid intaR i nd I)'peof
nuilk (Ofllumtd.
Obt,in vital sigrrs,
Enltwtt .ppropriatt labor'lOry findings (f. g., (Be, tlectrolytts, glumII', A 1 (
Itvtllipid ,nd rt nal fuoction nudits).
Assessment thro ughout administ ration:
Asst\S lor dtsirtd thtrapeutit t fftm dtpendent on tht INIon is
ONtn (f.g .. gIutOll' Itvtk. eItruoIyttS and osmolality f1'main within normal
limiu,Al( ItYl'ls dtmonstritt (ontrol of gIutOll').
Asst\S lor and promptly ft'pon any i dvtrv signs of hypogly{tmia
(t.g., n,u IN, paltnm, lWt'ating. diaphoretic, tfl'mOB, irrit,bility, ht.d.i(ht,
light-lItadtdntn, anxious,dttfl'altd It'Itl of (onsc:ioulnell) .nd
hypergly<:tmia (f.g. skin,poirJria, poIyphagia,poIydipYi,
knonuria, bruth),lipodyltrophy,and
inft<tion.
Pot entilll Nursing Dillgnoses
Imb,l,n{t(j Nutrition, ltsl Than Body Rrquirtmenu (I)'pe I
fl'bttd 10 b<k of insulin ""oibbility for nannol "",toboli<m)
Imb.l,n{t(j Nutrition, Mofl' Th,n Body (type 1 diabtte,
fl'lattd 10 imulin and intaR mOfl' than body nttm)
(drug tht r.lp)')
IfII'fit<tNe Thtrapeutit Rf9imt n Mil nagtment (fI'lattd to
knowIedgt or alttfl'd (ompliafl(t with pres(ribtd lIt'atment)
Alttrtd NolKompliafl(f (fI'lattd to mmplexil)' ofutatment
plan, knowledge)
Risk for DtrKitnt FkJidVolume (related to polyuria from hypergly(tmi.)
Risk for In;"'1 (fI'lattd to adY!'lSt drug fKed!, lack of st flliltion in
from nfUropathies)
Risk for Infe<tion (fI'lattd to hyperglyremia,imp,ifl'd cirtulation 10
fll'urop,thies)
Pl ll nning: Plltient Goa lsllnd Expect ed Outcomes
Tht paritnt will:
thtrapeutit tfftm (t .g., blood lugarwithin oonnallimitl).
Bt mt from, or txperitn((' minimal,.dY!'rst tfftru.
Verbalizt an ur.clentandin 9 of tilt drug's UII', adYerst tffrrts, iI nd fl'quifl'd prt<ilutionl.
mite selh:lministr,tion of tht medit.tian (t.g. dOlI', timiog. wht-n to notify provider).
Implementlltion
Intervent ions li nd (Rllti onales)
Ensuring tht rilpeutic effects:
Cominllt iI IStsSments de(ribtd for thtrapeutit tffr(15.
on the IMrity of hyptrgiy<:emia,bIood gkKOIf IMIs
gradually 10 normal.)
Adminilter in sulin y a nd pt r sc:htdult ordtfl'd (t.g.,
dosing with or without Iliding-sc:.ilt (_ragt)'planning irrsulin
,dminimation nd ,round meal limB. (Set "Minimizing adVl'rll'
tfft<ll"lattr in this liblt. Maintaining a lIe,dy ItYl'l of irrsulin with meal
riflll'l arranged 10 m,,,h peak irrsulin mivil)' will allisl in m'intaining a
It,blt blood gllKO\e 1eY!'I.)
Pati ent li nd Fll mily Educlltion
Ttilth tilt patitnt to fI'POn any Il'Nm of original5)'mptorm.
Tt ilth the patitnt tilt l)'IIIptoml of hyper-and hypogl)'(fmia to obll'fY!' lor
.nd inllnKt tht mt<k tilt (apillar-, glumll' Itvt'I
"Minimizing idYmt tfft<u"lattf in thi! t,blt) roorintl)o and ij s)'lllptorm
'fI' pr!"S<'Ilt Prompdy fI'POn any OOIimblt 5)'mptorm ,nd (onrurrtnt
tapillar-, gllKOSt ItvelIO tht lItahh (lfI' provider.
Tt ilth tilt appropnatf ,dminimation
ttmniqll('l for all types of in lui in ull'd, folla.re:l by rtlUmmomtr,tion
until tM or is (omfon,blt with tht tt<hniquf "Id
is ablt to perform it (ofTt(\ly. (SH"Patient self-adminim'tion of drug
therapy"later in this tablt.)
Ttilth tht (afl'giY!'f tilt inlulin It'Itls
,nd tht nted 10 trrsUfl' that adtquatt food soun:rs all' (onlUmed toavoid
hypogly(tmi,. PlIl'Iide writterl mattria Is for futurt fl'ft ren(t wheoeY!'r

LibraryPirate
NURSING PROCESS FOCUS PATIENTS RECEIVING INSULIN THERAPY (CooUnuedl
I mpl ITI4ffitatio n
and
ElIWrtdinilJ.-Is art mtI on lilt JIefd to iost.tain, Of mainuin
CIIntnt wtight gluaM 1M1s. Comull weh a dittitiln II nffiled.L:imit
Ilcohol 1M. (ldfqlWtl!' raion.: amounu and
Ind fs SUflPOf\S tht insuIiII !of gIucost con\llll.
Activity Ind &ftjtylt wiR lbo be fletoM no dietary Alcohol
rail r.iS!' and w.. prtcipitwslr Iowtr blood gluroS!' .Icohol is
mtt.boliltd,rai!ing tht risk
Minimizi l g adftrlf tfftds:
Continue t:I _tor capillary gU:IM IMk.HokI insulin cIoIf iltbt blood
SII9Ir 1M! is leu thJn 70 119'11. Of ptr pawnttm.1 ordtrtd by tilt h9lth

lJIiintiining wbit blood wil lid in tilt
IClPIOprilttlltll of tht currtnt inlUlin legimtn.)
Continue 10 _tor periodir lab gU:OIt,A Ie 1rfeI,
IiJ.id profile,osmollliity, btpuic iI"Id rtNI funclion
monitoring oflabW(lIt IISisb in dttermining glurOiecontrol, tht nHd for
iIIyeha!l9f ill iliulin rftCh,lnd alSl'SSI'S fof romprlUlicm.A Ie ItwIs
proYidt I mmurt of gkKost mnllOl MfSl"ftral moJldt<time.)
Mstsl for symptoms of hypogl)'":tmia, .round timt of iniUlin
puk Iymptoms ofh)'!lOgl)'C_lIre nottd. quitl-Kting
Cbohydr.l\t IOUrtt (t.9-,jui(t or othersimplt IIltn cW
capinary guOit 1t"lt1.1ltport I) IwIth prtl"fidtr if tilt gU:o!e IMI
is Itn thin 70 or IS ordtrtd If meal is not
_I) that Mt rt(U[
(Ifypoglytrmia iI fipt(iaIIy to OCQll" IlOUnd pt<lk illulin IttMty,
espt(ilily iffood SOlUtes .. ,dtquatt. PnMdi"9 a quid:..ai"9
CMbohydt<ltt IOUrtt and thMchtcking Ittt apill,..,. ghKost 1M! wi!
rmurt that gt.Jroit dots IlOl dKrel S!' iJnhn whilt IorJting 1M gU:o!e
ltlting tqUipllltrll When in doubt, I)"mptoJIII for SUlPKttd
is $,Iter dwn .wing fufthtr dKrellts" glucoS!' and
pouiblt lou of rOfllCiouIntsl with .J<Mrst tffKb. SIIIIII additionll
iIIlounuof Qlbohydrufl wil nOI drillliliully blood Illgif if
ItIting shows I hyptrgty.:emic tpisodt.)
Monitor blood g1uroS!' more pfriock ofillnessor Stml.
(Insulin nffih mlY irKrelst ()J during pfriock of hs or SIlts5-
frelJlfnt monitoring during tlJrst times "'!pi to gkKoSI'
(ontrol.)
ErKourigt ph"tlKII iCtiYily Iu monitor blood btfore Ind
aftt r exmiSI'JIld btgin II1J _ or inoNmI9m:ist IOlIint gr.J<U.,.
Continue to monitor for up hOUB afttr (Wrciit
ID 1M guOie mort' efliOtndy and iOONSfl in!Ulin
lilts in tht tillUts, Iowtring blood glll(Ole.BtJll'fllS of exmiSI' and IcJwtred
blood IugM JIll)' rontinut bUjl to 48 hoUB, inrrelling tilt rilk of
hypogl)'C_ !bing this timtj
and Family EduUltion
Rtvitw ditt.liftlt)le.and Ictivit)' IMI with the patitrlt.kratlgf I
dittitiln romull hmd on tIlt"HI! to ()J foodrhoUi. 1m" dIt
paUmt to limit .Irohol 1M. If .1mboIir om
COIIlUmtd. imitlO orot ptr dIy iIId ukt with I complttt JnNIIO
tr'ISUIt that: inu kt balarKts .kotIoI mtt.l boIism.
ins1JU(t the on blood monitoring appftlllria1t tKhniqUts t:I
obtain Qpilliry blood gU:o!e 1tveIi, foIlowtd by rttum-dtlllOltltr.tion,
and whtn to mnloJrt tilt IwIth Wt pJll"fM (r.g,gUIM 1m thin 70
Bl9fdL). Monitor 1M I nd trJllft 1M proptr iJnctioni"9 of II tqUiprntrltto
be ustd at home.
lni1JU(tthe on lilt nmlto return pniorI"K.11y for lib worl
"lurn the to alwa"tl wry I quirk--aaing wbohydralt MlIlKt"
use lymptOOlI of h)rpoglrtfmia O(rllr.1f UIIIUft vdltthtr IJII14ItornS
indKite Of I\ypt'lllycemii. tJtat 15 hypoglyttmia and thtn dttck
capillary not rtliMd in 10 to IS minultl,or if
blood is below 70 mgldl (or p.1ramttllfS 15 ordtrtdl, notify tht
ht.lth are pnMdtr immtrfiattly.
iJl'I1JU(t the to rhKk g/urOit Itvtk JIIOR' whtn ill Of
IIndtr It I!! s.11nts1, tsptCillly I5lOCiattd with <I nortllia, 1IIUIti, Of
lOOIiting. may dKrnst inscAin JII'fdI. No(jy tilt pnwidtr- if
llllabit tOUI JIOI"IfIII mull dwing ptriodiof iIInt!.s or .Iltss lor I pouibIt
dwl\9f in insulin dv..t.
"lurn the p.1lifnt 1M bentIi8 lICtirity but!O be9in Iny JII'W
routintor inauSI' in gradually: ExHist ihoold rut I hour
.a mfal Of al()" ()J 15-g Cbohydratt IIW<l to prf"mII. hypogl)'(trnii.
If fltMt is probJgfd. Qlbohydr.ate Irwrb an
rOlllUmfd f'H'1J 30 minute during It lJIiinllm blood 111gB.
IJlltnKt tht palifm to Itvtk JIIOR' briore Ind

(Conrlnued)
LibraryPirate
686 Unlt l The Er.docrl .... Sym'm
NURSING PROCESS FOCUS PATIENTS RECEIVING INSULIN THERAPY (ConrlmJed)
Implementillt ion
Interventi ons iII nd (Rill ti onales)
inwlin administration Wffki\'.lf hoIpitaliztd, aft'
If" used or diffKUk !O rNCh by tIM> patienllnsulin pump wbanantol6
mhtttr, mould lit rnaoged eYl'fY 2 to 3 days.(Roming
Wl'uly Mips to pn>l'Mt lipodymophy.lkt {.1UliGn if using !leW yte,
tspt(iali)o ij tilt pfffious sitt ustd by tilt [)alient uhibiu signs of
in an sitt may lit absor\wd moft'quicidy lhan
a lite wilh I"fWlting in pump
wbc:Utllll'OUS (a!helen should lit chaoged 2 10 3 days 10 pft'l'Mt
infttlions altht sitt of insffiion.)
Enwrt Ihe proprr 1l0fa9l' ofifllUlin to maintain maximum pDreoty.
(Unoprr.td inlUlin may be Itored at room trmprrnufl' but awid dirKt
lunlight and nmlm lItat.Openrd ifllUlin viak may lit ItOred at room
temprratuft' for up 10 1 manrn.lf a notKNbIr (hangr in >OIulion o((ur; or ij
forms, discard tIM> vial.)
Patimt undtrstanding of drug thtrap-,:
U,e opportuni1ie during oI dminimation of medications and during
10 discus, !he rationalf for dflllj de>ired thffilprutic:
mo!t common for when to {.111 tM
lItoikh taft' oI ny nttn sary monitoring or prKautions.(Using
timt ruring nur;ing tare IItlps 10 and I!'inkllu uy INthing
aft'asJ
Patient iII nd Fill mily Educilltion
InslnKl tIM> patient on !he III'td 10 rotlte insulin injKtion Y1l5 on a Wffki\'
bali! 10 plt'l'Ml lisWl' damagr or 10 rotate wbc:utaneousrnhtltf sites
(ifllUlin pumps) 10 3 days.
Tth !he patient methods for proprr ll000geofinsulin and for s!Oragr
ruring tral'l!!.
TIM> famii\', ort.lrt<jil'f should beablt!O stltr tilt INIOn for lilt
schtduling;what rllem to oiufft for
and wlltn !O report;nd any Ipt<ial fI'I1uin>mrml of medication tllrrapy
(e.g., ifllUlin nted! during iIInffi J.
Patimt stlf-administration of drug therapy:
InslnKttlM> [)alient to tarry a wallet idl'miflt.ltion card or Wl'ar medical
ide mifiulion jroMlry ind it.Jting diallt1I5.
--+--
When adminisltring 11M> mtdit.Jtion, inslnKl tIM> famii\', orurt<jim
in tIM> proper 5eif-iidminisuillion of lilt dflllj.(Proprr administration
inc:ft'a II'Ithe of lhe drug.)
TIM> famii\', ort.lrtgiYl'r is , blf!O diswss dosing and
administration neecls, inc:luding:
Proper of inlUlin: Rotate vials grotly and do nOI if
ifllUlins aft' m ixr<l, draw up tht qJicUsI acting ifllUlin and then longer-
atting ifllUlin ij tilt ifllUlins aft' nlu lin glargine or inlulin
drttmir should not lit miud with any otlltr type ofinlUlin.lM lilt
(100 unit) unlrls amourns of in wi in art
ordered. lhen obtain Iyringel with smalltf YOUl1lI'S 10 t nlUI"l' {Urate
doling.
Proper wbc:utanrous injection lechniqutS: Sele<1 and with
rotation at angle, applying pad 10 lilt lite
injto:tion but do not
Proper of all fquipmrm, inckiding blood glutOlf monitoring
rqJipmrnt and inlUlin pump.
EVillluilltion of Outcome Criteriill
lilt effKlmlll'1I ofdflllj by (onfirming thn patient goak and tllpr(ltd ootrome hoM mrt (Iff "Planning1.
5to r.bh H. ! ("'. 1;(<< d"'1J< whid> rJoos. OIJf<ing.aitJm ."pIy.
blood glucose levels when taken on a regular basis. Many
have the potential to cause hypoglycemia; therefore, peri-
odic monitoring of blood glucose levels is necessary. Doses
for the oral hypoglycemics are listed in Table 44.2.
Therapy of type 2 DM is generally initiated with a single
drug. If glycemic control is not achieved with monotherapy,
then a second drug is added to the therapeutic regimen.
Failure to achieve glycemic control with two oral hypo-
glycemic agents indicates the need for insulin to be added to
the regimen, though periodically a third oral drug will be
added at the same time as insulin.
SULFONYLUREAS
The first oral hypoglycemia available, sulfonylureas are di-
vided into first- and second-generation categories. Al-
though drugs from both generations are equally effective at
lowering blood glucose. the second-generation drugs ex-
hibit fewer drug--drug interactions.
The sulfonylureas act by stimulating the release of insulin
from pancreatic islet cells and by increasing the sensitivityof
insulin receptors on target cells. The most common adverse
effect of sulfonylureas is hypoglycemia. which is usually
LibraryPirate
TABLE 441 Oral Hypoglycemics
Drug RoutE' and Adutt DoSE' (max dose wN!re Indlc:atE'dJ Adverse Effects
ALPHA-Gl UCOSlDASE INHIBITORS
ik<lrbost (Prt<ost) PO; 25- 100 rng lid (madOO RIlfIj!fn<t eI,rrlw, Q/IdomhII
PO; 25-100 rng lid (max:300 rnWday)

IImlIlb:WIlii!irmllm
-
BIGUANIDe
o mtefonnil PO; SOO two IllIItsiday or &SO RIg OtI(t 10 1,OOl---25SO mg RrJIlIJm<t dnrlw, 1lllUSttl. orllWlict
mmtdiut rtlf:ast (Glumplligr, RiomK)
in two to tlHfI! dividtd dowday (mal: 255 g/day) abdcnri7d pdn, bit/If ormnolk Imfll
GlllTlflza: 1,lXO-lOOO mgOllCf d.lily (mal: 2 g/day) XR:
IMIkirjdmk
XR.GlI.II'IK:UJ sao 1119 OII(t daily (max:2 gJd.l,J
Fortamtt: l,(m mg met delly (mn: 2.S gfdiyJ
MEGLrTINIDES
nattgtinidt (StatlilJ PO;6.0-120mg 1id. 1-30mln priortomNh upptr lt5ji".ory
(Plilncln) PO; 0.5-4.0 RIg JO min pfioI'tomtils{mn: l' mgfday)
i1fMim, bk {!Din
H)'II2glntlllii (11f11lO1\. J1j!2ilili!m
m ali!'!91 M ytun pancrwiM
SUlFONYLUREAS, FIRST GENERATION
dllorpropamidt (DUbillMt) PO; 100-250 mgfday (max: 750 mgfday) IfIIIMq hstbum,diuilli!!.\,
toLmmide (Tolinast) PO; 100-500 mg _to two times/iii, (max: 1 g/lUr)
Iwdht, iJrrJOrwss
PO; 2SG-I,SOO mg _ 10 two tlmti/d.l, (max: J
HlI!!ISb:\m!Y (11P11'1M Ri!l!ililillm.
!,Nrati!'!!!) d!GltSlatic Wnd!ct blood

SUlFONYLUREAS, SECOND GENERATION
(Ama ryU PO; 1-4 mgfda1 (mid mg/day) IfIIlISfO.wrllum,dizzillm,
glipizidt (GlU(mI) PO; 2.5-10 mg one 10 II) linM'siday (max:40 mg/day)
Iwdht, dlflWlirwss
glyburilt (Di.J8tt, ) PO; 115-10 mg _ to rMllimtsldiy (m.u::20 mg/day)
(IrmlOn.
lWPati!'!!!1 dlof!:j!j!!k @lIndkr blood
gl)buridt miauniltd tabldS (Miaoo,st) PO; 0.75-12 mg _ 10 rMl tlrMslday (max: 12 mg/day)
""""'"
THIAZOLI DINEDIONES
piogIilalOM {Ioctos] PO; 1 5-30 mgtday' (mn:4S mg/day) Uff'IJ repfflfOly 11fto(tiln,
rosicJlitazorlt (AYiIlCN) PO; 2- 4 mg ont 10 (I) Iimtslday (nw::' mg/dayl
IIN1ht,tdIJIIII, wright gail
WmtnilgtfCHfdmlt!l li'm
ma!!la. bmt!2!2!!i:!!
fwl!tS hfjnfill!! I!MXjrdyl
......
MISCEUANEOUS DRUGS
bfomocr1lI:int (CJdoseIl PO; OJ-4.8 rngJd.ly upon.waktning NaIMq fmigut,tfziMl.\. KlIIIiting.
-'"
i!liti!i!m l!ilgg!!i!i!m!
mn.JUdt (SyKU) SubcutalltOU5; S-10!IKg ont to two times/day 6(1 min prior to i mfal
Um:tl1b:WIlY Rillli!ol!i!)m
"""'"
primlintide (Syrnlin) SubcuJalltQlS;1ypt 1 OM: 1HAmcgpriorlOmtais;l)'pt 2 OM: IfIIIISfO. ..,mlrilWJ,
(,(I-11Omcgp!iorlo muh mugh.fQIigut
H)l!2!l;!):tm!l (!rmlOn.
....,.".
iwgliptin (liMia) PO; l OOmg meedaily Ralrilm. tla., o/ldomhll
disttntion
(1 rml1m Ihlllli!ol!kim

(CmtlnUJ)
LibraryPirate
688 Unlt l The Er.docrl .... Sym'm
TABLE 44 21 Oral Hypoglycl!mics (conrlnuro)
"n"
Rout e and Adult Dose (max dose where Indicated) Adverse Effects
COMBINATION DRUGS
gipizilk-'!rnf,tlonnin
glytuilrJrnfifonni'l
1'0;1.5/250 mglday (max: 10 mg glipizid/, and 1,000 mg mmormillday)
1'0; 1.15 mg/l50 mg 0lIl' 10 (mll:1O mg glyburid! and

Sf! pagtfor i'ldil'idJal drug

PO; 15 mg or 15 mg{850 mg fixtd-do!C' pio9i\al{ll)t/mtlformin
daily (mll:.5 mg piogIitalOlll' and 1,00lmg IIItIfOllllin/day)
1'0; 4 mg/l mg,4mgl1
gimepride daily (max:S mg 4 mg gimepirid/,fday)
do!C' (max:S mg l,<m mg metforminlda,)
IIQIk! WIllmon id.".rlC' tfltas.
caused b),taking too much medicationor not eating enough
food. Persistent hypoglycemia from these agents rna)' be
prolonged and require administration of dextrose to return
glucose to normal levels. Other adverse effects include
weight gain. hypersensitivity reactions. GI distress. and he
patotoxicity. When alcohol is taken with these agents, some
patients a disulfiram like reaction that includes
flushing. palpitations, and nausea.
BIGUANIDES
MetfomIin (Glucophage), the only drug in this class. acts by
decreasing the hepatic production of glucose (gl uconeogene-
sis) and reducing insulin resistance. it does not promote in
sulin release from the pam:reas. Most advern> efTects are
minor and GI related,such as anorexia, nausea, and diarrhea.
Metfonnin does not cause hypoglycemia or weight gain,
which are major advantages of the drug. In addition to low
ering blood glucose levels, it lowers triglyceride and total and
lowdensity lipoprotein (LDL) cholesterol levels, and pro-
motes weight loss. Rarely, metformin has been reported to
cause lactic acidosis in patients with impaired liver function
due to the accumulation of medication in the liver. Sustained
release forms of metformin {Fortamet, Clucophage XR, and
Glwnetza} are a ..... ilable that allow for once daily dosing.
ALPHA-GLUCOSIDASE INHIBITORS
The alphaglucosidase inhibitors such as acarbose ( Precose)
act by blocking enzymes in the small intestine that are reo
sponsible for breaking down complex carbohydrates into
monosaccharides. Because carbohydrates must be in the
monosaccharide form to be absorbed, digestion of glucose is
Theseagentsare usually well tolerated and have min
imal adverse effects, such as abdominal cramping, diarrhea,
and flatulence. Liver function should be monitored, as a small
incidence of liver impairment has been reported. Although
a1pha gh,,;uociJ ...... i"hil>ilun; Ju uul pruJuu< hypugly,-"uua
when U'led alone, hypoglycemia may occur when these agents
are combined with ifl'lulin or a sulfonyiurea.lfhypoglycemia
does develop, it mwt be treated with glucose and not sucrose
(table sugar), because the drug inhibits the absorption of suo
crose. Concurrent use of garlic and ginreng may increase the
hypoglycemic action of alphaglucosidase inhibitors.
THIAZOLIDINEDIONES
The thiawlidinediones, or gJitawnes, reduce blood glucose
by decreasing ifl'lulin resistance and inhibiting hepatic gluco
neogenesis. Optimal lowering of blood glucose may tm J to
4 month<; of therapy. The most common adYerse effects are
fluid retention, headache, and weight gain. Hypoglycemia
does not oocurwith drugs in this dass.liverfunction should
be monitored, because thiazolidinediones may be hepato
toxic; in 2()()(), trogJitazone (Rezulin) was withdrawn from the
market because of drugrelated deaths due to hepatic failure.
Because of their tendency to promote fluid retention, thiazo
lidinediones are contraindicated in patients with serioU'l
heart failure or pulmonary edema. In 2007, black box warn
ings for congestive heart failure and for increased risk for my
ocardial ischemia were added to the rosiglitazone label. Using
this drug class in patients with heart failure can increasefluid
retention and exacerbate heart disease.
MEGLITINIDES
The meglitinides are a newer class of oral hypoglycemics
that act by stimulating the release of insulin from pancreatic
islet cells in a malUler similar to that of the sulfonylureas.
Both drugs in this class have short duratiofl'l of action of 2
to 4 hours. Their efficacy is equal to that of the sulfony
lureas,and they are well tolerated. Hypoglycemia is the most
common adverse effect.
NEWER AGENTS
Several new drugs have been approved that act by affecting
the incretin-glucose control me.:hanism. Incretins are hor
mones secreted by the intestine following a meal, when
blood glucose is elevated.lncretinssignal the pancreas to in-
crease ifl'lulin secretion and the liver to stop producing
glucagon. Both of these actions lower blood glucose levels.
Diabdi<.pati,,"l> ar" ullal>l" lu ,,,<.rt:\,, ul<.rdulS iu
amounts, thus disrupting an important glucose control
mechanism. Drugs may be used to modify the incretin sys-
tem in diabetics in two ways: by mimicking the actions of
incretins, or by reducing their destruction.
Exenatide (Byetta) is an injectable drug that mimics the
effe.:ts of incretins. Exenatide lowers blood glucose by in
LibraryPirate
Oru9' (or Olabete, Meliltu, 689
... Prototype Drug I Metformln (Fortamet; G/ucophage, G/umetza, others)
Therapeutic (I ass: Antidiabetic agent Pharmacolog ic ( lass: Hypoglycemic agent; biguanide
ACTIONS AND USES
is. orAl for mon.ging i)'p" 2 DM of
in tiflo(tiVl'1ItSS .nd safety. It is UIN or in combin.tion with other orAl hy-
poglytemic:.or insulin. It is appl"OYfd for "sr in {hildlt'fl.gr 10 or abo'll.'. k is
milablt as tlblrb, solution (Riollll't), And
forms GllKophagr XR, . nd GlUOII'w).
Metfonnin falling .md pOllprandiolgllKOII' Ievrk.A major adwn-
tageof thr drug i5 that it don not talM Ilypoglycmi . Thedrug actions do not
dtprnd on lIimuliiting insulin it is .bit to mr gUcosr levm in pa-
tients who 00 longer srrlt insulin. In addition to Iowrring blood gluc:OIt lev-
t is. it lowers triglywidt and total i nd Iow-dtnsity lipoprottin
Itoiris. and promotes wright
Metfonnin is U IN ofi-t.btl to urn womrn with poiy<ystic ovary syndrollll'.
WoOll'n with this .yndromr havr insulin ft'IistalKt i nd high II'IIIm insulin
rls. Mrtfonnin rtduc:rs inlulin which in tum IowrB insulin .nd an
drogtllltffis. thJ. ft'Itoring oormal mt nllrual cy<ltsand arolation.
ADMINISTRATION ALERTS
Sustainro.rrit.u tabitts must bt swallaMd wholt and oot {rushed or
,""".
Strum gu.:osr Ieffis shoold lit obtaintd 3 months,i nd tht, clost ad-
it/llod a{cordinqly.
Oiuontillll' lIII'dication if signs of "idosis orr prrsenl

PHARMACOKINETICS
Onset: Its. thdo I h
I- J h (regular rriNlI'); h (tlttndtd rMm)
Halflift': 17 h
Duration: 12 h (rtgular II'iNst};2( h {nttndtd ""NSt}
creasing the secretion of insulin, slowing the absorption of
glucose, and reducing the action of glucagon. The drug was
approved in 200S as an alternative to metformin in patients
who have not achieved adequate glycemic control during
metformin or sulfonylurea monothernpy. The drug must be
administered subcutaneously, often twice a day, and causes
significant nausea, vomiting, and diarrhea in some patients.
It does not cause hypoglycemia.
In 2006, the FDA approved sitagliplin (Januvia), the first
drug in a class known as the dipeptidyl peptidase-4 ( DPP-4)
inhibitors. The normal function of the DDPA enzyme is to
break down incretins. Sitaglipton inhibits DPP-4, thereby
reducing the destruction of incretins. Levels of incretin
hormones increase, thus decreasing blood glucose levels
in patients with type 2 DM. The drug is given once daily by
the oral route. Several other DDP-4 inhibitors are in the
later stages of clinical trials, and may be approved in
the near future.
Pramlintide ( Symlin) is an amylin analog, used along with
insulin in persons with type I or type 2 DM who are not able
to achieveJl,iucose control by the use of insulin alone. Amylin
ADVERSE EFFECTS
most <om ..... n . <MIW .ffom orr GI ... latod And in<kId. .. """iting.
abdominal disc:omfon, mmlli< taSit. diarThta, and anorexia. k may .Iso <OUII'
headacht. <lgitation, and fatigut. Unli e the OII'1form in
.. rrly {alMS hypogl}o:t mia or wright Tht most stnous ad!,M tffed is
lactic:acidosis, whim is i "II', though plttntiallyfatal,condition.The riskfor lac-
tic: icidosis is ilKrr.1N in patients with renal impainnrnt, liYer
infrction,('I(nY!' akohol intae, shock,or hypoumi .
Contraindimions: Mrtfonnin is coomindic:atod in patients with impairrd .....
nal function, btciUll' the drug <on list to lOIic Itffls. k is ilso {ont .. indicOltd in
patients with hei n failu .... liYer fai kJ .... history of Llctic: "idosis, or {onrurrrnt
miolJ! infK!ion.1t i5 contraindicated for 2 days prior to and 2 days .fler rrcffl-.
ill9lV r.diographic: (ontrast Metfonnin is ustd with <oution in patients with
antmi., diarThta, rorniting or dthydration, frYer, gastlOparrsis, or GI obstllJ(-
tion; oldtr adults; hyJll'rthyroidism; pituit.ry iosuffic:ielKr. trauma; ind prrg-
nancy and Iact.tion.
INTERACTIONS
Dru;rDrug: AkohoI inmns iMrist forlao:tic:
tht> for hypc9yr:fmia.1ke with IVraciographil: torlUN
may caust IKtK acidosis ioo aU!\' rtoal failUrt.1lIf folowill9 aug. I!Ia'f dtoMe
renal oUftion of rMformin:.mIoridf,<irnetidof,
ImljOne,prwinamile,q..rilioe. rani:idioe. triantmne, trilll@l.m,aoo
'I.lOOIOI)'<in.Acarbase OW)' dKrNIt blood IfwIs of IIIfIformin.1ke with olhfr
.JltHiabW< aug. plrtrliites h)1lOljlycfllic. fll"em.
Liil Tl5Is:ioieriorroi1l!1a'f IiIW iakf-poW'/f rtSlits fur IIinMy i21ones.
Herba VFood: MMforrnin declNlfS 1M absorption of litamirl 8" and folic acil. Garlic
.!lid gillfll!j may iooUlf h)l109lyu'II1ic etIim.
l INi ment of Dftrdose: For or of lactic: acidosis, he-
modialysis <on bt usod to corrK! the acidosis and remo'/t ('I(ffi IIII'tfonnin.
9/!{pf 10 M)Nurllllq/Ql for Q NlJrlifll) I'rIKm fool'; lpKlk 10 rN<i drui}
is a small peptide released by the beta cells of the pancreas at
the same time as insulin. Its natural function is to act syner-
gistically with insulin in glycemic control. Pramlintide slows
gastric emptying time and increases satiety, thereby leading to
reduced calorie intake. Pramlintide is administered subcuta-
neously immediately prior to each meal, using U-IOO iru;ulin
syringes. It cannot be mixed with insulin, and must be in-
jected into a different site than insulin. When initiating treat-
ment, rapid- or short-act ing insulin d= arc usually reduced
by 5O%.A major adverse effect is hypoglycemia.
In 2009, an old drug with a new use was approved to treat
type 2 DM. Bromocriptine (Parlodel ) was originally ap-
proved in 1978 to treat Parkiru;on's disease, pituitary ade-
noma, acromegaly, and for women with amenorrhea and
infertility caused by excessive prolactin secretion. The drug
acts on the central nervous system to increase levels of the
neurotransmitter dopamine. Marketed as Cydoset, the ex-
act mechanism by which it improves glycemic control re-
mains undear. The most frequent adverse events associated
with bromocriptine are nausea, fatigue, dizziness, vomiting,
and headache.
LibraryPirate
690 Unlt l TheEr.doar .... SyS!,-""
NURSING PROCESS FOCUS PATIENTS RECEIVING ORAL HYPOGLYCEMIC THERAPY
Assessment
Bilseline assess ment prior to administration:
Understand the reilson the drug hu litton pre<ribtd in onIer to for
therapeutic: tffNIs il nd to plan for te.l(hingl'ftds (t -9. new onll't of I)'pt 2
diabttrs with hypel<jl)'(emia aqenu to used aionl' or along
with IUppltmental insulin).
Obtain a (omplelt' health histol)' ilKluding rodoc:rinl', u rdioYa \lular, hepatic,
or R'nal dill'm; pregnan(y;or bR'ast-freding. Obtain a drug history ilKklding
allel<jies, cumm plfS(ription and OK herbal preparatiom, {afft inl',
niroti,.,.,.nd akoOOl UII'.Bt ,lert to po .. iblt drug int.radion .
Obtain a history of (urrent symptorm,dur.nion and l!"Ierit, and other related
signs or symptorm (t.g. pilresthesias of hands fffi i nd krftr
mremities for posible uker<lliom.
Obtain a dietary histol)' induding uloric imake, numbtr of mtak,and snoKks
ptr day.MII'S! fluid intake and typtof fluids ronwm.
Obtain vital signs,
Enlwtt ippropriate laboratol)' findings k g., (8(, Murol)16, glumII', Al (
profilt, hepatic ilnd R'nal fulKtion
Assessment throughout administration:
MIl'S! for desirft! gkKDlt ie\'els It'rruin within
oormallimits,Al( Itvels dernonstr<lle adequate (ontrol of gllK_).
CominUl' periodic monitoring fun{tion srudies.
Mlesl for and R'pOrt promptly ilny adYent eIfrru i ppropriate to the type of
oral aqeot:signs of hypog/yI:emia (most commonly ilSSociated with
sulfonylulffi and meglitinides) indude naUSfa, pale,l welting. diaphoretic,
tR'rnon, initability, hHdadJe, deeR' IevfI 01
(OIIS{iousnes So Also for and promptly R'pln signs 01 h)'PfI'llyr:rmia (5lJ(h
is AUIhed. dl)' !kin, polrJriiI, polyphagia, polydipsia, drowsiless, 9)'(01tm,
ketonuria,.l(ttont-b'Mh),gastricupltl,dianma, ilftction,andtdtma.
Potentii!ll Nursin9 Dii!lgnoses
Imbalanced Nutrition, MoR' Thin Body Rrquilt'mtrm (typt 2 diabtlt'S,
It'lattd to insulin and intake mon than body
Oeficirm (drug thtl<lp)')
lnefienr.e Theraptutic Regimen M.I nagement (R'lited to deficitm
knowledge or altered (ompliaoct with PR'S(riiltd ue<llmenQ
Altered Compliana, NOlKompliaoct (R'lattdto mmpleuty oltreument pl.lll.
dtlititnt knowledge)
Risk for In;"'1)' (relattd to drug elf1\, lack of sellliltion in ellR'mities
from
Riskfor Infection (relattd to hypel<jlycemia, impailt'd cirtulation to
f1{tlt'mities, neuropathies)
Pli!lnnlng: Pi!ltlent Goals i!lnd Expected Outcomes
The patient will:
ExperNoOCf therapeutic tihds (t -9. blood sugar within oormallimits).
St free from,or fxperience minimal. adYerse tiftds.
VerlJalizt an understanding of the drug's UII', advern t ffrru, a nd rtlJuired prfUutions.
properseihdministration of the mication (t -9.d<M, timing. when to notify plO'/id!or).
Implementi!lt ion
Interventions i!l nd (Ri!ltionales)
Ensuring thfrilpeutk t lffds:
--+
CominUl' a IStI>ments a I earlier fur thrraptUlic dftCI5.
on the of hyprrglycemia, supplemental inwlin may
I"ftdtd for blood gllKOSt le>iels to return gradually to normal.)
Ensure dietal)' nl'tlk are mtl ba>td on the need to Iose,gain, or maintain
cuntllt weight Ind gluro\e Ievell.Conluh with a dietitiln is needed. umit
or t limioatt akohol Ust.(Adequate ulori{ amounts and protein,
carbohjdralt'S,and fats supponsoral hypogl)'(tmic regimen forgllKolI'
mnuoLActjyity and lifestyle will ilsa fil{\olt'd imo
Alcohol tiln raill' and then plI'(ipitOlJlIy IoWfr blood sugar as akohol is
IIK'tabolizrd, l<Iising the lis k of hypoglyct mia. Patients on IUlfonyluR'as
should awid or tliminate to pl"fffnt a disufiram-like
R'adion.)
Patient i!ln d Fi!l mily Educi!lt ion
the patient to rtpOn any rrtum of origin.ll sympwm>.
Te.l(h the patitnt symptorm ofhyper-Ind hypoglyo:emia tooillerYe for
and instruct the patitnno mk the (apillary IIovel
"Min imizing eff !"I"later in this table) rootinely ilnd if sym ptorm
aR' prestlll Prom ptly R'pln any OO1iceabllo symptorm and concurrent
capillary gllKoseltvel to the heahh Ult' provider.
Re>iiew cumnt diM, lifestyle, and adjyity Itvel with the a
dietitian {onsuh bill'd on the I'ftd to alter dirt or food choic:es .TNth the
to limit or t liminalt'akohol ulI'.lf ilkoholic are
mmsumed, limit to On!' per day and take i long with i complete mt al to
enlUre that intake balaoces akohol metabolism.
Imtrutt the patient on sulfonyureas (t.g. glyburide) to avoid or t liminalt'
almholull'.
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0I ... l<r4ol 0"'9' (or Olabele, MeUllu, 691
NURSING PROCESS FOCUS PATIENTS RECEIVING ORAL HYPOGLYCEMIC THERAPY (conllnued)
Implementation
Interventions and (Rati onales) Patient and Family Education
Minimizing adft rse i!ffl!Cts:
ContinU!' to monitor lolpiliary gluc<M itftk.Cllfdwith tht lIt.Jkh .:art lostllKttht p"ifm on blood glucost monitoriog appropriatt t<'(hniqUf1 10
providtr giving an 0,,1 hypogl)'Ct mk ifblood glu= is len than 70 obtain .:apil b ry blood levds, foi loWl'd by rrtum.dtmonstrltion,
mgldl or per Il' rl as ordered. (D.!ily glll(ose tspt<Y II.,. before and when to ron\a(tthlo hIoalth wr provider (t.g.,gluc:<M than
meals, will mist in m,imaining ,dequate (ontrol of blood glucose .J nd aid 70 mgldl}.Monitor !Mand tilt proper lunctioniog of ,II OIquipmem
in mf lSiog tht appropriateness 01 rurrent dlll9 thtrapy.) 10 be used at homt.
(onlin ... to monitor ptriodk lab 1< l...d,
0
In<lllKt th. potirm on tilt to mum prriodiully for lob worl
lipid plOfiit. and and renallunction 51udies. (This mists in 0 Tta{h tht p-atifnt on suifonylurNsto immtdiately rtpOn any naUIN,
cleterminiog glucose lor any chall9f in mtdiLltion,and
yomiting. yellowing of I kin or l(1era, abdom inal or
assesses lor {ompliLltionl..A 1{ Ie\'els plWidea mt.nurr of gl(l(oll' {ontrol
darkt niog 01 Uriflf to the hIo,1th (.I re provider.
anr 1l"/eI".1 monlM'limt. SulfonykJlNI tna'J' (.lUSt hepatic:
0
TNch thtp-atitnton toimmtdiately reportlll)'
Biguanidfl may <aiM b{tic: Ilidosis.)
dtm-ued rflp;ratory rolle, or lJI'III'I"al body idles to the he!1th lol re provider.
kstssfor s)'lllptoms d hypogiyremia.1f al!' ooted, Trach the p-atitnt 10 always w ry a quid:-.Kting mbohydrate SooKt in
provide.J qtidt-aailg wbohydratf IOUKf (f 4, or other simple lUlar), <as!' S)"IIIptomsol hypoglyctmia ocrur.1f unsul!' whethtr symptoms
and then chedc the .:apila" IMI. RtpOfIguOlt Itvtk IfIs tllan 70 indicale hypo>- or hypt"llylt mia,ln'at as hypoglycemia and then m<'(k
mgloJ.. or u ordtrtd.1f tile mealtimt is oot immediate, PlOYide a Iongtr-tiog lolpillary gUcoll'.lf symptormare OO1 l!' lifoItd in 10 10 15 minutes,or if
protei! SOUII? to t nsure that hypoglycemia dots oot rtru". (Hypoglycemia is blood glucose is btIow 70 I119/dl (or Il'ramrtff"S aI oniered),ootify the
t!pf(ialy to oc:rur ij the Il'titm is takiog sulfonylul!'as or hNlth loll!' pfDl'idtr immtdiately.
although hypoj)umia may oc:rur with OIlItr I)' ptS of oral
t!pf(ialy if food SOUl\?! ,re Providing I -acting .:arbohydrate
lOIne ard rhm tbediog thelol pilary ItY!-lwil ffIIUl!'thatglucoll'
dots notdtcll'Nflnher whit iotatilg the tfll ingtqtipmtnl.When
in obJb!, tll'atilg symptoms for lUIpt<1ed hypogiyCffllia is sa!!'r than alowiog
further dtcI"Nses n gUrose ,nd possilr bu 01 conscioulntss with adYerst
d f<ts. Smal idditional amoumsli wbollydrates will not dramaticaly
iOONIof blood sugar if testing shows .J hYIlf"liyremic: rpisodtJ
0
Monitor blood glullllI' more duriog periods ofill!lflsor SUfIS.
0
lostllKt the patifm to dlfd Itvels wlltn ill or
(Blood gluc<M lel'fls mly ifl(rme or<lell!'aIf ruring ptriodsofilllll' ss or und ... slftosl.. m.J)' ifl( l!'ase blood glucose.J nd supplemental ifI\Ulin
SUfIS. FIl'qU!'llt monitoriJ19 ruring thtst limes helps to Pl!"leflt may be Il'quil!'d if oral hypogly{fmin do not rontlOl blood glll(_ .IIIf1f IS,
h)'p09I)1(t mia dnd ffl\Ull'"5 adtquatt gllKOIe controlJ fl pt<illily moc:ialtd with anoll'lia, naUSN,or vomiting. may dt<rease tilt
for an oralhypogiy!:emk dlll9. Notify thf he,kh I'I!' provider if
unable total normal meals during ptriods of illfIfII or SlIl'IS for I possible
(hange in the dlll9ll'9imt n.
[lI(oor'9f ifl( rtastd "'tivity but monitor blood btlol!' ,nd after
0 Trach tht p-atitnt the benefits olifl(rea!ttl "'tivily ,nd but to
OeltM and begin any new or ifl(rea!ttl l'Jtltise routilll' gradually. ContinU!' begin any new rootiflf or ifl(l!'all' in flmM gradually.
to monitor for hypoglycemia up 10 48 hours aft ... txen:M.(ExtrOse .J lSists
0
lostllKtthe patifm to dlfd glll(ost Itvels morf btfore ,nd
mUl(lts to UII' glll(_ 1OO1!' tffio:ifmly and ioouses ifI\Ulin in

tht tiSSllfl, towmog tht blood 1119" and dlSistiog with weight lontrol.
Benefits 01 v:en:M and lowered blood gluc<M may lontinue lor up to 48
hours, ill(l!'lsing the risk 01 h)'p09l)'Cf mia during this timt. FIl'qU!'nt
monitoring helps to f mtln' adequate gl(l(oll' (ontrol.)
0 Monitor for h)1lfrll'mitivity .J nd allergic: I!'actions. Contillll!' to monitor the Te.J<h thr p-atifm 10 imflll'diatt ly report <l ny itthing. rashes, or IWt'liing.
throughout therapy. (Ana phyl"'tic: I!'adions 'I!' pO! although Il'rtirul arly 01 11{f, tongue or la{f; urticaria; flushing; diuinflS; S)'l)(opt;
rare. As \efIIitivily OCIUII, rt'adions may (ontinU!' to <leYeiopj wheeling; throat tightness; or dilfKUlty breathing.
0
for Pll'9nanc;. (Some dfll9l .Jl!' loltegory C and
0
Te.Jch the Ifmate p.Jtifm of(hildbe,ring age to altrt the hf.J kh loll!'
mun be SlOpped during Pftgnancy.D.Jt to the in(l!'. siog mmbolic: III'tds providtr if plf9narq is IUIptUM
01 Pll'9narK): supplemental ifI\Ulin,or ,wit{hiog to insulin IDVtrage, may bt
rtqUil!'d.)
ContinU!' to monitor for tdtma, BP, Ind luog sounds in patients taking lostllKtthe pa\ifm to immtdiately I!' port any edem.J of hands orfeet.
thiaroiidionts. may " !Medema ,nd worsming of hea rt d)'lopflfa,or rJ<flSivt latigU!' to tilt provider.
f,i kJfI' J

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692 Unlt l TheErdo<:rl .... SyS!'-""
NURSING PROCESS FOCUS PATIENTS RECEIVING ORAL HYPOGLYCEMIC THERAPY (COlltlnued)
Implementlltion
Interventi ons and (Rationales)
Monitor for in palimts on (OOOJrTI'nt bet,
bioc:ker therapy. (lleta bkKkffi antagonize the auion of lOme oril
and may tht symptolmof.J hypoglyt:tmic fpisode,
,Uowing tilt blood goose to drop lower it is ptn:eivtd.)
Patimt undtrstanding 01 drug thuapy:
!ht opportunitie during administration of and during
mflSmtnts to discuu tilt rationalt for drug thtrapy, desired theraptu tic
most (ommon admseeflecu, paramt ttn for when to ull tht
lIt,kh any monitoring or prtUutions.(!hing
time ruring nUBing Wt helps to optimire and reinfon:t kry

Patient lind Family Education
Teach the plllient on (OIKurlt'llt bm-bkKktr therapy to monitorupillary
blood glll(= moll' to(heck the blood glll(= if minor
milH}tl in lM'rall frtling is ptKeiYrd (t.g., minor '9itation or anUeiy,

TIlt or(olll'9iY!'r should beable to SUle lilt I"NlOn for lilt
druq;.Jppropriated= and tflem to oiulft for
,nd wlltn to rt port;and any rrquilt'lllttm of mtdication therapy
(t.g.,drug nttdsduring eRltilt, illllflli).
Patient of drug therapy:
ImtllKt patient to carry a wa Iltt identification (oIn:! or r
idtntiliution jtw! Iry ind it.iting diabetes.
--+--
When idministering the mtdit.ition,imtllKt the or(olregivtor
in the proper of the drug. (Utilizing timt ruring nursl'-
adminil1ration of these drugs hel()lto reinfon:t tt.J{hiog.)
The patiml, lam or (oIll'9iY!'r is i bit to distuss i pplOpriatt and
adminimation needs, ill(luding:
Timing of giY!'n oll(e a day, takt approQmattly JO
mimMs beIorr tht fiBt mt al of the day.Alpha-<jlutosidast inhibitor;
(e.g.,aurbold !hoold be t,ken with ml'als.
Insulin requiremtnts:Whilt typt 2 diabetics proO:Kr IOmI' illlUlin,
illlUlin injections may be required in addition to the oral
drug on ocmion. This dots not IIf<ffiariiy signal a of the
diINst (ondition, but may be, tfmpoliry I"ftd.
EVlllulltion olOutcome Criterill
tilt ffiKli'l t ntss of drug therapy by confinning that patitnt goals and rlpKltd ootOOIlll'l haw mtl (1 "Planning1.
5H TGbIt .J (/If a 1& If dfl!lJS to which rIrm nll'irIIJ f1PliY.
COMBINATION PRODUCTS
Because the categories of oral hypogl)"emics work by dif-
ferent mechanisms to lower blood sugar and have different
pharma(ok..inE"ti," properties, (ombinations of antidiabetic
agents have been developed to maximize the therapeutic ef-
fects and minimize adverse effects. The main advantage of
taking a combination drug is that it is more convenientlhan
I .::: Chapter REVIEW
KEY CONCEPTS
taking two or more separate drugs, and it may improve ad-
herence to the therapeutic regimen. One popular combina-
tion drug is glyburide/metformin (Glucovance), which
comes in various strengths such as 1.25/250,2 .5/500. and
5/500 mg. Combinmion products are usually not indicated
for initial therapy, but are for patients who fail to adequmely
control glucose levels with the use of a single drug.
The nwnbt>red key concepts provide a succinct sUflUllary of the important points from the corresponding numbered section
within the chapter. If any of these points are not dear, refer to the numbered section within the chapter for review.
44.1 The pancreas is both an endocrine and an exocrinegland
Insulin is released when blood glucose increases, and
glucagon is released when blood glucose decreases.
44.2 lYpe I DM is caused by an absolute lack of insulin secre-
tion due to autoimmune destruction of pancreatic islet
cells. If Wltreatoo, it results in serious, chronic conditions
affecting the cardiovasculm and nervous systems.
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44.1 lYpe I OM is treated by dietary restrictions, ext'rcise, and
insulin therapy. The many types of insulin preparations
vary as to their onset of action, time to peak effect, and
duration.
44.4 lYpe 2 OM is caused by alack of sensitivity of insulin re
ceptorsat the target cells and a deficiency in insulin secre-
NCLEX-RNO REVIEW QUESTIONS
D A patient re.::eives NPH (Isophane) insulin at 7:30 A.M.
Based on an understanding of peak time, the nurse should
assess the patient for hypoglycemia at what time! Write
your answer below.
D The patient is scheduled to receive 5 units ofHumalogand
2S units ofNPH (Isophane) insulin priorto breakfast. What
nursing intervention is most appropriate for this patient!
1. Makesure the patient's breakfust is ready toeat before
administering this insulin.
2. Offer the patient a high-carbohydratesnad: in 6 hours.
3. Hold the insulin if the blood glucose level. is greater than
lOOmgldL
-4. Mministcr thc medications in two "'1"""tcsyringcs.
o The nurse is initiating discharge teaching with the newly
diagnosed diabetic. Which of the following statements in-
diCltes that the patient needs additional teaching!
1. "If I am experiencing hypoglycemia. I should drink 1/2
cup of apple juice.
2. "My insulin needs may increase when I have an
infection"'
3. "I must draw the NPH insulin first if I am mixing it
with regular insulin."
4. "If my blood glucose levels are 1ess than 70 mgldl., I
should notify my health care provider."
o What patient education should the nurse provide to the
diabetic patient who is planning an exerdse program!
(Select all that apply.)
1. Monitor blood glucose levels before and after exercise.
2. Eat a complex carbohydrnte prior to strenuous exercise.
CRITICAL THINKING QUESTIONS
1. A 28.yt'ar-old woman who is pregnant with her first child
is diagnosed with gestational DM. She is concerned about
the fact that she might have to take She tt'Us the
nurse at the public health dinic that she does not think she
can self-administt'r an injection and asks if there is a pill
that will control ht'r blood sugar. She has heard her grand-
father talk about his pills to control his What
should the nurse explain to this
2. A type 2 diabetic on metformin (Glucophage) reports
that he takes propranolol (Inderal) for his hypertt'nsion.
What concerns would the nurse have about this combina
tion of medications and what would the nurse teach tht'
patient?
tion.lfuntreated, the same chronic conditions result as in
type I DM.
44.5 lYpe 2 OM is controlled through lifestyle changes and
oral hypoglycemic drugs. More than six classes of drugs
are available for the pharmacothernpy of type 2 OM.
3. Exercise may increase insulin needs.
4. Withhold insulin prior 10 engaging in strenuous
exercise.
5. Take extra insulin prior to exercise.
D A type 2 diabetic has been NPO sinU' midnight for sur-
gery in the morning. He has been on a combination of
oral hypoglyU'mic agents (OHAs). What would be the
best action for the nurse to take concerning the adminis-
tration of his medications!
1. Hold all medications as JX'f the NPO order.
2. Give hinl the medications with a sip of water.
3. Give hinl half the original dooe.
-4. Contacllhc health OIl"<" provi<kr for funhcr orders.
o A 63-year-old patient with type 2 diabetes is admitted to
the nursing unit with an infected foot ulcer. Despitt' pre-
vious good control on g1yburide (Micronase), his blood
sugar has been elevated the past several days and he re-
quires sliding scale insulin. The most likt'ly for this is:
1. it is a temporary condition related to the stress response
with increased glucose rt'lease.
2. he iscon"ening toa type I diabetic.
3. the oral hypoglycemic drug is no 10ngerm>rJdng for
hinl.
4. diabetics who are admitted to the hospital art' switdied
to insulin for safety and tighter control.
3. The patient has insulin g1argine (Lantus) and regular in-
sulin ordered for every morning. Explain the implications
of administt'ring these two types of insulins.
Set Appendix D for all5weTl and rationalel for all activitiel.
EXPLORE
M)'ttJrsinyKit is \OOr Me tor oolite chapter [/!\liN! aM
resolKcu. f'l1lIl'we fa' WItl1 additimal NCt.x->I)1e llIactic!
QlIIlSIions. Intor;lCllw (lSS91m$1l& M(j actlYltios. web Iilks, animations
arld vi:l=.ammorel
Register )'0\1" access code 1Iam the frOnl of 'flU book at
www.mynurstngklteDIII.
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DRUGS AT A GLANCE
ollAt (ONTRACEPTIVES
,.695
o 000 nonrllindroM
(Ortho-NovumJ ,.XXJ
Progestl rKlnlyAgents ,.fiJt,
DRlJCiS FOR EMERC>ENCY CONTRACEPTI ON
AND PHARMACOlOGIC ABORTION pq JrXj
HORMONE REPlACEMENT Ttl.ItAPV pq lIH
Estrogens and EstrogeniPfOOtstin
Combilliliom /llI/' JIJI
o COI1jugatN ","'gnu ...
EnjuviQ,I'mrnI,;,,/ IIfti\lS
DltlHiS FOR !lTSfUNCTIONAl unRINE BlEEDI NG
...
Progeltlm IIIfti'OlJ
.-aaral.",",""Q)
...
ptlftlf1l
Oxytodo ,.u
Q oxyrodn(Pirodn) fJIIIJ'}QI}
&got Alkaloids ptqiU
Prostaglandins ,. JOI
TIXoIytics fIIIIltJr1l,
DR\JCiS FOR FEMAU INFERTIUTY
ANOENOOMETRIOSIS ,.m
KEY TERMS
(OIpIIl luteUIII fJIIJ'695
cl)'sUKtionalltl'fine blHding ,. JIJS
.lIdtmtri:lsis ,. m
eIIOtfn fIIJ1'69J
JoIid@'itilllWlinlitormOIll![FSII) jXkT695
gtnHOtropilHtlrning hor_IGnRH)
... m
Drugs for Disorders and
Conditions of the Female
Reproductive System
LEARNING OUTCOMES
After reading this chapter, the studmt should be able /0:
,. Describe the roles of the hypolllalamu5" pituitary,and in
maintaining female reproductive function.
2 . Explain the mechanim15 bywhkh estrogern and progestin! pre'Rnl
conception.
3. Explain how drugs may be used to provide emergencycontracfplion
and to terminate early pregnancy.
4. Describi' thf rolf of drug th-i'rapy In the trfatment of menopausal and
postmfl"lOpausal symptoms.
5. Identify t he role ofthi'female sex hormones in the Ireatment of calKer.
6. Discuss th-i' usesclprogestlns In the th-i'rapyof clysfulKtional uterine
blli'E'ding.
7. Compare and contrast t he use 01 uterine $tilTllllants and relaxants in the
treatment of anteparWm and postpartum patients.
8. Explain how drug therapy may bE' used to treat female infertility .
9. Describi' the nurw"s role in the pharmacologic management of
dl5Ofd&n and conditions of the femak! rfproductive system.
, O. For each of the das'ili'S shown In Drugs at a Glance. know representative
drugs.and the mechanisms of dlUg action. primary actions,and
Important adVl!fse effects.
". Use the nursing process 10 carl' for patients who arl'rKli'iving drug
thef<l PY fOf dlsOfOers and conditions of the female reproouctlvf system.
h_ II' pla(HlfQ\ (IIln 1""J'lf)4
inffrtililJ piq 7Il
lutfrimt honnorw(lHj piZ/t695
IIIfMIYNO jIIlIJt;t\l
o.,.1I1iMl fII1J' fiIj
111)1000 JlDIT lW
fII1J' 695
prosuglMlilil piqlfJ(J
IO(olyt!( fllJll'lW
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OIop1fl45 D"'9' lor Dbord<>" aM Condition, nftl>o Female ReptOducdve System 695
H
ormones from the pit uitary glllnd lind the ovaries pro-
vide for the growth lind continued maintenance of t he
female reproductive orgllns.Although they are referred to u
reproductive or sex hormones, these substances Impact vlr-
tuaMy every body syllem Including effects on cOiIgulation,
blood vessels, bone, musdes,overllli body metabolism, and
behaviOf. Hormonallherapy of the femille reproductive sys-
tem is used to achieve II variecy of goals, ranging
from replacement therapy, to prevention of pregnancy, to
milk production.Thlschapter examines hormones and drugs
used to treat assoclllted "";th the female repro-
ductive system.
45.1 Hypothalamic and Pituitary
Regulation of Female
Reproductive Function
Regulation of the female reproductive system is achieved by
hormones from the hypothabmus, pituitary gland, and
ovary. The hypothalamus secretes gOl"llldotropin rele,sing hor-
mone(GnRH), which tr.lVe1S a short distance to the pituitary to
stimulate the secretion of folliclt llimul"ing hormone (FSH) and
luteinizing (lHI. Both of these pituitary hormones act
on the ovary and cause immature ovui an follicles to begin
developing. The rWng and falling levels of pituitary hor-
mones create two interrelated cyd es that occur on a peri-
odic, monthly basis: the ovarian and uterine cycles. The
hormonal changl.'S that occur during the ovarian and uter-
ine are illustrated in ,.. Figure 45. 1.
Under the innuenceofFSH and LH,sevenl ovarian folli-
cles begin the maturation pro<:ess e:lch month during a
woman's reproductive years.. On approximately day 14 of
PHARMfACT5
Thm is. widr IlIII9I! d. 1\ which_IUd! mtllOpKlSe: aof 1110
wolllfnwilstop btfoIt '9t 4O,ind S of 1110 womenwil

About half the 01 :ly$functiollil blttding irtNgrlOSfd in
wollltn older tMn 45; mol USfS oco.rr ........ in !hOSt
younger th.n 20.
most common It.!:>n wtr,-womtll bfcomt prtgn1nt while on or.l
{onrfiCf1l\rnS i! skippilg. dolt.
A nonsmoking lIItd 25 !(I 29 hna 2 in 100,000 chancrof dying
from {omplic.llionsdulto contr.ctptrns. The rille thal1 woman in
thi! age group will die iI an .utomobilt 1COOtnt is 7. in 100,000.
Or.tl mmractptiW"l (onft! benefits btsidn COIIlr1ception. k i! estim.ted
!h.t urn rUT thf)' pmem tilt following:
50,000 fAstS of ptftM; distue
10.000 hospitaliutions for Kiopic prtgnincy
27,000 fAstS of imn-delicitll()' MfOI II
20,000 hospitaliutiOl1i for typtS of rtOOIrlilignint brost distoM
tbe ovarian cycle, a surge of LH secretion causes one follicle
to expel its oocyte, a process called The ruptured
follide, minus its oocyte, remains in the ovary and is trans-
formed into the hormone-secreting COt])l,lS l.t"l1. The
oocyte, on the other hand, begins its journey through the
ut erine tube and eventually relchl.'S the uterus. If concep-
tion does not occur, the outer lining of the uterus degenet"-
ates and is shed to theoul'lideduring menstruation.
45.2 Ovarian Control of Female
Reproductive Function
As ovarian foUicles mature, they secrete the female we hor-
moCll.'S estrO!lfrl and pT09tflHOIM'. Es trogen is actually a generic
term for three different hormonn: est(;lodiol, eslrone, and
estriol. Estrogt'fl is rnponsible for the maturation of the fe-
male reproductive organs and for the appearance of second-
ary sex characteristics. In addition, estrogen has numerous
metabolic effects on nonreproductive tiss ues, including the
brain, kidneys, blood vessels, and skin. For e.lample, estro-
gen lowers blood cholesterol levels and fadlitates calcium
uptake by bones to help maintain proper bone density
(chapter 47oo). When women enter menopause al ahoul
age 50 to 55, the ovaries stop secreting estrogen.
In the last half of the ovarLan cycle, the corpus lutrum se-
crete, a class of hormones called proge5tins, the most abun-
dantofwhich is progl.'Sterone.in combination with estrogen,
prog<.'Steronepromotes breast development and regulates the
monthly changes of the uterine C)'tie. Under the inftu.mce of
estrogen and progeslerone, the uterine endometrium be-
oomc:s vascular and thickens in preparation for receiving a
fertilized egg. High and eslrogen levels in the fi -
nal third of the uterine cycle provide negative feedback to shut
off GnRH, FSH, and LH secretion. This negative fe!dback
loop is illustrated in ,.. Figuft'45.2. Without stimulation from
FSH and LH,estrogen and ptuge$lerone levels fall sharply, the
endometrium is shed, and menstrual bleeding begins.
Estrogen and progesterone are used as drugs to Khieve
several therapeutic goals. The most widespread pharm:aco-
logic useof the female sex hormonl.'S is 10 pre\enl prerl;lncy.
They are also prescnbed to treat dysfulKlionai uterinebleed-
ing, symptofl"L<; of menopause, alld certain neoplasms.
ORAL CONTRACEPTIVES
Oral contraceptives (OC) are drugs used in low doses to
prevtnt pregnancy. Commonly referred to as "the piU; they
pr evtnt fertilization by inhibiting ovulation. Selectl oral
contraceptives art' listed in Table 45.1.
45.3 Estrogens and Progestins
as Oral Contraceptives
Mosl 0Cs contain a rombination of estrogen and prcgl.'Stin;
a fev preparations contain only progestin. The most com-
monestrogen used for contraception is ethinyl eslradiol, and
LibraryPirate
696 Unlt l The Er.docrl .... Sym'm
Ovarian
cycle
Ovarian
hor mone
cycle
Menstrual
(ute rine)
cycle
1
1
j
I

];
,
,
,
"
,
,


Secretory phase
Days: 0 7 14
"
Flgure45.' Hormonal changes during the ovarian and uterine cycles
Source Peaf50fl fducarioo/PH College.
the most conunon progestin is norethindrone. When U'ied
appropriately. female sex hormones are nearly 100% effective.
A large number of DC prepaf3tions are available, differ-
ing in dose and by type of estrogen and progestin. Selection
of a specific formulation is individualized to each patient,
and determined by which drug gives the best contraceptive
protection with the fewest side effects. Daily doses of estro-
gen contained in ()Q; have declined from 150 mcg,40 years
ago, to about 20 meg in modern fonnulatiollS. This reduc-
tion has resulted in a significant decrease in estrogen-related
adverse effects.
Typically, administration of an OC begins on day 5 of the
menstrual cycle, and continues forll days. During the other
7 days of the month, the woman takes a placebo. Although
the placebo serves no pharmacologic purpose, it does en-
courage the patient to take the pills on a daily basis. Some of
these placebos contain iron, which replaces iron lost due to
menstrual bleeding.
LibraryPirate
IlIopltl45 Drug; 10< DI"" ...... ' arod (oodlliom 01 I"" F""",'" Reproductlw SY;lem 697
C"
OvUBlion
Releaw
ot GnRH
""
Maturation ot follicles
Secn!lioo of &atf098n5
DlMllopfTlllOl cI corpus lutllUTl
Secn!lioo of progestins
Flgure45.2 Negative feedback control ofthi' female
reproducllve hormones
A U>IllIllU" l'fUul"Ill will, OG, ""d likt:ly lh" Ill""t [r,,-
quent reason for treatment failure (pregnancy), is forgetting
to take the medication daily. If one dose is missed, two pills
taken the following day usually provide adequate contracep-
tion. If two consecutive doses are missed, two tablets should
be taken on the day the missed doses are remembered and
again the following day. The regular schedule should then be
continued, but a second method of contraception should be
used for at least 7 days after restarting the pills. If 3 or more
consecutive days are missed, the patient should observe other
contraceptive precautions until the regimen can be restarted
in the next monthly cycle. Figure 45.3 shows a typical
monthlyOC packet with the 28 pills.
The estrogen- progestin combination 0Cs act by preventing
ovulation. Thory accomplish this by providing negative feed-
back to the pituitary, which suppresses the secretion of LH
and FSH. Without the influence of these pituitary hor-
mones, the ovarian follide mature, and ovulalion i,
prevented. The estrogen- progestin drugs also make the
uterine endometrium less favorable to recei ve an embryo,
thus reducing the likelihood of implantation. In addition to
their these drugs are sometimes pre-
to promote timely and regular monthly cydes, and
to the incidence of dysmenorrhea.
The three types of estrogen- progestin formulations are
monophasic, and triphasic. The most common is
the monophasic, which delivers a constant dose of estrogen
and progestin throughout the 21-day treatment cycle. In
biphasic agents, the amount of estrogen in each pill remains
oonstant, but theamoWlt of progestin is increased toward the
end of the treatment cycle to better nourish the uterine lining.
In triphasic formulations, the amounts of both estrogen
and progestin vary in three distinct phases during the treat-
ment cyde. All three types of OC formulations are equally
effective.
The progestin-only 0Cs, sometimes called minipil&, pre-
vent pregnancy primarily byproducing thick, viscous mucus
at the entrance to the uterus that discourages penetration by
sperm. They also tend to inhibit implantation of a fertilized
egg. Minipills are less effective than estrogen-progestin
combinations, having a failure rate of 1% to 4%. Their use
also results in a higher incidence of menstrual irregularities
such as amenorrhea, prolonged menstrual bleeding, or
breakthrough spotting. They are generally reserved for pa-
tients who are at high risk for estrogen-related side effects.
Unlike estrogens, progestins are not associated with a higher
risk of thromboembolic ewnts, and they have no effect on
breast cancer. The progestinonly products are pregnancy
categoryX.
Several long- term formulations of oontraception are avail-
able. These e.'(tended-duration fommlations are equally effec-
tive in preventing pregnancy and have the same basic safety
profile as 00;. Theyoffer a major advantage for women who
are likely to forget their daily pill, or who prefer a greater ease
of use. Examples of alternative formulations are as follows:
Depo-Provera: Deep 1M injection of medroxyprogester-
one acehte that provides 3 months of oontraceptive
protection.
_Implants: Implanon is a single rod containing the progestin
etollOgestrel that is inserted lUlder the skin of the upper
arm that provides 3 years of oontraceptive protection.
Norplant, which W3S removed from the U.S. market in
LibraryPirate
698 Unlt l .... Sy<!"",
TABLE 45. 11 S@I@ctedOral(ontrac@ptives
TradeName
MONOPHASIC
-"
Lotstrin 1.5130 f10
OrtlJo.<rdtr\.28
Yallllin
Estrogen
meg
meg
meg
meg
50 meg
meg
Progestin
dmgtIIl!l;O.15mg
oorrthindrorw; 1.5 mg
oorgrstinitt; 0.15 mg
drospirffl:lllr;3 mg
t!IJ)"Ilodioi 1 mg hwia 115OE2hnd 28
BIPHASIC
Ortho-tlovum 10{11
ffiridioilO mcgfor 21 diys; 10 mcgfor 5 diys
IIOII'thindrorw; 0.5 mg I) and 1 mg 1)
dmgtIIl!l; 0.15 mg for 21 diys
TRIPHASIC
Ortho.fIoyum 7{7f7
OrthoTri.(yden
PROGESTIN ONLY
tlliny! meg
meg
meg
meg
meg
tlliny! rWidiol;35 meg
rstridiol;30 meg
ffiridiol;40 meg
rstridiol;30 meg
-
-
-
2CXXl,consisted of sixsmall, plastic tubes filled with
lcvonorgcstrd implanted subcutaneously thot provided
contraception for up to 5 years. /adeUe is a two-rod system
oflevonorgestrel that is easier to implant and removethan
Norplant and provides 3 years of protection. /adel.le has
been approved bytbe FDA but has not yet been marketed.
Although not available in the United Stales, Norplant and
/adeUe are widely available in other countries.
OrthoEvra; Transdermal patch containing ethinyl
estradiol and norelgestromin. The patch is changed
every 7 days for the first 3 weeks, followed by no patch
during week 4.
NuvaRing; A 2-inch-diameter ring containing estrogen
and progestin that is inserted into the vagina to provide
3 weeks of contraceptive protection. The ring is removed
during week 4, and a new ring is inserted during the first
week of the next menstrual cycle.
Mirena; Polyethylene cylinder placed in the uterus that
releases levonorgestrel. About the size of a quarter and
shaped like the letter T, Mirena acts locally to prevent
conception for 5 years.
IIOII'thindrorw; 0.5 mg 1)
oorrthindrorw; mg 1)
oorrthindrorw; 1 mg 3)
oorgrstinitt;0.5mg (phu I)
oorgrstinitt; 0.75 mg (philt 21
1 mg (phu 3)
oorgrstl!l;0.05 mg 1)
oorgrstl!l;O.07S mg 1)
oorgrstrrl; 115 mg 3)
IIOII'thindrorw; 0.15 RIg
IIOII'thindrorw; 0.15 RIg
oorgrstl!l;O.07S mg
Extended regimen oral contraceptives; Seasonale
cotl5ists of tablets containing lcvonorgcstrd and cthinyl
estradiol that are taken for 84 days, followed
by 7 inert tablets (without honnones). This allows for
continuous contraceptive protection while extending the
time between menses; only four menstrual periods are
experienced per year. Seasonique is similar, but instead
of inert tablets for 7 days, the patient takes low-dose
estrogen tablets. Seasonique is claimed by the
manufacturer to have a lower incidence of bloating and
breakthrough bleeding.
Although OCs are safe for the large majority of women,
there are some potentially serious adverse effects. As wilh
other medications, the higher the dose of estrogen or prog-
esterone, the greater will be the risk for adverse effects.
With OCs, however, some effects are more promin",nt at
lower doses. Thus, physicians try to prescribe the combina -
tion with the lowest dose of hormones that will achieve the
therapeutic goal of pregnancy prevention with minimal
adverse effects. Table 45.2 swnmarizes the adverse effects
of the 0Cs.
LibraryPirate
Iluplfl.; Drug; for DI"" ...... ' ar>d (""dltlon, 01 the Fema'" Reproductive Synem 699
Numerous drug--4rug interactions are possible with 00;.
Certain anticonvuIs.ants and antibiotics can reduce the ef-
fectiveness of the contraceptives, thus increasing a woman's
risk of pregnancy. Because 00; can reduce the effectiveness
of warfarin (Coumadin), insulin, and certain oral hypo-
glycemic agents, dosage adjustments may be necessary.
The incidence of cancer in women taking 0Cs has been
stucli.,.j furs",v"TaJ <.l"""cl"" ill kiT!!'" llWllU",n. uf"",,,,,,,,.
studies have demonstrated that long-term use may pose a
slightly higher risk of breast cancer, while others have shown
no relationship. Cervical cancer is also slightly increased, and
this has been closely associated with human papilloma virus
(HPV) infections. However, oral contruceptives appe-ar to
have a protective effect for ovarian and endometrial cancer
that continues for many years after the drugs are discontin-
ued. A protective effect has also been observed for colorectal
cancer. Conclusions of these studies are that women who have
a personal or close family history of breast cancer should ex-
plore nonhormonal means of contraception. All women tak-
ing these drugs should be instructed to perform breast
self-exams and be aware of the importance of routine sched-
uling of mammograms appropriate for their age range.
Figure 45.3 An oral contraceptive showing the dally doses
and the different formulation taken In the Ian 7
28-daycyde
Oral conTraceptives are associated with an increased
risk of cardiovascular adverse effects such as hypertension
and thromboembolic disorders. The estrogen component
of the pill can lead to venous and arterial thrombosis with
resultant pulmonary embolism, myocardial infarction, or
thrombotic stroke. Other conditions associated with OCs
TABLE 45.2 1 Adverse Effects of Oral Contraceptives 10C]
Adverse Effect
Brull milk I!duction
0
i"lmilltd W!'j,jll g,in,

Lupus W'TbaTion
MmIIrnl
Mignintl
l!al/S!i .
Ttralogmidry
Thrombotmbolk dilOfdtrs
Prevention
Somt suggfII that OC, may the IhoUd not be taken IIllil' pollpartum.
I'Kwtten who ttl! for h!llliln papilOll\il virul h8if an iOOl'a ltd rilk of U'f'lKal patitnll should 11m
dltdHIp5. 8tcal/S! ffilO9ffil IJt'II1h of 'flail tyPfl of brUII (,JfI'I; palimll with a histOf} of {,JIl'f
should oot tolU IXI.
OC! m.y (,JUS! inume in bbxI p.ltitnushooJd 0( tlitlapy.
RisI:. iKrNltd with agt,rIoIt,and Iffigth ofThtrolpy.8iood shooJd til' ptriodicilly and
pRlUitll'das nffiltd.
oItm Iaultd b)' high amounll of of p-Ogtstin m.y fIffiI to til' 1000000d.
Wpo! IymptomS may btimt WOfll' illOfllt patimKA IX m.y til' i n opTion for thfIt patimu.
AmmorrllN or hypmnmorrllN oftm QuItd by low "marntl of progtSIil. Thf 00II' of progtstin llliy rH'fd to til' inut'astd.
Srrakthrough blffiliIg and spotting "II' (ommon with low-dolf IXI. Thf patitnt llliy nffil a hHjltr 00II' product.
Estrogffi may dMlI'.tII' or iKrri \I' tht inddmU' of migr"illfS. 8tcaUII' all' a risk fi aor for SlKiR, patitnu
migraill's 5houId seek advice from their he.J1lIt pooiTioner.
Thtst i f! (orrmon tfl'ffil oItm (']ultd b)' high amounu of estroljtll. Thfdoll' of fIIrtI9tII may fIffiI to til' Iowmd.
EstI09ffil if! prtgII"rKY Iat X. P"timulhooJd til' advilfd to IX! if prtglloirKY is (onfinntd.
[SlI09ffiI promott blood doning. IXI IhooJd no! III' pRlUibfd for dimu a histOf} of ttrornbomlbolk d IOIdffl, or
(orooiul autry dill'aII';orwho al"! smoke1\.
LibraryPirate
"

,


700 Unlt l
fIT Prototype Drug I Estradiol and Norethindrone (Ortho-Novum)
Therapeutic (lass: Combination oral contraceptive Pharmacologic (lass: Estrogen/progestin
ACTIONS AND USES
is typiul of the moOOphaSK OCs,(ontaining fixed amounn of 6-
trogtn (0.035 mg) and progesterolH' (1 mg) for 21 days,1011aMd b)'
ublm for 7 days. k iSlH'arfy 100% effective.n prrftnting (o'Ktption. Onho-
Noyum is.Jlso mililblt in biphasK and triphUK All Pfl'Pilrillions
pIl'YI'nt O\"IJlation by fttdbadc rontrol tilfl1eted at the hypothalamus
and the pituiury gland Whm right (ambi ... tion of fSlfl:I9tn and plO(jfSlin
is pIl'lfnt in the bloodstll'ilm, the relem ofFSH and Ul is inhibi!l'd. thus pre--
fmting indimions 10. the dlll9 inc:kKitac:ne Ie-
malts who have endometriosis, hypermenorrbN,.Jnd
dysfunctionill uterilH' bletdil"l(j. bmefilS 01 Ortho-Novum in-
dudt implO'femellt in tydt ll'9ularity and deu"a\fd inc:idenc:e of

ADMINISTRATION ALERTS
Tilblru must be uun U dill'tled
II a dol!' is misstd, tallt as soon as remembeml, or ullt two tabltn
III'lttday.
P.egnalKY megory X
PHARMACOKINETICS (PO)
Olllf"t: 30-60 min (I month 10. (ootra(eption)
Peak:l mo
Halflifr: 6-45 h
Duration: 3- 27 h
J
are abnormal uterine bleeding, benign hepatic adenoma,
multiple births, elevated plasma glucose, retinal disorders,
and melanoderma, a patchy or generalized skin discol -
oration caused by increased production of melanin.
HOME & COMMUNITY CONSIDERATIONS
Serious Adverse Effects of Hormone Therapy
Tll'illIIII'm with marand female hormoots,akhotHjh benm:ial,also plates the
patiem " risk for sfflJus ad\oe.se and oompliutions. EmphasUr to the pa-
tient
feelS SIKh as calf tenderness, chtst pilin, diuilH'l5, ilnd ilbnormal bIffiIing is
ess.rntial and must be reported immtdiall'ly to the heahh tall' plWi:Ie . Advist
patients who smokt ciga.tIII'I toentl'r a IOIIImunity Il.ppIglOUp 01 smoking
(eswlion betaull' smoking ilKft'.lll'l the risk 01 IOIIIplications, rspt-
(ially in WOIIII'I1 older than 3S.injJrm that hormone thrraP'J' for ffiII'I"-
gene:)' (OIlUoKeption or II'nni ... lion of pll'<JIanc:y may Il'SUt i1 Rgilal
blerdil"l(j. This ommnc:t InJII be reportfd to the hh Ull' proYider. 110Il1I0III'
therilP'J' may be UI!'d to tll'at (enilin millignam rumors in IIIiIIt female pa-
tients. Admst tffetts inc:kKit deYebpllll'm 01 (ha.actfflstin of the opposite
gtndrr.For mro,that incUIesgylH'romastia,changt in libido,and testlula. at-
ropIr;. For WOIIII'fI, that indudes. inc:rmrd IKial hail and drt'ptnil"l(j of the Oitr.
ThtSI' changes may have drYasuting flIIOtilnal on the patient and lam-
ily. Enc:oorage the patient to IftIc III*ssional help if symptoms 01 depll'lsiJn o.
i ... biity totopi' O(QJr.Familycoool!'liIg also be
ADVERSE EFFECTS
Tht mOlt ila.rrll' of Onho-Novum a.f naUll'iI, brem tfnde.-
IH'IS, Might gain, and bll'ilkthoough bletding.lrss (ammon indude
edema, (hanges in ision, gillbbdde. dill'.m, nausu, ilbdominal (rimps,
(hanges in urinar; function, dysmenorrhra, brmt fulllll'lS, falicjut, skin rash,
imr, "lilginal undidiasis, photOll'nsitivity, ind (hanges in urinar;
pinrms. Cudic:wll(ula. adl'rrll' tifeell, the mol1l1'rious of all, indude hypt.-
tt nsion and thlOmbotmbolK dison*
Contraindi(a\ions: 0Cs all' (ontraindicated in wolIII'n with the Iollowing (00-
ditions: QJlTI'm o. past history 01 thrombotmboll disordel5, strou, 01 roronar;
tumors; known OIsuspt<lfd un:ioolllil of the brNst,en-
domtlrium, 01 tumOl; ilbnormal ulI'rilH' bletding;
dIoIfSIatic jaundlt of Pll'9ni IKY 0 r jaundn with prior oral rontr.Krptil'l' UII';
known OIlUIpt(ted pfl'9l\ancy.
INTERACTIONS
I)ug-l)ug:
anlifl.ngik dKIl'u1lll' ofOCs, tilt riIk blefdi09


Lab Tem: ViUes of 1111' following Ina')' bt inc:1NSed: jnIInwnbin iiIIII', tfrtlin
<Ngwtion Iactoo, T .. plalrlel
Jr9ytfridel. YiIkIfs of tht IoIowing may bIo dfo"NSfd:antitl"lOlnun III, T " foIilf,
Dllitamin 8".
iWrbaLIFoo:l: 8r&Jktlllot9l blMling IIaI bHn lfJIOIIed with (Of)()If(Ht U'if of It

TrNtment of(Nerdose: Theil' is 00 sptciflt tll'atment jJ. OVl'rdoSI'.
RtI'tr III MyMnlngKl (or MnhIg PJe\S fixIIl sp/II( IrIIM <tug.
EMERGENCY CONTRACEPTION
AND PHARMACOLOGIC ABORTION
Emergency contraception is the prevention of pregnancy
following unprotected intercourse. Pharmacologic abortion
is the removal of an embryo by the use of drugs after im-
plantation has occurred. Drugs used for these purposes are
listed in Table 45.3.
45.4 Drugs for Emergency
Contraception and Termination
of Early Pregnancy
Statistics suggest that more than half the pregnancies in the
United States are unplanned. Some of these occur because
of the inconsistent use or failure of contraceptive devices;
OG u[0.3% tu 1%. LUll-
traception following unprotected intercourse offers a means
of protecting against unwanted pregnancies.
Plan B is the agent approved for emergency contraception.
This regimen involves taking 0.75 mgoflevonorgestrel in two
doses, 12 hours apart. Tht' drug acts in a manner similar to
0Cs; it prevents ovulation and also alters the endometriwn of
LibraryPirate
PATIENTS RECEIVING ESTROGEN AND PROGESTIN THERAPY (ORAL
NURSING PROCESS FOCUS CONTRACEPTIVES, HRT, ANDTREATMENTOF DYSFUNCTIONAL
UTERINE BLEEDING)
Assessment
Baselint assmmtnt priorto administration:
Undtrmnd INson the drug has prescribtd in ol'lltr to mes for
ptUlic: (f.g., oral UtUllK'IIt 01 dysfunctional
uteriIII' ble!ding. hormone repioKfment ther.!p)').
Obtlin a (omplete heahh hiuOl)' iMk.iding peripheral
htildad-.e, th)TOid, or ml,1
prt'9l1i1ncy;or bll'an-frfding. Notf peoonal or family hislol)' of
thromboembolic: dilorden; MI, CV A. PVD) ,md of II'procilKtiYl' (all(m
(t.g., uttrint,or ovatWn WKtr).
Obtain i drug hinol)' induding p=ription ind orc drugs.
htrbal plI'pmtOOs,akohoi ust, ind ilen to possible drug
inttroKtiolll.
appropriatf liboratol)' findill9l (f.g., C Be, pbtt leu, tle(trolylf"S,
gllKOSl',lipid,ind thyroid function Ie\'ek, Pap If"SQ.
Obtain vit.ll signs.
Asst ssmtnt throughout i dministration:
Alsel for dtlill'd thelipKIIK t ffe<ndtpendtrn on the lI'ilOn the drug is
given (e.g., pIl'9nanty prnention, symptoms of or dyslu II(tOO,1
Uterillf bleeding eille).
Contin!)!' periodic: monitoring ofC8C, pbttlru.and guOSl'.
Monitorvit.ll signs ,nd Wl'ight at f,d! he,lth Ull'
Asses for advmt t1fts: lIiIusti, 'IOmiting..headoKhe, weight gain, blNn
tendtmes,lkin lish,itnt, fluid change in mood,ind
breakthrough ble!ding. Rep:lrt im mtdiately t.l{hyardia, palpitationl, ind
hyp< rt.nlion, "P<'<iolly .Mori.l.d with on9illll; ...... 11' .... ..da< .... ; <II mping
in "im; P'lIitift Homan's sign; thet pain; or dyspne.J.
Potential Nursing Diagnoses
Dfcisional ConAict (mattd to (OIl(fIIlS ,bout bentfiuand risks of drug
thf liPY)
Disturbtd 80dy Image (1I'1attd to iging pnx6S, mlleeffe<nofdrug
ther.lPY)
KoowIedgf Idrug therapy}
Rille of Injury (lI'bttd to adwr-SI'drug
Planning: Patient GOcIIls and Expected Outcomes
will:
Experience theraptUlic: tffts It.g.tfffitin birth in lymptOms of meoopaust, dyslull(tOOal uterine ble!ding is dimini\htd).
from, or 9penrIKI' minimil, t1fis.
In undtrmndiog ofthedrug's tifll, and II'qJill'd plI'{autionl.
DmIonmate proptl stII-idministration of the mtdi{iltion timing. whf n to notify providtr).
Implementation
Interventi ons and (Rationales)
Ensuring thtrilptutic rffects:
Monitor iPPropriall' administration for optimum 1!"SlJ1ts.10Cs
all' lI!'arly 1m effffiiYl' whrn ilS lI'quill'd Skipping dam
the risk of PlI'9nilllty. Mainta iniog (olllilltllt daily dole! for lII'atmern of
symplOtm or dysfunniollill ble!ding will ensull'
hOl",oo.In.1> r. nldin ,ldbir .nd ',"'plo"" "SI'J
Patient and Famil y Education
Inmu(\ thr 10 thedrug at the daily 10 .... Ip
rf mtmber to tht pill. Do oot omit ilKll'iSl' or dl!i Sl' thf
dole without ronlulting tht he,1th {ilrt
For etrogen-progestin (ombination OCs:lf a doSl' is milltd, t.lke it al
IUln., it r."' .. .IId l.k the "".1 pill.l il' oolllldll, ... h.dultd
two ronmuti"l.dole ill' mis>fd, two tablets lhould be on
both day the dolI'S alt' II'I1len1btll'd and the following day.
Follow thf II'maining nht<iule of pills, rut USl' i sond method of
(onm(fption for at leall7 days antr R'St.Jrting the pilll.1f 1 or mOIl.'
(OllSf(utin days .II! misltd, ust another form of (ornr<l(fplion (t .g., a
b.Jrnrr method) unlil till' pilhQn lit in the nm momhiy [)tie.
For progestin-Qlliy 0Cs l"mini-piIl11: If a dOlI' is miurd, pill il
lOOn as rfmembtrl'd but ust an idditional form of until
the II!'I:i cycle of pills is St.lrttd.
For hormone rl'ploKtllll'nt the pills on i lI'9ulir
dose ill(lNII'S risk ofbrNk-through ble!ding.
(Continued)
LibraryPirate
702 UnII l The EocIottrne SySWI'l
PATIENTS RECEIVING ESTROGEN AND PROGESTIN THERAPY (ORAL
NURSING PROCESS FOCUS CONTRACEPTIVES, HRT, ANDTREATMENT OF DYSFUNCTIONAL
UTERINE BLEEDING) (COI1UIll!ffl)
Implementation
Interventi ons li nd (Rilti o nil les) Patient li nd Fll mily Educlltion
Minimldng . dytnt
o Monitor for symptoms of thromboembolism. Monitor blood plfllUrt at Nth o InllflKt the patient to immediately
dinial vilit(Thromiloembolic ,n eflKt of
IlyIpON,dltlt !)lin, or blood in IpUlUm pulmoouy mlbolism)
drugs. The rilk inmilll's with agt'0YeI' 35, in womm
!)Iin,or oYelWhelmiog fffling of f,tigut and
with a prfYious history of urdiov'lCUlar in wof1ll'n who
1(Ompanitd by and diapholfSis (possible Mil
wok<J
Suddtn, stlm if mociittd with dizziness;
diffirulry numbnesl in Jrm or Ieg;dilliculty vision
(ponible (VA)
Warmth, teodemm in ralfor pain on walkiog
(pouible mrombophlebitis)
TNth the patient to monilor blood prellUJt periodialty and any
blood prmurt il bolot 140190 mmllg or per pilr,f1II'ters by tht
heahh (ilrt provmt
o Enoorlgt smokiog ctSsation ilnd pfOllm information about smokiog o Advist the p.ltient of risk of smoking while using tstrogtns/progestins.
ctSsation progrilms.(Smoking glutty incrta!ts mt of tllt<ts of Pro-iidt rtftnal to appropriate IUpport groups and Ikmrurt on smoking
hormone meripy.) ctSsation PfOg"ms.
o Monitor blood gUOSt levrls in diilbftic: patient> f1Im irequently.(Estrogens o Ttach the woman with diabectS to monitor Cilpillary blood wgar f1Im
may affta u rbohydrlte mWbolism,ltading to inc"alfd glur;/M itvtls. f rtqUenliy while on drugs contai niog tsttogefl iI ndIor progtstin iI nd rtpOrt
Progestins may all t tndogtnoos iMulin It'Itls.) consistent tlt'lations to tht huhh Uft pro"Iidtr.
o Monitor htpiltit fulKtion tests nd symptoms of liwr dysfunction, lipid o ImtflKt the patient to IWJm for lab ttst>.
profile th)TOid IMk with
o Tfol(h the patient to immediately ft'port any symptoms of , bdominal or
, lUI! risk of liver tUIMf'I and may adl'fRrly affta (holtlterol
right upper quadrnt discomfort or pain, of tht d:in or 5Clera,
synthtsis, lipid thyroid in Itositivt patients.)
d.lrtentd uriflt,or nools.
o Monitorconwmnt drug thfiapy.(M,fIy drugidtutast or alter tIM: o Tfach tIM: patient to alMst all heahh calt providtrs of the ust ofalrogens
tfft<tivenm of tstrogens il nd progestins inckidiog drugs in the penitillin, aodl or progtstin I for contf<Ktption or for hormont replactffltrlt therapy
b.Jrbirurate,ilmMizu", oI nti.deprtsum,and IItnzodiil'l'pilH' clauH.Chrdl bfiofl' btginniog 'fly IH'W prtSCription.If' pmcriptiorr is Ifqui"d, discUls
fordrug intt roi Cbont thlt may afft hormofltrfftNtOtsS briort il OY ntw the nrfd for utatme:nt or birth control mtISU"S as oI ppropriollt.
prHcription is SUrltd.)
o Monitor yt.lrly Pap ItsIS ,nd In,st eums.(AnOUolI Pap tests and b"alt o TNth the patient haw to perform rnc:ouragt
t:urm, inckidiog mol mIMgraphy 's appropnatt, will monitor for the monthly rurm. For worntrllM'r 4O,advist Piltitnt on the r'ftd for
dMloprnrnt of brtast tumors or of cfrvic:al (anerr or HPV infection.) follow-up INmmogfilphy as IItr mt heahh CI" pmidtr.
o Advist the patient on tht fitI'd for anOUolI gyne(Ologic mms to ensu"
continutd lM:alm.
o Monitor thr oaurft'lKt of any bJtak-through blttdiog. Report any o Ttol(h the patitnt that sporliog mily occur midcydt while on
unU\lsa1. or he oII'y b (SO\iIII amoun" of "spotting" mily hormolH' drugs but to rtpOn any uOlIIU,1 chiflCjfl in tilt ilmount or if
oc(ur,tspially with 1ow4st hormont therapy"t midcyde.Any blttdiog continUts.
or heilVY bletdiog may indicate ildlomt tffB or
distasr oInd should lit Jtporlfd.)
Patimt understanding of drug thtrapy:
o opportunitifs during . dministfiloon of medications ,nd during o Thr patient should lit ,ble to state thr Jtol lOn for thr drug,appropriatr
'SItUf1II'nts to discUl stile rationille for drug therapy, dtsirro therapeutic:
dolt ,nd 5Chrruliog,and what ildIotBl' tffts to obitlVI' for and when to
outcomrs, most common adYffsttfftcts, paramrtm for when to ull the rtpOn thrm.
hea hh (jIft' 01 oy ntssary monitoring or prffilutions.(Usiog
timr ruriog nursing urI' htlps to optimizr ilnd rtinfon:r key tuchiog
ilR'ilSj
LibraryPirate
IlIoplfl45 Drug; 10< DI"" ...... ' arod C""dlliom 01 I"" F""",'" Reproductlw SY;lem 703
PATIENTS RECEIVING ESTROGEN AND PROGESTIN THERAPY (ORAL
NURSING PROCESS FOCUS CONTRACEPTlVES, HRT, ANDTREATMENTOF DYSFUNalONAL
UTERINE BLEEDING) (Conllnued)
Implementation
Interventi ons and (Rati onales)
Patirnt St!lfadministntion of drug tht rilPY:
Wlltn admininffing rntdiution,imtllKt p,.itm,
in thl- proptr l.imt
day to Il'mtmbl'r dosr.(Proptr adminismtion tilt
effeui'lrnessoltlltdrugs and 1It1p! 10 rtinion:Hra,hillQJ
Patient and Family Educati on
Trach the p;ltitnt to like IhI- drug following appropriate
Or,l drugs should be taken " tht samr timt NCh day 10 htlp Il'mtmbtr
thl- inmlKtiom if, rkM is missrd (mi:nsuring
lherapMic: disrusSfd tarlitr in this
Intra'ligillill rings all' ploK.-d in tilt l'iljina ,,-.:I Il'movtd alter 1 Wffks for
1 WffI: beIort a new ring is
U:tt nded formulations or SNsonalf) art laken for
approximiltd)o 3 momhs (84 dilys) and tlltn loIiowtd t, 1 days of
int n pills or 1ow4= hormoll!' pills.
Transdtrmal paoche (e.g., Orthovra) all'(hang.-d daily for 1 Wl'ru
foilOWl'd by 00 pal<h for 1 Wffl
Evaluation of Outcome Criteria
Evaluatt tht of drug thtrilPY by ronfinning that p;ltitm gNlsand 6 pKted oUl<omrs hal'l' been met (="Planninif).
the ulerus so that implantation does not occur. If implantation
has already occurred, Pian B will not terminate the pregnancy.
It isimportam thai the patient Wlderstand that Plan B will not
induce an abortion. A second emergency contraceptive,
ven, of a combination of ethinyl estradiol and
onorgeslrel; Ihis regimen is no longer available in the United
States.
Plan B must be administered as soon as possible after lUI-
protected intercourse; if taken more than 72 hours later, it
becomes less effective. By 7 days after intercourse, it is inef-
fective at preventing pregnancy. The normal rate of preg-
nancy from a single unprotected se."t act is 8%; Plan B is
estimated to lower this risk to 1% to 2%.Adverse effects are
mild and may include nausea, vomiting, abdominal pain,
TABLE 45.3 Drugs for Emergency Contraception and Pharmacologic Abortion
"n"
Route and Adult Dose (max dose where Indicated) Adverse Effects
EMERGENCY CONTRACEPTION
PO;2 ubltUwithin 72 h of IIIprotKltd followro b'f 1IMtl, mnili"i /lNdQdrI, mfIrStfUIll
2 tabitts 11 h tatfl (0.75 nI9 in mh pin rhafl9t!,brwrrtndlfflflS

PHARMACOLOGIC ABORTION
urbopoll lM;initial:l5O maj (1 ml) at 11l- 111lh inltrlill! if 1IMtl, IIrni!irli dorrllev, fern
(IItmabatr) indicaltd b'f utm

IlosaqI> may be illCll'.ilstd to SOO maj (2 ml) ifuterine (ontoolity is
dosts of 250 mOl (1 mil, not tou(ffiltotJl
rIosr of 11 rng or (ontinuousministration for 1 mo
diioprostOlll' hUaviginal;illlffl wppository high in Vigna, 2-5 h urtil
Prostin E,l abortion OCQUS or mflllbranes (max: IOtal rIosr 240 rngJ
mtthotrnatt with misoproslol (SO II\9fm') foIowtd 5 daystalffb'f intravaginal NaMG, dQrrIIev
800 roo;J of milOplOltoi
='

miftpristOlll'(Miftpll'l)with PO;1Hy 1:600 rng of miftprillone;lHyl(ifabortionhasootocwrred): NaMG, mniri"i dorrllev
misoprostol 400 roo;J of misoproslol
!W:D!II: bl:mllliIYlI:
IIQIio ammon id'1mI' striousadl'l'lll'
LibraryPirate
704 Unlt l lheErdoulnrSym'm
fatigue, headache, menstrual changes, diarrhea, dizziness,
and breast tenderness. Plan B is available over the counter.
Once the fertilized ovum has implanted in the uterus,
several pharmacologic choices are available for terminating
the pregnancy. A single dose of mifepristone (Mifepfe.l,
RU486) followed 36 to 48 hours by single dose of
misoprostol (Cytotec) is a frequently used regimen.
Mifepristone is a synthetic steroid that blocks progesterone
recepton; in the uterus. If given within 3 days of intercourse,
mifepristone alone is almost 100% effective at preventing
pregnancy. Given up to 9 weeks after conception, mifepris-
tone aborts the implanted embryo. Misoprostol is a
prostaglandin that causes uterine contractions, thus in-
creasing the effectiveness of the pharmacologic abortion.
Although mifepristone- misoprostol should never be
substituted for effective means of contraception such as
abstinence or oral contraceptives, these medications do of-
fer women a safer alternative to surgical abortion. The pri-
mary adverse effect is cramping that occurs soon after
taking misoprostol. The most serious adverse effect is uter-
ine bleeding, which m3}' continue for 1 to 2 weeks after
dosing. Pharmacologic abortion must always be con-
ducted under the close supervision of a health care
provider.
A few other agents m.ay be used to induce pharmacologic
abortion. Methotrexate, an antineoplastic agent, combined
with intravaginal misoprostol, usually induces abortion
within 24 houn;. The prostaglandins carboprost and dino-
prostone induce strong uterine contractions that can expel
an implanted embryo up to the st'l;ond trimester.
MENOPAUSE
Menopause is characterized by a progressive decrease in estro-
gen secretion by the ovaries, resulting in the permanent ces-
sation of menses. Menopause is neither a disease nor a
COMPLEMENTARY AND ALTERNATIVE THERAPtES
Black Cohosh for Menopause
Blac:k,ohosh \AaororartmOlll'j is, ptreoniill thngrows in United
Stneund pailS ofCmda.UsI' ofthe IN-'rb h.n been Ifforded byNniYe WI-
ieanl for than 100 yun.1t is uled .n , hormone b,l,ncer in peri-
m.nop,Jusal WOmM. gl.o<k <oh ... h hos bHn ,hown to in tho
m'ruogement of menopaUl.lI hot fluoo (Osmer!, Frifdt, liske, Schnitker,
Freudennein, & HeniieKkf..wn Upeiin,lOOS). Blac:k <oholh m,y f"I'l'II help
pre"l'!'nt osteoporosis in postllK'llOpoJU>al women.1lows of bl"k
IOmehmes I"nd,rdire<i by the amount of the <hemical 27-deoq,rtein,
which is ,n a<live ingitdienl A t)'pi,,1 doseof bla<k cohosh I'nges from 40
to 80 mg of dried herb per day. {Approximately 1 mg of is
in e,ch 21>-mg"blet or in 20 dropl of thr liquid formul.otionJ
Ahhough bloKk cohosh WilS 011<1' thought to h,,,,, phYloemogenic: tffem,
new ft'If,n:h questions its estrogenic: tifrC!l. So its "tu.l1 rnech,nilm of ,,-
tion is still effem indudt hypotension, uterine stimulation,
and GI complaints such.n Blac:k cohosh Gin tIN-' action of ,n-
tihypertensivrs,so mnc:unent 1M should be avoided.
disorder, but is a natural consequence of aging that is often
accompanied by unpleasant symptoms that include hot
flashes, night irregular menstrual cycles, vaginal dry-
ness, and bone mass loss.
45.5 Hormone Replacement Therapy
Over the past 40 years, health care providen; have commonly
prescribed hQrmone rtplmment thelilPJ (HRT) for menopause.
HRT supplies physiologic doses of estrogen, sometimes
combined with a progestin, to treat unpleasant symptoms of
menopause and to prevent the long-ternl consequences of
estrogen loss listed in Table 45.4. In 2001, more than 66 mil-
lion prescriptions for Premarin and Prempro were filled,
and sales of the two drugs exceeded $2 billion. All this
changed, however, in 2002 when the results of a large clini-
cal study, the Women's Health Initiative (WHI) were ana-
lyzed. The results of the study depended upon whether the
HRT consisted of estrogen alone or an estrogen/progestin-
combination. The following conclusions were reached:
Women taking estrogell/progestirr-combination HRT
experienced a statistically significant increased risk of
myocardial infarction (MI ), stroke, breast cancer,
dementia, and venous thromboembolism. The risks
were higher in women older than age 60; women aged
50 to 59 actually experienced a slight decrease in adverse
events.
Women taking esrrogell/progestirr-combination HRT
experienced a decreased risk of hip fractures and
colorectal cancer.
Women taking estrogell a/out experienced an increased
risk of stroke and thromboembolic disease.
Women taking estroge<l alone did not experience an
increased risk for breast cancer or MI.
The potential adverse effects docwnented in the WH! and
other studies were significant enough to sU8!!est that the po-
tential benefits of long-term HRT may not outweigh the risks
for many women. However, the results of this study remain
controven;ial. HRT does offer relief from the immediate, dis-
tressing menopausal symptoms, prevents osteoporosis-
related fractures, and m3}' offer some degree of protection
from colorectal cancer. These are certainly significant and im-
portanl benefits from HRT. from the WHI study and
HERS are still being analyzed and follow-up studies are being
conducted to detcrminewhich women benefit the most from
HRT and which are at greatest risk.
Short-term use of HRT for relieving acute symptoms of
menopause may be appropriate for women without a his-
tory of cardiovascular disease or cancer. Topical prepara-
tioru; may bring some benefit to women suffering from
vulvar and vaginal atrophy. Until research provides more
definitive answers, the choice of HRT to Ireat menopausal
symptoms remains a highly individualized one, between the
patient and her health care provider.
In addition to their use in treating menopausal symptoms,
estrogens are used for female hypogonadism, primary ovar-
ian failure, and as replacement therapyfollowinJ:l re-
LibraryPirate
a..p1fl4S Drug; 10< DI""""" arod (""dlliom 01 Il>e f"""'''' Reproductive 5y;lem 705
Prototype Drug I Conjugated Estrogens (Cenestm,fnjuVlQ,Premarm)
Class: Hormone Pha rmacologic Class: E;trogen; hormone replacement therapy
ACTIONS AND USES
Plt'fIlarin contl ins a mixt\Jrt of difft lfllt natural rstrogtn Conjugattd rsIl'OCjtn
A and(ooj:Jgaltd B(EojtMa) contlin a minull' of9- 10dil-
fmm s)'lllhetic plant rstrogtns. The primary indic.Jtion for oonjugolttd Htro-
hu 10 UNI modmte 10 Sfflll' symptoms 01 by
diminished truu9!'n 5e(ll'tion by tht ovaries. Othtr replaument in-
ckKlt treatmenl of lema It hypogonadism a nd lISt after oophorlomy. The d rug
is applOYtd for the paliiatiW' IlNtmenl af inoptl"able ancer.
Conjugattd rstrogeM 6ft1 It'Iffill mrubolic t ffts, induding an
incll'awo in bone deOlity and a Il'duction in LDL choltsterol.1t maya 110 IooMr the
riskaf coronary artery dist awo and coloo cancfr in IOIII!' patitnls. When uW'd as
postmenopaUlolI repLt.c:elll!'nl ther.lPY, fstrogtn is Iypically oombintd with .J
progestin,as in Prempro. Conjugated rstrogtos may he adminimll'C! by the 1M
or IV roote for abnarmal utfrill!' bftding dJI' to hormonal imbalaoct.
ADMINISTRATION ALERTS
Ust .J calibratt<l do!.agt applicatarfor administration af \GIginal clNm.
For 1M ar IV administration ofoonjugated reconniMt by fiBI
approximattly S ml of air from thedry-powdervial, then slowly
injea the diluent imo the aiming it at the sKIt af thf vial. Gently
lait ta disft;do not shake.
push !IowIy,ata rateof5mgfmin.

PHARMACOKINETICS (PO)

P9k: Unknown
Halflife:4-13h
Duratian: Unknown
distUrb.Jncrs,dtpIl'sWl,irritabiity
" lOmnia
"' ....
ITtgular menstrual (ydrs
Hfidicbtl
Vaginal incrtill'd p.linful
inttl"lJlI.rII'
Skin atKljtly
SUffi winary incmtilH'nce
SexUoJI dsintemt
Cirdio .... uculilrdiltall'
.. """"
Allhtimtr'riR dtmtntia
Colon cancer
ADVERSE EFFECTS
effects of conjugattd estlO9f1n ilKludt Huid Il' temion,
t<itma, bll'ast tendernrss, abdominal era mps and bloating.. anne palKreatiti
apptlitt cliaogrs, acnf, mental dt pl!1sion, dtclNW'd libido. headache, fa-
tigut, nt IWusness, and wtighl gain. HfKts art dtpeodtnl.
when ustd alolH', haW' associated with a h ightr risk 131 ultrilH' canm. A
though addinga progestin may txert a protlivt tfl"rct b)' IooMring the risk of
utt rinf salll!' studirs suggest the progt ltin may ilKll'awo the risk of
brt'ast cancer fallowing long-term USI'. The risk of adVl'Bt eflem incll'alt in
patitnu O'II.'r age lS.
Cantraindi (atians: Conju9olltd r!l'OCjtns all' cantraindicated in prtgnant pa-
tients and in women with known or IUIptlted carciooma of the bll'ast or other
rstroqeo-dtpl'ndent tumor. Caution should be ulI'd when tll'ating patients
with a history of thrombotmbolic diINwo, hepatic: impiillOl'nl, ar aboormal
uterine blttding.
INTERACTIONS
Drug-Drug:Orug interaction! a
cortKOIIl'loid Iffl'ttS, 0100 dKrNIfd . frem of l'IpKiaIy wirlaril.
The !ilKI'! of l'Wogeo IOi)' bt dl<lUed takfll with bartitwles or rifamjin, and
thffi' is a of tricyd"K Intidrprl!lsam I t.lbowith
l.i b Tl5ls: YatUK of thf loIowilgma:o' !If incrNlfd: promrombin tirM, eMail
myroid-biJKing gIoIUit,f'8t, aggreg.!lioo.and
uigl)ttrides. of thf fotlowilg lnay!lf dKre.ud: antithrombin ttl, T
and, itamilB"
Herba VFood: Red dovn and blad cooOlh IOi)' n!Hffno HtrogIO tll5.,.
EIIlns of l!llrogtn IOi)' bt ert.anced if cOll"lJinfd with ginlfllg.
l INI ment of Imrdase: Thtn' is 110 sprcific Ill'almeol lor
lifter Ie M}tII!rllllgm"" Q Nlmlnl} I'rIKm fools ljItCl/{ Ie rlrls
moval of the ovaries, usu."liJy combined with a progestin. The
purpose of the progestin is to oowlteract some of the adverse
effects of estrogen on the utt'l"us. When used alone, estrogen
increases the risk of uterine cancer. Estrogen without pro-
gestin is considt'l"ed appropriate only for patients who have
had a hysterectomy.
High doses of estrogens are used to treat prostate and breast
cancer. Proslate cancer is usually dependent on androgens for
growth; administration of estrogens suppresses androgen se-
cretion. As an antinooplastic hormone, estrogen is rarely used
alone. It is one of many 3gt'nts used in combination for the
chemotherapy of cancer, as discussed in chapter J SOO.
UTERINE ABNORMALITIES
Dysfuncti anal bleeding is a condition in which hemor-
rhage occurs on a noncydic basis or in abnomlal amolUlts .
It is the health problem most frequently reported by women
and a common reason for hysterectomy. Progestins are the
drugs of choice for treating uterine abnormalities.
LibraryPirate
706 Unlt l .... Sy<!"",
45.6 Pharmacotherapy
with Progestins
Secreted by the corpus luteum, endogenous progesterone
prepares the uterus for implantation of tht' embryo and preg-
nancy.lf implantation does not occur, of progeslt'rone
fall dramatically and menses begins. If pregnancy occurs, the
ovarycontinnes to secrete progesterone to maintain a healthy
endometrium until the placenta develops sufficiently to begin
pr<XIucing the hormone. Whereas the function of estrogen is
to canse proliferation of the endometrium, progesterone lim-
its and stabilizes endometrial growth.
DysflUlctional uterine bleeding em have a number of
causes, including early abortion, pelvic neoplasms, thyroid
disorders, pregnancy, and infection. Types of dysfunctional
uterine hleeding include the following;
Amenorrhea- absence of menstruation
Endometriosis--abnormallocation of endometrial tissues
Oligomenorrhea- infrequent menstruation
Menorrhagia- prolonged or excessive menstruation
Breakthrongh bleeding--hemorrhage between
menstrual periods
Premenstrual syndrome (PMS)- symptoms de'A'lop
during the luteal phase
Postmenopausal bleeding-hemorrhage following
menopause
Endometrial carcinoma--cancer of the endometriwn
Dysfunctional uterine bleeding is often caused by a hor-
monal inlbalance betw,n estrogen and progesterone. Al-
though estrogen increases the thickness of the endometriwn,
bleeding occurs sporadic.ally unless balanced by an adequate
amolUlt of progesterone. Administration of a progestin in a
pattern starting 5 days after the onset of menses and contin-
uing forthe next 20 days can sometimes reestablish a normal,
monthly cyclic pattern. Onll contraceptives may also be pre-
scribed for this disorder.
L IFESPAN CONSIDERATIONS
Estrogen Use and Psychosocial Issues
may oc:(ur with usr, nurw
priorto implementing drug ther'py.The
apiait' patient'l INdian 10 thrll' pott ntial
til'ms t motion.J1 Wpporls)'Sttm should also bt made btioll' drug
of hair, or a deepening of voKt (an oc:rur in the fr-
m.J1e ])atirnt Men may deY!-lop IffiIndary fl'lll,1e 5IKh .J S.J
higher YOU, lI(k of body and inCll'ilsrd blt'all sill'.lmpoirrur m,y , 110
and is I)'pically irwro <II a (OlKfln Jr,o mOil mf n.
Patirnu shook! br taught thai adYflSl' rfiKn all' lI'Ymiblt ,nd may
subsidr with adjustmtnl ofdcMgr or discontinuation 0/ ther'py.1his
kmwltdgrnwydow both Iml andwomen patieontolt'lllainWllpiiamwhnt
adYme tfl"tru ouur. Duril"f;l therapy, paMrm may nerd tmOtional !UppOII to
in dtaing with tw body illll9l' is5Uel. The LIn fIKOII"agr this sup-
pon,disruss IW issurs with mtmbm,and rmr patients for romseIing.
Forlhe irmaII' patirnt, the Ian ,",r toan usthetic:ian for h,i It'mov,1 or
wig rmilg. The nwlt paMnt and his sexual PIInllfl may netd .J rrfmal to deal
with surrounding impotrlKr and iu ellrn on Ihrir r&tionship.
.... Prototype Drug I Medroxyprogesterone Acetate (Provera)
Therapeutic ( lass: Hormone;agent for dysfunctional tnerine bleeding
AaJONS AND USES
is .J synthetic plOQI'Itin with a proJolIQrd duration of oK-
tion.As with its natural (oumt rpart, the prim,ry t'''ltllissur lor mtdrol)'pro-
grstrrolll' is the t ndometrium of U1l'M. k inhibits estrogen on
the thus restoring oormal hormonal balinft'. Applications indudt dys-
functional U1t ri ne bIte:Iing. Sf(ondary amtnorrhu, and (ontroKrption.
Mrdl"tlq'progestflOlll'mayalso 1M forthr ])allialian of mmstatic:tner-
int or It'nal Glruooma and <II a susuined rtlt, 1I' form (Otpl-Pl"ll'Ur.J) for
(omrac:fption.
ADMINISTRATION ALERTS
Givr PO with mrals to ,void gastric distJl'Ss.
ObII'M' 1M sites for plt'SflKr of lump <l nd discolor,tion oftissUl'.
Prtgnanq rntgOry X
PHARMACOKINETICS (PO)
il1S!'t Unlmo'Ml
Peak:2-.4 h
30
Ouration:Unknown
Pharmacologic (lass: Progestin
ADVERSE EFFECTS
The most frrlJlrm rffrm of medrol:)'Plogrsttronr alt' brtm troder-
III'SS, lmoakthrough blrtding. and other menllru,1 irrfgularitits. Wright gain,
dtpJl'Soon, hyptnt noon, n'lIIN. yomiting. dysmt norrlle.J, and 'I<lIginal LIn-
didialis may , Iso oc:rur.1hr moll serious ,dvern rffffi is , n ilKlNseri risk for
thrombotm bol ic: dismf. The drug has a blld box warning that !lSI' of tht drug
mayLl!lSl' a Ion of bont mineral
Contrai nd ications: Medrol)'plGgesttronr is (onm indicated during prtgnanC)'
.J nd in womtrI with known or suspled (artinoma of the brtul (.JUlion Ylould
lit used when IImill9 patirnu wilh a history of Ihrombotmbolic hr-
p,tic or undiagllOled vaginal bftding. Tht drug shoold br usrd
in patienu with a histoll of psychic: drpll'Soon and thr drug discon-
tinued at fillt sign of IKUrrill9
INTERACTIONS
])ug- ])ug: Strum I@ve/sof deomPd by
amiooglutflhinidt, barbinratH, jHnilonf, rifampin. rifabutin, and topiramatf.
tab Teu: ina&lie TM for alblirw
gIumII' toteraMf !f51IGTn,and HOI..
Ik>rbaVFood:St..kmi wort Illa)'dI<:rl!Rw of
and (iW' abnormaIlIIfIlruuai blffcing.
Trtatment of Onrdost': Theil' is 00 sptCifk IJeiltment for
Rtftf III MyMlsJflqKl (or MnJnq /'ro(e\S fixIIllpf(1it III 1M iJ"IJg.
LibraryPirate
a..p1fl4S Drug; 10< DI""""" arod (""dltiom 01 tl>e f"""'''' Rep'oductlve 5y;tem 707
In cases of heavy bleeding, high doses of conjugated es-
trogens may be administered for 3 weeks prior to adding
medroxyprogesterone for the last 10 days of therapy.
Treatment with nonsteroidal anti-inflammatory drugs
(NSAIDs) sometimes helps to reduce bleeding and ease
painful menstrual flow. In 2009, the FDA approved tranex-
ami<: acid (Lysteda) for the treatment of cyclic heavy men-
strual bleeding. If aggressive hormonal therapy fails to
stop the heavy bleeding, dilation and curettage (D & C)
may be necessary.
are used for palliation, usually in combination with other
antineoplastics. Selected progestins and their dosages are
listed in Table 45.5.
LABOR AND BREAST-FEEDING
Progestins are occasionally prescribed for the treatment
of metastatic endometrial carcinoma. In these they
Several agents are used to manage uterine contractions and
to stimulate lactation. Oxytocia are agents that stimulare uter-
ine contractions to promote the induction of labor. Torolytiu.
are used to inhibit uterine contractions during premature
labor. These agents are listed in Table 45.6.
(Oiman, E5irldmn,

(ypionatt
Midio! (Deltstrogm,
Du"igen-10, VoIlqen)
(Ctntltin, fnjll'lii,
Prrmarin)

PROGESTINS


((rtIorIt. Endomtirln,
ProdtiM, Promtlrium)
PO;05-2mgdaily
Tranldmnal I titlltr wmJy (Oimari) ortwia 'IoftkIy
(0.025-0.1 mgltlayj
Topical gtl;ApproIinatrly 11S glda,
Intril'ilginal nstrt 2---4 glda, for 1 wk.tllffi Iflb:r to Y:.tll! dose
for lwk, thtn UII' I 9 _ to tinel/wffl;
1M; I- S mg wi:

PO;OJ-1.2S mgiday for 21 days 00 month
PO;0.74mgidayforll daysudt month

1M iIltpo--PKl'lffil); ISO mg daily 10, 1 months.Givt til! dose dJlilg ttw, firs!
S days ritht lllfflSlrual period or withil til! S days postpanum if not
brffil-fffililg
S!.tKuta!leOlll (depMlbQ-Prom"lit 104 mg !!aMy for 3 months. GiYe the first dose
dlling til! rrll 5 days of til! menllnJill pffiod or at ttw, 6th WffI; postpanum if not
brulIfffililg
PO;03S mglda, on day 1 of menstrual
NMnorrhtl or fIIKtIoni l UIl'rlne bIffiIl1g: 1M; S- 10 mglday
rtprochKtM ttdtnolog)': Intr.l'i(jinil; 90 mg gel 000' daily or 1 (J().mg ubltis
IWOto tines/day
ESTROGEN-PROGESTIN COMBINATIONS
Q MogtnS (tquine)1

-",)
MidiolillOl!lhildrone
(Aail'elli)
PO; 0.615 mgidaily on days H8;idd S mg
rnedllJX)1l109tltffiHll'
PO: 03 mgand 15 mg
Intravaginal 'I, to 2 gdai, for 1- 6 months.
PO; ll1b1ti of 1 mg fSU"adid for 1 days, 1oI0000d by 1 of I mg ffi,adol
combined with 0.09 mg lIOfgeIIinate for l day;. Rt9inrn isrepe't(([ (ontilUCllSly
without ilterruption.
PO; ll1b1ti daily, wIidt (ontains 05-1).1 mg of ffiOOioland 05- 1 mg
noretlind!orlf
Tranldmnal I wMIy
gallbladde(
djIwr tbmmbPflnbg!j(
disorlIrn,iOONIN yom rill!
BIfotlIIroogh blfflling. 5pOIfiIg.
iwMllffllitml'lJ, wtighrgDin
AmmorrIIN dl'll!ltllOl!!ltt,
Ihrombornlbolic:
""""
for adYmr
ffiJOgffiSand
LibraryPirate
708 Unlt l The Er.docrl .... Sym'm
TABlE4S.61 Uterine Stimulants and Relaxants
DN, Route and Adult Dose (max dose where Indicated) Adverw Effects
OXYTOCICS
Q oxytlKi11Pitodn) To ronuol postpartum blMIIg: 10--40 urill ptr infulion pump lioll5ill, Klmiring, mQltmaldylmyr/imios
in1.lmmLoflVI\Jid
Em) 1tu1b:1ilu1io 1II1l1W: [tloIl iollilWDioIl
To labor: IV 1 iOOl'a tiN-' htf!lOllilaot. Witt!" intoxiylion. f(taI brain htmoo!laoe
dolt 110 gfNter than milliurinlmin at 30-60 iltffials
until (ootrKtioo panml is6Ublishtd
ERGOT ALKALOIDS
maleall' (Ergotrale) 1'0: 1 tabltt 101 mg) thilitJirth for a maximLm of I wi; Iiwlfo.lOmiring,umint CTaI1I'1'f1g
meth)"lft9OOO'lint maiNte 1'0:0.1--1).4 mg bid-iJid m:11!:!lenlion,dvIrlMhmias
(Methm;int)
PROSTAGLANDINS
lM;initial:lSO IIK9 (1 ml) repeall'd at iuervak ff liawo. 1Omiring, diall/rto, hfIlIIocllt, d1Ilh, ultIiflt
iodiulled by uteri1e mrmpirlq
dinoprostorle (Cm-idl, Prtpidl, hualllgillil; 10 mg 1oi ll:1iIIiIlD! III ill"""
Promn E,)

misoprostoilCytottt) huavagillil:15 meg (1/4 of 100 111(9 tablet);may 1--6 h
TOCDLYTICS
magntsi:Jm IV; 1-4 9 ill 5% r1e1lrOlt by skM infusion max dolt = 10-14
Ruslirrg,fMQring,musdt wfaknru
gld.y. tiH-'o 110 mOl! tlwllo-40glrlay at oJ max ratt of
hea!] bI!l!!, (i1:uiaJID: colla!!! !nRira!o[!
""'"" rifedipint Prowdia) I'O:lniliai dosage of 10 mq. foIowtd II)' 20 mg orally min Ruslirrg,lliI'Qring,musdt W!atnru
H contrKtions pmill, tiH-'raP'f un be 20 rng Dlaly
=" " .. ,
I
, ; ,
Mf'/ h for a maxinum doItof 160 mglday
Aller 71 hoIn, if maifteDilK is
nifedipillt 30-60 mg daily un be used
ttlbutaline sulfalt (BrethiOl') 10 II\(glmill; MI1102fj minUles;dll"Jtion of
iofusioo = 12 h lmax: 17.5-30 II\(glmin)
I'O:mailttnallll'riosI':1.5 IOmgMf'/4-6h
Irdb iodiute (OO1mon oJdvmt di'ttlS; !llderliri!l!! indiute serious di'ttls.
45.7 Pharmacologic Management
of Uterine Contractions
The mosl widely used oxytocic is the natural hormone
oxytocin, which is secreted by the posterior portion of
the pituitary gland. The target organs for oxytocin are the
uterus and the breast. As the growing fetus distends the
uterus, oxytocin is secreled in i ncreasingly larger
amounts. The rising blood levels of oxytocin provide a
steadily increasing stimulus to the uterus to contract,
thus promoting labor and the delivery of the baby and
the placenta. As pregnancy progresses, the number of
oxytocin receptors in the uterus increases, making it even
more sensitive to the effects of the hormone. When used
as a drug, oxytocin rapidly causes uterine contractions
and induces labor.
In postpartum women, oxytocin is released in response to
suckling, which causes milk to be ejrcted (let down) from the
8foothocoo lIrittion, dy\!!rt!hmiat and
[tioIlb!:oII1Wf
mammary glands. Oxytocin does not increase the volume of
milk production. This function is provided by the pituitary
hormone prolactin, which increases the synthesis of milk.
The actions of oxytocin during are illustrated
in Figure 45.4.
Several prostaglandinsarealso used as uterine stimulants.
Unlike most hormones, which travel through the blood to
affect distanl tissues, prostaglandins are local homlOnes that
act directly at the site where they are secreted. Although the
body makes dozen<; of different prostaglandins, only a few
have clinical utility. In the uterlL'i, prostaglandins calL'ie in-
tense smooth muscle contraction<;. Carboprost ( Hemabate)
is often used to control postpartum hemorrhage. Dinopro"
stone (Prepidil, Cervidil) and misoprostol (Cytotec) are
prostaglandins used to promote cervical ripening, a soften-
ing and dilation of the cervix that must occur prior to vagi-
nal delivery. The prostaglandins may also be used to induce
pharmacologic abortion.
LibraryPirate
IlIoplfl45 Drug; 10< DI"" ..... ' arid (""dlilom 01 I"" FE'ma'" Repmductlw 'ytlem 709
Hypothalamus
sends impulse to
po!lt""'"
Milk
"-
/thalam.m

NetVe i"""'l .....
,
Muscles contract,
squooza out ,",Ik

Milkproducing coil.
Flgure45.4 Oxytocin and breaslfeedlng
Prototype Drug I Ocytocln (Pltocrn)
It is important to note that oxytocin and other uterine
stimulants are only indicaled when there are demonstrated
risks to the mother or fetus in continuing the pregnancy. Be-
u[ ,huul<.l ""."r],"....,<.l
for elective induction of labor.
Some women enter labor before the baby has reached a
normal stage of development. Premature birth is a leading
cause of infant death. Tocolytics are uterine relaxants pre
scribed 10 suppress pretenn labor contractions. Suppressing
labor allows additional time, usually 24-72 hours, for the fe
tus to develop and ntaypermit the pregnancy to reach normal
tenn. Typically, the ntother is given a monitor with a 5e!l<;or
that records uterine contractions, and this information is used
to determine the doses and timing oftocolytic medicatio!l<;.
Only a few drugs are available as tocolytics. For over 30
years, magnesium sulfate has been the traditional drug of
choice for suppressing pretenn labor, but evidence suggests
it may be and poses undue risks to the fetus and
mother. The only drug Ihat is FDAapproved for this indica
tion is ritodrine (Yutopar) but it is no longer being manu-
factured for use in the United States. Calciwn channel
blockers such as nifedipine (Adalat, Procardia) and beta-
adrenergic agonists such as terbutaline (Brethine) appear to
be effective but are not approved for this indication.
Therapeutic Class: Drug to induce labori uterine stimulant Pharmacologic Class: Hormoneioxytocic
ACTIONS AND USES
Oxytoc:in is a natural oormoll!' !I'(rt'lf<l by posterior pituitary that is a drug
of(oou forinduc:ing Iabor.fuytoI:in isgiml by!l"lefal diffrl\'lll
ing on its inlendfCI iction.Gil'!'n inlepanum by IV infusion,ol)'loc:in indum la-
bor by in(rt'asing and Ioru of (omraction,. k is timtd to
Iht final st. of (ffi'iJ ha, dilated, mmbrilW1 rup-
turt'd,and prt'll'nution oftht fetus ha, oc:(urrtd Do!I'S in an IV infusion aft' in-
(IN,td gradwlly, 15-1 minu1l'l, until a normJI labor is
fiublishf<l.
Oxytocin II'\a)' also lit mministe..:'d postpartum to ..:'din
"puloon of the ploKenta, and to Jid in rt'Iuming normallllJl(ular tont to the
uterus.lmranasal form I used to promote milk letdown aft' no avail-
able in the Unitf<l SUtts.
ADMINISTRATION ALERTS
Dilutt 10 unit, ol)'llXin in 1,000 mlIV lkJid prior to administration. For
postpartum mminislluion,may add up to 40 u nits in 1,000 mL IV Huid.
Imidt nu of allergic: ft'Jctions is hight r when 1M 01 by IV
rathe, than IV infUoon.
PlI'9nancy uttgory X
PHARMACOKINETKS
Onset: Immf<lialt

Halflife:1- 5min
Duration: 1 h
ADVERSE EFFECTS
The m05l (ommon efftcU d oxy\O(in aft' rapid, painfUl uttrill!' rontrac:-
lion, and fetal 1a(/)ytardia. When gi'o'!'n IV; vital signs of the fetus and mother J ft'
monitortd (ontinUOUlly to avoid {omplic:alions in tfl t fetus. IlKh a > dysrhythmia I
or intriKl1lnial IN>monhage. Striou> romplic:ation, in the motlN>r may indUiX
utt rine ruplurt', roma .Ri,k of uteriII!' ruptuft' ill(lN!I'1 in womtII who
delil'!'rt'd 01 mOrt' midrtn. Though nperirnu has mwn tIN> of
ol)'loc:in to lit quitt ,aft,labor Ihould lit induc:f<I by drug only whm theft'
art' demonltritf<l ri>ks to the molher orfetus in (Ominuing the PII'9IWIIC)I.
Conllaindi u tions: Antepartum is (ontraindiulf<l in the following: signif-
Kant (fpllaloptlvK disproponion; unfavorable fetal position, that are
erable withoot (olMrWn btfoft' delrmy;oblletric:al in whic:h
btnefit-to-rilk ratio for the felUl 01 fawB IU"lKal fetal
distlffi when delivrl)' is not immint nt;whtn actjyityfaiis to
oKhieYl> satisfactory PI09rt'ls;whfn uterus is alrt'idy hyperactil'!' or h)oper-
tonK; v.t.en vagilWl is (om,aindic:ate<i, >lJ(h as cerYic:a 1
noma, aniVI' gtnital total placmta prt'Yia, '/.H.l prffia, and (ord
prt"!I'f1tation 01 of the (Old.
INTERACTIONS
Druq-DIIJ!I: Yol\IXOIISlIinor U!I'd (OII(UflflliIy witl1 oxytocin may (iU!I' W'Il'II'
h_
lJbTesll:UnkrocJrwn
Herba VFood: HI1M' known
TlNt mem of O'ffrdo,e: (aUStlllrong uterine (Omractiolll, whic:h
may lead to uteriII!' lac:eruions discontinuation of the
dlUlJ is nMSlary,along with ,ymptomatK trt'atment.
Rtftr Ie M)NUrllllgm kif Q IWrli"9 I'rIKJlj fOOI5lpt{1k Ie rIIt!
LibraryPirate
710 Unit. TheEndoal ..... Sjr.t"'"
NURSING PROCESS FOCUS PATIENTS RECEIVING OXYTOCIN
Assessment
a55tSi.,nt prior to administrlltion:
UMtrmlld the 1M dnIg hilS been pres<ribt<i in CIfdef to ISseIS (of
thtJapMic (t.g.,labor irlliKtion,lfltroi of posIJIaftum
Dluin a Mtol} induclintj a.mm Imgdt of pregfllncy
4J,.tion; pltStllCt of 01 t<limpu.; J!<tltt IabOl;t)'pl! of
* livtry; hist3!y of Of n Stiom; {ilrdicmwulu, ntUlVlogic,
hepatic,or tflStaSl';dybt!:ts;alld IRm-ftding.
Dltlin drug hillOlY indlltflllO 111tf9it's. wrrtnt prtSCfiptiolt and OK dNgs,
he!bal alld smoking.8t altrt to possible drug
iIItractions.
&Iullt appropriate labontol} findifl9\ (e.g.CB<. pIilteltu, coagulation
l1119t'leSiJm IeftI. fun<tioo
sllldits).
Obuin beight, weight, llId yital sigIIS.
Obtain htal IINrt alld inlr.luttfine positioning.
Chec.k for !be pmtrKt of (trWai diLition alld
.1Id dUrMion of 11'1'1 nisting (ontrilClions.Mo!titor fetailfSponlt to
mntractiom,noting an, sign of
Potential Nursing Diagnoses
P.in tdittd to strong uttri lit (OfttrKtiolll)
IneflfttiYr B_tfrtding,Pottn!yl for EffKtM Brtut-fffding

Rist (pititnt or to ilMne drug tffKts.IUOntj
utfflrtt (00 tliClion:!
Rist for ImbiLinctd Fluid Volumt rtLittd to w IIt1' inrOJication
from the drug's ho!mone tfftS)
Ched: for postpartum blttdintj.wld nolf the IIlmbtl' of pills \MurMtd.
---+---------------------
throughout .d.,inlstfillion:
AsIHS iJrdtsftd tlttrapeulir tffn *pmrlt!tt 00 1M IUSOfl wdnJg is
g;..rn (t.g. stlOfl9, conI/actions supportr.t of..,).
Continuously monitor timi ng. qllillity, and Ibllion of {ontr.lctions.
kII rnediatrly SllStiintd IIIt rine {ootractions to 1M hHhh (,J
.......
Continuously monitor tilt Iml heart rorlt oIIId to mntractions..
m rnedytrly sig iii of fmI dislllfSs II tilt healtlt (,J pIOyidtL
Continue ptriocIic monitoring ofCBC,platMn. tltctrolytts,g1uc.ost. and
l1119t'leSiJm !MI.
Monitor ritaI sigIIS alld immediately M11 BP aboft 14Q{90
mmHg 01 1m tllirt 90/60 mmHg tIPKiIIy 1 i(companied by tach)IUrdii,
Of per pa,.mrten., to tilt hNlth pnII'idtr.
Continue to postpartUm bleeding and COUnlNotify tilt
providtf if molt thin two pads.It \Mtnttd in 2 hOOJB' time.
16\l'15 iJr.dmr niUW, omiling, and
palpitations, ind hyptnfnsion.tIPf(idy will
hHdlche,OI d')ospne. bt mrnediMtly.lmmtdiatt ly
11'1'1 iibdominil pail. SllStaine<i uttrint (ootlKlion, dimi nishtd urW
drtMsi-.mnlusion,dIi in of mnsciorMm,
01 stizUffS.
Planning: Patient Goals and Expeded Outcomes
'lhtpatitlttwi:
Ex;ttrifIKt thtJaptUtic: tffts (f.g., llrong Libor {ontmtiom wpponiv! of milk IHdown poslplfMII blttdill9 is
diminillttdj.
8t frre minillloli. idwnf tffrru.
Ikrbalizt, iIII Ulldmtancing ofw drug's 1M, tfIem,ind requftd prfUUtioM.
proptr !tIf-administration ohllt mtdio:.Jtion (t.g.,d<M, timing. when to notify plll'Vidfr).
LibraryPirate
OIIpler 4. DJU9S for DllOfden , r.d Conditions of tile FHnaIe Reproductive System 711
NURSING PROCESS FOCUS PATIENTS RECEIVING OXYTOCIN (CDnrJnuf!d)
Implementation
Interventi ons and (Rati o nales)
Ensuring tht r, pt utic effects:
Monitor for optimum
must be giftn yja an inM.ion pump to ,11ow for
pm:ilf dming. (Infusion pumj ,11ow for rapid doI'gf ,djustments to
maintain supportNe of labor and cffi'Kal dilollion 1m
approlimatl'ly S to6cm.)
Minimizing ad'fttlt rfflKts:
Monitor the timing. quality. and duJltion of {ontrl ctions CDIltinucusly.
Immediately <lny contriKtions to tht hNkh
pIO'Iidtr. Stop tltt infusion. infusing norm.1 orlOkrtion as 0I'dmd,
and place the paumt on her Iide until follow-upordtn ,re obtained if
contr.ldions cominue wst,ined.(Oxytocin may CilM sustained utttinr
muscif: cootrlction with pottm ial uttrinr Uterine contractions
must bt cootiroously
Continuoudy monitor feu I heart I'iIte and ltiponlf to conttlctions.
Immediately signs offml distlffi to the health {,Ire proYicltr.
(Utrrinr{ootr.ctiom (,n all'fCI the ,moum ofblood flow through the
p!acenti with to the fetus. (hanges in Itti I heart
rate may sign.1 fml and the paumt should bt placed on htr side.
,dministtrrd. the inrusion stopptd, and the heakh provider
notifltd)
Monitoryiul signs urinroulpUl fJtqllelltly and any BP .I11oe
140190 mmHg or less thIn 90/60 accompanied by
t,dryeardia. or diminished urint: to the health ure pnrtidtr
immediatf Iy. (Oxytoc:i n has YIIIoconstrictiY!' proptJtHoslnd wattt
8P or pYM flte mffiiing parametef\ incJNIing disorientation
orconfusion,and diminished urintoutpYt may signift <lCiYefW drug eife(ts
or possibif: compliutionsJ
Monitorfundal firmnrss and Iocation"nd bftding and pad
count (Oxytocin may postpartum bleeding. lochia that
if \W(I or more plltisalt' S.tUfl!td O'Ifr a 2-hour ptriod, should
be to the c.Jrt proYidtf immtdilttiy.)
Palirnt understanding of drug therapy:
1M opponunitirs during administration of medic.Jtionland during
as to discuss the fltionale for drug therapy. desired thmptUlic
outcomel,tnoSt commonly observed ImJ'lf eim:tl, parameter! forwhtn
to {,IlIthe health all)' nmslal)' monitoring or
pm:aUlions.(Wng time ckJring riming (,Ire helps to optimize ,nd reinforu
keytt lChing areas,)
Pati ent and Family Educati on
Innruet the plltiem aboutlht ratioroaif: for .11 IV and monitoring
equipment and the nwl for monitoring, to .1I.y anxiety.
Teich the patient that laborcootr.diom willgtldually incrNse , nd that
the drug will bt or stopped f'N(h an optimum
.'"
Encourilgt the patient in labor to use p.in..:ootrol mmufts (t.g ..
ther4ptUlic brt41hing) or lBt pain (ontrol dl needed and
TeICh the patient that laborconmdiom will incrtl lf in and
durMion and will bt monitored throoghout.lnnruet the to
immediately report Ill)' sustained or any st'fm .bdominal
pain.
Tmh the patient that the Ittil heart ratf will also bt monitored along
with UltrilM' contl'ilctions. b:plain the purpose for all monitoring
equipment to allay anlitty.
IlIltruet the PJtient to immtdiately rtport.1l)'
disorientation or confusion, pi Ipitltions, OJ chest or pain.
Imtruet the p,tirm to 'Il)' sudden in lochia, dizzintss or
light-headednrss,or if more than two saturatrd alter 1 houn.
The p,tirnt should 10 state tIM- rNson for the
dolfand ICheduling, monitoring n<ls, and wh.t . mJ'lffim:u to
ob!erY!' for and when to them.
Evaluation of Outcome Criteriill
the of drug therapy by confirming that p.nirnt goakand tJ:pfCloo outcomes h,Y!' bten mtI (see Planning").
TIIbIe5 45.1 & 45.6 for Q lisr of ttugs /0 1+1ridr fhrst OOM9 lions 1JIfiy.
LibraryPirate
"


t

712 Unlt l The ErdoallM' Sym'm
FEMALE INFERTILITY
Infertility is the inability to become pregnant after at least I
year of frequent unprotected intercourse. Infertility is a
common disorder, with as many as 25% of couples experi-
encing difficulty in conceiving children at some point dur-
ing their reproductive lifetimes. It is estimated that females
contribute to approximMely 60% of the infertility disorders.
Agents used to treat infertility are listed in Table 45.7.
45.8 Pharmacotherapy
of Female Fertility
The three primary causes of female infertility are pelvic in-
fections, physical obstruction of the uterine tubes, and lack
of ovulation. Extensive testing is often necessary to deter-
mine the exact cause and it is not Wlcommon to find multi-
ple etiologies for the infertility. For women whose infertility
has been determined to have an endocrine etiology, phar-
macotherapy may be of value. Endocrine disruption of re-
productive function can occur al the level of the
or
targeted to the specific cause of the dysfunction.
Ovulation (and thus pregnancy) cannot occur unless the
ovarian follicles receive a hormonal signal to mature each
month. This signal is normally supplied by LH and FSH
during the first few weeks of the meru;trual cycle. Lack of
regular ovulation isa cause of infertility that can be success-
fully treated with drug therapy. Clomiphene (Clomid,
Milophene, Serophene) is a preferred drug for female infer-
TABLE 45. 7 Agents for Female Infertility
tility because it stimulates the release ofLH, resulting in the
maturation of more ovarian follicles than would normally
occur. The rise in LH level is sufficient to induce ovulation
in about 90% of treated women. The pregnancy rate of pa-
tients taking clomiphene is high. and twins occur in about
5% of treated patients. If ovulation is not induced by
clomiphene, human chorionic gonadotropin (HCG) may
be added to the regimen. Made by the placenta during preg-
nancy, HCG is similar to LH and can mimic the LH surge
thai normally causes ovulation.
If the infertility is a result of disruption at the pituitary
level, therapy with hwnan menopausal gonadotropin
( HMG) or gonadotropin-releasing hormone (GnRH) may
be indicated. These therapies are generally indicated only af-
ter clomiphene has failed to induce ovulation. Also known
as menotropins ( Pergonal, Humegon), HMG acts on the
ovaries to increase follicle maturation, and results in a 25%
incidence of multiple pregnancies. Newer formulations use
recombinant DNA technology to synthesize gonadotropins
containing nearly pure FSH. Other medicatioru; used to
stimulate ovulation are gonadorelin ( Fact rei), bromocrip-
tine (Parlodel), and HCG.
Ihe of oocyte from the
ovary before it has fully matured, is another cause of infer-
tility. GnRH antagonists such as ganirelix (Orgalutran) and
cetrorelix (Cetrotide) suppress LH surges, thus preventing
ovulation Wltilthe follicles are mature.
Endometriosis, a conunon cause of infertility, is character-
ized by the presence of endometrial tissue that has im-
planted oUl5ide the uterus, in locations such as the surface
of pelvic orgaru; or the ovaries. Being responsive to hor-
Mechantsm Drug

domiphmt lCIomid,
danazot
I
Rfduction of Iiojl prolactin IMIs
Promotion of loIid1' maturation and owlation
Anaboi( IIm1id; 5l.ppIelion of FSH (OIltro1 of ffidometriW!
FSH AND LH ENHANCING DRUGS
chorionic: gon.Jdotropin-HCG (tIoYarti. 0vi1Rt.
IIII'noIropns (HLmI'IjOO. RtproIII'x)
foIitroPn IHI (GonM)
loIitropn lIN Ifdliltim)
OOlfoltitropin
GnRH ANTAGONISTS
a'tromil (CMrotidt)
g,Ilirtlil oKttltt
GnRH ANALOGS/AGONtSTS
goItItliI a(l'\,Jte (lolidex)

nafirtlin
Promotion of loIid1' maturation and owlation
I of prtmaturt Owtion or (ontro1
S!.pprelion of FSH and (ontro1 of
LibraryPirate
o..pur45 Drug; 10< Ill"" ..... ' ar.d Condltlom 01 the f"""'''' Rt'p.oductlw S)'Item 713
monal stimuli, this abnormal tissue can cause pain,dysfunc-
tional bleeding, and dysmenorrhea.
Leuprolide ( Lupron) and nafarelin (Synarel) are GnRH
agonists that produce an initial release of LH and FSH, fol-
lowed bysuppression due to the negative feedback effect on
the pituitary. Many women experience relief from the
symptoms of endometriosis after 3 to 6 months of therapy.
i ~ : ~ Chapter REVIEW
KEY CONCEPTS
At; an alternative choice, danaml (Danocrine) is an anabolic
stE'roid that suppresses FSH production, which in turn shuts
down both ectopic and normal endometrial activity. While
leuprolide is given only by the parenteral route, danaml is
given orally. Estrogen- progestin oral contraceptives are also
useful in treating endometriosis.
The numbered kE'y wncepts provide a succinct summary of the important points from the corresponding numbered se;;tion
within the chapter. If any of these points are not clear. refer to the numbered section within the chapter for review.
45.1 Female t"E'productive function is controlled by the secre-
tion of GnRH from the hypothalamus. and FSH and LH
from the pituitary.
45l Estrogens are se;;reted by ovarian follicles and are respon-
sible for maturation of the sex organs and the secondary
sex charactE'ristics of thE' female. Progestins are se;;reted
by thE' corpus luteum and prepare the endomE1riWll for
implantation.
45.3 Low doses of estrogens and progestlns prewnt conceptton
by blocking ovulation. Longterm formulations are avail -
able that offer greater convenience.
45A Drugs foremE'rgencycontraception may be administered
within 72 hours after Wlprotected sex to prevent implan-
tation of the fertilized egg. Other agents may be given to
NCLEX-RNO REVIEW QUESTIONS
D The patient is admitted with pain in the calf, shortness of
breath, and SE'vere chest pain. A medical history reveals
that the patient is taking oral contraceptives. Based on this
assessment, the patient may be experiE'ncing a:
I. cerebrovascularaccident
2. hypertensive crisis.
3. hyperglycemic reaction.
4. thromboemboliSJll.
D ThE' nurSE' includes which of the following discharge in-
structions to the p.1tient receiving HRTI
t . Ao,utd foods that contain caffeine.
2. TakE' medication 30 minutes before mm.
3, Disoontinue medication if utt'rine bleeding begins.
4. Monitor for a suddE'n increase in IDLcholesterol
D The nurse's assessment of the patient receiving an IV in-
fusion of oxytocin notes that uterine contractions are 4
minutes apart and 60 se;;onds in duration. Which of thE'
following nursing interwntions is most important based
on this assessment?
stimulate uterine contractions to expel the implanted
embryo.
45.5 Estrogen-progestin combinations are used for hormone
replacement thE'rapy during and after menopause; how-
ever, their long-term use may have serious adverse effects.
45.6 ProgestillS are pres<:ribed for dysfunctional uterine bleeding.
High doses of progestins are also used as antineoplastic:s,
45.7 Oxytocics are drugs that stimulate uterine contractions
and induce labor. lbcolytics slow uterine contractions to
delay labor.
45.8 Medications may be administered to stimulate ovulation,
to increase female fertility.
1. Administer oxygen via face mask.
2. Monitor the patient for water intoxication.
3. Position the patient on her left sidE'.
4. Discontinue the infusion immediately.
o The patient has made the decision to use Ortho-Novum
1135 for contraception. The nurse includes which of the
following instructions to the patient about this medica-
tion! {Select all that apply.}
1. Take the first pill of the pack on the fifth day of the
menstrual cycle.
2. The placebo mUSl be taken to decreasee:sl:rogen-related
adven;e effects.
3. Pos5ibie side effects indudE' intolerance to contact
lenses, abdominal cramps, dysmenorrhea, and breast
fulill=
4. Barrier contraceptives are nreded if a daily dose is
missed
5. Breakthrough bleeding indicates that ovulation has
_red
LibraryPirate
714 Unlt l lhI'Er.doo1""S)lmm
o The patient questi ons the nurses a bout how she could
ha ve become pregnant while she was takin g oral contra-
ceptives. Which of the rollowingstatements best describes
the primary reason a patient would become pregnam
whUe on oral contraceptlvt'$!
I . Antlblotlcs were taken In conjunction with theoral
oontraceptive.
2. 1\<,0 or more doses of the oral oontraceptive Wl:'re
skipped.
J. The dosageofthe esUogen In the o ral contraceptive was
too iow.
4. The oral oontracepthe was taken I.n combinatioo with
an anticonvulsant.
CRITICAL THINKING QUESTIONS
1. A 28-year_old woman hasa J _year history of pelvic pain,
dyspareuni a. and Infertilit y. She has been dLagnosed with
endometriosis and is prescribed leul)rolide {Lul'JOn} once
a month per intramuscular injection. Disrus-s the mecha-
nism of action of Ie nproli de in managing the patient's en-
do metriosis. What Info rmation should be Included in a
plan for a pati ent receiving this drug!
2. A labor and delivery nurse places one fourth of a tablet
(crushed) of misoprostol (Cytotec) on the cervix of a pa-
tient who is being indnced because she is 2 weeks past her
due date. After .several hours, the patient begins to have
contractions, and the nurse notes late decelerations on the
monitor. The nurse fl ushes the drug out of the patient's
vagina with saline per hospital protocol. What is the use
and action of misoprostol!
o A patient has started taking clomiphene (Clo mld,
Serophene) after an InfertiHty workup and asks the nurse
why she is not having in-vitro fertilization. Which of the
following nursing statements would be most helpful in
explaining the use of d omlphCll e to the patient !
I . Her diagnostic workup suggested thlllinfrequent
ovulation m."If be the Clusefor her Infertility and
clomiphene incnmes ovulation.
2. In_vitro fertilization is expensive and since clomiphene
is Jess apenslv.-. It is always tried fi rst
J. There Is less risk of multiple births with clomiphene.
4. Her past history of oral contraceptive use has prevented
ber from ovulating. domipbene is given to stimulate
ovulation again In these Ilmditions.
J. A nurse is assessing a 32_year_old postpartum patient and
notes 2+ pitting edema of the ankles and pretibi al area.
The patient de nies havlng"swelling" prior to delivery. The
nurse reviews the paUen!"s chart and notes that shewas in-
duced with oxytocin (Pitocin) over a 2J-hour period.
What Is the relationship between this drug regimen and
the patlent'scur re nt What additional assess-
ment s should be made?
See Appendix D for answers arid Ttltionales for all activities.
EXPLORE . ------,
M)lIInirlQlld is ore slop f(H" chaptl'T rfView and
1!ISOUI\:8S. Prl! jJlr\I 11K SUce8Sll with lDIi1kIrnI NIlX"' sl.yla practice
tJJestioos. i1tela:trve as.sIgnmenlS aM lJC1iYi!ie!l, well i rlkS, anil11/l!IOOS
and videos. and moral
Agi srer 1001 atalSS oo:l e from me front at your at
www.mynursi-lgkitcom.
LibraryPirate
DRUGS AT A GLANCE
PHARMACOTHERAPVWITH ANDOOGENS JI'19'116
o fIIJII/ 719
DRUGS FOR MALE INFERTILITY ".m
DRUGS FOR EREalLE DYSfUNCTION fIIlIJ'lf9
Phosphodiesterase-S lnhlbltors nlil
o (V"oogrl ptJIJt m
DRUGS FOR BENIGN PRDSTATK HYPERPLASIA
""no
AlpharAdrenerglcBlorurs pagtm
S-Alpha-Reductase Inhibitors fIIJII/ li5
o finQI/f rnH (/'r()KQlJ ,.127
KEYTERMS
aniboli n teroids fDIF 717
androgl'l"5 fllXJ'716
u oospermiil fX1IJ' 718
benign prostitic hyperpluiil (BPH) fIIJII/ 7U
corpori (avernosil fJIJIT 719
Drugs for Disorders
and Conditions of the
Male Reproductive System
LEARNING OUTCOMES
Afrl'r re<lding mil c/loplef, rhe should be able to:
1. Describe the lOIeS ortnl' hypothalamus, pltultary,and testes In
regulating male reproductive function.
2. Identify indkations for pharmacotherapy with androgens.
3. Describe the misu$l! and dangers associated with the uw of anabolic
steroids to enhance athletic performance.
4 . Explain the role of medications In the treatment of male Infertility.
S. Descrl be the etiology, pathogenl'Sis, and pharmacotherapy of erectile
dysfunction.
6. Describe the pathogenesis and pharmacotherapy of benign prostatic
hyperplasia.
7. Describe the nurse's role In the pharmacologic management of
disorders and conditions of t he male reproductive sY5tem.
8 . Forea<h of the drugs/classes listed in Drugsat a Glance. know
representative drugs, and explain the mechanism of drug action.
primary actlons, and Important adverse effeas.
9. Use the nursing process to care for patients who are receiving drug
therapyfordisordersand <onditions of the male reprodu<tive system.
follid .. honnonf (FSHI fIIXJ' 716
piJIJt 716
fllXJ'719
If ulfinizilll hormone (LH) fIIXJ' 716
libido ptJITlIl
oligospermi a fIIXJ' 711
{JIJ1t 716
irililition fIIXJ' 717
LibraryPirate
7 16 Unlt l .... Sy<!"",
A
s in women, reproductive function in men is
by a small number of hormones from the hypothala-
mus, pituitary, and gonads. Because hormonal secretion in
men is relatively constant throughout the adult life span, the
pharmacologic treatment of reproductive disorders in men
is less complex, and more limited, than in women.This chap-
ter examines drugs used to treat disorders and conditions of
the male reproductive system.
46. 1 Hypothalamic and
Pituitary Regulation of Male
Reproductive Function
The same pituitary homlOnes that control reproductive
function in women also affect men. Although the name
follide-stimulating hormonr (FSH)applies to its target in the female
ovary, this hormone also regulates spenn production in
men. leuteinizing hormonf (lH), more accurately called
interstitial ceJ/- stimulming hormone (lCSH) in the male re-
prod uctive system, regulates the production of testosterone.
Although they are also secreted in small amounts by the
adrenal glands in women, androgfns are considered male sex
hormones. The testes secrete iestosuronf, the primary andro-
gen responsible for maturation of the male sex organs and
the secondary sex characteristics of men. Unlike the 28-day
cyclic secretion of estrogen and progesterone in women,
testosterone secretion is relatively constant in adult men. Be-
ginning in puberty, testosterone production increases rap-
idly and continues to be mainl3ined at a high lewl until late
adulthood, aft",c which it slowly declines. If the lewl of testos-
t",rone in the blood rises above normal, negative feedback to
the pituitary shuts off the secretion of LH and FSH. The re-
lationship between the hypothalamus, pituitary, and the
male reproductive hormones is illustrated in .. Figure 46.1.
Testosterone has profound metabolic effects in tissues out-
side the reproductive system. Of particular note is its abilityto
build muscle mass, which contributes to differences in mll'i-
cle strength and body composition between men and women.
PHARMFACTS
Male Reproductive Conditions and Disorders
Ermiledysfunction ilffem 10to 15 million American Ollt
in four mtn 65 )'Nfl.
Smoking thin 20 ciqarettes I day h.tl been shown to pnxluc:f a 60%
highff risk of t lfttile dyslulKtion. Ten or fewer (icjaftltts daily still
in(ftale tIIuisk by Iii%.
In tht United Sme, 11 million mtn ,It' e timated 10 ha\\'
h,pogonadism.
BPH affects 5O%of mtn 0100 than 60 )'NfI,and 9O'Mi ofmen oIdtr than 80.
BPH is tilt moll wmmon btnign ntoplillm alfliog middlHged and

30% of men aftsublffiile, and u lean 2'l(, of men aft
totally infertilt.
e
Ret .... se
ot GnRH
""
Secmt"'" cI \estostl!,..".,.,
Stimulation 01 spermatogenesis
.. FlguTe46. 1
hormones
Hormonal control of the male reproductive
ANDROGENS
Androgens include testosterone and related hormones that
support male reproductive function. Other important a ndro-
gens include androstenedione and dehydroepiandrosterone
( DHFA). Therapeutically androgens are used to treat hypo-
gonadism and certain cancers. These agents are in Table 46.1.
46.2 Pharmacotherapy
with Androgens
Lack of sufficient testosterone secretion by the testes can re-
sult in male hypogonadi'lm. Hypogonadism may be congenital
or acquired later in life. \\/hen the condition is caused by a
testicular disorder, it is called primary hypogonadism. Ex-
amples of disease states that may cause primary testicular
LibraryPirate
(hopltl46 Drug. IOf 0110,<1<>" and Coooltian. 01' the Mak> Rep'oductlve 5y;tem 7 17
TABLE 46.11 SQIQctQd AndrogQns
On.
dalluol
Route and Adult Dose (max dose where Indicated)
PO;200-400mgbidfor
Adverse Etfl!.cts
AuIt, fJ)'rIK001Q5lio, hiwlism molt !fl"
morrxrtmOO (i" womt"!,sodimorr/

tffiiniar alrophy and
oiQ!J!Dt!mia at high dolts
ftUOX)'Jnffitronr (H lIin)
c.JpsOO (Android, Tffiltd.
Vinoo); tabItIs (Mtllilffi)
-""'-
PO; 5 mg 0IIt to fOIl"
PO; 11)-50 III9Iday
Bu:c.JI: mglday
lM;50-200mgIwI;:
oxandrolorit (Oundrin)
oxymrtholonf (Androl-SO)
PO; 15-20 mgltlay djyjdtd two to 1011" for 2-4 wks
PO; 1-5 mgltglday
o IffiomfOM (Striant) Bu:c.JI; 30 mg 12 h
(Tffiodffin TTS, Androdffin, othm) Ttltodtrm TTSpault: apply 1 daily;Androdffin
patd1:opply 15-7.5 mg patd1 daily
(AnItoGtI. Tffiill) Gd;apply 51J1arn, daily (mall0 lJIam,)
It'ltOItffilfll' (Dtpotw, AIIdfO..(yp.
Dtpo--TeltOltmmt)
It'ltOItmmt (Andro L.A. 0tIa1ffi,
OtIatetryl)
1M; SO-4OO mg el'tfY 14 wi::
1M; 50-400 mg el'tfY 14 wi::
failure include mumps, testicular trauma or inflammation,
and certain autoimmWle disorders.
Without sufficient FSH and LH secretion by the pi tuitary,
the testes will Lack their stimulus to produce testosterone.
This condition is known as secondary hypogonadism. Lack
of FSH and LH secretion may have a number of causes,
cluding Cushing's syndrome, thyroid disorders,
secreting tumors, and ther.lpy with GnRH agonists such as
LeuproLide (Lupron).
Symptoms of male hypogonadism include a diminished
appearance of the secondary sex characteristics of men:
sparse axillary, facial, and pubic hair; increased subcuta-
neous fat; and small testicular size. In adult men, lack of
testosterone can lead to erectile dysfunction, Low sperm
counts, and decreased libido, or interest in intercourse.
specific complaints may include fatigue, depression, and re-
duced muscle mass. In yOWlg men, lack of sufficient
testosterone secretion may lead to delayed puberty.
Pharmacotherapy of hypogonadism includes replace-
ment therapy with testosterone or other androgens. Within
days or weeks of initiating therapy, androgens improve li-
bido and correct erectile dysfunction caused by low testos-
terone levels. Male sex characteristics reappear, a condition
called masclllini:wtion or virilization. Depression resolves, and
muscle strength rapidly improves. Therapy with androgens
is targeted to return serwn testosterone to normal levels.
Above-nonnaL levels serve no therapeutic purpose and in-
crease the risk of adverse effects. Testosterone is available in
a variety of different formulations, as listed in Table 46.2, to
better meet the individual patient preferences and lifestyles.
Androgens have important physiologic effects outside the
reproductive system. Testosterone promotes the synthesis of
erythropoietin, which explains why men usually have a
slightly higher hematocrit than women. Testosterone has a
profound anabolic effect on skeletal muscle, which is the ra-
tionale for giving this drug to debilitated patients who have
muscle-wasting disease.
Auboli ( steroids are testosterone-like compoWlds with
hormonal activity that are taken inappropriately by ath-
letes who hope to build muscle mass and strength, thereby
obtaining a competitive edge. Use of steroids is high
among teens, who sometimes take these drugs because
they believe it improves their appearance. When taken in
large doses for prolonged periods, anabolic steroids can
produce significant adverse effects, some of which may
persist for months after discontinuing the drugs. These
agents tend to raise cholesterol levels and may cause low
sperm counts and impotence in men. In female athletes,
menstrual irregularities are likely, with an obvious increase
in masculine appearance. Oral androgens are hepatotoxic,
and permanent liver d1mage may result with prolonged
use. Behavioral changes include aggression and psycho-
logic dependence. The use of anabolic steroids to improve
athletic performance is illegal and strongly discouraged by
health care providers and athletic associations. Most an-
drogens are classified as Schedule III drugs because of their
abuse potential.
High doses of androgens are occasionally used as a pal-
liative measure to treat certain types of breast cancer, in
combination with other antineoplastics. At the high doses
required for breast cancer treatment, some virilization will
occur in most patients. Because the growth of most
prostate carcinomas is testosterone dependent, androgens
should not be prescribed for older men Wlless the possibil-
ity of prostate cancer has been ruled out. Patients with
prostate carcinoma are sometimes given a GnRH agonist
such as leuprolide (Lupron) to reduce circulating testos-
terone levels.
LibraryPirate
"


t

718 Unlt l
TABLE 46 1 Androgen Formulations
"'""
Drug
Implantabll-' ptlru r 1-1> pdiell ft imiUnlrd on thf
(5lbrutantOUS) antrrior abdominal wall dtpffiding upon

Intramu5(IJlilr(lM) cypionalr (.TffiOllrrtlllt)
and trstOllrrone tflinthalr IDdalt 5lry!1
TtllOltffiHll' buc:<al Sirianl tablet isapplifd 10 tilt gum"N
",.
jUl1abM ind5or, hoIdif19 in plac:r
for SKonds.
Tramdmnal AndroGtl and Tffiim arr applird OIKt
tffi05lmr gd daly 10 upprr arms, shoUdtrJ. or
abOOmrn.
Transdrrrnal Androdmn p.llm isapplied daily 10 Ihf
tffi01lmr p.llm upprr arm. th91,had or abdomm,
rOl.ti"'l .pplirnion !.itt!.
L IF ESPAN CONSIDERATIONS
Human Chorionic Gonadotropin (hCG)
Abuse by Athletes
Most hNkh (aR' art' familiar with tht probltm of anabolic:
lk-'roid by athletes and Iffill. feo.m, IR' familiar with abo.M of
tilt pla!:rntal hCG in thil population. hCG il notan anabolic: steroid
Why would a n uhltte lakt a hormone? TIIm aR' IlI'a\OO
Mtn taking anabolic: ltl'lOiIk nprritnu a natural frtdba(k pile-
IIOllH'lIOn. Tht high Itoiels of anabolic: stt roidl providt 10 thf h)1lO ..
thalamus a nd pituitl ry to !hut down production of tellmtt rone by the
Whtn theath(tttnops taking thentroids the testMr"ftd sMr.l(Wftbtore-
and man maysufft r from km of strength,tn tic:ular atrophy,
loll of libido,and impottnu. Taking hCG duringthil rillH' immtdi ..
raises tilt man's lewl bKaUIl' hCG rNmbltsleuteiniling
hormone, the natullllstimui.Js for prodlKlion. Thus, hCG il und to
tramition to regular li.l'. IIOMteroidJ mining. hCG allo milln sttroid !III' by
dlillI9ing tilt rypn of l1eroidl,lnd amounts, that mow up on Iabor.llOry
(ondKted by athlttic organizationl.
The nurse nffils to tta<h taking iIIega( subnallCH that hCG
and anabolK stt roicb both haw major idYer"lr tffe(B.1 heir tholt
of ItYels: testicular atrophy, femin iznion (ml'Sstrstos-
il mttabolizfd to estf09l'llJ,stunting of growth in
young tel'm),1 il'rr damagt, and psyt:hiatric: di IOrdrn.
MALE INFERTILITY
Advanlages DI!iadvantages
Dose IiIIl-4 mil InlLlmllliltion or inlrnion may octur
aroundinSffiionsitr.
Dose 1i112--4 wi; Strum IMIs will vary
widdy iflr! admiri 5llalion,IiIU1ing
p.ltiffitto e1ptrit1Kr
ftuwmions in thrir ibido and
rnMJ)',and rxpffitrKt mood
\Wings. Patitnls II'IHI to (OIlliUin 01
SlKrotSl 011 thf ofinjKtion.
a lUpp/J of mtfIl!qJR lWia-dai)' doling.
in blood. Lool irritalion to tht blKul mlKOIi
mayoror.
lilt drug il ablCKbrd intothf skin in about Gr!liIn transfrrrrd 10 anothrr
rrlusrd tht prrson II)' skirHo"w.. (on\a(\
bIood.CaUlrS 1m skin iritation lhan oflrmaie
""".,
(Ofltulland lrul harm.
Rash may 0((\1" atthf sittofp.ltm
appi<ation.
46.3 Pharmacotherapy
of Male Infertility
Like female infertility, male infertility may have a nwnber
of complex causes. The most obvious etiology is lack of
sufficiem sperm production. the presence of
less than 20 million sperm/mL of ejaculate, is considered
abnormal and can lowt'r reproductive success.
the complete absence of sperm in an ejaculate, may indi-
catt' an obstruction of the vas deferens or ejaculatory duct
that can be corrected surgically. Infections such as mwnps,
chronic tuberculosis, and sexually transmitted diseases can
contribute to infertility. The possibility of erectile dysfunc-
tion must be considered and treated, as discussed in Sec-
tion 46.4. Infertility may occur with or without signs of
hypogonadism.
Tht' goal of endocrint' pharmacotherapy of male infertil-
ity is to increase spt'rm production. Therapy often begins
with 1M injections of human chorionic gonadotropin
(hCG), three times per week over I year. Although hCG is
secreted by the placenta, its effects in men are identical to
those of LH: increased testosterone secretion and spermato-
genesis. Speml counts are conducted periodically to assess
therapeutic progress. If h.CG is unsuccessful, therapy with
menotropins (Pergonal ) may be attempted. Menotropin
consists of a mixmre of purified FSH and LH. For infertile
patients exhibiting signs of hypogonadism, testosterone
therapy also may be indicated.
It is estimated that 30% to 40% of infertility among couples
is caused by difficulties with the male reproductiw system.
Male infertility may havea psychologic etiology, which must
be ruled out before pharmacotherapy is considered.
Other pharmacologic approaches to treating male infer-
tility have bet'n attempted. Antiestrogem such as tamoxifen
(Nolvadex) and clomiphene (Clomid) have been used to
block the negative feedb:lck of estrogen (from the adrenal
LibraryPirate
Choplfl46 Drug. fOfDhorde" .nd (oooltion. 0( the M.", Reproduc!lV1' System 719
...
Prototype Drug I Testosterone
Therapeutic (lass: Male sex hormone Pharmacologic (lass: Androgen;.mabolic steroid; antineoplastic
ACTIONS AND USES
Tilt primary therapMK 01 '1'1' fur tht tlMmI'nt 01
pubmy and in malts.lht drug yirilimion. induding
enlargtml'nt of tilt sew.! OOjans.growth 01 I,cial hair. ,nd a di'tptning of tilt
you.ln adJk rna Its. ttstosteroll!' administration will inaease libido and It'Iton'
masaJlill!' (harmeristia tNt rna)' dt rKitnt Tetosteront is appfOYl'd to tll'at
elt'(til!< dyslulKtion that uustd by low androgtn lenl!. The drug is also mA
pplO'led fur tht palliuiYt lIt'atmem of inOptfilbie breast ulKer in womtn.
"15 by Itimulating RIIA I)'flthesis and protein mttabolism.
High may T etolleront is admin istell'd by
the 1M route, i khough otter sa kl art available lor tilt transdtrmal. implantable
ptlltt,and butul route.
ADMINISTRATION ALERTS

II using. p.t<h. pI.u on h.ir_!r .... d!)' don of thl .bdo ...... n. back, thigh,
upptr arm,or as

Alternate pa\{h site daily. rotlting site tvrry 7 days.

Give 1M injtction into ,luINI mUl(its.

Pregn.nq mrgory X
PHARMACOKINETICS
Onl('\: Unkna.vn
Ptak:Unkna.vn
Halflife: Unkna.vn
Duration: 1- 3 (2-4 Wffks for 1M and ptlltt forms)
glands) to the pituitary and hypothalamus, thus increasing
the levels of FSH and LH. Testolactone (Teslac), an aro-
matase inhibitor, has been administered to block the meta-
bolic conversion of testosterone to estrogen. Various
nutritional supplements haw been tested, such as zinc to
improve sperm production, L-arginine to improve sperm
motility, and vitamins C and E as antioxidants to reduce re-
active intermediates. Unfortunately, these and other thera-
pies have not conclusively been shown to have any positive
effect on male infertility.
Drug therapy of male infertility is not as successful as
fertility pharmacotherapy in women, because only about
5% of infertile male> have an endocrine etiology for tht'ir
disorder. Many years of therapy may be required. Be-
cause of the expense of pharmacotherapy and the large
numbt'r of injections needed, other means of conception
may be explored, melt as in vitro fertilization or in-
trauterine insemination.
ERECTIlE DYSFUNCTION
Erectile dysfunction, or impotence, is a common disorder in
men. The defining characteristic of this condition is the
ADVERSE EFFECTS
An obY<M, dl'l'Mei'fe(tol Il5ta>tt roll!' therap)' is virilization. whKh is
only of (olKtm wlltn tht drug is taken by moal!< patitnu.llKfNstd libiCo rna)'
Q(QJr. Salt.nd W"l'f are oiten retJintd, causing tdem and a dUlt'tK may
irod icared. Liver da"",* is fare, a khough it is a potentially i oMf\e tffHt
with 1OIII!'01 tlltorally administtlt'd androgens.Aclll'and skin irritation i;com-
mon during therapy. may experience supPfffiion of owlation or mt n-
struation. [xtreml' in men (.naboiK I1troid rna)' talM
ratlltr than virilization bt<iIM ums is
to estrogen.
Contraindications: is (omriindicated in men with kna.vn Of WI-
pK\ed blNlt or prostatic can:ioomas ind in women who all.' or may bMome
(talrgory X).lhe drug shoold uled with uulion in patients with
Il'nal or htpatK disNse.
INTERACTIONS
Drug-Orug: 1rsto1terone may poIefltialr 1M rtfeas of orill alticoagWnll atld
incrHl( tfMo rilIt of s.MIf bIHdiIg. (onrunnt 1IIf d tfllOSItrOM with
cortiul\U'roO! ma, Gl1lIf additi'lf edana. which (iJf1 tit seriom IlIIOO1 [01 thcsf
willt helrt f\@patOlOlicdrugsslKUdtltiMliderlbtutM!II!'wi:h
te'iIOIIeJOMun
La b 1i511: YalUfS of 1M foIowin9 may tit deu!Nd: 1 4. th)'rOIilf-binding gIobt.lin,
Iff1J!l a kim, DI donilg 00011 It Y.I-lI. ,nd X. (RIllinnr. may tit inc!Mfd, ltd
cholfsttrol maybf l'ithf! ilaNSN or
Herbi IiFood: The rillt of hepal:OIolidty may inoNst whert teI1051eron!' UIfd lrillt
rdlifla(1.l.
Treatmfm 01 Overdose: There is 00 Ipt(ific:tll'aunent for OY!'rdose.
""fer Ie M)NulllnglJr tx Q Nrm/fJ,l1'rlKm fooJllpP(1k Ie rIr/s
consistent inability to either obtain an erection or to sustain
an election long t'nough to achieve successful intercourse.
46.4 Pharmacotherapy
of Erectile Dysfunction
The incidence of erectile dysfunction increases with 1ge, al-
though it may occur in a adult male of any age. Certain dis-
eases, most notably atherosclerosis, diabetes, kidney disease,
stroke, and hypertension, are associated with a higher inci-
dence of the condition. Smoking increases the risk of erectile
dysfunction by 30% to 60%, in a dose-dependt'nt manner.
Psychogenic causes may include depression, fatigue, guilt, or
fear of sexual failure. A nwnber of common drugs cause im-
potence as an adverse effect, including thiazide diuretics,
phenothiazines, selective serotonin reuptake inhibitors (SS-
RIs), tricyclic antidepressants (TCAs), beta- and alpha-
adrenergic blockers, and angiotensin oonverting enzyme
(ACE) inhibitors. Low testosterone secretion can cause an
inability to develop an erection, due to a loss of libido.
Penile erection has both neuromuscular and vascular
components. Autonomic nerves dilate arterioles leading to
the major erectile tissues of the penis, called the (orpora (aver
nasa. The corpora have vascular spaces that flll with blood to
cause rigidity. In addition. constriction of veins draining
LibraryPirate
720 Unlt l TheEr.doar .... SyS!,-""
NURSING PROCESS FOCUS PATIENTS RECEIVING ANDROGEN THERAPY
Assessment
BUfline l zessmfnt prior to administration:
Understand the the drug hil been prfnriilfd in order to for
dftm 1"'tieu"', filiu"", ""byrd puborl)' in boy>
1Wt'I1S, hypogonadilml.
Obtain a complete health hillol)' induding wdiollasc:ula" peripheral
va sc:ular, thyroid, or renal diseale; diabetes; proltltic hypertrophy; 0'
promtic or tanCfl".
Obtain a drug hiltOl)' ilKluding aJrTrm presc:ription and OK drugs,
herbal preparations,akohol use, and smoking.Bealen to drug
imerJcticm.
E"lawte appropriate laborato!), findings (e.g., C8(, Mctrolytes, glucose,
lipid IeYels, PSA).
Obtain vital signs.
Assessment throughout administration:
Asses5 for desired therapeutic rfffeB dependent on thr INson thedrug iI
givrn (f.g., hormolll' IevrIs oormalizr, oormalligns of m.lIaJlinization arf
prerml.
CominUl' periodic roonitoring ofCBC,Mtrolyte,gluc:ose.lipid IeYeis,
hepatic and renalfunaion lab!. and PSA
Monitor filal signs, at u{h heakh W I' visit.
fur dIl"",. .. n.,l" rrdU","", Y"nrnir'I,L h....!""' 'l"irr.lluid
ioomed blood pl!"IWJe,changel in mood, irritabilit"and
agitation. Allo ilses5 for tachymdY. palpitations, or hypenenlion.
r!pl'(iall)' i s!ociated with angina or d)"spnea;abdominal pain; or ligns of
hepatotoJicity.
Potential Nursing Diagnoses
Oisturbed Body Imagf (rt'lated todrug rfif<tl. oIgill9 plO(m)
Sexual Dysfunaion (lI'Iated 10 drug rfif<tl)
Fuid Excess (related to ad\'el"lr drug eflem)
[lefidem Knowledge (drug therapy)
Plllnning: Plltient Goalsllnd Expected Outcomes
The patient will;
ExpenrlKf therapeutic fffrm (e.<J . normill virilimion and development of IffiIndary let {haraoctrriltill (ontinutl).
Br mr from, or upeOeo{(' minimal.adYersr fffrm.
VerlJalizf an undentandin 9 of the drug's U"'", atlYenr tffrm, J nd rl'quirt'd preuutions.
proper selhdminilu"ion ofthr medication (e.<J. dose, timing. when to notify plO'/iderl.
Implementlltion
Interventi ons li nd (Rlltionalesl
Ensuring tht rapeutk effeds:
Monitor appropriate medication adminilmtion.(Appropriatr
adminiltration. r!pl'(iall)' of gels or transd!'rmal forms, will optimize drug
ablOrplion and therapeutic: rffKlsJ
Minimizing ildftBf efftds:
Monitor blood presurt' at NCh dinical visit.Chrck body and for the
preelKt of edema. (Androgens (au If \Odium a nd water ft'tention with
ft'IUking in blood prt'!1Urt'. and f!1ema. Report
promptly any BP O'I!'I" 1401'JO mmHg, periphtral edema.or lignifitant
Wl'ight gJin a Ihort amount of time.)
CominUl'to monitor elKtrolytes, lipid le<iris,ind hepatic fuodion labs
prriodic:ally. (AndrogeM mav arod akium Imk.
nd noopb "'" 10ft' but polfmi.ol
rfff<tlJ
Patient li nd Fll mily Educllt ion
Teach the patient approprialt admioilmtion tr{hniqUl'! (Iff Patiem srlf
adminiltration of drug therap(laler in thil table).
Teach the patient to monitor blood prfllUre on i Wl'l'kI)' Wiil, f nsurill9
proper functioning of any rqJipment used at home. Report any BP IMr
140190 mmHg or <lI dirt ued by the health pra<ider. Report any
Wl'ic;rht gain lib in 14 hours or Ib in 1 week. Report any peripheral
edema.
InstnKt the patient to return periodicalI)' for Lib tflt!.
Teach the patientto immediately ft'JIOrt any symptoms of abdominal or
righ( upper discomfort 0' pain, ydlowing of (h. skin or Kina,
fatigU!'. aoort'Ua. darkened or cLly-<oIorrd stool
naulfa,or omitill9.
LibraryPirate
(hoplfl4/; Drug' (Of Dllorde" and Coooillon, 01 the Mali> Rep,odunlw S)'5lem 721
NURSING PROCESS FOCUS PATIENTS RECEIVING ANDROGEN THERAPY (Confinutd)
Implementation
Interventi ons and (Rati onales)
Monitor blood gl(l(oll' Ievcls in diabttic: j)atitnu fll'quently. (Androgens
mly IffKt wbohydrillt metlboIism,ltlding 10 i I ltd gllKOII' ItYeIs.
Mtn with diabttfi ,hoold monitor their(apillary blood gl(l(OII' mOIl'
frequently.)
Monitor height Ind growth in {hildren and adolt:KenU. tAndf09l'll
adminisuillion may (aUSt pmniliUrt (Iosureof !as,of
nannll growth pillII"fns.)
MonitorlM in iIdolt!(ent patiems.(Abuse of arodrogtns arod
anabolic steroids with I!"IUking artm!l' effects.)
Patint understanding of drug tht rapy:
lIII' opponunities during administration of mMimion,and during
at!esmentl todisW15 the rationalt for drug theraPl',
most {ommonly ildvtlll'riIe<lI, pilramtten for when
to (all tiM' health ure and all)' nKtSsary monitoring or
prtlautions.(Using rime during riming (are to optimize arod reinfon:e
keyttil{hing iIIeatJ
Patint of drug thflil PY:
the mtdicillion,instrun the patient. family,oruregim
in proper self-adminismtion ofdrug. e.g.,comillently ill same timt
eil(h riayto help tiM'dose. (Proper .tdministration will incft'ast
rffectMlII'II of tht drug.)
Patient and Family Educati on
Ttl{h IIII'n with diabetfi to monitor {ilpillary blood gluc:O!I' more
fll'quently whileon drug Ind Il'pOn tlmtions to hNhh
prOYider.
Tt.t{h the pillitm. f.Jmily, or mrgimto htight OrKe ptr month or
at Return for dinical at !emll'nts at I"ftdtd approximately M'f)'
6 momh, to monitor
Tta{h tht idolescent patient to m.J imain riaily at instructed a nd
not to incft'ast dos.igt unltu in ,lnKted 10 do so by htalth Cilft'
drug shoold never besharrd with others.
The piltiem should beable to !late the INson for the drug. .J ppropriate
dose and S(htduliog. i nd what ad!'rll' rffects 10 obll'r!' for arod to

Tmh the piltitnt to take drug following appropriate guidelintl:
0,,1 drugs ,hoold be IiIken at tht same iiIIII' filCh dlY to maintain
consistent drug Itl'ls.
Transdtnnal pitches shoold be applied 10 tht !(rotJl aft'iI afterdry
,hilYing; do oot lM depilatories. (hallgt piltth and rotate Sitfi ria ily and
report any 5kin irrimion.
BucCilltabiru ,hoold be ptac:M be1Wffn the chtt-k arod upper IJIm and
held in place for lO from side to side,mliding illNS of
irritation .
Gels and cft'ams should beapplied to the upper tooo. tnremitits,or
abdomen. Swimming and shOWl'ring should be ilWidtd for smral
houB following administration. Do oot allowwomen or children to
COliii' in ronlild with drug or application sittS ill the drug rub off
and UU!l' adYtr-st effects.
Transdtnnal pelitts.Jre implanted in wall M'f)' 3 10 6
month!.
Injections should begiven into deep glulNlllIII(lt.1f piltient is to
adminil1era.vn injections, tmh the appropriate techniqut, followed by
re\urn-ilemonstration until tht piltitnt is comfortlblt arod
demon,tralts proper technique.
Evaluation of Outcome Criteria
Evaluatt the tffectiYentss of drug therapy by ronfirming that CJNlsand 6ptCtM outcomes ha!' been IIII't != Plannin().
5rf TDbIt 4/i I rot Q isr of /hfJ5 Ie wIidr rI!e!t oolli" Iioo! tIpp/y.
blood from the corpora allows the penis to remain rigid
long enough for successful penetration. After ejaculation,
the veins dilate, blood leaves the corpora, and the penis
quickly loses its rigidity. Organic causes of erectile dysfunc-
tion may include damage to the nerves or blood vessels in-
volved in the erection reflex.
The development of sildenaftl (Viagra), an inhibitor of
the enzyme phosphodiesterase-5 (PDE-5), revolutionized
the medical therapy of erectile dysfunction. \'/hen sildenaftl
was approved as the first pharmacologic treatment for erec-
tile dysfunction in 1998, it set a record for pharmaceutical
sales for any newdrug in U.S. history. Prior to the discovery
of sildenafil, rigid or inflatable penile prostheses were im-
planted into the corpora. As an alternative to prostheses,
drugs such as a1prostadil (Caverject) or the combination of
papaverine plus phentolamine were injected directly into
LibraryPirate
722 Unlt l Thi'Er.doa1neSym'm
TABLE 46.3 1 Drugs for Er"ctil" Dysfunction
Drug Route and Adult Dose (max dose where Indicated) Adwr'll' Effl!cts
(0) (V"IJ'J) PO; SO mg 30-60 min briOfl' intmGUBt (mn: 100 mg onw'day) MllQ/ hfodxh(, fodd flwJing, dzzilltJ5,
Ii lioo abnorrmlBriff,
udalilfil PO; 10 mg Jpprtllinattiy 30 rrin briOfl' inltr<tWt (max:20 mg OIKt/da,)
0ncHiII1)' 00sIng:25- S mg dilly
IIypotPlKinnwh. n IObn w;m ";lm ... nriapillll
IINring anterior iscllerri{ optic
'lal'llmafil (lni\ra) PO; 10 mg i pprtllinattiy 1 h intMOII'lt (max:20 mg onw dily)
"""""
lidifl {l)ItI1OOIt ftfffls;.!.!:lli!!i!!m.indicite smous
the corpora cavernosa just prior to intercourse. Penile in-
jections caw.e pain and reduce the spontaneity associated
with pleasurable intercourse. These alternative therapies
are rare today, though they may be used for patients in
whom phosphodiesterase-S inhibitors are contraindicated.
The PDE-S inhibitors do not cause an erection; they
merely enhance the erection resulting from physical contact
or other sexual stimuli by maintaining relaxation of the
smooth muscle in the penis and increasing blood flow. These
drugs are not as effective in promotingerectioll'i in men who
do not have ED. Despite cOll'iiderable research interest, PD E-
5 inhibitors have no effects on female sexual function, and
these drugs are not approved for use by women.
Two other phosphodiesterase-S inhibitors have
approved by the FDA. Vardenafil (Levitra), acts by the
same mechanism as sildenafil but has a faster onset and
,.. Prototype Drug I Slldenafil (Vlagra)
slightly longer duration of action. Tadalaftl (Cialis) acts
within 30 minutes and has a prolonged duration lasting
from 24 to 36 hours. Drugs for erectile dysfunction are
listed in Table 46.3.
The three phosphodiesterase-S inhibitors are equally effec-
tive at promoting erections in 60% to 80% of male patients,
and adverse effects are similar. The most conunon adverse ef-
fects are nasal congestion, headache, facial flushing, and dizzi-
ness. These drugs product" a 5- to lO-mm fall in blood
pressure, but this drop is usually not clinically important. In
patients who are taking nitrates or multiple antihypertensive
medications, this blood pressure change may pro-
duce symptoms of hypotell'iion. Phosphodiesterase-S in-
hibitors are contraindicated in patients taking nitrates.
TadaIafil produces less blood pressure decrease than the other
drugs in this class.
Therapeutic (lass: Drug for treating impoten{e Pharmacologic (lass: Phosphodiesterase (PDE)-S inhibitor
AalONS AND USES
Sildenafil iru by smooth musdts in W{orpori lal'MlOSi, thus allow-
ing inaNst<i blood flow imo tilf penis. Tilf blood flow rtlUm in a
firrntr ind Iongrrlasting maion in about 700M. of IIItn taking the drug. Tilf on-
sd of lion is rapid, less than 1 hour,and itstifrcts bst up 10 4 hours.
Sildenafil bkKks myrtle phosphodif,strrast-S.
Si1denafil also for the of pulmonary h)1ltlttlllion.
Blod:ing in pulrrooary mrulu sroooth YoI-
sodi Lnion and rrouaion in i rteri,l Tilf drug (a-
pali!), in
ADMINISTRATION ALERTS
Ayoi;I adminismtioo of with m(.!is, high-fat mtals,
i b50rption is
Al'Oid graptfruit when administering sildenafil.
PHARMACOKINETICS
IAtset: 20-60 min
f'f: .k:30-11Omin
h
Duration: 14 h
ADVERSE EFFEaS
Sildlonafil is well tolerated and adYmt tfflods uswlly transient , nd mild.
Comrron tfFIs indudlo diuines, flushi ng, rash, and nas.il
{OnqtStion. Tilf most serious hypottn mn, ocrurs in p.ltienl! (on-
ukingol9inK for angil\j andGln rI'Iuk in MI and suddenGlr-
dia( dIoath. Sildtoafil u n blurred vision, sensitWity 10 or
{hillCjl'S in (lIlor ptfuption. Priapism, a sustained lasting longer than 6
hoofS. has with use and may lead to prnnanent
darN9!' 10 ptnile tis!Ul's.
Contraindkations: Sildenafil is (omraindilllted in patif, nts taking nitrates and
in with hyptfunsitivi!), to drug. '9!'n!s in
patif, ms with urdiomruLtr I!(tnt Ml, stOOR, heart dys-
rftythmias" nd in thl> of anatomillli dtfonnititsof the
INTERACTIONS

sidmJfil and tlKl'lWlt Iowfr drug nilrilles wil trlUt in
twotfl1licn I'fotease itibitor; will aust iooNsfd
sidmJfil lfwis, whidt may iEOOto toliritJ Ri/aqIin Ina\' deuueWtleMi lewis.
leadingto rieaf<t lfd
Lab Tl5ls: Iktnown
IlerbaVFoo:l: GralM'fnir: j.ict ilKfNlfl thf plasma (OfI(t rlraticnl of IidmafiI and

Tl9tment of tNerdose: is 00 Spr(ifK tlNlrtlelt for overdose.
Rmf MlsJnqPrOCell" fixfIl sp1/I( 1II1M1tlig.
LibraryPirate
(hoplfl4/; Drug. IOf DllOrO<>rs.oo Cor.dltlom of the Mal<> Reproductive Synem 723
NURSING PROCESS FOCUS PATIENTS R.eElVING TR.ATM.NT FOR .REaIl. DYSFUNCTION
Assessment
Baselinr assrssment priort o admini stration:
Undtrsund thr IN.on the drug has bn prescribtd in ordtr 10 me. lor
llitra pwlic: effts kg., inability to obui n orillStain .n M'ction).
Obtain a lIt.hh induding peripllt .. 1
vaswla\ thyroid, hepatic:, or rtnal di.rbrlri;.nd
hypertrophy.
Obtain. drug induding alitrgies,rurft'nt plt"lCriplion oInd OTe druqs,
htrb.1 prtp.,mtion',akohol 1M, and ,moking.Be <Iitrt to usr of.ny
antihyperw..imand any po.,ibledrug interolaiom.
appropriate I.boratory findings (t.g., e &, eieulViytes, gluc:ou, lipid
itl'els,PSA).
Obtain bistlint vital blood presSUrt.
Assell mrnt throughout iI dministration:
A.ses lor dtsired tlitrolptUlK t ffemdtptndtnt on tilt rt.lOn tilt drug
gil'tfl (t.g., rtpOrt of ability loac:hitvt or maintain i n t rffiion).
Monitorviul blood pres'Urt. Report any blood prrssUft'
below 90160 mmHg.or ptr paramtlm, 10 the lIt.hh caft' providtr.
A.ses lor .dvent eII"ts: 1IiI1M. , wmiting,dt<IN.ed blood pft'lSUrt,or
diuinns. ToI(hymdia, palpitations, or hypotelllion, especially a >5lXialed
with ngillil or should bt rtported im mediattly.
Potential Nursing Diagnoses
SeJwlOysfulKtion

Knowledge (drug lherapy)
Rilk for Injury (rtlatM to <Idvtllt drug
Planning: Patient Goals and Expected Outcomes
Tht patient will:
ExperielKt llitrapwlic: effts k g., . biliry 10 ac:hitvt and maintlin an M'(tion).
Be from,or txptritnc:t idvtlSl' effts.
VerWlizt an undtrmndill9 olthedrucjs ule,advtlSl' tffe(\S,.nd rtrr.rired prtl:.ulions.
DMIOnl1rate proper seII",dministration of tht mediLltion k g.,d=, timing, when 10 notify pro'Iidtrl.
Impl ementation
Interventi ons and (Rati onales)
Ensuring therilptutic effects:
Monitor appropriate mtdiation for optimum ft'IUlts.
(Appropriatt administration will absorption .00 thtr.lpwlK
t l'fe<K)
Minimizing adft rsf effKls:
Monitor blood prtSSUrt at ta(h dinic:al visit Report any BP btlow 90160
mmHg,rspt(ially if mompanitd by tac:hycardia,diuiness,or (hest pain, to
tilt lItallh cart plll'/ider. Assffi lor (OlKUlTtnt USt of nitralf"s or
antihyperttfllimand rt'Iiew.ny new prfl(ription.
inhibitors (aIM Y<lsodilation and may rtlUh in lignifKant hypotenlion.)
Monitorlor (han91's in vision, ilKluding blurrtd vilion,manges in thf .bility
10 liM {olors and for . ny suddtn pain or lights or llasllt. in
(Phosphodieslt.-inhibitors may .ffect tilt abiliry 10 let mlors,tlpt{iilly
blUI' and .nd may cau.t blunM lilion. Optic: a raR' bul
Ieriou,adYflSf efftd.nd .ignitiGinl visual changtsorf)'l' pain should bt
immedialtlyJ
Monitorlor the dtftlopmtnl of priapism.(Any trtction Iastinglon9l'rth.n
4 hours shoold bt rtpOrted to Iht lIt.kh cart providtr for prompt trmmtnt
as tillUl' necrosis may ocrurJ
Patient I nd Family Educati on
Teach the patient appropriate administration tKhniques (_ ' Patient lelf
administration of drug thtrapy"l.Jtt r in tabid.
Teach the IHItient 10 monitor blood prffiuft'on a wrekly bisis, ensuring
proper functioning of any fquiplIII'nt used 011 home.Report.ny BP below
9Of60mmHg.
InstllKt Ihe palient to 001 takt tht drug if (UlTtntiy taking nitralts for
(hest iton!)' on i pm ba.is.and consult with the ht. kh caft'
proI'idt r befort slaning any new Pft'!{rip tion, tspecial!)' lor h)"lltrten.ion.
Caution lilt patient to tmcile caution when driving orwith oKtivitits
inwlving visua I aruity until t ffts 01 tht drug a ft' known. Pitienll who
pilot ain:raft shoold chtdwith thtir t mployer or FAA rtguiationsabout lilt
USt 01 tht drug btfort flying.
InstllKt Iht p.tient to immediiltly rtport any signilic:.nt changts in isual
aruiry, t)'f pi in, lights, or flasl-rts in tht to tht ht.kh ca ft' provider.
InstllKt the patient to rtport .ny sust.intd erKtion lasting 0YtI4 hours, or
an trtdion with .ignific.nt pain, to Ihe lItakh cart providtr oInd Ietk
prompt mtdic:.illrtalmtnl
(conrlnuefi)
LibraryPirate
724 Unit . The Er.doc:.l .... Sy.tem
NURSING PROCESS FOCUS PATIENTS RECEIVING TREATMENT FOR ERECTILE DYSFUNCTION (Contlnuw)
Implementation
Interventi ons and (Rati onales)
Patitflt undt rstanding of drug thrrap-,:
Use opportunitits during Jdminil1llluon of medications Jod during
.""" .... m. to di5<ul< tho r.rtio .. 10 for drug thoropy, dosirm thctop<lltK
ookomes, mon (ommonly oIMMd adY!'M efff,ru, forwhen
10 call hralth prOYidtr, .tod any newu!), moniloriog or
preuutions.(Usiog time during nUBiog to optimiH< and
kr, leaching arl'ols.)
Patitflt stlfadministrati on of drug tht rapy:
When mtdiution,iostllKt
in t!lf proper at t!lf samr
lime each day to help II'membtr ibedost. (ProPf'r administration inma!f1
the eli"fdiY!'Olss of the drug.)
Pati ent and Family Education
p;atienl shoold be abit to stale t!lf rm on for t!lf drug,approprinr
",hrdJliog.ond whu .dvt"" off\> to ob..,vo for.od whrn to
II'porttlitm.
Teach lilt patientlo lake the drug following appropriale guidtlilltl:
Sildtnafil should be taken u INsllO minutf"l btfoII' inten:ouM iod
tffem may lasl up to 2 hool>.
Vardenafil wore more qJiddy but haSi longer dJrition of
action.
Tadalafil may be liken 1 hour btfoII' intici pited Itlllil inlet(oul>e but
dJration up to 16 houl>.
Evaluation of Outcome Criteri a
Evalu.Jte the efffdiwOl'sS of drug looar; by ((Infirming mi t p;atiertt goals.Jnd l'Jpl'(led OUICOmes h,J\'(' betn
';t\' TGbIt 46.1 fIJI rt dfl!(p III which rhm nmirrg Qaicm t1pply.
H OME & COMMUNITY CONSIDERATIONS
Sample Packs of Medications
for Erectile Dysfunction
k is not oocommon for men to occasion.Jl rll'ctir diffku!ties. Thm
OUllfll(fI lend 10 happen mort.' often.H a man ages. Drugs for rll'ctiit tiysfull(-
lion all' being giYl'o 10 male patients n an ""r-ill(lI'oI sing tatt .Many hNlth
proIIidtB giY!'p;atientasamprp;a(kofmediutioOI
tiYtllflS prior to iIkiH;J the patient to PUKhalt 01 pr=ription.Some metl may be
giYfn a different sampit piCk 10 II)' at Nm offiu visit. espt<ially if t!lf did
notNilheplE"t'NdlU] i; importlmlOilllllllt
patients to tike only 001' of any kild 0/ rll'ctir dysfunc.tion drug on iny one day.
Tilt Pitient must be educated that all the miLtbit drugs i ll' from the same drug
dau ,nd wil GlUIt harm iflOO mlKh is !.lUll
DRUGS FOR BENIGN
PROSTATIC HYPERPLASIA
Only a few drugs are available for the pharmacotherapy of
benign prostatic hyperplasia. Early in the course of the dis-
ease, drug therapy may relieve some symptoms. These
agents lire listed in Table 46.4.
46.S Pharmacotherapy of Benign
Prostatic Hyperplasia
Beni gn prostatic hyperplalia (BPH) is the most common benign
neoplasm in men. It is characterized by enlargement of the
prostate J!;land that decreases the outfl ow of urine by ob-
structing the urethra, causing difficult urination. Symp-
tom .. indude im:reased urinary (usually with
small amounts of urine), inueased urgency to urinate,
postvoid leakage, excessive night-time urination (noc-
turia), decreased force of the urine stream, and a st'nsation
that the bladder did not empty completely. The urinary
outlet obstruction can lead to seriouscomplicatiorusuch as
urinary infectioru or renal failure. In advanced cases, a sur-
gical procedure called transurethral resection is needed to
restore the patt'ncyofthe urethra. BPH is not considered to
be a precursor to prostate carcinoma. BPH is illustrated in
", Figure 46.2.
The pathogenesis ofBPH involves two components: static
and dynamic. The static. factors relate to anatomic enlarge-
ment of the prostate gland. The gland can double or triple its
size with aging and cause a physical block of urine outflow at
the neck of the bladder. Thedynarnjefactors are due to exces-
sive nwnbers of alpha,-adrenergic receptors located in
smooth-muscle cells in the neck of the urinary bladder and
in the prostate gland. When activated, the alpha,-adrenergic
receptors compress the urethra and provide resistance to
urine outflow from the bladder. The two mechanisms of dis-
ease, stlltiC lind dynamic, have led to two different classes of
drugs used to treat symptoms of BPH (Table 46.4). The
mechanisms of action of these drugs are shown in Pharma-
cotherapy Illustrated 46.1.
Certain frequently used medications can worsen symp-
toms of BPH. Alpha-adrenergic agents, which include de-
congestants such liS pseudoephedrine and phenylephrine,
may activate alpha,-adrenergic receptors in the bladder
neck, restricting urine flow. Drugs with anticholinergic
LibraryPirate
Choplfl46 Drug' rot DllOrrler. and (oooillon, of the Mal<> Repmductlw 'ytlem 725
TABLE 46 4 Drugs for Benign Prostatic Hyperplasia
0""
ROUM and Adult Dose (max do5ol' where Indicated) Adverse Effects
ALPHA,-ADRENERGIC BLOCKERS
PO; 10 rngItiay (mil: 10 rngIday)
PO; 1- 8 m9Ida:I (mad rngItIa,)
mgftla, (rnax:8I1191da:1)
PO;OA mg]O a meal (max:0.8 mg.ItIa,)
Fi1IjIolI' pheoomrnoo (sum byoolfDjjoo and WDrgpr)
......
(lkwual)
(unhn)
XI. (unhn XU
tarrIIlbin (Flomil)
(Hytrin) PO;!Ia1 with 1 mg at btdtifM, then 1- 5 (rnax:lO mgftlay)
5-ALPHA-REDUCTASE INHIBITORS
duta5lmdt(Avodirt)
Q fina5lmdt (PrOlCilr)
PO;05mgltla,
P0;5mg/tiay
italia intkau ammon id'Ime Ioffiousadmslo


,.,
wal dys(rmcrioo, b"bido, d!N!#II tj/KIJIQ1e
1WImf, gynomosrio
No IfflouS idl'l'fg tfftg,
effects such as antihistamines, TCAs, or phenothiazines
may also worsen urinary retention. Testosterone and other
anabolic steroids may increase prostate enlargement, thus
worsening the physical obstruction of the urethra. Drugs
that worsen symptoms of BPH should be avoided in el-
derly men .
The goal of treatment for patients with BPH focuses on
minimizing the urinary obstruction and preventing compli-
cations. Drug therapy can only treat symptoms; it cannot re-
verse or cure BPH. Patients who are asymptomatic or who
present with mild symptoms generally do not receive phar-
macotherapy. Not all BPH is and many patients
never experience moderate or advanced symptoms. Patient
education such as avoiding caffeine or alcohol intake, elim-
inating drugs that worsen BPH, and restricting fluids dose
to bedtime may be sufficient to achieve symptomatic im-
provement. The patient is re-evaluated at 6- to 12-month
intervals to assess for worsening symptoms.
When symptoms ofBPH worsen, pharmacotherapy is in-
dicated. A1pha
l
-adrenergic blockers are often drugs of
Hypertrophied
,..,.
Natrow<ld'-_--';:-1'1I
urtllhra
,0,
U';M'Y
..... ,
True proslale
..
Flgure46.2 Benign prostatic hyperplasla:(a) normal pronate with penis; (b) benign prostatic hyperplasia
Source: RIce. Jane, Medical TefmlllOkxjy with Human Aro.Jtomy, 5rh ed. O lOO5,p. 538. Reprinted by perml55/on ofPearKJfl fdumrion, Inc., iWr
Saddr..RIver.NJ.
LibraryPirate
726 Unlt l Thi> Er.do<rlJW'YfSlem
PHARMACOTHERAPY ILLUSTRATED
46.1 Mechanisms of Action of Antiprostatic Drugs
Static factor.:
Gland .,laogee under the
inA""""" of t __
Enlarged gland creat ...
'"
0,"",.
Alph ..... duct ... inhibitor.
interfere with t .... IOOIt...,.,..
melaboliom.
choice for treating moderate symptoms of BPH. The selec-
tive alpha, blockers relax smooth muscle in the prostate
gland, bladder neck, and urethra, thus easing the urinary
obstruction. DOXllwsin (Cardura) and terawsin (Hytrin)
are of particular value to patients who have both hyperten-
sion and BPH; these two disorders occur conUlrrently in
about 25% of men older than 60. A third alpha, blocker,
tamsulosin (Aomax), has no effe!:t on blood pressure, and
its only indication is BPH. Drugs in this class improve urine
flow and reduce other bothersome symptoms of BPH
within I to 2 weeks after administration. Primary
effects indude headache, fatigue, and dizziness. Doxawsin
and tt't"awsin are not associated with an increased risk of
sexual dysfunction, but ejaculatory dysfunction has bet'n re-
ported with tamsulosin. Reflex tachycardia due 10 stimula-
tion of barorect'ptors is common with alpha blockers.
Dyn.mic factor.:
receptors are
activated in emooth ,""""Ie in
unoth.a and neck of blO>dder
Smnnlh m, ."IA"""t,,,,,,,, k>
namM' the lumen of the .... thra
Alph.,-ad",nergi c bIocka",
pnovenl the activation of mPha
receplors.
COMPLEMENTARY AND A LTERNATIVE T HERAPIES
Saw Palmetto
Saw palmttto (Sm:m rtptm) is bulh, palm that CNILllrrgions
of the IWIhrm Unittd SLlta The portion Uitd i1 is btrm of
thepl, nlMoll'ttun 2 mili:mmtnlMl.lwpalml'uo in
BPH.likr I.lW pilmttto is thought 10 btlp stop usadt of proltill'-
d'fNljing tIIl)'mtI that may ClNj" BPH.1t also bilding on the
proStlll' thataft' 0Upird by dilljdrotl'ltostelOOl' (DIU), an enzyme
that rna, trigger BPH.AItIKuj! clinitalstudies have Suggtlll'd that I.lW
pammo is as fillll\l'rid" i1 trrating mikllO moderate BPH and pr0-
duce ffo.m eflKts, rww II'lNlth i1dkatl'l that it tu s 00 brnefn in tINt-
ing BPH Kane. Shinotur.J, Neuhaus, Hudl'S, Goldberg, & AIvim. 2006).
5.iw may (,JIM damage to the liver panuus,1G it is vital thu
thorough hNlth , nd history, .J ndadvill'lbt
of in potential ad ..... rll' effect!.
LibraryPirate
Chopltl46 Drug' rot Dllorders.OO Coooillon, 01 the Mali> Rep,odunlw S)'5lem 727
Prototype Drug I Flnasterlde (Proscar)
Therapeutic (lass: DrugforBPH Pharmacologic (lass: 5-alpha reductase inhibitor
ACTIONS AND USES
Finastt ride am by inhibiting tht enzymt rt'IpOIISiblt for
coo!'rting ttstoSlmot 10 Oot of its metabolitts, 5-.lpha-dih)'droltstoslmot.
This activt mmbolilt UUIn prolift ration of prona1l' erik "Id prorro!tS M-
largtmtnt 01 tht gland. BtcalM it inhibits tht mt tabolism of tt dostt ront,
fin.lI1l'ride is sometimt1 u lltd an anriondf09/'fl Finantride prorro!tS !ohrink-
'91' of Mlarged prOn<ll6 and htlps !!"Stolt urinary funuion. k is
lOOn tifecti!' in patients with lafl1ef pro\la1l'l.
Finasttridt is aha marRied as Propecia, which is prtlaibed to promott hair
rtgrowth in patitrru with m.lt-pattt m baldllfls. of fin<l'1l'ride all'
timt. higlltrwlltn prr!(ribed for BPH than whtn prescribed for baldnrSl.
ADMINISTRATION ALERTS
Tablet! may bt Ulllht d for oral <l dministr<llion.
Tilt pll'gnanl pharmacist Ihould avoid handling (rushtd mtdica-
lion, as it m.ty bt absorbtd through tilt ,kin and UUII' harm to a malt !eM.
Mtn who take finasltridtlhould 001 donalt blood whilt on drug therap)'.
(It may bt giftn to <I !emalt patient with II'sulting adl'tBt t ffrets.)
PHARMACOKINETICS
Onset : Maximum effrm may loll- mo
PNk: l - 1h
Halflift : S- 7h
Duration: 5-7
Additional information on the alpha blocl(t'rs and a proto-
type feature for doxazosin are presented in chapter 2300.
Some patients are unable to tolt'rate the cardiovascular ef-
fects of the alpha1-adrenergic blockers. For these patit'nts.
the 5-alpha-reductase inhibitors offer an alternative. These
agents block an enzyme in the testostt'rone metabolic path-
way, thus eliminating the hormonal signal for prostate
growth. The most commonly prescribed drug in this class is
finasteridt' (Proscar), which is featured as a prototype for
BPH. Th ... e agent. may take several month. to mrink th ..
KEY CONCEPTS
ADVERSE EFFECTS
Fioalleride is well and gentrally mild and lJaositnl
Finasttride UUIn v.rious type 01 II'lWI dysfunction in up 10 16% 01 patitnts,
ilKluding impoteoU', impaired fertility, diminishtd libido, and
function.
(ontraindi cations: Tht (omraindic<llion is hypmtOSitMt)' to tilt drug.
INTERACT10NS
Dru;rDrug: IIIf with an tidIoIiIfr9iG may dKrNsf tIMo finaruricIf. Ust of
fillilltlidewith 1!'I!lI:I1m1nt wil in a rmtion in 1IIP both
La b TI5II: YilIIlPI f(f lilT and p6W1f.!pf{iIK antigfo may bf drorud.
TflllI:I1HOnt may bf iMJ&lIfd.
HI'IiIa VFood: Saw parneno may poifJIliitt tIMo Iinasttridf.
TlNt mf m of On-rd05t: Therr is 00 !pt(jfK Irratmeol for O!'rdost.
/It ftr to M)NurllllgKJr (or Q NurlIrr; I'rrxlss Foo!s sp1k to rills dJll9
size of the prostate; thus, they are not appropriate for severe
disease. The 5-alpha-reductase inhibitors produce few ad-
verst' rlfects, although they can cause se.'(ual dysfunction in
some patients.
Drugs for BPH have limited effectiveness and have value
only in treating mild-to-moderate disease, as an alternative
to surgery. Because pharmacotherapy alleviates the symp-
toms but does not cure the disease, these medications must
be taken for the remainder of the patient's life, or Wltil sur-
8"ry i. indicated.
The numbered key conrepts providt' a succinct sununary of the important points from tht' corresponding numbered section
within the chapter. If any of these points are not clear, refer to the numbered section within th .. chapt .. r for reviEW.
46.1 FSH and LH from the pituitary regulat .. tht' secretion of
testosterone, the primary hormone contributing to the
growth, ht'aith, and maintenance of the male reproductivt'
system.
46.2 Androgens are used to treat hypogonadism in males, and
br .. ast cancer in females. Anabolic steroids ar .. frequently
abused byal hl .. tes, and can result in serious adverst'eifects
with long-term use.
LibraryPirate
728 Unlt l The Er.docrl .... Sym'm
463 Malt' inft'rtility is difficult to treat pharmacologically;
medications includt' HCG. menotropins, testolactone,
and antiestrogens.
46A Erectile dysfunction is a (ammon disorder that may be
successfully treated with sildt'naftl ( Viagra), an inhibitor
of the enzyme phosphodiestt'!"aSe-5.
NCLEX-RN" REVIEW QUESTIONS
D Which of the following nursing assessments would beap-
for the testo.teronel (Select
that apply. )
I . Monitor for a decrease in hematocrit (Hct).
2. ARSS for signsoffluid retention.
3. Assess for increlsed musclt' mass and strength.
4. Check for blood dyscrasia&.
5. Assess for musdt' wasting.
D Which of tht' following nursing assessment findings may
be evident in a patient who has undergone testosteront'
tht'rapy?
1. Virilization
2. Electrolyte imbalances
3. Hepatomegaly
4. Precocious puberty
D The nurse assesses for which of the following medications
that may predispoSl' the patient to t' rectile dysfunction!
1. Insulin
2. Nonsteroidal anti-inflammatory drugs {NSAIDs}
3. Phenothiazines
4. Oral hypoglycemiC'i
D Which of the following questions should the nurse ask
prior to the administration of sildenaftl (Viagra)?
I . 'Are you rurrently taking mediCltiorts for angina! "
2. "Do you have a history of diabetes?"
CRITICAL THINKING QUESTIONS
1. A 78-year-old widower has come to see his health care
provider. The nurse practitioner in terviews the patient
about his past medical history and current health con-
cerns.. The p.1tient states that he is planning to marry "a
very nke lady," but is concerned about his sexual perfor-
mance. He asks about a prt'SCription for sildenafil (Via-
gra). What additional assessment data does the nurse need
to collect given this patient's age!
2. A 16-year-old adolescent goes out for the football team.
Ht' is immediately impressed with the size of several jun-
ior and senior linemen. One older student oITers to "hook
him up"with a source for androstenedione (Andro). From
a developmental perspe<:tivt', explain why this young man
maybe susceptible to anabolic steroid abuse. Can anabolic
steroid abuSl' affect his stature?
46.5 In its early stages, benign prostatic hyperplasia may be
treated successfully with drug tht'rapy, including finas-
tt'ridt' {Proscar} and alpha, -adrenergic blockers.
3. "Haw you ever had an allergic =ction to dairy
productsl "
4. "Haw you ellerbeen treated for migraine
II Tht' patient with a history ofBPH is complaining of feel -
ing like he "cannot empty his bladdt'r." The nurse antici -
pates that the ht'alth care provider will order what
medication?
1. Tadalafil (Cl'llis)
2. Sildenafil (Viagra)
3. Ths\ostt'rone (Andro)
4. Finastt'ride (Proscar)
o A patient is given a prescription for finasteride {Froscar}
for treatment of benign prostatic hyperplasia. Essential
teaching for this patient includes: {Select all that apply. }
I. full therapeutict'ffectsmaytake 3 t06 months.
2. hair loss or male-pattern baldness maybean adverse
"''''.
3. the drug should not be handled by pregnant mlmen,
if it is crushed
4. blood donation should not ocrur while taking this drug.
3. A 68-year-old man has been diagnosed with BPH. As the
nurse prepares to eduClte him about his prescription for
finasteride (Proscarj, he says that he has been hearing
about tht' benefits of saw p.l.lmetlo, an herbal preparation.
Discuss the mechanism of action of finasteride and com-
pare it with that of saw palmetto.
See Appendix D for answers mId rationales for all activities.
EXPLORE
MylkJlYIgKd iwr one onl ine chapter reoiew matenals I!I1d
resouroos. Preporo for success with ad!ilflnll NCLeo:-style
QuestklnS, assignmentS In:! wee *lKS, ! nlmatklM
and i idoos. and mIn!
Aegister your a.;c! !I!l CMe from tne from of your 81
www.mym."'gkill:om.
LibraryPirate
CHAPTER 47 Drugs for Bone and Joint Disorders
CHAPTER 48 Drugs for Skin Disorders
CHAPTER 49 Drugs for Eye and Ear Disorders
U NIT 9
The
Integumentary
System and
Eyes/Ears
LibraryPirate
DRUGS AT A GLANCE
PHARMACOTHERAPY OF HYPOCALCEMIA pqJtJJJ
CalciumSupplemenu fJt1Itll4
Q caklumsolts (l!JgtlJ4
PHARMACOTHERAPY OF METABOLIC BONE
DISEASES pJtJJJ
Vitamin DThmpy ,.114
o caknrlOl (Ca/cljelt, Rocaltrol) pqgt lJ5
Bisphosphonates ptlJtlJ6
O o/endlt>flare(f0s4r1l<U) ".111
Selec:tin Estrogen RtctptOt Modulators
"",m
O roloxlfmt(Evtsto} fI1IjtJ)
Cakitooin IUIllll
PHARMACOTHERAPYOF JOiNTOtSORDlRS ,.JJ
Disuse-Modifying AntirlltumlllK Oru95
pqgtUl
o hydroxy<h/oroqu/M (PIoqINflIQ ,. m
\ki( Add Inhibitors ,.U4
o (CoJcryt) ,.'44
KEY TERMS
mrtegoutyarthritis (XI/tJ44
utoantibadies fJII9f741
bisphosphonates /#It 136
bone Ili9t JJ1
bone morption (IIl9t l1J
GJkiftGol ,. J1J
Glkitoni. p!IIItlJJ
Drugs for Bone
and Joint Disorders
LEARNING OUTCOMES
Alrer reading this chapIn', the student should be obit to:
1. Describe the role of calcium In the body In malnu.lnlng In
the nervous,muscular,and nervous systems.
2 . Identify the recommended dietary all owance and the normal serum
level s of calcium.
3 . Explain the roles of parathyroid hormone,calcltonln, and vitamin 0 In
maintaining cakium balance.
4. Explain the pharmacotherapyofhypocalcemla.osteomalacla,
osteoporosis, rickets, osteoarthritl rheumatoid and gout.
S. Otoscribe the nurse's role in the pharmacologi c management of
disorders related to bones and joints.
6 . For each of the drug classes list ed in Drugs at a Glance, know
repre-sentative drugs, and explain their mechanisms of action, primary
actions, and/or important adverse effect s.
7. Use the IlU"sing process to care for patients receiving drug the rapy for
bone and joint disorders.
nkitriol
cholKaldMroi tuJf 7Jl
diINIP-rmdif-,ing i ntimfumatic drug (DMARD)
""m
9001 piI}t UJ
plllJl'143
lIlftabolic bone cise_ (MSD) tuJf m
Olttoarthritil(OA) fJiJ9tl4l
olttomalacia (JQ9t Jj)
olttoporosb (JI)JtlJS
PIgeI's diSfHf (llJ9tl)l
rMlmltoid arthrim. (RA) pogt 141
5fietti"ft fS1nI9fn rtplor modIILltors (S ERMs)
"",m
LibraryPirate
T
he skeletal system and joints are at the core of body
movement. Disorders associated with this system may
affect II patient's ability to fulfill daily activities and lead to
immobility. In addition, the skeletal system serves as the pri-
mary repository for calcium, one of the body's most impor
tant minerals.
This chapter focuses on the pharmacotherapy of impor-
tant skeletal and joint di sorders such as osteomalaaa, osteo-
porosis, arthritis, and gout. The chapter stresses the
importance of caldum balance and the action of vitamin D
as they relate to the proper structure and function of bones.
Paratt.;roid gl ands
CNplfr47 0"'9' for Booe and Join! Olsordl'l' 73 1
47.1 RoleofCalciumandVitaminD
in Bone Homeostasis
Calcium is the primary mineral responsible for bone forma-
tion and for maintaining bone health throughout the life
span. This major mineral constitutes about 2% of our body
weight and is also critical to proper functioning of the ner-
vous, muscular, and cardiovascular systems. To maintain
homeostasis, calcium balance in the body is regulated by
parathyroid hormone ( PTH), calcitonin and vitamin D, as
shown in ~ Figure 47.1.
Se.:reted by the parathyroid gland" PTH ,timulat .... bone
cells called o5trodasts. These cells accelerate the process of
Parathyroid glandli cause:
o Ael ....... of calcium from bone
a Incnoued calcium "'absorption
from kidneys
'"
'"
Lowe, lewis 01 calcil.m
in the bloodstream
Thyroid gland
Thyroid gland causes:
H ~ I I"""", uf ....J .. y'"
in the bloodstream
.. Flgure47.J (a) Parathyroid hormone (PTH) and (b) calcitonin action
o '"",,,,,sed absorption 01 calcium
in small intestine (with help 01
calcitriol Or vitamin OJ
Hig>er levels 01 calcium
in tho bIoodst",.m
o Addition 01 calcium to bon"
e o..c",ased absorption of
CIIIciIm in """,II intestine
Low" , lewis of CIIIciIm
in the bloodslrMm
LibraryPirate
732 UnII' The Intequmeomy SY'tem ar.d EyI>"Em
bonr demineralization that breaks down bone into
its mineral components. Once bone is broken down (re-
sorbed), calciwn becomes available to be transported and
USt'd elsewhere in the body. The opposite of this process is
bonr deposition, or bone building, accomplished by cells called
osteoblasts. lbis process, which removes calcium from the
blood to be placed in bone, is stimulated by the hormone
\Vh"" ,,,rUIl1U1kiUlIJ l"vd", b"""",,, d"val.,u, uol -
citonin is released by the thyroid gland.
PTH and calcitonin control calcium homeostasis in the
body by influencing three major targets: the bones, kid-
neys, and gastrointestinal (Gl ) tract. The Gl tract is influ-
enced mainly by parathyroid hormone and involves
vitamin D. Vitamin 0 and calcium metabolism are inti-
mately related: calcium disorders are often associated with
vitamin D disorders.
r
Skin
Vitamin D is unique among vitamins because the body
is able to synthesize it from precursor molecules. In the
skin,(holr(alcifrrol, the inactive form of vitam in D, is synthe-
sized from cholesterol. Exposure of the skin to sunlight or
ultraviolet light increases the level of cholecalciferol in the
blood. Cholecalciferol can also be obtained from dietary
products such as milkorother foods fortified with vitamin D.
... FiKur" 47.2 illu,lral"" [h" ",,,[abuli,,,, uf vilami" D.
Following its absorption or formation, cholecalciferol is
converted to an intermediate vitamin form called (I lcifediol.
Enzymes in the kidneys metabolize calcifediol to G1lcitriol, the
active form of vitamin D. Parathyroid hormone stimulates
the formation of cakitriol at the level of the kidneys. Pa-
tients with extensive kidney disease are unable to adequately
synthesize calcitriol and thus frequently experience calcium
and vitamin D abnormalities.
Calcilediol
(inlermedialelorm)
PT"
Parathyroid glands



vitamin 0)

Increased absorption
01 calcium in
the small intestine
... Flgure47.2 Pathway for vitamin D activation and action
LibraryPirate
The primary function of calcitriol is to increase calciWll ab-
sorption from the GI tract. Dietarycalcium is absorbed more
efficiently in the presence of active vitamin D and parathyroid
hormone, resulting in higher serwn of calciwn, which
is then trall'iported to bone, muscle, and other tissues.
The importance of proper calcium balance in the body
cannot be overstated. Calcium ion influences the
ity of aU neurons. When calcium concentrations are too
high (hypercalcemia), sodiwn permeability decreases
across cell membranes. This is a dangerous state, because
nerve oonduction depends on the proper influx of sodium
into cells. \I/hen co.lcium levels in the bloodstre"m "re too
low (hypocalcemia), cell membranes become
citable. If this situation becomes severe, convulsions or
muscle spasms may result. Calciwn is also important for the
normal functioning of other body processes such as blood
coagulation and muscle contraction. It is, indeed, a critical
minernl for life.
47.2 Pharmacotherapy
of Hypocalcemia
Hypocalcemia is not a disease but a sign of underlying
pathology; therefore, diagnosis of the cause of hypocal-
cemia is essential. Many factors can cause hypocalcemia.
Lack of sufficient dietary calciwn and/or vitamin D is a
common cause,and one that can be easily reversed by nutri-
tional therapy. If hypocalcemia occurs with normal dietary
intake, GI causes must be examined, su<:h as excessive vom-
iting or malabsorption disorders. Chronic kidney disease
may cause excessive loss of calciwn in the urine. Another
etiology for hypocalcemia is decreased secretion of PTH, as
occurs when the thyroid and parathyroid glands are dis-
eased or surgically removed.
Drug therapy is occasionally a cause of hypocalcemia. Blood
transfusions and certain antioonvulsants such as phenytoin
can lower serum calciwn levels. In addition, overtreatment
with drugs used to lower serum calcium can result in "over-
normal levels. Some of these include furosemide
(Lasi."l) , phosphate therapy, or bisphosphonates (see Section
47.4). Of special concern is long-term therapy with cortico-
steroids, which is a very common cause of hypocalcemia and
osteoporosis. To help prevent oorticosteroid-induced osteo-
porosis, patients should receive daily supplements of calciwn
and vitamin D.
Signs and symptoms of hypocalcemia are those of nerve
and muscle excitability. Assessment may reveal muscle
twitching, tremor, or abdominal cramp ing with hyperactive
bowel sounds. Numbness and tingling of the extremities
may occur, and convulsions are possible. Confusion and ab-
normal behavior may be obserwd.
Unless the hypocalcemia is life threatening, adjustments in
diet should be attempted prior to initiating therapy with cal-
ciwn supplements. Increasing the consumption of calcium-
rich foods, especially dairy products, fortified orange juice,
cereals, and green leafy vegetables is often sufficient to
store calcium balance.
CNplfr47 0"'9' for Booe and Join! DIsord ... , 733
If a change in diet is not practical or has not proved ade-
quate for reversing the hypocalcemia, effective and inexpen-
sive calcium supplements are readily available over the
counter (OTC), in a variety of formulations. Calcium sup-
plements often contain vitamin D. Severe hypocalcemia re-
quires the intrnvenous (IV) administration of calcium salts.
Calcium has two major forms: comple:wd and elemental.
Most calcium supplements are in the form of complexed
calcium. These products are often compared on the basis of
their ability to release elemental calciwn into the blood-
stream. The greater the ability of complexed calcium to re-
le"se element,,1 c"lcium, the more potent i. the .upplement.
Table 47.1 lists calciwn supplements.
PHARMACOTHERAPY OF METABOLIC
BONE DISEASES
is a general term referring to
derscharacterized by defects in the structure of bone. MBDs
are caused by abnormal amounts of the minerals or hor-
mones required for proper bone homeostasis, such as cal
cium, phosphate, vitamin D, or PTH. Some MBDs have a
genetic etiology while others are iatrogenic, caused by cer
tain drugs and therapies.
47.3 Pharmacotherapy
of Osteomalacia
Osteomalacia is a MBD characterized by softening of bones
due to demineralization. \Vorldwide, the most frequent
cause of osteomalacia is a deficiency of vitamin D and cal-
cium in the diet.1bis risk factor for the disease, however, is
rare in the United States because many processed foods in
this country are fortified with these vitamins. In the United
States, osteomalacia is most prevalent in older adults, in
premature infants, and in individuals on strict vegetarian
diets. The term osteomalacia is usually used for adults with
this MBD; if it occurs in children, it is called rickets.
Signs and symptoms of osteomalacia include hypocal-
cemia, muscle weakness, muscle spasms, and diffuse bone
pain, especially in the hip area. Patients may also experience
pain in the arcru, legs, and spine. Classic signs of rickets in
children include bowlegs and a pigeon breast. Children may
also develop a slight fever and become restless at night.
In extreme cases, surgical correction of disfigured limbs
may be required. Drug therapy for children and adults con-
sists of calcium supplements and vitamin D.lnactive, inter-
mediate, and active forms of vitamin D are available as
medications. Drugs used for these conditions are summa-
rized in Table 47.1.
The daily vitamin D needs of people vary depending on
how much sunlight is received. After age 70, the average rec-
ommended intake of vitamin D increases from 400 units!
day to 600 units/day. In severe malabsorption disorders,
patients may receive 50,000 to 100,000 Wlits/day. Because
vitamin D is needed to absorb calciwn from the GI tract,
LibraryPirate
734 UnII' arid E)o''' Em
TABLE 47 1 Selected Calcium Salts and Vitamin 0 Therapy
Drug Route and Adult Dose (max dosewhere Indicated) Adverse Effeds
CALCIUM SUPPLEMENTS (ooSES ARE IN TERMS OF ELEMENTAL CALCIUM)
calwm Tums,olhtn)
calwmchlorid/,
calwm dtratt (Gtraul)
calwm gllKonatt (Kalonatt )
calwm lKtatt (CaI..LJo:)
PO; 1-1g bid- tid
IV; O.H g byslo.v infusion (1 mUmin)
PO; 1-1g bid- tid
PO; 0.5- 2 9 bid- tid
IV; O.H 9 by !law inMions (1 gIh)
PO; 100- 100 mg Iidwith rntals
PO; 1-1 g bid- tid
PO; O.lS IIKglday
PO; 400-1,1XKI irlelnationallllits daily
(OfIlIiporioo, nDlI1& Klllliring. rom/Ik lOla>
Sf riwI adyrnr; t lfMj art oWrvtd 000 wjth IV
administooion.HYDma!rnii
Inhargy hNda(iIt
vomit"ng,ioomtd uioation and tliDtl
wrtrabmbj yrdjKam! roohnjpn delirium
--
calwm phosphitt t rbi5k (F\Jst!Jl'J
VITAMIN 0 SUPPLEMENTS
Q uldtriol (Cildjft,Roultrol)
dIoIKaIdftrol (DtluD)
dih)'ltotadlysterol !OHT, H)"literol)
doJo:t.lkifffill (lIKtorol)
PO; 0.15- 15 mgfday fOilMlal 0.1- 1 mglday
PO; 10 lIKg.tl"ffl timm k (mu:60 m(gIwt)
Side dfem In 001 o/Mrtlld i1I oormoI diMs.
0vtnI0g Dl9dlKts mns ofhmykrmi.,boor
pain le!hugyano,uia !IilU<eiandvomitioo
inal'alt!! urination, halludnatioO!, and
vnrtrahmjaj
IV; 411K<J, tint timWwk (mil: 1811KgIwt)
POIIM;2S- 12S IIKg/day for 6-11 wi! trgocaldfffill (Cikiferol. DrisdoI)
pH;Jldtoi (lmipiM) IV; O.OH.l rmy otherday (max:14 mcg/tg)

Irdia oornrron oJCI'imt tfl'Ms; lIII1aIiliDg. indicitts smous
many combine' vitamin D and cakiwn into a
single tablet.
Vitamin D is a fat-soluble vitamin that is stored by the'
body; therefore, it is possible to consume too much of this
vitamin or to show signs of overdose from prescription or
.... Prototype Drug I Calc!um Salts
OTC mediOltioll5. Excess vitamin D will cause calcium to
leave bones and enter the blood. Signs and symptoms of hy-
pel"Clkemia, such as anorexia, vomiting, excessiw thirst, fa-
tigue, and confusion may become' evident. Kidney stones
may occur, and bones may fracture' easily .
Therapeutic ( lass: Calciumsupplement Pharmacologic ( lass: HypoU1lcemia agent
AcrtONS AND USES
For mild. (hronic: hypookerniJ, ine!pensiYr c.kium suppltments art t firail'!'
and rtadily anilt bit OK. in of forrrulations. Calcium U1rbonatr .nd
ukium two mo<l rommon ",In. for rouli"" ,upplernentation. ln
addition to or lI"I'.ting hypookrmit,(.kium salts 011"1' administered
for osteoporosis, Pagr(s osteomalacia, chronic: hypoparathyroidism,
pregnant)', lactation,and r.pid childhood growth.
For!f"Yffl' of hypouktmi., inlusionsof ukilm salts may br
nt<elsary to mum smrm "kium 10 oormalievels. Constant monitoring of
u kilm is required during IV administration 10 prewnt thr dmloprntnt
of hyperuktmia.
ADMINISTRATION ALERTS
!Uppltmrntswithmt aborwithin 1 hourfollowingrnealI.
Administer IV slowly 10 .wid h)1lOtrnsion, dysrhythmia!, .nd u rdia.c: amst.
Prrgoall()' 8
PHARMACOKINETICS
Ihr pharmJroki""tiu of "kium sa hs yari6 b)' tIlr route of .dministration
and the spedfK forrrulation.
ADVERSE EFFECTS
0r.J1 U1D1n products JI"I' sale when ultd as ml"l'('(m most oornmon . dYe!w
ishypmakrmia,caultd b)' taking too mud! ofthissLppltrntntS)Tl1ptoms
01 h)1lOUhmi.o ino:lud.d""""n.... IHlur<JII, W<'Jkrws<, h...da.ch.,a",,",,"., n.lu-
IN and vomiting. nc:1N1td urioation, and administrati:m of cak:iJm may
c.JUII' hypotmsion, brtdylardi.o, dysrhythmits, and cardiac: anm
Contraindirations: Calcium salts art rontraind"Kiled in )lttirnts with I'tntriru-
It r fibrillttion, meu stttic: bont 1"1'001 I "kuli, or hypertak:tmia.
INTERACTIONS
I)ug- l)ug: (OOOI"fm U\f with dgoxin irKrNsH tbf rill; of dysIhyttmias.
Mq.nivm mq mpetf for GI absorption. CakMn deufNs tbf abIoIpIion of
tftnqOni'S. CakMn tbfffftm ofukUn manntl bIcKIIfo.
lab Tet!: Ukium may iIKrNIt Yalues for blood pH and cakium.l! may
d!oau\.! IffIIII iOd poIiI\!iiurn urilarymagnNJrn.
IlerballFood: lill(rkh foodlmq detre.e the absorption 0( talcUn. AkohoI,
Gltfeint, and carbonaIed .fIK! tbf absorp!ion of cakiurn. Oxak in
SJinidt, rlUltrb, sm d\ao"d, and bfeu can \l.Wfll ull:Un absorplion.
T rmtmfnt of Mfasu 1"1'1 br u bon to lI"I'at "rditc abnorm. litirs
uultd b)' the IfIUlting hyprrtakernia.
Rtfer 111 MytmJnqKI fer a MnJng Procell FooII Ip/It 111 1M ItuiJ.
LibraryPirate
CNplfr47 0"'9' lor 8001' Joint O""rd .... , 73 5
..
Prototype Drug
I
Calcltrlol (Calc/)ex, Rocaltrol)
Therapeutic (lass: V"lIamin D Pharmacologic ( lass: Bone resorption inhibitor
ACTIONS AND USES
Ca kitriol is tht activto fom of vit,min D.1t promolts tht inlt,tin, I ab50lJItion of
ukilm ,lndelevaltS 1I'1U1I1tek ofukium.Thil mtdiution is Ulrd in p"itnu
who h,YI' imp.lirrd kidllt)' function or hypop,r,thyroidilm. Cakitriol rrru.:n
bone ,nd is Ull'ful in U"uting rieken. Tht tffectiYl'ness of ukitriol!lt-
prndl on ,n ,!ltqJ"t ,mount of ukium; it is usually pl!"ICn"brd in
combin,tion with ukiull supplements. k is 'lIIil,1* as oral ublets ,nd 5010-
tions, ,nd b)' tile IV
ADMINISTRATION ALERTS

ProtKt UPIUits from light ,nd htU .
PlI'9n,IKY mtgory (
PHARMACOKINETlCS (PO)
Dnll't:2- 6h


Duration: 3- 5 da)'i
47.4 Pharmacotherapy
of Osteoporosis
Osteoporolis, the most common MBD, is responsible for as
many as 1.5 million fr3ctures allllually. This disorder is usu-
ally asymptomatic until the bones become brittle enough to
fracture or for a vertebrae to oollapse. The following are risk
factors for osteoporosis:
Menopause
High alcohol or caffeine conswnption
Anorexia nervosa
Tobacco u,e
Physical inactivity
Testosterone deficiency, particularly in older men
Low vitamin D or calcium in the diet
Drugs such as corticosteroids, some antioonvulsants, and
immwlOsuppressants that lower serwn calcium levels
The greatest risk factor associated with the development of
osteoporosis is the onset of menopause. \'/hen women reach
menopause, estrogen secretion declines, and bones become
weak and fragile. Onetheorytoexplain this occurrence is that
nonnal levels of estrogen may limit the life span of osteo-
clasts, the bone cells that resorb bone. When estrogen levels
decrease,osteoclast activity is no longer controlled, and bone
demineralization is accelerated, resulting in loss of bone den-
sity.ln women with osteoporosis, fractures often occur in the
hips, wrists, forearms. or spine. The metabolism of caJciwn in
osteoporosis is illustrated in Figure 47.3.
ADVERSE EFFECTS
Vitamin D tht"py m,y Ut/Sl' symptoms indudt
t.ltionl. anorffl.!, n'UlI'a, vomiting.. blurl!d vilion, pootophobi', constip"ion,
,bdorrin,1 mmpl, metallic IaStt, hu!bcht, ....,.,knns, dry moulh,lhirs/, in-
urin"ion,and mUldt or bone p,in.
Conmindimions: This drug should not be giYen to !!'IimU with h)1ltKal-
crmia orwith MIltner of vi/,min D toxicity.
INTERACTIONS
DrurOrug: iliilidt lilntiG may eoIIanao 1M ffftm of"IiUmiIl D, OOIing
Too mlKhvitamin D ma)'GIUIf d)Vfl)1hnin i1 patimts rtcei"lilll]
not bf 9NerI <roaIIIfIltly dJt
10 tIw inoN\.ed rill;
lib il5ts:VILJmi1 Drruyilmu!fl\lO cholelrtrol, magne\Un, II'
cMcJum\\llUl!I.tt ma)'dmNlf"lilklls lor akaIiof
HerbaHood: oflOlgfamoootsoflilkiulIHi:h foodswith vitamin DIIII'f
(lUll' h)'pI'IakfllN.
T real mfnt of D-nrdolr: Vit,min D OYI'rdoII' rrsulu in hyptfukrmi"
ciuria, and hyperphosphatrmia. Tht p,timt is Irr"ed symplom,tic,ly ,nd
placed on, Iow-<alcium dit! until symptOllll
IItI'tf rc M}NurJlIIgKJ/ fr1r Q NurlIrrtj I'rDm.! fooJs lpI(lk 11/ rills drug.
(a.) Nocmal cak>um intaka
Qel106ij.i:>r,

To body
(b) Low calci..., inlake
tl depoSifbq
Inl ... tine
;0 """
...
Normal bone
homaotaois:
Ooposilic:n"

...
Os1eopor<ltio bone:
Resorption exceeds
deposition. Bone
Iragilo.
F/qure 47J Calcium metabolism In osteoporosis



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0
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0:
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LibraryPirate
736 UnII' The ar.d EY""Em
Many drug therapies are available for osteoporosis. These
include calcium and vitamin D therapy, estrogen replacement
therapy (ERT), estrogen receptor modulators, statins, slow-
release sodium fluoride, bisphosphonates, and calcitonin.
Teriparntide (Forteo) is a newer drug for osteoporosis pro-
duced through recombinant DNA technology that resembles
PTH. Some of these drug classes are used for other bone dis-
orders or for conditions wtrelated to the skeletal system. Se-
lected drugs for osteoporosis are listed in Table 47.2.
PHARMFACTS
Osteoporosis
Ihttoporolil is tht most prevalent bOIII' di50rotl" in Mttriu.
On an annual millioo p.ltienU urtither diagn05td with
ostropolOlis or(onsidertd to bt at mlt'mt rille for this disordtr.
Womtn ,It' Iourtimts mort likelytode-.oelop ostroporosis than mtn.
M.nywOlllfll with ostroporosis.1t' of postmtnoplUlaI q.
After the "91' of SO,oneol womt n.nd oneof t'ltry t ight mtn
alt' likely to dtl'flopa Iri(tult' R'lattdto os1topOrosis.
BI SPHOSPHONATES
The most conunon drug class for treating osteoporosis is the
These drugs are strucrural analogs of py-
rophosphate, a natural substance that inhibits the break-
down of bone. Bisphosphonates inhibit bone resorption by
suppressing osteoclast activity, thus increasing bone density
and reducing the incidence of fractures by about 50%. In
addition to treating postmenopausal osteoporosis, some of
the bisphosphonates are approved to treat corticosteroid-
induced osteoporosis.
The beneficial effects of bisphosphonates on bone mass
density increase rapidly during the first year of therapy and
plateau after 2 to 3 years. Even after discontinuation ofther-
apy, bone density will remain increased for up to a year. For
optimum effects, the patient must have adequate dietary
consumption of calci um and vitamin Dj any deficiendes
should be corrected prior to initiating bisphosphonate
therapy. Research studies suggest that once-weekly dosing
with bisphosphonates ma y give the same bone density ben-
efits as daily dosing because of the extended duration of
drug action.
TABLE 47 2 Selected Drugs for Osteoporosis and Other Bone Disorders
Drug
HORMONAL AGENTS
BISPHOSPHONATES
Q altndronatt lFosamax)
bandrooail' lBoninl
panidronatt l,lndia)
riltdronatt (,l,aontl)
tiudronatt lSWd)
Route and Adult Dose (max dose where Indlcatedl
Hyptraktmia: RiKllliUltOlJIIIM; . illfmarionallllitlikg tid
OIItop01"OSis: intr.lnlsal; 1 !pray/day oro inttmationalllliu) in
OIIC nosuil,aHematiog tit" day
PO;runwith 30 mg 0IICl' ddr. may i1Ifl'N tl'fr)' 24 Wffkl
ulfil taJgel iPIH of 150- 300 P91mL lmax:300 mglda,)
Subwtallfous;20 mC9fday
OIiNpOr01i1: PO; , - I 0 I119iday
hgtfl dilt. II':PO; 40 mgfday for 6 mo
1'0:,- 10 mg/day for 6 moor 11- 20 mglkgldayfor 3 mo
I'O;B I119iday orone 1,IHng ubltt ]1ft" mo, tal:.m on tht samt

1'1'; 1,- 90 mg i11,OOO mL ramal salinl' or D5W om 4-24 h
1'0;30 I119iday at Itast 30 mil befort tht first drink ormeal of
....
1'0;0100 I119iday takm with 6-8 ozofwattl" 2 h btforI' or after
foodforlmo
1'1' (lomN);okTig lingltdost i1fwd om at Itast 15 mil
Adverse Effucts
Rliniris, 1Iu5hi1lg uf rhl' (IKe QOO poi" rhl'
i"irionsire
Aniph'llaxi!
Villilll'll, hyptrrtmion,
tmrtrio, hyl'lKl1/wni!l,
HvpOQI(fOlia, ltinrm
Brml !MjD Rainal blttdjDQ.Qnrumgo@ dJOI

de,:nWon, immrnio,
f1ulM, .. rlrolqio
Synwpt angina
doll' i1fwd Irm at INnIS min'--__ --' ___ _
Ildiaindic.Jtt (OItImon adl'tl"Sf Iotrioui adve"1I' tllem.
LibraryPirate
Bisphosphonates are also drugs of choice for the pharma-
cotherapy of Pagets Therapy of this MBD is usually
cyclic, with bisphosphonates administered lUltil serum alka-
line phosphatase (AlP) levels return to normal, followed by
several months without the drugs. When the serum ALP
level becomes elevatoo, therapy is begun again. The phar-
macologic goals are to slow the rate of bone reabsorption
and encourage the dtposition of strong bone. Patients with
Paget's disease should maintain adequate calcium and vita-
min 0 in the diet or as supplements, on a daily basis.
The most frequent adverse effects of bisphosphonates in-
clude GI problems such as nausea, vomiting, abdominal
pain, and esophageal irritation. Because these drugs are
poorly absorbed, they should be taken on an empty stom-
ach, as tolerated by the patient.
SELECTIVE ESTROGEN RECEPTOR MODULATORS
Srl!'(tive estrogrn mrptor modulators (SERMs) are a relatively new
class of drugs that are used in the prevention and treatment
of osteoporosis. When SERMs bind to estrogen receptors,
they may activate or inhibit them. Thus, SERMs may be es-
PI' Prototype Drug I Alendronate (Fosamax)
Choplfl47 0"'9s10l B""" and Joint O""rdl'lS 737
trogen agonists or antagonists, depending on the specific
drug and the tissue involved. For example, raloxifene
(Evista) blocks estrogen reptors in the uterus and breast;
it ha; no estrogen-like proliferative effects on these tissues
that might promote cancer. Raloxifene does, however, de-
crease bone resorption; thus, it increases bone density and
reduces the likelihood offractures. It is most efftiveat pre-
venting vertebral fractures. Another SERM, tamoxifen, is
used to treat breast cancer (chapter 3700).
CALCITONIN
Calcitonin is a hormone secreted by the thyroid gland when
serum calcium is elevated. It acts in direct opposition to
PTH and vitamin D. As a drug, it is approved for the treat-
ment of osteoporosis in women who are more than 5 years
postmenopausal. It is available by nasal spray or subcuta-
neous injtion. Calcitonin increases bone density and re-
duces the risk of vertebral fractures. Adverse effects are
generally minor; the nasal formulation may irritate the
nasal mucosa, and allergies are possible. Because the par-
enteral form causes nausea and vomiting,it is rarely used. In
Therapeutic (lass: Drug for osteoporosis Pharmacologic (lass: Bisphosphonate; bone resorption inhibitor
ACTIONS AND USES
Altndronatt smlm alkalifll' pholphmW', ffll)'llII' with
bolll' turllO'leT. most RqUfml)' prescribtd drug in this c!as5, it is oIpplOVl'd
for tilt followiog indiuticns:
Prewntion ind trMll1f1It ofOltroporos.is in poslllll'Oopausal wolIII'n
r reatmmt of osttoporosis in roth womfn and IIlI'n
00111' mm in IIII'Il with osteoporosis
ofsymptomatic: Pa9f\'\ disease in both wornt n and IlII'n
Seoirrallf9 illll'nl for aru'Iailablt:o!l(t daily (1 0 mg), I'm'kly
(35 mg), Of (ill mg).Although is moft'
higher un produc:t mort GI-related !ide rflem. All doW'S must bt Iolken
on an nomad!. prrfrrably in 01 folltiog Ilate 2 btfM' bft' akf'll
ffm:1I of altldron.te molY tike 1 to 3 months 10 appear and may
contintll' for I>t'Y!'r al months therapy is discominutd. fosoI max plus D com-
bines altndronatr oInd 'liumin D intoa lioglt tabltt.
ADMINISTRATION ALERTS
rake on an tmpt)' ntmach with plain pft'ftrabl)' 2 hours btfoft'
breakfast.
Rtmain in i n upright position for at Itm 10 minutl'l aftrr 01 doW' and un-
til aftt r the first food of day 10 !!duc:t inilollion.
Plf9nalK)' megCIT)' C
PHARMACOKINETICS


Halflife: 10 yr jdut IOsiow from Iktltton)
Uwkorlllm
ADVERSE EFFECTS
Adl'fll! tfIf(1S of .ltndronate diarrllta, ronstipation,lIatultlKf, nlusra,
wmitilg, mmllic: Iastt, hypophosphlltt mia, abdomin.1 pain,
dyspepsia, a nhralgia, myalgia, and fillh. Pathologic: frac:turl'l rr ay oc:-
cur if til t drug is taken Iongmhan 1 mornhlor in mesof mronic: O'/erdoW'.
Contra n diu tions: Contraindication I indude patitnts with ol1M1maooa, ab-
normaitirs of l'IOphagus, or who have hyprrsfnsitiYity to the drug. Cau
tion IlIouki bt in patienll with ft'nal ht an failurt,
lim d iW'.ut , fever Of infKlion, oKti'll' Uppl'l GI problem
and plfgnanC)'.
INTERACTIONS
Drug-Olll!l: Ukium, iroo, iIIltacick (ontailing alminum 01 magllNlm. aoo ooain
n me..ewithtlw abIorption of alMdronatr ollld h.m tIw
pounti.ll to i6 incrNsr tIw rill: of
osteopcrosil...-.l (;!(M IjNriI: ilitoiHn
libTI51I:Unmown
Herbi Hood: The dirt mtIIt have idfquat! amounts of '/itarnil D, cakium, oIIId
phosp/utl'S. ukium oIIId food da' ypro.ilml rfducralMdronate
_'m
Treat mr rn of OverdOlO!: Hypoukt mia is an and rray be
with or.1 or IV calcium salts.
IIfftr Ii1 M)Nurs/srqfJI/i:lf Q Nurlifllj Pn:m! fOOIllpt(1/{ Ii1I1r/s


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LibraryPirate
738 UMit The InltgumenurySyslfm;nd E)ft'E.llt)
NURSING PROCESS FOCUS PATIENTS RECEIVING PHARMACOTHERAPY FOR OSTEOPOROSIS
AND OTHER BONE DISORDERS
Assessment
8. ltll"t ISSfiIIl1UI priOf' 10 .dminbttMion:
Undtn!.JI.I the ,mon tbedrug hilbeom pRMribed inonitfloll\e1 for
thtfapMic: rffts ( .g.. replM:tment tlwnPl' for dtfKirrlcie or OIlHSf,
hullh mainttMllCt).
Obt,in a hiIto'l inducing
nfUroloqi(.tro:io<rinr.1wp.aIio:, 0' rmll
mult.Obuin a drug histOl)' CUlmlt prtKription and
ore dfll9\ hefbli prtpi miom" k:ohol-. or imoking. alrrl to POllilir
drug intmctiom.
Obtain iI hislO!Yoi any aK'rtnt Iymptoms and tl'lt<t on AIXs.AsItSIIIMdt
and nolt '11'1 polin or diKootort on mamnml or ,I rtSt.
Obt,in lIudri II ordr,mi
Obt.in a diru'l hiltO'lllOting adtquKy at ftSf nda! l'itimim, minmb. and
nutritnll obt,intd through fool WUItr!" pMticularly c.. 'fitimin O. and Mg.
!$ott thr llIKUIt 01 IOda int.liz daily.
!$ott IUnl(rttft lilt .nd tht amoont 01 lOA txpOiUlf.
Obt,in hastft htighl, ,nd riYl sigm.
i1PP'OpMt iabonlO'l findi"91
pbolfjhorus..nd m.gntSium btl!; lltp.ltit.nd rtnal irnction 1tucSits).
AsSf1sment throughout ad.,inist ration:
AsItIS fordeiRd lheripeUlil tfftcll (t.g.,ukium, p/Iospt..tr, and
Inm art within normal !how
ilIproverIWIId.
ContinUf II'IOIIitoring lab 'Ailltl II 'ppropriate.t!pialyu. pho!phonn.
."' ..
AsItSS for and p!OII1ptly JdYfl'lf rffts:n.lJ\t,\ 'IOIIIiting. abdominal
"" in. 1 itritltion, N'I!tip.ltion 01 dia rrfIt".nd tltctrol)'lt
ilIbalalKrI. Sntrt GI i nitation or pain should lit rtpOfItd immtdi.l1fl,.
Potential Nu rsing Diagnoses
Awl, or (hrmil P,in (bontOl' jginll) todi!tutcondition)
Dclilitm (drug WI39Y)
Risk for In;..y, Risl for Falls {lflittd 10 disusr a>ndilion, ad'IMt drug
"""l
Planning: Pat ient Go. ls and Expected Outcomu
p.titmwin:
UptritllCt thtfij)tUlic tfftcts (t.g" m.WfNllCt 01 Jdtquate bonrdtruity, It!Sfntd n.clUrt risk).
frtt m .. imal,.ct/mt rifKIl.
Vtrbalizt an undmtanding 01 thr drlllfs 1M, idIIfflt tfWm,.nd rtquftd prwuCom.
Dcmonm.1I! proptr atw mtdic.tioft (t.g.dost, timin!l, whtn to notify plO'ficltf).
Implementation
Interventions and (Rationa le5)
hl,ring effeds:
tilt diNry hiltorywiththt patitflund food _Itt optiom
for{orrtaing IIIr ak:iJrn or mmin Enmurigt tht ""titnI: 10
hNItIrf of _lItd physil.1
txjIOSurt, limitd (. fftinr.and!Oda incaR,Jnd limiMd .mhol
mmumption.(Adtqllillt .mount! 01(., ri1amin O. il.l M9Jrt nmItd for
bont hr.Ith.Any dtficitocits sIIould IItmlfKttd btfort bispholphollilft
irt laM lUll txpOiUrt m'r mill in vit.nWJ 0 formation.
ElKmNt !Oda Ofaffloiot inul::t may inuNsrthr risk
Pati ent and fami ly Educat ion
ErKour. gt adrq.Jatt.rnooots ole.. vitamin O nd Mg from food WUfm.
Prootidt tduulionil pamphlm 01' wrb-bisrd leirll'fl{ft to rtpllta bit
Prol'idt oltliti.ln rtfrmlll nmItd.
ErKour.gt 1imi1rd mou Illi of wn t xpollft dailr without IIIflI(fffI1I,
.pproximattly 15 to 20 mioutts. Oisc:OUIigt prolongrd lOA tlpOWrt.
lNdJ thr patitnnhat a!mm !Oda int.lkt may takt tilt plic:t 01
"",,rille willi milk or eli iry. Ea:esift afhoirlt COIIIUmption may diminish
tilt alMrption 01 Olffi'l alWm.
ErKouragt I<IMty,t!pi.lllyftighl-iltarin9 tlItfri!t, thrtt' 10
fitttimtlptfWHl
LibraryPirate
CNplfr 47 Oru9' lor 800e Joint O""rd"" 739
NURSING PROCESS FOCUS PATIENTS RECEIVING PHARMACOTHERAPY FOR OSTEOPOROSIS
AND OTHER BONE DISORDERS (Continued)
Implementation
Interventi ons and (Rati onal es)
Follow i dminisllaDon guidl'lillH for optimum rmlu. (u
vitamin 0 .hould b. ukon with meals or within 1 hour aft .. mNls.
Bilplmpoonatft ,hould 1M- bun on an !"ftlpty siomi{h with a fullglm of
water i nd the should upright for 30 mirutts to 1 hour.
Bisplmphonatftand ukiJm preparatiom mould b. ukon 1 hours a])art)
Minimizing adn rle rifKts:
Monitorfor GI irritllion or abdominal ])ain.IBilphosphonatft may (.Iuse
=Ph.gr.1 irriution and erosion.lncreasing nau,u.nd gastric: or
abdominal piin should b. rr pontd immediately.)
Continue to monitor periodic: lab u,Mg,phosphorus
and (lNtininr as III'tdr<i.Asses, far lign,or symptoms ofhypo- or
(C., Mg,ind phosphorus levels 5/lould to, and ft' m.in
within, Inue.sed Itftls milY
di!(ontiruation af mtdiution,.)
lkJid in!akt ,avoidiOC) ufltinr or soda.(ln(rNstd Auid imako
detft'.ses lhe rille of ft'nal (alculi formation.!
Monitar .dherelKt ta (Bolli' oxwrs
It'Iml momh,' tillll'.Tht patitnt may dinontintJl' drug bm!Mof peKtiYtd
lac:kof 16pl1lSf.)
Pationt understanding of drug therapy,
1M opponunitir5 during adminisuillion of mrdiYtions.nd during
as ses'lIII'nu to disWlS the rationalt fur drug therapy, tlltrapeutic
CHII{omt<,moli (ommoniy absftwd ])arimrtr rs farwht n
ta ull tilt health and . 1l)' nmssary monitoriOC) or
prt'uutioll5.(lking timt rluriOC) rursiOC) help, to
kl'ytri{hiOC) areas.)
Patitnt Hlfadministriltion of drug thtrilp),:
Whrn administering thr meditation, illltllJnthr Pitirm. family,or
(arrgm r in the ptopl'r se(f-administrition of tht drug, t.g., taken with
addition.1 fluid .. (Propl'r i dministration irKft'aIeS the of tht
."",1
Patient and Family Educati on
Tt a{h tht ])iItirm appropriate .dmin guidrlines. that the
patifllt is. blt to rf main upright.fter .dministration il bi.pho!;phon. t ..

ImtMt the patirm to ill)' nrw onSfl of or i ll)'
ilKl"N,ing or !eI'm dlrSt or ilbdominal d iscomfon or pain.
ImtMt patirm on the r"ftd to return ptriodiully for lab work.
ImtMt the p.tirm to immediattly rt'port ,ymptoms of lrypoukmlia
(mUlIt 'pa snu, fi{ialgrimacinQ. irritability, hyper-ft'fltJe1) or
hyperuktmia (in(rNstd bonr ])ain, iOOft'lia, na!Ma, vomiting,
(on >lipation, thirs!, Itthargy, fatigut).
ElKourq til!' patitntto fluid intake loll offluid per diy, divided
tfJroughoUI lhe day, but '\'Did highly {,)f!tin.ttd btvrrages and
soda inuke.
Tei{h the ])iItirnt to{ominue uking the drug therapy rt'!Jllarly to
fUll tfit{u. Therapeutic: ft'Sponse may take 1 ta 1 momlrs . nd t fleru
(ontinue after tht drug has bet-n discontinued.
Thr p.tirm should br ablt to stair the reason for thr drug;appropriate
c10seand schtduliOC);what .mlSe rfINu to oIurw far and when ta
report; and tht itngth of mtdiution therapy.
Ihr patirm is ablelo and administration needs.
Evaluation of Outcome Criteria
haluatt tht rfito:tie0e5' of drug by mnfinniOC) that ])atirnt go;alsand Hprcttd oukomrs hiyt bten met (set Planning").
addition to treating osteoporosis, calcitonin is indicated for
Paget's disease and hypercalcemia. For osteoporosis,
tonin is less effective than other therapies and is considered
a treatment.
OTHER DRUGS FOR MBD
Cinacalcet (Sensipar) is a calcium modifier approved to
treat hypercalcemia caused by parathyroid gland cancer or
for hyperparathyroidism due to chronic kidney disease.
Cinacalcet is a calcium mimic; the drug is recognized as cal-
cium by the parathyroid glands. When the drug is present,
the parathyroid glands shut down the production of PTH,
serum calcium falls, and bone resorption diminishes.
Cinacalcet is an oral drug. Nausea, vomiting, and diarrhea
are common during therapy.
T"ripu"liJ" (Furl",,) i,,, fUTm uf hWllall PTH,
by recombinant DNA technology. Theactions ofteriparatide
are identical to those of endogenous PTH.lt is the only drug
available t hat will increase bone form.1tion. The only ap-
proval indication for teriparatide is for the treatment of os-
teoporosis in men and postmenopausal women. The drug is
usually reserved for patients with a high risk of bone fractures.
LibraryPirate
740 UnII' The IntegumeomySY'tem ar.d EyI>"Em
A disadvantage of the drug is that it must be given daily by the
subcutaneous route. The drug is well tolerated with dizziness
and leg cramps being the most frequent adverse effects.
TREATING THE DIVERSE PATIENT
The Impact of Ethnicity and lifestyle
on Osteoporosis
\\bmen of Caucasian and Asian Anman de!!mt haY!' a hi9:"otr 0101-
than !host of African American ahhouijl po!Imenopal/l<ll
rilkin
men also an dtYelop this dwse.
MIl though mNi:atDnS <Ill' n-ailable to hah bonedtttmmion,pmoention
u,.f1tablilhingand maintaininga healthy liflostyleis the 0\tI10-
pomis.L\Jring dliklhood ilnd the 10m Ihwkl be on llIikling bone
mass.Chikllt'fl s/wld be erJ:lUaged to Nt bods h9J in akUn and vitallin 0.
and avoid !IIIOkiIg and mmiYe UII' of akohol. [).ri-,g iduh-
hood,tIr f00/l5houki beon !Nintlining bone mmand rontiruing hNhhy Ii-
mry ardemcis.e habits.Vitamin maybe tlktnon theadvicf,ofthe
heahh rare proYidtor. WOIIII'n shtUd forus 00 pIl'YI'ntmg bone
ms.ln aO:lition to maintaining a hNlthy lifestyle. patienn !hd:l haY!' bone dtn-

with their health (,lll' prom
Prototype Drug I Raloxlfene (Evlsta)
JOINT DISORDERS
Joint conditions such as osteoarthritis, rheumatoid
tis, and gout are frequent indications for pharmacotherapy.
Because joint pain is common to all three disorders,
gesics and anti-inflammatory drugs are important compo-
nents of pharmacotherapy. A few additional drugs are
specific to the particular joint pathology.
A VOI DI NG ERRORS
The M"Oing nurse on drty <l dministm mediutDns at 10:15 p.m. When <I
nuBl' Brown's room,Ms. Brown is alll'ady in bed and falling ilftp.
The nuBl' shakrs her <l nd says, ' l h.M)OOr 10 Ms.
Brown. Ahhough the pilient awa bons, she is not fully <l wa boo Tht ruBe hands
htr tht mNiution <lnd a gl.m of waif r.Ms. Brown l.ikf"l the mediutDn and
qui:kly ll'Iums to llfeping.ln lI'aling..tht nUBe noti:f"I the I0OIII rumber and
Il'alilflthat mediution was just giffi to who is in a room down
the hall from should the nuBl' 11m dollf dilFell'ntlyl

Therapeutic (lass: Drug for osteoporosis prevention Pharmacologic (lass: Selective estrogen receptor modulator
AalONS AND USES
is a stll'dive estrogen tectptor modulillllr (SERM).lt decrta5tl boof
r=rptDn and incll'a5tl bollf mmand dtnsity by acting through tht f"ltrogen
teceptor.Ralolifent is prilllilril)'!Md fortllt pIl'Vtntion of OItroporosis in post-
meoopausal women. Ahhough the drug rMures nrtebral caused by
osteoporosis of the spine, it dots OOt appear to II'dlKe tilt inddenre of frac:rure
at oolTlmtbl1llsitfl. This drug al50 Il'dKes strum total {holl'sttrol and Ul
(Jow.dtnsit-; lipoprott in) without Iowfring HOL (high-densit-; lipoprotein) or
triglyr:ericll's.
In 2007, was applO'fl'd for inmive bll'illl Gln{fI prophylaxis in
postllll'oopaUl.llwootm at high rislc for bll'illl calKer. k is importlnt for nuBl'S
and patienu to undmtand that this drug is for the pIl'Vmtion, OOt tll'i1mf nt,
of bll'ast carcioolN.
ADMINISTRATION ALERTS
GiYt wilhorwithoutfood.
Pregnancy category X
PHARMACOKINETICS
Onset 8 Wl'eki
Ptilk:Unkrnwn

Duration:Unknown
ADVERSE EFFEaS
Tht most {ootmon adveBf e1fecu of ralol:ifme therapy all' hotllashel, leg
{ram pi. and Wl'ight gain. {ommon effects in{kidt feYfl, archralgia, dtpll'l-
sian, insoot nia,dlet pain. peripht ral edtma, declfa sed IfIIIm {holl's1flOl nau-
lI'a, flatulen{e, {)'Stili!, IkJlibo
endometrial brNSl pain, and 'liginal bletrling. Ralol:jff llf has two
bla{k boxwamings.FiBt it may iOUNII' the risk fordeepvtin thrombosisorpul-
IOOnaIY embolism. mood, use of ralcoifene may in(ll'ast tilt risk ofdNth dU!'
to mob in women with {oronary hean disull'.
Contraindications: This drug is <omraindiuted Iklring lacution and JIIl'9-
oaocpnd in WOIIII"O who may bt<OIIIe Pll'9nam.Patitnu with a history ofvt-
OOIIS throm botrn bolism and thOIt' hypeBl'ositil'l' to ralolifflll' should not take
this drug.
INTERACTIONS
I)ug-l)ug: (OOOI"lI"Ot 1M with willtarin !Ny dPoUSl' proOvOOlbin
Dtamfd raloDlI'fII' ibIoIptioo wil from (OOQIIfi(
list of raloml'lll' "";!h othtr higbt, proIm.boIIid druos
indornethacil, dimpam, etc.) may intelfflf with bindi"lg sites. Pilients should oot
t.Jkf {boItsteroI1owHi1llj dnq; IJ I'IIrOljl"O {OOQIIl'Otlywith
thislMdicaion.
Lab Tl5Is: iLllmifl'Of iMJNII'I Ullfl of ipolipoprotein A,. anir:oSienid.ti1cJir19
iIIId thyrOIinHindilllj gIobuIin.ltlNY deuNIf"lillllfl of dloII'IIfId,
1lKi00000,apoipoprotein B,iIIId IipofxotHl .. total protein,
andalbumin.
HtrbaVFoo:J: 8Iid at.o\h has I5IroC]I'I1ir: flfeas and IIW1 with thf aaions
of riklrffM!'.
TrNtment OfOYfrdOse: Thtll' isoo Spt{ifK tlNtment for afl'rdost.
IWtr /lllIIylUsJflgKlrfor MnIftg I'I1Kei! Foo/l sptd/I( /111M /tug.
LibraryPirate
PHARMFACTS
Arthritis
10 and 40 millioo propl!o in Slates by
OIteoarthritis.
After igr 40, than 9O'Jj, of populuion Iwvr Iymptoml of
OIteoarthritis in major'Mightburing joints.Ahr 70)'UB of age,almost
,Upatients IwVfsymptomlof osteoarthritis.
Of the WOrld'l populuion, 1% hil'f rlwumatoid arthritis, which roost
often alfh puitou beIWffiI 30 and SO ),!,aB of age. Women art
to rll'f times roo", likt-ly to dtvelop rlwumatoid arthritis than men.
a..-. 1"" .nd tho U.s. popubtion.", .fftctrd by gout. Most of
thr pnirou,,,, men bHwffn the'lIH oflO and 60. Most WOmtn ,'"
affffifd after menopault.
47.S Pharmacotherapy
of Osteoarthritis and
Rheumatoid Arthritis
Arthritis is a general term meaning inflammation of a joint.
There are several types of arthritis, each having somewhat
different characteristics based on the etiology. Coutyarthri-
tis is presented in Section 47.7.
Nonpharmacologic therapies are sometimes effective at
relieving arthritis pain. The use of nonimpact and passive
range-of-motion (ROM) exercises to maintain flexibility
along with adequate rest is encouraged. Splinting may help
keep joints positioned correctly and relieve pain. Other ther-
apies commonly used to relieve pain and discomfort include
thermal therapies, meditation, visualization, distraction
techniques, and massage. Knowledge of proper body me-
chanics and posture may offer some benefit. Surgical pJ"O(;e-
dures such as joint replacement and reconstructive surgery
may become necessary when other methods are ineffective.
OSTEOARTHRITI S
Ostl!Oarthritis (00 is a progressive, degeneratiw joint disease
caused by the breakdown of articular ca.rtilage. It is the most
common type of arthritis. Weight-bearing joints such as the
knee, spine, and hip are most frequently affected. Symptoms
include localized pain and stiffness, joint and bone enlarge-
ment, and limitations in movement. OA is not accompanied
by the severe degree of inflammation associated with other
forms of arthritis. Manyconsider this condition to bea nor-
mal part of the aging process. A patient with OA is shown in
Figure 47.4.
The goals of pharmacotherapy for OA include reduction
of pain and inflammation. The initial treatment of choice is
acetaminophen because it is inexpensive and relatively safe.
For patients whose pain is unrelieved by acetaminophen,
w-uK"' ( NSAIDs), illduJillK
naproxen and ibuprofen-like drugs, are usually given. Be-
cause high doses ofNSAIDs can cause GI bleeding and affect
platelet aggregation, patients must be carefully monitored.
Aspirin is no longer recommended because the high doses
needed to produce pain relief in OA patients may cause GI
bleeding. Tramadol (Ultram) has become a popular drug for
CNplfr47 0"'9' for Booe and Jornt Olsoml'l' 741
Figure 47.4 Patient with osteoarthritis
the treatmem of moderate to severe pain. Although classified
as an opioid, tramadol does not have abuse potential and is
not a scheduled drug. Opioids such as codeine may be com-
bined with acetaminophen for severe pain. The student
should refer to chapter 18 for a complete discussion of the
actions and side effects of analgesicsOO. In acute cases,
intra-articular glucocorticoids may be used on a temporary
basis. Note that aU these therapies are symptomatic; none of
these drugs modify the progressive course of OA.
Many patients with osteoarthritis use OTC topical creams,
gels, sprays, patches, or ointments that include salicylates
(Aspercreme and Sportsueme), capsaicin (Capzasin), and
counterirritants (Ben-Gay and Icy Hot) . These therapies are
well tolerated and produce few adverse effects.
A newer approach to treating with moderate OA
who do not respond adequately to analgesics includes
sodium hyaluronate (Hyalgan), a chemical normally fOWld
in high amounts within synovial fluid. Administered by
injection directly into the knet' joim, this drug replaces or
supplements the body's natural hyaluronic acid that deteri-
orated because of the inflammation of osteoarthritis. Treat-
ment consists of one injection per week for thret' to five
injections. By coating the articulating cartilage surface,
Hyalgan helps provide a barrier that prevents friction and
further inflammation of the joint.
RHEUMATOID ARTHRITI S
Rheumatoid arthriti, (RA) is a chronic, progressive disease that is
characterized by disfigurement and inflammation of multiple
joints. RA occurs at an earlier age than osteoarthritis and
has an autoimmune etiology. In RA, autoantibodies caUed
rheumatoid factors attack the person's tissues, activating com-
plement and drawing leukocytes into the area, where they at-
th" ""US uf th" 'y"uvial JJJ"JJJUrdlJ"" uluod. TIll'
results in persistent injury and the formation of inflanuna-
toryfluid within the joints. Joint capsules, tendons, ligaments,
and skeletal muscles may also be affected. Unlike OA, which
causes local pain in affected joints, RA truly produce systemic
manifestations that include infections, pulmonary disease,
periClrditis, abnomlal numbers of blood ceUs, and symptoms
LibraryPirate
742 UnII' The IntegumeomySY'tem ar.d EyI>"Em
of metabolic dysfunction such as fatigue, anorexia, and
ness. A patient with RA is shown in Figure 47.5.
and inflammation. NSAIDs for RA patients are llSuallygiven
in higher doses than those for patients with osteoarthritis.
Aspirin is not recommended for long-term therapy due to its
adverse effects on the Gl system and platelet aggregation. Ac-
etaminophen is effective at relieving pain and fever, but has
no onti _inflontllUltory .ctions. Although these onalgesics re_
symptomatic pain, they have little effect on disruse pro-
gression. Because of their potent anti-inflammatory action,
glucocorticoids may be used for RA flare-ups but are not
used for long-term therapy because of their adverse effects.
The primary goals of RA pharmacotherapy are to control
inflammation, reduce pain, and minimize physical disability.
Phannacotherapyfor the relief of pain associated with RA is
begun with NSAIDs, because these 'gents relieve both poin
Flgure47.5 Patient with rheumatoid arthritis
Coorte>yofDf . .Jason L Smith.
Unlike OA, the progression of RA can be modified with
drug therapy. These disNsf-modifying antirheumaticdrugsl DMARDsl
belong to several drug classes and have been found to re-
duce mortality due to RA. DMARDs are administered after
pain and anti-inflammatory medications have failed to
achieve the desired treatment outcomes. Many physicians
begin therapy with a DMARD within the first few months
after a confirmed diagnosis of RA. It would not be unusual
for a patient to be taking st'Verai DMARDs and analgesics
concurrently. Maximum therapeutic effects may take sev-
eral months to achieve. Because many of these drugs can be
toxic, patients must be dosely monitored. These agents and
their adverse effects are Listed in TabLe 47.3.
TABLE47.3
Selected Disease-Modifying Antirheumatic Drugs (DMARDsl
Dru, Route and Adult Dose (max dose where Indicated) Adverse Effects
(CRno:g) 1V;500-I,1XKI 000, 2, aod. MIl 4wbtooufter
I mg Mf'/ other wtdr
",y.Igiq),
anakirn (KiImI) 100 mglday
Oppommj5li<infrajons Ijnd:!djngIB Ifpti
hrNtiti! B I'OOMtion and infffiioml,
mtolizumab (GmLl) 400 mg initiall)' aod at 'IIftks hod . ,followtd by
... tumor!I!i! (mUl(imabl
200 mg Mf'/ orherwlr
WOlll'ni ng of hl'an fJilufl' ( (wolizumab. inffillimabl
tiJIM'KrpI(&lbrrI) 25 mg WffkIy;/KO.081119ik9 or SO mg 000
Stmm Iobn\9D syndrome hrp,ugtpxjd!y
-'"
Ildlllomidtinlbimabl mJlignJlKirllmtiah
goIim.mab (Sirrponi) SO mg
- ilfliximab [RemK.ldf) IV! lmr}Itg at wePks 0, 2, and 6, then fVl'ij 8 wi::
lttIunornidt (AraQ) PO; 100 mg Ioadilg dOIf 11K 3 then 20 mglday
ri\Ul(imab IV; 1,000 mg 1 wIr for a total oflWO dOIfl
alilhiopilM' pmuran. Aman) PO; 1 or in dividtd 00st1 bid 11K 6--8 wi! (hils, (PM'! maIorist, myrrlgio
(max:15 mgJkg/day);

Miintenarn 00st is 1- 1.> mgfcg/day.tl J ordivided
Q PO;400-600 mglday 11K 4-11 wk. thm 1OO-400mg dail)' Anomi4 00UlN, d/o"9fl
Miintenarn 00st: Il>-20 I119iday
methotrmtr (RhNmilUU, Tfl'ull) PO; 75 mg onWwIr or 15 rug 11 h for !hIM OOstslHKr/Wk g/oJ'iitis, 1"9i litH, mild Ifl!koprIio. rrouJeII
(max:20mglwk)
gomalKlt
anemia. htpali!: drrhosiJ. !@hrotoxicity.suddendrath.
allioullllXlllliI aormia
apia 11K jnemii, fl'naJ tt@lOQe!il:itv
lIMa5alilzilM' (AlLlfKiilM') PO; 500-1,000 mglday (miX: 3 g/day) IIeJIdQcIrf, QlICflXi4l1DulM,
AOiobylaxis 5tmm JOhD\90 smdmme
mn!l!2OOol!t
lIo1kJ iodilitr rommon advtrJ.! !llderiiniog iodilitrs striouI rfIlom.
LibraryPirate
COMPLEMENTARY AND A LTERNATIVE T HERAPIES
Glucosamine and Chondroitin for Osteoarthritis
GllKosamilll' iu nalurallUbstllKf thlt iun imporhm building bIoc:k of ur-
tilaoge. With aging. glucOSolmint is Ion with the natural thinning of mtillgt. As
unilagt Wl'ars rIown,jointslost tlltir normal ioning ability, r=king in
the pain and inflammation of onroanhrilis.Glua.Jmilll' IUHall' is
aun orc dittalllUpp!emfnt. SoIM studits hm shown it to lit molt' rife<-
than i pbc:ebo in rwing mild anhritis and joint pain.1t is purpont<l to
promote canil,gt ft'pair in tilt joims.A typical Om is SOO to 10,000 mgIday.
Chondroitin is aoother dietary IUppltlMm purporll!d to promoll'
It'pai[ k is a nltur<lllUtntllKf that forms pan of tilt mauu bflWl'tn clnilage
Chondroitin i, ,"k Ind limon rr.. of rfkct>. A typiul dolt is 400 to
1,500 mgfday for months. Chondroitin is combintd with glu-
cosamilH.' in !pf(ific anhritis formulas. Rf"ll'iln:h fuM that giucosamilH.' and
chondroitin may lit flfectift only for modtrall' to ostfClilnhritis pain
(Clfgg ml.,lO(6).
The choice of specific DMARD depends upon the experi-
ences of the health care provider and the response of the
patient to therapy. Therapy often begins with hydroxy-
chloroquine (Plaquenil ), methotrexate (Rhemnatrex, Trex-
all ), or sulfasalazine (Azulfidine), because these drugs have
the most research-based evidence for reducing morllllity
due to RA. Gold salts, o-penicillamine (Cuprimine), aza-
thioprine (lmuran), cyclosporine (NaHal ), and cyclophos-
phamide (Cytoxan) are used as second- line drugs because
they are more toxic. Biologic therapies such as etanercept
CNplfr47 oru9' for Booe and Jorn! Olsoml'l' 743
(Enbrel), anakinra {Kineret ), and the recently approved cer-
tolizumab pesol (Cimza) are newer therapies that block
steps in the inflanunatory response. The biologic agents ap-
pear to be effective and relatively nontoxic, although they
are more e.lpensive than first-line therapies.
47.6 Pharmacotherapy of Gout
Gout is a form of acute arthritis caused by an accwnulation
of uric acid (urate) crystals in the joints and other body tis-
sues, causing inflanunation. These crystals are the result of
increased metabolism of nudeic acids or the reduced excre-
tion of uric acid by the kidneys. Uric acid is a waste product
created by the metabolic breakdown of DNA and RNA. An
important metabolic step in the pharmacotherapy of this
disease is the conversion of hypoxanthine to uric acid by the
enzyme xanthine oxidase.
In patients with gout, uric acid accumulates and hyperuric:emiil,
an elevated blood level of uric acid,occurs. Patients with mild
hyperuric:emia may be asymptomatic. Once the level of uric
acid rises to saturation levels in body fluids, urnte crystals
fonn and symptoms appear, usually with a sudden onset.
Gout may be as primary or secondary. Primary
gout is caused by a hereditary defect in uric acid metabolism
that causes uric acid to be produced faster than it can be ex-
creted by the kidneys. Secondary gaut is caused by diseases
or drugs that increase the metabolic turnover of nudeic
acids, or that interfere with uric acid excretion. Examples
of drugs that may cause gout include thiazide diuretics,
Prototype Drug I Hydroxychloroqulne (Plaqueml)
Therapeutic (lass: Antirheumatic drug;anti malarial Pharmacologic (lass: Disease-modifying antirheumatic drug
ACTtONS AND USES
H)':IlOX)'(hloroquilH.' is an older drug that is for rhfumnoid anhrilis
i nd in p.ltitnts who hal'!' not ft'spondtd wtll to
iI nriinflam matory druqs.This drug is also ustd for prophyWis and tit' atment of
malaria, but (hloroqJilll' (Aralen) is the prtferRd agtm for this parasitic: inIK-
tion ((haptfr 3SGlQ). It'litvfs the R"Itft' inflammation
characteristi< of these disorders,iI hhough its mt<hanism of <I ction is not known.
For lull h)':lroxyt:hloroquilll' is most often prtSuibed with SilKy-
LItH and giucocortic:oids.
ADMINISTRATION ALERTS

Administerwith milk to dtclNSf GI up!et.
Slorr drug in saft place,as it is l'l'IytoxK to children.
PlI'gnillK)'U1egoryC
PHARMACOKINETICS
weeks for Imirntumatic rf"lllOIU

Halflift: 1l- S2 cia)'!
Duration: Unknown
ADVERSE EFFECTS
AdYelSf elferu ilKludt aooft'm, GI dilluroalKf"I, loll of hair, headacht, Ind
moodand mental t fIKts in{k.idt blurrm YKion, phOb-
phobia, diminished ability to ru d, and bladced-out Ift'as in tilt visual field. With
high dosts or prolonged therapy, tllesf (dinal chil nges may lit in
IOIllf patitms.
Contraindications: Patitnu hyptrsensitivt to the drug or who u hibitlfti-
nal or viscy I Id ChingH mociatfd with quinoline drugs not If(eivt
hydroxyc:hloroquine.
INTERAalONS
Dru;rDrug: AnOOds rontairing aUrinlll1 or crrq.nium may prt\'au abIoIption
01 hydrorydlloroquillf. Hydroxychoroqvinf may OOUlf tilt ri!Ir of
wIIfn minisleI!CI with ilfpatorOIil: drugs:il kohol U\f sboUd be eliminatPd during
thtrapy. TIii aID may N:t to inmastd dgmcin k>wk. iOd may intalm with
tlltp.atil'Ofire\jlOO5C' 10 riiM!! voKCillf.
liIbTl5u:Unknown
Herba VFood: IkMown
TlNt mem of OverdOSt: may lit thlt'illl'ning. in
d",n. Th .... py with . ntKORYub'n!"."oprHIDrs,and . ntid"rhythmio .....,. bee

LibraryPirate
744 UnII' The Integumeotil'ySynem EyeIlEm
..... Prototype Drug I ColchICine (Co/erys)
Therapeutic Class: DruO;J for 901.11 PharmacoloO;Jic (lass: Uric acid inhibitor
ACTIONS AND USES
Cokhic:iDl' is <I natur<ll prodKt from thr autumn (fUS that has been
thr trlditiorul or,1 drug of dlOicr for thr trNlmtnt of <l rult gouty arthritis.1t
hn lMd ,rod was appro.'td by the FDA in 1919. k is molt ri-
flive taktn within 24 hours alter the onset of symptom5. The drug redum
inftamm<ltion mociated with acute gouty arthritis by inhibiting the \)'llIhesis
01 mic:rotubults, for helping whitr blood (rlls
infiltrate an arN.Although <okh ic:iDl' has no anllgtlit properties. patitnts fI-
ptritn ' pain dut to the red uuion in infl.1 mmation.lt m<ly tI ktn to pit-
\'tnt or trut acute often in combirution with other uric: <lad-inhibiting
ilgtnts.ln 2009, cokhicinr brarne thr first druglppflfl'ed by thr FDA to
II milial MrditerTall!'an (FMf ), I hered itI ry disorder ch<l r<ICterizfd by <lCute
inflammuion loci arthritis.
AOMINISTRATION ALERTS
T.1ce OII.n empty Itoma<h, when symptoms first .ppur.
CoIIfgory C. Parmter.l l dotH mUlt not be givrn to pregnant

PHARMACOKINETICS
On'itt:l1h


Dmtion: Unknown
l
aspirin, cydosporine,and alcohol, when ingested on a chronic
basis. Conditions that can ClUse gout include dia-
betic ketoacidosis, kid ney failure, and diseases associated
with a rapid ceJl turnover sum as leukemia, he molytic ane-
mia, and polycythemia.
Arult gouty uthritis occurs when needle-shaped uric acid
crystals accumulate in joints, resulting in extremely painful,
red, and inflamed tissue. Attacks have a sudden onset, often
oc,ur at night, and may be triggered by ingestion of alcohol,
dehydration, stress, injury to the joint, or fever. Gouty
arthritis most often occurs in the big toes, heels, ankles,
wrists, fingers, knees, or elbows. Of patients with gout, 90%
are men. Kidney stones O(xur in 10% to 25% of patients
with gout and are more likely to oc,ur in patients with low
fluid intake and when the urine is acidic.
Thegoals of gout pharmawtherapyaretwofold: termina-
tion of acute attacks and prevention of future episodes.
NSAlDs are the drugs of choice for treating the pain and in-
flanunation of acute attacks. Indomethacin (Indocin) and
naproxen (Naprosyn) are NSAIDs that have been widely
used for acute gout. Glucocorticoids may be used to treat
exacerbations of acute gout, particularly when the symp-
toms are in a single joi nt, and the medication can be deliv-
ered intra-articularly.
ADVERSE EFFECTS
Adwrv rfieru SIKh <1\ I'Omiting, di,rrhe", and abdominal
pli n art cornmOlllt thr begin ni ng 01 thrr<l py. The drug m<ly (ILIV boor mlrn:M
tOl idty, and a pllltic: all!'mil, Ifuo:openia, thromlxKytopenia, or
lNyour.
Contraindi(ations: This drug is contraindic,ted in patients with a known hy-
prn.rnsitivity to mkhicinr,an d in tt-.u with seriou I GJ, ft'"IIal. hepatic:, or mdiac
impairmtnt. flatirnn with blood IIOt IfNf mkhicill!'.
INTERACTIONS
i)ug-On.og:eona.rftII!6r wkh HSAIDs n-..y 100_ tilt risk
WdidDl' may fnlit additM bont INIIIl'II' tuxidty with (Jdo!.poriflf,
phefl)"looWOOf,MId othrr atlKI bofIfmarrow.El)'\I"Iomtcin
may imaIt serum (okhidDl' Irwell.loop di.ntics lNy !lrcrflllf (okOODI' KIt<!\.
AkdlOl or prodoos that COIItail akohollNY QUSf Win r.sllts rfSIJI ln
INtr damage. (okhidnt 1M)" InuNlt SffISitl"lity to (NS di'pm:slts.
lab Tets: {okhKi"lr may with Iriny lIeroid detHm ina!;oos, am rn.y
gi'/f laISf-positi'If , akIrs lor uinary ff)'throcytelMld
IItrbaVhod: (okhidflf rM)" nMft' with tilt Iblorption of l'itamin au. r ODds that
ow rich In ptJines,locIlKlng wai:ltl,Mldotgillt mUll sIIoUd be
owolded./oods IUt_tllt m to btuuotmore , !YI .... m.<IY 100_ tilt riskol
hlney 1Ins, iIldudillg mil!, fruits. CIfbonatPli dim, moll 'IfgeIabIrs, 1OOIaIsa,
and bating lOdo!.
T ru tmfll t of O'/froos.: Ovrrdose (induting lCCidfIlul ifl9tStiln d autumn (10-
CUI) may<JI.M shod, delmm, rtspi"<IIorY
<!Nth. Tre.lIment lNy Jd.degutric Llvage lrod htmodialysis.
IIt(rf S/MyMIJIngK' S/ 1M /trig.
Pro phylactic therapy of gout includes drugs that lower
serum uric acid. Prophylacti c therapy is U5ed for patients
who suffer frequent and acute gout attacks. Combination
thef3py using uri c acid inhibit ors such as colchicine and
antigout medications such probenedd (Benemid) and
allopuri nol (Zyloprimj are the mainstay of go ut prophy-
laxis. Colchicine reduces the accumulation of uric acid in
the blood or uri c acid crystals within the joitlls. Probenecid
inneases the excretion of uric acid by blo,king its reab-
sorpt ion in the kidney. Allopurinol blocks xant hine oxi-
dase, thus inhibiting the formation of uric acid. When
uric acid accumulation is blocked, symptoms associated
with gout diminish. In 2009, the first new antigout drug
in over 40 years was approved by the FDA. Febuxostat
(Uloric) acts by the same mechanism as allopurinol but
is safer for patients with renal impairment because it is
not excreted by the kidneys. Drugs for gout are listed in
Table 47.4.
A plan for gout management should include dietary
changes and avoidance of drugs that worsen the condition
in addition to treatment with antigout medications. Patients
should avoid high-purine foods sum as meat, legumes, al-
coholic beverages, mru;hrooms, and oatmeal, because nu-
cleic acids will be formed when they are metabolized.
LibraryPirate
CNplfrol7 0"'9' lor Bone and Joint Olsord .... ' 745
TABLE 47.4 Drugs for Gout
"n"
Route and Adult Dose (max dose where Indicated) Adverse Effects
alopurinolllqlt1in.I)'loprim, olhm)
PO (primary); 100 mg/day;may by 100 mg/wk llrowlinm, !kin roll!, diarrhttJ
(max:SOO mg/da,)
S:mu: lIIio Il:j!.lillll' ttIlIIr: IIIIlIllllfl .. illll
PO (wrondary); 200-800 mgld,., for 2 1 longtr hepato!oxi(ily Itllillfil!u
Q (Cokrys) PO;05-11 mg. folWd by O.S- O.& mg MI)' 1-2 h !Illil p.lin MwllO, I'Omi6ng.d..meo, Gll!jIJff
iiltlm(lIIu:Ullll}lddy)
Boor ,JQlii5licaormia
ltIioomii
diarrhea. fS!hroloxidty
friHlXOItlqulorK) PO;4G-SOmgOlKedaiy MwJlfl,rr15ir
lill:l
r-probffiKid (Bmmrid, ProbaIan) PO;2S0 mg bid for 1 wk. tIIffi SOOmg bid (mil: 1 glday) MwllO, fltJWdflKl!
!!:l'ere2jn
suffinp)'l<ll_ (MIUlallt) PO; 100-100 mg bid (or I wk.lhffi inuu\e 10 ZOO--4QO RIg bid I.ildi5Im!,roJir
Blood neRhrolil!!iasil
IIQIio ilKkale ammon seriousadvmr
NURSING PROCESS FOCUS PATIENTS RECEIVING ANTIGOUT THERAPY
Assessment Potential Nursing Diil gnoses
BiSfline assrSl mrnt prionto administrat ion:
Activit)' IntoieralKf (relat:rd to joim pain)
Undel'\tand liMo rNlOn the drug h" bffiJ pltS(ribtd in order 10 "Iffi for
IherapMK tifKls le.Cj.deuusing aWlr inflammalOry
!t(ulTI'IKe).
Disturbed Body Image (mated to joint inflammation and swelling)
Illtain a mplele hNlth history muding IIIISCIblrleul gastroinlestinal
yrOo.-alWar, rre\J'Obgi<:. todouiIe. iMopatic.or 1!I\,J1,wall'. Obtain a dlUl
1i110r)' iKk.ding um'm pmuiption alii arc dlUljJ, htlbal
akohol UJI', or smoking. lit alert 10 aug interactions.
Illtain a history 01 art)' QJnm\ S)'''1lIOffiJ /lid aflffi on ADU. Assn lor
inflamrnation,ioYtiJn.and ootrall)'p.lin ordiKomlorton rno.'!'II'IffiIor all!St
Obtain a dietary history, noting (orltlatiom betwffil food imake and
ilKrtasr in fluid intake.
Illiain baltlilll' weighl and 'lital sigm.
E'/awl\' appropnatr laboratory findings (e.g., un.: ac:id (B(, hr patK
"Id rrnal function lIudits, urin,lysiJ).
Assessment thro ughout administration:
Allffi for deirtd therapeutK tife(H drpermnt on tilt for thr drug
(r .g., symptornJ of ac:ute inflammation ,It diminishrd or absent. no Itlum
of lymptoms).
ContinUl' monitoring of'lital ligm ,nd urilltoutput.
Cominue to monitor un.: uid It-lri, (SC,and hepatK and Itn.J1 Jludits.
Alsrsl br /lid promptly rtpI adverse effects: 1WII'i, 'IOIIlililq. abiomillill pain.
skin raJh, pruritus, urilt rutput. infei:m.
DefKitm Knowled9l' ldrug Iherapy)
Risk for In;"., to aWlr inflammatory (ondition)
Plilnning: Pilt ient Goals il nd Expect ed Outcomes
TiMo palitnl will:
tiMorapeuti( tfftl {t .Cj.,diminishrd inflammation, dr<lturd or joim pain.in(ltiJrd .Jbility to (ontinUl' AOl5).
Be frer from, or l:lpMtnc:e minimal,ad'irrsr tfftl.
VerlJalizto an understanding of the drug's use, ad'lersr tffKts, a nd ItqJill'd prtUutions.
Dtmon IIrate proper Jelfa dministl1llion of liMo mrdK,lIion (r .Cj., dole, timing. when 10 notify provider).
(Conrlnued!
LibraryPirate
746 UnII' The IntegumeotorySYltem arid Ey<>"rEars
NURSING PROCESS FOCUS PATIENTS RECEIVING ANTIGOUTTHERAPY ICOnrlnutd)
Implementlltion
Interventions lind (Riltionilles) Plltient lind Fllmily Educllt ion
Ensuring therapeutic effects:

RnifW tilt dietary history, noting (orrel.Jtion beIWffn ditl and Entou,aljt thr patiem to kpa food diary, noting any OIrurrrntr 01
<ymptoll'll, PI p .. iolfy .11 .. ingPltion of puri .... .(om.ining food<. Avoid I.rge irKr .. ,ing of 'ymplom. ret.t.d to food or wr>g. im.l<..
Ousofvitamin C.(Gout mol Y O((U, 10 O'frrproduction or
Trac:h thr patientto limit imakeofhighpuri .... bods (f.g., Sillmon,
undernc:rl'lion of uric atid or a rombination of both. Correlating symptoll'll
organ mrats, akohol, mUShfOOlI'II,ltlJlme5,OIItmraO and to limit
to imake of highpurinr foods assisu in detennining tilt most efi .. livr drug
or eliminate akohol consumption.
therap)'. Luljt of vit.amin ( II\a)' ac:idily tilt urinr Itading to formation
oIuric ac:id nollH.)

Inm'.m Huid intake to 2 to4l porr day.Monitor urinr output and obtain

Trac:h tiMo patitntto ilKlN!r fluid intake to 2 to 4l prrday, taken
porriod ic: urinalysis. (llKft'a5f<t fluid imake uric ilid t );{rt lion and throughout thr day.
prMnll urinary uric: add (rystal formation or rmal (akuli.)

Continue to roonitOi !fIUm <lnd urinary uric acid ItYrls and Mtt

Entouraljt tht patiem to maintain consislrnt drug dosing to uric
improl'tl!ll'llt in I)'mptom ,of arult inflammation, gouty and aoo diminilhing.
improYed mO'femrrtt with Itss pain 01 afittled joinu. (As uric <lcid ItYeis

IlIItnKt tilt patient on thr nted to ft'tum for ptriodit Lib trlting and
decft'alt, inflammation due to uric acid crystals ,hould improvt.)
urinal)'!is.
Minimizing ild"ffBe effKb:

Moniklr ItlUm and urinary uric I(id IeYeis j nd !ymptorm mo(iated with

IlIItnKtthe patient to repon any IDntirmd infLImmation, pain, ioomed
aM. infLImmatol)' period.(Cominued 01 in(ft'.!Iing inflammation II\a)' joint of 'ymptOIll! promptly.
inditatt thr IIffii for adciitiou I mt<lic:ation.)

Monitordaily and urina l)' OUIput (Uric acid mrMion may (.11M

IlIItnKt the patienllo repon any diminished in
urate ayml formation in the kidnt)'! with IrIUlting rl'nal impai,mtnt Daily urintappearantf,OI flank pain,and to rrlu,n prrioditalfy for urinaiylis.
wtight is an muratr ofOYefall body fluid wkJmt.)

HaYe the piltient 'Migh at thIo Silmt timt nth day and ft'POn any
wtight 9.in of O"o'tr lib (1 kg) in. 24-hour ptriod to It.. h .. lth carl'
provider.

0taN1t the intau of purint.wntaining foark.Avoid Llrge doltS of vitamin

Teac:h thIo patitnt to awid foark with a high purine 01
t (lntakr 01 highpurint foods Jnd akohol may production of uric rliminatt a/lohol consumption, a nd avoid ilKrl' a 5ed vitamin ( intal<. or
ilidlirge 01 vitamin ( II\a)' inclNst the fomtiltion of urit uid supplemrntation. Pmride a dietitian consuk as needed.


fo, ,kin rash .. , floVff,lIomatitis, IkJlil<. !ymptoms,or Ijtntfal

Teac:h tiMo pat;'nt to immt<liateiy ft'pon anyflulik. 5)TIIptorm,
malaisr. (Bone marrow supprtlsion may O(rur with <I migout drugs and mouth irritation or 01 wn rasht-<.
ft'IUk in Itukoptnia and in ilKrrJ5ed ride ofinfffiion. Sf'/tft' dennatologit
R'ac:tions Jft' pomiblt and any ,kin rJshl-l, tspetiollywith thr Jppmantt of
blisten and diltotoration, should lit ft'POned immtd i.ltei)'.)
Patimt understanding of drug thuapy:

Ust opportunitits during administration of medic:atiolll and during

The patient should lit ablt 10 state tilt rl'.IlOn for thedrug;approprialt
.llltI5mtnu to discus, rationalt for drug thffilpy, de! ired theraprutic: and ItlltdJling;what adYmt rflKl! to obSl'M' for and wiMon to
ou\(omes,lIIOIt (ommon adm-seefiens, paramt trn for when to ull thIo ft'pon;and liMo anticipated length of mtditation tiMorip)'.
hrahh tift' i ny nKtslal)' monitoring OrprKautions.(Using
tim. dJring nursing wr htlps to optimizr and rtinfon:r key INthing
aft'.!IJ
Patimt self-administration of drug therapy:

When administt ring the mrdic:uion. illltnKt the patient famillo. or

The patient is abltlodiscuslippropriatr doling and administration IIffiis
(aft'gil'l in tho proper stlfadministration of tilt drug. r.g., taktn on an ilKkJding taling mt<lic:atiolll at tho fiBt sign oIgout attatk.
tmpty stom<l{h or with mr a Is, with additionallkJids. (Proprr administration

Cokhic:int ,hould lit taken on empty stomac:h. OtiMor antigout
ilKrl'JIts the drugs.)
mtdiutions lhould lit taun with food or mt Jk.
EVlllulltion of Outcome Criterill
haluate tiMo efitdmntll of drug therap)' by (onfinning thu f)atitnt goals and rlpf(\td outlDlIII'S h.M mfl (1ft "Planning1.
5H TiIbIt 47. 4f1lf liM If dfIJljS ril whidI rJrm IIOOirrq
LibraryPirate
OIIpwr41 DNg. for Bone and Joint 747
--
Chapter REVIEW
- -
KEY CONCEPTS
The numbered key concepts provide a sucdnct summary of the Important poinTs from the corresponding IlUOlbcrt.-d section
within the If any of points these are not clear. refer to the numbered sedion within the chapte r for review.
47.1 Adequate levels of calciuOl in the body are necessary to
properly transmit nerve Impulses, prevent muscle spasms,
and provi de stability and movement. Adequate levels of
vi t amin D. parathyroid hormone. and calci tonin are also
ne\:e&Sary for these functions.
47.2 Hypocalcemia is a serious condition that requires imme-
diate therapy with calcium supplements, often concur-
rently with vitamin D.
47.1 Pharmacothernpy of osteomalacia includes calcium and
vit amin D supplements.
NCLEX-RNO REVIEW QUESTIONS
D The nurse completing a physical exam on a child diag-
nosed with osteomalacia would expect to flnd:
l. bowlegs and a " igeon breast.
2. deformities of the fingen; and toes.
3. shortnessofbrl'ath.
4. the use of CIlltches for walking.
o The patlent's calcium level Is reported as 5.6 mgtdL The
nurse should assess the patient for:
l. ht'3dache.
2. anorexia.
). muscles spasms.
4. dro .... 'Si ness.
D The patient r&eiving allopurinol (Lopurin) for treatment
of gout asks why he should avoid consump tion of alco_
hol The nurse's response Is based on the knowledge that
alcohol:
I. causes liver danmge.
2. inlE1'feres with the absorptiOl\ of antigout medications.
3. raises uric acid levels.
4. causes the urine to become more alkaline.
o The patient is admitted with a diagnosis ofhypercalcemia.
The nurse would assess for which of the following? (Sele<:t
all that apply.)
47.4 Pharmacotherapy of osteoporosis includes bisphospho-
nates, estrogen mo dulator drugs, and c;alcitonin.
47.5 For osk'OOrthrltl s. the main drug thernp)' Is pain medica-
tion that includes aspirin, acetaminophen. NSAlDs, or
stronger analgesics. Drug therapy for rheuJrultoid arthri-
tis includes analgesiC$, anti_inflammatory drugs. gluco-
cortlcolds, alld disease-modifying a11llrheum.1tlc drugs.
47.6 Gout is characterized bya buildupofur icacld in either the
blood or the joint cavities. Drug therapy includes agents
that inhibit uric acid buildup or enhance itsexcretion.
1. Cardiac dysrhythmia,<;
2. Patl8lle
). Bone fradures
4. Increased muscle strength
5. Hunger
D Sodi um hyaluronate (Hyalgall) Is prescribed for a patient
with ostoo:lrthrltb. The nurse explains thi s drug will be
administered by which method?
1. Intramu.scularly
2. Directly into the joint
). Intravenously
4. Suocutuneollsl y
1:1 A patient has receivooa prescription for alendronate (Pos-
amu) fo r treatme nt of osteoporosis. The nurse would be
concerned aboUllhls order If the patient Tt.jXIrted: (Select
all that apply.)
1. she enjoys milk, yogurt, and other d.1iry products and
tries to COJ\SllIlle some with each meal
2. she is llllable to sit upright for prolonged periods
because of severe back pain
3. she is la<:1ose intolerant and rnrely conSllmesdairy
products.
4. she has had trouble swallowing and has been told she
has uproblems with her esophagus."
LibraryPirate
748 u .. , ...
CRITICAL THINKING QUESTIONS
1. A young woman calls the triage nurse In her health care
provider's office with questions concerning her mother's
mediation. The motller, age 76, has been taking alen
dronate (Fosamu) after a bone.density study revealed a
decrease In bone mass. The daughter is worried that her
mother may not be taking the drug correctly and asks for
information to minimize tile potentia] for drug adwrseef-
fects. What information should the triage nurse inmrpo-
nul' in a teachlngpJan regardIng tile ora] administration of
alendronat&.
2. A community health nurse hasdedded to discuss the bene-
fits of oral adciurn supplements with an 82 year old female
patient The patimt had a stroke 6 years ago and requires
help with most activities of daily living. Since her husband's
death 18 months ago, she rarely leaves home. She has lost 2S
Ib because she can't get interested" in her meals.. She re-
fuses to drink milk. What considerations must the nurse
make before recommending calcium supplementation!
3. A 36-year-old man comes to tile emergency dcpanment
compL1ining of severe pain in the first joint of his right big
toe. The triage nurse Inspects the toe and notes that the
joint Is red, swoUen, and ext remely lender. Rerognizing
this as a typical presentation for acute gouty arlhritis, what
historical data should the nurseobuln relevant to this dis
ease proo::ess1
See Appendix D for Imswtn and mtionaies for all activities.
EXPLORE
t.I\'f.l.JJmgKl 1s)'OOt" ane stDp !or enloe chapt .. l!!\flew and
resources. f'repa.t ftr $UCCe$lI with ItCU:x -$tyle practlQ!
QUeliti:Jns. inlln:tive ..:I adMties, web Ii1i<s, animations
and videos, and 1II(Je!
AegISltr yow aX!SS code from tI1e Iron! 01 yow book III
-..yn .. silgl!il.com.
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DRUGS AT A GLANCE
DRUGS FOR SKIN INFECTlDNS J'4ltW
Antibacteriab,Antifungals, and Antivirals
",,",
Scabiddes and Pedi(Ulicidts {IIXJt 75J
o permethrln (Actle'n, film/If, NOO ;ogt lSJ
DRUGS FOR ACNE AND ROSACEA pilft155
Benzoyl Peroxide (J09tl%
Retinoid!
Q treltlOin (Avtta, Rffrl-A 7tenrtn-.'( otlwf$)
"",lSl
Antibiotia {IIlI}tlS4
DRUGS FOR DERMATITIS (IlJIItlS9
Tapial Corticosteroids pot}t 1(1)
DRUGS FOR PSORIASIS ptIItlfJ)
Tapial Cortiwsteroids pogt 161
S)'5temi(Agents ptJlJtl'61
DRUGS FOR SUNiURH AND OTIIER MINOR BURNS
... ",
SlIlbbb fJI1I1IJ6J
local AnestMtics ptJtlO
KEY TERMS
ac:nnulglris pqllS
romfdone pa)f 156
PIl!/t7S9
Knrnl ,..1S9
trytMlN pilI}/'l'lJ
fxmriation PIl!/t lS9
Drugs for Skin Disorders
LEARNING OUTCOMES
Aher f?Qding this the student should be to:
1. Identify the structure and functions of the skin layers and ilS$OClated
structures.
2. Explain the process by which superfidal skin cells are replaced.
3. Describe drug therapies for skin Infections, mite and li ce Infestations,
acne vulgaris, rosacea, dermatitis, and psoriasis.
4. Describe the prevention and management of minor burns.
S. Describe the nurse's role in the pharmacologic management of skin
disorders.
6. Foreach of the listed In Drugs at a Glance,know representative
drugs, and explain the mechanisms of drug action, ""tlons,
effects.
7. Use the nursing process to care Jar patients who li fe receiving drug
for skin di50rders.
kfratolytic minoid pogtl56
nits pq 75J (jt 157
pfdirulicidf,s pi1Jt 751 rosKfa {A1It m
pruritlK JIII1I7'lJ (Xl9tlSJ
psoralen pi1Jt 76J {!09f 755
JIII1I76D IIfIKW (llJlltl5C
LibraryPirate
750 UnII' The ar.d Ey<>"rEars
T
he integumentary system consists of the skin,hair,nails,
sweat glands,and oil glands.The largest and most visible
of all organs, skin provides an effective barrier between the
outside environment and the body's internal organs. At
times, however, external conditions become too extreme, or
conditions within the body change, resulting in unhealthy
skin. When this occurs, pharmacotherapy may be utilized to
improve the skin's condition. The purpose of this chapter is
to examine the broad scope of skin disorders and the drugs
used for skin pharmacotherapy.
48.1 Structure and Function
olthe Skin
To understand the actions of dermatologic drugs, it is nec-
essary to have a thorough knowledge of skin structure. The
skin wmprises three primary layers: the epidermis, dermis,
and subcutaneous layer. Each layer of skin is distinct in fom}
and fimction and provides the basis for how drugs are in-
jected or topically applied.
EPIDERMIS The epidermis is the visible, outermost layer
that wnstitutes about 5% of the skin depth. The epidermis
has either four or five sublayers depending on its thickness.
The five layers from the innermost to outermost are
stratum basale {also referred to as the stratum germina-
tivum).stratum spinolUm, stratmn granulo5um, stratum lu-
cidum, and the strongest layer, the UTatwlI corneum. The
stratum corneum contains an abundance of the protein
keratin, which forms an effective barrier that repels bacte-
ri.1 and foreign matter: Most substances cannot penetrate
this barrier.
The deepest epidermal sublarer, the stratum basa.le, sup-
plies the epidermis with new cells after older superficial cells
have been damaged or lost through normal wear. Over time,
these newly created cells migrate from the stratum basa.le to
the outermost layers of the skin. As these ceUs are pushed to
the surface they are flattened and covered with a water-insol -
uble material, forming a protective 6""1. On awrage, it takes a
cell about 3 weeks to move from the stratum basale to the
body surface. Specialized cells within the deeper larers of the
epidermis, called melanocyres, secrete the dark pigment
melanin, which offers a degree of protection front the SWl'S ul-
traviolet rays. The nwnber and type of melanocytes deter-
mine the overall pigment of the skin. The more melanin, the
darkfr the skin color.
DERMIS The middle larer of the skin is the dermis, which
accounts for about 95% of the entire skin thickness. The
dermis provides a fOWldation for the epidennis and a"es-
sory structures such as hair and nails. Most sensory nerves
that transmit the sensations of touch, pressure, tempera-
ture, pain, and itch are located within the dermis, as well as
the oil glands and sweat glands.
SUBCUTANEOUS TISSUE Beneath the dermis is the sub-
cutaneous layer, or hypodermis, consisting mainly of adi-
pose tissue, which cushions, insulates, and provides a
source of energyforthe body. The amount of subcutaneous
tissue varies in an individual, and is determined by nutri-
tional status and heredity. Sonte sources consider the sub"
cutaneous layer as being separate from the skin, and not
one of its layers.
48.2 Causes of Skin Disorders
Of the many types of skin disorders, some have vague, gen-
eralized signs and symptoms, and others have specific and
easily identifiable causes. Urti(.ria is a hypersensitivity re-
sponse characterized by hives, often accompanied by pruri -
tus, or itching. Allergies to foods often manifest as urticaria.
Pruritus is a general condition associated with dry, scaly skin,
or a parasite infestation. Pruritus may also be a sign of
systemic pathology, such as serious hepatic or renal impair-
ment. A substantial number of drugs have urticaria or pru-
ritus listed as potential adverse effects. Erythema or redness of
the skin accompanies inflammation and many other skin
disorders. Inflammation is a characteristic of burns and
trauma to the skin.
One simple method of classifying skin disorders is 10
group them as infectious, inflammatory, or neoplastic.
Skin disorders, however, are diverse and difficult to clas-
sify because they frequently have overlapping symptoms
and causes. For example, lesions characteristic of acne
may be inflamed and become infected. Characteristics of
these three classes of skin disorders are summarized in
Table 48.1.
Dermatologic signs and symptoms often result from dis-
ease processes o"urring in other body systems. Skin ab-
normalities such as changes in skin turgor and in the color,
TABLE 48.1 Classification of Skin Disorders
"'"
Example5
Infectious Saamal inptliljC\and ilftclf<i hili
folidts
fIrogal infwions:riror-m nai
ilfedion
ioftaioos: ticks, mill"!, and
Y"nl ioftaions:roId lOR"!, fev bIislm (hptS simpln).
dJidrn pol. llioglts {ht!pes ZOIlI.
(rubtolal. and Gtrmao (nftlla)
Inftarnmalory 10)1ry and 6p&IU1! 10
Combinalion of gland!, hormont
prodooion,and/or infwion sudJiII oKIII' and IOIi(U
[ijsocders with KdJing. craOOng, and lilwmfort IlKh al
atopic: dmnatilis. rontaa di'rmatil:iI, srborrhric dmnatilil,
psoriM

Skio (til urdoorna.baQI cell ta1:illOllU,
and maWgnanl mNilorna
Bffii9n ur.losiland rnalOilunlhorna
LibraryPirate
size, types, and character of surface lesions may have sys-
temic causes such as liver or renal impairment, cardiovas-
cular insufficiency, mE1astatic twnors, recent inj u ry, and
poor nutritional status. The relationship between the in-
tegumentary system and other body systems is illustrnted
in ". Figure 48.1.
The pharmacotherupy of skin disorders mar be con-
ducted with oral or topical drugs. In general, topical drugs
are preferred because this route delivers the medication di-
rectly to the site of pathology and systemic adverse effects
are rare. If the skin condition involves de.."er skin layers or
i< exteIwve, oral or parenteral drug therapy mar be indi-
cated. Some conditions such as lice infestation or sunburn
with minor irritation warrant only short-term phanna-
cotherapy. Prolonged and extensive thernpy i< sometimes
required of eczema, dermatitis, and psoriasis.
Chopl .... Drug' fotSktn O""rd .... , 75 1
PHARMFACTS
Skin Disorders
An estimated 3 million ptOpIe with ntW me oIlic:t infestation art
tll'itfd t<Kh in tIN> Unilfd Statrs.
Ntul)o 17 million in !hi> Unitfd States hae <Knr,making it tIN>
roost mmmon disraSor.
Moll' than 15 million proplr in Unitrd SliIlrs haff symptOIlll 01
rlrrmatitis.
Of inlints and 100119 (hiidll'n, 10% symptollll oIdenn.nitis;
roughly 60% oltllesr inlants cominUl' to haff symptollll imo idukhood.
1% to 2%ur tlo" U.5.pupul.olim. Tioi. diwnlrr unun in.1I
agr glOO[II- adJits mainly- affoxting about thr rumoo of mtn
aswomtn.
Endocrine syatem
Hotmones influence
glandula. activity, calcium
homeostasie, and skin h .... llh.
The integumentary
ay.tem
Nervous syatem
Emoliomo sfteeI skin
coIoralion. The skin is a
Muacula. ayatem
The &kin and ....,...,les a re
importanl lot proper body
movemenl and expression.
Lymphltic syatem
Helps fight disea .... s and
inteclions 01 the &kin.
Digestive aystem
Prope. is imporlan\
to. healthy skin.
Urine. y s y.tem
The ao:um.Jlation 01 Io>cic
54.bslar>c:ola in the
bIoodslream willllfac1 the
skin advorsely.
Fo. all sy.tems
The &kin larms a p>teetive
ba ..... r a9"inst hazardous

". Flgure48.1 Interrelallomhlps of the Integumentary system with other body systems
sensory organ.
Cardiovascular s yatem
The blood canies oxygen
and carbon dioxide, 1ae\ore
1h&t influance skin health
and ooIotrllion.
Reapinotory syatem
The lungs provide
oxygen 10 all celie
in the body.
Skeletal syatem
The bonaa are II. stora.ge site
Ier calcium. an important
"';""ral connecle<l w;th
vita"';n 0 lundion.
Reproductivs ay.tsm
The skin oovers eld""",1
genitalia. Sex ho""""""
innue""" skin health.
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752 Un'" The System EyKIEm
SKIN INFECTIONS
The skin is normally populated with microorganisms or
flora that include a diverse collection of viru.ses, fungi, and
bacteria. A5 long as the skin remains huhhyand intact, it
provides an effective barrier against infection from these or_
ganisms. The ski n is very dry, and keratin is a poor mergy
source for microbes. Although perspintion often provides a
wet environment, its high salt conU'nt disoourage:s micro-
bial growth. Furthermore. the outu layu is continually be-
ing sloughed off, and the microorganisms leave with the
dead skin.
48.3 Pharmacotherapy of Bacterial,
Fungal, and Viral Skin Infections
Bacterial skin infections am occur when the skin is
tured or cut, or when the outer layer is abl"3ded through
trauma or removed through severe burns. Some bacteria
also infect hair follicles. The two most common bacterial in-
fections of the skin are caused by SlIIphyl{J({J(ClIS and
Strept{J({J(cus, which arealso normal skin inhabitants. S. au-
reus is responsible for furuncle:s (boils), carbuncles (ab-
scesses), and other pus-containing lesions of the skin. Both
s. aureus and S. pyogenes can cause impetigo, a skin disorder
commonly occurring in school-age children. Cellulitis is an
acute skin and subcut aneous tissue infection caused by
SUlphylococcus and
Although many skin bacterial infections are self_limiting,
others may be serious enough 10 requirt pharmacothel"3py.
Topical anti-infectives are safe. and many are available OTC
for self-treatment. If the infection isdeq> within theskin,af-
fects large regions of the body. or has the potential to be-
come systemic, then oral or partnteral therapy is indicated.
Furthermore, the incidence of methicillin.re:sistant
Staphyloroaus tlllrrus (MRSA) skin infections is increasing,
which often requires with r,.,'() or more
antibiotics. Some of lhe mort common topkal antibiotics
include the following:
Bacitracin ointment
Erythromycin ointment (Erydtrrn, others)
Gentamicin cream and ointment
Melroniduole cream lotion
Mupirocin (Bactroban)
Neomycin with polymyxin B (Neosporin), cream and
ointment

FlUlgal infections of the skin or nails such 35 tinea pedis
(athlete's foot) and cruris (jock it,h) commonly occur
in warm, moist areas of the skin covtred by clothing. Tinea
capitis (ringworm of the scalp) and tinu unguium (nails)
are also common. These pathogens are re:sponsive to thel"3py
with topical arc antifungal agents such as unde.;ylenic acid
(Cruex, Desenex, others). More serious fungal infections of
the skin and mucous membrane:s,such as Candida albiCil/ls
infections that occur in immunocompromised patients, rt
quire systemic antifungals (cholpttr 350"0). Clotrimuole
(M)'U'lex, Lotrimin, others) and miconawle (Monistat, oth.
ers) are common antifungals available as creams or oint
ments that au used for a variety of dermatologk mycoses.
Certain viral infections can manife:s t with skin lesions. in
cluding varkella (chicken pox), rubeola ( measles). and
rulodb ..... ll r.
limiting and IX)flspecific.so treatment is directed at control-
ling the extent of skin lesions. Viml infections of the skin in
adults include herpes zoster (shi ngle:s) and herpes simplex
(cold sores and genital lesions). Pharmacotherapy of severe
or persistent viral skin lesions may indude topical or 01"31
antiviral ther-apy with acyclovir (Zovirax), as discu.sscd in
chapter 3600.
SKIN PARASITES
Common skin parasites include mites and lice. Scabies is an
eruption of the skin caused by the female mile, SnrroplN
scabiei, which burrows into the skin to layeggs that hatch af_
ter about 5 days. &abies mites are barely visible without
magnification and are smaller than lice. Scabies lesions most
commonly occur between the fingers, on the extremities, in
axillary and gluteal folds, around the trunk, and in the pu-
bic area, as shown in Figure 48.2. The major symptom is
intense itching; VigOroWi scratching may lead to 5eCondary
inf..ctions. Scam ... i. readily sprl1lld through with
upholstery and shared bed and bath linens.
Lice are larger than mites, measuring from I to 4 mm in
length. They au readily spread by infected clothing or close
Figure 48.2 S,.blei
SouIl:O':CwltelY ofDr. JO:ion L Smrlt
LibraryPirate
Flgure48.J Pediculuscapilis
Source: Coone.\)' of Dr. )awn L Smlrh
personal contact. These parasites require human blood for
survival and die within 24 hours without the blood of a hu-
man host. Lice (singular: louse) often infest the pubic area
or the scalp and lay eggs, referred to as nits, which attach to
body hairs. Head lice arl! fl!fl!rred to as PediculuJ capitis
(. Figure 48.3), body lice as P. corpus, and pubic lice
Phthirus pubis. The pubic louse is referred to as a crab louse,
because it looks like a tiny crab when viewed under the mi-
croscope. lndividuals with pubic lice will sometimes say that
they have Pubic lice may produce sky-blue macules
on the inner thighs or lower abdomen. The bite of the louse
and the release of saliva into the wound lead 10 intense ilch-
.... Prototype Drug I Permethnn (AcrICrlt Ellm/re. Nix)
ClIopl .. 4I Drug'/OfSklnDIsom ... , 753
ing followed by vigorous scratching. Secondary infections
can result from scratching.
48.4 Pharmacotherapy
with Scabicides and Pediculicides
Scabicides are drugs that kill mites, and prdirulicides are drugs
that kill lice. Some drugs are effecth-e against both types of
parasites. The choice of drug depends on where the infesta-
tion is located, as well as factors such as age, pregnancy, or
breast-feeding.
The preferred drug for lice is permethrin, a
chemical derived from chrysanthemum flowers and formu-
lated as a 1% liquid (Nix). This drug is considered the safest
agent, especially for infants and children. Pyrethrin (RID,
others) is a related product also obtained from the chrysan-
themum plant. Permethrin and pyrethriru:, which are also
widely used as insecticides on crops and livestock, kill lice
and their eggs on contact. These in about
90% to 99% of patients, although a repeat application may
be needed. Side effects are generally minor and include
stinging, itching, or tingling. Malathion (Ovide) is an alter-
native for resistant organisms.
Permethrin is also a preferred drug for scabies. The 5%
permethrin cream (Elimite) is applied to the entire skin sur-
face and allowed to remain for 8 to 14 hours before bathing.
A single application cures 95% of the patients, although
itching may continue for several weeks as the dead mites are
from the skin. Crotamiton (Eurax) is an alternati\'e
scabicide available by prescription as a 10% cream.
Therapeutic (lass: Antiparasitic Pha rmacologic ( lass: Xabicide; pediculicide
ACTIONS AND USES
Hi. is marlcelfd 1\ <I (rum,lotion,Of shimpoo to kill htad and mb and
miln,<lnd thtirova.A 1% lotion is lor Iic:t and a S% lotion
lor mitH. Tht mtdic:atioo shoold bt <l11owtd to rennin on the h<lir and stalp 10
btlorr II'moval. Patitots should bt awall' that proetratioo of the skin
with mitts (aws it(hing.. whic:h lamup to 20r 3WffHt'lfO aftt rtht paruitn
killtd.
Suc:ttlsful 01 parasitt infKtions should iIKUdt II'm>m1 of nits
with a nit(omb, washing btdding,and dtaning or rMJO'/al of objtds thit w
lIttn in rontau with the htad or hair.
ADMINISTRATION ALERTS
Do not UIl'on prema!ulI' infants and dJildrtn )'OUlI9fr than 2
Do not UIl'on all'as of skin thit wabrasiom, r<lSh, or infLlmmatioo.
PregnancymtgoryB
PHARMACOKINETICS
Onset: 10 min
Pt-ak:Unkl"lown
Half-life:Unknown
Ouration:3h
ADVERSE EFFECTS
I'Mntthrin uws few systemic: rlftm. Lotalll'<lctioos may oc:rur and induoX
pruritus, rash, transil'm tingling..buming,lIinging.. rrythema,and tdema of the
alfecttd all'a.
Contraindi (<l tions: Contr<lindiutions iIKludt hyprrll'nsitivity to p)'II'thrins,
chrysanthtmurm, IUlfites, or othtr plI'SfrntiYH. Pt lll"ll'thrin !hoold lit uSfd
over inflamtd !kin, in tOOIl' with uthma, Of in I<Ictating womm.
INTERACTIONS
Dru;rDIII!I: No dnKaly s9Wfunt 'lfrac:tionI 11m bft'O do<umtored.
li b Tesll:Uoinown
Herb<lVFood: Unknown
Tll'at ment of Overdose: No sprcilK trtatmmtloromrdoll' is <l nil<lblt.
/II11i>r Ie M;MJrJIngIJ/ A>r Q NiJrJill9 I'n::mJ fOOl! JpKtk Ie IN!
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754 Unlit The aod
NURSING PROCESS FOCUS PATIENTS RECEIVING THERAPY WITH SCABICIDES
AND PEDICULICIDES
Assessment
Siseli .e assessme.t prior to administration:
Undmtand the rmon the drug hn been in order to lor
therapeutic tfftns (t .g. specific t)'JIt ofinftstation such as licd.
Illtain. complt!t health history includingdennato!oqicandsocial history
01 rKfIIt tlj)ORJrI'.
Illt.in a drug histOfY including aUt"1ie,currtnt prescription and OTe drugs,
herbal preparations, akohol use, and smoking.Be alert to possible drug
interactions.
Assm wn artas to be truttd for signs 01 inftstation (t.g., lict or nits in
tnc. artas wtbs 01 fingtB,around belt or elastic
fines), irritation. enoriation, or driinage.
Illtainbaselineheight, weight,u.d vital
Assessment throughout &dministration:
Asstss for desired therapeutic rffKts <leptndent 00 tht ft'asoo the drug is
given (e.g., visible inltstation is gone, nits arl' haling is
visible).
Assm for ad'ttfSt tfftas: IourlZtd pruritus. or burning.
SP'ltrt skin !factions or should be ft'poned promptly.
Potential Nursing
Disturbed Body Im.gt
Imjliired S.in Integrity (rtlattd to pruritllS and possible skin Itsions)
Deficient Koowltdgt (drug thuapy)
Risk lor Poisoning (rI'littd to inwrrtct l/Sf of the drug,adYffit drug
tfl'ec:u)
Planning: Patient Goals and Expected OUtcomes
The patient will:
Experience therapeutic: efhru (e.g., infmation has cleuedl.
Be fnot from, or experitfl(e minimal,a!hmt effKtS.
VMlalize an understanding 01 the drug's use, a!Nmt tffms,and ft'quirl'd prtc:all1ions.
OtmonSlla1l' proptr sell-adminiSll.tion 01 tht mtdic;ation whffi to notify proyided.
Implementation
Interventions and (R ationales)
hSiring thfnptutk effects:
Monitor appropriatt medication adminillrlltioo for ojltimum I'tSlIl1S.
Monitor the .ffected area .after treiltment DYtr the following 1 to 2 wNI;s to
ensure the infestation has been eiiminattd.{Appropriateidminillrationwill
optimizt. theraPfutic: efftc15 and limit need for retreatment)
Minimizing .dftfSe effects:
Monitor lhe arl" ofinftstation over the nut 1 to 2 weeks.ReinftStatioflS
may appear within 1 wetk and need to be retreated ilt timr. (Most
trl'atments aft' highly efftie when administered correctly. Retlt'atmmt
rMj be nfflled dtPfndel1t on the type of inftstation.)
Monitor family membm, those in dost (arl' of patient, or sexual (ontaro for
inftStation. Bedding and pefson.J1 ob;t<ts shotJld be de.1nstd heforl' 1Mt.
{Reinftst<ltion may reoJf if those in dost contact wi th the patient art
inftSted (lose contam should be tseattd at the Silme time as the patient.)
Monitor in arl'u that have been tsnttd.Promptly report any irritation,
broken skin,erythema, ras hts, or edema. (Skin It'actions ,rt rtlitivtly
uncommon but may occucAllergK reactions should be reported promptly. )
Patient Llndtrnanding of drug therapy:
Use opportunities during administration of medications .nd during
ilSsessments to discuss tile ratioNIt for drug therapy, cltsired therapeutic
outcomes, rommon advtlSl! effects, parameters for whm to (.Illlhe health
C'rI' providtt and irrj nec:essary monitoring or (Using time
d.Jfing I'A.lning cart helps to and reinfortf Ry teaching
Patient and Famil y Teaching
Teach the patient appropriate adminismtion trchniqUtS (set "Patient stlf-
administration of drug thmp(lattr in this table).
Instruct tile patient. family, or caregiver to (ootinue to asstSS tht illN daily
for 1 to 2 and cootact the htalth (.IrI' prtwider for a SKOnd
prtsoiption if rrinfestation is nott<!.
Instruct the patient, family, or caregiver to wash btdding,dothing IIStd
CUrrtfltly, il nd combs ilnd brushes in wattr and dry thoroughly.
Va<Wm fumituft' or fabric that <annot be dnned to rtlflOYt any tmnt
Yfnnin. Dry dNn hats or (.Ips that cannot he washed Stal children's toys
inpiasticbags for 2wteksiftheyunnot bewashed.
Ttach the patienl,family,orcarl'giverto report any
itching. or e)l(oriation, oril complilints of burning CUt to the htalth Uri'
provider.
The patient should be ,ble to stilte tilt reilson for tilt drug,appropriatt
dose and and what advelst tffects to obstrn for and when to
rtpOrttiltm.
LibraryPirate
ClIopl .. 4I Drug' fo< Skin Dl1Ord ... , 75 5
NURSING PROCESS FOCUS PATIENTS RECEIVING THERAPY WITH SCABICIDES
AND PEDICULICIDES (Continued)
Implementation
Interventi ons and IRati onales)
Patint selfadministriltion of drug thtrilPY:
Wlltn administtring thl medKation,instnKI patitm,
in lilt proptr of the drug, !.g.,IM waly" or
per p;lckagt direions.1 Proptr administration ilKlNSti tilt of
IlltdrugsJ
Patient and Famil yTeaching
Teilch p;ltitm 10 tike tilt drug following appropriate guidelints:
A,ply thedrug ptr j)OCUgr dilroions and allow 10 II'main in the hiir or
on the skin the PII'I(ribtd itngth of (lIIUIIlly approximately 10
minute). Most (omain enoogh drug rorone IlI'illlIIfIlt
athough alf({lnd paWge may bt lI'qui.ro if hair is long.
DI)' lhoroughly aflrr shoWl'ring or shampooing tilt drug OUI of !lair
ollkin.
Ccmb through hairwith the smalltoolhed (omb providtd 10 II'mO''
ary rffluining dtad IKe, nits, or nit {asings.
If illI' inftslrd,appiy alhin (Oill of perroirumjelly to
oru . dory fur t w ... k.Cornh Thmugh II.i"'l . 1IM1I.'PIW)!' ramn
(trd webbings offingenand tOts,and btlt or lints for
of lI'inftstation O'/rr tht oo:t f 1Iffiitd, a lI'{ond ipplKilion
ofthedrug (in bt tMd after 1 Wl'rk.
Evaluation of Outcome Criteria
[valuatr the of drug llitra py by ronfinning that p;ltit nl gN Is and OpKte<l have bffil mel (Ite Plannin(].
The t raditional drug of choice for many decades for both
mites and lice was lindane (Kwell). Because lindane has the
potential to cause se,ious nervous system toxicity, it is now
prescribed only after other less toxic drugs have failed to
produce a therapeutic response.
All scabicides and pediculicides must be used st rictlyas
directed, because excessive use has the potential to cause
serious systemic effects and skin irritation. Drugs for the
treatment of lice or mites must not be applied to the
HOME & COMMUlllTY CONSIDERATION5
- -- - -- ---
Psychosocial and Community Impact of Scabies
and Pediculosis
Childll'n and paniWrty tt-.u illl'lariYrl)o afflutnl all'lS, IIW)' apress
fe.!.ing LlKiran or that Ihti- has betn IaNtnd whtn thf, all',jag
with IUbier or prdinAosis.Somt patienlS think that only horntItss ptrwns
or allow inrome gettll!5l' disordm. dK;atr tht patitnt .md fami! IIII'm
benabrut wIidt rontraulGlbits or pedirubsi\ .md theW8fl
in which these infl'si.rtJJns may be plM'nlm Help thor! alFtt:trd 10 maintain
thtir srK.eterm and aoopu lItakll)' attitudt. PeIlOlll with SGlbits or prdirukllis
IIIijI tend to isolatt lO(ia." but 1m is lJlllta'lwl)' if pll'{iutions art t1ke-n 10 net
shall' wthing,rorrbr,or cdrr or hm bodily({lllixtwith othm.
Subits or IKf un r.Jpidly Ipll'ad in a nuning lI'Iidtmial
bKomea(ommunityhukh probirm. School
nurstl mUI! a\ srss tilt fur studtnu or patitnu (onuding SGlbirs or
IKt and ,ake mmurrr. This may ilKlude fll'qutm .J!SI'ssmems of
the oposr<l skin, and elimination of ron and hat r<l(D andop
plrtunitits to iliaII' or swap dothing andior toWl'is. Xhool dJildll'll .J nd thtir
f<lm ilits IIffil edlKation on pll'Yl'lltion and tll'UIIIl'IIt. Patitnu and thtir fa m
ilits II'porting \(abits or prd"KUIoIis to nunt should be tll'iltrd in an at
(tptiog. manner.
mouth, open skin lesions, or eyes, because this will cause
severe irritation.
ACNE AND ROSACEA
A-cne vulgaris and rosacea are two disorders that produce
similarappearing lesions on the face. Although the two
conditions have some visual simil.1fities and sharf a few
common treatments, the pharmacotherapy of the diwrders
is very different.
48.S Pharmacotherapy
of Acne and Rosacea
Medications used for acne and related disorders are avail
able OTe and by prescription. Because of their increased
toxicity, prescription agents are reserved for more sevue,
persistent cases. These drugs are listed in Table 48.2.
ACNE VU LGARIS Arnnulgaris is a common disorder of the hair
and sebaceous glands that affects up to 80% of adolescents.
Although acne occurs most often in teenagers, it is not Wl-
usual to find patients with acne who are older than 30 years,
a condition referred to as mature acne or acrle tardiw. Acne
vulgaris is more common in men but tends to persist longer
in women.
Although the precise cause of acne is unknown, several
factors associated with acne vulgaris include abnormal
formation of keratin that blocks oil glands and seborrhea,
the overproduction of sebum by oil glands. The bacterium
Propionibacterium awes grows within oil gland openings
and changes sebum to an acidic and irritating sub.tance.
LibraryPirate
756 UnII' The ar.d Ey<>"rEars
TABLE 48.2 1 Drugs for Acne
Drug Rl!!T1arks
idaJlalelll'lootmo)
imait uid (Azdex, Finaa'a,othm)
bmzoyI pl'rOlidt FoIiex,othm)
(ompollld UItd tOUNt aaM' 10000000tion
to ilflallll1ita}
(ombinf<i with ft)'throm)'<in or dindamydn (SMuClin) lor
oKIIt t.lUltd by P.Q(ntf
diodolmydn and uetiooio (Dina)
ethinyl (Eltirr,1l
iIotretiooio (AaUtiIll'J
Combination product with.lO oIntibiotitand j retiloid in 01 gel ba!t;for mild 10 rnOOeralt oIUlI'
Oral (ontroKtptive lI!ed for etratiol pkII (Onllo TrHydtn28)
F !f'Im' oKJlI' with 'Ysn or lItnt forTntd in Ynall, IOIIIdtd rna\.Se; prtgnaocy X
5Ufitmmide (Cetamidt, K1aron, othel!) F skin; (ombined with 5UI1l' 10 pl' d llg, in tonditioo roSoKN; illO U!I'd lor
(onjllotti'litil
tmrotrlll' (T.uor.Kj
tetraqdioes
A reliloid ttug that may allO tit UItd lor pIOIiaIis; MI antiprdi/ and aotHnftammatory
Amibiotiu; rtfettodwplet 3400
O trrtinoin
To prt'Imt dog4jing 01 porr loIlidts; allO u!I'd for ummmt 01 aM\' promytlotytit IetJkemii ind
As a result, small inflamed bwnps appear on the surface of
the skin. Other factors associated with acne include an-
drogens, which stimulate the sebaceous glands to produce
more sebum. This is clearly evident in teenage boys and in
patients who are administered testosterone.
Acne lesions include open and closed comedones. Black-
heads,oropen romedonn.occurwhen sebwn has plugged the
oil gland, causing it to become black because of the presence
of melanin granules. \Vhitehcads, or closed comedones, de -
velop just beneath the surfa'e of the skin and appear white
ratherthan black. Some closed comedones may rupture, re-
sulting in papules, inflammatory pustules, and cysts. Mild
papules and cysts drain on their own without treatment.
Deeper lesions can cause scarring of the skin. Acne is graded
as mild, moderate, or severe, depending on the number and
type oflesions present.
The goal of acne therapy is to treat existing lesions and to
prevent or lessen the severity offuture recurrences. The reg-
imen used depends on the extent and severity of the acne.
Mechanisms of action of antiacne medications include the
following:
Inhibit sebaceous gland overactivity
Reduce bacterial colonization
Prevent follicles from becoming plugged with keratin
Reduce inflammation of lesions
Benzoyl peroxide (Benzalin, Triaz, others) is the most
common topical OTC medication for acne. Benzoyl perox-
ide has a kmtolytit effect, which helps dry out and shed the
outer layer of epidermis. In addition, this drug suppresses
sebum production and exhibits antibacterial effects
against P. acnes. Benzoyl peroxide is available as a topical
lotion, cream, or gel in various percent concentrations.
Typically, the patient applies benzoyl peroxide once daily
and in many instances, this is the only treatment needed.
The drug is very safe, with local redness, irritation, and
drying being the most common side effects. Other kera-
tolytic agents used for severe acne indude resorcinol, sali-
cylic acid, and sulfur.
Retinoidsarea class of drugdosely related to vitamin A that
are used in the treatment of inflammatory skin conditions,
dermatologic malignancies, and acne. The topical formula -
tions are often drugs of choice for patients with mild to
moderate acne, particularly those with the presence of in-
flammatory cysts. Tretinoin (Retin-A) is an older drug with
an irritant action that decreases corned one formation and
increases extrusion of comedones from the skin. Tretinoin
also has the ability to improve photodamaged skin and is
used for wrinkle removal. Other retinoids indude
isotretinoin (Accutane), an oral vitamin A metabolite med-
ication th.1l aids in reducing the size of sebaceous glands,
thereby decreasing oil production and the occurrence of
dogged pores. Although extremely effective, isotretinoin is
rarely used due to the potential for birth defects (pregnancy
category X) and the fact it has been associated with a risk of
suicidal ideation. Therapy with retinoids may require 8 to
12 weeks to achieve maximum effectiveness. Common reac-
tions to retinoids include burning, stinging, and sensitivity
to slllllight. Adapalene (Differin) is a third-generation
retinoid that causes less imitation than the older agents. Ad-
ditional retinoid-like agents and related compOlmds used to
treat acne are listed in Table 48. 2.
Antibiotics are sometimes used in combination with acne
medications to lessen the sevt're redness and inflammation
associated with the disorder, especially when the acne is in-
flammatory and results in cysts and pustules. Doxycycline
(Vibramycin, others), minocydine, and tetracycline, ad-
ministered in small doses over a long period, have been the
traditional antibiotics used in acne therapy. Erythromycin
and clindamycin are frequently used topically and have a
low incidence of adverse effects.
Oral contraceptives containing ethinyl estradiol and
norgestimate may be used to help dear the skin of acne.
The agents are reserved for women who are unable to
take oral antibiotics or when antibiotic therapy has
LibraryPirate
Choplt... Drug. fOf Skin Disorder, 757
Prototype Drug I Tretlnoln (AVlta, Retm-A, Trentm-x. others)
Therapeutic (I ass: Antiacne agent Pharmacologic ( lass: Retinoid
ACTIONS AND USES
T""inoin d. ... ohiumin A thal ;. iMiuted forthe"ArIy lI .. t_
mtnt'M mntrol of mild 10 moderille oK/I!' vulg,ris. Renm ;. A topic,1 form of
tretinoin 'PPlO'fed to liNt fi,", i.lCi,1 wrinkles 'M hyptrpigmmtnion associ-
ated photodamaged skin.Trriiooin has antinroplu1K <l rtions;,no"llorm
(Ve-\aooid) ;. appWled to <l Me promyelorytic itukemia ,lnd Ina)' be Pll'-
I(ribed ofF.Jabei for skin
Symptorm t,kt 4-8 Wffb 10 improYr, aM maximum therapeutic
ilia)' take momhs. Bffilu," of potfntialiy II'nous dfe<ts, this drug
is most 1l'1I'rYe<! for ryitic aorne or kmtinization disorders.
ADMINISTRATION ALERTS
Avoid adminimring ore II!' medication! and using sl::in produm that
WIII' I'J{l1si"l'!' drying of the skin during therapy.
kroid dill'ct rxPllUll' 10 sunlight or UV lamps.
Do oot administerto p-atienG whoall' alier9ic to rlSh product contains
rlSh protti ns).
Pll'9nanry Ulfgory (
PHARMACOKINETICS
Unkoo'Ml
Pf,ak:Hh
0.2- 2 h
Duration:Uoknown
proved ineffeclive. For Ihe actions and contra indica-
tions of oral contraceptives, see chapter 4500.
ROSACEA Rosa(fil is an inflammatory skin disorder of un-
known etiology with lesions affecting mainly the face. Un-
like acne, which most commonly afffCts teenagers, rosacea
is a progressive disorder with an onset between 30 and 50
years of age. Rosacea is characterized by small papules or
inflammatory bumps without pus that swell, thicken, and
become painful, a hown in ... rigure 48.4. The face take.
on a reddened or flushed appearance, particularly arolUld
the nose and cheek area. \Vith time, thf redness becomes
more permanent, and lesions resembling acne appear. The
soft tissues of the nose may thicken, giving the nose a red-
dened, bullous, irregular swelling called rhinophyma.
Rosacea is exacerbated by factors such as sWllight, stress,
increased temperature, and agents that dilate facial blood
vessels including alcohol, spicy foods, skin care products, and
warm beverages. It affects more women than men, al though
men more often develop rhinophyma .
The rnu most effe.;:tive treatments for rosacea are topical
metronidazole (MetroGel, MetroCream) and azelaic acid
ADVERSE EFFECTS
All p-atienu using "'pical twinoin will ",.;. ..... =Iing. ery.
thema, CMting, and pffiing of the Ikin. Skin irritation ran be II'Yl'Il' aM Will'
diKontinuation of therapy; aM' stll'nqth solution mi y bt Otrma-
tologic adYersr elle.:ull'solvt ooce dil(ootinue<i. D"ltooapy un
\kin olIIYenerifms.
VrfY high doll'! u n Il'SIlIt in adY!'M including OOIlt
p-ain, '""', headoKhe, yom iting, ra 5h, stomatitis, pruritu I'M ating, aM
orular disorders. The oral drug has black 00. warnings, inckJding the p0-
tential for rapid of k-ukorytosiland the polIsibility of reac-
tions in with promyelocytic leukemia.
Contraindicdions: Com"irKiutioos for tapinl iKUIe rmma,
elpolUll' 10 sunlight or IN raY', sunburn, hypmrn to the drug or vitam in
A preparation, and children !tss than 12 )'u rs of age. This drug is
duringlaaation or prt'9nancy. Oral minoin is cont"iMinied in p-atienB who
haYe hepatic disem, !tukoptnia or neutroptnia,or who to
the drug.
INTERACTIONS
Dru;rDrug: arnt rflOlCoo, bfnzO)"I pl'IOlide. and
sak)1ir iddl may incll'R inllammation and PfMng; lopnl tro1KB (OOtainiog
_OhOI or IIlfOthot 1M)' rauseSlillQinq.Addili"ll' phoIOIOIidty IiIII ouII"ifUMiooi1
II!I'd (OII(IJIflltlyWithotllfl pI\o!OImOc drugsSU!h ill tetrarydioH,

Ll bTl5ts:NOOftmwn
HI'IiIiI VFood: all"llUllB of vitamin A or Sl. John\ '/IOCIIM)' II'IUk in
pho\oII'nIiI:ivily.
Treatmf nt D-muse of the topical drug will lead to eJ(tlsiY!' sl::in
drying and Symptoms of oral all' oornptrifk and resol"l'!' with
symptomatic treatrroent
IItftrlOM)MmllrgmfrlfQNlmlnl} I'nxm foaTispKlklOrlrlsdrui}.
.. Flgure48.4 Rosacea
Source CourfqatDr. Jawn L Smlrh.
(Finacea). Benwyl peroxide maybe applied as needed.Alter-
native medications include topical clindamydn (Qeoon-T,
ClindaMax) and sulfacetamide. Tetracycline amibiotics are
of benefit to rosacea patients with multiple pustules or with
ocular involvement. Severe, resistant cases may respond to
isotretinoin (Accutane).
LibraryPirate
NURSING PROCESS FOCUS PATIENTS RECEIVING ANTIACNE MEDICATIONS
Assessment
Billtlilt .S5tIl IlUI prior 10 adminiltr.ion:
Undmtandtllt rmon IfIedrug IlisbmJ preuibed fOi
tl!trapeutk tfft<u of I(nt, ligns of of
cilnmtrutrnoent).
Olltil" iI (()mpie1t history induding
dilordM; plf9ll.il"lC)';or brull-fding.
Illt.l" iI drug including prtICIiption and OK dRllJ5>
htrb.I prtpal1tiolll, akollol UIf, ind wnoking. lit aitrt to poilible drug
intfl1CtioM.
EnUlte .pplOpliile Iaboriltory findings (t.g., (1IC,lipid PfOfiits, 01
function
Illtilin biitlinuiul signs.
AsstlS/Mftt thlllughout "'lIinistration:
As_ il, dtsirtd tfffCb (ltg.,stin is dtMing of atilt Itsions).
Cominuf Pfriod"l( profilt,gl!KOSf,.nd IIfpitk
funtion tem if on oral drug.

Monitortyt IINItb period"Killy wilt! tyt tnminalions Mry 6 mantlts whit
on oral drug tllmp-,.
As_ br adftnt t'ffecu: Iociliztd skit irril.ttioft, trytMmiI, pruritus, dry
01 lkin,ck)' mouth,tyft,OIIIOSf milY ouur. in mom.
tspKiil/ly or suicidil lhouid be It$IOIted immediately in
on oral
Potentl.1 Nursing 01'9nOstS
Disturbed Body Imilgt'
Sbllmfgril)' (rNM to sllin wndition ldvtlSf drug efffCbl
Defw:itn! (drug tlttrajly)
Rist for in;"" (rNitd to drug tfI"ts)
PI.nnlng: P.tlent Go.Is.nd Expectt'd Outcomes
Thf ponnt will:
Ihtrapturic ffffCb (e.g.. arnf Iniom wring. appt.lnao of WTin kIes 01 skin dal1\i9f is imprwing).

an lRim!ancliJg 01 the drug'1 !M,.dYme tffrts,lnd mjuirtd jRc.Jutiom.
proper IeIf-adminisuiltion 01 !Itt IIltdkiltion (t 4- dose. timing. whtn 10 notify pfOYidtr).
Implementation
Interventions and (Rationales)
E.I u ring I htr .pt\l1 ie tffe<t I:
p.tient li nd Fllmily Education
--+-
Monitor i1ppropNtf mtdication idminilmtion foropMium rrwIts. (Topiul
trUlmtllt iI_ shoold s'-signs of imp_ent widlin 2-(
trulmen! is lIIlIiIlIy IIJ((nlkJl within Ont toIInl .nd a Iond COlIIit IIIl1 be
dtJ.)ttd for _ill wteb 10 monit(on!inuing improwmtnt)
Minillwng Idwru tffts:
Monitor artil undt!- topic.Jl !rta!rntl't lor txttSSiwt dryntSsand m.tion.
(OvrHWMing of 1bt skin miIY make tfw, (ondition wolII'.1
ltac:h paOOJupproprialudminilmOOn ttdllliqurs Iflf-
Idminiltmion of drug thrrip(t.w in this tablt) .
ltac:h the paOOJt 10 9tfIIly dtilflSf tilt skin usirlg iI nonoily SOolp and
noidilllJ O(lJJ\ lilt I nonoily lotion
tUJUsof drynesl..
Monitor patienlSon isouninoin b """tion.1 hfakh 01 manges .. mood. Instruct tilt patient l.imii)", 01 wtgiYtr II) rtporI.ny ligns of
(Otjmsion,induding with wkidil ideation, llis bHft noted ill MI 16itnt mood,ilfffl:t dtpltSsion, 01 rxpItSsed suicidill thoughts 10 tfw,
tfff(l..) -, __ provicIK.
Monitor (Be, lipid Itvrh,and function Lib! ptriodiuli)"1or pi!itnu on Instruct tilt patient to IrtJm pm,dk.Jllyfor Lib !eh.
0Ia! mtdiciItion.{Lipid !Mil may incrt.1f in up to 7(19(, of Piltieflts on OIl! ltac:h patitflt to rtport Iny symptOms of ibdominill 01 right IJIlPfr<lfJldlitot
.(IIt Ibtrapy: Hepatotoxicity is In rfft of orill drugsJ !b:omfort or pain, of the stin OIldm, fatigue, arIOfniil,d.lrtened
mordil,-<oIortd stools immtdimlJ
Monitor lor ilion ch.ngtS.. (ComNI opac:i!ie Of (.talKtl I rt In .chme
tfft<! of al antiil(1It medi<ations.Oryntss of t)'H!bing tfUtmtot is
rommon. Night vision may be dim iniIhtd during IrtltmentJ
InstnKt the patienlto mainQin eums ilnd to I!pOII any daingrs
in l'isual leviI)', tspfciillywitlt night drmog.
Tth the pabtot !!wt artifiOlllNr lOIutiom may iII!&! in !Mring f'ft dQorss.
LibraryPirate
(lIoplOl41 Drug,ro<SklnDMrd ... , 759
NURSING PROCESS FOCUS PATIENTS RECEIVINGANTIACNE MEDICATIONS (Conllnuw)
Implementation
Interventi ons and (Rati onales)
Monitortllt !)oItiem's tlpOwrt to wn 100 UV light (Drying. ,kin
I!'nsitiYity,aOO pttling ,kin all' possibtt, adYmr for
on Ill'1iooin.Proledion from sun expilSUIl' is
Monitol(omplia with ' iPItdqt ' Il'qU ill'll1tnl! for !)oItienu on isotft'b noin.
(iPItdqt is Il'quill'd of all palilom. on isotrttinoin btfoft' I
pIl'!{ription or Il'filk of the drug. k requill'S tht patient to t murt that all
ll'qIIirtllll'flu 10 leratogenic tfffm 11m betn
Pati ent and Family Educati on
Tt-i{h tht- !)oItienl TO un sunl(ll'tlllofSPF 15 or higher and to
protl'ltiYfclothing TO avoid sun UPOSUft'!o art-a, under lIl'almtnl.
Tt-ach tht- patilonlillat UV light Iherapyfrom a health cart- prOYider is
monitoll'd and tanning btd, i ll' not i subslitutt- and ,hould lit aroided.
Inmuct patilom on isotft'uooin of tht of tht iPItdqt
IIIIIndalory progrlm 10 trlSUIl' ronbnlll'd pll'l(riptions induding:
FMlaie of thild-btiring aqt must UII' two melhodsof binh comrol
whitt, on tht drug.
ltin.Jie of child-btiring aqt must two pll'gnancy tests
Oil!' month brioIl',ckJring..aOO after drug thffilpy,condKted at certified
'''.
Patint understanding of drug thtrapJ:
Matt, patienll mustffnry that thty will UI!' a barrMor melhod of binh
comrol and 001 donate blood on lilt drug.
--+--
1M opplnunitilos ckJring administration of mtdic.ilion,aOO ckJring
all!'SlIIII'nll toalS{\/\! the rltionalt for drug therapy, dtsill'd tlltrapNIK
OI/Icomrs, most COll1 mon adYerSt tfffm, parameters for when to call lilt
hNlth call' prOYider,and anYII!'(t-.ury moniloring or pIl'taUtiolll.(lking
ulIII'during nursing call' help, to optimitt and Il'inforu' kl'yttaching

Patint selfadministrilt ion of drug therilPY:
Wlltn administtring tilt mic.ilion,in'lfIKt tht patilom,
in tllr prop'r .. If...vlmini,t rllinn Df dnH). P.g.. TOpiul dIU] i. lKf<I
iPItdqt program is folta-l.(Proprr administration will
in(rtast tilt ef!e<tiventSs of tilt drug.)
Ihr patitnt should bt able to ,latt tht INion for tht drug.appropriate
doI!'and Ilhtduling.ind what adYl'lIl' tffl'ltS to obSl'l'YI' for 0100 wlltn TO
Il'portthem.
Tta{h tht patienl TO takt- tilt drug following appropriatt- guidelint-S:
Gtmly lilt affted Ikin twicedaii-; with ooooily soap, IvoidinQ
flmsive or vigorous I(rubbing.
Apply a thin Iayerohopiul drug altmlmsing skin. Allow 10 dry and
al'Oid contact with oothing.loWl'ls,or bedding to avoid staining or
blu{hiog.
For oral medications, lakl' in tilt morning and if twice-a-day dosing is
ortle Il'd, takl' tilt second dosr i pproximaltly 8 hour; after tilt first.
Evaluation of Outcome Criteria
E'f<Iluatt tht of drug thtrapy by mnfinning that patiem goalsand aptCled oukomrs haYe betn met
COMPLEMENTARY AND ALTERNATIVE THERAPIES
Aloe Vera
Alor mol is deriYl'<i from the gel inside tilt- of tile alor plim, which is a
mrmbtrof tilt lily I'ffiI romains
ing amioo iKids, vitamins, and enzymrs. wbsialKrs aft'
dilimed to kill a 'f<IrMol)' ofmicroorglnisrm.de{ft'i\!' Il'duc:t- localized
inflammi tion.Alorvm 011,0 has yallll' for ill moisturizing il nd woond IItlling
proprrtits.1t has used for lhousanm of yrm. Tlltft' art nu-
merous alor prodJru in{kiding ind sun-
bIoc:ks. Theil' brrn few standardill'd dinicllll'lI'aKh studies rumining
thr rfftaiYenm of ilor vera gel.
DERMATITIS
Dermatitis is genernl term that refers to superficial inflamma -
tory disorders of the skin. General symptoms include local
redness, pain, and pnuitus. Intense scrntching may lead to
no:oriat ion, scratches that break the skin surface and fill with
blood or serous fluid to form crusty scales.
48.6 Pharmacotherapy of Dermatitis
A large number of factors can ClUSt' dermatitis, and symp-
toms may differ dependin8 on the cau.alive a8"nt. The thr"e
most common types that respond to topical pharmacother-
apy are atopic, contact, and seborrheic.
Atopic dermatitis, or rrnoma, is a chronic, inflammatory
skin disorder with a genetic predisposition. Patients present-
ing with eczema often have a family history of asthma and
hay fever as well as allergies to a variety of irritants such as
cosmetics,lotions,soaps, pollens, food, pet dander,and dust.
About 75% of patients with atopic dermatitis have had an
initial onset before I year of age. In those babies predisposed
to eczenm, breast -feeding seems to offer protection, as it is
care for a breast -fed child to develop eczema before the intro-
duction of other foods. In infants and small children, lesions
LibraryPirate
760 UnII' The IntegumeomySY'tem ar.d EyI>" Em
usually begin on the face and scalp, and then progress to
other parts of the body.A frequent and prominent symptom
in infants is the appearance of red cheeks.
Contact dennatitis can be caused by a hypersensitivity re-
sponse, resulting from exposure to specific natural or syn-
thetic allergens such as plants, chemicals, latex, drugs, metals,
or foreign proteins. Accompanying the allergic reaction may
be various degrees of cracking, bleeding, or small blisters.
Seborrheic dermatitis is a form of eczema that can affect
patients at any 3ge. The exact cause of seborrheic dermatitis
is WIknown, but homlOne levels, coexisting fungal infec-
tions, nutritional deficiencies, and immunodeficiency states
are associated with the disease. Seborrheic dermatitis pre-
sents as greasy, not dry, scales that affect the scalp, central
face, and anterior chest, often presenting as scalp scaling, or
dandruff. Other symptoJru may indude redness of the
nasolabial fold. particularly during times of stress, blephar-
itis, otitis externa, and acne vulgaris.
Pharmacotherapy of dennatitis is symptomatic and in-
volves lotions and ointments to control itching and skin
flaking. Antihistamines may be used to control inflamma-
tion and reduce itching, and analgesics or topical anesthet-
ic); m:l}' he for relief. Ato]'>k Cln
be controlled, but not cured, by medications. Part of the
management plan must include the identification and elim-
ination of allergic triggers that cause flare-ups.
Topical corticosteroids are the most effective treatment
for oontrolling the inflammation and itching of dermatitis.
CreaJru, lotions, solutions, gels, and pads oontaining these
drugs are specially formulated to penetrate deep into the
skin layers. Topical corticosteroids are classified by potency,
as listed in Table 48.3. The high-potency agents are used to
treat acute flare-ups and are limited to 2 to 3 weeks of ther-
apy. The moderate-potency formulations are for more pro-
longed therapy of chronic dermatitis. The low-potency
glucooorticoids are prescribed for children.
Long-term corticosteroid use may cause irritation, red-
ness, hypopigmentation, and thinning of the skin. High-
potency formulations are not advised for the head or neck
regions because of potential adverse effects. If absorption
occurs, topical corticosteroids may produce Wldesirable
systemic effects including adrenal insufficiency, mood
changes, serum imbalances, and loss of bone mass, as dis-
cussed in chapter 4300. To avoid serious adverse effects,
c.<ITeflll mllst he given to the of glllCOCOT_
ticoid applied, the frequency of application, and how long it
has been used.
Several alternatives to corticosteroids are available. Pa-
tients with persistent atopic dermatitis not responsive to
corticosteroids may benefit from oral immunosuppressive
agents, such as cyclosporine. This drug is generally used for
the short-term treatment of severe disease. The topical cal -
cineurin inhibitors pimecrolimus 1% (Elidel) and
tacrolimus 0.03%,0.1 % ( Proto pic) are available for patients
older than 2 years of age. These medications may be used
over all skin surfaces (including face and neck) because they
have fewer adverse effects than the topical corticosteroids.
Adverse effects include burning and stinging on broken skin.
TABLE 48.3 Topical Corticosteroids
Generic Name
VERY HIGH POTENCY
auglllffill' d, uum
dOOelald

HIGH POTENCY
amdoonidlo

haldnoriill'
MEDIUM POTENCY
bctamcthasone
bctamcthaOlll'
doconolone

ftuodnolOlll'
fturandl!llOiill',aNm
ftutiu lOlH'
ItydllXorti!Olll'


LOWEST LEVEL OF POTENCY

.... "
PSORIASIS
TracK> Nam1'5


""""
Topilon
S)"nalal
Cordlan
U/lMlt

",,00

Ado'o',le
DtsooaIl',DeIOwm,
.....
... -
H":OII
Psoriasis is a chronic, noninfectious, inflammatory skin disor-
der that affects 1% to 2% of the population and appears
with greater frequency in people of European ancestry. The
onset of psoriasis is generaUy established by 20 years of age,
although it may occur throughout the life span.
48.7 Pharmacotherapy of Psoriasis
Psoriasis is characterized by red, raised patches of skin cov-
ered with flaky, thick, silver scales calledplaqlles, as shown in
Figure 48.5. These plaques shed the scales, which are some-
times grayish. The reason forthe appearance of plaques is an
extremely fast skin turnover rate, with skin cells reaching the
surface in 4 to 7 days instead of the usual 14 days. Pl aquesare
ultimately shed from the surface, while the underlying skin
becomes inflamed and irritated. Lesion size varies, and the
shape tends to be round. Lesions are usually discovered on
the scalp, elbows, knees, and extensor surfaces of the arms
and legs,sacrum,and occasionallyarolUld the nails. Thevar"
iow; forms of psoriasis are described in Table 48.4.
LibraryPirate
Flgure48.5 P'sorlu's
Source: CooneI)' afar. Ja!Of"l L Smirh
Although the etiology of psoriasis is incompletely under-
stood, it appears to have both genetic and autoimmune
components. About 50% of the cases have a genetic basis,
with a close family member also having the disorder. One
theory of causation i.; that psoriasis is an autoimmune con-
dition, because overactive immune cells release cytokines
that increase the production of skin cells. There is also a
strong environmt'ntll component to the disease: factors
such as stress, smoking, alcohol, climate changes, and infec-
tions can trigger flare-ups. In addition, certain drugs act as
triggers, including allgiotensin-=nverting (ACE)
inhibitors, beta-adrenergic blockers, tetracyclines, and non-
steroidal anti-inflammatory drugs ( NSAIOs).
The goal of psoriasis pharmaootherapy is to reduce skin
reddening, plaques, and s.:ales to improve the cosmetic ap-
pearance of the patient, leading to more normal lifestyle activ-
ities. This is accompfuhed by reducing epidermal cell turnover
and promoting healing ofthe psoriaticle:sions. Choice of ther-
apy depends on the type and extent of the disease, and the his-
tory of response to previous psoriasis treatmE"l1t.A nwnberof
TABLE 48 4 Typesof Psoriasis
(1101'1 .. 41 Drug. fo< Skin O""rd ... , 761
pres<ription and OTC drugs areavailable forthe treatment of
psoriasis and are listed in Table 48.5. Therapy is often con-
ducted in a stepwise manner. Psoriasis is lifelong, and there is
no phamlacologic cure.
TOPICAL THERAPIES
Topical corticosteroids are the primary, initial treatment for
psoriasis. These drugs are effective, inexpensive, and rela-
tivelr safe. Examples include betamethasone (Diprosone)
oi ntment, lotion, or cream and hydrocortisone acetate
(Cortaid, Calderort, others) cream or ointment. Topical
corticosteroids reduce the infiammationassociated with fast
skin turnover. Initial therapy may begin with a high potency
agent for 2 to 3 weeks, to obtain rapid clearing of lesions or
to treat acute flare-ups. The high potency formulations are
best lpplied to areas thickest with plaque, such as hands or
feet, and should not used on the face and genital arrus. For
chronic, maintenance therapy, the patiE"l1t is switdJed to
modernte- and low-potency corticosteroids became they
have a lower potential for adverse effects.
Topical immunomodulators (TIMS) are another class of
agents that suppress the immune system. One example is the
calcineurin inhibitor tacrolimus (Protopic) ointment.
Other agents applied topically are retinoid-like compounds
such as calcipotriene (Dovonex), a synthetic vitamin D
ointment, cream, or scalp solution; and tazarotene (Taw-
rnc},a vitamin A derivative gel or cream. These drugs pro-
vide the same benefits as topical corticosteroids but exhibit
a lu,,t:r uf auvt:r"t: ""Y pro-
duct' hypt'rcalcemia if applied over large areas of the body or
used in higher doses than recommended. This drug is usu-
ally not nsed on an extended basis.
Other skin therapy techniques may be used with or with-
out additional psoriasis medications. These include r.lrious
fonns of tar treatment (coal tar) and anthralin, which are
applied to the skin's surface. Tar and anthralin inhibit DNA
synthesis and arrest abnormal cell growth. These are ronsid-
ered seoond-line therapies.
Form of Psoriasis OescrlpUon MOSI Common Location of lesions Comments
(dropliu) or IrionSlnlilitr thin lhost of psoriilsis UpptrU\JnkatM! utremitie MOIl' (OfIlmon in ps3fUsis;
psori.tsis vul9aris
can ippur ,nd resoM !pOIItlfP.(llJs/y
, few Wffks following i strepto:ox<al
inftctioo
Psoriasis v!Jgaris Irionsare papule lhilr form inro So. salp,tlbow5,and MOIl (OfIlmon form; Iotg.
ftYiIH'marou, pIique' with llid, Ioi 'lff, possibllo inywhm on lhtbody ltrlll
<II g"'Y pioqll!'< rhor lit....:! whM
retr"lllftd;plique in
ildivilWl, oftffi oppeir purpIt
Psoriaric iUlvitis Rermble rlraullitoid Fingtl'! indtotl it riml inttrphalill9t'l About 10% of patients with psoiasis
joinll:L1Il iflKlSm loci nails ,Iso
Psorialic or Gmrrlliloo All body Suriiffi lNII oommon form
ufoliiltil'l'rlffinalitis
"'"
Pustuir psoriasis Eruption of pustule; of ft'In- TDllkand ippur on kln-'ge 'ge of 0IlItI is 50
,nd nail bed,


,


"
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762 UnII' 1h<!lnlt<}'JlTllary SY'I"m ar.d Eyo!"Em
TABLE 48.S I Selected Drugs for Psoriasis and Related Disorders
Drug Route and Adult DoSl! wiler. Indk:ated) EffI'CIS
TOPICAL MEDICATIONS
Iopic.1I:AwtI thin one 10 two tlmtSldlY 8UnVlg,stlfI9IfI9, fo//kiJ6ti1 irflli"19
HI!
(Ojltir othm) lopital:AwtllOi ffffird qid irlirorioo,
!:!r!
NMJOgmI,OIhm) lopic.1l:AppIy lOilftrd IIUS tid-qiclln (OIKtrltr"iom ranging skin
from2-10%

UliKlit'1H' (Tazorac) w: Apply Ihil fikn 10 d'y !blly ProriM, oomi"4- stirlt}irlg, sU! irlilarioo,
PlaqUl' psoriasis:Applylhin film !blly Intlle Mring
ofpsqjjs
tie &i2VSMfottnrrffrQ!
SYSTEMIC MEDICATIONS
acitrtlil (SoriaUnt) PO; 25-50 mg/!bywith ihI' main mHI I>ry mourII, I1Ioptdo, rty
_lIII'm/lrQlIt$
h'Kill ltd rrigMnjdn and d'!QIffitr91
!I!1!llu1!!r!!siY Rm!!!!I.
Pil:Ildnlumgr ,rrtbri dmrmjoo donN!
Ijye! hmajnn I'll< tmtggerjrjry
IHumlra) SulxUUIH'OIIS; 40-&:1 mg f'/ffY OIhtr wm Upptr rrspifllfllfY 6Jjt<rion silt
IfIXri()/)lllNdQdtt fDih
Il:IiII!D
altfactpl (Arnt'iM) 1M; 15 mg for 12 wffiH P/gyngili G31Jt}h, IlQUW. Prurifli1
(N11 irriotI silt rtoonr
il:Iill!D ilItI:!iPDl
bW!O\9Xkttv Iympboptnia
qdolpCllilH' (SindimmulH', Nrorall (w PO; 1.25 mglkg bid 11IIiI:. mglkglday) Hirwliilll, IrtffiOl: hNdodtt IWriM,
pag!' m for Ille Protorypt DruIJ boxOO)
_, Imliting. diorr118
Hypt'lm#oo II!' onP9!gri,jIy
il:YRI:i:UlUDii gi!l\linl mluV:tIDmi

(&lbrrI) SuixutalH'Olls; 25 mg lWicf/Wk or 0.08 mgfl:g or 50 mg 1IIa'lwk (poin,
I(IIIIjrifl9,
......
par",IOD<:lii
ilfliJirnab (Rmlicadt) IV; 5 mgfl:g wilhadditional dostI hnd 6 wkafttf lhf I/aJh,mioor nfriam
ilfUlilll,thtn e'lery 8wk IhtrUfttf
BUI!m1; gg 11lIf:ai2l!r
maigna!ld!:s. WSIlng 0/ heart falhrrt
hepjUolfl1!irtty
metholrm!f (Rhtumaun, Trrxall) PO; 1.5- 5 mg bid for thfM dolI'S mhwm: (mu:15- 30 mg!wkJ llfadtxht, gifl9lrilh
pag!' m for I(w, DruIJ boxOO) IM/IV; 10- 25 mg/wk
-

,plank .oroja bMI
!!!ddffi llh D11lmonary
fibrosi!
umkinumab (Slmra) SulxutalH'Olls;45--90 mg and 4 Wffb latfl; fdlowfd by lItMp/I<ryngili 1!Jpptf rtspifll/"Y /rOO"
45- 90 mg f'If!Y llWfl'b infKtiOl1, 1wdIxhf, foligut
ilkllillDlllliltiglliDdti
la .. 48.1 for lopical (ortkosteroid! forplOlialis.
Irk OOIIImon arIw5f effects; !lldcr!inioo indicilts !I'rious idm!l' efil'ds.
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SYSTEMICTHERAPIE"S ___ _
5011ll,' patients have severe is rd istlntto lopi-
cal therapy. BKau.se the5e drugs have the cause
more serious advSe dfecu, they are generally only U5td
when topical drugs and pholotherapy (ail 10 produce an ad-
equate rdponse. ln $Orne cases, systemic drugs may be used
for a few weeks 10 produce a rapid improvement in symp-
toms before beginning topicalthl-rapy.
The most often prescribed systemic drug for severe psori-
asis is methotrexate. Methotrexate (Rheumatrex. TrelGlll ) is
used for a variety of disorders, including camr)()lnas and
rheumatoid arthritis. inaddition to bei ng used for the treat-
ment of psoriasis. Methotrexate is presented as a
drug in chapter J700.
Other systemic drugs for psoriasis include acitretin (5ori-
atallt), which is taken orally 10 inhibi t excessive skin ceO
growth. Cydosporine (Sandimmune. NeoraJ). an immuno-
suppressi\'l! agent. may be used for severe condi ti ons. The
newest psoriasis therapies include biologic agenlJ such as
a1efacept (Amevive). adalimumab (Hllmira). usttkinumab
(Stelara). etanmept (Enbrel), and inflillimab (Remicade).
These drugs :act by suppressing specific aspects of the in-
Dammatoryand immune responr.e:s.Several of these arealso
used to rheumatoid arthritis (chapter 4700). A major
disadvantage of these biologic drugs is that theyare very ex-
pensive and not available in oral formulations.
NONPHARMACOlOGICTHERAPIES
Phototherapy with u.ltrrnolet-A (UVA) and u.lturiolet-B
(WB) light is used in cases of seven" debilitating psoriasis.
Phototherapy wi th UVA is combined with a
drug from a chemical family known as the psor.Jem. The con-
current use of UVA and the drug is called PUVA therapy.
Psoralensareoul or topical agents that produce a photosen-
sit ive reaction when exposed 10 UV light . This reaction re-
duces the number of lesions, but unpleasant side effocts
such as headame, nJusea, and skin sensi tivity still occur,
limiting the effectiveness of this therapy.
UVB therapy is 1es5 hazardollS than UVA therapy. The
of UVB usimilar 10 sunlight. and it reduces le-
5ions covering a laflll' area of body that normally resist top-
ical With dose this type of
phototherapy can be administered at home. Keratolytic
pastes art often applied betwetn treaunenlS.
SUNBURN AND MINOR BURNS
Burnsare a uniqUt t)'pto! stress that may affect
the skin. Minor, first-degrff burns affect only the outer lay-
ers of the tpidermis. are by redness, and are
analogous to sunburn. Sunburn results from overexposure
of the skin to UV light, and is associated with light skin
complexions, prolonged exposure to the sun during the
more hazardous hours of the <lay ( 10 a.m. until J p. m.), and
lack of protective clothing when outdoors. Chronic sun ex-
posure can result in serious conditions, including eye injury,
cataracts. and $kin cancer.
48.8 Pharmacotherapy of Sunburn
and Minor Skin Irritation
In addition to producing local skin sun overexpo-
sure releases toxins may produce effects. The
signs and symplonu of sunburn indude erythema, intense
pain, nauSoea, vomiting. chills. edema, and head3che. These
symptoms usually resolve within a matter of hours or days.
dependi ng on the severity of the exposure. Once sunbum
has O(:wrred, medications can only alleviate the symptoms;
they do not speed recovery time.
The best treatment for sunburn is prevcltWn. Sunscreens
are liquids or lot ions applied for dtemical or physical pro-
tection. Che",iaU IUNCIftOS absorb the spectr um of UV
light that is respomible for mOlt sunburns. Chemical sun-
screens incl ude those that contain benzophenone for pro-
tection against UVA rays; th05e that work against UVB rays
indude cinnamates, p-aminobenzoic acid (PABA). and saI-
icylates. Physical SUnKTns ,uch as zinc oxide. talc, and ti-
t:anium dioxide reflect or 1Cll1ler light to prevent the
penetration of both UVA and UVB rays. !'alSOl is another
sunscreen product that is being used more frequently as a
key ingredient in lip balm.
Treatment for sunburn consists of addressing symptoms
wi th soothing lotions. rest. prevention of deh)'dration, and
topical anesthetic agents, if lleC'ded. Treatment is llSually
done on an outpatient buis. Topical anesthetics for minor
bums include bmlexaine (5olarcaine), dibucaine (Nuper-
cainal). lidocaine (Xylocai ne). and tetracaine Hel (Ponto-
caine). Aloe vera is a popular natural therapy for minor skin
irritations and burns. These same agmts may also provide
relief from minor pain due to insect bites and prurit us. In
mOrl.' Sl'\-ere cases. oral analgesics such as aspirin or ibupro-
fen may be indicated.
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Chapter REVI EW
KEY CONCEPTS
The numbered key concepts provide 3 succinct summary of the important points from the corresponding numbered $!"Clion
within the chapter. If any of these points are no! clear, refer 10 the numbered section within t he chapler for review.
48.1 Three layers of skin, epidermis, dermis, and 5utxutaneous
layer, provide effective barrier defenses for the body.
48.2 Skin disorders that may benefit from pharmacotherapy
are acne. sunburns, Infections.dermatitls. and psoriasis.
48.3 When theskin inlegrityiscompromised,n;.cteria, virU5eS.
and fungi can gain entrance and callS<' infections. Anli
therapy may be Indicated.
48.4 5cabiddes and pediculicides are used to Ireal parasitic
mite and lice infestalions, rtSpf'Cllvely. Pmnethrin Is an
Igent of choice for these infections.
NCLEX-RNe REVIEW QUESTIONS
o The patient is treated for head tire with permethrin (Ae-
tleln, Ellmite, Nix). following treatment. the nurse rei n-
folU'S instmclions to:
I . remain isolated for48 hours.
2. lnspea the h:tir shaft, checking for nltsdaUy for 1 ",10:
following treatment.
J. shampoo with permethrin three times perday.
4. w.Jsh linens with cold and bleach.
o Careful attention to directions for application of perme-
thrine (ActJdn, lImite, Nix) Is emphasized by the nurse.
Signs of inapproprhte include; (Select
aU that apply.)
\. nausea and vomiting.
2. headache.
J. irritation.
4. diaphoresis.
5. resde:ssness.
o The nurse evaluates the patient's understanding of the
procedure for application of triamcinolone (Kena\og,
Aristocort ) cream for acute contact dermatitis of the
neck, sewndary to a reaction to perfume. The patient a5ks
why she jus! use up some f1uocinonide ( Udex)
cream she has left owr from a poison ivy dermatitis last
month.nlbe nurse's response will be based on the knowl -
edge that:
4lLS The phamlacotherapy of acne includes treatml'lll with
benzoyl peroxIde, retinoid$, and antibiotics. Therapies for
rosacea include rctinoids and metronidazole.
4&., The most effective treatment fordermatltis Is topia] gJu-
cocortiooids, which are claSSified by their potency.
4&.1 Both IOpical and drugs, including cortico_
steroids, immunomodui.acors,and methotreJUlte, are used
to !rut psoriasis.
4&.1 The pharmacotber.lpy of sunburn Includes the sympto-
matic relief of usIng soothing lotions. topIcal anes-
thetics, and analgesics.
] . hlgh-potencywrticosteroid creanlSshouid be amided
In the neck or bee beClIuseofthe J106SIbiUtyof
additional effects.
2. an CJl'llIl1$ sl\Quld be discafded after the initial oondilion
has resolved.
J. fluoctnonidecream is too low-potency to use for
oontact dermatiti$.
4. oontaCl deTrll<ltitls from perfume Is harder to treat than
poison ivy denruitilis.
U The teaching plan for a 24-year-old female receivtng
tretinoin (Avita, Retin-A, Trentin-X) ror treatment of
acne should indudeinstructions to: (Select aU that apply.)
I . obIain 20 to JO mlnutcs of sun exposure pel" d.1)' tohelp
dry the skin and prevent breakouts.
2. wa!J:J face with a mild soap. 3\o"Oiding 5crUbbing. twice a
<by.
3. use oil-free SUJlS(:reE'DS, sun hats, and protective clothing
to avoid sun exposure.
4. expect some dryness, redness, and periing while on the
drug but R'port st'\'ere skin irritation.
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II A lS. year-old patient started using topical benzoyl perox
ide (Benzalin, Fostex) 1 week ago for treatment of acne
and is discouraged that her acne is still visible. The nurse's
best response will be:
1. "The cream should've started working by mw. Oteck
with your provider about switching to a different type."
2. "Some improvement will be noticed quickly but full
effects may take several weeks to a month or
3. "Acne is very difficult to treat It may be several months
before you notice any effects."
4. "If your acne is /lOt gone by now, you may need an
antibiotic too. Ask your provider."
CRITICAL THINKING QUESTIONS
1. A senior nursing student is partidpating in well-baby
s.:reenings at a public health clinic. While examining a 4-
month-old infant, the student notes an extensive, conflu-
ent diaper rash. The baby's mother is upset and asks the
student nurse about the use of OTC corticosteroid oint-
ment and wonders how she should a pply the creanl. How
should the student nurse respond!
2. A 14-year-old girl has been placed on oral doxycycline
{Doxy-Caps} fo r acne vulgaris because she has not re-
sponded to topical antibiotic therapy. After 3 weeks of
therapy, the patient returns to the dermatologist's office
complaining about episodes of nausea and epigastric pain.
The nurse learns Ihal the patient is busy with school
activities" that she often forgets a morning dose and "dou-
bles up" on the drug before bedtime. Devise a teaching
pbn rel""",nt to drug takes into eonsider:ltion
the major side effects of this drug and the cognitive abili-
ties of this patient.
ClIopl .. 4I Drug. fOf Skln Olsord .. " 765
o After trying many other treatments, a 28-year-old female
is started on isotretinoin (Accutane) for treatment of se-
vere acne. While she is on this medication, she mll'lt fol -
low explicit instructions to: (Select aU that apply. )
1. use two forms of birth control and have pregnancy tests
before beginning, during, and after she ison the therapy.
2. have vision checks perfomled every 6 months.
3. increase intake of vitamin A- rich foods.
4. return every 2 to 3 months for lab tests..
J. A 37-year-old woman is referred to a dermatologist for in-
creasing redness and painful lesions. The patient is
frll'ltrated with her attempts to camouflage her "teenage
face" with makeup. She relates to the nurse that she had
aeneas a teen but had no further problem until the last II
months. After consultation, the dermatologist suggests a
3-month trial of isotretinoin (Accutane). What are the
specific repr<XIuctive considerations for this patient! What
information should this patient be provided in relation to
reproductive concerns?
Su Appendix D for answers and rationalel for all activitiel.

EXPLORE
II )'0<1' "". <fOp lor onti .... erlal>\Of .. "' .... ",. lor1. lS.rIC!
resources. Pnpale tor with addibonai 11ClEX""'1lie practice
QUeSIiOr13. Imeracr:m a'lSIQIlIllert13 ood actl'lltles. well lirils. antma00n5
and videQ$. and lI\\lI"el
P!egisler )'OUIIICceSS code Irom the fi ont cI yoor book at
_.myntlilflgkllCOI'II .
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DRUGS AT A GLANCE
DRUGS FOR GLAUCOMA {l'J9t169
Prostaglandins )ll9t169
Q knaooprost (Xa/aran) {IJ9t m
AutonomicDrugs /it169
Q IImOlo1 (BetlmOl, IStalot T1moprJc)
""m
CarbonicAnhydrasf Inhibitors (XIItllJ
OsmoticDiurfliG ,.71J
DRUGS FOR EYE EXAMINATIONS AND MINOR EYE
CONDITIONS r1fJ74
Sympathomirnetio ptJIJtlJ4
Antkholinergia plIgtlJ4
lubrkantund Vaso<onstrktors (XIIt lU
DRUGS FOR EAR CONDITIONS (XIItll5
Antibiotio p!I9t 116
CerumenSoftenen pogtl16
KEY TERMS
Iqueoushumor p<1Jt761
doSfd.angle glalKOITIII fJ09f loa
cydoplegkdrug1 pqjtJ74
melTWlotiris I#ItllS
Drugs for Eye
and Ear Disorders
LEARNING OUTCOMES
After this the student should be ablt to:
1. Identify the basic anatomic structures of the eye.
2. Describe the major risk factors aSSOCiated with 9'111,1(00'1,01.
3 . CUIllp"'" .mY up""""yl,, driU du.o:d' dnyh.' yl"",<..",,,, .. ,
4 . Explain the two primary mechanisms by which drugs reduce Intraocular
pressure.
S. Describe the nurse's role In the pharmacologk management of eye and
ear disorders.
6. Identify drugs for treating glaucoma and explain their basic actions and
adverse effects.
7. Identify drugs that dbte or constrict pupils, rela. ciliary muscles,
constnet ocular blood moisten eye
8. Identify drugs for treating ear conditions.
9. Use the ...... sing process to Gart for patients vdlo are receiving drug
therapy for eye and ear disorders.
gluromil pai/tl6iJ
pu;t176
ptl/fll'J
pu;t ll'J
mydriaticdrugs fJI1Jfll4
optn-anglt glatKoma
media (#It l7S
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T
he senses of vision and hearing provide the primary
means for us to communicate with the world around us.
Disorders affecting the eye and ear can result in problems
with self-care, mobility, safety,and communication. The eye is
vulnerable to II variety of conditions, many of which can be
prevented, controlled, or reversed with proper pharma-
cotherapy.The first part of this chapter cover.; drugs used for
the treatment of glaucoma and those used routinely by oph
thalmic health care providers. The remaining part of the
chapter presents drugs used for treatment of common ear
disorders, induding infections, inflammation, and the
buildup of ear wax.
49. 1 Anatomy of the Eye
A firm knowledge of basic ocular anatomy is required to
understand eye disorders and their pharmacotherapy. Im-
portant structures of the eye are shown in Figures 49.1
and 49.2.
Ante,io,
dlambe,
Co,nea

pUp'1
Visual


I,;,
Conjunctiva
Flgure49.1 Internal structures of the eye
5v.Jfce: PeaSOfl EducarkxlJPHCoIlegI!.
,

A fluid called aqueous humor is found in the anterior cavity
of which has two divisioll'i. The anterior chamber
extends from the cornea to the anterior iris; the posterior
chamber lies between the posterior iris and the lens. The
aqueous humor is formed by the ciliary body, a muscular
structure in the posterior chamber.
Aqueous humor helps retain the shape of the eye and cir-
culates to bring nutrients to the area and remove wastes.
From its origin in the ciliary body, aqueous humor flows
from the posterior chamber through the pupil and into the
anterior chamber. Within the anterior chamber and around
the periphery is a network of spongy cotulective tissue, or
trabecular meshwork, that contains an opening caUed the
canal ofSchJemm. The aqueous humor drains into the canal
of SchJemm and out of the anterior chamber into the ve-
nous system, thus completing its circulation. Under normal
circumstances, the rate of aqueous hwnor production (in-
flow) is equal to its outflow, which helps to maintain in-
tI"3ocular pressure (lOP) within a normal range.
Interference with either the inflow or outflow of aqueous
humor, however, can lead to an increase in lOP.
and .... in

'"
Post..,;."
.. .... ,
&m_
,-
Bony orbit
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"


t

768 UnII' The ar.d EY""Em


Anterior
,.j
Canal 01

Trabecular
meshwork and canal

(b) "
Slowly Ming
intraocular
pressure
Flow 01 aq"'"ous
,-
Notmll a/\Iorior
ct.amber angle
Posterior
chan-ber
Rapidly rieing
intraocular
preseure
ClD&8d anterior
mmmb", anglo
Flgure4g.2 Forms of primary adultglaucoma:(a) In chronic
open..angle glaucoma, the anterior chamber angle remains
open, but drainage of aqueous humor through the canal of
Schlemm Is Impalred;(b) In acute closed-angle glaucoma, the
angle of the Iris and anterior chamber narrows,obstructlng the
outflow of aqueous humor
GLAUCOMA
Glauroma is an eye disease caused by damage to the optic
nerve that results in a gradual loss of vision, possibly ad-
vancing to blindness. This disorder is usually accompanied
by increased intraocular pressure (lOP). Glaucoma mayoc-
cur so gradually that patients do not seek medical interven-
tion Wltil late in the disease process.
49.2 Types of Glaucoma
Glaucoma occurs when the lOP becomes so high that it
causes damage to the optic nerve. Although the median lOP
in tho:> population is IS to 16 mmHg, nOmlal pressure varies
greatly with age, daily activities, and even time of day. As a
rule, lOPs cOfl'iistently above 21 mmHg are considered ab-
normal and at risk for glaucoma. Many patients, however,
tolerate lOPs in the mid to high 20s without damage to the
optic nerve. lOPs above 30 mmHg require treatment be-
cause they are associated with permanent vision manRes.
Some patients of Asian descent may experience glaucoma at
lOP values, below 21 mmHg.ln addition, patients
who have had Lasik surgery, which removes corneal tissue to
correct myopia, may appear to have normal lOPs yet have
glaucoma.
Glaucoma usually occurs as a primary condition without
an identifiable cause and is most frequently found in per-
sons older than 60 years. In some cases, glaucoma is associ -
ated with genetic factors; it can be congenital and occur in
YOWlg children. Glaucoma can also be secondllry to eye
trauma, infection, diabetes, inflammation, hemorrhage, tu-
mor, or cataracts. Some medications may contribute to the
development or progression of glaucoma, including the
long-term use of topi cal corticosteroids, some antihyper-
tensives, antihistamines, and antidepressants. Other major
risk factors associated with glaucoma include high blood
pressure, migraine headaches, high degrees of nearsighted-
ness or farsightedness, and normal aging. Glaucoma is the
leading cause of preventable blindness.
The two principal types of primary glaucoma are closed-
angle gbucoma and open-angle g!.1ucoma, as illustrated in
Figure 49.2. Both disorders result from the same problem: a
buildup of aqueous humor in the anterior cavity. 1bis
buildup is caused either by excessive production of aqueous
hlUllor or by a blockage of its outflow. In either case, lOP in-
creases, leading to progressive damage to the optic nerve. As
degeneration of the optic nerve occurs, the p.1tient will first
notice a ioss of visuai fieid, ihen a ioss of centrai visuai acuity,
and tlnallytotai blindness. Majordifferences between dosed-
angle glaucoma and open-angle glaucotrul include how
quickly the lOP develops and whether there is narrowing of
the anterior chamber angle between the iris and cornea.
Closrdangle glaucoma, also called narrow-angle glaucoma ac-
counts for only 5% of all primary glaucoma. The incidence
is higher in older adults and in persons of Asian descent.
This type of glaucoma is usually unilateral and may be
caused by stress, impact injury, or medications. It is typically
caused by the normal thickening of the lens and may develop
progressively over several years. Pressure inside the anterior
chamber increases suddenly because the iris is being pushed
over the area where the aqueous humor normally drains.
The displacement of the iris is due in part to the dilation of
the pupil or acconunodation of the lens, causing the angle
between the posterior cornea and the anterior iris to narrow
or dose. Signs and symptoms, caused by acute obstruction
of the outflow of humor from the eye, include dull
to severe eye pain, headaches, bloodshot eyes, foggy vision
with halos around bright lights, and a bulging iris. Ocular
pain may be so severe that it causes vomiting. Once the out-
flow is totally closed, dosed-angle glaucoma constitutes an
emergency. Laser or conventional surgery is indicated for
this condition. Options include iridectomy, laser trabeculo-
pLasty, trabeculectomy, and drainage implants.
Oprnanglr glau(oma is the most common type,accoWlting for
more than 90% of the cases. Its cause is not known and many
patients are asymptomatic. It is usually bilateral, with in-
traocular pressure developing over years. It is called "open an-
Rle"because the iris does not cover the trabecular meshwork;
LibraryPirate
PHARMFACTS
Glaucoma
WOrlclwi.lIlCe lII'n 5 mi50n ptopIt IIiIII! lost lhervision"" ID
tNn 50,000 oftlltse people Ut in Iht Uniled StiffS.
0"" SO'Kof the peofIle withgIMO!I\i m tlut they "'W thr
.....
Thf irKidHKr of glMlHN in people of ID fiw
timts higbrrtlwn in ,,,,otlltl" ttbnic 910'"
GIiulIHN is most 0Hnm0n in JNtienboldertil160yuli..
.o\nnglauronw isollrnUlMd byhNd
"""'-
Chronic simple gIIuu!nw 1or9O'ilo of gl.il.l((llll,l gosH.
it remairuopen.lf discovered early, most patients wi th open-
angle glaucoma can be succtsSfuUytreated with medications.
49.3 General Principles of Glaucoma
Pharmacotherapy
Some health care providers initiate glaucoma pharmacother-
apy in aU patients with an 10)"1 greatcr than 21 mmHg. Because
of the expense of pharmacothero py nnd the potential for ad-
verse drug effects, other health ClIre providers will instead care-
fully monitor the patient through regubr foll ow- up e.'UlI11S
and wait until the lOP rises to 28 to 30 mmHg before initiat-
ingdrug therapy. [f signs of optic nerve damage or visual field
changes are evident, the patient is t reated regardless of the TOP.
When beginning glaucoma pharmacotherapy, a target
TOP is established. During therapy, revaluation of the TOP
and the extent of visual fi eld changes is performed after 2 to
4 months to chKk for ther.apeut ic efft iveness. Someofthe
antiglaucoma drugs take 6 10 8 weeks to reach peak effect. If
the therapeutic gools are not achieved with a single medica-
tion, it is common 10 add a se<:ond drug ftom a different
class to the regimen to produce an additive drtase in lOP.
Some of the drugs may continue to have effKts on the eye
for 2 to 4 weeks after they are discontinued.
Drugs for glaucoma work by one ofrwo mKhanisms: in-
creasing the outl1ow of aqUf.'OUS humor at the canal of
Schlemm or decreasing the formation of aqueous humor al
the ciliary body. Many agents for glaucoma act byaffKting
the autonomic nervous system (chapter 13
00
).
49.4 Antiglaucoma Drugs
There are many drugs available to treat gbucoma. Although
topical drugs are most frequently prescribed, oral medica-
tions are available for severe disease. Drugs for glaucoma,
listed in Table 49.1 , include the following classes:
Prostaglandins
Autonomic agents, including beta-adrenergic blockers,
nonselective sympathomimetics, alpha1-adrenergic
and cholinergic agonists
Carbonic anhydnlse inhibitors
Osmotic diuretics
CIIoptor49 ON9!10I E)'und Ear Olsorder! 769
PROSTAGLANDINS
ProstagLandin analogs are a more recent theropy for g1au_
coma,and one of the most effective. They are often drugs of
choice for glaucoma because they have Iongdurationsof :ac-
tion and prodoce fewer adverse effects than drugs from
other classes. They may be used as moootherapy or com-
bined with beta-adrenergic blockers to "roduce an additive
reduction in lOP in pdtienls with resistant glallCOma.
Prostaglandin analogs decrease lOP by enhandng the
oull1ow of aqueous humor. Latanoprost (Xalat.;ln) , available
as an eye drop solution, is one of the most frequently pre_
scribed prost.;lglandin analogs and is a prototype drug in
this chapt .. r. Several other ocular prostaglandins have been
approved, including bimato prost ( Lumigan), travaprost
(Travatan), and UllOprostone (Rescula). An CKClsional ad-
verst' effKt of these medications is heightened pigmenta-
tion, which turns a blue iris to a more brown oolor. This
change may be irreversible. Many patients experience
thicker and longer eyelailies. These drugs cause local irrita-
tion,slinging of the eyes, and redness during thefirst month
of therapy. BKause of these effects, prostaglandins are nor-
mally administered just before bedtime.
Autonomic Drugs
Several structures within the eye receive signals from the
sympathetic and parasympathet ic divisions of the 3uto-
nomic nervous system. As such,a significant number of au_
tonomicagents have been used to treat glaucoma and to aid
in ophthalmic examinations of the eye.
BETA-ADRENERGIC BLOCKERS Before the disoovery of {he
prostaglandin analog.'!, beta-adrenergic blockers were drugs
of choice for open-angle glaucoma. These drugs act by de-
creasing the prodoction of aqueous humor by the ciliary
body, and can lower lOP by 20% to 30%. Beta-adrenergic
blockers generally produce fewe r ocular adverse effocts than
other autonomic drugs. In most patients, the topiCllJ admin-
ist ration of beta blockers does not result in signifi cant Sy-\-
lemic absorption.. Should absorption occur, however,
systemic adverse effects may include bronchoconstriclion,
dysrhythmias, and hypotension. Because of the potential for
systemic effts, these drugs should be used with cauti on in
patients with asthma or heart failure.
AGONISTS Asn-
nists act by dreasing the producti on of aqueous humor.
Only two alpha,-adrenergic agoni sts are currently ap_
proved for open-angle glaucoma, and neither of them is
frequ .. ntly prescribed. Apraclonidine (Iopi dine) is indi _
cated for the reduction in l OP during or following eye sur _
gery and brimonidine (Alphagan) is used as an adjunct in
combination with other antiglaucoma agents. The most
significant adverse effects are all ergic reactions, headache,
drowsiness, dry mucoSOlI membranes, blurred vision, and
irritated eyelids.
CHOLINERGIC AGONtSTS Qwlinergic agonists are auto-
nomic drugs that act ivate cholinergic receptors in the eye
LibraryPirate
770 UnII' The ar.d EY""Em
TABLE 49.1 Selected Drugs for Glaucoma
Drug
PROSTAGLANDIN ANALOGS
bimatopmt (lIIIligan)
Q) litanop""1 (XIliun)
tral'(ljlfOll(T!a\'llan)
BETA-ADRENERGIC BLOC KERS
betaxolol
ItIWunoIoI (Brogan)
mtlipranolol (OptiPranolol)
Q Tmoptic:)
ALPHA,.AORENERGIC AGONISTS
apradonidiM (lDpidilll')
brimonidilll'lAlph'gan)
Route and Adult Dose (max dow where Indicated)
1 dropofo.o391> 5durim in lilt fflIlilg
1 dropofO.OOS% >oIurion ddy in lho:
1 dropofO.00491> 5durion in lilt fflIlilg
1 dropof0591> >oIurion bid
1-1 drops 01 O.15-{15 91> Kllution 0IIt to 1'IIOllirltslday
1 dropof0J9I> 5durion bid
1- 1 drops 01 0.2'-{l5 91> Kllutoo 0IIt to t'llOllirltslday
Gd daily
1 dropofO.5% 5durion bid
1 dropofOl% 5durion lid
CARBONIC ANHYDRASE INHIBITORS
a(eQzoLimidt(Diamoxj
brinrolamidt (Azopt)
dorzoLimidt (T!IIIOpI)
md harolamidt (NepI.WIt)
CHOLINERGIC AGONISTS
Glrbidlol (Mioltatj
iodidt
lodidt)
(lIopIo Cirpilll'. PilopiIII')
PO; 250 mg OIItto ku timwday
1 dropof1% 5durion lid
1 dropof 2% 5durion in tid
PO; 5(1.-100 mg bid-tid
1- 2 drops 010.75- 3% Kllution in (onjuoai'lill !a( MIl
4htid
1 dropofO.03-0lWo 5dution 0111'10 twotillll'S/day
... 1 drop of 1- 1% Kllutim fflI} 5-10 min for
3-1i OOstS
(hJorlkgla\KOllla: 1 drop 010.5-4% solution Mr,4-12 h
NONSELECTIVE SYMPATHOMIMETICS
dipivefrin IKI (Propiflt)
OSMOTIC DIURETICS
iIosoJbidt (kmotic}

1 dropofO.l% 5durion bid
PO; 1- ] g.1cg 0IIt to two tillltliday
IV: 15-2 m9as a 15- 25% 5dution 30-60 min
(ommon advMo!
Adwrse Effects
IrvmW /engrII mdlhidnrulXtytlolhtl,. dorkmmglX I
lfIIS4rionoffoflliQII in rhtfl'!
XOouI idvt!}C dftm lhat may Q![ with systtmic:
abso!p!ioo; inlt<tionlflu muscle or

local i/rhilg 000 bumif"4 blimrd "lion, dry mouth
" Ii
For ropKol b/urrtd IiWn.. birm rOile, dry t)f,
/0(0/ irdiilg. 5eJuoOOi IX fr.nign body n 1M
",_.
&r QIiII roult:diU!t!il.tkro!m imbilarm ijood
dnlmia:!, fta(od
IrIdurrd rt dIJmJri5ua/aruiryinlowlighl, l)'t
lleadache
XOouI idymc dftm IIIaI INY OIIwith systtmit

I:tonmowalm IWr-a1i!l!l
loco/ oomil9 Qoollingif"4 /IIurrtd "lion, IIeodQdiI,
p/rJIOSfMifiriry
Ychl'OOii,!lI'tIwnlioo
OrtirOltoti( ilypott11lim, flrdol fluIhing, iItododlf,
paltilori/1m.
Xvm !\rididi!:, dl!'Olytt imbalarm tdema
and produce miosis, constriction of thi' pupil, and contrac-
tion of the ciliary muscle. These actions physically pull open
the trabecular meshwork to allow gri'ati'r outflow of aque-
ous humor and a lowering of lOP. The cholini'rgic agonists
are applied topically to the eye. Pilocarpine (Isopto-
Carpine, Pilopine) is the most commonly prescribed
cholinergic agonist. Mversi' effects include headache, in-
duced myopia, and decreased vision in low light. Because of
their greati'r toxicity and more frequent dosing require-
ments, cholinergic agonists are normally used only in pa-
tients with open-angle glaucoma who do not respond to
other agents.
NONSELECTIVE SYMPATHOMI METICS Nonselective sympatho-
mimetics activati' thi' sympathetic nervous system to pro-
duce mydriasis (pupil dilation), which increases the outflow of
LibraryPirate
C/up!fr49 ON9' lor E)'" .00 Ear Disorder, 771
Prototype Drug I Latanoprost (Xalatan)
Therapeutic (lass: Antialauroma drua Pharmacologic (lass: Prostaalandin analoa
ACTIONS AND USES
lataooplOSt is a prostaglandin analog thllt lOP by tilt oot-
flow of humoc It is lMd to Ut al glau(oma. TIlt rom-
mtndtd doN i, Olll' drop in tilt <l fffited eyt{sj in tilt tvl'ning.1t is metabolized
to in a(tivt Ionn in tllt(olTl!'a, ll'<Khing in peak tfftll in .boot 12 houn.
ADMINISTRATION ALERTS
iWmol'f (onUC! lens btioll' instilling ('ft drops. Do not l'I'in Iff! contm
15minutts.
lII'oid touc:hing tilt or with any jlan of tilt tytdropper to
,,'Oid clOSHontamination.
Wait 5 minutt s btfowaltt r instillation of <I diffeft'nt plfScription to
admini5ter t yedrop(l).
Pll'gn<lnquttgoryC
PHARMACOKINETICS
Onstt3-4 h

Hilf lire: 17 min
Duration:Unknown
ADVERSE EFFECTS
AdYerst tfFeru indudt orul.r symptoms wc:h <IS con;.JIIctiYal tdt rna, tearing,
drynffi, burning, pain, inila!ion, iuhing, of Ioft'ign body in plio-
tophobg, andlor visuil disturNmf5. TIlt l)'tlashes on tht trt altd fYf may
grow and Changrs may O((llr in pigmtnUtion of tilt iris of tilt
tft'attd ,nd in tht ptriocular \kin.
Contraindication!: Contraindiutions ilKkide to tilt drug or
aoothtr rompolll'nt in tilt solution, pll'gnanq, i.Ktllion, intraocular infection,
or ((Injunctivitis.1t shoold not be administerfd to patitnlS with dost d-anglt
glalKorna.
INTERACTIONS
Dnq-Drug: Lmnop-OII inlfroKU with tilt P-Nf"Iati'll' II UIfd
(ooumn!ly with 0IIti e)'f.tops (oouiling thilllfllM, PfKipiUtion may Q(OI".
liIb Ti5IS: Unknown
HerlIiJVFood: Unknown
TlNtmt nt of Imrdose: Ow-rdosr with ophthalmic solution is unlilo:el)o.
III' ftf I!I M)M!rslrlg/f1l for Q NwI"9 I'n:>:m fOOI5!pf(1k I!I rIr/s
.... Prototype Drug I Trmolol (Betrmol, lstalo/, Trmoptrc)
Therapeutic (lass: Drugfor glaucoma Pharmacolog ic (lass: Miotk;beta-adrenergic antagonist
ACTIONS AND USES
Timalol is a oonstlt<til'l' beta-.dll'llergic b!ocur milablr in sevrral oph-
thalmic Ionnulations. 8etimol and Timoptic art 0.15% or 0.5% ophthllimic so-
kllions taun !Wict dail)'. TimoptK XE i nd Inalol aft' Ioog-ting solutions that
allow for olKr daily dosing. Timolollowers KIP in chronic open-angle glalKorna
by rtducing thr formation of iqtJfOUS humor. Thr drug ha I no sign ilieant rfferu
on viswl arui!)" pupil lize, or accommodation. Tl'I'atmrm m,y ft'quill' 2 to.
Wffics for maximum lhrrapruti( tiff(l k. an oral mrdication, timolol is Pl'l'-
scribtd to tft'at mild hypertt nsion, Itablt angirw, prop/lyluis of lI1)'[I(ardgl in-
lan:tian,and migraillf5.
ADMINISTRATION ALERTS
Proprr administration thr dangrr that the drug will be absorbrd
Systrmil: absorption u n mollk symptoms of hypog1yc:tmg.
Pll'gnanquttgoryC
PHARMACOKINETICS
Onstt30 min
Prak: 1- 2 h
Halllilf: Unknown
Duration: 12- 24 h
ADVERSE EFFECTS
Tht mon art 001 burning and ninging on innillation.
Y"rsion brromr temporaril)' bUlTI'd In most pnitnts thtre is oot t noogh
ablorptian to UUlor sysll'mic adVt'lSl' rfftm 011 long 011 rimolol is applitd ((Ir-
I'I'ctl)'.11 absorption [l(all!, hypott nsion or dysrhythmgsart possiblt.
Contraindications: Timalol is rontraindicated in patirfm with asthma, Sr'ltll'
chronic pulmona!)' distasr, sinus brad)'Cardi., !e(ond- or third-
dtgrtt atrioYl'ntrirular block, hurt lailurt, cardiogeoic !hock,or hyptrsrnsitiY-
i!)'totlltdrug.
LNTERACTIONS
Drug Drug: Drug inlln<tions may 1M" if lignffia,u syu.mi< absorption 01"' .
fmolollhoWd brused with (;1M in brIa bIockM
odditWf cardoK fffI>m. (mURalt U\I! with anticho1i1frgicl, niUitrs, rNrpilf,
1MhyIdopa, III wrap.!llil (OUd Iud 1 0 h)"potmlioo and brad)Uf(ia. pinPJhft

liIbTi5Is:Unmown
HerlIiJVFood: Unknown
Trmmfnt of OY!'rdosr with ophthalmic solution is unlil<el)'.
Sir IWtr 111 My/UsJnqKI for MnIng 1'rt5.! fo:uI sp/It 1II1M Itr!g.
LibraryPirate
772 UnII' The IntegumeotorySYltem arod Ey<>"rEars
NURSING PROCESS FOCUS PATIENTS RECEIVING OPHTHALMIC SOLUTIONS FOR GLAUCOMA
Assessment
BUfline assessmrnt prior to administration:
Understand the the drug his been prtnriilfd in order to for
dftm k'l.,op"n or dosI.nglo, =or.d.1!)' 10<")'0
trauma).
Dbtain a complete health hillol)' indudi ng ophthalmologic.
caidio'lalwlar, and f ndouill!'
AlSfIS viSUilI acuity and vi5ualfields. AsltIslor the of !XIin,
yilwl sud! as hilos around liglm, diminished "ior}g( vision, or
loss of pt'ripheral vision.
AlSfIS lor histo!), of rtr:rnt eye muma or inlrction.
Db"in a drug histOl)' including wmm prl'llription and OK
herbal preparations,akohol USI', and smokillCj. Be alen to possible drug
imt ractioM.
Db"in baltline vital signs.
Assessment throughout administration:
AlSfIS lor dtsirft! therapt' utic rfft<:u dependent 00 the thedrug is
givtn (f.g, intraoorlar pre remains below 20 mm Hg or it target value,
improvemffit in yilual Jruity or fields).
Allffi for tflrm;(onjuncti'f<ll edemt, burning,.
p-ain,irritation, itchini srm.uion body in photophobia.
visual disturba""H pain "'auld be promptly rt'pOn.d to tho
heakh ptO'Iider.
Potentilll Nursing Diagnoses
rAsturbed Ptl(t ption (Vilwn
AnIitt)o (,.,lat<d to """am. of los. ofy;';"n,.,.. pain)
Pain condition, tll'iltment adYl'lSt efftm)
Delicirm (drug
Risk for to 'liwal acuity derICits)
Defi<itnt Ability (relat.d to impaired vision)
Plllnning: Patient Goals lind Expected Outcomes
The will:
UpeMIK' therapeutic tfftas (f.g,f)'f his vimlawity.nd vilwl fitlds rem.in st.ble).
8. 1m from. or txptrience minimal. .dvers. tflrcts.
VerlJalino an understandin 9 of the drug's .Jdo.m. tflrm, a nd prtautions.
Demonstrall' proper self-administration ofthr medication timing. when to notify provided.
Implementlltion
Interventions li nd (Riltionilles)
Ensuring thfriptutic tffects:
Monitor yilwl acuity, vision (E)'f
Itss than 20 mmHg or pt'I" paramttrn Id by heakh
proyider. Vilual .Jwity and fields int.ct)
Minimizing .Jdft rst rffKtli:
Monitor administration of dlll9 to noid rxtraoorlu tflrCI5.
(E)'fdrops should be instil1ft! into the conjunctivall.Jc.nd tht lacrimal duct
htld with gentit for 1 fun minuteto prtl'tnt dllHJ into
the nalOphi!),nx with poI-Sibit rfiKII.j
Monitor intraoc:ular period"KaIIy.(Consisttnt .baft thf
Lll9ft value molY indicalf wofll'ning dMu. or improperuSl' of drug
thera)))'.)
Monitor for inclUSing eye sfllsitMty, or dlilngtS in
visual .Jwity. (Ey. (haOljfl or pain may indicalf wofll'ning dis ..
inft<:tion,or eff.as.)
Remol't contact itnltl administf ring ophthalmic solutions.(Cornact
lense may hinder the f)" solution from fully all t)'f surface or
may absorb solution, rrsuhing in higher than e'Xpt<:1I'If amounu in
tiflll'.)
Patient li nd Fllmily Education
lnstMt the patient to immediarel-; II'pln changrs in vision, f)'f pain,
light -Itnsitivity,hilos .round lights, or he ad,uM to tho h kh
provider.
Trac:h the patient plOpt'l" administration for drops. Oral
flll'dicatioM should be t1ken as regularly throughout the day.s possible
and with (Oosistent dosing.
InstMt the patient of the imponaIKf to for and maintain regular

InstMt the patient to .Jwid IOIKhing the f)'f drop tip to the conjunctiYal
sac: when instilling II'pln any
')'f p-a in, d rainaljf, or (hJ ngtS in yision.
InstMt the patitnt to renJa<. (001.1(\ itnlfS priorto administering e'$'
drops .J nd wait at least 15 beloit thmt.
LibraryPirate
C/up!fl49 DN9' lor E)'" .00 Ea. D""rde" 773
NURSING PROCESS FOCUS PATIENTS RECEIVING OPHTHALMIC SOLUTIONS
Implementation
Interventions and (Rati onales)
Monitar viul ptriodiully lar al systemic: allsorption 01 topical
(Ophthalmic: drugs SIKh u betJ bkKkersor(holinergic: drugs
may r=k in Of bradyardia il tilt drug is absorbed
systemic:ally. ERlUIt' the patient isadministering drops appropriately if
changtS in blood pr!"SlUrt 'R' noted.)
Providt lar comlan IlKh aI ,rieqwtely lightN room.(Ophthalmic: drugs
SIKh I. brtl bIocktrs!Md in lJ .. t ..... m ofgtlucOlllO <In <lU'" mio.i>
and diffKUky Iffing in low light ItvrkJ
Monitar adhmnct to the R'9i ..... n. may rf"IUh in
tilt totalioss of visionJ
Patimt unMrstanding of drug therapy:
UII' opplnunities <iJring administration of mNic:.ilionsand <iJring
alll'lmltnll todimll5 tht for drug thtrapy, dtsiR'd thmpMic:
most (omrron adYerst t!fem, p,rameters for when to (all tilt
htillth caR' prOYider, ' nd a ny flt(tsury rronitaring Of precautions. (lking
time during nursing caR' IIeIps to rti nfolU' kty

Patimt selfadminilitntion of drug thfrilPY:
Wlltn administtfing tht medic:ation, instruct tht patient, famii)o,or
cartgmr in the proptr II'Ifadminimation 01 tht drug. t.g., a
instillation 01 drops. (Proper ,dministration inclNsI"I tht tifediYl'lltl5
ofthedrug.)
Patient and Family Education
Tt,{h tht j)<ItNont to rttum ta the ht alth cart prOYider ptriodically lar
rronitoring. blood PIffiUR'OllCt ptf week and repln any aoo
bs than 90/60 mmHg or ptr R'port '11)'
headache,
Caution tht palNont about driYing or other activities in low-light conditions
0.11 night untit th 1Iff" of tho drug 1ft known.
Tt.ch tht p.iltNont 01 the imporunct in adlltring ta tht mtdication
's PIfI(ribf<i.
Addrffi i ny tht patient may haw.' about mst and discomlan
rt latN to drug thmpy and providt appropriate (t.g., social
II'IYic:t ,gtncy) aI I"ftded.
Tht pariem should to statt tilt 1I'aI0Il for
doseand srnNuling.,nd what adw.'f'" rfl"tcts to ob!m'e for and wlltn ta
rtport them.
Tmh tht j)<ItNont totakt tilt drug following tilt guidtlillH provided bytht
htalth cart proYider.
Evaluation of Outcome Criteria
tht of drug tlltra py by (onfirming tM p..ItNont goa Is and txpKIN outcomtS h,w.' bten mtt (= Pianninif).
St<' TobIt 4 9. 1 (llf Ii5lIf ftu!p re whKh riel lUling QPPIy.
aqueous humor, resulting in a lower l OP. Theyare not as ef-
fective as the beta-adrenergic blocktors or the prostaglandin
analogs in treating open-angle glaucoma. Epint'phrine is no
longer available for glaucoma. Dipivefrin is converted to ep-
inephrine in thus, its Effects are identical to those of
epinephrine. If t'pint'phrine reaches the systemic circula-
tion, it inneases blood and heart ratt'. Be,ause of
tht' pott'ntial for systemic adverst' effects, these are rarely
prescribed for glaucoma.
Carbonic Anhydrase Inhibitors
Carbonic anhydrase inhibitors (CAIs) may be administered
topically or systemically to reduct' l OP in patients with
11,,"Y ad \'y th"
tion of aqueous humor.
CAls art' grouped into topical or oral formulations. Dor-
zolamide (Trusopt) is used topically to treat open-angle
glaucoma, t'ither as monotherapy or in combination with
other agents. Dorwlamide and other topical CAIs are well
tolerated and produce few significant adverse effects other
than phot osensitivity. Oral formulations such as acetazo-
lamide ( Diamox) are very effective at 10wt'Ting l OP, but are
rarely used because they produce more systemic adverse ef-
fects than drugs from other classes. Systemic effects include
lethargy, nausea, vomiting, dt'pression, paresthesias, and
drowsiness. Patients must be cautioned when taking these
medications because they ,ontain sulfur and may ,ause an
allergic reaction. Because the oral formulations are diuretics
and can reduce l OP quickly, serwn electrolytes should be
monitored during treatment.
Osmotic Diuretics
Osmotic diuretics are occasionally used preoperatively and
pu,tup"nliivdy wilh sUfll"r y ur as
ment for acute closed-angle glaucoma attacks. Examples in-
clude isosorbide (lsmotic), urea, and mannitol (Osmit rol).
Becaust' they have the ability to quickly reduce plasma vol-
ume (cha pter 30 00), these drugs are effective in reducing
the formation of aqueous humor. Adverse effects include
headache, tremors, dizziness, dry mouth, fluid and electrolyte
LibraryPirate
774 UnII' The IntegumeomySY'tem ar.d EyI>" Em
imbalances, and thrombophlebitis or venous clot formation
near the site of IV administration.
49.5 Pharmacotherapy for Eye
Exams and Minor Eye Conditions
Various drugs are used to enhance diagnostic eye examina-
tions. Mydriatic drugs dilate the pupil to allow better ............
ment of retinal structures. Cydoplegic drugs not only dilate the
pupil but also paralyze the ciliary muscle and prevent the
lens from moving during assessment. Agents used for eye
examinations include anticholinergics such as atropine
(Isopto Atropine) and tropicamide (Mydriacyl), and sym.
pathomimetics such as phenylephrine (Mydfrin).
Mydriatia cause intense photophobia and pain in reo
sponse to bright light. Mydriatks can worsen glaucoma by
impairing aqueous humor outflow and thereby increasing
lOP. Cycloplegia cause blurred vision and loss of
near vision. The response to mydriatics and cycloplegics can
last 3 hours up to several days. The patient needs to be
taught to wear sunglasses and that the ability to drive, read,
and perfoml visual tasks will be affected during treatment.
Drugs for minor irritation and dryness come from a broad
range of classes. Some agents lubricate only the eye's surface,
whereas others are designed to penetrate and affect a specific
area of the eye. Vasoconstrictors are commonly used to treat
minor eye irritation. Common vasoronstrictors indude
phenylephrine {NeoSynephrine), naphazoline (ClearEyes),
and tetrahydrowline (Altazine, Murine Tears Plus, Visine).
Adwrse effects of the vasoconstrictors are usually minor and
include blurred vision, tearing,headache,and rebound vasodi
lation with redness. Examples of cycloplegic, mydriatic, and
lubricant drugs are listed in Table4g.2.
Conjunctivitis is an inflammation or infection of the lin-
ing of the eyelids. Topical corticosteroids and nonsteroidal
a"liinflamJllalury (NSAlDs), ",,<.11 <I" k<:turub<.
(Acular), can be used to treat conjunctivitis and other in
f1ammatory conditions. Several medications, including
antihistamines and mast cell stabilizers, are used to de-
crease the redness and itching associated with allergic con
junctivitis. Topical mast cell stabilizers, with or without an
antihistamine, are the preferred treatment for allergic con-
junctivitis because they do not cause drying of the
eyes. Two more recent drugs, olopatadine (Patanol ) and
pemirolast (Alamast ), provide for daily dosed treatments
for allergic conjunctivitis. Azelastine (Optivar) and epinas-
tine (Elestat ) are combination antihistamine-mast cell sta
bilizers, indicated for twicedaily dosing. Bepotastine
(Bepreve) is an antihistamine approved in 2009 for itching
associated with allergic conjunctivitis.
EAR CONDITIONS
The ear has two majorseruory functions: hearing and mainte-
nance of equilibriwn and balance. As shown in .. Figure 49.3,
TABLE 49.2 II
Drugs for Mydriasis, Cycloplegia, and lubrication of the Eye
Drug Routeand Adult Dose (max dose where Indicated) Adverse Effects
MYDRIATICS: SYMPATHOMIMETICS
phtnMhint 1 drop 2.5% or lC1l1l IOhnion briorr wm [ )It p/rorlMlHirifiry, f'yr
III let the Prototype Drug box 00)
--
CYCLDPLEGICS: ANrICHOUNERGICS
(lsoplO 1 1 dropofO.5%soIUlion mhday [)It irrilalion 000 rtdnru, d,., mou!h,/orol
letJlw, Proiotype Drug box OQ) bllJrrwI
cydopffitolatt (C)'dogyI, Ptntoliir) 1 dropof05-2% lOIution 40- 50 min "'ft t Um
p/lorrMmirWiry, KlIImo!oid
dermoritiJ (llopo/aninf U!J!icanidej
homarropilH' (Isopoo Homatropint, olhm) 1- 2dropsof 191, or S% IdUlOO btfOll' f!"It. wm
5gmngltnct t.ubWa (DQYu!sioos.
lCopobmilr hydrobromidt HyoICilH'j 1- 2dropsof0.25% lOIution 1 h briort t'jt tUm
mtn!!l(
tropicamidt T ropi<acyl) 1- 2dropsof05- 1% soknOO btfOll' f!"It.
inlr.JO(W[ PR$llR /homalrwiod
LUBRICANTS ANO VASOCONSTRICTORS
lioolinakohol (OOiIhbtj Awly athinfilm IOlilt Ttrnparary oomiflg or lmging, f'yr irdiflg IJf
flH'lh,!ll' luw V"1II:WIr.OIi1tfll l- 1drOPlprD

naphilolint (Alhalon, Altrts!, olhm) 1- 3dropsofO.l % lOIution t'mY 3-4 h pm
t!o!(liou! idl'tl!(dltds
QX)T11eQmlinc Visinc LR) 1-1 drops of 0.025 9(, !OIution qid
poIy'Ii"ll akohol (Liquifilm, OIhtrsl 1- 2dropsprn
(Collyrium, Murint 1-1 drops of 0.05 % solution bid- tid

Ildb Itrioui advtrl>! dltm.
LibraryPirate
Helix ----.,
Anlihelix
Ca,lilege
,-- cenels (equilibrium)
hc!-{?-' r-
G
" ". ot the vestibule, ne,ve

... 'J';..--. n. -f"-'--- Stapes (stirrup)

Concha (bowl) Cochlaa (hearing)
Exte,nal acoustie _______ ___ 0
meatus
Mastoid process
L -'\; __ "",+,;-_" Vestibule

Tympanic
L ___ Eustechian tube
( .... rdrum)
Internal carotid ar1erv
Flgure4!l .3 Structure<i of the external ear, middle ear,and Inner ear
SW,ce; Pea'>OO f dKartJnJPHCoIlege.
HOME & COMMUrllTY CONSIDERATIONS
---- - -- -------
Ophthalmic Drugs in the Home Setting
In modem Amrriun adults ilia)' lift or with other rldtrty
family 01 friends. JIr'lplr ofuon to US!' ophthalmic drugs at homr.
As ItSS thrability olthr agirlg ind MdUillto safrly mministrr ophthalmic drugs
in thr homr lfIIing. RWJm drmonstration b)' the patirm lIIiIy bt (ritical br
thr IIJrsr to olIltSsthr oidfl a<kJk's dmeril)' and skill in stH-administrring
mNic,lIions. H rffied. INsonabir wm as from a
neigh bar, family mrm or (')l!giYt r.
ing is critiu I for j:OIitiYt OUKOmrs in this POpIJlation. oIdrr adJk
nHCk to uncWrsund th.t lOIKhing 01 rubbing the f'jf un in infedion or
damal}!' to the f'jf. BeraUSf vision may bt (ompromiSfd, the older
aduk ilia)' bkJIIN vision that shoold dear in a lNIonabir timr if-
tt r using ophthalmic drugs. Caution older i <kJ1ts about trying to drill!' or rim
amoolatl' until this ulKlrar vision improl'!5.Additionilly, with f)'r problrms,
diminishN vision puts thr oIdrr aduk at risk for falls.
homr and IIIiIkt suggrstims 10 improll!' safety. should ill' taktn to label
f)'r mrdiutionsto indicatl whic:h is fo, the Itft and whic:h is for the right
xht<kJling mrd ic:ations '!!Iund a SIKh as mr.1s, a ko ilia)' hrlp the
oldtr adJk Il'ml'IlIbtr to t.Jkt tht ophthalmi( mrdic.tions as Pll'l(ribed, in-
nKesary rompiianU' fo, hraling.
PNiatric: aR' ala tft'atN at homr for disordtrs. Cal!gill!'rs in
thr homr aR' rrsponsiblr :Or administrating and rnsuring thr patiem's (om-
plialKf with thr drug thrllpy. Thr limr mministration in!lructions apply to
both geriatric: and pedialrK populatiorlS.Caution against IOIKhing and rubbing
thr the mr of infam, toddlrl\ and Yl'ry young rnildren, it may bt II!'(-
miry to US!' tlbow splint5 and guards to PR'!'lltthrm from bting ablr to
R'arn thti, ryt1.
AND ALTERNATIVE THERAPIES
BilbQrry for Eye Health
Bilbtrry (Voccinium myrtiHlIl), a pint lravfS and fruit UIfd
ilal)", i; foondin(flltralaoo nonhtm NonhAmtria.lthis btrn
5hown in dilic:al slIKits to iKft'il1t ronj.JfJ:tival (apillary in patitnu
with<iabttK II'tinopathy, theft'by pl!l'lidng prottdion agarnt hemonhiI;r 0/ thr
Jttiru.Dnt (ompound in bibto): anthocy.nosicIr, has a ooIlagm .. rf-
ffl:lln(ll'astd synthf"lis of (onnmlve tilW!' lilKluding (ollagrn) it of
t hr (ontriooting factors that ilia)' Irad to blindne-s5 (aUlfd by tiabttic
Silbtrry has also UIfd to rrdu(r rye inliamm,tion .nd im
P""'" night vision. gilb."y m.y braken ... tN to liNt nonspKific di.".h ...
<tnd Iopiully to trrat inflammation of thr m!KOIJI mrmbrants of themouth
indthlOlll
tbrH structural areas, the outer ear, middle ear, and inner
ear, carry out these functions. The basic treatment for ear
conditions is topical preparations in the form of ear drops.
49.6 Pharmacotherapy
with Otic Preparations
Otitis, or inflammation of thr ear, is a common indication
for pharmacotherapy. [_temal otitis, commonly called
ll'Vimmers ear, is inflammation of the outer ear that is most
often associated with water exposure. OtitismNia, inflamma-
tion of the middle ear, is most often associated with upper
z


"




,
LibraryPirate
776 UnII' The IntequmeotorySyslem arid Ey<>o;,IEars
TABLE 49.3 1 Otic Preparations
ON,
,J(id and Ilydroo:ortisoM (VoSollK)
lKruociilll' and anlipyrilll' lAuraigan)
Route and Adult Dose (max dose where Indicated)
3- 5 drops 4 h qid for 24 h, 111m 5 drops tid- qid
AdwlW Effects
fGrirririon.lrxQlllir19ing fI(
blmirrg. diIIintlJ
Fill m tanal with !OiLtion lid for 2-1 days
... boomidr: 1"'1>.IIiIJ.( ildJIUlj 1- 5 drop. 6.5% ""uli .. , bid I .. 4 ddy.
Al a tuctiom (wibiolja\
dprofloxadn and dr:Jl.imelha5Olll' ICiproDu)
dprofloxadn and hyd rororti5Olll' (Cipro)
poIyfll)'lin 8, lII'OIIlydn, and hydroc:ortisolll' lCortisporin)
Childrtn to aduk:4 drops in affffied bid for7 days
lltops oflht IUIptnSion inltiled ilto m bid for 7 days
4ltops irlNrlid-"d
Iralio (OOlmon indjyle smomadvme trfffiS.
RM alsolo dlapltr of Drug Admi niSlration,"forproptr ad"ninistra!ion for ur!tops 00.
respiratory infections, allergies, or auditory tube irritltion.
Of aU ear infections, the most difficult ones to treat are in-
nerear infections. Mastoiditis. or inflammation of the mastoid
sinus, can be a serious problem because if left untreated, it
can result in hearing loss.
Olloramphenicol (Chloromycetin, Pentamycetin) and
ciprofloxacin (Cipro otic) are commonly used topical otic
antibiotics. Otitis media is treated with a course of sys-
temic rather than topical antibiotics. Amoxicillin, at a dose
of 80 to 90 mglkglday, i. pre.Kribed for mo.t children.
In cases of otitis media, drugs for pain,edema, and itching
may also be necessary. Topical corticosteroids are often com-
bined with antibiotics or other drugs when inflammation is
present. Exampl es of these drugs are listed in Table 49.3.
Acetaminophen or NSAIDssuch as ibuprofen are used to re-
lieve pain and reduce fever.
Mastoiditis is frequently the result of chronic or recurring
bacterial otitis media. The infection moves into the bone
Chapter REVIEW
KEY CONCEPTS
and surrounding structures of the middle ear. The treat-
ment of acute mastoiditis involves aggressive antibiotic
therapy. Intravenous gentamkin or ticarcillin may be used
initially; thenlpy may be adjusted once culture and sensitiv-
ity results are obtained. Therapy is continued for at least 14
days. If the antibiotics are not effective and syntptoms per-
sist, surgery such as mastoidectomy or meatoplasty may be
indicated.
Cerwnen (ear wax) softeners are also used for proper ear
health. \.\'hen cerumen accumulate.., it the urcanal
and may interfere with hearing. This procedure usually in-
volves instillation of an earwax softener and then a gentle
lavage of the wax-impacted ear with tepid water using an
asepto syringe to gently insert the water. An instrument
called an ear loop may be used to help remove earwax, but
should be used only by health care providers who are skilled
in using it. Examples of earwaJI. softeners include carbamide
peroxide (Debrox) and triethanolamine.
The numbered key concepts provide a succinct summary of the important points from the corresponding nwnbered section
within the chapter. If any of these points are not clear, refer to the numbered section within the chapter for review.
49.1 Knowledge of basic eye anatomy is fundamental to under-
standing eye disorders and pharmacotherapy.
49l Glaucoma develops because the flow of aqueous humor in
the anterior eye cavity becomes disrupted, leading to in-
creased intraocular pres:;ure. The two principal types of
glaucoma are dosed-angle glaucoma and open-angle
glaucoma. Therapy of acute glaucoma may require laser
surgery to correct the underlying pathology.
493 The goal of glaucoma pharmacotherapy is to prevent
damage to the optic nerve by lowering lOP. Combination
therapy may be necessary to achieve this Iloal.
49A Drugs used for glaucoma decrease lOP by increasing the
outflow of aqueous humor or by decreasing the formation
of aqueous humor. Drug classes include prostaglandins,
beta-adrenergic blockers, alpharadrenergic agonists, car-
bonic anhydrase inhibitors, nonselective sympatho-
minlt'tics, cholinergic agonists, and osmotic diuretics.
49.5 Drugs routinely used for eye examinations include mydri -
atics., which dilate the pupil, and cycloplegics, which cause
both dilation and paralysis of the ciliary muscle.
49.6 Otic preparations treat infections, infiammation,and ear-
wax buildup.
LibraryPirate
NCLEX-RN" REVIEW QUESTIONS
D A patient with a history of glaucoma who has been taking
latanoprost (Xalatan) eye drops complains of st'Vert' pain
in the eye, severe ht>adache, and blurred vision. The ap-
propriate nursing action is to:
1. document the occurrence; this symptom is expected.
2. medicate the patient with a narcotic analgesic.
3. IIOtify the health care provider inunediately.
4. place the patient in a quiet darkened environment
D Tht' patient should be aware of pOlential side efft'CIs of
prostaglandins used in the treatment of glaucoma. The
nurse should include which oflh .. following in the teach-
ingplan1
1. HYJX'rtfnsion
2. Loss of lashes
3. Dilation of pupils
4. Brown pigmentation of treated eye
D Beta-adrenergic agents may be used to trrut glaucoma.
The nurse should teach the patients and family to:
]. monitor urine output
Z. monitor bloo::l glu(O,'if.
3. monitor pulse and blood Pressun'.
4. monitor respiratory rate.
D The nurse emphasizes to the patieDi with glaucoma the
importance of notifying the health care provider perform-
ing an eye examination of a glaucoma diagnosis because
of potential adverse reactions to which drugs!
1. Antibioticdrops
2. Cydoplegic drops
3. Anti-inflanunatorydrops
4. Anticholinergic mydriatic drops
CRITICAL THINKING QUESTIONS
1. A 3-year-old girl is playing nurse with her dolls. She picks
up her mother's flexible ntetal necklace and places the tips
of the necklace in her ears for her A few
hours later. she cries to her mother that her "ears hurt."
The child's mother takes her to see the health care provider
at an after-hours clinic. An examination rewals abrasions
in the outer ear canal and some dried blood. The health
care provider pres.:ribes corticosporin olic drops. What
does the nuTSl' need to teach the mother about instillation
of this medication!
2. AM-year-old man hasbet'n diagnosed with primary open-
angle glaucoma. He has COPD following a 40-year history
of smoking. Is he a candidate for treatment with timolol
(Timoptic)? Whyor why not! Is there a preferred agent?
Chopllr49 ON9' lor Ey<' Ea, 0"",<1<>" 777
II The patient is pres.:ribed timolol {Tintoptic} for treat-
ment of glaucoma. The nuTSl' assesses for which of the fol -
lowing medical disorders during the history and physical.
which may be a contraindication to the use of this drug?
(Select aU that apply. )
l. Heart block
2. Congestive heart failure
3. Liver disease
4. COPO
5. Renal disease
1:1 Appropriate administration is key for patients taking eye
drops for the treatment of glaucoma to optimize thera-
peutic efft'{ts and reduce adveTSl' efft'{ts. The nurse
would be concerned if the patient reports administering
the drops:
]. into the conjunctival sac.
2. holding slight pressure on the tear duct {lacrinlal duct}
for I minute after using the eye drops.
3. avoiding direct contact with the eye dropper tip and the
'Y'.
4. leavtngcontact lenses In to be sure the eyedrop Is
maintained in the eye.
3. To determine a patient's ability to administer glaucoma
medications. the nurse asks the 82-year-old mlman to in-
still her own medications prior to discharge. The nurse
notes that the patient is happy to cooperate and watches as
the patient quickly drops her head bad::, opens her eyes.,
and drops the medication directly onto her cornea. The
patient blinks several times., smiles at the nurse, and says,
"There, it is no problem at aU!" What correction should
the nurse make in the patient's technique?
Set Appendix D for answers and rationales for all activities.
EXPLORE
M)'NursingM i:I yoor one srlIl for oriine ClHIllIer Itliew materials and
reooolCOlS. for success with ad!Jilional tlCLU"-sti\ll IIflIcticlt
que3liDns, In!eractl\Ie Q[lI'IIOOnl'I and aC1l\ii!ies, well tlnks. mtmations
and morel
Regllll er your a.cce!B roIIe fmm me Iron! 01;001 000k at
www.myn .. U\tkilcClm.
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TI,is page intentionally left blank
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ISMP'S LIST OF HIGH ALERT MEDICATIONS
High-alert media.tions are drugs thaI bear a hrightened risk
of causing significant palient harm when they are used in
error. Although mistakes mayor may nol be more common
with these drugs, the consequences of an error are dearly
more devastating to patients. The nurse should use this list
to determine which medicatiOI15 require special safeguards
to reduce the risk of errors. This !my intlude stl'1llegies like
improving access to infonmtioo about these drugs; limiting
acct'$s to high'alft"1 mIications; using auxiJi:try bbels and
automated alerts; standardizing the ordering, storage,
preparation, and administration orlhesC' products; and em-
ploying redwxlancies such as autolruUed or independent
double-checks when necessary. (NOll': manual independent
double-checks 3Tt nOI always the optimal error-reduction
st rategy and may not be practical for all of the mediallions
on the list.)
Clanlls/Categories of Medications
adrf-nergic agonislS: IV (e.g., epinephrine, phenylephrine,
norepinephrine)
adrenergic antagonists: IV (e.g . propranolol, metoprolol,
Iabetakll )
anesthetic agents: general, inhaled, and IV (e.g., propofol,
ketamint)
antiarrhythmiQ: IV (e.g., lidocaine, amiodarone)
anti thrombotic agents (anticoagulants), including warfarin,
low.molecular.weight hepari n: IV unfractionated he
parin, Factor Xa inhibitors (fondaparinux),direct throm-
bin inhibitors (e.g., arg;lIroban, iepirudin, bivaJirooin),
thrombolytia (e.g., aJ leplase, reteplase, tenectcplase),
and glycoprotein IIbIIIIa inhibitors (e.g., eptifibatide)
cardioplegk w1utions
chemotherapeutic agents: parenteral and oral
dextrose, hyperlOnk, 20% or greater
dialysis w1utions: peritoneal and hemodial ysis
epidural or intratheal medications
hypogl,,:emia: oral
inotropic medications: IV (e. g., digoxin, mi lrinone)
liposomal forms of drugs (e.g., liposorruJl amphotericin 8)
moderate sedation agents: IV (e.g . midazoLam)
moderate sedation agents: oral. for children (e.g., chloral
hydrate)
narrotialopiates: IV, transdermal, and oral (including liq-
uid concentr.ues, immediate and 5usbined-release for-
mulations)
". ,.
"
Appendix A
neuromuscular blocking agents (e.g., succinylcholine,
rocuronium, vecuronium)
radioconlrast agents: IV
total parenteral nutrition sol utions
Specific Medications
tpoprostenol (Aolan): IV
insuli n: subcutaneous and IV
magnesium sulfate injection
methotrexate: oral, nononcologic use
opium tincture
oxytocin: IV
nitroprusside sodium for injection
potassium chloride for injection concentrate
potassium phosphates injection
promethazine: IV
sodium chloride for injection, hypertonic (greater than
0.9% ooncentl1ltion)
sterile waler for injection. inhalation, and irrigation (ex-
cluding pour bottles) in containers of 100 mL or more
Background
Based on error Il.'pOrts submilted 10 the USP ISMP Medica-
tion Errors Reporting Program, reportsofharmful errors in
the literature, and input froln practitioners and safety ex-
perlS, ISMP created and periodically updates a list of poten
tial high-altrt medications. During 2007,
no praclitioners responded to an ISMP survey designed to
identify which medications were m05t frequently consid-
ered high.alert drugs by individuals and organizations. Fur-
ther, to assure relevance and completeness, the dinical staff
aI ISMP, members of our advisory board, and sa(etyexperts
throughout the United Stales we" asked to review the po-
Itntial li.sl. This list of drugs and drug categories reflects the
collective thinki"8 of all who provided inpul.
s..trtC tSM P p.". ... hoion io InIIltd 10 .... 1fti.aI1or
inte. nal ncwde'\tn or a>mtR,.nk;n;on. with propr. Imibu,ion, OlhfT
h prohibited without wrinrn p<rmiooion, IJnIno _L ,tports
_ .... th ....... III. USP-tSMP Mediation !'.:non Rq>ootina Prosnm
(MERP).lIq>orIlctuaI Ind poc.ntiol modic:alioa ....... II> .... Mf.RP m 1ho
...0 at www..iomp.orsorb,-caIlinJl .... FAIL.-SAF(E).ISMPptan_
<lI>Ilf'dralUoIi'T 01 inb-maioA .....,.;,...,j ..... onporu >riIba U 10
tho Ir..t 01 douiI j.,dadrd in pab/ialioDI.
LibraryPirate
, Appendix B
TOP 100 DRUGS RANKED BY NUMBER OF PRESCRIPTIONS
Top 100
Rank Generic Drugs
..
,.
,.
..
,.

,.
..
..

H.
U.
H.
...
".
,.
".
...
".
"-
D.
n.
D.
,..
D .
,.
D.
U.

...
".
".
D.

D .
,.
n.


"'.
...
u.
v.
.

..
".
.
fi.
>0.
I.,do ' D. w/ APAP
litinop<il
.un ....... ,.

.mo:clcill.in
.:cltbromycin
hydrocblorothiuido
.Ip ... ...u.m
........
JDftformin
metoprolol .lKcinato
furo .. mi"'onl
metoprolol tan ....
_ofu.
om<pruol.
....pidmJ ",rtnk
o:<ya>dono w/APAP
ibuprohn
prlnioonr oral


c:q>hakxin
... ..,...,
cl""'orpam
dulopnm
_ ....
p bopattin
cipl<>floucin
... w/ APAP
lisiaoprillHCTZ

davul.n.tt
cydobr=princ
."'""'-
kmfftladi_
R..ne_ ... IIR
p.an>n!tine
lon ... tin
trim<thoprimlou\f.r.
!but....! Krosol
.u..,....
pr ....... in
. m aminophenJ<Odtin<

.mitriptyli_

ft,,,,,,,,,,,,
tnabpri1
< ..... dilol
roni. idin.
Top 100
Rlink Generic Drugs
SI. dinycydine
52. tlriooprodol
53. .lIopouin<>l
S4. m<lhy!prl"is<JIon. .. ,,,
55. moloxlc.,.,
56. omlDdipif>f/bmaupri1
57. potuIoium cillo,;""
SolI . clonidine
59. prt>m<th.zm.. .. 1>0
W. ioooorb;& ....,"""il .....
,I. folic tcid
62. opin>nobctono
63. &Iimcp'rido
6<1. pan!<>prU01<
&5.
".
67. .... ' .... Inobuliuroolution
611 . tridi<!ni,
69. '""'uq>Om
70. . riamcinoiont aC1Ol<>nido. ropial
11. p"aiciD.in VK
n . ""'""""
71. m<lformin HCl ER
7<1. b ...... pril
7S. w .. d..
76. cJinchmycin .,.mmJc
n . ramlpri
78. IMlronidaJOielaN
79. dipJin
l1li. m .. odop<amXk
81. .. radioI .... '"
82. h)'d=rz;illf
SJ. .mphctamu. WI c:ombinalioa
8<1 . <Idof""""
85. grmlibroril
86. p"'J'rlDOld HQ
87. vitamia D
sa. quinapril
89. promed>.>:in</<O<Irino
90. donzooi.
91. mUtaupi ...
92. &IipiDde ER
91. pbentr.mine
9<1. .qd",jr
9';, m.wzm..
96. potassium chloride
97. nllrofutontoin
941. tulbmcthoumldt,imt1hop,im
9'}. f'.1II.nyI
100. bwpUoI><
Top 100
Rank Brand Name Drugs
..
,.
,.

,

,.

.

H.
U.
".
..
" ..
".

".
,.
D.
n.
D.
,.
"
,.
n.
,.
n.
"
".
" D.
"
"
,.
n.
,.
" .

u .
.,
U
u .
" ..
".

...
,.
Up;to
N .. ium
-.
Slnguloir
PI ... ix
Syntluoid

A<lvair !)i,k ..
E/kmrXR
-"
,_.
VytOfin
_ .
Pro-AirHFA
"'.,,",
rno...nHCT
Lcnquin
,-
"--

"'"
.""
CrIrb ...
N .. o",",
Premarin_ Tabs
""'.,
Vi.J1'
,-
.,...
Add.r:oll XR
v"m.
"'""
Topamu
c-
"-.,.
..
Amblm CR
Spiriu
Bonicu
""'m
BolliclrHCT
Ariorpt
Onho Tri .c,dtn La
.",. ..
Tri-Sprint
a ",
o.,c-m
AcipHu

lamkbl
Top 100
Rank Brand Name Drugs
51.
52. o..nliI
53. A .... pro
Sf. Pmwntil HFA
55. AbUlfr
56. V mln 2&
57. 81>d<prioa XL
58. Ni."I'""
59. CombiwDI
60. lamn';"
61. Bonin
62. TriNeosa
n Nu .. Ring
64. Risperoal
65. fulymagma PLaln
66. Ro\oftlt HFA
67.
6& Evi
69. AodoJ:
70.
71. Pmtollix
n. Avalido
n. Liodtrm
74. Z1l'r<:U
15. N..-nd.
76. l\usiono::<
n. Thyroid ...... mDII.
78. Humaloc
79. Vipmo:<
80. TomilI:u
81. Bl>d<prioll SR
82. Suboooo ....
83. Lano:lin
84. Loeotrin Fo
85. A...ian
86. Cownodin ,abo
87. Wtll>utrin Xl
88. Endotct
89. Sbluin
90. N ... "". AQ
91. J:q>p ...
92. Allqro D II hr
93. SIr Ol ICl" '
0< .....
95. Avandi.
96. Octl[
97. Vynnoe
98. Toprol Xl.
99. lrvitno
100. A"din
So ... "," Dat. from http://.m.p.pico.moo.mmedidn<.oom/.m.p.piQ/do,.; .. ti<l.standardildrugtopiul222001l15998<<1anid . pdfand
bnp:lldrugtopia.mod..nm.ctIicioo.com/dr""opiaId .. .;llrtldHtaodudJ/dn/a!:opia/22lOO9/S9'J8.IS/artidt.pdf; Stp .. ",bft 2009.
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Ludwig, 10.1., We<lergaard, L G., Diedrich, K., & Ande,"""n, C. Y.
(2003). DMrtlopmrnl5 in drugs for ovarian stimulation. B,sr
Praaia and Rsearch. Oinical Obste,ric> and Gyn,rokigy, 17(2),
231- 247.
Olds, S. B., London, M. L., P.A., & Davidson, M. R. (2008).
Matenlal ..... <"Wborn nu"ing and ""mfn', heal,h "Ir" (8th ed.).
Upp<r Saddle Ri""r, Nr: Prenlia HaU Health.
O:smers, R., Friede, 1.1., Li>ke, E., Sl:hnitkc:r, J., Freu<lenSiein, I. &
Hrnnei<h-"m Zep<:lin. H. H. (2005). Efficacy and .. fet Y<lf
isopropanolic black who.h a1ract for dimacteric symptom .
Obstetrk. G,..,..,rology, 105{5 pt I), 1074-1083.
Prine, L. (2007). Mythsand fau ..
Obstetrk. and Gynerolcgy Clinic, ef North Am",ica. 34( I),
127- 136.
St ... rns, V. (2007). Clinical update: Now lreatmenls for hot flash ...
111 ,""Met, 369(9579),2062- 2064.
Chaptlllr46
lknt, S., Kane, C., Shinohara, K., Nrnhaus, r., Hudes, E. 5., G<!ldbag,
H., &Avins,A. L. (20(6). Saw palmeno for ""nign pro<latk
hyperplasia. Neo. England lournal ofMedkine, 354(6), 557- 566.
Bullock, T. L, &AndrioJr. G. L. (2006). Emergingdrug therapies for
brnig.n pro.tatic hyperplasia. Xper< Opini<m "" D .... g<.
1I(1),lll- 123.
Carri .. , S. (2003). Pharmacology of pho.phodirsteraso 5 inhibitors.
Canadian klu,nal ofUrelov: 100Suppl Il. ]2- 16.
Ficordli, C. (2007). Untangling thr complexities of male infurtiUty.
Nu"ing, 1007, 37(1), 24-26.
Gordon,A. E., & Shaughnessy,A. E (2003). Saw palm<l!o for
pro,tate disorde .... A"'N'ican Family Phy,icu"" 67(6), ] 281- ] 283.
Kassabian. V. S. (20(H). Sexual function in patients trealed for benign
pro,tatic hyperplasia. 361(9351), 6(ki2.
Kltastgir,J.,Arya, 10.1., S., Ka.lli,/. S., Minha .. S., & Mundy,
A. R. (2002). Current concepts in the pharmacothrrapyofbrnign
prostatic hyperplasia. XP"' Opinwn on Ph"rnuu;othmlpy, 3( ]2),
]727- ]737.
Mdeod, D. G. (20(3). Hormonal therapy: HiSiorical persprctivr to
futuro direction . Urol"SY, 61(2, Suppl. I), 3-7.
P. J. (2006 ).Androgcns. In L. L Brunton, J. S. Lazo, and
K. L Parker (Ed.o.), Goodman ";'Gilman', TM pharmaroklgical
basio ef,h",aproric. (]]th ed., pp. ]573-1586). Now York, NY:
McGraw-Hill.
Sprncer, M. (2007, March JO). Managc:mem of dysfunction
in primary",..,. GP: Gen"",II'rtlNitiour. 36- 37.
Steiner, B. S. (2002). Hypogonadism in mcn.A rrnowof diagnosis
and tn:atmem. AdwlMct< for Nu"" Priu:titicn"", 10(4), 22- 27, 29.
Chapter 47
Burke,A., Smyth, E. M., & G.A. (2006).
Analgcsic-antipyretic aunts; of gout. In
L. L Bn..tnton, r. S. Lazo,and K. L. Parhr (Ed . ). ...
Gilman', 1"/", p""","""ological basio ef th"",putics (] ] th rei.,
pp. 67] - 716). Now York, NY: McGraw- Hill.
Clegg, D.O.. Rla, D. J., Harris, C. L, Klein, M.A., O'Ddl, I. R.,
Hooper, M. M., ... & H. J. (2006). Gl"", .. mine,
chondroitin sul fate, and the two in combination for painful kn
osteoarthritis. Neo. England klurna/ ofMedicin', 354(8), 795-f108.
CUrry, I.. c., & Hogslel, M. 0. (2002). OSiooporosis. Amerirll7l
10u"",1 efNurs;ng, 102. 26-32.
Friedman, P.A. ( 2006). Agc:ntsafftcting ion homeosta.is and
bonr turn"""r. In l. L. Brunton,l. S. Lazo.and K. L Pdrker (Eds.),
Good",an &- GiI"'''n', The ph"rm<>cologic,,1 bas"
(] Ith ed.,pp. ]647- ]677). New York, NY: McGraw- Hill.
Kuehn, B. (2007). Knee therapi .. probed. lou"",/ eftlu Amfritwo
Medical A.ssocillrion, 29ii(20). 2361.
(2003). Dietary nrrels for bone health and pre"ention of
o<lcoporosi . Bri,,,hleurfI,,1 ofNursit,g, 12(1), 12- 2].
Ol .. n, N. /., & Stein. C. M. (2004). Nowdrugs for rheum.toid
arthriti . Nfo. Engt..nd llnlrnal of Medicine, 35/X2] ), 2167- 2179.
Qa_m,A., Snow, V., P., Hopkins Ir., R., Forded, M.A., &
Owens, D. K. (2008). Scrning forosleoporo,is in men: A clinical
practice from the American CoUoj" of Physidan ..
Annal! effn,,,,n,,/ Medicine, 148(9), 68tH>S4.
Secrist, J. (2003). OSleoporo.>i .. P.rt IV. Rapid n:viewof drug
therapies (A to Z) for pKVcnting male o,lOOporosis/fraclun:s.
IJroIosy Nursing, 23(2), 168-]74.
Wans, N. B. (2003). Bi.phosphona,e tr ... tmem of osteoporosi .
Clinical Geri",ric MedidllC,I 9( 2), 395-414.
Chapter 48
Bayliffe, A. I., Brigandi, R. A., VI"tlkin .. H. /., & lfvkk, M. P. (2004).
Emaging therapeutic targets in psoriasi . Cu,""'t Opinion' in
4(3), 306-3 10.
Fox, L P., Merk, H. E, & Biehrs, D. R. (2006). D",ma,ological
pharmawlogy.ln l. L Brunton,l. S. Lazo, and K. L Parka (Ed . ),
Goodman";' GiI",,,n'. The p/ulrmlUlcgical ba.i,ofth.",pt"'1<tic.
( ] Ith ed., pp. 1679-]7(6). Now York, NY: McGraw- Hill
/e.itus, /. (2007). Rosacea rcqui..,. multifaceted approa,h.
DermtltoWgy Tim,., 28{] ), 50-<;3.
Lrbwohl. M. (2003). Psoriasi . 361. 1]97- 1206.
Leung, D. Y.,& Boguniowicz. M. in allagic skin
disca .. A/Jersy ,,,,d QiniaJ 1II(Suppl. J),
S805--S812.
Murphy, K. D., Ltt,). 0 . &Hemdon, D. N. ( 2003) . Qurem
phamla>lhrrapy for th. Ueatmmt of so ... ae bum .. Xpero
Opinion on Pham,aroth,,,,py, 4(3), 369-384.
Nash, K (2007). Options stiU limited for age-old problem.
De,mtltoWgy Tin".., 28(6) , 40--41.
Schwanz., R.A.,lanuS2., C.A., & lanniger, C. K. (2006). Seborrheic
d.rmatiti .. An",rican Family Phy.icitln, 74(1), ]25-130.
Smith. G. (2003). Cutaneous expression of cytochrome P-450
CYP25: Individuality in regulation bytheraprutic agenlsfor
psoria,i. and skin d;,.a .... La""", 361, 13.J.6-]344.
SmoUnski, K. N., & Yan,A. C. ( 2004). Acne update: 2004. Curren,
Opinion in 16( 4),385-391.
Snow, M. (2007). Thelruth about "",bie . Nursing, 37(2), 28- JO.
ChaptQr49
Anterican Academy of Family Phy,icians and American Academy of
Pediatrics. ( 2004). Diagn""" and ""'nage"",n, of at1t,e e,iti, medic.
lktri" ... d September 8, 2008, from http://www.aafp.orglonline/
en IhonlC/clinicall din icaln:-c", aom.html
Brs, S. L, & Abramo, T. /. ( 20(4). Otiti xterna review. I'fdiarri<;
Emers""<Y CAre, 20(4) , 2>0-256.
Fingc:re{, M. (2007). Undemanding glaucoma medication .. Rview
efOptometry. 144, 13- ]5.
Frirdman, D. (2007). Primaryangk dO,Un:-glilUOOIllil. RITieo.ui
Optometry, 144, 26-27.
H"nd . .. c,). D.,S. Ropuano, C.). (2006). Ocular phumacolosy. [n
L. L Brunton, /. S. Law, and K. L. Palker (Ed .. ), Goodman do-
Gilm"n:' The ph,,'macologic,,1 00.;. ef ( 11th ed.,
pp. ]707- 1737). Now York, NY: McGraw-Hill.
McCartor, D., Courtney, A., 8< Porta, S. (2007). Cernmm impaction.
AmN'ican fumily Physicitln, 75(10), ]523- ]528.
Osguthorpr, r. D., & Nid .. n. D. R. (2006). Otitis extema: Rc ... iowand
clinical Family Physician, 74(9), 1510-1516.
Schw.nz., K.Io.., & Bud. nz. D. B. (2004). Current managemmt of
glaucoma. Opinicn in Oph,lwlmcltJsy, 15(2) , 119-]26.
Tripathi, R. C., Tripathi, B. J., & Haggc:ny, C. ( 2003). Drug-induad
glauwmas: and managc:ment. Dntg5llfrty, 16(]] ),
749-767.
Wrighl, /. (2005). Common ear problem' in the primary care .. lIing.
]0""",/ efCAmmuni,y Nursing, 19(9). 4J.--46.
LibraryPirate
ANSWERS
Chapter 1
to Cri tia l Thinking QUHtion5
The patient may choose OTC drugs nth"" than more
(<<live prescription medications for a variety of reOl5ORS.
arc drugs do not require the palko! to SoU a health care
provider to write a prtseription for the drug. Dy not see-
ing a heoalth care provider, the patient saves lime and
monty. ore drugs art obtained much more easily than
pres<:ription drugs. Patients often think they can rife<:
lively Irtat themselves and that OTC drugs do 001 have as
many side effects as prescription drugs.
2 The FDA is the agency responsible for detennining
whether prtScription and OTC drugs may be used for
therapy. By reviewing the availability of safe, effe<:tive
drugs. the FDA is respo/lSibJe for keeping unsafe and in-
effective drugs off the market. Another of the agency's
goals is to improve the heoalth of Americ:ms and ensure
that drug infonmtion is clear and uoSily understandable.
Over the yeaN, the scope of Ihe FDA has been broadened
to include informat ion on biologics, wruch include
.serums, vaccines, and blood products. The FDA also has
the authority to recommend civil penalties if the guide-
lines are not followed and to remove dietary supplements
that cause a significant risk to the public.
J The FDA takes put in the poslmarketing surveillanu
stage of the drug approval process. In this phase, the drug
is monitored for harmful effects in the larger population.
The FDA hokb public meetings 10 receive feedback from
patients and organizations reg.;mijng the safely and effec-
tiYt'I1CS5 of new drug therapies.
4 Nunes are responsible for the safe administration of med-
ications, monitoring for therapeutic and adverse effects of
those drugs,aod for providi"8 education for their patients
who are taking dfll85. Learning phannacology, the proper
administr.ation of medications, and patient education are
all nursing responsibilities. During Ihe drug approval
Proa.'$S, $Orne nurses may administer medications to pa-
participating in phase II and III clinical trials, but all
nurses participate in phase IV p05tmarketing surveillance
by reporting adverse drug reactions.
Chapter 2
Answen to Crit ical Thi nking Queltions
The therapeutic ciassiflClltion is a method of organiring
dr ugs based on their therapeutic usefulness in treating
particular di.sea.ses. The pharmacologic dassifi cat ion
meN 10 how an agent worb at the molecu1ar, tissue, and
body system levels. A beta-adrent!'gic blocker is pharma-
,
Appendix 0
cologie; an oral contraceptive is therapeutic; a laxalive is
therapeutic; a folic acid antagonist is plulrmacologic; an
antianginal agent is thenpeutic.
2 Prototype-drugs exhibit typical or essential features of the
drugs withi n a specifK dass.
J Gmeric advant;ases include cost lavings to the patient
and the fact that only one name is assigned for the drug;
therefore, the name is less complicated and ea5ier to re-
member. However, because gmenc drug formularies may
be different, the inert ingredients may be somewhat dif-
ferent and, consequently, m;ay affect the abili t y of the drug
to reach the target cel ls and produce an effect.
4 Schedules refer to the potential for abuse. Theseschedules
help the nurse identify the potential for abuse and require
the nurse to maintain complete records for aU quantities.
The rugher the abuse potential, the more restri ctions are
plated on the health care provider and the mUngof remls.
S This Schedule III d rug is a cont rolled substance restrkted
by the Controlled Substance A.c t of 1970 and is regulated
by the DEA. A Schedule 111 drug has a moderate potential
for abuse aoo physica.l dependency and a high potential
for pS}'l:hoJogjc dependence .
Chapter]
Amwe.n to NCLEX-RN. Review Questions
I Amwer:'
Rationale Tbe primary responsibility of the nurse is to en
sure patient safety when administering prescribed medica.-
tions. Pati ent includes much more than
watching p.1lient take medica.tions.Accurate health care
provider ordeN are a p.1rt of ensuring safe medication
ministration. Cog"ifive Le.'tl: Comprthension. Nursing
PrCH:dS: Implementation. Patient Nerd: Health Promotion
and
2 An.fwrr: J
Rationale: The enteral route involves the process of swallow-
ing by definition. Cognitive Le.'eI; Comprehension.
NUNing PrCH:eu.: Assessment. Nerd: Health Promo-
tion and Maintenance.
3 J
Rationale: This question :lSks for the highest priority; there-
nre, all the answers al't correct. but one should stand oul as
the first action the nurse should take. Think about patient
safety. In this example. t he drug luis been nMY prescribed;
thel'tfore, notifying the health care provider of the patient's
reaction takes priority SO that new medication orders can be
received to add/l.'55 the allergic reaction and to discontinue
the present order. Cognirive u,-eL Analysis. NUNinR Proem:
Implemmlation.l'fIril'"t Need: Physiological Integrity.
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796 AppeoolxO
4 NtSWer: 2
Rationale: STAT means immediately. ASAP orders should be
administered within 30 minutes. Cognitive woe/: Applica-
tion. Nursing Process: Implementation. Patient Need: Phys-
iologicallntegrity.
5 NtSWers: 2, J, 5
Rationale: Enteric-wated tablets are designed to dissolve in
the alkaline environment of the small intestine. Sustained-
release medications dissolve wry slowly over an extended
period for a longer duration. IV medications are designed to
enter directly into the bloodstream. Liquid forms or finely
crushed tablets are the preferred forms. Cognitil-e w'el:
Application. Nursing Process: Implementation. Patient
Need: Physiological Integrity.
6 An.s ... .,,": 4
\'lhile a patient who is NPO for surgery is not usually al-
lowed anything to eat or drink, crucial medications such as
drugs to control blood sugar may be allowed or a different
form (e.g., insulin by injection) may be givt'n. The nurse
should contact the health care provider and check if any ad-
ditional orders are needed. Cognitive Level: Analysis.
Nursing Process: Implementation. Pa tient Need: Physio-
logical Integrity.
Answers to Critical Thinki ng Questions
Although the nurse is responsible for safe medication ad-
ministration, errors continue because many disciplines
are responsible for safe and accurate drug administration.
Many steps are involved in the safe administration of
medications, and there are multiple points where errors
can occur.
2 To help ensure drug compliance, the nurse and patient
should formulate an individualized plan of care using the
nursing process. Including the patient in this process en-
ablcs the patienl to psrticipsle fully, which encouragcs
compliance with the treatment plan.
3 The IV route has the fastest onset because medicationsare
administered directly into the bloodstream. IV medica -
tions also bypass the digestive system and the first-pass ef-
fect. \'lhen administering parental medications (IV,
intradermal, subcutaneous, and 1M routes), the nurse
must ensure that aseptic techniques are strictiy U.'ied.
4 The metric system is much more accurate than thehouse-
hold or apothecary system. Using the metric system helps
ensure that the safest, most accurate doses are prepared
and administered.
Chaptar4
Answers 10 NCLEX-RN" ReviewQuestions
I Answer: I
Rationale: Some medications can be affected by foods, bewr-
ages, or other drugs. The effect of calcium, iron, and magne-
.iwn on tetracycline i< an e""mple of a food-drug
interaction thM OCCllrs in the ah_<Clrption pm"""' _
2 Answer: I
Rationale: The blood-brain barrier may cause difficulty in
treating tumors. Most antitumor medications do not cross
the blood- brain barrier. Cognitive ul'el: Anal)'Sis.
Nursing Process: Assessment. Pmient Need: Physiological
Integrity.
3 Answer: 1
Rationale: The liver is the primary site of drug metabolism.
Patients with severe liver damage, such as that caused bycir-
rhosis, will require reductions in drug dosage because of the
decreased metabolic activity. Cognitive Level: Analysis.
Nursing Process: Implementation. Patient Need; Physio-
logical Integrity.
4 Allswer:4
Rationale: Some oral drugs are rendered inactive by hepatic
mt'tabolic reactions, during the process known as the first -
pass efft. An a1tt'rnatiw routt' may need to bt' assessed.
Cognit ive Application. Nursing Process: Implemen"
Mion. Patient Need: Physiological Integrity.
5 Answer: J
Rationale: The kidneys are the primary site of excretion. Rt' -
nal failure increases the duration of the drug's action be-
cause of decreased excretion. Tht' patient must be aS5eS&ed
for drug toxicity. Cognith-e uvel: Anal)'Sis. Nursi ng
Process: Assessment. Patient Need: Physiological Integrity.
6 A"S1>-ers:I,2,J
Rationale: Glandular activity is an elimination mechanism
in which water-soluble drugs are excreted into saliva,
sweat, and breast milk. Secretion of drugs in the bile is
known as biliary excretion. Cognit h-e Ln'd: Application.
Nursing Process: Implementation. Pil tient Need: Physio-
logicallntt'grity.
Answers to Critical Thinking Questions
For most medications, the greatest barrier is crossing the
many membranes that separate the drug from its target
cells. A drug taken by mouth must cross the plasma mem-
branes of the mucosal cells of the gastrointestinal tract
and the capillary endothelial cells to t'ntt'r the blood-
stream. To leave the bloodstream, it must again cross cap-
illary cells, travel through intt'rstitial fluid, and enter
target cells by passing through their plasma membranes.
Dt'pending on the mechanism of action, tht' drug rnay
also need to enter cellular organelles, such as the nucleus,
which are surrounded by additional membranes. \'lhile
seeking their target cells and attt'mpting to pass through
the various membranes, drugs are subjected to nwnerous
ph)'Siologic substances such as stomach acids and diges-
tive enzymes.
2 The plasma half-life is the time required for the concen-
tration of the medication in the plasma to decrease to half
its initial value after administration. This value is impor-
tant to nurses because the longt'r the half-lift', the longer
it tala>. the mooication to be excreted_ Th .. medication
will then pmilllce a loneer effect in th" hody. half_lif"
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determines how often a medication will be administered.
Renal and hepatic diseases will prolong the halflife of
drugs, increasing the potential for toxicity.
3 The degree of ionization of a drug affects its absorption.
The pH of the local environment directly influences drug
absorption through its ability to ionize the drug. The re-
lationship between pH and drug excretion can be used in
critical situations to either increase or decrease excretion
of the drug.
4 Many oral drugs are rendered inactive by hepatic meta-
bolic reactions. Alternative routes of delivery that bypass
the fin;t-pass effect (sublingual, rectal, or parenteral
routes) may need to be considered for these drugs.
Chapter 5
Answers to NCLEX-RN" ReviewQuestions
I Answer: 2
Rationale: Unpredictable and unexplained drug reactions
are labeled idiosyncratic. Cognitil-e Lnel: Analysis.
Nursing Process: Implementation. Patient Need: Physio-
logical Integrity.
2 Ans"",r, 1
Rationale: An antagonist occupies a receptor site and pre-
vents endogenous chemicals from acting. An agonist pro-
duces the same type of response as the endogenous
substance. A partial agonist is a medication that produces a
weaker response than an agonist. Cognitive Lewl: Applica-
tion. Nursing Process; Implementation. Patient Need:
Physiological Integrity.
3 Answer: 2
Rationale: The most important property is efficacy.
Efficacy is the magnitude of the maximal response that can
be produced from a drug. Cogflitive Level: Application.
Nursing Process: Implementation. Patienf Need: Physio-
logical Integrity.
4 Answer: 1
Rationale: The tenn efficaciou5 refers to the response that
can be proouced from a particular drug. Cognitil-e Lele/:
Application. Nursing Process: Implementation. Patient
Need: Physiological Integrity.
5 Answer:4
Rationale: A drug that is more efficaciou5 produces a higher
maximal response. If other drugs for pain were not effective
in relieving the pain, morphine would be considered to have
a greater efficacy in relieving this type of pain. Cogrritil-e
Level: Application. Nursing Process: Implementation.
Patient Need: Physiological Integrity.
6 Answer: 2
A narrow therapeutic index indicates that there is only a
small amount of difference between the dosage needed to be
effective (EO,,) and the dosage that will be toxic (LO,,). Ex-
tra caution should be taken with drugs with a narrow ther-
index to giviJlj,lan exce&6ivedose to ensure
Appendix D 797
patient safety. Cognitive Level: Application. Nursing
Process: Implementation. Patient Need: Physiological In-
tegrity.
Answers to Critical Thinking Questions
The other SO% of the patients did not experience the de_
sired effect from the dose.
2 An agonist binds to the receptor and produces the same
or a greater response than the endogenous chemical. An
antagonist occupies a receptor site and prevents the en-
dogenous substance from acting. Antagonists compete
with agonists for binding sites. An antihistamine would
most likely be an antagonist.
Chaptllr6
Answers to NCLEX-RN" ReviewQuestions
I Answer: I
Rationale: NANOA classifies a nursing diagnosis as a clini-
cal judgment about individual, or community re-
sponses to actual or potential health/life processes. Per
NANOA, nursing diagnoses provide the basis for the selec-
tion of nursing interventions to achieve outcom ... for which
the nurse is accountable. Cognifile Lewl: Analysis. Nursing
Process: Assessment. Patient Need: Health Promotion and
Maintenance.
2 Answer: 2
Rationale: Goals f(X;us on what a patient should be able to
achieve and outcomes provide the specific, measurable cri-
teria that will be used to measure goal attainment. pa-
tient will demonstrate self-injection of insulin (what should
be achieved) using a preloaded syringe, inlV the subcuranams
tissue of the thigh prior to (specific, measurable
criteria used to measure goal attainment). Cognifile ul-el:
Application. Nursing Process: Evaluation. Patieut Neelt
Physiological Integrity.
3 AnSlwr: I
Rationale: NANOA defmes Oeficient Knowledge as lacking
the specific knowledge necessary to make informed choices.
Noncompliauce is incorrect because it assumes the patient
has made an educated decision about the treatment plan. By
stating that she udid not want to gain weight and is afraid of
needle marks,w this patient has identified a lack of knowl-
edge related to the effects of insulin (effect on weight} and
administration techniques (needle marks). The nurse plays
a key role in educating the patient about the effects of in"
sulin and appropriate techniques. Coglrifil-e
Lelel: Application. Nursing Procrss: Intervention. Patient
Need: Psy,hologiQ[ Integrity.
4 Answer:4
Rationale: Evidence of therapeutic benefit (i.e., efficacy) is
the most important factor to assess when evaluating the ef
fectiveness of any Cognitile Lelel: Application.
Nursiug Process: Evaluation. Patienf Need: Physiological
Integrity.
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798 AppeoolxO
5 N,swer: 4
Rarionale: The purpose of evaluation in the nursing process
is to determine whether the goals and outcomes have been
adequately met by the patient. Cognitive Le,'el: Application.
Nursing Process: Assessment. Patient Need: Health Promo-
tion and Maintenance.
6 Answer: J
Rationale: By monitoring the patient for both therapeutic and
adverse effects, the nurse carries out the e"aluation phase of
the nursing process. Cognitive l.enr: Analysis. Nursing
Procen: Evaluation. Patient Need: Physiological Integrity.
Answers to Critical Thinking Questions
The nurse would need to determine whether the patient
and her mother have had sufficient information about the
patient's type 1 diabetes in order to make appropriate
choices regarding the patient's eating habits, weight, and
diabetes management. A dietary history should be as-
sessed including frequency of meals and snacks, types of
foods consumed, overall number of calories per day, and
theavailabilityofhealthyfood choices at home,at school,
and during athletic activities. An assessment of the
type(s) and amount of insulin taken as well as an assess-
ment for adverse effects should also be gathered. Cost is-
sues related to insulin administrati on or equipment for
monitoring should also be discussed with the patient and
mother. If indicated, a physical exam should be recom-
mended because weight loss is a symptom of uncon-
trolled type I diabetes. The nurse would also explore the
patient's and her mother's understanding of the diagno-
sis, their npectations about the treatment plan, and any
previous teaching given, correcting any misWlderstand-
ings or misinfonnation. Noncompliance asswnes the pa-
tient has made an educated decision about the treatment
plan. If insufficient knowledge about the condition, treat-
ment plan, or care needs is the reason behind the health-
seeking behavior in this case example, noncompliance
would be an inappropriate nursing diagnosis.
2 Since an insulin pump will be a new component of the
patient's treatment plan, the following nursing diagnoses
would be appropriate for this patient:
Deficient Knowledge (related to new or changed treat-
ment routine)
Ineffective Therapeutic Regimen Management (related
to deficient knowledge or altered compliance with pre-
scribed treatment)
Risk for Infection (related to implanted subcutaneous
catheter used for delivering insulin via pwnp)
Risk for Injury (related to adverse drug effects, hypo-
glycemia or hyperglycemia related to insulin dosage)
3 State Nurse Practice Acts and accrediting organizations
such as JCAHO consider patient education as a primary
role for nurses. In order to ensure the safe and effective use
of medications, patient education concerning medications
should include the therapeutic uses and expected effects,
monitoring for side and adverse effects and how to handle
them, how to correctly administer the medication, and any
ul1",r r"'"luir""'''lJi.'; lJ.,.,u.,u lu "'lSur"
effect. Each time a medication is administered presents an
opportllllity for pMient education and small portions of
information given over time are often better than large
amoWlts of inforn13tion presented all at once. It also pro-
vides the patient with an opportunity to ask questions
about the medications or the treatment plan.
ChaptQr 7
Answers to NCLEX- RN" ReviewQuestions
1 Answer: J
Rationale: Isotretinoin (Accutane) is FDA pregnancy cate-
gory X and is contraindicated during pregnancy. It should
not be used at all during pregnancy. Cognitive Level: Appli-
cation. Nursing Process: Implementation. Patient Need:
Physiological Integrity.
2 Answer:4
Rationale: Administration immediately after breast-feeding
allows as much time as possible for the medication to be ex-
creted from the mother's body prior to the nellt feeding. The
other options do not provide enough time forthe medication
to be e.xcreted. Cognith-e Lel'el: Analysis. Nursing Process:
Implementation. Patiem Need: Physiological Integrity.
3 Answer:J
Rationale: Medications should be stored in child-resistant
containers and out of reach of children. Patients with
arthritic hands may request special easy-to-open medica-
tion containers to make self-administration easier. These
two situations may be in conflict if elders and children are
present in the same home. Toddlers are at risk for poison-
ing. If the patient cares for a young child, explore options for
keeping the medication away from the child such as using a
locked box or other safe storage options. lltis would allow
the patient to continue to visit with or care for young chil-
dren if desired. Cognith'e Lewl: Analysis. Nursing Process:
Evaluation. Patienf Need: Physiological Integrity.
4 Answer:4
Rationale: Toddlers may resist taking medications. Short ex-
plaruotions foUowoo by immedial .. (kind but ftrm) dmg ad_
ministration are best. Children should not be told that
medicine is candy for safety reasons. A toddler is not able to
make a decision regarding medication administration. When
medication is mixed with liquids or other food products, a
small amount should b .. used; g oz is too much liquid to use
for mixing. Cognifi ve Lel-el: Analysis. Nursing Process: Im-
plementation. Pafient Need: Physiological Integrity.
5 Answer: I'IISfUS /mera/is
Rationale: The middle third of the vastus lateralis muscle is
the preferred site for intramuscular injection in the new-
born. The middle third of the rectus femoris is an alternate
site, but its proximity to major vessels and the sciatic nerve
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requires caution in using this site for injection. Cognithe
Level: Comprehension. Nurs ing Process: Implementation.
Patient Need: Physiological Integrity.
6 Answer:]
Rationale: V-.'ith each visit, the nurse should take a medica-
tion history of aU OTC and prescription medications, not-
ing any new medications not previously mentioned. A
pharmacy history" will draw atto:>ntion to tho:> possibility
that the patient is obtaining medications from more than
one pharmacy, a potential problem in polypharmacy.
Cogllitive Analysis. Nursillg Process: Implementa-
tion. Patiell t Need; Physiological Integrity.
Answers to Crit ical Thinking Questions
Pyelonephritis is frequently associated with preterm la-
bor in pregnancy. Before initiating antibiotic therapy, the
nurse should first determine the fetal gestational age.
The potential for a drug to be teratogenic is highest dur-
ing the first trimester. The nurse should also look up the
pregnancy classificat ion 01 the antibiotic. Selected agents,
such as tetracyclines, should not be used during preg-
nancy. The nurse should address any concerns regarding
the drug category with the health care provider.
2 Prior to considering a sedative agent, the nurse should as-
sess the patient for other physical causes of confusion. For
example, in the frail elderly, alterations in electrolytes,
drug side effects, and rapid environmental changes can
contribute to confus ion. Attempts at reorientation should
be made. The nurse should determine how diazepam
(Valium) is distributed and metabolized. Valiwn is a fat-
soluble drug; thus, because elderly patients have increased
total body fat, the drug has a much longer half-life. In ad-
dition, numerous drugs decrease the metabolism of di-
azepam and may contribute to an increased half-life and
enhanced CNS depression. If sedation is deemed neces-
sary, other drugs should be wnsidered.
3 The nurse should consult with the providerorpharmacist
regarding the need to repeat the dose. Many oral e!i:tirs
are absorbed, to some degree, in the mucous membranes
of the ora 1 cavity. Therefore, the nurse may not need to re-
peat the dose. Acetaminophen can also be toxic to the
liver in doses only sl ightly higher than normal and extra
caution should be used for all drugs containing acetamin-
ophen. The nurse should consider using an oral syringe to
accurately measure and administer medications to in-
fants. The syringe tip should be placed in the side of the
mouth, not forced over the tongue. Conditions affecting
the GI tract, such as gastroenteritis, can affect drug ab-
sorption because of their effect on peristalsis.
ChaptQrS
Answers to NCLEX-RN8 ReviewQuest ions
1 Allswer: 2
Rationale: Many cultural groups believe in using herbs and
other alternative therapies either along with or in place of tra-
Appendix D 799
ditional medicines. The nurse should examine bow these herbal
and alternative therapies will affect the desired phannacother-
apeutic outcomes of the prescribed medications. The physician
or prescriber should be notified if the patit'nt refuses to take the
prescribed medications and for any questions the nurse may
have concerning the safetyof the herbal and prescribed medica-
tion interactions. Level: Assessment. Nursillg
Pracess:Application. PatielJl Neett Physiological Integrity.
2 AnswerJ: 1, 2,]
Ratianale: Writtt'n materialsallowtht' patient and fumilyto re-
view information on additional occasions at borne, but up to
48% of English-speaking patients do not the basic ability
to read, understand, and act on health infomlation. This rate
is even higher among non-English-speaking individuals and
older patients. The nurse must be aware of the patient's liter-
acy level and take appropriate action to ensure that informa-
tion is understood. An assessment of visual impairmt'nt
should also be made and large-print matt'rials provided when
necessary. Cognitive Assessment Nursing Process:
Analysis. Patiellt Need: Health Promotion and Maintenance.
3 AIIS",er: 2
Rationale: Women seek health care earlier than men. Men
and women are both affected by Alzheimer's disease; how-
ever, women are one and a half to three times more likely to
develop the disease. Cognitive Analysis. Nursi llg
Process: Diagnosis. Patient Need: Health Promotion and
Maintenance.
4 AIIS",er: 2
Rmiollale: When patit'nl5 have strong spiritual or religious be-
liefs, these may greatly influence their perceptions of illness
and their preferred modes of treatment. III health and spiri-
tual issues can have an impact on wellne:ss, nursing care, and
pharmacotht'rapy. !.n-el: Analysis. Nursing
Process: Assessment. Pafient Need: Psychosocial Integrity.
5 Am",er: 1
Rationale: Slow acetyiators experience a delay in drug me-
tabolism in the lher. This can caust' the drug to build to
toxic levels and result in drug toxicity. Coglliti>-e Ap-
plication. Nurs illg Process: Evaluation. Patient Need: Psy-
chological Integrity.
6 AIISwer:4
Rationale: To treat a patient holistically, the nurse seeks to
undt'rstand the multiplt' factors that may contribute or help
solve a specific patient problem. By asking for the patient's
own evaluation of the problem, the nurse can detennine the
severity of the problem and the impact it has on normal ac-
tivities. These determinations help to develop a plan of care
specifically tailored to individual patient needs. Cognith-e
!.nel: Application. Nursing Process: Assessment. Patient
Need: Safe, Effective Care Environment.
Answers to Crit ical Thinking Quest ions
The primary concern for this patient would be the potential
for drug-food interactions. Warfarin (Coumadin) achieves
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800 AppeoolxO
its anticoagulant effect by interfering with the synthesis of
vitamin K-dependent clotting factors. The antiooagulant ef-
fect ofCoumadin can be decreased by a diet high in vitamin
K. Fresh greens and tomatoes from the garden areexceUent
sources of vitamin K. The nurse must include questions re-
lated to the dietary intake of these foods. It is conunon for
rural people to "eat out of their gardens" during the grow-
ing season. The nurse must also determine whether other
medications have been added to the patient's regimen that
could interfere with the 3l:tion of Cownadin.
2 As women age, they experience a 10% decrease in total
body water. In general, body weight also decreases in this
aging population. The nurse should carefullyas.sess the pa-
tient's current weight and compare it with the previously
docwnented weight. In addition, because this patient's
body weight has decreased, she may also have decreased
serum protein. The dose of furosemide is dependent on the
degree of protein binding; therefore, less serum protein
could make the drug more pharmacologically active. The
patient may need to have the dosage adjusted.
3 Per assessment in tlte clinic, it was noted that the patient
is possibly a migrant farm worker, has limited English
proficiency, and has a condition wltich has developed
over time (abscessed teeth). This may indicate a potential
lack of heal tit care, a knowledge or a therapeutic manage-
ment deficit, or other related concerns. Cost issues, fear
related to potential immigration status, lack of available
Itealth care, misunderstandings related to limited English
profici,mcy, or lack of time available to leave work and
take care of his health care needs could all be factors lead-
ing to his condition. Further holistic assessment of the
patient will help the nurse determine probable reasons for
his present condition.
ChaptQr9
Answers 10 ReviewQuestions
I Answer: 4
Rationale: Nurse pract ice acts encompass all aspects of nurs-
ing, including the definition of professional nursing, med-
ication administration, and definition of standards of care.
Cognitive Level: Analysis. Nursing Process: Implementa -
tion. Patient Need: Safe, Effective Care Environment.
2 Answer:]
Rationale: The nurse is responsible for docwnenting med-
ication errors and completing an incident report for review
by the facility's quality assurnnce personnel. Cosniti,e
Level: Analysis. Nursing Process: Implementation. Patient
Need: Safe, Effective Care Environment.
3 Answer: I
Rationale: Prior to administering medications, the nurse
should assess renal and liver function and impairments of
other body systems that may affect pharmacothernpy. This
is especially important when administering medications to
elderly and severely debilitated patients. Cogniti,e LewE:
Analysis. Nursing Process: Assessment. Patient Neetl: Phys-
iologicallntegrity.
4 Answer:4
Rationale: The Foodand Drug Administration (FDA) and the
National Coordinating Council for Medication Error Report-
ing and Prevention (NCC MERP) encourage nurses and
other health care professionals to report medication errors.
This aids in e.'l:lmining interdillciplin.1ry causes of medication
errors and developing methods to prevent them, thereby pro-
moting medication safety. Cognitive Le.-el: Analysis. Nursing
Process: Implementation. Patient Need: Safe, Effective Care
Environment.
5 Ans,,-ers: 1,4,5
Rationale: After a medication error involving a medication
given to the wrong patil.'nt, the nurse must notify the physi-
cians for the patient who received the incorrect medication
as well as the patiem for whom the medication was intended
if the medication was omitted. The medication as given
should be charted on the MAR for the patient receiving the
medication. A facility report of the error, sometimes referred
to as an Report
H
or other related terms, documents
the error and related corrective actions taken. Most fucilities
do not require notation of the error in the nursing notes. Vi-
tal signs should be assessed dependent on the medication
given. Cognithe Le,e/: Analysis. Nursing Process: Imple-
mentation. Patient Need: Safe, Effective Care Environment.
6 Answer: 2
Rationale: This approach best ensures a ooUaboration be-
tween the nurse and patient, allows the nurse to ensure the
medication is taken, and provides an opportunity for the
nursl.' to teach the patient about the medication. Cognithe
Level: Application. Nursing Process: Implementation.
Patient Need: Safe, Effective Care Environment.
Answers to Critical Thinking Questions
The nUTre should be well organized in preparing for drug
administration. The MAR must be assessaI at the begin-
ning of the shift, and the nurse should develop a system
that will serve as a reminder of when drugs are due to be
administered. In most institutions, regularly scheduled
drugs may be administered 30 minutes before and 30 min-
utes after the assigned time. If administered within this
time frame, the drugs are considl.'red to have been given "on
Institutional policies vary and should be consulted.
2 This order as written does not oontain an indication for
"right dose."TylenoI3 could represent a oombination drug
of acetaminophen and codeine (i.e., "Tylenol #3 "), or three
plain Tylenol tablets,given orally. A potential error is to as-
swne that the healthcare provider meant for the palienllo
have one "Tylenol #3" tablet by mouth. Prior to adminis-
tering the dose, the nurse should consult with the health-
care provider to clarify the intent of the order.
3 There are nwnerous members of the health care team who
may have contributed to the medication error for this pa-
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tient. The prescriber could have assured that the
ate dosage for the weight of the patient was ordered. The
nurse may have checked the KFive Rights
M
of drug admin-
istration but did not note that the dost' as writtt'fl was not
in the aa:eptable range giVt'fl the patit'flt variables of age
and weight. The phannacist is also respofl'lible for check-
ing the drug against patient-specific variables. In order to
I'[" .. ... r" amI "rr.,..uv" <.Irug all Ill"Ill-
bers of the health care tt'am must work togE1:her to ensure
every drug and administrution meets tht' five Rights. When
new to a unit, particularly when administering unfamiliar
drugs or drugs ordered in different dosages than the nurst'
has administt'red before, it is always saft'r to check the drug
and dose along with patit'nt variables such as weight brlore
giving the medication. The nurse is the last link in tht' chain
of administration and is often key to preventing
tion errolS.
Chapter 10
Answers to NCLEX-RN@> ReviewQuestions
I AnslI"er:4
Rationale: Some herbal products contain ingredients that may
as agonists or antagonists to prescription drugs. Herbal
supplements should not be taken without discussing their U'ie
with the health care provider. Ht'fbal supplements are
ered less potent than prescription medications, but whensim-
ilar drugs arc taken together, there is the potential forodvcrsc
rea,tiofl'l. Cogrrifhe woe/; Analysis. Nursing Proem: Imple-
mentation. Patient Need: Physiological Intt>gl"ity.
2 Answer: I
Rationale: Natural products contain many active ingredi-
ents, many of which havt' not been tested or identified. Pa-
tients with known allergies to food products or medicines
should seek medical advice befort' using herbal supple-
ments. Dietary supplt'ments must state that tht' product is
nOI intended to diagnose, treat,curt', or prevt'nt anydist'ase.
Cognitive wel: Analysis. Nursing Process: Implementa-
tion. Patient Need: Physiological Integrity.
J Answer: 2
Rationale: Saw palmetto is used to relieve urinary problems
related to prostate enlargement. Cranberry juice (or the
berries) is used to prevt'nt urinary tract infectiofl'l. Soy,
evening primrose, and black cohosh art' used for mt'nopausal
symptoms. Cognitive uwel: Analysis. Nursing Process: Im-
plt'mentation. Patient Need: Physiological Integrity.
4 Answer:4
Rationale: Fevt'rfew may interact with aspirin, heparin,
NSAIDs, and warfarin to cause increased bleeding.
Cognitive Level: Analysis. Nursing Process: Assessmt'n1.
Patient Need: Physiological Integrity.
5 Answers:l,2,J,5
Rationale: Serotonin syndrome is a rare but potentially life-
threatening medical condition that may occur when
App<>ndlx D 801
tients are taking two or more drugs, one of which is a selec-
tive serotonergic medication. Synlptoms include agitation,
dizziness, sweating, and headache. Patients should discon-
tinue use of tht' medication and seek medical care immedi-
ately. Cognitive Lelel: Analysis. Nursing Process:
Assessment. Patient Need: Physiological Integrity.
6 Answer:J
Ratiol/ale: Specialty supplements are nonherbal dietary
products used to enhance a wide varie-ty of body functions.
In general, specialty supplements have a legitimate rationale
for their use. But tht' link between most specialty supple-
ments and their claimed benEfits is unclear and the body
may already have sufficient quantities of the substance. Tak-
ing additional amounts may be of no benefit and large
amOWl1S of some supplements may be harmful. Specialty
supplements may give patients false hopes of an easy cure.
Cognitive Ul't:/: Comprehension. Nursing Process: Imple-
mentation. Pafient Need: Physiological Intt>grity.
Answers to Critical Thinking Questions
Tamoxifen is a selective estrogen receptor modulator
(SERM) that acts by preventing estrogen from binding to
the estrogen rect'ptor in breast cells. Therefore, breast cell
proliferation is inhibited. Many women assumt' that be-
cause they are taking a SERM, estrogen replacement is in-
dicated. In fact, tamoxift'n's effect in tissues other than the
breast is similar to that of estrogen. Tamoxifen does not
cause menopause and does not prevent pregnancy. If the
patient takes a product, it may interfere with
the desired action of tamoxifen. Her concern should be
acknowledged, but she should be warned not to consume
any herbal product without first cOfl'lulting ht'r health
care provider.
2 Both garlic and gifl'leng a potential drug interaction
with the anticoagulant warfarin (Coumadin). It is known
thm ginseng is cap.1ble of inhibiting platelet activity.
Wht'n taken in combination with an anticoagulant, these
herbal products are capable of producing increased
bleeding potential.
3 St. John's wort interacts with multiple drugs. It is impor-
tant that the patit'nt stop taking St. John's wort at least
3 weeks prior to the surgery, be'3USt' it ,an pott'ntiate se-
dation when combined with CNS depressants and opiate
analgesics. St. John's wort can also decrease the effects of
anticoagulants.
Chapter 11
Answers to NCLEX-RN@>ReviewQuestions
I Answer::!
Rationale: Some patients and health care professionals believe
that therapeutic use of scheduled drugs creates large numbers
of addicted patients. Prescription drugs rarely cause addic-
tion when U'ied according to aa:epted medical protocols. The
risk of addiction for prescription medications is primarily a
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802 AppooolxO
function of the dose and the length of thernpy.
un:/: Application. NUTting ProU'lJ; Impl ementation.
Patienf Need: Physiologkal Integrity.
2 Nuwer: 2
Rationale: ToIl'!"anc:e is a biologic condition that occun when
the bodyadaplS 10 a subslalXe aftl'!" repeated administration.
Ovl'!" time, higher closes of the drug are required to prodoct'
the samt initial efftct. uw/: Application. NUNi"g
Process: AMessmmt. Altim! Nd: Physiological Integrity.
3 Answer:"
Rationnle: Use of marijuana slows mO(Qr activity. decreases
coordination, and causes disoonneded thoughts, feetinS'l of
parnnoia, and euphoria. It iIXreases tnirst and crnving for
food,especiaUy chocolate and O(htr candies. Heroin produces
a britf, intense rusn of euplloda sougllt by addicts. Individu-
als exptrience a rnnge of CNS effiXIS from I!Iltreme plea:;;ure
to Mowed body activities and profound sedation. Signs in
clude constricted pupils. an increase in the pain tnresllold,
and rc:;piratory Crack cocaine produces f.,.,linS"
of intense i"'Uphoria, a dene:lSe in hunger, analgesia, illusions
of physical strength, and inntased sensory perception. Larger
doses magnify these effeclS and also cauS(' rnpid heartbeat,
sweating,dilation of the pupi!s,and an elevated body temper
ature. Large doses ofb,arbitur:lles drugs suppress the respira-
tory centers in the brain. The uS('r maystop breathing orlapS('
into a coma. Cognithoe Le.oel: An.:Ilysis. Nursing Process: As-
sessment. Patient Need: Physiological Integrity.
4 Allswer: J
Rationnle: Patients eJlpl'l"imcing alcohol withdrnwal typi -
cal ly experience tremors, fatigue, anxiety, abdominal
cramping, haUucinations, confusion, seizures, and delirium.
Cognitn'e Lenl: Analysis. Nursing Prouss: Asses.sment.
Patient Need: Physiological Integrity.
S Answers: J, 2, "
Rationllle: Symptoms of nicotine withdrowal indude irritabil-
ity, anxiety. restlessness, hea<:bches, increased appetite, insom-
nia, inability to ooncentrnte, and a decrcaw in heart rnte and
blood pressure. Cognitil'e Leve/: Applkat ion. Nursinf{ Process:
Implementation. Pntient Physiological Integrity.
6 Answer: 1
Ratiollllle: Phpical dependence and psychological depen-
dence may occur together and in drug-seeking behav-
ior. But physical dependtnce occurs as the body adapts to
the substance such that withdrawal symptoms will occur if
the substance is stopptd. Physical withdrawal symptoms do
not occur with psychological dependence altllough an in
tense craving for the substance may be felt. Cognit;"e Le"e!:
Comprehension. Nursing Procel$: Assessment. Patient
Need: Physiological Integrit y.
Answers 10 Critical Thinking Questions
The NationailnSlitute on Drug Abuse offeTS a link titled
Info Fact&, which provides a grut deOll of information
about MDMA (www.drugabuse.gov).This drug is a neu-
rotoxic agent. When taken in high doses it can produce
malignant hyperthermia, which can lead to muscle dam-
age and renal and cardiovascular system failure. Physical
symptoms ofMDMA use include muscle tension, nausea,
rapid eye movemenl, faintness., chills. sWeOlting, increased
heart rale and blood pressure, and involuntary teeth
clenching.
2 The NIDA InfoFacts sheet on steroids (www
.drugabme.gov) points out that aggression is a common
psychiatric side effect of anabolic steroid abuse. Research
indicates that users may e:tperieoce paranoid jealousy. ex-
treme irritability. delusions. and impairtd judgment.
Other symptoms are extreme mood and manic-
like symptoms, even when the user (tports feeling
3 The principal danger associated. with prolonged use of
barbiturates is tolernnce and physical addiction. Barbitu-
rates generatl y lose their effectiveness as hypnotics
within 2 weeks of continued USt. This patient is demon-
strating signs of developing tolerance. He needs 10 dis-
continue the drug gradu.aJly to denease the risk of
complications associated with sudden withdrawal. These
symptoms include severe anxiety, tremors, marked ex-
citement, delirium, and rebound eye movement
(REM) sleep. Today, nonbarbituralts are usually pre-
scribed as firstline hypnotics.
Cha tllr 12
Answers 10 NCLEX-RN" Review Questions
] Answers: J, 5
Rationale: Anthrax affects therespirntory system. Fevl'!", peT-
sisknt cough, and dyspnea are all initial symptoms of in-
haled. anthrax.. Cognitwe Le"el: Analysis. Nurli"g Prouu:
AMessment. Patielft Nud: Physiological Integrity.
2 AlfSlO't'r: 2
Rorionale: The potassium iodine prot ects only the thyroid
gland from 113L No other body orpns art protected by
this medication. Coglfitil'f! Analysis. Nu"i lfg Process:
Implementation. Patient Null: Physiological Integrity.
3 Answer: I
Rationllle: Overstimulation of the oeurotransmitter acetyl-
choline causes convulsiol15 and loss of consciousness within
seconds. Cognitive Level: Analysis. Nu'sillg Procell: Assess-
ment. Patimt Need: Physiological Integrity.
4 AnSlO't'r: 3
Rationale: The antibiotic cipronoxadn (Cipro) has been
used for both prophylaxis and treatment of anthrax.
Cognitivl Lel'e/: Analysis. Nursing Pf'()ess: Planning.
Pafient Need: Physiological Integrity.
5 An",oer: 2
Rationale: The COC has categoriud biologic threau based
on their potential impact on public health. The goal ofbio-
logic terrorism is to cause widespread casualti es. Cognifi.oe
un/: Analysis. Nursilfg Process: Asses.sment. Patient Need:
Safe, EffectiveCare Environmmt.
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6 Answers: 1,2,4,5
Rationale: Nurses and other health care providers may be
consulted by neighbors, friends, and family in the e'"ent of a
potential bioterrorism attack or for how to prepare. Partici-
pating in planning for any type of disaster, recognizing and
reporting key signs or symptoms that may be related to an
attack, having a list of agency resources available, and keep-
ing up-to-date with emergency management protocols are
all ways a nurse may benefit the community. Specific med-
ications, antidotes, vaccines, and supplies are kept in strate-
gic locations by the federal government and are available
quickly for emergency use. They are not part of an individ-
ual's disaster preparedness strategy. Cognifive w-el: Com-
prehension. Nursing Process: Implementation. Altient Need:
Health Promotion and Maintenance.
Answers to Critical Thinking Questions
Mass vaccination of the general public for anthrax and
smallpox should be avoided at this time because there is
ongoing controversy regarding the safety and effective-
ness of these vaccines.
2 KI ifrnken ]'>rior to or immediMely rndiarion
exposure, can prevent up to 100% of radioactive iodine
from l'fItering the thyroid gland and damaging the th)'-
roid tissues. Iodine is an integral component of thyroid
hormone (T, and T.) and as such, KI will concentrute
predominately in the thyroid gland.
3 The SNS is designed to ensure immediate deployment of
essential medical supplies to a community in the event
of a large-scale chemical orbiologicattlck. Push packages
of preassembled medical supplies and pharmaceuticals
are designed to meet the needs of an unknown biologic or
chemical attack. They are strategically located around the
United States, can be deployed rupidl)', and reach any af-
fected community within 12 hours of an attack. VMI
packages are shipped if necessary and require identifka-
tion of the type of chemical or biologic attlck. Theycon-
tlin supplies more specific to the type of attack and can
reach an affected commWlity within 24 to 36 hours.
4 Nurses playa key role in preparing for an emergency of
any kind, natural or human-made, by educating patients
and their communities, M'rving as volunteers for emer-
gency medic.:!1 corp_, Cllrrent knnwledge nf
resources, and in the early detection of possible emer-
gencyconditions. Through educating their patients, fam-
ilies, and communities, they are also a primary source of
information in the prevention of poisonings or for earl)'
treatment.
Chapter 13
Answers to NCLEX-RN'" ReviewQuestions
1 Answer: 1
Rationale: Adrenergic agonists stimulate the sympathetic
nervous system and produce symptoms of the fight-or-
fliJl,ht response. Nausea, vomiting, nervousness, bronchial
App<>ndlx D 803
dilation, and hypertension are potential adverM' reactions
related to the use of adrenergic agonists. Hypotension is a
potential adverse reaction related to the use of adrenergic
antagonists. Cognitive Level: Assessment. Nursing Process:
Application. Pafiellt Need: Physiological Integrity.
2 AII5I.-ers: I, 2, 4
Rationale: Anticholinergics are used in the treatment of
peptic ulcer disease, irritable bowel syndrome, and brady-
cardia because they suppress the effects of acetylcholine
and stimulate the sympathetic nervous system. Anticholin-
ergics may cauM' decreased sexual fWlction because the
parasympathetic impulses are blocked. Urine retention is a
potential side effect of anticholinergics. Cogllifhe Level:
Analysis. Nursillg Process: Diagnosis. Patiem Need: Physi-
ologicallntegrity.
3 AIISM'er: 1
Rationale: Potential adverse reactions associated with the
UM' of adrenergic antagonists include tachycardia, edema,
and heart failure. Bronchodilation is associated with the use
of adrenergic agonists. Cog"itive Level: Analysis. Nursing
Process: Assessment. Patient Need: Physiological Integrity.
4 AnSIO'er: J
Rationale: The nurse should monitor elderly p3tients for
episodes of dizziness caused by CNS stimulation from the
parasympathomimetic. Diaphoresis and dizziness are po-
tential side effects related to the use of bethane.;:hol.
Bethanechol is used to treat urinary reten-
tion. Cognifil"e Level: Application. Nrmi"g Process: Imple-
mentation. Patiellf Need: Physiological Integrity.
5 AII5M'er: 2
Rotionale: Anticholinergic medications slow intestinal
motility; therefore, constipation is a potential side effect.
Heartburn and hypothermia are not associated with the use
of benztropine. Cognifi,e Level: Application. Nursing
Process: Assessment. Patient Need: Physiological Integrity.
6 Amover: 1
Rotionale: Overdosage of parnsympathomimetics (cholin-
esterase inhibitors) may produce excessive sweating, drool-
ing, dyspnea, or excessive fatigue. These symptoms should
be promptly reported. Cognithe Level: Analysis. Nursing
Proem: Assessment. Patient Need: Physiological Integrity.
Answers to Critical Thinking Questions
Terbutaline (Brethine) is a sympathomimetic that was orig-
inall), prescribed for the treatment of asthma. Terbutaline
promotes bronchodilation and therefore reduces bron-
chospasm by inducing smooth-musde relaxation. Today,
terbutaline has found widespread lISe asa torolytic because
it also produces smooth-muscle relaxation in the uterus.
BecauM' terbutaline is a sympathomimetic, the nurse
should prepare the patient for potential a<M!rse reactiofl'l
such as nervousness, tremor, and tachycardia. The nurse
should also teach the patient to take the medication exactly
as directed and on schedule, and instruct on the signs and
symptoms of preterm labor in case they occur again.
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804
2 Bethanechol is a direct-acting cholinergic agt'nt that
works by stimulating the par.asympathetic nervous sys-
tem. The desired effect, in this case, is an increan in
smooth-muscle tone in the bladder. Any side effects
would be related to anoverstimulation ofthepar.asympa-
thetic nervous i)l$t...,.. ffillowing ue ou88", 11I'<I nursing
diagnoses:
Risk for Injury (rebted to sid .. effects of cholinergic
agents: hypotension, bradycardia, and syncope)
Alteration in Comfort (related to adverse drug effects:
abdominal cramping, nausea, and vomiting)
Risk for Ineffective Individual Therapeutic Man.;J.ge-
ment (related 10 side effects and precautions of using
cholinergic agents)
3 Benztropine (Cogentin) is an antichol inergic. Blocking
the pansympathetic nerves allows the sympathetic ner-
vous system to dominate. The drug is given as an adjunct
in Parkinson's disease to reduce muscular tremor and
rigidity. Anticholinergics affect many body systems and
produce a wide variety of side effects. The nurse should
monitor for decreased heart rate, dilJted pupils, de-
creased peri stalsis, and decreased salivation in addition to
decreased muscular tremor and rigidity. Many of the side
effects of anticholinergic; are dose dependent . Adverse ef-
fects include typical signs of sympathetic nervous system
stimulation.
Cha IIr 14
Answns to NCLEX RN" Review Questions
I AIISw .. r: J
Rationale: CNS side effects for lorazepam (Ativan ) include
amnesia, weakness, disorientation, ataxia, blurred vision,
diplopia, nausea, and vomiting. Cognitil'e Level: Analysis.
Nur5ing Proctu: Assessment. Patient Need: Physiologkal
Integrity.
2 Amwfi":4
Rationnlt: The nurse should recognize that this medication
is ordered fOf insomnia. Therefore, the patient should btu-
periencing relief from insomnia and reporting feeling rested
when awakening. Ln'e/: Analysis. N.ming
Procns: Evaluation. Patient Nd: Integrity.
3 N .n .... r:J
Rational" F1umneniJ ( Romancon) is a benrodiazepine-re-
ceptor blocker which may be used to reverse CNS depres-
sant effects. Nalo.wne ( Natan) is an opioid antagonist.
Cognitive Lt.-e/: Analysis. Nursing Pro.:el$; Evaluation.
PIlfie,,' Netll: Physiological integrity.
4 Answ.-r; J
Rlltionnle: Benzodiazepines should not be s topped
abruptly. The health care provider should decide when and
how to discontinue the medication. Cogniti" e Lt .. tI:
Analysis. Nursing Process: Evaluation. Patient Nd: Phys-

5 Answer: 2
Rationllle: The statement by the patient needs to show
clt-arly that the expted benefit of tM medication therapy
has been experienced by the patienl. Cognitn'e Lewl: Analy-
sis. Nursing Proceu: Evaluation. Patient Need: Physiologi-
cal Integrity.
6 Answer:4
Counseling or behavi oral techniques such as stress reduc-
tion will assist in addressing the underlying problem and
help ensure the drug is not taken longer than necessary.
Benzodizepines are not stopped abruptly or rebound an.:u-
elf or cardiovascular effects may occur. Cognitive LntI:
Analysis. Nursing Proc .. ,,: Evaluation. Altie .. t Need: Physi-
ological Integrity.
Answers to Critical Thinking Qunlions
Pain is empha5ized as being the fifth vital sign. The assess-
mmt and appropriate man.;J.gement of pain is a nursing
function. A nurse might be templed 10 give this patient a
sleeping media tion alone, fearing 1M side effects that
might occur if given in combination with an opioid nar-
cotic. Secobarbital is a short -act ing barbiturate. Barbitu-
rates are not analgesics and sefK'rnily do not
produce significant hypnosis in patients with sewre pain.
The barbiturate may intensify the patient's r!.'action to
painful stimuli. Administering a barbitunte with a potent
analgesic appears to reduce analgesic requirements by
about 50%. The nurse may oeed to consult with the health
care provider regarding lowering the dose of narcotic.
2 Lorazepam (Ativan) is USI as an antianxiety agent but it
also has an off-label use as an antiemetic. For a patient
with St'vere nauSt';l and vomiling, lorazepam may offer an
additive effect when combined with the odanesetron for
enhanced therapeutic effects.
3 A thorough assess ment of the patient's sleep patterns
should be conducted. [n addition, nonpharmacologia l
interventions such as a (Col room, quieting activities be-
fore bedtime,and of MOlV)' meals,alcohol, and
caffeine before bedtime should also be considered. In
older adults, the total amount of sleep does not change;
however, the quali ty of sleep dNeriorates. Time spmt in
REM si'P and stages 3 and .. NREM sleep shorteru.
Older adults awaken more often during the night. Thi s
sleep dilurbance can be compounded by the presence of
a chronic illness. The altention in sleep patterns mayal so
be due to changes in the CNS that affect the regulation of
sleep. After a thorough assessment, the nurse should di s-
cuss age related issues, health concerns, and environmen-
tal factors that may be affecting the quality of sleep.
crn. er lS
Answers to NCLEX-RN. Review Qun tions
I AlfSlO't'r; J
Rarionale: Seizures nlOlY be caused by inflammation, head
iujuc;"", uc luw lIl........! k .. "i>. Rapid-KWW;UI!.
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occupying lesions in the bI'3in, which increase intI'3cranial
pressure, may allSe seizures, but not tumors, within the
muscles. Cog"itive Le,e/: Analysis. Nursillg Process: Evalu-
ation. Patiem Need: Physiologiallntegrity.
2 A 'ISIver: J
Rationale: The influx of sodium into a neuron enhances
neuronal activity. The delay of an influx suppresses neuro-
transmitter frequency. C08"ifil'e Ln'el: Analysis. Nllrsi"g
Process: Assessment. Pmiellt Need: Physiological Integrity.
3 II "Slver: 2
Rationole: GABA drugs mimic GABA by stimulating the in-
flux of chloride ions into the neuron, leading to the suppres-
sion of neuron firing. Cog"ithe LeW!/: Analysis. Nursi"g
Process: Assessment. Patiem Need: Physiological Integrity.
4 A "Slver: J
Rationale: Valproic acid may produce an idiosyncratic re-
sponse in children, including restlessness and psychomotor
agitation. Cognitive Level: Analysis. Nursi"g Process: As-
sessment. Pafiem Need: Physiological Integrity.
5 lI"swer:J
Rationale: Carbamazepine affects vit amin K metabolism
and may lead to blood dyscI'3sias and bleeding. Cogtlitile
Le,-el: Application. Nursi"g Process: Implementation.
Patient Need: Physiologial Integrity.
6 A"swers:I,2,4
Rationale: The phenytoin-like drugs are used to treat partial
seizures. Diazepam (Valium) is a benzodiazepine that is
used to treat tonic-clonic seizures and status epilepticus.
Cognitive Le,e/: Analysis. Nursi"g Process: Implementa-
tion. Patient Need: Physiologial Integrity.
Answers to Critical Thinking Questions
Carbamazepine (Tegretol) is the second most widely pre-
scribed antiepileptic drug in the United States. Common
side effects are drowsiness, dizziness, nausea, ataxia, and
blurred vision. Serious and sometimes fatal blood
dyscrasias secondary to bone marrow suppression have
occurred with carbamazepine. The patient's hematocrit
suggests anemia, and the petechiae and bruising suggest
thrombocytopeni.1. The nurse should evaluate the patient
for complaints offever and sore throat that would suggest
leukopenia. This patient needs immediate evaluation by
the health care provider responsible for monitoring the
seizure disorder.
2 This question requires that the student consult a labora-
tory reference manual. The therapeutic drug level of
phenytoin (Dilantin) is 5 to 20 mg/dL. Patients may be-
come drug toxic. and demonstrate signs of CNS depres-
sion. Exaggerated effects of phenytoin can be seen if the
drug has been combined with alcohol or other agents.
Phenytoin also demonstI'3tes dose-dependent metabo-
lism. When hepatic enzymes necessary for metabolism are
saturated, any increase in drug concentI'3tion results in a
disproportionat .. incr .. as .. in plaSJlla conc .. ntration l .. v .. !.
Appffidlx D 805
3 Long-tenn phenytoin therapy can produce an androgenic
stimulus. Reported skin manifestations include acne, hir-
sutism, and an increase in subcutaneous facial tissue--
changes that have been characterized as ~ i l a n t i n fucies.
These changes, coupled with the risk for gingival hypertro-
phy, maybe difficult for the adolescent to cope with. In ad-
dition, the adolescent with a seizure disorder may be
prohibited from operating a motor vehicle at the very age
when driving becomes key to achieving YOWlg-aduit status.
The thoughtful nurse will consider the range of possible
support groups for this patient once she is dis<:harged and
will encourage the patient to discuss her concerns about
the drug regimen with her health care provider.
Chaptllf 16
Answers to NCLEX-RN@> ReviewQuest ions
1 Amwer:4
Anticholinergic effects such as blurred vision, dry mouth,
and constipation may occur during the first weeks of ther-
apy. ToleI'3nce to anticholinergic effects tends to develop af-
ter seVl:!ra] weeks of regular use. They can be managed
symptomatically by increasing fluid intake, being cautious
with activities that require visual acuity (e.g., driving), and
increasing fiber in the diet. Psychomotor symptoms, tachy-
cardia, hypertension, increase in respiratory rate, and tar-
dive dyskinesias are potential adverse effects of TCA
antidepressants but are not related to anticholinergic ef-
fects. Cog"iti,e Lnel: Application. Nursi"g Process: Assess-
ment. Patie"t Need: Physiological Integrity.
2 AlI5wer: J
Rationale: Methylphenidate ( Ritalin) is a Schedule II drug
with potential to cause drug dependence when used over an
extended period. The drug holiday is to decrease the risk of
dependence and to evaluate behavior. Cognitive Level: Ap-
plication. Nursing Process: Implementation. Patie"t Need;
Physiological Integrity.
3 AIISIO-ers: I, 2, 5
Rotiollale: Diarrhea, ataxia, hypotension, edema, slurred
speech, and muscle weakness are signs of lithium toxicity.
Dehydration can lead to lithium toxicity. Cogllith-e Level:
Analysis. Nurs ing Process: Assessment. Patient Need: Phys-
iological Integrity.
4 AlISwer: 2
Rationale: Taking St. John's wort with an MAOI could result
in hypertensive crisis; patients should always consult with
their health care provider before taking any medications or
OTC drugs/herbal remedies. Cognitive Le,d: Application.
Nursi"g Process: Implementation. Patient Need: Physio-
logical Integrity.
5 AIIS"",,r: J
Ratiollale: Nardil is an MAOI. This class of drugs has many
drug and food interactions that may ause a hypertensive
crisis. Cognitivt Level: Analysis. Nursing PrOCtss: Plalllling.
Pmi"n( N .... d' Physiological Integrity_
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806 AppeoolxO
6 Allswer:3
Antidepressant drugs such as the SSRIs may not have full ef-
fects for a month or longer but some improvement in mood
and depression should be noticeable after beginning ther-
apy. Anything less than a month is too early for filII effects
although some improvement may be noticed.
Level: Application. Nursing Process: Assessment. Pmient
Need: Physiological Integrity.
Answers to Critical Thinking Questiolls
Methylphenidate (Ritalin) therapy is usually administered
twice a day, with one dose before breakfast and one dose be-
fore lunch. A child in school would be required to visit a
school nurse to receive a dose of Ritalin bernre IWlch. Am-
phetamine (Adderall) requires once-a-daydosing and may
be better accepted by the child and his or her family because
treahttent can be privately managed at home. Although
many children cope effectively with treahttent for ADHD, a
12-year-old girl might be concerned about being usingled
out" for therapy. She is old enough to realizt> her problems
in perfomlance. The self-esteem of children in this age
group is tied to sua:ess in school, a characteristic of Erik-
son's dev .. l0l'm .. sme" of industry v ...... ". inf .. riority.
Otildren who have difficulty in school perceive thenlSelves
as being inferior to peers. Helping the child with ADHD
pharmacologically may require the health care provider to
be sensitive to social factors such as dosage regimens.
2 The nurse should teach the patient that it might take 2 to
4 weeks before she begins to notice therapeutic benefit.
The nurse should help the patient identify a support per-
son or network to help assist as she works through her
grief. The nurse also needs to instruct the patient that
both caffeine and nicotine are eNS stimulants and de-
crease the effectiveness of the medication.
3 The use of any drug during pregnancy must be carefully
evaluated. Sertraline (Zoloft) is a pregnan'")' category B
drug, which means that studies indicate no risk to animal
fetuses, although safety in humans has not been estab-
lished. Thehealth care provider must weigh risks and ben-
efits of any medication during pregrumcy. The nurse
should recognizt> this patient's risk for ineffective coping,
as evidenced byher history of depression, and help the pa-
tient identify support groups in the community. She may
be functioning in some degree of isolation from family or
other parenting women, which is typical of women who
suffer postpartum depression. Identifying community
resources for the patient is one intervention designed to
provide more holistic care.
Answer to Avoiding Medication Errors
Unless there is a health care provider's order, it is never per-
missible to leave medications at the bedside of a patient. It
is possible that the patient will deliberately discard them,
save them for a later overdose, or forget to take them. It is
also possible that the medications could be inadvertently re-
moved with the food tray or taken by another patient. Al-
ways supervise all medication administration a nd be certain
that the drug is swallowed. Never leave medications Wlat-
tended in a patient's room. If there are concerns that the pa-
tient may not have swallowed the medications, ask the
patient to open his or her mouth. The risk that a depressed
patient will take an intentional overdose increases as the
medication begins to work and gives the patient more en-
ergy to carry out a suicide plan.
Chapter 17
Answers to NCLEX-RNIit ReviewQuestions
I Answer:4
Rationale: Symptoms of psychosis are likely to return and
manifest as agitation, distrust, and frustration. Cognithe
Leyel; Analysis. Nursing Process; Implementation. Patient
Need: Physiological Integrity.
2 Answer: 2
Rationale: Acute dystonias occur early in the course of ther-
apy. These are severe muscle spasms, particularly of the back,
neck, tongue, and face. Level: Analysis. Nursing
Process: Planning. Patient Need: Physiological Integrity.
:1 An5wer: 2
RIltionale: Antipsydtotic drugs such as risperiodne (Risperdal)
treat the positive and negative effects of the underlying men-
tal disorder. A decrease in delusional t:hink.ing,lessened hallu-
cinations, and overall improwment in mental thought
processes should be noted. Improvenlettt in sleep patterns,
anxiety, and nutrition may be noted as secondary effects of
treahttent oftheWlderlying thought disorder. Orthostatic hy-
potension, reflex tachycardia,or sedation are potential adverse
effects. Cognithe Level: Application. Nursing Process: Assess-
ment. Patient Need: Physiological Integrity.
4 Answers: 1,2,4
Rationale: Alwninum- and magnesiwn-based antacids de-
crease absorption of haloperidol (Haldol). Haldol also has a
high incidence of EPS. Haldol must be taken as ordered for
ther:lpeutic results to oa:ur. It is contraindicated in Parkin-
son's disease, seizure disorders, alcoholism, and severe mental
depression. The sustained-release forms must not be opened
or crushed. Coglliti,e we1: Analysis. Nursing Prouss: 1m-
plemenl3tion. Patient Need: Physiological Integrity.
5 Answer: 3
Rationale: Fluphenazine (Prolixin) is a phenothiazine drug.
Use is contraindicated in patients with CNS depression,
bone marrow depression, and alcohol withdrawal.
Cognitiyt Analysis. Nursing Process; Assessment.
Pafient Neelt Physiological Integrity.
6 Answer; J
Rationale: Acute dystonias are characterized by acute spasms
of the tace, tongue, neck, or back. Dry mouth, constipation,
and blurred vision are aclwrse effects related to anticholiner-
gic activity. Pacing and squirming are signs of akathisia, and
bradykinesia and tremors are symptonlS of pseudoparkin-
sonism.lnvoluntary lip-puckering and wormlike movements
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of the tongue symptomatic of tardivt' dyskinesias.
Cognith-e Lnoel: Application. Nursing Process: Assessment.
Patient Nterl: Physiologicallmegrity.
Answers to Critical Thinking Questions
Tht' patit'llt is exhibiting signs of EPS. Initially, the nurse
would assess the to ensure he had sustained no re-
cent neck injury or trauma, but if the neck spasms started
spontaneously, Ihe nurse would then assess for the por.si-
bilityof EPS. The patient probably needs to be on med-
ication such as benztropine (Cogentin) to decrease the
EpS effects. Tht' patient should be taught to recognize the
symptoms of EpS and to seek medical evaluation when
the symptoms occur.
2 The patient is elderly; thus, safety is a priority when ad-
ministering this medication. Postural hypotension and
dizziness common; Iherefore, the ne<!ds to
move and change position slowly. Constipation is also a
concern for a patient on this medication, especially el-
derly patients.
3 The nurse should initially ar.sess whether the patient has
been taking the medication as ordered or has altered the
dose in any way. It is not uncommon for a young person
to "cheek" the medication or attempt to cut back on tht'
dose because of the lack of desire to take the medication
on a continual basis--e:specially when the patient begins
to feel better. It is important that the patient wtderstand
the necessity of being on this medication for a lifetime,
and that the dose is not to beadjusted without consulting
a health care providt'r.
18
Answers to NCLEX-RN@> ReviewQuestions
1 Answer: 2
Rationale: When U'ied concurrently with medication, non-
pharmacologic techniques may allow for lowt'r doses and
possibly fewer drug-related adverse effects. Relaxation tech-
niques and imagery may also be used in the acute care setting.
Cognitive Level: Analysis. Nursing Process: Implementation.
Patient Nwt Physiological Integrity.
2 AnsM'Cr:]
Rationale: Some opioid agonists,such as morphine, activate
both mu and kappa receptors. Cognitive ul-el: Analysis.
Nursing Process: Implementation. Patient Need: Physio-
logical Integrity.
3 Answer:]
Rationale: Vicodin is a combination drug of hydrocodont'
and acetaminophen. Acetaminophen "an be hepatotoxic,
and this patit'nl has hepatitis B, a chronic liver disorder.
Cognitive ul'e/: Application. Nursing Process: Implemen-
tation. Patient Need: Physiological Integrity.
4 Answers: 4, 5
Rationale: Opioids activate mu and kappa receptors thai
... pfUfuumj
App<>ndlx D 807
respiratory rate should remain above 12 breaths per
minute. Although the patient may also become drowsy, he
or she should not become unresponsive after administra-
tion of morphine sulfate. Cognitil'e L('I..,I: Analysis.
Nursing Process: Implementation. Patient Need: Physio-
logical Integrity.
5 AlI5wer: 1
Ratiol/ale: Opioids suppress intestinal contractility, increase
anal sphincter tone, and inhibit fluids into the intestines,
which can lead to constipation. Cognitil'e Level: Applica-
tion. Nursing Process: Implementation. Patient Netd:
Physiological Integrity.
6 Answer:]
Opioid pain relievers should be given as consistently pos-
sible, and before tht' onset of acute pain, in the immediate
postoperative period WJ..less the patient's condition does not
allow the consistent dosing (e.g., vital signs do not support
regular doses). Giving the drug only wht'll the family mem-
bers report that the patienl is complaining of pain, every
time the patient complains of acute pain, or only when the
nurse observes signs and symptoms of pain. These methods
of drug administration would potentially allow pain to be-
come severe before being adequately treated. Patients or
family members may not always report pain or may down-
play the severity. Cultural norms may also influence the
lient's way of exhibiting pain. Cognitil.., Ln'el: Analysis.
Nursing Process: Implementation. Patient Need: Physiolog-
ical Integrity.
Answers to Critical Thinking Questions
The nurse should initially manage the patient's airway,
breathing, and circulation (ABCs) by opening Ihe airway
and providing oxygen support, and then stop the PCA
pwnp.Although the nurse's first reaction maybe to go di-
rectly to the pCA to stop Ihe medication, it is important
to manage the patient's airway before stopping
the PCA because it is unknown how long the patient has
been hypoxic. The nurse then needs to administer IV
naloxone ( Narcan), which is a narcotic antagonist. After
these initial steps have bet>n completed and the patient is
stabilized, the nurse must inform the health care provider
of this adverse effect of the morphine.
2 Sumatriptan (Imitre.'l) is not recommended for patients
with CAD, diabetes, or hypertension of the
drug's vasoconstrictive properties. The nurse should re-
fer the patient to the health care provider for review of
medications and possible adverse reactions related 10
sumatriptan.
3 The patient should be taught not to take any medication,
including OTC medications, without the approval of the
health care provider. This patient is taking an anticoagu-
lant, and aspirin increases bleeding time. The patient
needs to be taught how to recognize the signs and symp-
toms of bleeding related to the anticoagulant therapy. The
wiLh (h" h ...... llh pfUviu"r h"r
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808
medications. Possibl y, her anti-innammatory medication
can be changed from aspirin to a nother drug fo r treat -
ment of arthritis.
Chapter 19
Ans"'rel'll 10 NCLE.X-RN.
1 Answn: I
Rmionnle: The is anesthetized d uri ng a gamosoopy.
Monitor the patient for return of the gag renex before the
patient drinks or eats. Ensuring an airway is the prio rity
when caring for these pat ients. Abdominal pain, abili ty to
stand, and ability to urillOl te are not priorities..
uw': Application. NUrfing Procn.: Assessment. Putient
Need: Physiological Integrity.
2 AnsIO'er: 4
Rationalf: Solutions of lidOOli ne contai n ing preservatives or
epinephrine are intended for local anest hesia only and must
never be given IV for d ysrhyt hmias. Cognifil-e bl-e/: Analy-
sis. Nursing Proct'ss: Implementation. Pafiem Nfe/I: Physi-
ological Integrity.
3 An .... er::J
Rationale: The first step of the nursing proCe$S is assess -
ment. Assessment of prior knowledge provides the basis for
the development of a t.::aching plan. The other options take
place after a thorough assessment. uvel: Applica-
tion. Nurs;IIg Proceu: Assessment. Patient Netll: Physio
logical Integrit y.
4 Answtr.J
Rationalt: Nitrous oxide suppresses tile pain mechanisms
within the CNS, thereby causing analgesia. It does not pro-
duce complete 10iSS of consdousne$s or profound relaxation
of skeletal mUlKle$. Nitrous oxide does not induct stage 3
analge$ia or a loss of consciousnli'Ss. Cogniti ... ! Ln-e/:
Analysis. Nursing Proceu;. Implementation. Ptitient Ntelt
Physiological Integrity.
5 AnsK'ers: I, 4
Rationale: Succinyh:holine (Anectine) ClIn oomplete
paralysis oCthediaphngm and intercostal muscles. BradYCllr-
dia and respintory depression are expe<: ted. Medunical ven-
tilation 5hould be avaiUblt. Cogniti,-e Lel'tl: Analysis. Nursing
Process: AssessmenL Ail it'" t l'-Jcul: Physiological Integrity.
6 AnSIO'er: 4
Rationale: Neuroleptanalgesia drugs such as ketamine do
not re5u1t in full loss of cOl1S(:iousness but ca use disconnection
from events occurring. Confusion, anxiety, fear, or panic
may occur in the immediate post p rocedure period if sen-
sory stimulation is misinter preted. Sen$Ory stimulation
should be kept to a minimum during thi s period for this
rea$On. Frequent assessments above thost required for pa-
tient safet y increase sensor y stimulation and may result in
extreme patient rtactions. Cognitivt Level: Analysis.
Nursing ProCf!ss: Implementation. Patit nt Nud: Physio
logical Integrity.
Answers t o Critical Thinking Qutstions
The nu!'l;t' 5hould question the health care provider regard-
ing this order. lidocaine is an appropriate choke for a local
anesthesia but not if it includes epinephrine. Epinephrine
hasalpha-adrenergic properties. is a potent vasooonstnctor,
and may cause ClIrdiaC dysrhythmias in this elderly patient.
Epinephrine istraditionally not in the
nose, beause these areas may suffer adverse
effects from the vzoconstricti,"t propertie$ of tht drug.
2 The nurse understands that this drug is a depolariring
medicatio n and therefore has the pottntial to increase
potassiwn release. The nurse is aw;)tt that this patient is
on digoxin (Lanoxin) and has renal fa ilure, and therefo re
is not a good candidate for this drug because of the po-
tential hypt'rkalemia that may result in life-threatening
cardiac dysrhythmi as.
3 The priority postoperative drug is St. John's wort bause
it may prolong the effects of anesthe$ia and opioid s in the
patient's system, causing depression of the eNS and rli'S-
piratorysystem. The patient should al$O be monitored for
postoperative bleeding related to the use of ibuprofen.
TIle digoxin =nooentratioLl be 3 theral""utic
lewl prior to surgery to decrease possible adwrse effects
of the cardiovascular system postoperntively.
(hapter20
Answers t o NCLEX-RN" ReviewQutst ions
I AnSWl'r. 2
Rntionale: Extnpyramidal symptolN may be life threatening
without intervention. The patient should be immediately
transported to the emergency depar tment. DipbenhydF.llni lK'
must be given parenterally for effective treatment. The drug
dosage should nol be increased, symptoms may be-
come worse. CognilM w-el: Analysis. NII"ing Proctss: Im_
plemI.'ntation. Pritknt Need: Physiological Integrity.
2 AnSWl'r: 1
Rationale: Pharmacotherapy dotS not cure or stop tht dis-
ease process but dotS improve the patient's ability to per-
form normal activities 5uch astating, bathing, and walking.
Depending on the drug thenpy, EPS may be an adverse ef_
feet. Cogllitile UItl: Analysis. Nurl ing Proc .. u: Implemen-
tation. Need: Phy5iologicaJ Integrity.
3 AnSlO-er: 4
Rationale: A decrease in kidney and liver function mayslow
the metabolism and excretion of the drug, leading to over_
dose and to:ucity. Levodopa does not cause the urine to turn
orange. It is not reasonable for a patient to moni tor his or
her blood pressure every 2 hours during the first 2 weeks of
therapy. Cognitivt Le,'''': Anal ys is. M'Ning Pro(tu: Impl e-
mentation. Patint Need: Physiologicallnttgrity.
4 Answer. I
Rationale: The cause is unknown; however, str uclUrai dam_
age consisting of amyloid plaques and neurofibrillary tan_
LibraryPirate
gles has been found within the brain at autopsy. Alzheimer's
disease has not been associated with intracranial bleeding,
loss of circulation to the brain, or loss of dopamine recep-
tors. Cognirive Level: Application. Nursing Process: Imple-
mentation. Pll tient Need: Physiological Integrity.
5 Answers: I,)
Rationale: Symptoms of overdose include severe nausea and
vomiting, sweating. r.alivation, hypotension, bradycardia, con-
vulsions, and increased muscle weakness, including respiratory
muscles. Tachycardia, hypertension, emotional withdrawal,
tachypnea, and increased muscle strength are not associated
with overdose ofthesedrugs. Cognitive Leve/:Analysis. Nursing
Process: Assessment. Altie", Need: Physiological Integrity.
6 Answer:)
Rationale: Blepharospam (spasmodic eye winking) and mus-
cle twitching are early signs of potential overdose or toxicity.
Orthostatic hypotension,drooling, nausea, vomiting, and di-
arrhea are potential adverse effects unrelated to toxicity or
overdosage. Cogniti,e Lend: Analysis. Nursing Process: Im-
plementation. Patient Need: Physiological Integrity.
Answers to Critical Thinking Questions
The patient should with a health care provider
the need for regular Mylanta. This drug contai/lS magne-
sium, which maycause increased absorption and toxicity.
The patient needs teaching on decreasing foods that con-
tain vitamin B. (for example, bananas, wheat germ, and
green vegetables) because vitamin B. may also cause an
increase in the absorption of the medication. Teaching
should include information about a potential loss of
glycemic control (because this patient is diabetic) and
safety related to postural hypotension.
2 A patient on benztropin (Cogentin) has a decreased abil-
ity to tolerate heat. Arizona in July is hot, so the patient
should betaught to avoid hot climates, if at all possible,or
to increase rest periods, avoid exertion, and observe for
signs of heat intolerance. \'lhen symptoms occur, the pa-
tient must immediately get out of the heat and rest.
3 The nurse should refer the patient and his wife to a health
care provider regarding the appropriateness of this med-
ication (this is not a nursing function). Thecoupleshould
be educated regarding safety issues su,h as postural hy-
potension and bradycardia that may occur with this med-
ication. Anorexia is also a potential problem; this patient
has diabetes and thus may have glycemic issues.
Chapter21
Answers to NCLEX-RN8 ReviewQuestions
I Answers: 1,2,5
Rationale: Adverse reactions to cyclobenzaprine include
dizziness, dry mouth, rash, and tachycardia. Be-
cause medication can cause drowsiness and dizziness, en-
suring patient safety must be a priority. Usually, patients
experiencing back pain have orders for limited ambulation
App<>ndlx D 809
until muscle spasms have subsided. Cognitil-e Lewl: Analy-
sis. Nursing Process: Implementation. Patient Need: Physi-
ological Integrity.
2 AIISwer: 4
Rationale: An adV\'rse effect of botulinum is pain. The drug
is injected directly into the muscle. Pain associated with in-
jections is usually blocked by a local anesthetic. Treatment
with botulinum helps improve muscle strength, bUlthera-
peutic effects are usually by a few days. Cogniri,-e
Lewl: Analysis. Nursing Process: Implementation. Pll tient
Need: Physiological Integrity.
3 Amwer: I
Rationale: FJevated serwn liver enzymes should be reported
to the health care provider. Cyclobenzaprine may cause se-
rious liVe!" damage. The medicalion should be held until the
health care provider has been notified. Cognitive Lewl:
Analysis. Nursing Process: Implementation. P<lfient Need:
Physiological Integrity.
4 AIIS,,"er:)
Rationale: Muscle relaxers such as cydobenzaprine may cause
hypotension. Given concurrently with such
as propranolol may increase the risk of hypotension. Cy-
clobenzaprine may h.we CNS effects such as drowsiness,
dizziness, or fatigue but should not result in neurologic
changes. Giving the drugs concurrently greatly increases the
risk of hypotension. \Vh.ile renal functioning labs may be
monitored periodically, propranolol will not haV\' direct ef-
fects on thaI lab test result. Cognitive Levd:Ana/ysis. Nurs ing
Process: Assessment. Patiem Need: Physiological Integrity.
5 AIIS,,"er: 4
Rationale: Patients should be instructed to report side ef-
fects such as muscle weakness, drowsiness, dry mouth,
dizziness, nausea, diarrhea, tachycardia, erratic blood
pressure, photosensitivity, and urine retention. Until ef-
fects are known, the patient mould not drive. II may take a
few hours for the drug to become effective. Cognitive
Level: Analysis. Nursi ng Process: Evaluation. Patient
Need: Physiological Integrity.
6 AIISM-er: I
Rationale: Muscle relaxers such as baclofen work best when
taken consistrntlyand not pm. Noting cornistentlyof dosing
helps to detemtine the appropri.1leness of dose, frequency,
and drug effects. Consumption of alcohol or increasing the
dose of muscle relaxers will increase the risk of sedation and
drowsiness. The patient's log of symptoms and drug dose and
frequency may assist the provider in determining the thera-
peutic outcome of the medication. The patient's report of
pain or oontinued spasms should be oonsidered an accurate
account. Cogni fivt Level: Analysis. Nursing Process: Assess-
ment. Patient Need: Physiological Integrity.
Answers to Crit ical Thinking Questions
The nurse would anticipate a decrease in the patient's
spasticity after I week of therapy. If there has been no
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810 AppeoolxO
improvement in 45 days, the medication regimen is usu-
ally discontinued. In this case, the nurse should evaluate
the patient's muscle firnmess, pain experience, range of
motion, and ability to maintain posture and alignment
when in a wheelchair. When spasticity is used to maintain
posture, dantrolene should not be used. In this case, the
patient's spasticity involved only the lower extremities.
1 Leg and foot cramps have been anecdotally 3.ISOciated
with tamoxifen, an antiestrogenic drug. Tamoxifen,
which has been shown to reduce the recurrence of some
breast cancers, has been demonstrated to preserve bone
density. Tamoxifen has several side effects that affect
lifestyle, including the potential for weight gain and leg
cramps. The nurse should assess the following factors be-
fore responding to this patient's concerns:
\'lhat is the patient's activity level? Muscle cramps are
3.ISOciated with muscle fatigue.
Does she take exogenous calcium?
Can she tolerate dietary sources of calcium?
Interventions for leg cramps include the following:
Stretching exercises before sleep
Daily calcium and magnesium supplements
Increasing dietary calciwn intake
Drinking a glass of tonic water (co ntaining quinine) at
bedtime
This patient needs to relate her concerns to the oncologist.
A health care provider may consider starting the patient on
quinine 200 to 300 mg at bedtime.'Th.is is an off-label use
and requires careful patient evaluation.
3 Cyclobenzaprine (Rexeril) has been demonstrated to
produce significant anticholinergic activity. Students
should re\;all that antidlOlinergics block the action of the
neurotransmitter acetylcholine at the muscarinic recep-
tors in the parasymp.1thetic nervous system. This allows
the ... of The to dom_
inate. In this case, the result has been a decrease in oral se-
cretions and relaxation of the smooth musde of the GI
tract. Decreased peristalsis and motility can result in con-
stipation. The anticholinergic effect is also responsible for
urine retention because of increased constriction of the
internal sphincter.
Chapter 22
Answers 10 ReviewQuestions
1 Answer: 1
Rationale: HMG-CoA reductase inhibitors may cause rhab-
domyolysis, a rare but serious adverse effect. Constipation
and hemorrhoids may result from bile acid sequestrants.
Flushing or hot flash- type effeds may result from nicotinic
acid. Cognitive Level: Analysis. Nurs i ng Process: Asres!;-
ment. Patient Need: Physiological Integrity.
2 Answer: J
Rationale: The goal of lipid-lowering therapy is to decrease
total cholesterol and LDL, while raising HDL levels.lli
other chojces do not decrease the levels of harmful lipid lev-
els. Cognitive Level: Analysis. Nursi ng Process: Evaluation.
Patient Need: Physiological Integrity.
3 Answer:4
Rationale: One adult-strength aspirin taken 30 minutes be-
fore the nicotinic acid may reduce the adverse effects of
flushing and feelings of hot flashes. Taking the drug one
hour before meals with plenty of water, mixing the drug
thoroughly in water before taking, and taking other medica-
tions 1 hour before or 4 hours after the drug are guidelines
reconunended for bile acid sequestrant drugs. Cognithe
Level: Application. Nursi ug Process: Implementation.
Patient Need: Physiological Integrity.
4 Answer: J
Ratiouale: The nurse teaches the patient with a diagnosis of hy-
perlipidemia about lipids in the body. The nurse informs the
patient that the major storage form of fat in the body is triglyc-
erides. Cognifh-e l.ewE: Analysis. Nursing Process: Implemen-
tation. Patient Health Promotion and Maintenance.
5 A"m-ers: I, 2
Rationale: Long-term use of lipid-lowering therapy may
cause depletion or decreased absorption of folic acid and
the fat-soluble vitamins. Decrease in potassium, iodine,
chloride. and protein is not a direct-effect of lipid-lowering
therapy. Cognitil'e Level: Application. Nursi ng Process: Im-
plementation. Patient Need: Physiological Integrity.
6 Answers: 1,2,4
Rationale: Vegetables such as broccoli and carrots, most
nuts, and fish such as salmon and sardines provide soluble
fiber and are good sources of omega-3 fatty acids and coen-
zyme QIO. Grapefruit and grapefruit juice may inhibit the
metabolism of the statins and lead to potentially toxic lev-
els. Cognifive l.e,eI: Application. Nursing Process: Imple-
mentation. Patient Need: Physiological Integrity.
Answers 10 Cr itical Thinking Questiolls
Photosensitivity is a major problem with
(Lipitor), so the patient must take precautions such as us-
ing sunscreen, wearing sunglasses and protective cloth-
ing,and staying out of the direct Silll as much as possible.
This will probably be a lifestyle change for this patient,
and education with reinforcement is necesS<lry.
2 1bis medication has the possibility of causing esophageal
irritation, so taking the proper fluids or food with this
medication is important. Pulpy fruit such as applesauce
oouldbe used for dual purposes with this drug, because the
applesauce works for the esophageal irritation, and it also
may help prevent the constipation caused by the drug.
3 The nurse should advise this patient to seek medical ad-
vice before self-medicating--especially because this pa-
tient has diabetes, and many drugs affect hyperglycemic
LibraryPirate
medications and blood g1uc06e levels. Niacin can cause
hypergl ycemia in this so S('r um glueQse levels
should beevaluated. The flushing and hOI fl ashes all' nor-
mal side effects of this mediation.
Answer to Avoiding MediCoi tion Errol"$
The nurseshoukl h';l\eadministered molestyramine alieasl
4 bours before or 2 bours digo.'(in and tetracycline
cause thell' is decreased absorption if they are adminislered
together.
Chapter 23
An5\\ers to NCLEX- RN. Review Questions
I A.nswer: J
Rationale: Furosemide was prescribed as an adjunct treat -
ment for hypertension. Blood pressure within norma! lim-
its indicates thatlTeatment has beffi effective. Absena- of
edema, weight loss, and frequency of voiding is ll'lated to
fluid status. Cognit io'e Le.'e/; Anal ysis. Nursing Process:
Evaluation. Pat ient Need: Physiological Integrity.
2 Answer: I
Rationale: HCfZ is a thiazide diuretic. II acts on the kidney
tubules to decrease the of sodium. \\fhen reab-
sorption is blocked, more sod ium issent into Ihe urint'. Tht'
most common side effect of HCTZ is electrolyte sodium
and potassium depletion. The patient's potassium level is
decreased at 2.8 mEq/ ml. Administering HCTZ eQuid fur-
ther deplete the potassium level. Cognitiw Lew':
Analysis. NIl"i ng Prouu: Diagnosis. Alti'"t Nud: PhysiO-
logical Integr ity.
3 Answer. 2
Rarionllle: The advantage of using two drugs is that lower
doses of each be used. resulting in fewer side effects.
Compliance will iocll'ilSe due to fewer unromfortable side
effecls. Cognit ive Lew': Appliation. Nursing PrOctu: Plan-
ni ng. Putie nt Nd: Physiological Integrity.
4 Ans .... er: J
Rationale: ACE inhibitors block the effects of angiotensin II ,
decreasing blood pressure through two mechanisms: lower-
ing peripheral resist ance and de<:reasing blood volume.
Cog,.it i,e Le.e/; Appl icati on. Nursing ProceS$: Assessment.
Pafienf Need: Physiologic:ll iotegrity.
5 A.u ..... rs: 2, 3, 4, 5
Side effects of ACE inhibitors include persistent ,ough and
postural hypotension. Hyperkal emia may occur and can bt'
a major concern for those with diabeles or renal impair-
ment and in patients taking potassium-sparing diuretics.
Though rare, the most adverse effect of ACE
hibitors is the development of a ngioedema. Cogfl itivt Lele':
Analysis. NllrJillg Proc:eJS: Assessment. Patiem Need:
iological Integrit y.
6 AIIsw.>r. 2
Ratiunillc Propranolol and other drugs are
used to prevent ll'f1ex tKhycardia that may occur as a reo;uJt
,tt
of treatment with direct-acting Giving two an_
tihypertensive drugs together may lower blood pressure
further but the drugs also lower the heart rate
and are given in this case to reduce the chance for reflex
I3<:hy<:ardia. Propranolol has not been demonstrated to have
effects in preventing lupus and is not adiuretk . alt houghju-
dicious diuretk therapy may be necessar y if excessive Iluid
gain is an :ilherse effect of direct-acting vasodiJator therapy.
Cognitil"e w'e/: Anal ysis. NUN;lIg Proctn: Implementa-
tion. Adient Need: Physiological Integrity.
Answers t o Crit ical Thinking Quest ions
T raditionaUy, if the patient has a systolic blood pressure of
less than 110 mmHg, the dose should be held unless ver-
ified with the health care provider that the dose should bt
given. The patient is on a low-sodium, low-protein diet.
which may oontribute to hypotension. Beause the pa_
tient has mild rena! failure, the excretion of the drug may
be prolonged and also contribut e to the hypotensive ef-
fects. If the health care provider wanls the patient to re_
ceive the benuepril (Lotensi n), then the blood pressure
should be rechecked at 30 minutes and 60 minutes after
the mediution is given. The patient should be cautioned
about postural hypotension.
2 Atenolol (Tenormin) is blocker Ihal
works directly on the heart. The nurse and the palient
need to be aware that the patie nt's heart rate will rarely go
above 80 beats per minute because of the action of lhe
medication. Tachyardia is one of the adrenergic signs of
hypoglycemia that would not be evident with this patient.
Both the nurse and patient need 10 aware of the more
subtle signs of hypoglycemia {or any ()(ner condition that
may be recognized by tamycardia) that would not ev-
ident with a patient 011 beta-blocking mediClitions.
3 'fht> nurse must beClireful that the patient's blood pressure
is not lowered too dramatically, or hypotension may (K-
,ur. This is an example of a case in whim t 2Q/80 mmHg is
not necessarily an ideal blood pressure readi ng. Typically,
the blood pressure is not lowered below 160 mmHg sys-
tolic. Tht' patient is reevaluated and then (often many
hours later) the blood pressure is brought clown further.
This drip is light sensitive and must renuin oovered with
foil during infusion. Once ptqXlred, the drip is stable for
only 24 hours. NitropruWiide is a cpnide by-product;
therefore, any patient On thi . drug mu! t be Illonito,cd for
cyanide toxicity.
Chapter 24
Answers to NCLEX- RNI> ReviewQuu tioM
I Amwers: J, 4
Riltiollale: Digoxin helps increase the contractility of Ihe
heart thus increasing cardi ac output. The heart rale will de-
crease with the use of digoxin. Cogni,;.'f! Level: Analysis.
Nursing Process: Evaluation. "",ient Nud: Physiological
Integrity.
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812 AppooolxO
2 NISWtr: 1
Rationale: Normal serum potassiwn level is 3.5 to 5.0 mEq/L
Hypokalemia may predispose the patient to digitalis toxicity.
Cognitil'e U!'d: Analysis. Nllrsing Procns; Implementation.
Palient Need: Physiologic:allnttgrity.
3 NISlWt: J
Rationale: ACE inhibitors u.n u.use severe hypotension
with initial doses. The nurse should monitor the patient
closely for several hours. Cogniti.'e U!'e/:
Nursing Process: Implementation. Patient Need;
logical Integrity.
4 Answer: 1
Rntionnle: Potassium levels should be closely monitored.
Encouraging die eating of foods rich in potas.5ium could
help maintain potassium levels. Cogn;ti"" Le."f: Applica-
tion. Nursing Process: PLanning. Pn'ien' Need: Physiologi-
cal Integrity.
5 Answers: J, J, 4, 5
Rntionnle: Side effKU of this medication may include
cough, headache, dizzines.s, change in sensation of taste,
vomiting and nnd hypotension. Hyperkalemia
may occur, especially when the drug is taken concurrently
with potassium-sparing di uretics. Ccgniti''e Lel'el: Analysis.
Nursing Process: Assessment. Patient Need: Physiological
Integrity.
6 Nlswer: J
Rationale: Digoxin and other positive inotropiC drugs in-
creaS{' myocardial contractility, allowing the ventricles to
ejed blood more forcefully and maintaining organ perfu-
sion. In hean failure, blood pressure may be lower than nor-
mal or hypotensive due 10 decreased cardiac output and
urinary output dKlines as renal perfusion decreases. Ther-
apeutic l'ffeets include normalized blood pressure and urine
output. Positive inotropes exert effects on hean rate
through incrl'ases in cardi:ac output. In addition, digoxin
slows heart rate do to effeclS on the conduction 5y5tem. Pos-
ith"l' inotropes do nol have diurelic effeclS. Increased urine
output is secondary to increased reffill perfusion. Whil e
digoxin eJU'rlS l'ffects on the cardiac conduct ion system, oot
aU positive inotropes affect the conduction syStem.
Cognitive Le"d: Analysis. Nur$ing ProcelS: Implementa-
tion. Pa';enJ Need: Physiological Integrity.
Answers to Critical Thinking Quest ions
The nurse should first note improved signs of perfusion if
this ml'dication is l'ffective. The nurse would evaluate the
patient's skin signs, blood pressure, hean rate, and urine
outpu!. If the medication is effective. all these will be
within normal limits, or at least improved from the pa-
til'nt's baseline. The ECG may show improvement with a
nonnal sinus rhythm once the digoxin (umoxin) has
reached a therapeutic level.
2 The nurse understands that there is a cross sensitivity be-
!wet'n sulfa and furoSli'mide ( Lasix) and therefore would
inform thl' health care provider of the patient's allergy
status so a different diuretic might be utililed. Morphine
is an appropriatl' medication forthis patient, not only for
its analgesic and sedative effects but also forthe increased
venous capacilanCl' that it callSes.
j This diabetic patient needs 10 be educated about the im-
portance of regular glucoSl' checks, bKause this medica-
tion may cause the blood sugar to vary spoooiolly.
Typically, hypoglYCl'mia is more of a problem. so the pa-
tient Deeds to be especially aware of the symptoms and
treatment of hypoglycemia. Safety should be emph.asized.
especiaUy regarding postural hypotension.
Chapter 25
Answers to NCLEX-RN- ReviewQuest ions
1 AnSloO'er: 2
Rationale: At the initial onset of chest pain, sublingual nitro-
glycerin is administl'red 10 assist in the diagnosis, and three
doses may be taken 5 minutes apart. Pain that persislS 5 to
10 minutes aftl'r the initial dose may indicate a myocardial
infarction, and the pntienl should seek medienl 3s&istanee.
Cognitive uw/: Application. Nurs/llg Procell; Impl emen-
tation. Patient Need:
2 Answer:4
Rationale: Antianginal drugs act by decreasing myocardial
oxygen demand. This is accomplished by decreasing heart
rate, preload, contractility, and afterload. Cog"iti.'l' U!'e/:
Application. Nursing Process: Implementation. Pa,ien'
Nffd:
3 Answt'r: J
Rntiorrale: Bl'ta blockers decrl'3Sl' the workload of the heart
by slowing heart ratl' and reducing contractility. Calcium
ch.annel blodc:ers decrease periphl'ral resistance. Nitrates re-
lax arterial and venous mUs<:Ies. eog"iti"e U!,tl:
Application. Nursing Process: Assessment. Patient Need:
Physiological Integrity.
4 A"sworr: 4
Roti01lole: Patil'nlS are often instructed to remove the trans-
dermal patch for 6 to t2 hours uch day or withhold the
night-time dose of the oral medications to delay the devel-
opment of tolerance. Because the oxygen demands of the
hean during sll'ep arl' diminishl'd, the patient with stable
angina experil'nces few anginal episodes during this drug-
free interval. Cognitive uve/: NUfl;IIg Proceu:
Impleml'ntation. Patient Need: Physiological Integrity.
5 Answers:J,1,J,4
Rationale: Prior to 3dministering nitT;Jtes for chest pain, the
nurse must first assess loration,qua]ity, and intensity of pain.
Nitratesmould not bl'administl'fed if the is hypoten-
sWeor if thl' heart rateis below 60 bealS per minule. Once ni-
trates are administl'red, blood pressure must be monitored,
because hypotension may occur. of interven-
tions and outcomes is essential to the patient's health history.
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Cognitive Application. Nursing Process: Implementa-
tion. Pat ient Need: Physiological Integrity.
6 Answer: 2
Rationale: Erectile dysfunction drugs such as siidenafil (Vi-
agra), vardenafil (Levitra), and tadaIaftl (Cialis) decrease
blood pressure. \I/hen combined with nitrates, severe and
prolonged hypotension may result. Erectile dysfunction
drugs do not contain nitrates. These drugs are not recog-
nized as useful for the treatment of anginal pain. These
drugs do not oontain nitrates and do not lead to nitrate tol-
erance. Cognitive Lel'el: Analysis. Nursing Process: Imple-
mentation. Patient Need: Physiological Integrity.
Answers to Critical Thinking Questions
The nurse needs to verify blood pressure. A major adverse
effect of nitroglycerin is hypotension. If the systolic blood
pressure remains below 100 mmHg, the nurse needs to
notify the health care provider of the patient's chest pain
and blood pressure.
2 Beta blockers slow the heart rate to a desired 50 to 65 beats
per minute (beats/ min). Many patients suffer from pos-
tural hypotension if the heart rate drops below 60 beats!
min; therefore, the nurse needs to educate the patient
about the necessity of changing positions slowly. The
nurse must be aware that a cardinal sign of decreasing
cardiac output is tachycardia-a heart rate greater than
100 beats/ min for the patient not on beta blockers. If the
patient is on beta-blocking medication, the heart rate
may not go above 80 to 85 beats/min and is considered
tachycardia for this type of patient.
3 Diltiazem (Cardizem) has been given to lower the heart
rate and to decrease the myocardial oxygen conswnption
for this patient with chest pain. The nurse must monitor
closely for hypotension, because this medication lowers
the heart rate but also lowers the blood pressure, and this
patient already has a borderline low blood pressure of
100/60 mmHg. The patient should be on a cardiac mon-
itorwith frequent monitoring of blood pressure.
Chaptlu 26
Answers to NCLEX-RN'" ReviewQuest ions
1 Answer:4
Ral;Ollale: Beta blocker, d""rea.se the bodr', adrenergic
"fight-or-flight" response and may block the symptoms and
signals of hypoglycemia that a diabetic normally perceives
as the blood sugar drops. Beta blockers may inhibit
glyoogenolysis, resulting in hypoglycemia and have no effect
on the development of insulin resistance. Cognitivt w'el:
Analysis. Nursi ng Process: Implementation. Pat ient Need:
Physiological Integrity.
2 Answer: 1
Rationale: In the absence of ECG monitoring, the nurse would
assess the pulse for rate, regularity, quality, and volwne, not-
ing any changes. The nurse should also teach the patient to
Appendix D 813
monitor the pulse for rate and regubrity, before sending the
patient home. The nurse is monitoring for the therapeutic ef-
fects of antidysrhytlunic therapy. While blood pressure and
drug levcl rnay also be monitored, they do not evaluate the
therapeutic effects of the drug. Urine output may change re-
lated to the type of drug given and any effects on cardiac out-
put, but frequent output monitoring is not indicated in
routine antidysrhythmic therapy and will not assess for ther-
apeutic drug effects. Cognitil-e Analysis. Nursing
Process: Assessment. Patient Need: Physiological Integrity.
3 AlISwer: J
Ratiol/ale: Calciwn channel blockers such as verapamil
(Calan) are used cautiously or are oontraindicated in patients
with heart failure because of the negatiVl.' inotropic effects on
cardiac muscle which may precipitate or worsen heart failure.
Verapamil and calcium channel blockers are often prescribed
to treat these conditions. Cognitil't Level: Analysis. Nursing
Process:Assessment. Patient Need: Physiological Imegrity.
4 Answers: I, J, 4
Ratiol/ale: Because antidysrhythmicscan slow the heart rate,
the patient may experience hypotension, dizziness, or weak-
ness. Cognit ive Level: Anal)l5is. Nursing Process: Assess-
ment. Patient Need: Physiological Integrity.
5 AIIS",er: 2
Ratiol/ale: Beta blockers such as propranolol should never
be stopped abruptly because of the possible reboWld hyper-
tension and increased dysrhythmias that may occur. The
nurse may teach the patient to take the medication on an
empty stomach and to be cautious with drowsiness while
taking beta blockers. However, these are not as significant as
the hypertension or dysrhythmias that may occur from
abrupt cessation. Therefore, these are secondary teaching
points. Hearing loss is not a common side effect of beta
blockers. Cognitil'e LeIel:Analysis. Nursing Process:
mentation. Pat ient Need: Physiological Integrity.
6 AlI5wer:4
Ratiol/ale: Potassium channel blockers such as amiodarone,
like other antid)l5rhythmics, may cause significant brady-
cardia and hypotension. The light-headedness and dizziness
may be associated with a drop in cardiac output due to
bradycardia and hypotension. The significant finding of
dimness would first be assessed in relation to the known
adverse effects of the drug. If pulse and blood pressure are
within normal limits, the nurse could oonsider sleep depri -
vation, allergies, and drug blood level as a cause of these
symptoms. Cognitivt Lel-el: Analysis. Nursing Process: As-
sessment. Pat ient Need: Physiological Integrity.
Answers to Crit ical Thinking Quest ions
Propranolol (Inderal) is a nonselective beta-adrenergic
blocker, which means it acts on both the intended sys-
tem (heart ) and the lungs. This may cause the patient to
have untoward lung problems such as shortness of
breath; therefore, this patient should not be taking pro-
pranolol.
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814 AppeoolxO
2 The patient should be monitored closely for hypotension,
especially in the first few weeks of treatment, and should
be taught about postural hypotension. Pulmonary ta."cic-
ity is a major complication of this drug, so the patient
should be monitored for cough or shortness of breath.
Because both digoxin (Lanoxin) and amiodarone (Cor-
darone) slow the heart rate, the patient must be moni-
tored closely for bradycardia. Safety and pulmonary
symptoms are priorities of care for this p.1tient. Amio-
darone often increases the effects of digoxin and warfarin
(Cownadin) and thus must be closely monitored.
3 Bradycardia is a potential problem for a patient taking ve-
rapamil (Isoptin) and digoxin. The patient may exhibit
signs of decreased cardiac output, such as pale skin, chest
p<lin, dyspnea, hypolension, and altered level of ,on-
sciousness. The patient needs to be taught how to recog-
nize the signs of decreasing cardiac output as well as how
to assess heart rate.
Answer to Avoiding Medication Er rors
The nurse should not administer the medication. Research
the correct dosage and administration. The correct dose of Ii-
docaineis I to I.:; msfkg IV every) to:; Llunutes up to a max-
imwn dose of 3 mglkg. It should be given over a 2-minute
period, and the nurse should obtain an apical heart rate. The
instructions regarding the continuous infusion are unclear.
Lidocaine is generally administered I to 4 mg/min after a bo-
lus dose. Nurses should never proceed with drugadministra-
tion lUltil they are confident of the correct parameters for the
particular medication.
Chapter 27
Answers to NCLEX-RN" ReviewQuestions
I Amwer: 4
Rationale: Prothrombinase conwrts prothrombin to throm-
bin. Thrombin then converts fibrinogen to long strands of
fibrin, which provide a framework for the clot. Thrombin
and fibrin are formed only after the injury occurs. Fibrin
strands form an insoluble web over the injured area to stop
blood loss. Cognirive Lel-el: Analysis. Nursing Process: Im-
plementation. Patient Need: Physiological Integrity.
2 Answer: 2
Rutiu"u/e; du Hul Ih" uf II,,,
blood. Instead, anticoagulants exert a negative charge on the
surface of the platelets, so that dwnping or aggregation of
cells is inhibited. Cognitive Lne/: Analysis. Nursing Process:
Implementation. Patient Need: Physiological Integrity.
3 Allswers: I, 2, 3, 4
Rationale: Enoxaparin is a low-molecular-weight heparin
(LMWH). This class of drugs has fewer side effects, includ-
ing being less likely to cause thrombocytopenia. Patients
and family can be taught to giw subcutaneous injections at
home. Teaching should include not taking any other med-
ications without first consulting the health care provider
and recognizing the signs and symptoms of bleeding.
Enoxaparin is given to prevent development of ovr. Pa-
tients should be taught signs and symptoms of ovr to ob-
serve for and should contact their health care provider
immediately if these develop. Cognitive Analysis.
Nursing Process; Implementation. Patient Need; Physio"
logical Integrity.
4 Answer:4
RatiONale: aVf is the ooagu.lation study that monitors oral
anticoagulant use, such as warfarin. A result of one and a
half to two and a half times the control value indicates ade-
quate anticoagulation. aPT"T is the coagulation study that
monitors heparin use. An aPT level of one would indicate a
less-than-therapeutic level of anticoagulation. Cognirhe
Level: Analysis. Nursing Process: Assessment. Patient Need:
Physiological Integrity.
5 Ans,,-er: J
Rationale: Thrombolytic agents dissolve existing clots rap-
idly and continue to have effects for 2 to 4 days. All forms of
bleeding must be monitored and reported immediately.
Skin rash with urticaria, wheezing with labored respira-
tions, and temperature elevation of lOO.8F are not symp-
tom.,> of adverse dir""t1y attributed to
therapy. Cognitive Analysis. Nursing Process: Assess-
ment. Patirnt Need: Physiological Integrity.
6 Answer: 2
Rationale: Antiplatelet drugs such as clopidogrel are given to
inhibit platelet aggregation and thus reduce the risk of
Ihrombus formation. Anliplatelet drugs do nol exert anti -
inflammatory, antipyretic, or analgesic effects. The an-
tiplatelet and anticoagulant drugs do not prevent emboli
formation. Thrombolytics dissolw existing blood clots.
Cognitive w-e/: Analysis. Nursing Process: Implementa-
tion. Palient Need: Physiological Integrity.
Answers to Cr itical Thinking Questions
The nurse should question the health care provider about
this order. No patient who appears to be having a CVA
(brain attack) should have heparin until a CT scan of the
brain has been done. Approximately 20% ofCVAs are he-
morrhagic; these types ofCVAs must be ruled out before
an anticoagulant is given.
2 Themajor adverse effect of a fibrinolytic drug is bleeding.
All tubes (nasogastric, Foley catheter, or endotracheal)
must be inserted, bloo;:l needs to be drawn, and IVs need
to be inserted before the medication is given. Otherwise,
the drugs may potentiate bleeding in this patient.
3 Whether the nurse gives this drug or is teaching the pa-
tient to self-administer the medication, proper placement
of the needle in the abdomen is vital. The injection must
be given at least I to 2 inches away from the umbilicus.
Major blood vessels nm close to the umbilicus, and if the
LMWH is given near one of these vessels, there is an in-
creased chance of bleeding into the abdomen or forma-
tion of a large (and often initially occult) hematoma in
the abdomen.
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Answer to Avoiding Medication Errors
Most health care providers recommend that mothers not
breast feed while taking warfarin (Cownadin). Heparin is
considered safe for breast-feeding mothers. Warfarin is
pregnancy category X. Heparin is not excreted into the
breast milk.
Chapter28
Answers to NCLEX-RN@> ReviewQuestions
I Answers: 1,2,3
Rationale: Iron preparation<; mould be taken on an empty
stomach, diluted,and taken through a straw ifliquid prepara-
tions are used. In addition, extra fluid and fiber will help pre-
vent oonstipation. Sll'itained-release medications are specially
formulated to absorb slowly and should never be crushed or
dissol'cd. Cogniti.'C Uyc/: Application. Nursing Proccu: Im-
plememation. Patient Need: Physiological Integrity.
2 Answer:3
Rationale: Secreted by the kidney, erythropoietin trawls to
the bone marrow, where it interacts with receptors on
hematopoietic stem cells with the message to increase ery-
throcyte prodnction. The primary signal for the increased
secretion of erythropoietin is a rednction in oxygen reach-
ing the kidney. Cognitive L e ~ e : Analysis. Nursing Process:
Assessment. Patient Need: Physiological Integrity.
3 Answer: 2
Rationale: This medication does not cure the primary dis-
ease condition; however, it helps reduce the anemia that
dramatically affects the patient's ability to function. The
hematocrit and hemoglobin levels will provide reference for
evaluating the drug's effectiveness. Cognithe Leyel; Analy-
sis. Nursing Process: Evaluation. Parie"t Need: Physiologi-
cal Integrity.
4 AnJWer: 1
Rationale: This drug increases the risk of thromboembolic
disease. The patient should be monitored for early signs of
CVA or MI. Cognlthe Level: Analysis. Nursing Process: As-
sessment. Patient Need: Safe, Effective Care Environment.
5 Answer: 2
Rationale: Filgrastim stimulates granulocytes (\'/BO;). Fil-
grastim does not stimulate RBC production or enhance/
replace electrolytes. Cognitil-e Levet. Application. Nursing
Prouss: Implementation. Patient Need: Physiological In-
tegrity.
6 Answer: 1
Filgrastim stimulates grannlocytes (WBCs) and is used in
the treatment of conditions such as cancer and in HIY. The
patient remains at risk for infections nntil WBC counts in-
crease. Routine monitoring of vital signs is followed and
ECG or intake and output levels may be monitored based on
patient condition but are not required specific to filgrastim.
Cognitive Le.el: Application. Nursing Process: Implemen-
tation. Patient Need: Physiological Integrity.
AppendlxD 815
Answers to Critical Thinking Questions
Patients with chronic renal failure often have decreased
secretion of endogenous erythropoietin and therefore re-
quire a medication such as epoetin aIfa (Epogen) to stim-
ulate RBC production and reduce the potential of
becoming anemic (or to decrease the effects of anemia).
Teaching points should include the importance of moni-
toring blood pressure for hypertension. Side effects such
as nausea, vomiting, constipation, redness/pain at the in
jection site, confusion, numbness, chest pain, and diffi-
culty breathing should be reported to the health care
provider. The patient should also be instructed to main-
tain a healthy diet and foUow any dietary restrictions nec-
essary because of renal failure.
2 Patients who are receiving fllgrastim ( Neupogen) should
have their vital signs assessed every 4 hours (especially
pulse and temperature) to monitor for signs of infection
related to a low WBC count. Other nursing interventions
include assessing for signs and symptoms of myocardial
infarction, dysrhythmias, and hepatic dysfunction during
treatment.
3 Patients taking this drug need to be educated about the GI
distress that may occur while on iron supplements. lbis
medication may be taken with food to reduce the poten-
tial for GI upset. Constipation is a common complaint of
patients on this medication, so preventive measures need
to be taken. The patient needs to ensure that this medica-
tion has a child resistant cap and is safely secured, be-
cause overdose of iron supplements is a common
toxicology emergency for children.
Chaptllr29
Answers to NCLEX-RN" ReviewQuestions
I Answers; I, 2,4
Rationale: Crystalloid solutions such as lactated Ringer's
closely approximate the electrolytes and ooncentration of
blood plasma. They help increase vascular vollIDle byreplacing
fluid and promoting adequate urine output, and help maintain
normal intrnceUularvolume. Crystalloid solutions are given to
maintain osmolarity and intracellular volwne within normal
limits. Cogrri'ive Lel-el: Analysis. Nursing Process: Implemen-
tation. Patil'nt Need: Physiological Integrity.
2 Answers: 1,:1
Rationale: \'/ith increased cardiac output, renal function
should improw, and there should be an increase in urine
output. BUN and creatinine lewlsshould be normal. Blood
pressure should increase. Cognitive Level: Analysis. Nursing
Process: Evaluation. Patient Need: Physiological Integrity.
3 Answer: 2
Rationale: Dobutamine is beneficial when shock is caused
by heart failure. The drug increases contractility and has
the potential to cause dysrhythmias. Cognitive Level:
Analysis.Nursing Process: Assessment. Patient Need: Phys-
iological Integrity.
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816 AppeoolxO
4 Nlswer:J
Rationale: Anaphylactic reactions may occur with the use of
plasma protein fraction (Plasmanate). Symptoms include
periorbital edema, urticaria, wheezing, and respiratory dif-
ficulties. Cognitive Level: Analysis. Nursing Process: Assess-
ment. Patient Need: Physiological Integrity.
5 Amwu: I
Rationale: Albumin is a colloid solution. Colloids pull fluid
into the vascular space. Circulatory overload may occur. The
nurse should assess the patient for symptoms of heart fail -
ure. Cognitive Level: Analysis. Nursing Process: Assess-
ment. Patient Need: Physiological Integrity.
6 Answers: I, J, 4
Rationale: A5 fluid volume increases beyond the ability of
the heart to adequately pump the volume, pulmonary con-
gestion may occur; changes in level of consciousness may
indicate increasing intracranial pressure due to increased
cerebral volume; and an increase in daily weight may indi-
cate fluid retention. Crystalloid solutions may affect elec-
trolyte levels but these are not accurate indicators of fluid
volume excess. aPTI, aPr, or INR levels are monitored when
patients are given colloid solutions. Cogni t h"e Level: Appli-
cation. Nursing Process: Assessment. Patient Need: Physio
logical Integrity.
Answers to Critical Thinking Questions
A major action of this vasoprer.sor medication is its posi-
tive inotropic effect on damaged myocardium that is hav-
ing difficulty maintaining a good cardiac output (and,
therefore, blood pressure). Nursing assessments include
constant monitoring blood pressure, heart rate and
rhythm, fluid volume status, and urine output. The drip
must be slowly tapered to a point at which the blood pres-
sure is well maintained, normally a systolic blood pres-
sure of greater than 100 mmHg. The nurse must never
consider a blood pressure reading as okay and shut off the
vasopressor drip--the patient may immediately become
acutely hypotensive.
2 This isotonic solution is appropriate for this patient.
Based on history and assessment, the patient is demon-
strating signs of being hypovolemic (heart rate of 122
beats per minute) and requires a solution that will meet
the intracellular need. The patient must be monitored for
hypernmremia and hyperchloremia if more than 3 L of
normal saline is given. As the patient responds to the
fluid, the nurse will note a corresponding decrease in the
heart rate.
3 This is not an appropriate IV solution for a patient with a
head injury. Once this IV solution is infused into the pa-
tient, it is considered to be a hypotonic solution that
moves fluids into the cells. A patient with an increased
ICP cannot tolerate an increase of fluid at the cellular
level because this may cause the brain to herniate and lead
to death.
Chapter 30
Answers to NCLEX-RN" ReviewQuestions
I Answer: 1
Rationale: Because the kidneys excrete most drugs, patients
with renal fuilure will need a significantly lower dosage of
medications that may damage the kidneys, to avoid fatal
consequences. Cognitive Analysis. Nursing Process:
Implemenrntion. Patient Need: Physiological Integrity.
2 Answer: 1
Rationale: Potassium is a serious side effect of loop diuret-
ics, and this is a serious concern for patients being treated
with digmin (Lanoxin). Cognithe Analysis. Nursing
Process: Evaluation. Plltient Need: Physiological Imegrity.
3 An5'i"er:.J
Rationale: Rapid excretion of large amounts of fluid predis-
poses the patient to potassium deficits and is manifested by
hypotension, dizziness, cardiac dysrhythmias, and fainting.
Polydipsia is not associated with hypokalemia, but with di
abetes. Hypertension is an indication for the use of diuret-
ics. Diarrhea can be associated with hyperkalemia.
Cognitive Analysis. Nursing Process: Alsessment.
Patient Need: Physiological Integrity.
4 Answer: 2
Mannitol increases osmolarity of glomerular filtrate,
which mises osmotic pressure in renal tubules and de-
creases absorption of water and electrolytes. Although
mannitol increases urine output, it does not dmw excess
fluid from tissue spaces and should be used with caution
in patients with CHF. Acetawlamide is used to
decrease intraocular fluid pressure patients with open-
angle glaucoma. Bumetanide (Bumex) and ethacrynicadd
(Edecrin) are loop diuretics. Cognitive Level: Analysis.
Nursing Process: Assessment. Patient Need: Physiological
Integrity.
5 Answers: 2, 4
RatiO/lale: Type 2 diabetes is the most common cause of
chronic renal failure; hypertension is the second leading
cause. Cognithe Application. Nursing Process: As-
sessment. Patient Need: Physiological Integrity.
6 Aflswer;4
Rationale: ACE inhibitors or ARBs taken concurrently with
potassium-sparing diuretics increase the risk of hyper-
kalemia. NSAIDs are used cautiously with aU diuretics be-
cause they are e."l:creted through the kidney. Corticosteroids
and loop diuretics may cause hypokalemia and may be
paired with a potassium-sparing diuretic to reduce the risk
of hypokalemia developing if a diuretic is needed. COKnitile
Level: Application. Nursing Process: Implementation.
Patient Need: Physiological Integrity.
Ans ..... ers to Critical Thinking Questions
Losartan (Cozaar) is an angiotell'iin II receptor antago-
nisi =mmonlr pre:s.:;ribed for hypertension. Because
LibraryPirate
some patients do not respond adequately to
apy, a drug that offers combined thernpy, Hyzaar, is
added. Hyzaar combines losartan with
azide, a diuretic. This combination decreases blood pres-
sure initially by reducing blood volume and arterial
resistance. Over time, the diuretic is effective in maintain-
ing the desired change in sodium balance with a resultant
decrease in the sensitivity of vessels to norepinephrine.
Angiotensin II-receptor antagonists appear to prevent
the hypokalemia associated with thiazide therapy.
2 The nurse should carefully monitor fluid status. Because
the primary concern is cardiopulmonary, the nurse
should assess and document lwtg sounds, vital signs, and
urine output. Depending on the patient's condition, a
Foley ,athf.'ter may be inserted. to pf.'rmit the measure-
ment of hourly outputs. Daily weights should be ob-
tained. Edema should be evaluated and documented, as
well as status of mucous membranes and skin turgor. Be-
cause furosemide (Lasix) is a loop diuretic, the nurse
would anticipate rapid and profound diuresis. Therefore,
the nurse should also observe for signs of dehydration
and potassium depletion over the course of therapy.
3 Cerebrnl edema occurs as a result of the body's response to
an initial head traWlla.ln this elISt', the patient sustained a
skull frncture and wtderwent the trnuma of required sur-
gery. The nurse should explain to the mother that mannitol
(Osmitrol) helps reduce swelling or cerebral edema at the
site of her son's injury. The nurse might explain that the drug
hf.'lps "pull" Wlltf.'!" from the site of injwy and ,aery it to the
kidneys, where it is eliminated. The patient's mother mould
wtderstand that the goal of decreasing swelling is to pro-
mote tissue reoovery. Nurses must be sefl'litiw to the fact
that family members may haw severe emotional reactions to
a patient's injury and need help to focus on short- tenn goals
for reoovery when the long-term prognosis is not known.
For additional information on the action or administration
of mannitol, students should oonsult a drug handbook.
Chapter 31
Answers to NCLEX-RN8 ReviewQuestions
1 Allswer: 1
Rationale: Thirst is the most important regulator of fluid
take. Cognithe Len/: Analysis. Nursing Process: Assess-
ment. Parienr Need: Physiological Integrity.
2 Allswer: 2
Rationale: Dextran 40, a plasma volwne expander, causes
fluid to move rapidly from the tissues to vascular spaces,
which places the patient at risk for fluid overload. Cognirile
Level: Analysis. Nursing Process: Implementation. Patient
Need: Physiological Integrity.
3 Allsl1'ers:l,4
Rationale: Hypernatremia is defined as serum sodium levels
higher than 148 mEq/L. A slight increase in sodium can be
managed by diet. The health care provider should be noti-
Appendix D 817
fied of any elevated lab values. Cognitive uw/: Analysis.
Nursillg Process: Implementation. Patient Need: Physio-
logical Integrity.
4 AlIJwer: 4
Rationale: Hyperkalemia, a serum potassium level greater
than 5 mEq/L, predisposes the patient to cardiac and mus-
de irregularities such as cramping in the calves, paresthe-
sia of the toes, and palpitations. Cogllitil'e ul'el: Analysis.
Nursing Process: Diagnosis. Patienr Need: Physiological
Integrity.
5 Amwer:3
Rationale: Bananas, strawberries, tomatoes, dried beans,
and fresh meats are natural sources of potassium. The
other food items have low levels of potassium but may be
part of a healthy diet. Cognirivt Lnel: Application.
Nursillg Process: Implementation. Patien r Need: Physio-
logical Integrity.
6 Amwer:l
Rationale: A weight gain of I kg (approximately 2 lb) or
more may indicate fluid retention. Signs of fluid retention
include hypertension and edema. A complete nursing as-
sessment is needed to determine other signs or symptoms
that may be present. Checking dietary history may be con-
sidered after the nursing assessment is completed. Changing
diet or medicatioru is part of the collaborative treatment
plan with the health care provider. Cognitive Level: Analy-
sis. Nursing Proccss: Assessmcnt. Patiellt Need: Physiologi-
cal Integrity.
Answers to Critical Thinking Questions
Aggressive treatment with loop diuretics is a common
cause of hypokalemia. As in this example, hypoiGllemia
can produce a myriad of sequelae including dysrhyth-
mias. KCI is indicated for patients with low potassium
levels and is preferred over other potassium salts because
chloride is simultaneously replaced. The nurse adminis-
tering KCI must keep in mind several critical concerns to
safeguard the patient. The primary concern is the risk of
potassium intoxication. High plasma concentrations of
potassium may cause death through cardiac depression,
arrhythmias, or arrest. The signs and symptoms of pot as-
sium oVl'rdose include mental confusion, weakness, list-
lessness, hypotension, and ECG abnormalities. In a
patient with heart disease,cardiac monitoring may be in-
dicated during potassiwn infusion. Students should con-
sult their drug handbooks and look up the maximum
rates for infusing KCI in adults and children.
To prevent potassium intoxication, the nurse should
carefully regulate the infusion of IV fluids. Most institu-
tions require that any solution containing KCI be admin-
istered using an infusion pump. Prior to beginning and
throughout the infusion, the nurse should assess the pa-
tient's renal function (BUN and creatinine levels). A pa-
tient with diminished renal function is more likely to
develop hyperkalemia.
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818 AppeoolxO
2 The patient may be considered dehydrated despite her ap-
pearance as indicated by her elevated hematocrit and he-
moglobin Most pregnant women
present with normal or slightly decreased hemoglobin and
hematocrit levels related to the increase in intravascular
volume during pregnancy. The midwife recognizes the
need to increase the intravascular fluid compartment to
promote renal and uterine perfusion. Careful monitoring
of the patient's blood pressure, pulse, and weight should be
maintained.
3 Excessive renal fluid loss due to diuretic therapy, such as
with furosemide (La six), can contribute to fluid volume
deficits in patients taking these medications. Because
pharmacotherapy with thiazide or loop diuretics such as
furosemide is the most common cause of potassium
loss, patients taking these diuretics are usually in-
structed to take oral potassiwn supplements to prevent

Answer toAvokiing Medication Er rors
Student nurses are held to the same standard as nurses
holding a license. Like the student nurse, the nursing in-
structor and the primary nurse are responsible if they
checked the medication dosage prior to administration
and did not question the order. The health C<lee provider is
responsible because the order was incorrect, but the errors
should have been identified prior to reaching the patient.
The nurse manager retains accolUllabilityfor the lUlit.
Chapter 32
Answers to NCLEX-RN" ReviewQuestions
1 Answer: 4
Rationale: Due to immune system suppression by the med
ication, infections are common. Cognitive Level: Application.
Nurs ing Process: Diagnosis. Patient Need: Physiological
Integrity.
2 Answer: 4
Rationale: Grapefruit juice increases cydosporine levels
50% to 200%, resulting in drug toxicity. Hand washing is
important to prevent infection. Renal toxicity and hyper-
tension are adverse effects of cydosporine therapy.
Cogni tive Lnel: Analysis. Nursing PrOU5$; Assessment.
Patient NeeiC Physiological Integrity.
3 Answer: 2
Rationale: Seventy-five percent of patients on cydosporine
experience decreased renal output because of physiological
changes in the kidneys, such as microcakification and inter-
stitial fibrosis. The serum creatinine test is a good indicator
of renal function. Cognit ive Level: Analysis. Nursing
Process: Assessment. PllIie"t Need: Physiological Integrity.
4 Answers: 1,2,4, 5
Rationale: Pregnancy, renal or liver disease, and metastatic
cancer are contraindications to the use of immunostimu-
lant drugs. Infection, immunodeficiency disease, and cancer
are indications for use of these drugs. Cognitive Lewl:
Analysis. Nursing Proce5$; Assessment. PariI'm NeeiC Phys-
iological Integrity.
5 Answer: 1
Rationale: Active immunity occurs when the p.1tient has re-
ceived the vaccine. Passive immunity is achieved by directly
administering antibodies to a patient. A titer is a measure-
ment of the amount of antibody produced after a vaccine.
Cognitive Application. Nursing Pro,e5$; Assessment.
Patient NeeiC Physiological Integrity.
6 A"swer:4
Rationale: Live vaccines may be contraindicated when patients
present an exposure risk of the infectious agent to immuno
compromised patients such as those on chemotherapy or im-
munosuppressant therapy. The patient's cousin having the fiu
is not a potential contraindication, asswning the cousin has a
nomlal and active immune system. The mother would not be
at risk and since she has received recent vaccinations, assess-
ment of her immune "Ystent 'M>uld been compteted at
that time. Soreness of the injected arm is a potential (mild) ad-
verse effect of immunizations and can be managed "Ympto-
matically. Cognitive w-ei: Application. Nursing Process:
Assessment. Altient Need: Physiological Integrity.
Answers to Critical Thinking Questions
Sirolimus (RapamlUle) is an immunosuppressant. The
nurse should assess for any signs and symptoms of bleed-
ing or jalUldice and infection. The nurse should question
the patient regarding activities that may cause bleeding.
The nurse should also assess for signs and symptoms of
liver impaimlent. The nurse should notify the health care
provider of the laboratory findings and educate the pa-
tient to report any bleeding to the provider. The patient
should also report signs and symptoms of infection.
1 The patient needs the protection of this passive formofim-
mllllity after an exposure to such an illness. The gamma
globulin will act as a protective mechanism for 3 W\'eks
while the patienl is in the window of opportunity for de
veloping hepatitis A. This drug does not stimul.1le the pa-
tient's immune system but will help protect the patient
from developing the disease. The nurse should inform the
patient that the shot is far less debilitating than the disease.
3 Cydosporine is a toxic medication with many serious ad-
verse effects. The nurse must understand that this drug
cannot be given with grapefruit juice; patients who take
this medication need their kidney function assessed reg-
ularly (not because of the kidney transplant but because
cydosporine reduces urine output ). The nurse also must
assess whether this patient is rnkingsteroids, which are of
ten given concurrently with cydosporine, as the serum
glucose needs to be monitored regularly.
Answer to Avoiding Medication Errors
Methotrelate is given for rhewnatoid arthritis in smaller doses
than when used in cancer chemotherapy. It is thought to block
LibraryPirate
metabolism of folic acid. For rheumatoid arthritis, patients
take 10 to 12 mg once a week. It may modify the disease man-
ifestations, or it may just improve symptoms and qualityoflife.
Chaptlllr 33
Answers to NCLEX-RN"
I Answer:]
Ratiollale: Acetaminophen has analgesic and antipyretic
properties, but no anti -inflammatory actiollS. Cogniril'e
Level: Analysis. Nursing Prouss: Implemt'ntation. Patient
Need: Physiological Integrity.
2 Answer:]
Ratiollale: High doses of aspirin can produce side effects of
tinnitus, dizziness, headache, and sweating. Cognith'e Lel'el:
Analysis. Nursing Process: Implementation. Patient Need:
Physiological Integrity.
3 Answer:4
Ratiollale: Side effects that need to be rt'ported immediately
includt' difficulty breathing; heartburn; chest, abdomen, or
joint or bont' pain; nosebleed; blood in sputum when
coughing; blood in vomitu. , or .toot.; chill. or
signs of infection; increased thirst or urination; fruity
breath odor; falls; or mood swings. Cognith'e Lel'e/: Analy-
sis. Nursing Proc.ess: Implementation. Nursing Process:
Physiological Integrity.
4 Answer:4
Rationale: Monitor for development of Cushing's syndromt'
(adrenocortical excess) with signs and symptoms of bruis-
ing and a characteristic pattern of fat dt'posits in the cheeks
(moon face), shoulders (buffalo hump), and abdomen.
Cognitive Level: Analysis. Nursing Process: Diagnosis.
Patient Need: Physiological Integrity.
5 Answer: 1
Rationale: Excessive doses of acetaminophen or regular con-
sumption of alcohol may increase the risk of ht'patic toxic-
ity wht'n acetaminophen is used. Rt'nal damage, thrombotic
effects, and pulmonary damagt' are not adverse effects asso-
ciated specifically with acetaminophen. Cognitive Lel'e/:
Application. Nursing Process: Assessment. Patient Need:
Physiological Integrity.
6 Ans ... .,r: '
Rationale: Aspirin and salicylates are associated with an in-
creased risk of Reye's syndrome in children under 18, espe-
ciaUyin the presence of viral infectioru;.Acetaminophen is not
quantifiably different than aspirin or salicylates for the treat-
ment offever. Use of aspirin or salicylates should not increase
fever although maycause nausea or vomiting related to GI ir-
ritation but is not contraindicated in children specifically for
this reason. Cogrritil-e w-el: Application Nursing Prouss:
Implenlentation. Patient Need: Physiological InttWity.
Answers to Critical ThinkingQuestions
This patient has many potential problems related to the
use of prednisone over a sustained period. The primary
AppendlxD 819
current concern is the hyperglycemia- an adverse effect
of the prednisone that can become serious when the pa-
tient is diabetic. Blood pressure mltst be monitored for
potential hypertension, which is related to sodium rett'n-
tion and, tht'refore, increased water retention caused by
the prednisone. The patient is also at high risk for infec-
tion while on prednisone because of suppression of the
immune system, also related to the diabetes.
2 The nurse should give the patient celecoxib (Celebrex) for
the elbow inflammation and pain. This medication
should provide adequate relief of the symptoms for this
patient. Eru;ure that the patient is not allergic to sulfa
prior to giving this medication. The patient should not
take acetaminophen (Tylenol ) because of related pott'n-
tialliver compromise secondary to alcohol abuse. The pa-
tient should not take ibuprofen (Motrin) because of the
potential for gastric bleeding. The patient's stomach is aI-
readyat risk because of alcohol abuse, and the chance for
bleeding is elevated because of potential liver problems
secondary to alcohol abuse.
3 Tht' nurse should educate the mother that aspirin and
aspirin-containing products should not be given to chil -
dren YOlUlger than age 18. These drugs have been impli -
cated in the development of Reye's syndrome.
Acetaminophen is the antipyretic of choice for treating
most fevers. The nurse should also further question the
mother regarding the length and severity of symptoms.
Chapter 34
Answers to NCLEX-RN@> ReviewQuestions
1 AnSlwr:4
\'lhen normal flora are decreased or killed byantibac-
terial therapy, opportunistic organisms such as viral and
fungal infectioru; may occur. The other options are not def-
initions of superinfectioru; although they may be adverse
drug effects of antibacterial therapy. Cognith'e
cation. Nursing Process: Assessment. Patit nt Need: Physio-
logical Integrity.
2 AIISwer: 1
Rationale: Many people will discontinue medication after
improVt'ment is noted. All antibiotic regimens must be
completed to prevent recurrence of infection. Some peni-
ciUins (amoxicillin) should be taken with meals, whereas all
otht'rs should be taken 1 hour before or 2 hours after meals.
Penicillins should bt' used with caution during breast-
feeding. Cognitive uw/: Analysis. Nursing Process: Imple-
mentation. Patient Netxl: Physiological Integrity.
3 Answer.4
Rationale: This drug has the ability to cause permanent
mottling and discoloration of teeth, and therefore is not ap-
propriate for children younger than 8 years of age. Tetracy-
clines have ont' oftht' broadest spectrums of the antibiotics
and are .contraindicated in pregnancy. Cognitive
Analysis. Nursing Process: Implementation. Patient Need:
Phj1Siological Integrity.
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820 AppeoolxD
4 Nlswer: 1, 1
Rarionale: Ciprofloxacin (Cipro) is a fluoroquinolone
antibiotic. Fluoroquinolones may be taken with food or
meals but dairy, ferrous sulfate or antacids may affect
absorption and should not be conswned at the same time
as the is Fluoroquinolone. been
associated with tendonitis and tendon rupture and any
Wlusual pain, especially in the heel, lower leg or calf, or
difficulty walking should be reported to the provider.
Cogni five Ln-e/: Application. Nursing Process: Application.
Palienf Need; Physiological Integrity.
5 Answers:l,2,J
Rarionale: For t he medication to reach the microorganism,
it is critical that the medicine be taken for 6 to 12 months,
and possibly as long as 24 months. Antitubercular drugs are
also used for prevention and treatment. Multiple drug ther-
apy is necessary because the mycobacteria grow slowly, and
resistance is common. Using multiple drugs in different
combinations during the long treatment period lowers the
potential for resistance and increases the chances for suc-
cessful therapy. Cognitive Level: Analysis. Nursing Process:
Implementation. Patie'" Need; Physiological Integrity.
6 Answer: 2
Penicillin antibiotics may significantly decrease the effec-
tiveness of oral contraceptives and another method of birth
control should be suggested during the time the drug is
taken. The other options are not adverse drug effects associ -
ated directly with penicillin antibiotics. Given the ageof this
patient, concern for possible pregnancy prevention would
be a high priority. Cognifi,e Level: Application. Nursing
Process: Assessment. Pa fiem Need: Physiological Integrity.
Answers to Critical Thinking Questions
This patient should not be on tetracycline (Achromycin)
while pregnant because tetracycline is a category D drug
that has teratogenic effects on the fetus. CoWlseJing
should be provided for alternative sources of care for her
acne as well as for use of drugs when pregnant.
1 The nurse should not give the erylhromydn. This p.1 tient has
a history of hepatitis B, and this medication is metabolized by
the lirer.An alternative type of antibiotic should be utilized.
3 This medication is typically reserved for more serious in-
fections because of its higher potential for toxicity. Renal
function is a priority assessment for this patient. The
nurse should monitor urine ontput, urine protein, and
serwn BUN and cre-atinine on a regular basis. A second-
ary priority is hearing assessment. because ototoxicity is
common for patients on gentamicin.
Answerto Avoiding Medication Errors
The nurse should have questioned the health care provider
regarding Bactrim, which contains sulfamethoxa.wle. Be-
cause the patient has an allergy to sulfa drugs, he would be
allergic to Bactrim as well. Some individuals experience
nausea, a side effect of sulfa drugs. True allergies involve
hishmine_med.iated responses result in symptoms such
asa rash or hives. In severe cases,bronchospasm and cardio-
vascular compromise are possible. Because the drug is a
large tablet, it is permissible to break the tablet in half and
provide a large glass of water.
Chapter 35
Answers to NCLEXRN* ReviewQuestions
I Answer: J
Rationale: Systemic antifungal drugs have little or no anti-
bacterial activity. Auid intake should be increased with this
medication because it can affect renal function. The full
course of therapy should be completed. All intramuscuJ.1f
sites have the potential to bruise. Cognifive Level: Analysis.
Nurs ing Process: Implementation. Patient Need: Physio-
logical Integrity.
2 Answer: 2
Rationale: The patient needs to be assessed for pre-existing
cardiovascular disease. and an ECG should be done. Qui -
nine therapy does not require a consent to be signed, but ed-
ucation is needed. All medication should be continued
wtless otherwise specified. Cogniri,-e Level: Analysis.
Nursing Process: Imptementation. Pa fiem Need: Physio-
logical Integrity.
3 Answer:4
Rationale: Chloroquine (Aralen) is the classic antimalarial
for treating theacute stage. Proguanil (Paludrine) is the pro-
totype antimalarial for prophylaxis. Rizatriptan (Maxalt) is
used in the treatment of migraines. Cognilhe Level: Analy-
sis. Nursi ng Process: Implementation. Pa fiem Need: Physi-
ological Integrity.
4 Answers:I,2,J,4
Rationale: Play habits and hygiene of children can con-
tribute to the transmission and reinfestation of pinworms
and roundworms. It is important that all family members
understand the importance of hand washing to prevent the
transmission of worms. Correct hand washing should be
taught, and children should not be allowed to play in sand-
boxes that are left uncovered. Children should also wear
shoes when outside playing to prevent skin invasion.
Cognifive Lew:l: Analysis. Nursing Process: Implementa-
tion. Pafient Need: Safe, Effective Care Environment.
5 AnSM-er:4
Rationale: Concurrent use of alcohol during metronidawle
treatment may cause a d isulfiram-like reaction with exces-
sive nausea, vomiting, and possible hypotension. The other
options may have slight GI effects (e.g., mild nausea) but
would not be a cause for concern if taken with the metroni-
dawle. Cognifhe Levtl: Application. Nursing Process: Im-
plementation. Pa fiem Need: Physiological Integrity.
6 Answers: I, 2, 4, 5
Rationale: Metronidawle may cause a metallic drug taste
during therapy and may cause urine to darken. Taking the
drug with food or milk may hetp reduce CI effects. Current
LibraryPirate
sexual partne1'5 do not usually require treatment for Giardia
infections unl ess they are also experiend ngsymptoms. The
entire COUl'5e of metronidazole therapy should be com-
pleted, even if symptoms are diminished or absent, to en-
sure adequate treatment . Cognitiv, uvel: AppliC3tion.
Nursing Process: Implementation. Ptllienr Nud: Phys iolog-
iad Integrity.
Answers to Critical Thinking
A5 always, the ABCs are a priority for any patient and
mustbe considered. Thenurse must monitor the patient's
airway for evidence of bronchospasm or decreased gas ex
change, such as coughi ng, poor color, and decreased oxy_
gen saturation. The nurse must understand that
leukopenia iii a problem for thew patitflts (related to the
amphotericin B and the patient's own depressed immune
status); therefore, prevention of infection is always a pri-
ority. The patient"s renal status (urine output, serum
BUN, and creatinine) also must be dosely monitored be-
cause approximately 30% of patient s on this media tion
suffer renal damage.
2 This patient has vaginal candidiasis.so it must be stressed
that her partner be treated concurrently or reinfection
may result. Alcohol must be avoided while on this med-
ication to prevent profound vomiting. It is important to
stress that alcohol is found not only in alcoholic drinks
but also in products s uch as cough medicine, vanilla ex-
tmct , 3nd "",en in perfume that is absorbed via the skin.
3 This drug can have profound adverst elfe<:ts, and the pa-
tient must be a refully screened and educated about this
drug prior to taking it. The patient must have a baseline
physical assessment , incl uding an ECG and blood pres-
sure aMeSSment, liver and renal funct ion tests, and a hear-
ing and visual assessment screening. B:aUSl!' the patient
may suffer permanent organ damage while taking this
medication, Nseline information is crucial.
Chapter 36
AnS1o'>'ers to NCLEX.- RN. Review Questions
I Answer; 2
Rationale Drug thenpy has not produced 3 curt' but has re-
sulted in a numberofthenpeutic successes. There is no vac_
cine for HIV. Cogni,i,'1I Le,'1I/; A ppliOition. Nursing Process;
Implt'mentation. Pu,iell' Need: PhysiologiOlJ Integrity.
2 Ans"'1Irs: J, 4
Rationale: Two laboratory tests used to guIde pharma-
cotherapy are an absolute CD4 count and an HIV RNA
measurement. Clotting factor3 and a CBC do not provide
information for guiding HIV-AIDS therapy. Coglli, ive
Level: Anal ysis. Nursi"g Proc:t,,: Implementation. Pmie1lf
Need: Physiological Int egrit y.
3 Answer. I
Riltiorlilir. The medi cat ion should be taken on an empty
_tom.:ldl for m:u:imum absorption. C"8",,;r; ... L.vel, Anat y_
sis. Nursi"8 Process: Implementation. Pulien! Netll: Phys i-
ological Integrity.
4 Ans"'1Ir: 2
Rilrionale: Oseit3mivir (Tamiflu) and unamivir
are available and may prevent the flu or if taken within
48 hours of symptoms, may limit the length of the disease.
Immunity begins approximately 2 weeks after immuniu-
oon. Vaccination is recommended (or high-risk populat ions
and for healthy adults over 65. Ru may be highly contagious
and at-risk patients shouid not wait until symptoms begin
to seek vaccination or treatment. Cognili."t' w -r/: Applica_
tion. Nursing Proceu: Implementat ion. Patiell' Nud: Phys-
iologicallntegrity.
5 AnSh'1lr: J
RatioMle: Neurologic adverse effects may occur but dizzi_
ness, sleep disorders, nightmares, and diffi cul ty thinking
dearly tend to improve after } to 4 wks. Neurotoxici ty may
occur and increasing confusion, delusions, or seizures
should be reported immediately. Drugs for HJV-AIDS help
limit the viral load and maintain a longer symptom-free pe-
riod. All drugs used for HiV-A1DS have significant advel'5e
effects. Taking efavirenz (Sutiva) with a high-fat meal may
increase its absorption by as much as 50%, leading to to){ic-
ity. Cogni,ive Ln'd: Application. NUrl;ng Process: Imple-
mentation. PIl ,ie,,' Need: Phys iological Int egrit y.
6 Answers: I, 2
Rationale: Acyclovir can be renal to.tic and fluids should be
increased throughout thempy. Neurotoxicity may occur
and increasing dizziness, tremors, or any confusion should
be reported immediately. Fluid intake soould be increased,
not decreased, and the drug must be taken consistentl y
throughout the entire (()urse of ther.lpy. Suppressive thn_
apy may also be ordered. Cogniti."t' Level: Application.
Nursing Process: I.mplementation. Putient tktd: Physio-
logical Integrity.
Answers to Crit ial Thinking Questions
The best approach to inOuenza infection is prevention
through annual vaccination. Those who benefi t greatly
from vaccinations include residents oflong-tenn care fa_
cilities. The drug amantadine (SynunetreJ) is used to pre-
vent and treat influenza. The nurse should work with the
health care provider to obtain an order and make
arrangements to administer the medication.
2 This medication may cause bone marrow supprCS$ion.
This patient is alreJdy immunocompromised, and the po-
tential for leukopenia is high. The patient should be taught
to watch for any evidence of infection, monitor tempera-
rure, and have regular lab tests. The patient also needs in_
structionabout the importance of good hand washing and
safeguarding against potential soutces of infection.
3 The nurse should inform the health care provider that the
mediation needs to be administtred over a minimum of
1 hour,and that the nurse is unable to give tht medication
as a bolu_or IV pisgybxk (or leu th;l. n I hour. Th. IV _it.
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822 Ap""O>dlxD
must be monitored dosely for potential infiltration while
the medication is infusing. If this occurs, the IV must be
stopped immediately.
Chapter37
Answers to NCLEXRN. Review Quest ions
I Answer: 1
Rmionnle: Effectiveness of dlemotherapy is increased by w;e
of multiple drugs from different classes that attack cancer
cells at different points in the cell cycle. Thus.lowerdosesof
each individual agent can be used to reduce side dtects. A
third benefit of combinat ion dlemotherapy is reduced indo
dena of drug rt$istance. Cognitive un!': Application.
Nursing Process: Impl ementat ion. Pelt;en, Need: Physio
logical Integrit y.
2 Answer:3
Rarionalt: For maximum effect, patients starting therapy
with agents with high emetic potential should be given an
antiemetic prior to the start of treatment. COK',iti.e we':
Application. Nursillg Process: Implementation. Peltient
Need: Physiological Integrit y.
3 Answers: 4, 5
Rationale: Patient and family members should avoid receiv.
ing live virus vaccinations or becoming exposed to chicken
pox. The patient could have an e.ucerbation or a more pro
nounced episode of chi cken The patient should also
avoid crowds. Cogni,i.'e woe': Analysis. NIINing ProceJJ:
Implementation. Patien, Nud: Physiological Int egrity.
4 Answer: J
Rarionnle: The nurse should monitor for blood d)'Krasias
rt$u1tingfrom bone marrow suppression by monitoring the
eBC with differential and platelet count. Cog"iti.'Ct w'Ct':
Analysis. Nursing Process: Pat;,mt Need: Physi
ological Integrify.
S Answer. 1
Rarionnle: The most serious side effect of vincristine is nero
rous sr.;tem toxidty. Paralytic ileus is likely in young children.
Cognilive Ln'Ct1: Analysis. Nur$ing Process: Implementation.
Peltiellt Need: Physiological Integrity.
6 Answer: 1
Rarional .. : The nadir is the point of greatt$t bone marrow
suppression, as measured by the lowest neutrophil count.
Nadir does not refer to chemotherapy dose, level, or patient
symptoms. Cognitivr uvtl: Appliotion. Nursing Process:
Assessment. Pellienl Need: Physiological Integrity.
Answers 10 Critical Thinking Questions
The patient needs to be taught stralegit$ for coping with
thesideeffeclli of the chemotherapy regimen. Nutrition is
a major focus. The patient should takeantiemetics
1 hour prior to chemotherapy, eat small frequent meals,
drink high-calorie liquids if unable to eat solid food, and
increase nuids if diarrhea occu.rs.
2 Thepatient and familyshou.ld be t<lught about the poten
tial for infection related to immunosuppression. The
nurse should stress frequent hand washing, avoiding large
crowds. seIfassessing temperature accurately at home,
and knowing when to call the health care provider. Nu/"Sf$
take these basics for granted even though patients often
have m:iscono::eptions about them.
J The nurse should remain with the solution and call for
someone to bring the chemo spin kit immediately. While
waiting for lhe spill kil, the nune may cover the cont<lm
inated Ouid with paper towels ( the nune musl not touch
the solution withoul wearing protective equipment). The
nurse should clean up the spill and dispose of the waste
per hospital protocols. AI no time should the chemother
apy spill bf left unattended.
Chapter 38
Answers t o NCLEXRN. ReviewQuest ions
1 Answer: J
Rarionale: Prolonged use of oxymetazoline ouses hyper
secretion of mucWi and worsening IUIsal congestion, result
ing in increased daily use. This medication should not be
used for longer than 3 dar.; and shou.ld be used only as di
rected. Cognitive Le.tI: Appliotion. Nursi ng Process: 1m
plementation. Paliem Need: Physiological Int egrity.
1 A,,_rs;-2. J
Rational/': The device delivers a metered spray that regulates
the dosage and keeps it consi!;tenl.lI5eof intranasal gJucooor.
ticoids may require 2 10 4 weeks. Side effects include drying
and bleeding of the nasaI cavity. Saline nasal sprays may be
used 10 aUeviale drying. The medication should be used as
prescn"bed. eog"itil"e Level: Application. Nursi"g Process:
Implementation. Patient Need: PhysiologicaI Integrity.
J A"swer. J
RatUmale: Firstgeneration H,. receptor antagonists are
contraindicated in patients with a history of dysrhythmi.as
and heart failure. These mediotions can cause vasodilation
ofvessels due to H, stimulation. These medications h.we no
relationsh.ip to wright gain or Pfptic u.lcer disease.
Cognitive Lew': Analysis. Nuni ng Proceu: Assessment.
Patient Nerd: Physiologicallnt<'gl"ity.
4 Answers:J,1,5
Ratiollale: The device must be primed prior to initial use.
The nose should be cleared prior to not af
terward, so that medication remains in the n:J5al cavity. Any
excess that drains into the mouth must not be swallowed
but should be spit out. Cogll ilive u>'Cl: Application.
Nursing Process: Implement3tion. Patient Nee./: physio.
logical Integrity.
S AnSl<"er: J
Rationale: A major side effect of antihistamint$ relates to
their anticholinergic effects. Anticholinergic effects can also
cause urinary hesitancy and should not be used in patients
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with a history of prostatic hypertrophy. Cognitive Lele/:
Analysis. Nursing Process: Assessment. Pmie", Need: Phys-
iological Integrity.
6 Answer:J
Rationale: Single-symptom OTC prepar:ltions are preferred
ovt'r multiuse preparations to avoid additional drugs that
are not needed for symptom relief and to decrease risk of
additional adverse effects. Dosing of any GTC preparation is
carefully calculated to provide precise dosing for age and
symptoms. Antibiotics may Ix> required for serious infec-
tions but for common symptoms, OTC remedies are recog-
nized as safe and effective but should not be used
indefinitt'ly without consultation with a health care
provider. Cognitive Lele/: Application. Nursing Process:
Implementation. Palient Need: Physiological Integrity.
Answers to Critical ThinkingQuestions
The nurse needs to ensure that the patient Wldt'rstands
the pott'ntial side effects related to the anticholinergic ef-
fects of this medication. The patient (based on age) is at
higher risk for urine retention, glaucoma (or other visual
changes), and constipation.
2 Although codeine is a more powerful antitussive, it can
cause dependence and constipation. Dextromethorphan
is a more appropriate choice for this patient initially, with
codeine syrup as a potential later choice for more severe
cough symptoms.
3 Intranasal glucowrticoids, such as Ronase, may take as
long as 2 to 4 weeks to work. The medication should not
be discontinued prematurel),. If a decongestant spray is
being used along with the Ronase, the decongestant
should always be administt'red first to dear the nasal pas-
sages, which will fucilitate adequate application of the
glucocorticoid mist.
An5Wer to Avoiding Medication Errors
iknz.onatate is chemically related to the local anesthetic
tetracaine (Pontocaine) and suppresses the cough reflex by
anesthetizing stretch receptors in the lUllgs. The perles (cap-
sules) must Ix>swallowed whole and not be chewed or pUIlC-
tured so the liquid may be swallowed. The drug insidt' the
perle can cause nwnbing of the mouth, pharynx, and
epiglottis, leading to aspiration, respiratory distress, or ar-
rest. Iftht'patient cannot swallow the medication whole, the
health care provider should be contacted for a possible
change in orders.
Chapter 39
Answers to NCLEX-RN8 ReviewQuestions
1 Answer: 2
Rationale: An aerosol is a suspension of minute liquid
droplets or fme solid particles in a gas. Aerosol therapy can
give immediate relief for bronchospasm or can loost'n thick
mucus. Tht' major advantage of aerosol therapy is that it de-
livers medications to the immediate sites of action, thus re-
App<>ndlx D 823
ducing systemic side effects. The main disadvantage is that
the precise dose receiwd by the patient is difficult to mt'a-
sure because it depends on the patient's breathing pattern
and the correct use of the aerosol device. Cognithe Lend:
Application. Nursing PrCKess: Implementation. Patient
Need: Physiologic:t.l lntegrity.
2 AlI5wer: 2
Rationale: Beta-adrenergic agonists (sympathomimetics)
act by rela.Ung bronchial smooth muscle, resulting in bron-
chodilation that lowers airway resistance and makes breath-
ing easier for tht' patient. Beta-adrenergic agonists do not
liquefy or reduce mucus production. Cog"ithe Level:
Analysis. Nursi"g Process: Implementation. Patient Need:
Physiological Integrity.
3 AlI5wer:4
Riltionale: Tolerance may develop to the therapeutic effects of
the beta-adrenergic agonists; therefore, the patient must be in-
structed to seek medical attention if the drugs become less ef-
fective with continued use. Increased he.'IJ"t rate is a side effect
of bela-adrenergic agonists. The patient should not change the
medication dosage without fim consulting the health care
provider. Cognitive l.el"el: Analysis. Nursing Process: Imple-
mentation. Patient Need: Physiological Inlt'grity.
4 AlI5l1'er: J
Rationale: Anticholinergic bronchodilators should be used
cautiously in elderly men with benign prostatic hyperplasia
and in patients with glaucoma. An enlarged Jiwr and diar-
rhea have no relationship to the use of ipratropium.
Cognitive Lele/: Analysis. Nursing PrCKess: Implementa-
tion. Patient Need: Physiological Integrity.
5 Amwers: J, 4
Rationale: If taken for longer than 10 days, oral glucocorti-
ooids can produce significant adverse effects, including ad-
renal gland atrophy, peptic ulcers, and hyperglycemia.
Long-tern} oral glucocorticoids can cause osteoporosis.
Changes in level of consciousness rna)' be related to oxy-
genation lewis and need to be reported to the health care
provider. Cognithe Level: Analysis. Nursing PrCKess: As-
sessment. Patient Need: Physiological Int egrity.
6 AlI5wer. J
Rationale: Beta-adrenergic drugs such as a1buterol
(Proventil, Ventolin) are most often used for rapid bron-
chodilation. Glucocorticoids such as bedomethasone,
leukotriene modifiers such as zileuton, and long-acting
beta agonists such as salmE1:erol may be used for mainte-
nance therapy to prevent or control asthma attacks but do
not act quickly enough for acute attacks. Cognitive Level:
Application. Nursing Process: Implementation. Patie"t
Need: Physiological Integrity.
Answers to Critical Thinking Questions
The nurse needs to ensure that the patient lUlderstands
the potential side effects related to anticholinergic effects
of this medication. The patient (based on age) is at higher
LibraryPirate
824
risk for urine retention, glauooma (or other visual
changes), and oonstipation. These are also common
problelll5 fo r patients who are taking this medication.
2 Once the patien!"! condition begins to improve, the nurse
should asse5Il the patient's understanding of the asthma
regimen. The patient should re'ive instroction on the
side effects of glucocorticoid therapy. GllK()OOrticoids
can supprl'SS the hypothalamic-pituilary axis. Abruptly
discontinuing a glurooorticoid after long-term therapy
(greater than to days) can produce cardionsrular 001-
lapse. lbe patient nefds to be instruCloo on the
regimen for prednisone, which tn;Iy indudean incremen-
tal decrease in the drug dosage when discontinui ng the
drug. The patient should be monitored for hyper-
glycemia, peptic ulcer disease, signs and symptOIll5 of GI
poor wound healing, infections, and mood
changes.
3 Key patient education points of emphasis regarding
administering medications via an inhaler indude the
following:
I. Shake the canister well immedi3tely before each use.
2. Exhale completely to the end of a normal breath.
3. With the inhaler in the upright position, place the
mouthpiece just inside the mouth and use the lips to
form a tight seal.
4. While pressing down on the inhaler, take a slow, deep
breath and hold for approximately 10 seconds.
5. Wait approximately 2 minutes berore taking a second
inhalation of the drug.
6. Rinse the mouth with after exh U5I!' (especially
after U5ingsterold ml1.alers,De<:ause thedrug may cause
fungal infections of the mouth and throat ).
Chapter40
Answt'r's to NCLEX-RN- Review Quest ions
1 Allswer: J
Rationale: Antacids are generally oombinations of alu-
minum hydroxide and magnesium hydroxide. Hypermag-
nesemia can develop with use of ore antacids while on
renal dialysis because the kidneys are unable to excrete ex-
cess magnesium. Hyperkal emi a is a complication of renal
failure. Hypernatremia can occur with use of antacids.
Cognitive Levt/: Analysis. NIJ"ing Proreu: Implementa-
tion. Patient Physiological Integrity.
2 Answer: I
Rationale: Two or more antibiotics are used to lower the po-
tential for bacterial resistance and increa5l!' the ettectiveness
of therapy. Bacterial infections can recur, requiring future
treatment. Cogni,i.-e w-el: Analysis. Nursing Process: Im-
plementation. Pillien' Need: Physiological lntegriry.
3 Answer: 1
Rationale: Simethioone is used along with other GI drugs or
alone to decrease the amount of gas bubbles that accumu-
late with GI disorders or indigestion. Simethicone will not
affect the acid-fighting ability of medications, or prewnt
constipation or diarrhea from developing. Level:
Application. Nursing Process: Implementat ion. Patient
Need: Physi01ogicallntegrity.
4 A"swers: 2,3
Rnrionale: Bismuth compounds may be added to the regi_
men trcatment of Hclicolxu:tcr pylori. Thcsc producu in_
hibit bacterial growth and prevent H. pylori from adhering
to the gastric mucosa H.-re'ptor blockers are;ilio used to
help eradicate H. pylori. NoneoftheO(heroptions is used in
the treatment of H. pylori. Cog"i t;.-e Le.'tl: Analysis.
Nursi"g Process: Implementation. Patien. Need: Physio-
logical Integrity.
5 Anm-ers: " 2, J, 5
RatiO/lale: Risk factors associated with peptic ulcer disea5l!'
include a family history of peptic ulcer disease; blood group
0; smoking tobacco; caffeine, aspirin, glucocortiooid, and
NSAID use; excessive stress; and H. pylQri. Type 2 diabetes
mellitus has not been associated with peptic uker disease.
Cognitive Le.-el: Analysis. MINing Proctu.: Assessment.
Pafient Need: Physiological Int egrity.
6 Anm-er:4
Rationale: Proton-pump inhibitors such as omeprarole are
recommended (or short- term therapy and are associated
with a possible increased risk of gastric cancer when taken
long term. If symptoms of epigast ric pain and disoomfort
continue, other therapies and screening for H. pylori maybe
indicated. Switching to another proton pump inhibitor stiD
exceeds the recommended time of U5l!' for this category of
drugs.. H,-receptor blocken may be indicatoo but their use
should he evaluated by a health care provider be<:ause more
definitive treatment (t.g., for H. pylori) may be requirOO.
Proton pump inhibitoD should be taken 30 minutes before
meals. Cogn;,in Level: Application. NUNi"8 Process: Im_
plementation. Patient Need: Physiological Integrity.
Answers to Critical Thinking Questions
1 Regular of aluminum hydroxide (Arophojd) may
cause hypercalcemia because calcium and phosphorus
have a reciprocal relationship; that is, if the calcium goes
up, the phosphorus goes down.A patient with low serum
phosphorw; often exhibits signs of increasing weakness.
The treatment is to replace the aluminum hydro)lide with
a different antacid and take oral phosphorus supplements
Wltil serum phosphorus returns to a normal level.
2 The stomach is empty during the sleep cycle, the time
when the protective protein peptide TFF2 IS most eltt'(-
tive at repairing the mucoprotective lining of the stom-
ach. For the TFF2 protein to reach its maximum
effectiveness, the person a minimum of 6 hours of
LibraryPirate
lUlintt'rrupted slt't'p, which is uncommon in people who
slet'p during the daytime.
3 This patient has a history of PUD; thert'fore, alcohol and
smoking are contraindicated because they will e."lacerbatt'
the condition. This patit'nt is on ranitidine (Zanlac), and
smoking decreases the effectivt'ness of the medication.
Alcohol is a dt'pressant and can caust' increased drowsi-
ness in combination with ranitidine. 1his patient should
IX' advised to stop smoking and drinking alcohol if PUD
is to be resolved.
Chapt8r41
Answers to ReviewQuestions
I Answer: 1
Rationale: When contents lost from the stomach are
strongly vomiting the pH of the blood,
resulting in mt'tabolic alkalosis. With severe loss, acid- bast'
disturbances can lead to vascular collapse. Patients' respira-
tions may increase with prolonged vomiting. Esophageal
tears with prolonged vomiting occur rarely. Cognitive
Analysis. Nursing Process: Assessment. Pmiellt Need: phys-
iological Integrity.
2 Answer: 1
Rationale: Dramamint' is most effective when taken at least
20 to 60 minutes before tht' intended use. The other options
are not within the range of optimal effectiveness. COgrl i/ ive
Level: Application. Nursing Process: Implt'mentation.
Patient Need: Physiological Integrity.
3 Answer: 1
Rationale: Stress is one of the major factors in developing
IBS. HelicoblKter pylori is associated with developmem of
peptic ulcers. GERD is associated with esophageal disorders.
Cognitive Level: Analysis. Nursing Process; Assessment.
Patient Need: Physiological Integrity.
4 Answers;1,5
Rationale: Prochlorperazine (Compazine) and promethazine
hydrodlloride (Phenergan) can cau.o;e the anticholinergic side
effects of dry mouth, coru;tipation, urine retention, and a
rapid heart rate. Peppermint induces a calming effect. Lop-
eramide (Imodium, Kaopectate) and diphero:tylate (LamotiI)
are antidiarrheals. Cognitire woe/: Analysis. Nursing Process:
Implementation. Allient Need: Physiological Integrity.
5 Answers:l,1,J,4
Rationale: Sibutramine (Meridia) is a CNS agent that iscon-
traindicated in patients with a history of hypertension,
CAD, and renal and hepatic impairments. The patient
should be assessed for abdominal pain after medication has
been initiated. Cognitive Level: Analysis. Nursing Process:
Assessment. Patielll Nted: Physiological Integrity.
6 Answer: 1
Rationale: ProchJorperazine may cause decreased blood pres-
sure or hypotension as an adverse effect. The blood pressure
AppendlxD 825
should IX' taken before administering and the drug held if the
blood pressure is below 90/60 mmHg or below parameters as
ordered by the provider. The pulse will be taken along with
the blood pressure but may increase in relationship to hy-
poteru;ion (i.e., reflex tachycardia). Prochlorperazine does not
directly affect llUlg solUlds or temperature. Cognitive l.el"el:
Application. Nursing Process: Implemenilltion. Pa/ient
Need: Physiological Integrity.
Answers to Crit ical Thinking Questions
A priority for the nurse is to assess the potential for dehy-
dration. The nurse should assess the patient for possible
hypotension and tachycardia. The cause of this ongoing di-
arrhea needs to be investigated by the health care provider.
2 The patient needs to be informed that prochlorperuine
(Companne) is administered in its own syringe and must
not h" mixed with any other <irlle. The nil"'" m1llti notify
the health care provider that the patient wants a change of
antiemetic to one that can be combined with an analgesic
and given in the same syringe.
3 This patient needs to take a contact laxative to stimulate
the nerve endings and fJcilitate a bowel movement. A
bulk-forming promotes bowel regularity. The liq-
uid stool may be a result of fecal impaction, in which only
liquid seeps out. If this patient has ongoing bowel irregu-
larity problt'ms, the bulk-forming laxative may be helpful
later. The nurse should assess the abdomen for bowel
sounds and educate the patient to drink plenty of fluids
when taking bulk-forming laxativ<'S.
ChaptQr 42
Answers to NCLEX-RN" ReviewQuestions
I Answer:4
Pernicious anemia results in the inability to absorb vitamin
B" d ue to the lack of intriru;ic factor in the gut. Replacem"nt
therapy must IX' administered via intramuscular injection
becaust' oral supplementation will not be absorbed. Perni-
ciou, anemia affect.. vitamin D" absorption. Cog"i/;. ....
Application. Nursi ng Process: Implementation.
Patient Need: Physiological Integrity.
2 Alf5wers: 1, J, 4
Rationale: Circulatory ooUapse, complete heart block, and
respiratory failure are aU known to occur in patients receiv-
ingmagnesium sulfate intravenously. The therapy should be
used cautiously in patients with renal impairment.
Cognitive wei: Analysis. Nursing Process: Assessment.
Pmient Need: Physiological Integrity.
J AlI5wer: J
Rationale: Hypomagnesemia should be assessed. Patients a-
periencing hypomagnesemia may experience general weak-
ness, dysrhythmias, hypertension, loss of deep tendon refiexe;,
and respiratory dt'J'ression. Cognifive Level: Analysis. Nursing
Process: Assessment. Patient Need: Physiological Integrity.
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826 AppeoolxO
4 NISWtr: 4
Rarionale: Alcohol is known for its ability to inhibit the ab-
sorption of thiamine and folic acid. Alcohol abuse is the
most common cause of thiamine deficiency. Cognithe
Levtl: Analysis. Nursing Process: Implementation. Patient
Nud: Physiological Inlegrity.
5 Answer: J
Rationale: Vitamin K should be given to the patient to im-
clotting. \Vithout vitamin K, abnormal prothrombin
is produced and blood clotting is affected. Cognitive Lewl:
Analysis. Nursing Process: Implementation. Patient Need:
Physiological Integrity.
6 Answer:J
Rationale:TPN access sites, tubing,und parenteral nutrition
bag are all areasat risk for contamination and for bacteria to
enter the patient. The nurse should assess the IV access site
for redness, streaking, swelling, or drai nage and all tubing
and bag for signs of cracks, cloudiness, or precipitate. Glu-
cose and TPN orders will be assessed periodically but
do not directly contribute to the dewlopment of infection.
Periodic chest x-ray monitoring may be ordered and should
be obtained if adventitious breath sounds are noted.
Cognifive Level: Applicalion. Nursing Implemen_
tation. Patient Need: Physiological Integrity.
Answers to Critical Thinking Questions
The !"Itient is experiencing a normal reaction to the
niacin but should be instructed to follow up with the
health care provider for guidance on the appropriate dose
of niacin to take.
2 This patient should be instructed to see a health care
provider regarding the appropriate doses of vitamins. Vi-
tamin A can cause increased intracranial pressure, which
could be the cause of the headaches. Patients need to be
instructed about the appropriate amounts of vitamins
and potential adverse effects----especially when taking
megadoses of vitamins.
3 This patient needs to be assessed for possible renal calculi.
The patient is taking 500 mgofvitamin C daily to prevent
an upper respiratory infection, but vitamin C is con-
traindicated in patients with a history of renal calculi be-
cause the vitamin may exacerbate the problem.
Chaptllr43
Answers to ReviewQuestions
1 Answer: 1
Rai1onale: Glucocorticoidscan incre3S(' the risk of pepticul-
cers, decrease wound healing, and increase capillary
fragility. Glucooorticoids place the patient at increased risk
for infection. The other options do not cause increased risk
for peptic ulcers, delayed wound healing, or infection.
Cognitive Level: Analysis. Nursing Process: Implementa-
tion. Patient Need: PhysioloJ!;icai InteJ!;Tity.
2 Answer: 1
Rationale: This drug may mask the signs and symptoms of
infection. Hydrocortisone is contraindicated in patients
with known infections or hypersensitivity to the drug. Skin
infections, heart failure, and hearing loss are not associated
with Ihe use of hydrocortisone. Cogni,;' ... Le,e/: Analysis.
Nursing Process: Implementation. Patient Need: Physio-
logical Integrity.
3 Answer: 2
Rationale: Circulatory collapse can occur if hydrocortisone
use is discontinued abruptly. The patient may experience
nausea, vomiting, lethargy, and confusion, progressing to
coma and death. Diabetes insipidus is caused by ADH defi-
ciency. Myxedema is related to hypothyroidism. Cushing's
syndrome is caused by excess gluCQCortiooids. Cogniti \'e
Level: Analysis. Nllrsing Process: Assessment. Patient Need:
Physiological Integrity.
4 Answer: 2
Rationale: The patient may have the hormonal condition
hyperthyroidism. Symptoms of hyperthyroidism include
diarrhea, stress intolerance, and weight loss. The other dis-
ease processes are not related to the thyroid gland. Cognith ...
Level: . Nursi"g Process: Implement:ltion. Pmien'
Need: Physiological Integrity.
5 Answers: 2, 5
RatiO/lale: Because small doses of radiation will be emitted
for up to 1 week, patients should avoid close contact with
children or pregnant women after drug administration. Ra-
iodine is used to permanently decrease thyroid
function. Patients may experience hypothyroidism, includ-
ing signs and symptoms such as general weakness, muscle
cramps, and dry skin. Ruids do not affect radiation levels.
Cognitive Lewl: Application. Nursing Process: Implemen-
tation. PMient Need: Physiological Integrity.
6 Alls" ... r: 4
Rationale: Desmopressin nasal spray should be used in the
evening to mimic the body's own natural rhythms. Gently
rotating the bottle rather than shaking, storing the bottle in
room temperature conditions lllliess excessive heat is pres-
ent, and spraying the drug high into the nasal cavity are all
appropriate administration techniques. Cognitive Level:
Application. Nursing Process: Implementation. Patient
Need: Physiological Integrity.
Answers to Critical Thinking Questions
To answer this question the student should refer to a
medical--surgical text or a laboratory manual. A child
with diabetes insipidus produces large amounts of pale or
colorless urine with a low specific gravity of 1.001 to
1.005. Daily urine volwne may be 4 to to L or more and
result in excessive thirst and rapid dehydration. Desmo-
pressin is a synthetic analog of ADH. It may be adminis-
tered intranasally and therefore maybe better tolerated by
a child. With pharmacotherapy, there should be an inune-
LibraryPirate
diate decrease in urine production and an increase in
urine concentration. The child's mother or caregiver
should be taught to use a urine dipstick to check specific
gravity during the initiation of therapy. A normal specific
gravity would range from 1.005 to 1.030 and would indi-
cate that the kidneys are concentrating urine. The care-
giver also should be taught to monitor urine volume,
color, and odor until a dosing regimen is established.
2 The nurse must be empathetic with the patient's father
and allow him to express his concerns. He may feel guilty
about contributing to his son's current health crisis. Once
the patient's condition begins to improve, the nurse
should assess the father's lUlderstanding of the asthma
regimen. The father and the patient should receive in-
stru, tion about the side effects of glucocortkoid therapy.
Glucocorticoids used for anti-inflammatory purposes
can suppress the hypothalamic- pituitary axis. Abruptly
discontinuing a glucocortkoid after long-term therapy
(more than 10 days) can produce cardiovaocularcollapse.
The father needs to be instructed about the dosage regi-
men for prednisone, which may include an incremental
decrease in the drug dosage when discontinuing the drug.
The nurse might also be concerned about the family's
economic needs. Referrals to a resource providing fman-
cial support for medication is appropriate.
3 The instruction needed by the parents should include the
following points:
a. Drug action: The drug stimulates growth of most body
tissues, especially epiphyseal plates; it also increases cel-
lular size.
b. Instructions for reconstituting the medication, site selec-
tion,and technique for 1M or subcutaneous injection.
c. Dosing schedule: Somatropin injections are usually
scheduled 48 hours apart.
d. Pain and swelling at the injection site.
e. Importance of regular follow-up with the health care
provider, including checks on height, weight, and bone
age.
f. A discussion of the cost of the medication and an op-
portunity for the parents to raise any concerns they
may have for appropriate referral to the prescriber or
social services department.
Answer to Avoiding Medication Errors
No. The infant's weight of 2000 g is equivalent to 2 kg.
Therefore, 25 mglkglday would be 50 mg. When given in
two equally divided doses, the correct dose is 25 mg.
Chaptllr44
Answers to NCLEX-RN8 ReviewQuestions
I Answer: I6()O
Rationale: The onset of NPH is between I and 4 hours, and
it peaks between 8 and 12 hours. Cognitil'e Applica-
Appendix D 827
tion. Nursing Process: Assessment. PtlIienf Need: Physio-
logical Integrity.
2 Answer: I
RatiO/wle: Humalog is a rapid-acting insulin that is admin-
istered for elevated glucose levels and should be given 0 to
IS minutes before breakfast. Hypoglycemic reactions may
occur rapidly if Humalog insulin is not supported by suffi-
cient food intake. The medication can be mixed in one sy-
ringe. Cognitive Application. Nursing Process:
Implementation. Pafient Need: Physiological Integrity.
3 Answer:3
Rationale: Additional teaching is needed. The clear solution
(regular insulin) should be drawn into the syringe first fol-
lowed by the cloudy solution ( NPH). The other options
demonstrate an understanding of discharge instructions.
Cognifive Level: Analysis. Nursing Process: Evaluation.
Patient Need: Physiological Integrity.
4 AlI5wers:I,2,3,4
Rationale: The patient needs to understand that exercise
may increase insulin needs. Blood glucose levels should be
monitored prior to startinp; and after endinp; exercise, and
addressed appropriately. A complex carbohydrate should be
consumed prior to strenuous exercise. Cognitive
Analysis. Nursing Process: Implementation. Patitnf Need:
Physiological Integrity.
5 AIIS"lwr:4
RotiO/wle: The health care provider should be contacted for
further orders. The need for oral hypoglycemic medication
may haw been overlooked or other measures, such as in-
sulin, to treat glucose needs during the surgery may be
planned. Contacting the provider ensures that the provider
is aware that the patient is a diabetic and is aware that no
medications for diabetes were ordered. Holding all medica-
tions as ordered will not address the patient's glucose needs
during surgery. Intravenous fluids during this time may
contain glucose solutions, resulting in a hyperglycemic con-
dition.lt is not within the nurse's scope of practice to inde-
pendently change a medication dosage order or to give
medications when an NPO order has been written. The
provider should be contacted before these decisions are car-
ried out. Cognifh'e Application. Nursing Process: Im-
plementation. Patient Need: Physiological Integrity.
6 Aml>"er: I
RatiO/lale: The stress of hospitalization and infection may
cause the release of glucose as a responsetothis stress. Blood
glucose levels will continue to be monitored and control
may improve as the infection clears and the patient is dis-
charged. The pathogenesis of type I and type II diabetes is
different. Type II diabetics may eventually need insulin but
for reasons other than the pathogenesis of type I. Immedi-
ate changes in response to an oral hypoglycemic drug are
not known and diabetics may continue to take all-oral med-
ications while in the hospital. Cognitil"e Levtl: Application.
Nursing Process: Implementation. Patient Need: Physiolog-
icallntegrity.
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828 AppeoolxO
Answers to Critical Thinking Questions
The nurse should first explain that management of type I
diabetes is initiated with diet, exercise, and home blood
glucose monitoring. Compliance with prescribed regimens
may reduce the patient's fasting and postprandial blood
glucose v:t.lues to acceptable levels. Mothers with type I di-
abetes must keep their blood glucose lewl within a very
narrow range to prevent the nwnerous complications that
can occur because of elevated blood glucose during preg-
nancy. These complications can range from fetal deformity
to fetal macrosomia and its subsequent sequelae. Someau-
thorities recommend that the fasting blood gluoose levels
be maintained at or below 100 mgldL and the postprandial
glucose below 120 mgldL The nurse should prepare the
patienl for insulin therapy in <;ase diet and exerdse fail to
maintain control. Oral hypoglycemic agents cross placen-
tal membranes and have been impliClted as teratogenic
agents. Their use is not reoommended during pregnancy.
2 Beta-blocking drugs such as propranolol have the poten-
tial to affect type II diabetics on oral hypoglycemics byal-
tering the way hypoglycemia is perceived. In recent
studies, hypoglycemia was perceived differently in pa-
tients taking concurrent beta-blocker therapy than pa-
tients who were not. Diaphoresis was a common
symptom when blood sugar decreased among those pa-
tients on beta blockers along with their oral hypoglycemic
drug. The nurse should teach the patient to be aware that
should his blood sugar begin to decrease, symptoms nor-
mally f .. 1t (e.g., nervousnt'SS, tremors, agitation) may be
perceived differently and that should diaphoresis occur,
he should check his blood sugar immediately.
3 Insulin glargine (Lall1us) is a newer agenl1hat is a recom-
binant hwnan insul i n analog. It must not be mixed in the
syringe with any other insulin and must be administered
subcutaneously. Insulin glargine appears to have a con-
stant long-duration hypoglycemic effect with no defined
peak effect. It is prescribed once daily, at bedtime. The
nurse should question the order for Lantus to be admin-
istered every morning.
Chaptlilr45
Answers to ReviewQuestions
I A'lSwer4
Rationale: Use of oral contraceptives puts a patient at risk for
thromboembolism, which is manifested by calf pain, shortness
of breath, and chest pain. level: Analysis. Nursing
Proem: Assessment. Patient Need: Physiological Integrity.
2 Answer: 1
Rarionale: Caffeine and estrogen may lead to increased CNS
stimulation. Cognitive level: Analysis. Nursing Process:
Implementation. Patient Need: Physiological Integrity.
3 Answer::Z
Rationale: The assessment of the patient is within normal
parameters for a patient in labor. Antidiuretic hormone can
cause water intoxication in patients with prolonged IV infu-
sion of oxytocin. Cognitil-e Level: Analysis. Nursing
Process: Assessment. Patient Need: Physiological Integrity.
4 Allswers: 1,:Z
Rationale: Barriercontraception is needed only when two or
more doses are missed. Placebos are usually iron, which has
no effect on estrogen-related adverse effects. Side effects in-
clude intolerance to contact lenses, abdominal cramps, dys-
menorrhea, breast fullness, headache, acne, skin rash,
hypertension, and thromboembolic disorders. Cogllitile
Level: Analysis. Nursillg Process: Implementation. Patient
Need: Ph}'!;iological Integrity.
5 AIIs .. -er::Z
Rationale: Although some antibiotics and anticonvulsants
can reduce the efficacy of oral contraceptives, the most com-
mon cause of pregnancy in patients using oral contracep-
tives is skipping two or more doses. Cognirh-e
Analysis. Nursing Process: Implementation. Patient Need:
Physiological Integrity.
6 AIISIWr: I
Ratiollale: Infertility may result from physical obstruction,
pelvic infections, or endocrine-related reasons resulting in
lack of ovulation. If a fertility workup suggests that infre-
quent or anovulation isa primary cause, clomiphene may be
tried to increase ovulation and is approximately 90% effec-
tive for patients with ovulatory-related infertility.
Clomiphene will not be therapeutic if the causes of infertil-
ity are other than lack of ovulation. The risk of multiple
births is higher with ovulatory stimulants with approxi-
mately 25% resulting in multiple births. Contraceptives do
not continue to suppress ovulation after they have been dis-
continued. Cogllitile Application. Nursing Process:
Implementation. Parient Need: Physiological Integrity.
Answers to Critical Thinking Questions
The student should be able to use this example to help il-
lustrate neuroendocrine control of the female reproduc-
tive system. Leuprolide acetate is a synthetic GnRH
agonist that acts by stimulating the anterior pituitary to
secrete FSH and LH. The pituitary receptors become de-
sensitized, which causes a decrease in FSH and LH secre-
tion. Consequently, estrogen production, which is
dependent on ovarian stimulation, is diminished and the
patient"s menstrual cycle is suppressed. The goal 01 sup-
pressing the menstrual cycle is to decrease hormonal
stimuli to abnormal endometrial tissue. It isexpected that
will result and that endometriosis lesions
will decrease. A decrease in lesions will likely enhance the
patient's fertility or improve her level of comfort during
menstruation. The patient will remain on this drug ther-
apy for approximately 6 months. Menstrual periods usu-
ally resume 2 months after the completion of therapy.
2 Misoprostol (Cytotec) isa prostaglandin that maybe pre-
scribed as an antiulcer agent. The drug also has two off-
label uses, which include cervical ripening prior to
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induction of labor, or termination of pregnancy when
used with mifepristone. It is known that prostaglandins
have a role in the initiation of labor,:l.S h:l.S be-en demon-
strated with the vaginal application of prostaglandin E.
Misoprostol is a prostaglandin E analog that has clearly
been demonstrated to produce uterine rontractions. In
this example, the fetus was not tolerating the uterine ron-
tractions and the nurse used correa judgmenl in quickly
acting to remove the drug.
3 Oxytocin exerts an antidiuretic effea when
tered in dosesof20 milliunitslminor greater. Urine out-
put decreases, and fluid retention il'l(reases. Mon
patients be-gi n a postpartum diuresis and are able 10 bal-
ance fl uid volumes relatively quickly. However, Ihe nurse
should evaluate the patient for signs of water inloxica
tion, which include drowsiness, listlesmess, h.-adache,

Chapter 46
Answers to NCLEX- RNe RevitwQuestions
I AllsIi'ers:2,J
RatiOlwle: A side effect of testosterone therapy is fluid reten-
tion. Testosterone is also used to increase muscle mass and
strength. The usually increases with the use of
testosterone, because it promotes the synthesis of erythro-
poietin. Cognitive Le"d: Analysis. Nu,.,in8 ProceJS: Assess-
ment. Piltient Nud: Physiological Integrity.
2 Answer. I
Rorionllle: The primary use of testosterone is 10 Ireat
hypogonadism in men with delayed pUberty. Tl"Stosterone
therapy promotes normal gonadal development and often
restores reproductive funct ion. Seroodary .seJ: characteris-
tics or viriliution also occur. o,gniti>le Level: Analysis.
NUN'''g Proceu: J\ss<,ssment. Pat i<,nl NeM' I' hylIiological
Integrity.
3 A"s .... er: J
Rationale: In men, some medications such as phenothi -
azides, thiazide diuret ics, SSRls, TCAs, propranolol, and di
azepam cause impotence beause of low testosterone
secretion. Cog"i'ive Level: Analysis. Nursing Prouss: As
sessment. PIl ';en' Nttd.' Integrity.
4 Allswer: 1
Rationale: Life-threatening hypotension is an adverse effect
in patients who are taking sildenafil (Viagra) and organic
nitrates. Clls ni.ive Le"e/: Analysis. Nu,.,illS Process: Assess-
ment. Patient Needs: Physiological Integrity.
5 AlIslI'l'r:4
Rilrionllle: Finasteride promotes shrinking of enlarged
prostates and helps restore urinary function. Tadalafil and
sildenafll are wed in pOitients experiel'l(ing ert'Ctile
tion. Testosterone is used in the treatment of hypogo-
nadism. Cog"i.iv, le1'd: Analysis. NurJi"s ProcesJ:
Implementation. Altie"t Need: Physiologkal!nlegrity.
.. o 829
6 A/lJl\!erJ: I, J, 4
Rilrionale: Enlarged prostatic tissue will dt'Crease over a pe_
riod of 3 to 6 months. The drug is teratogenic and should
not be- handled by pregnant women. Blood donation should
not occur while takingfin:l.Steride because it maybe- given to
a woman. Finasteride in lowerdose:s is given under the t rade
name KPropecia- for treatment of baldness. Cog"irh-e Level:
Application. Nurs;"g Process: Implementation. Altien.
Nud: Physiological Integrity.
Ann ." TS to Critia l Thinking Quest ions
This patient's age puts him at risk for a variety of health
problems. Conditions such as renal or hepatic dyfunction
mayaJter the manner in which the drug is metabolized or
excreted. The potential impact on pil tienlS with coronary
artery di!it'3se who are using nitrales has been well docu
mented. Because the patient is requl"Sting a prescription
for sildenafil (Viagra), the nurse should ensure that the
history includes the following data: sexual dysfunction,
cardiovascular disease and use of organic nitntes, severt
hypotension, and renal or hepatic impairment-which
requires a decrease in the prescribed dose. Nurses can be
effect ive in initiating conversations about Stud-
ies have shown that are often forthcoming with
concerns about sexual performance when an interviewer
is open and professional.
2 A.:oording to Erikson's theory of psychosocial develop-
ment, this young man is in the stage of identity versus iso-
lation. The family has been replaced in its influence largely
by the adolescent's peer group. This young man's desire to
be- accepted as an athlete and a team member may produce
a wiUingness 10 do what it takes to fit in. In addition, the
)Uung man may have aspirat ions of a caretr in sports and
recognize the need to in optimum physinl rondition.
This patient may not realize that the use ofteslosterone in
immature men has not been associated with signifinnt in.
ereases in muscle mass. Such increase has been docu
mentedonly in mature men. In addition, testosterone can
produce premature epiphyseal closure, affect
ing this )Qung man's adult height
3 Finasteride (Proscar), an androgen inhibitor, is used to
shrink the prostate and relieve symptoms associated
with BPH. Finasteride inhibits 5-a1pha-redUClase, an
enzyme that converts testosterone to the potent andro
gen Salpha-dihydroteslosterone (DHT). The prOl5tate
gland depends on this androgen for ilS development, but
excessive levels can cause prostate cells to increase in size
and divide.A regimen of6 to 12 months may be nt'Cessary
to determine patient response. Saw palmetto is an herbal
prepamt ion derived from a shrublike palm tree that is na_
iive to the United States. This phytomedi-
cine compares pharmacologically with finasteride in that
it is an antiandrogen. The mechanism of action is virtu_
ally the same in these two agents. Authorities note no sig-
nificant adverse effeas of saw palmetto e.'ttract and no
known drug-drug interactions. Just as with fin.asteride,
long-term use is requi red.
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830 Ap""O>dlxD
Chaptlr47
Answers to NCLEX RN_ Review
] Answer: J
Rationale: Osteomal3da, referred to as r!eke" in chi ldren, is
a disorder characterized by softening of bones without al-
teration in basic bone structure. Classic signs of rickets in
children include bowlegs and a pigoon bre4lst. Shortness of
breath, crutch walking, and finger and toe deformities are
not associated with 05toomalacia. Cognitive wei: Analy-
sis. Nursing Process: Patien, Nud: Physiolog-
ical lntegrity.
2 Answer: 1
Rationnle: A normal level is 8.5 to 1]5 mgJdL
Sigru; of hypocalcemia ioclude mu.sde spasms, facial
twitching, and paresthesi;l..s. Anorexi.a, headache, and drowsi
ness may be associated with hypercalcemiol. Cognilive Le .. r l:
Analysis. Nursing ProcrS$: Assessment. Protiml Need: Phys i
ologicallntegrity.
3 Answrr:1
Rationale: Gout is a metabolic disorder charncterized by the
accumulation of uri c acId In the bloodstream or join! cavi-
ties. Alcohol increases uric acid levels. Although long ternl
alcohol use may affect the liver, it is not related to uric acid.
Alcohol does not affect the absorption of antigout medica
tions. Alcohol increases urine acidity. Cognit in: L .. el:
Analysis. Nursing Process: Assessment. Pt,tient Need: Phys-
iologicallntegrity.
4 Allswers: J, 2, J
Rationale: Signs and symptoms of include
anorexia, vomiting, excessive thi nt, fatigue, and confu sion.
Kidney stones may IXcur, and bones may fracture easily.
Cardiac dysrhythmias may IXcur, because calcium ions
influena the elICitability of all neurons. Whenever calcium
concentrations are too high, sodium
:Kross cell membranes. This is a dangerous state, because
ner..-e conduction depends on the proper influx of sodium
into cells. Cognitive Lew/: Analysis. Nursing ProUfJ: As
....... Nd: PhY3iologkallnt egr ity.
5 Answer: 2
Rationale: Sodium hyaluronate (HyalganJ is administered
by injection directly into the knee joint. Thi s medication reo
places or supplements the body's ru.tural hyaluronic acid
that deteriorated be,ause of the inflammation of os-
teoarthritis. AU other routes are incorrect. Cognit i,-e L"e/:
Analysis. Nurs ing Process: Implementation. Palient Need:
Physiological Integrity.
6 Answers: 2, 1, "
Rationale: Bisphosphonates such ll5alendronate require the
patient to tau the drug on an empty stomach and remain
upright for 30 minutes to J hour. Adequate serum calcium
levels should l>econfinned before starting bi sphosphonates
and adequate calcium and vitamin D intake should be en-
couraged while on drug therapy. Any narrowi ng of the
esophagus may pla,e the patient at risk of increased adverse
esophageal effects from the drug. Adequat e calcium intake
is advised while on bisphosphonates to maintain normal
serum calcium levels. Cognitil-e Le' 'I'i: Applicat ion.
Nursing Process: A.s.sasment. Pat;ent Need: Physiological
Integrity.
Answers t o Critical Thinking Qut$tions
A1endronate ( Fosamu) is poorly absorbed afier oral ad-
ministration and can produce significant GI irritation. It
is important that the patimt be educated regarding sev
eral elements of drug administration. To promote ab-
5Orption, the drug should be taun firs! thing in the
morning with 8 02 of water before food or beverages are
ingested or any other medications are taken. It has been
soown that certain bewrages, sum as orange juice and
coffee, interfere with drug absorption. BydeLayi ng eati ng
for 30 minutes or more, the patient is promoting absorp
tion of the drug. Additionally, the patient should be
taught to sit upright afier taking the drug to reduce the
risk of esophageal irritation. Alendronate must be used
carefully in patients with esophagiti s or gastric ulcer. If
the patient misses a dose, she should be told to ski p it and
not to double the next Alendronate has a long half
life, and missing an occasional dose will do littl e to inter
fere with the therapeutk effect of the drug.
2 Frail elderly patients may be suscepti ble to hypocalcemia
caused by dietary defi ciencies of calcium and vitamin D
or decreased physical activity and lackof exposure 10 500-
shine. This patient has aU these risk faClOrs. She is unin
terested in eating, has physicallimi latioru, and is not able
to g<'l out of the house into the sunshine without assis-
tance. Orally administered calci um requires vitamin D
for absorption to take plxe. Because this patient does not
coru;ume milk, the most recognizable source of vitami n
D, she needs to be encouraged to increase her intake of
other dietary sources of this vitamin. Foods rich in vita
min D include canned salmon,cereals, mealS, beans,
and potatoes. To promote the effect iveness of calcium
supplement::r. tion, the nun.e must remember the impor
tance of drug-nutrient inleractioru;.
J Thetriage nurse should obtain inform;J.tion about the on
set of symptoms, degree of discomfort, and frequency of
attacks. A familial history of gout can be predictive, be
caru;e primary gout is inherited as an Xlinked trail. A
past medical history of renal calculi may also be predic-
tive of acute gouty arthritis. The nurse should ask the pa
tient questions about his diet and fluid intake. An attack
of gout can be precipitated by alcohol int ake (particularly
beer and wine), starvation diets, and insufficient fluid in
take. In addition, the should obt ain informat ion
about prescribed drugs and the use of OTC drugs con
taining salicylates. Thiazide diuretics and salicylates can
precipitate an attadr.. The nurse should :also ask about reo
cmtlifestyle events. Stress, illness, trauma, or strenuous
can precipitate an attack of gouty arthritis.
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Answer to Avoiding Medication Errors
This error occurred because the nurse administered the
medication to the wrong patient. Patients must be correctly
identified by checking the identification band or by another
identifying method and not by relying on patients to re-
spond to calling them by name. When there are two patient:!
with similar names, it is particularly important to double-
check the room number and identification band. Perhaps
Ms. Brown was responding to being awoken. Best practice
requires that proper patient identification occur prior to
any medication administration. The nurse must adhere to
the five rights of medication administration:
I. Right patient
2. Right drug
3. Right dose
4. Right route
5. Right time
Chapt8r48
Answers to NCLEX_RN8 ReviewQuestions
I Answer: 2
Rationale: To ensure the effectiveness of drug therapy, pa-
tients should inspect hair shafts after treatment, checking
for nits bycombing with a fine-toothed comb after the hair
is dry. This procedure must be conducted daily for at least
I week after treatment. The patient does not require isola-
tion. Linens should be washed with hot water; bleach is not
required. Cognithe Ln-el: Analysis. Nursing Process: Im-
plementation. Parient Need: Physiological Integrity.
2 Answers: 1,2,5
Rationale: The directions for scabicides and pediculicides
must be followed carefully. If these doses are overapplied,
wrongly applied, or accidentally ingested, the patient may
experience headaches; nausea or vomiting; irritation of the
nose, ears, or throat; dizziness; tremors; restlessness; or con-
vulsions. Eye irritation does not occur with over:lpplication.
Cognirive !.nel: Analysis. Nursing Process: Implementa-
tion. Pmirnt Need: Physiological Integrity.
;, Answer: I
Rationale: High-potency corticosteroid creams such as fIu-
ocinonide should be avoided in the highly vascular neck and
facial regions because of the possibility of adverse effects.
Topical corticosteroid creams may be kept at room temper-
ature until the e."lpiration date unless there are signs of dis-
coloration of the cream, unless otherwise stated on the label
or as instructed by the health care provider. Ruocinonide is
one of the higher potency creams available for topical use.
Contact dermatitis is a skin reaction to contact with anti-
genic material and the body's reaction depends on the anti-
gen-antibody response, not necessarily to the antigen itself.
Cognitive Lele/: Application. Nursing Process: Implemen-
tation. Patienr Need: Physiological Integrity.
App<>ndb<O 83 1
4 AnSlwrs: 2, J, 4
Rotionale: Washing the face gently with a mild soap and us-
ing sunscreens and protection from sun exposure are part of
the care required for patients taking tretinoin. Mild dryness,
redness, and peeling skin are all possible adverse effects that
are e.. ""<pected but any , kin irritation or pain , hould be
reported. SWl exposure should be avoided unless specifi -
cally instructed to do so by the health care provider.
Cognitive Lele/: Application. Nursing Process: Implemen-
tation. Patienr Need: Physiological Integrity.
5 AIIS"",r: 2
Rotionale: Initial drying of the skin caused by benzoyl per-
oxide will help to clear acne lesions in the early stages of
treatment but it may take several weeks before full effects are
visible. One week of keratolytic therapy for acne should
demonstr:lte the begilllling of therapeutic effects. Most acne
is responsive to keratolytic therapy but may need an antibi-
otic included as part of the treatment plan after a full course
of the ker.ltolytic has been tried. Only in severe cases is oral
drug therapy usually considered, after other treatment op
tions have not been successful. Cognifile Level: Application.
Nursing Process: Implementation. Patielfl Need: Physiolog.
ical Integrity.
6 AlISwers: I, 2, 4
Rationale: Isotretinoin is ter:ltogenic and pregnancy must
be avoided whileon this medication. To be eligible for treat-
ment, female patients must agree to frequent pregnancy
tests and commit to using two forms of birth oontrol while
on the drug. Because of adverse visual, hepatic, and lipid ef-
fects, periodic vision screening and lab work must be mon
ito red. IsotrE"linoin is a retinoid doselyrelated to vitaminA.
Vitamin A may be toxic when taken in large doses and nor-
mal daily intake is usually sufficient to meet the body's
needs without supplementation. Cognifh-e Level:
tion.Nursing Process: Implementation. Patient Need: Phys-
iological Integrity.
Answers to Critical Thinking Questions
To establish a rapport with the baby's mother, the nurse
should first respond to the mother's anxiety. She should
validate that the baby's condition iscause for concern and
commend the mother for seeking medical guidance. The
nursing student should recognize that the availability of
OTC preparation.!can a to a young mother
who only wants to see her infant more comfortable and
relieved of symptoms.
However, the student nurse must also reoognize that top
ical use of corticosteroid ointments can be potentially
harmful, especially for )'QWlg children. Corticosteroids,
when absorbed by the skin in large enough quantities
over a long period can result in adrenal suppression and
skin atrophy. Children have an increased risk of to.ucity
from topically applied drugs because of their greater ratio
of skin surface to weight compared with that of
adults. The student nurse should ensure that the health
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832 0
carl' provider at thl' public health dinic sees thi s patient.
Ona a drug treat ment modalityis prescribed, the st udent
nul'$l' should makl' 5Url' that thl' b.aby's mother under-
stands the correct method for drug administration.
2 According to Piaget, this 14-year-old patient is Cllpable of
formal oPfrations, thl' highest level of cognitive develop-
ment. A young person in this age group is :l.ble to think
logically and make dedsions regarding health care prob-
lems and take control of a treatment regimen. To 5;lfdy
self_medicate, the teenager needs information about the
medication, i ts administration, and side l'ffect!. Teenagers
need dl'3r instructions and often respond to a roregiver
outside thl' family as a re:soUfCl' for information.
The nul'$l' should reoosnize that this patient is l'Xperienc-
ing GT sidl'effects that are oonunon in all
tetracycline t reatmenl. Recent studies have dl'monstrated
cast$ of tsOphagitls in teenage fXltienls. Todl'Vdop :l.n ef-
fective teadiing plan, the nurse will need to:l.SSess the fXI -
tient's dOiSing regimen and current dietary patterns. A
teaching plan would indude the following:
Encouraging oral fluids 10 maintain hydration even if
nausea occurs
Drinking 3 full glass ofwat ... r with the medication to re-
duce g:Jstric irritation
Sitling up for}O mi nutes after the night-time dose to
reduce gastric irritation and reflux
Consuming small frequent meals to t'I1.Sure adequate
nutrition
Taking the drug I hour before or 2 hours after meals to
promote its absorption and effectiveness (if nausea
persists, however, the patient should be encouraged to
take the do.lycycline with food)
Taking doxycycline with milk products or antacids de-
Crl'3Se5 the absorption of the drug; therefore, other
remedies for GI irritation will need to be discussed
with the health care provider
3 This patient's presentation is typical of ro5;lcea. To pre-
ventlong-term changes in the skin, therapy should be ag_
gressive despite the fact thai this patient is also of
child-bearing age.lsotrelinoin (Acculane) is a pregnancy
category X drug and has a picture of a fet us overlaid by
symbol on the package. Reported teratogenic ef-
fects indude- severe CNS abnormalities such as hydro-
cephalus, microcephalus, cranial nerve deficits, and
oomprornised intelligence scores.
Thi s needs 10 understand that she must use con-
traCl'ption while receiving drug therapy and for up to 6
momhs 3fter therapy is discontinued. She should nOI be-
gin therapy unless she first demons trates a negative preg-
nancy test. In lIddition, she should be laught to begin
therapy on the second or third day of her norrnal men-
strua/ cycle. Teenagers whoareon isolrelinoin should an-
ticipate monthly pregnancy tests.
Cha tllr 49
Answers to NCLEX_RNII Review Questi ons
I J
Rationllle: Closed_angle gl3ucoma is an acute type of gLau-
((Ima that is caused by stress, impact injury, or medications.
Pressure imide the anterior chambtr increases suddenly ""-
cause the iris is pushed over the area where the aqueous fluid
normally drains. Signs 3nd symptofll5 include intense
headaches, difficulty concentrating, bloodshot eyes, blurred
vision, and a bulging iris. ClOsed-angle glaucoma oonstitutes
an emergency. AU other options are inappropriate in this
emergency. eognitil"l! Level: Application. Nursing Prouu:
Impleme-ntation. Patient Need.
2 A,/fSh'l'f: 4
Riltionale: Side effects indude eye irritation, ((InjunctiY:lI
edema, burning,stlngLng, redness, blurred vision, pain, itch_
ing, the sensation of a fortign body in the eye, photophobia,
and visual disturban,es. The patient may experience the
phenomenon of in'feasing amounts of brown pigmenta_
tion in the treated eye only and thickening of the eyelashf.'S
and hair adjacent to the treated e)e. General body symp-
toms such as f1ulike symptoms, nuh, or headache may oc-
cur. Loss of lashes, hypertension, and dilation of the pupils
do not occur with the use of prostaglandin!>. Cogn;t;,'/!
uvel: Analysis. Nursing Proceu: Implementation. Parien'
Need: Physiologica.l Integrity.
3 A,nswer: J
Rationale: Beta_adrenergic drugs may redua rf.'Sting heart
rate and blood pressure. The patient and family should be
taught how to check the pulse and blood pressure before ad-
ministration and to notify the health care provider if l'X-
tremes occur. Beta-adrenergic drugs do not affect urine
output, respiratory rate, or glucose levels. Cognitivr u''e/:
Analr-;is. Nurs ing Prore$S: Implementation. Patien' Neell:
Physiological Integrity.
4 Answer:4
RaNonair Some drogs are- desiSruod for eramining
the eyes of patients. These include cydoplegic drugs to relu
ciliary muscles and mydriatic drugs to dilate the pupils. One
has to be especially areful with anticholinergic mydriatics,
because these drugs Clln worsen glauooma by impairing aque-
ous hwnor outflow and thereby increasing intraocular
pressure. Cognitive LeI'd: Analysis. Nursing Process: Imple-
mentation Patien, Need: Physiological Integrity.
5 A,nswers:l,2,4
Rationale: The nul'$l' needs to notity the health care provider
if the patit'nt has second- or third-degree heart block, brady-
cardia, cardiac failure, CHF, or COPD because timoloJ may be
contraindicated for J>lltients with these oonditions.lf thedrug
is absorbed systl'lllically, it will these conditions.
ProPfr adminislration lessens the danger that thedrug wiH be
absorbed SYSlt'lllically. TIle renal and hepatic systt'fJ1S are not
affected by timolol. CognitiOT l.e>-rI: Nursing
Prouss: Assessment. Pallent Nt'ffi: PhpiDIogicallnlegrily.
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6 ,4"SWl"r.4
RJltronlllr. Conuctlenses should be nrnm'N before instiU-
ing eye drops and remain out for a minimum of 15 minute
after instilling qe drops. Administering drops inlo the
conjunctival sac. applying $light pressure to the Iacrinul
duct for 1 full minuu. and avoiding dirKt contatt with the
dropper tip and are all appropriate IKhniques to use
when administering eye drops. Cognitive Lncl: Applica-
tion. NUN;nK Proceu: Implementation. Ptuil.' n( Netd: Phys-
iologicallntegri ly.
Answerl lO Crili cal Thinking Questions
Conisporin Otic is a combination of neomycin,
polymyxin &, and I'MI hydrocormooe. The technique for
instilling this drug applie to most eardrops. Th.e nurse
nms to instruct IIw molher 10 position her daughter in
a side-lying position with the affected ear !adng up. The
mothtr nOOs to inspect the ear for the prek'n<e of
drainage or cerumen and, if present, gently remO\"e it with
a cotton-t ipped applicator. Any unusual odor
could indicate a ruptured tympanic membrane and
should be reported to the health care provider. Nat, the
mother should be laught to straighten the mild's external
ear canal by pullins down and back on the auricle to pro-
mote distribution of Ihe medication to deeper external
ear 51rUClUTe5. Af'ttr the drops are instilled, the mother
can further promote medication distribution by gently
pressing on the tragus of the ear. The mother should be
taught to keep her daughter in a side_lying position for
J to 5 minute after the drops are irutilled. lf a cotton ball
has been prl'5Cribed, the collon ball should be piKed in
the ear aprlYins pressure. lbe cotton ball can be
removed in IS minutes.
2 limoptic. a beta-adrenergic blocking agfnl, is con-
traindicated in individuals with COPD. This agfnt has
been known to produce brondlOspasm by blocking the
stimulation ofbetaz-adrenergic receptors. When beta
z
re-
ceptors are stimulated. relaxation of bronchial smooth
muscl es is facilitated. Timolol is contraindicated in
COPD, an air- trapping disorder, and may be contr.1indi-
cated in chronic asthma. In bolh cases, the beta adrenergic
blocking effea of timolol could be pottntiallylife threat-
ening. Betamlol (lktopl ic) is also a beta-adrenergic
biock:ing agent bUI is considered 5ilfer for use in p;ltienu
wilh COPD who require utatment for glaucoma.
J All ophthalmic agenu should be administered in the con-
j unClivai $aC. The cornea is highly innervated, and direct
applic:Uion of medication to the cornea can result in ex-
cessiVl' burning and stingi ng. Tke conjunctival sac nor-
mally holds one or two drops of solut ion. The patient
should be reminded to place pressure on the inner can_
thus of the followin8 administration of the medica-
tion to prevent the medication from flOWing into the
nasolacrimal duct. Thi s maneuver helps prevent systemic
absorption of medication and decreases the risk of side
effects commonly :wociated with antiglaucoma agenl5.
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CALCULATING DOSAGES
I. CALCULATING DOSAGE USING RATIOS
AND PROPORTIONS
A. A mno is used to express a relationship between two or
more quantities. Ratios may be written using the
following notations.
1: 10 means 1 part of drug A to 10 parts of
sol ution/solvent
In drug adculations. ratios are usually expressed as a
fraction:
I part drug A
10 parts solution 10
A proportion shows the relationship between two
ratios. It is a si mple and effel.:tive means for !;lIkulating
certain types of doses.
Dose on hand
Quantity on hand
Desired dose
Quantity desired (X)
Using 'TOSS muitiplkation, we can write the same
fonnula as follow:>:
Quantity desired (X) =
Desired dose
Dose on hand X quantity on hand
E.J:ample 1: The health care provider orders
erythroru)\:in 500 mg. [t is supplied in a liquid form
oontaining 250 mg in 5 mL. How much drug should
the nufloe administer?
To calculate the dosage, use the formula:
Dose on hand (250 mg) Desired dose (500 mg)
Quantity on hand (5 ml) Quantity desired (X)
Then, cross-multiply:
25Op(gXX=5 mL X500pfg
Therefore, the dose to be administered is 10 mL
B. The same proportion method can be used to solve
solid dosage calculations.
."
Example 2: The health care provider orders
methotrexate 20 mgfday. The methotrexate is available
in 2.5-mg tablets. How many tablets should the nurse
administer each day?
Desired dose (20 mg) Dose o n hand (2.5 mg)
I tablet Quantitydesired (X tablets)
Cross-multiplication gives:
2.5mgX = 20 mg X 1 tablet
Therefore the nurse shoul d administer 8 tablets daily.
fl . CALCULATING DOSAGE BY WEIGHT
Doses for pediatric patients are often calculated by using
body weight. The nurse must use caution to convert be-
tween pounds and kilograms, as ne.;:essary (see Table 3.2 in
Chapter 3, page 21). Use the formula:
Body weight X amountlkg = X mg of drug
Example 3: The health care provider orders 10 mgfkg
of methsuximide for a dient who weighs 90 kg. How
much should be administered?
The patient should re<:eive 900 mg of methsuximide.
Example 4: The health cue provider orders
5 mglkglday of amiodarone. The JXltient weighs
I 10 pounds. How much of the drug should be
administered daily?
Step I: Conver! pounds to kilograms.
II0lb x 1 kg/2 .2 Ib = 50 kg
Step 2: Perform the drug ,alculation_
50;g (body weight) X 5 mp/;g = 250 mg
The patient shoukl receh'e 250 mg of amiodarone per day.
111. CALCULATING DOSAGE BY BODY
SURFACE AREA
Many antineoplastkdruS" and most pediatrk doses are cal-
, ulated using body surface area ( BSA).
The formul a for BSA in metrk uni ts is:
BSA =
weight (kg) X height (em)
>600
The formula for BSA in household units is
\\-eighl (Ib) X heighl (inches)
BSA=
3\31
Example 5: The health care provider orders 10 mgfml
of an antibiotk for a ' hild who is 2 feet l:IlI and weighs
30 lb. How many milligrams should be administered?
LibraryPirate
Sttp I: the !!SA of the child.
30 X 24
3\3]
rna
BSA - "rut
BSA _ VO.2JO = 0.48 m
l
Step 2: Calculate the drug amount .
\0 mg/m2 X 0.48 m
l
TIle nurse should administer 4.8 mg of the antibiotic to
the child.
IV. CALCULATING IV INFUSION RATES
Intravenous Buids administered over time in units of
mllmin or gu/min (gil: drops).lbe basic tquation for IV
drug calculations is as follows:
mLofsolution x gtt/mL glt
h ohdministration x 60 minfh min
835
Example 6: The health ClIre provider o rders 1,000 mL
of 5% normal Jalior to infuse over 6 nours. What is the
flow rate?
X IOglt/ . 28gt!
6 j( x 60 minf)f min
Other IV convenion formulas may use include the
following:
mcg/kgl h ..... mL/ h
.. """.. "'" mL mL
X - h- X \,00094 X J7g = h
mcgfml/ h ..... mLfh
pi """pi "'" mL mL
X --h- X 1.0009>4 X P7s = h
mcg/kgfmin ..... gil/min
8
min 1,000 p;;?g
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A..o fi ben I'Ien\'$thlttnnsmlt sensations of sharp pain
Absence u izure seilurewlth a 1055 or reduction of flOfll1al at-
tNity. inciudlngsurln& and tnm4enlloss of
Absorplton the pr0ces5 of ll10Ying a drug KlOSS body

Acetylchol ine primary neurotransmitter of 1M pansympa-
thc'lic IltO'OU5 system; also present .1 somatlc neuromuscular
junctions and at sympatMk pregangllonk otrvtS
Acetyk holinestel"1lSle (AchE) enzyme thai degrades atttyl-
dJoIjot ",ithin the 5)'1llplk deft. enhalKing effects o( the
neurotransmitter
Acidosis oondltlon of havlnS too much add In the blood;
pwnu pH below 7.3S
Arne vulgaris oondition characterized by snull inflamed
bumps that appear on the surhce oflheskin
Acquired immunodeficiency syndrome (AIDS) infection
caused by the human Immunodeficiency virus ( HIV)
Acquired resistance the capacity of a microbe to no longer be
affected by a druS folklwlnsantJ . lnfectllo1:' plurmacotherapy
Adton potential eledrtc.al dianvs in the membraot of a mus-
deor nel'l'l' cell due 10 changes In membranepermeabiUty
activatoo chaK(t;olI short_term treatment (withln60 minures) af-
ter a patient has ingested a threatening amount of carbon-based
polson; molecules adhere to adlvated charcoal and minimize or
prevent poisons from IbsorpUon
Ad ive im munity resl5tanct resulting (rom a previous uposure
to an antigen
Mute gouty . rthriti . condition In ",,1Ilch uric add crystals
alXumulate in the ;oint$ of the big toes. ankles. wrists. finsen.
knees. or elbows, result'", In red. swollen. or inflamed tissue
Acute radi alton syndrome Ufe-lhreiltenJng symptoms result-
Ing from acutt exposure 10 Ionlling radbtlon, Induding nausea,
vomltins. severe kukoptnb., thrombocy1openla, anft1lla, and
.""".
Addiction the GOOtlnued use of. substalKe despite ilS negaliw
Malth and sodal ronsequences
Addison's di sease hyposecmlon of glucoconicoids and a1dos-
terone by the adrenal corlD:
Adenohypophysis anterior portion of the pltuiury gland
Adjuvant chemotherapy technique In whkh antineoplasties
are adminl5teml afltrsurgery or radiation toeffee! a cure
Ado1eKence period from ]) to 16 yeus of age
Adrfnergic relaUng to nCfves that releaSl! norepinephrine or ep-
inephrine
Adrenergic . nt agonbt druS that blCKks the actionsof the sym-
pathetk n.ePiOUS system
Adrenoconical insuffICiency bek of adequale corticosteroid 5e-
cre!ion by the adrenal gland
AdreOOCOr1 icolropic hormone (ACTH) hormone seemed by
the anterior pitultary that stlmuJares the release of sJucoconl-
ooids by the adrenal rorlex
Aerobic pertaining to an 0X)"8t!l envlronrnmt
Aerosol 5U5pC'llSion o( minute liquid droplets or fine solid par-
tides in a gas
'"
Affmity chemial allrxlion that impels cenaln Il10kcules to
unite others to form oomplexes
Afterload pressure thou must be ovtrromt for the ventricles to
eject blood from the heart
Ar,onisl dru& !hatls capable of binding with rtCl'pIOrs 10 Induce
a ceUubr response
Akathisia inability to remain still; constantly moving
Aldosterone 5t(f('Ird by the adrenal cortex that In-
Q'elI5t'S$Odium reabsorption in the dlsultubuJe of the kidney
Alkalosis oonditlon ofhavlng too many basic SUDstaIKes in the
blood; plasma pH .bow 7."S
Alkylation pr0ces5 by which certain chemIcals atbch to DNA
and chanse lIS structure and function
AI1crgen anylhlng lhat Is rtrognlzed as forelsn by tM body't de-
fense system; also called antigen
Allergic reaction acqUired hyperresponse of Dody defenses to a
foreign substance (allergen)
Allergic rhinit.is inflammatIon of the nasal mucosa due to el"po-
sure to allergens
hair loss
Alpha receptor type of subm:eptor found In the sympathetk
nervou.s system
AlzhdmH's disea.se most common dementia, charocterlzed by
loss of memory, delusions, hallucinations, oonfusion. and Io6s of
_.
Amide type o( chemlca.l linkage found In IIOOM' Jocal anesthetics
in\Olvlng carbon. n1tfO&C!n, and oxygen (-NH-CO-)
Amytoid pbques abnormal protein fragmenl$ rebted to neu-
ronal <bmage;. 5ign of A1:d1elmer'$ disease obstrvedduringau-
.-
Anabolic steroids compounds resembling testosterone with
hormonal activity commonly abused by .thlefes
Anaerobic penalninSIO an envlronmenl without oxygen
Analgesic drug used 10 reduce or elimInate pain
Anaphylactic shock type of shCKk caused by an acull.' alkrgic

Anaphylaxis acute aUersk response to an antigen that rewJ.1S In
severe hypotension and rTllI)' lead to Il(e-threatenlngshock If un-
treated
Androgens steroid sex homlones that pronloce the appearance
of masculine characteristics
Anemia lack of adequate numbers of red blood cells. or de-
creased oxysen-carrying capadty of the blood
Angi na pedoris chest pain on physiOll or enl<Mional ex_
ertion due to inadeqwte Qi[fgtn supply to the
Ansiotensin II chemical released In response to f.alIinS
blood pressure that ClIU5t5 vasoconstrlction and release of
aldosterone
Angiotensin.convrrti ng enzyme (ACE) enzyme responsible
for conwrting angiotensin Ito angiotensin II
Antons challed Ions
Anore:t:aa 1055 o( appetite
Anorexiant drug. used to suppress appelite
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Ant acid drug that neutralizes stomach acid
Antagonist drug that blocks tht' response of anotht'r drug
Ant epartum prior to the onset of labor
Anthrax microorganism that can cause severe disease and high
mortality in hWllans
Antibiotic wootan"" produced by 3 microorganism that in
hibits or kills other microorganisms
Antibody protein produced by the body in response to an anti-
gen; used interchangeably with the term immunoglobulin
Anticholinergic drug that blocks the actions of the parnsympa-
thetic nervous systt'm
Anticoagulant agent that inhibits the formation ofblo<Xl dots
Antidepressant drug that alters levels oftmJ important neuro-
transmitters in the brain, norepinephrine and serotonin, to I'l'-
duce depression and anxiety
Antidiuretic hormone (ADH) hormone released by the poste-
rior pituitary gland when blood pressure falls or when the os-
motic pressurt' oftht' blood increases
Antiemetic drug that prewnts vomiting
Antiflatulent agent that reduces gas bubbles in the stomach and
intestines., thereby decreasing bloating and discomfort
Antigens microbes and foreign substances that elicit an inullWle
"'1"'=
Anti-infective general term for any medication that is effectiw
against pathogens
Antipyretic drug that lowers body temperature
Antiretroviral drug that is effectiVl' against rt'Iroviruses
Antithrombin III protein that prevents abnormal dotting by
inhibiting thrombin
Antitussh-e drug used to suppress cough
Anxiety state of apprehension and autonomic nervous system
activation resulti ng from exposure to a nonspecific or Wlknown

Anxiolytks drugs that relit'wanxiety
Apoprotein protein component of a lipoprotein
Apothecary system older systt'm of measurement that uses
drnms; rarely used
Aqueous humor fluid that fills the anterior and posterior
chambers of the t' re
Aromatase inhibitor hormone inhibitor that blocks the enzyme
arommase, which normally converts adrenal androgen to estradiol
ASAP order (as soon as possible) order that should be available
for administrntionto the patient within 30 minutes of the writ -
ten order
Assessment pnase appraisal of a patient's condition that in-
volves gathering and interpreting data
Asthma chronic inflammatory disease of the lungs character-
ized by airway obstruction
Astringent effect drops or spray used to shrink swollen mucous
meJ\lbranes, or to loosen secretions and facilitate drainage
Atherosclerosis condition characterized by a buildup of fatty
plaque and loss of elasticity of tht' walls of the arteries
Atonk seizure very-short-Iasting seizure during which the pa-
tient may stumble and 111 for no apparent reason
Atrio'-entrkular (AV) node cardiac tissue that receivesele<:tri -
cal impulses from the sinoatrial node and conveys them to the
vemridt'S
Gto. ... y 837
Attention deficit/hyperactivity disorder (ADHD) disorder
typically diagnosed in childhood and adolescence characterized
by bypemclivity as well as attention, organization, and behavior
control issnes
Aura sensory cue such as bright lights, smells, or tastes that pre-
cedes a migraine
Autoantibodies proteins called rheumawid /acwn released by B
lymphocytes that tear down the body's own tissue
Automaticity ability of certain myocardial cells to sponta-
neously generate an action potemial
Autonomic nervous portion of the peripheral nervous
system that governs involuntary actions of the smooth muscle,
cardiac musde, and glands
Azole term for the major dassof drugs used to treat mycoses
Azoospermia complete absence of sperm in an ejarulate
Bacteriocidal substanct'that kills bacteria
Bacteriostatic snbstance that inhibits the growth of bacteria
Balanced anesthesia use of multiple medications to mpidly in"
duct' unconsciousness, cause musde relaxation, and maintain
deep anesthesia
Baroreceptors nerves located in the walls of the atria, aortic
arch, vena caVd, and carotid sinus that sense changes in blood

Basal metabolic rate resting rate of metabolism in the body
Baseline data patient information that isgathered before phar-
macotherapy is implement ed
basic care one of the first elements of toxicity treat-
ment in'-olving maintaining the patient's airway, breathing, and
circulation; making sure proper blood glucose levels are stable;
maintaining proper arterial blood gases; treatment of develop-
ing seizures; and management of acid-base disturbances
B cell lymphocyte responsible for humoral immWlity
Benign prostatic hyperplasia (BPH) nonmalignant enlarge-
ment of the prostate gland
Benzodiazepines major class of drugs used to treat anxiety
disorders
Beriberi deficiency of thiamine
Beta-Iactam ring chemical structure fOWld in most penicillins
and some cephalosporins
Beta-Iactamase/penicillinase t'nzyme present in certain bacte--
ria that is able to inactivate many penicillins and some
cephalosporins
Beta receptor type of subreceptor fonnd in the sympathetic
nervous system
Bile acid resin drug that binds bile adds, thus lowering
cholesterol
Bioavailability ability of a drug to reach the bloodstream and
its target tissues
Biologic response modifiers natural cytokines that boost spe-
cific functions of the immunesystem
Biologks substances that produce biologic responses within the
body; they are synthesized by cells of the human body, animal
cells, or microorganisms
Bioterrorism intentional use of infectious biologic agents,
chemical substances, or radiation to cause widt'Spread harm or
'm=
Bipolar disorder syndrome characterized by and op-
posite moods, snch as euphoria and depression
LibraryPirate
838 Glo".ry
Bisphosphonate5 class of drugs block bone resorption by
inhibiting osteoclast activity
Blood-brai.n barrier anatomlc:J.l structure that prevents cer-
tain sublitalK:es from S;Unlng access to the bf;Jln
BodymaSli index (BIIoU) obesItydttermined by
dividing body weight (in kil0Vo"ns) by the sqlUf(' of height (in

Bone depo.oition of bone raorption; the prou ..... of
depositing miner.ll components Into bone
Bone resorptio n process of bone de!nlfl('r;J!izatlon or the
breaking down of bone Into minml components
Botania l plant extnct used to treat or pro."l'tnt iHT11'$5
Brad)-irinesi a difficulty Initiating movement and C()lItroLling
Hm.' mlKle lIIO'I'ements
Broad-5pect rum antibiotic anti-infective that Is effective
against many different gram-positive and gram.negatiw
organisms
Bronchospasm rapid constriction of the airways
Buccal route administratioll of a tablet or C1psule by placing it
in the or;J! C1vitybetween the gum and the cheek
Buffer that helps nulnuln normal body pH by neu-
tralizing strong acids or bases
Btmdle branch elect rical conduction pathway In the heart [{",jding
from the AYbundJe and through Ihe waD the ventricles
C fibers nen-es that transmit dull, poorly locaHud p;!in
Calcifediol subst.'1nce formed In the first step of vitamin D for-
nutlon
Calcineurin intracellular messenger molule to which im-
munOMlppreM.Ult. bin.!
Calcitonin hormone secreted by the thyroid gland tnat in-
the deposition of calcium In bolle
Calcitriol substancetRnsformed In the kk\ntyS duringthe5l'C.
ond step of the corl\-ersion of vitamin D to Its active form
Calciumcha nnel blocker drug tlut blocks the bof caldum
ions into m)UQrdlal cells
Calcium io n channd pathway In a plasma membrant" thfOll8h
which calcium ionsenter and leave
Camptothecinl class of antineopwtlcs that Inhibit the enzyme
topoiwmt'r.lSe
Cancer/carcinoma malignant disease characterlwd by rapidly
gru.ving, invasive cells that spread to other regions of the body
and l'VCfItually kill the host
Capsid protein coat tholt surrounds a virus
eruyme that forms carbonic acid bycom-
bining carbon dioxide and Willer
Cardiac output amount of blood pumped by a ventricle in
I minute
Cardiac remodeling change In the size, shape, and $Iructure of
the myocardial cells that occurs over time In hean
failure
Cardiogenic shock type of shock caused by a diseased hean
that cannot malnt.1in circulation to the tissues
Cardioversion/ detibrillation converslon of fibrillation to a
nornul heart rhythm
Carotene dass of yellow- red pigments that are prerursoTS to vi-
tamin A
Cat echolamine! class of lIgenlS.scatted In response to \ri'SS
that ilK:lude epinephrine, oorepinephrille, and dopamine
Cathartic substance that causes complele e=tlon of the
bowel
Cations positively charged Ions
CD4 receptor protein that accepts HIV and aUowsentryoftbe
virus into the T4lymphocyte
Central nervous system (CNS) division of the rltI'vousS)'Stem
consLsting of the brain and spinal oord
Chemical na me otrid chnnkal nomenditure wed for naming
drugs established by the International Union of Purt and Ap-
plied O!emiWy (IUPAC)
<llemoreceptor trigger zone{CfZ) location In the cerebral COf-
rex ",hid!. sends sensory signals to the vomiting center
Chemoreaptors nerves located in the aortic arch and carotid
sinus tnat in oxygen content, pH, or dlox
ide levels in the blood
Chemotherapydrug treatment of Clncet'
Chief ceDs cells 10Clted in the mucosa of the stomach that se
crete pepsinogen, an inactive form of the enzyme pepsin that
chemically breaks down proteins
Cholecalciferol vitamin D, formed in the skin by exposure to
ultraviolet light
Cholinergic relating to nerves tholt release acetylcholine
Chronic bronchitis recurrent disease of the lungs character.
ized byexcess mucus production, Inflammation, and coughing
Chronic obstructive pulmonary diSf'ue (corD) generic
term used to descrihe several pulmonary condItions character-
ized by cough, muws production, and Imp.1lred g.as
exchange
Oinical invmigation second stage of drug testlll8 that Involves
clinical phase trials
Qinia l phase trials testing of iii IICW drug In selected patients
Oonk spa5l1l multiple, IOlpidly rtpe;lttd mUSQllar
contractions
Oosed-angle glaucoma :tCUte glaucoma that Is caused by de-
creased outflow of aqueous humor from the anterior dnmber
Ootting factors substances contributing to the process of
blood hemostasis
Coagulatio n pJ'()('l5ofblood dotting
Coagulati on cascade complex series of steps by wflkh blood
-''''''
CoUoid rypt' of IV fluid wnsisting of large orpnlc molec:ules
thaI are unable to cross memblOlne5
Colony-stimulating factors hormones tlut regulate the
growth and maturation of specific WBC populallons
Combination drug drug product with more than one
generic ingredient
Comedolle type of acne lesion tholt develops Just beneath the
surfaU' of the &kin (whitehead) or as a result of a plugged oil
g!.lIld (blackhead)
Complement ..,ri ... of proteins Involved In thenonspeclfk dl'_
fense of the body that promote antigen destructIon
Complementiilry and alternative Dledici ne (CAM) treat
ments that consider the heahhofthe whole person and promote
disease prevention
Complementary and alternative thenlpi es treatments oon-
sidered outside the rea1m of conventional Wes\o..'1'n medicine
Compliance taking a medication In the manner prescribed by
the health care provider, or, in the case of
(arc) foUowing the instructions on the label
LibraryPirate
Conjugat es side chains that, during metabolism, make drugs
more water soluble and more easily excreted by the kidney
Comtipation infrequent passage of abnormally hard and dry
stools
Contractility the strength with which the myocardial fibers
contract
Controlled substance in the United States, a drug whose use is
restricted by the Comprehensive Drug Abuse Prevention and
Control Act; in Canada, a drug subje.::t to guidelines outlined in
the Canadian Narcotic Control Act
Convulsion oocontrolled musdecontraction or spasm that oc-
curs in the mce, torso, arms. or legs
Coronaryarterial bypass graft surgery (CABG) surgical pro-
cedure performed to restore blood flow to the myocardium by
using a section of the saphenous win or internal mammary ar-
teryto go around the obstructed coronary artery
Corpus cavernoo;um tissue in the penis that fills with blood
during an ere<:tion
Corpus luteum ruptured follicle that remains in the ovary after
ovulation and S&retes progestins
Corpus striatum area of the brain responsible for unconscious
muscle mowment; a point of contact for neurons projecting
from the substantia nigra
Cz-ohn's disease chronic inflammatory boW\'1 disease affecting
the ileum and sometimes the colon
Cz-oss-tolerance situation in which tolerance to one drug makes
the patient tolerant to another drug
Crystalloid type of IV fluid resembling blood plasma minus
proteins that is capable of crossing membranes
Otltural competence tbe ability of health care providers to care
for people with diverse values, beliefs, and behaviors, including the
ability to adapt delivery of care to meet the needs of these patients
Otlture set of beliefs, values, religious rituals, and customs
shared by a group of people
O"ltlJre and ""ns;t;v;tyle.sl;ng l,oo",toryenfll "sed 10 ;den_
tifybacteria and to determine which antibiotic is most effective
Otshing's syndrome condition of having an excessive concen-
tration of corticosteroids in the blood; caused by excessiw secre-
tion by the adrenal glands or by overdosage with corticosteroid
medication
Cydooxygenase kt>y enzyme in the prostaglandin met:Jbolic
pathway that is blocked by aspirin and other NSAIDs
Cycloplegic drugs drugs that relax or temporarily paralyze cil -
iary muscles and cause blurred vision
Cytokines chemicals produced by white blood cells, such as in-
terleukins, leukotrienes, interferon, and tumor ne.::rosis factor,
that guide the immune response
Defecation evacuation of the colon; bowel movement
delta-9-tetnhydrocannabinol (TIle) the active chemical in-
gredient in marijuana responsible for its psychoactive properties
Delirium tremens a syndrome of intense agitation, confusion,
terrifying hallucinations. uncontrolL1ble tremors, panic attacks.
and paranoia caused by alcohol withdrawal
Delusions false ideas and beliefs not fOoode<! in reality
Dementia degenerative disorder characterized by progressive
memory loss, confusion, and the inability to think or communi -
cate effectively
Dependence strong physiological or psychological need for a
substance
GIoss y 839
Depolarization reversal of the plasma membrane charge such
that the inside is made less negative
Depression disorder characterized by depressed mood, lack of
energy, sleep disturbances, abnormal eating patterns., and feel-
ings of despair, guilt, and misery
Dermatitis intlallUllatory condition of the skin characterized
by itching and scaling
Dermatophytic relating to 3 superficial fungal infection
Designer drug substance produced in a laboratory and in-
tended to mimic the effects of another psychoactive controlled
substance
Oiahetu ;ns;p;dusc!i<o,tler ma,b>c1 hyf'n'",,<;ve ",;nM;on tl"e
to lack of secretion of antidiuretic hormone
Diabetic ketoacidosis a type of metabolic acidosis due to an ex-
cess of ketone bodies, most often occurring when diabetes mel-
litus is uncontrolled
Diarrhea abnormal frequency and liquidity of bowel
movements
Dietary nondrng substance regulated by the Di-
etary Supplement Health and EducationAct of 1994 (OSHEA)
Dietary Supplemettt and Nonprescription Drug Consumer
Protection Act law that requires rumpanies that market herbal
and dietary supplements to include their address and phone num-
ber on the product labels so consumers can report adverse events
Dietary Supplement Health and &lucation Act of 1994
(OSHEA) primary law in the United States regulating herb and
dietary supplements
Di sease-modifying antirheumatic drugs (DMARD) drugs
from several classes that modify the progression of rheumatoid
arthritis; include hydroxychloroquine {Plaquenil}, methotrexate
(Rheumatrex), and sult:'1S3Iazine (AzulfKline)
Distribution the process of transporting drugs through
the body
Diuretic substance that increases urine output
Dopamine type 2 (D) receptor receptor for dopmlline in the
basal nuclei of the brain that is associated with schizophrenia
and antipsychotic drugs
Drug generaJ term for any substance capable of producing bio-
logic responses in the body
Drug- protein oomplex drug that has bound reversibly to a
plasma protein, particularly albumin, that makes the drug un-
available for distribution to body tissues
Drypowder inhaler (DPI ) device used to oonvert a solid drug
to a fine powder for the purpose of inhalation
Dysentery severe diarrhea that may include bleeding
Dysfunctional uterine bleeding hemorrhage that occurs at
abnormal times or in excessive quantity during the menstrual
"de
Dyslipidemia abnormal (excess or deficient) level of lipopro-
teins in the blood
Dysrhytlunia abnormality in cardiac rhythm
Dysthymic disorder less I''(ere type of mood disorder that may
prevent a person from feeling well or functioning normally
Dystonia severe muscle spasms, particubrly of the back, ne.::k,
tongue, and face; characterized by abnormal tension starting in
one area of the body and progressing to other areas
Eclampsia pregnancy-induced hypertensive disorder
Ectopic focus pacemaker cardiac tissue outside the normal
cardiac conduction pathway that generates action
LibraryPirate
840 Glo .... y
Eczema abo called aroplc dtrmmlrlr, skin disorder with unex-
plained symptoms of infl ammation, Itching. scallng
Efficacy the ability of a drug to produce a desired respomje
Electrocardiogram (OCG) devke that reoords the electrical ac-
tivity of the heart
Electroronvulsh,,, therapy (ECI) treatment wed for serious
and life threatening mood disorders In patients who are UIU't'-
sponsh-e 10 pharmacothenpy
Electroencephalos,nm (HG) dJ.asoostk test that records
bnin"'";lu.'Slhrough electrodes auachlto the scalp
Elect rolytes dlalt'd substance5 [n the blood such as sodium,
poIaMiwn, calcium, chloride, all<!
Embolus blood clot carried in the
embr)Vnk period period oflife from 3 to S weeks poslmnct'p-
,,,"
Emesis mmiting
Emet ic drug used to induct mmiting
Emelic potential usually applied to antlnooplastlc de-
gree to which an agenl is likely to trigger the vomiting center in
the medulla, resulting in nausea and vomiting
Emetogenic potcntial the aapaclty of a chemotherapeutic drug
to cause vomiting
Ilmphysema terminal lung disease characterized by permanent
dilation of the alvroll
Endogenous opioids chemicals produced naturally within the
body that decrease or eliminate pain: they closely resemble the
actions of morphine
Endometriosis presence of endometrial tissue In nonuterine
locations such u the pelvis aoo ovaries; a common cause of in-
fertility
Enteral nutrition nutrients supplied orally or by f-ting mbe
Ent eral route administration of drugs onlIy, and through na-
sogastrk or gastrostomy tubes
Entericcoated referring to tablets tmt m"", a hard, waxy coat-
ing designed 10 dissol\-e in the alkaline environment of the
intestine
Enterohepatic recircul at ion recytUng of dross other sub-
stances bythedrrubtion ofblle throush the Intestine and liver
Enzyme induct ion process in which a drug changes the
tion of the hepatic microsomal enzymes and Increases mmbolic
activity in the liver
Epilepsy disorder of the CNS by sekures andJor
wn\'u1sions
Ergocalciferol activated form ofvlumin D
ErgOliterol lipid substance in fungal reII membranes
Erythema rednessassoc:iated with skin Irritation
Erythrocyti c stage phase In maL1r1a during ...mlch Infected red
blood ct'Hs rupture, releasing and causing fever and
chills
Erythropoietin hormone by the kidney that regulates
the processofred blood ct'U formation, or erythropoiesis
esophageal reflux baddlow of stomach contents into the esoph-

E.!iter type of chemical linkage found In some local
involving carbon and aqgen (-CO-O-)
E.!itrogen class of steroid SeI hormonessecreled by the ovary
Ethn.icity referri ng to peopif having a common history and
similar genetic
Evaluation phase objective assessment oftheeffectll'l.'f1ess and
impact of inter'ientions
Exroriation scratch that breaks the skin 9.lrface and fills with
blood or serous fluid to form a crusty scaJe
Excretion the proces/i of removing substances from the body
Expectorant drug used to increase bronchial secretions
External otitis commonly called swimmtr's Mr, an Inflamma-
tion of the outer ear
ExtnceUular Duid ( ECF) compartment body liuJd lying out-
side cells, .... hich indudes plasma and IntelSlitial fluid
ExtnpynmidaJ side effects symptoms of ilC\!te dystonIa,
ilithisia, parkimonism, and tardi"'" dyskinesia often caused by
antipsydlotic drugs
FDA critia l path init iative national strategy for transfonnlng
meway FDA-regulated prodllCtS are developed, evaluated, man-
ufactured, and med.
seizure tonic-donic motor actlvlty lasting I to 2 mIn-
utes with rapid return of consciousness that OUTS In conjUll(-
tion "ith eleYated body temperature
one oft ... ;o protein complexes that maintain Iron stores
Inside cells (hemosiderin is the other)
fetal period period of life from 9 to 40 weeks postconct'ptlon
Fetal-placental barrier special anatomical structure that In_
hibits entry of many chemicals and dmgs to the fetus
Fibrillation type of dysrhythmia In which the chambers beat In
a highly disorganized manner
Fibrin an insoluble protein fomled from flbrinogen by the;l(-
tion of thrombin in the blood clotting process
Fibrinogen blood protein that is oonwrted to fibrin by the ac-
tion of thrombin in the blood ooaguiation proces/i
Fibrinolysis rt'lTlovai of a blood dot
Fight-or-fl ight response characteristic set of signs and symp-
toms pro<lutai ... 11m the sympathetic nervous system is
activatec!
Filtrate Duid in the nephron that is !l1tertd at Bowman's
Q,...
Fi n t-pass effect medtanism whereby drugs are absorbed across
me Intestinal wall and enter Into the hepatic portal
circuL1tion
Fi"", rights of druS admin;/it nol; on principles toot offer slm
pie and pnctical guidanct' ror nurses to use during drug prepa-
ration, deliWI"}', and administration
rolic acid/folat e B vitllmin that Is a coenzyme In protein and
nucleic acid metabolism
rollicle- stimulating hormone (FSH) hormone secreted by
the anterior pituitary gland that regulates sperm or egg
production
rollicular ct'lls cells in the thyrOid gland that secrete thyroid
hormone
Food and Drug Administration (FDA) U,s, agency responsi-
ble for the evaluation and approval of new drugs
rormulary list of drugs and drug recipes commonly used by
pharmacists
Frank-St arling law the greater the degree of stretch on the my-
ocardial fibers, the greater will be the rorce by whleh they mn-
mct
Frequency distribution cur'"" g.raphical representlltlon th3t il_
lustrates interpatient variability In responses to drugs
LibraryPirate
Fungi kingdom of organisms th3t Includes mushrooms, yeasts,
and molds
Gamma-aminobutyric acid (GADA) neurotransmitter in the
CNS
ganglionic synapse the juncture between two multipolar neu-
rons located outside of the (.tntral nervous system (CNS), when'
uon terminals from the first neuron make oontact with cell bod-
w..and P.'<f ............ nf' .... . <KI'M1od """mn
gastric lavage and Ispiration oourse of treatment (within 60
minutes) after the patient has a potentially life-threat-
ening amount of polson: this Is performed by washing out the
stonuch with Slerile water or a saltwater solution followed by re-
moval of the Huid or l1'Illt'd substaoces
Gastroesophageal nnuJ( (GERD) rtgurgitation of
Slotmch contents into the esophagus
General anesthesia med!ca1 produre Ihal produces UIKOll-
!iCiousnessand Iossof 5erIsation throughout the entire body
Generalized a nxiely di sorder (GAD) difficult-tn-control.
excessive aru:il'ly that lasts 6 months or mon, focuses on a v_
ariety of life events, and Interferes wIth oormal day-to-day
fun(\ions
Generalized seizures that trol\'l throughout the entire
brain
Generic name nonproprll'lary ",1me of a drug assigned by the
government
Genetic polymorphism changes In enl)'llle structure and
function due to mutation of the encoding gene
Gi1ucoma oondition that is charaderized by optic neuropathy
with graduallos.sof peripheral vision and usually accompanied
by imreased inlraocular pressure
Glycoprotein Il blllla enzyme that binds fibrinogen and von
Willebrand's factor 10 begin plalelet aggregation and blood co-
agulalion
Goal any ob;ect or that the patient or nurse seeks to at-
uin o r achieve
Gonadotropin- releasing hornlOoe hormone secreted by
the hypoIhaiamUSlhat stimulates the socretion of follide-stimu-
lating hormone ( FSH) and lutdnlz.ing honnone (LH)
Gout metabolic disorder (har.w:terlled by the accumulation of
uric acid in 1M bloodstream or joint cavities
Graded dose rdatlonshlp between and measurement
of the pJtierll's response obIalned at different doses of a drug
Gram negative bacteria b;w;:terla tt\:J.t do not retain a purple
stain because lhey h:ive an outer envelope
Gram positive bacteria bac\t..'tla that stain because they
h:ive nO OUler I'Ill\'lope
Graves' disease syndrome caused by hypersecretion of thyroid
homlOne
Growth fraction r:Jtlo of the number of replicating (.tlls to
resting cells in a mmor
H+, K+ -ATPase en:cyme responsible for pumping acid onto the
mucosal surfa(.t of the slonulCh
HI rKeptor sile located on smooth mU!iCle (.tlls In the brondiial
tree and blood vessels byhlstamine to produce
bronchodilalion and vasodllatlon
Hr receptor antagoni $1 drug that Inhibits the effects of hista-
mineal its receplOrs in the Gllract
Hallucination St't'ing. hearing. or feeling something that is not
""
Glosmy 641
Heart failure (HF) disease in which the heart muscle cannot
contract with sufficient for(.t 10 meet the body's metabolic
,,"',
Helicobader pylori bacterium assoclaled with a large percent-
age of peptic ulcerdisease
Helminth typf'ofHal, round, or segmented worm
Hematopoiesis proct'SS of I'f)'throqote produdion that begins
with primitive cen. trun "",de In bone Ill3ITOW
He mophilia hereditary lade. of a spt'Clfic blood dottIng factor
He mosiderin one oflW:l prolrin mnpleres that maintain iron
inside cells (ferrilin is the other)
Hemostasis the slowing or Slopping of blood flow
Hemostatic drug used to inhibillhe normal removal of fibrin,
used 10 speed clot formal ion, and keep the dot In place for a
longer period
Hepatic microsomal enzyme S)'$lem as It rela\t'!!S to phaTITl<l-
cotherapy, liver enzymes Ih:it InactIvate drugs alld accelerate
their e1l:retion; somi"limescaUed the P-450 system
Hepat itis viral infection ofllle liwr
Herb plant wilh a soft stem Ihat Is used (or heaUng or as a
seasoning
High-density Iipoprolein (HDL) llpld-carrylng partIcle In the
blood that contains high amounts of proteln and lower amounts
of cholesterol; considered t o lJto"good" cholesterol
Highly adive antiretroviral therapy (HAART) drug therapy
for HN infection thaI includes high doses of multiple medica-
tions given concurrently
Hippocampus region of the bnin responsible for learning and
mo>mory; a pari oftm, limbic system
chemical released by mast celli In miPOnse 10 an
antigen that causes dilalion of blood vessels, bronchoconstrk-
tion, tissue swelling,and itching
HlV-AIDS acronym for human !mmunodeflclency virus-
acquired illllllUlk' defldmcy syndrome; characteriud by pro-
found inunullOMlppression Ihat leads to opportunistic Infec-
tions and rnalignancies not (J()mmonly found In patients with
functioning immUIll' defenses
HMG-CoA reductase primary enzyme In the biochemical
pathway for the synlhl'sis of chQkosterol
Ho listic viewing a pelliOn as an Integrated biologic, psychoso-
cial, cultural, communicat ing whole, and fundioning
within the communal environment
Hormone chemical secreted by endocrlne glatlds that acts as 3
chemical messenger to affecl homeostasis
Hormone replacement therapy (HRT) drug therapy collSist-
ing of estrogen and progeslin combinatiOnS; used to treat symp-
toms associated with menopause
Host flora normal microorganisms found In oron a patient
Household system older system of measurement that uses tea-
spoons, tablespoons, and cups
Humanimmunodclicit'ncy virus (HIV) the causative agent for
AIDS
human integration pyramid a conceptual framework for deal-
ing wilh patients in a holi!Olic manner
Humoral immune response a spKific body defense meclunlsm
involving the production and releaseofantibodles
high levels of cholesterol In tile blood
Hyper&lyumia hi9,h st1umse leveIln 1M blood
LibraryPirate
842 Glo".ry
Hw rhkmia serum potassium above 5 mEq/L
Hyperlipidemia ew'$S amount of lipids in the blood
Hypernatremia high sodium Ievtlln the blood
Hyperosmolarhyperglycemlc $late (HHS) acute complication
set'n in persons with type 2 diabetes, that is characterized bya-
treme hyperglyumla, hypero, mobrity with dehydration, the
absence ofh-toocidosis. and CNS dysfunction.
Hypertensi on high blood pressure
Hyperuricemia eleVllled blood kwI of uric acid, which ClImes
"XU
Hypervitaminosis exl:.eS5lnt:ake of vitlmlns
Hypnotic drug that causes skql
Hypogonadism below-normal secretion of the steroid Sol"J[ bor-
Hypokalemia serum poIas.slum lewl below 3.5 mEqlL
Hyponatremia low sodium level III the blood
Hypovolemic shock type of shock Olused by loss offluidssuch
as occurs durins hemorrhage, extensive burns. or severe '"Omit-
ing or diarrhea
Idiosyncratic response unpredictable and unexplained drug
reaction
Illusion distorted. pe:eption of actual sensory stimuli
Immune response spedfk reaction of the body to foreign
agent. involvins B T lymphocytes
[mmunomodu1ator general term that refers to drugs that affect
bodydefenses
Immunosuppressant any drug, chemical, or physiOlI agent
that lowers the immune defense mednnisms oflhe body
implantable cardiovt'l' ter defibrillotors (ICD) a devire placed
in patients to reo;tore normal card!:.c rhythm by either pacing the
heart or giving il an eleclTic shock when dysrhythmias ocrur
Implementltion phase when the nurse applies the knowledge,
skills, and principles of nursing care to help move the tn-
ward thedesired goal and optimal weOness
Impotence inability 10 obuln or sustlin an erection; called
utm1t dysfunctiOtl
Inhncychild younger Ihm I year
Infertility inability 10 become pregnant after at lea5l ] year of
frequt'nt, unprotected In t .... rourse
Inflammation non$pedfk body defense that occurs in response
to an injury or anligen
Inflammatory bowe1 (I SO) disease charllcterlzed by the
presence of ulem; in distal portion of the small intestine
(Crohn's disease) or mucosal ero6lonsln the large intestine (uI-
cerativecolitis)
Influenza common viral Infection, often called fin
Inotropic agent drug o r chemical the force of con-
traction oftbe beart
Inotropic effect change [n the strength or contractaity of the

Insomnia inability to fall asleep or stay asleep
InSillin analog modtfled human Insulin with pharmacokinetic
advantages,such as more rapid onset ofactlon or prolonged du"
ralion of action
Imulin r esistanu O(curs In type 2 dlabe1es melUtus; although
insulin is secreted, insulin re<:eplors in urge! tissues become
inwnsiriw to insulin, binding of Insulin to these receptOIli de-
creases, less effect is amleved
Interferon type of seCll.'ted by T cells In response to
antigens to protect uninfected cells
Int erl eukin class of cytokinl'$ synthesized by lymphocytes,
monocytes, macrophages., and rertaln other rells that enhance
the capabilities of the immune
Int .. rmittenl ,b"dimt ion rondit ion caused by inmffidoent
blood flow [0 skeletal muscles in the icM"r Ilmbs, resulting in is-
dll'mia of :lkelel:aI muscles and seven:' paIn on walking, especially
in calf II1U'iCIeoi
intraceUuJar fluid (l eF) m mpanmenl body fluid that is Inside
I:ells; acoounts for about two thtrdsoflhe total body IVllter
lntracellular parasite infectious microbe that lives Inside host
""' Intradermal (ID) medication administered Into the doermis
It)"r of the sldn
Intramuscular (1M) delivery of medication into specific
m='"
Intravenous (lY) administration of medications and tluldsdi-
redly into the bloodSiream
Intrinsic factor chemical substance secreted by the cells
in the stomach tbat is essential for the absorption of vitamin Bu
Invasiveness is the ability of a pathogen to grow el.tremely rap-
idly and cause direct damage to surroundIng tissues by their
sheer numbers
Investigationall1l.'w drug (IND) application to tbe FDA that
contains aU the animal and cell testing data
Ionizing radiation radiation that [s highly penetr.ltlng and can
cause serious biologic effects
Irrit able bowel syndrome (IBS) Inflammatory disease of the
small or lalB" intestine maracll.'riud by Intense abdominal
cramping and diarrhea
lsI.el5 ofLangerhans cell clusters In the pancreas responsible for
the secretion of imu1in and glucagon
Kappa receptor type of opiok! receptor
Keratolytic aaion that promotes5heddJnsof old 5kIn
Ketoacid .acidic ".:aste produ.ct of lipid metabolism that 1o'I'n
the pH of the blood
Latent phase of HlY infect ion period of HIV Infection during
whim there are no symptoms
Laxatn'e drug thai promotes defecation
Lecithin phospholipid that is an Important component of ceU
membranes
Leukotriene chemical mediator of lnf!amlT\3tlon stored and re-
leased by mast cells;effects are similar to those of histamine
Libido interest in sexual activity
ill the ur4lll fOI ""lotlun, I., .... u-
ing, memory, motivation,and mood
lipaseinbibitors drugs that block the enzyme that br ...
lipids
Lipoprotein substance carrying Up[ds in the bloodstream that is
composed of proteins bound to fat
Loadingdose comparatively large dose given at tbe beginning
of treatment to rapidly obtain the therapeutic effect of a drug
Local ane5thesia loss of sellsatlon to a limited parI oflhe body
without loss of com:ci.ouSJ1eSS
Long-t erm insomnia inability 10 sIeql for more than a few
nights, often caused by depression, manic disorders, and chroniC
pWn
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Low-demity lipoprotein (LOL) lipid-carrying particle that
contains relatively low amounts of protein and high amounts of
cholesterol; considered to bekbad" cholesterol
Low-molecular-weight heparins (LMWHs) drugs clost'ly re-
sembling heparin that inhibit blood clotting
Leutinizing hormone (LH) hormone secreted by the pituitary
gland that triggers ovulation in the female and stimulates sperm
production in the male
Macromineral (major mineral) inorganic compound needed
by the body in amounts of]OO mg or more daily
Maintenance dose dose that keeps the plasma drug concentra-
tion continuously in the range
Major depressive disorder a depressed mood lasting for a min-
imumof2 wreks that is present for most of the day, everyday,or
almost every day
Malaria Tropical disease chm',Kterized by $lNere fever and chills
alused by the protozoan Plasmodium
Mania condition characterized by an expressive, inlpulsive, ex-
citable, and overreactiw nature
Mast cell connective tissue cell located in tissue spaces tll.1t re-
leases histamine following injury
Mastoiditis inflaJlUllation of the mastoid sinus
Mechanism of act ion the way in which a drug en>r\s it.H'ffects
Median effective dose (ED5O) dose required to produce a spe-
cific therapeutic response in 50% of a group of patients
Median lethal dose (LDSlJ often delt'rmined in preclinical trials,
the doseof drug thatwill be lethal in 5O%0f a group of animals
Median toxicity dose (TD5O) dose that will produce a given
toxicity in SO% of a group of patients
Medication drug after it has been administered
Medication administration record (MAR) documentation of
aU pharmacotherapies received by the patient
Medication error any preventable event that may aluse or lead
to inappropriate medication use or patient harm while the med-
ication is in the control of the health care provider, patient, or
consumer
Medication error index altegorization of medication errors
according to the extent of the harm an error can cause
Medication reconciliation the process of keeping track of a pa-
tient's medications as they proceed from one health alre
provider to another
Menopause period of time during which females stop secreting
estrogen and menstrual cycles cease
Merowites transformation of sporozoites carried by the blood
to the liver inside the human host where they multiply into mil-
lions of progeny
Metabolic bone disease (MilD) refers to a duster of disorders
that have in common defects in the structure of bone
Metaboli sm total of aU biochemical reactions in the body
Metastasis travel of cancer cells from thci r original site to a dis-
tant tissue
Md"red 0..10""' inhal", (MOl) ,J""j ..... ..".,.,] to ,Jdj .. 'r a p"" .. j".o
amount of drug to the respiratory system
Methadone maintenance treatment of opioid dept-ndence by
using methadone
MethyLxanthine chemical derivative of caffeine
Metric syst em of measurement most common system of drug
measurement that uses grams and liters
GIoss.ry 843
Micromineral (trace mineral) inorganic compound needed
by the body in amounts of20 mgor less daily
Middle adulthood person from 40 to 6S years of age
Migraine severe headache preceded by auras that may include
nausea and vomiting
Milk-alkali syndrome syndrome caused by the administration
of calcium carbonate antacids with milk or food containing vi -
tamin 0; symptoms include headache, urinary frequency,
anorexia, nausea, and fatigue
Minimum effective concentration anlount of drug required
to produce a therapeutic effect
Mio. i. constriction ofth .. pupil
Monoamine oxidase (MAO) enzyme that destroys norepi-
nephrine in the nerve terminal
Monoamine oxidase inhibitor (MAOI) drug inhibiting
monoamine oxidase, an enzyme that terminates the actions of
neurotransmitters such as dopamine, norepinephrine, epi -
nephrine, and serotonin
Mood disorder change in behavior such as clinical depression,
emotional swings, or manic depression
Mood stabilizer drug tb.1t levels mood that is used to treat bipo-
lar disorder and mania
Mu receptor type of opioid re<:eplor
Mucolytic drug used to loosen thick mucus
Mucosa layer inner lining of the alimentary canal that provides
a surface area for the various acids, ooses, and enzymes to break
down food
Mucositis inflammation of the epithelial lining of the digestiw
Imct
Muscarinic type of cholinergic receptor found in smooth mus-
cle, alrdiac muscle, and glands
Muscle spasm involuntary contraction of a muscle or group of
mllS(;les, which become tightened, develop a fixed pattern of re-
sistance, and result in a diminished level of functioning
Mutation permanent, inheritable change to DNA
Multiple sclerosis (MS) autoimmune disorder of the central
nervous system; a condition where antibodies slowly destroy tis-
sues in the brain and spinal cord
Myasthenia gravis motor disorder caused by a destruction of
nicotinic receptors on skeletal muscles and characterized by pro-
found muscular futigue
Mycoses diseases caused by fungi
Mydriasis pupil dilation
Mydriaticdrug agent that causes pupil dilation
Myocardial infarction blood dot blocking a portion of a coro-
nary artery that causes necrosis of cardiac mllS(;le
Myocardial ischemia lack of blood supply to the myocardium
due to a constriction or obstruction of a blO<Xl
=1
Myoclonic seizure seizure characterized by brief, sudden con-
tradiolts of a group of muscles
Myxedema condition caused by insuffiCient secretion of thyroid
hormone
Nadir lowest values of erythrocyte, leukocyte, and platelet
counts caused by chemotherapy
Narcotic natural or synthetic drug related to morphine; nl.1y be
used as a broader legal term referring to hallucinogens, eNS
stimulants, marijuana, and other illegal drugs
LibraryPirate
844 Cilo"''Y
Narrow-spectrum antibiotic anti-infective that is effective
against only one or a small number of organisms
Na usea Wlcomfortabl .. wavelike sensation that precedes
vomiting
NDA review third stage of newdrug evaluation by the FDA
Nebulizer device used to convert liquid drugs into a fine mist
for the purpose of inhalation
Negative symptoms in schiwphrenia, symptoms that subtract
from normal behavior, including a lack of interest, motivation,
responsiveness, or plt'3sure in daily activities
Neoplasm abnormal swelling or mass; same as nmwr
Nephron strucrural and nUicrional unit of the kidney
Ner ve agent chemical used in warfare or by bioterrorists that
can affect the central nel"\Uus sysiem and cause death
Neurofibrillary t angles bundles of nerve fibers found in the
brain of patients with Alzheimer's disease on autopsy
Neurogenic shock type of shock resulting from brain or spinal
cord injury
Neurohypophysis posterior portion of the pituitary gland
Neurolepanalgesia type of general anesthesia that combines
fentanyl with droperidol to prodnce a state in which patients are
consdous though insensitive to pain and unoonnected with sur-
roundings
Neuroleptic drug used to treat "nervous-type conditions like
psychoses
Neuroleptic malignant syndrome potentially fatal condition
caused by certain antipsychotic medications characterized by an
extremely high body temperature, drowsiness, changing blood
preo;sure. ir .... gular muscle rigidity
NeuromuKUlar blo<:ker drug used to cause total muscle rem-
ation
Neuropathic pain caused by injury to nerves and typically de-
scribed as burning, shooting, or numb pain
Nicotinic type of cholinergic receptor found in ganglia of both
the sympathetic and parasympathetic nervous systems
Nit egg of the louse pamsite
Nocicepti ve)'ll in pain produced by injury to body tissue
Nociceptor receptor connected with nerws that receive and
transmit pain signals to the spinal cord and brain
Nonspecific syst em def ense defense such as inflanumtion that
protects the body from invasion bygeneral hazards
Nonspecifi c cellular response drug action th.1t is independent
of cellular receptors and is not associated with other mecha-
nisms, such as changing the permeabilityof cellular membranes,
depressing membrane excitability, or altering the activity of cel-
lular pumps
Norepinephrine (NE) prilllllry neurotransmitter in thesympa-
thetic nenuussystem
Nosocomial infection infection acqui .... d in a health CIT<.' set-
ting such as a hospital, physician'softice, or nursing home
Nursing diagnosis clinically based judgment about the patient
and his or her response t o health and illness
Nursing process five-part decision-making system that in-
cludes assessment, nursing diagnosis, planning, implementa-
tion, and evaluation
Objective dat a information gathered through physical assess-
ment, laboratory tests, and other sources
disorder recurrent, intrusive thoughts
or repetitive behaviors that interfere with normal activities or re-
lationships
Older adulthood person older than age 65
Oligomenorrhea infrequent menstruation
Oligospermia presence ofJe ... than 20 million "perm in an
"",,
Open-angle glaucoma chronic, simple glaucoma caused
by hindered outflow of aqueous humor from the anterior
chamber
Opiate substance closely .... lated to morphine ertrncted from the
poppy plant
Opioid substance obtained from the unripe seeds of the poppy
plant; natural or synthetic morphine-like SlIbstance
Osmolality number of dissolved particles, or solutes, in I kg ( J
L) of water
Osmosis process by which water mows from a .... as oflow solute
concentration (low osmolality) to a .... as of high solute concen-
tration (high osmolality)
Ost eoarthritis disorder characterized by degenerntion of joints;
particularly the fingers, spine, hips. and knees
Ost eomal acia rickets in children; caused by vitamin D defi -
ciency; characterized by softening of the bones without alter-
ation of basic bone structure
condition in which bones lose mass and become
brittle and susceptible to fracture
Otitis media inflammation of the middle t'3r
Outcome objective measurement of goals
Ovulation release of an egg by the ovary
Oxytocia agents that stimulate uterine contractions and pro-
mote the induction of labor
Paget's di sease disorder of bone formation and resorption
characteriLed by weak, enlarged, and deformed bones
Palliation form of cancer chemotherapy intended to alleviate
symptoms rnther than cure the disease
Panic disorder anxiety disorder characterized by intense feel -
ings of immediate app .... hension, fearfulness, terror, or impend-
ing doom, accompanied by increased autonomic nenuus sysiem
activity
ParafoUicular cells cells in the thyroid gland that secrete
calcitonin
Paranoia having an extreme suspicion and delusion that one is
being followed and that others a .... trying to inflict harm
Parasympathet ic nen "ous system portion of the autonomic
nervous system that is actiw during periods of rest and that re-
sults in the rest-or-.... laxation response
Parasympathomimet ic drug that mimics the actions of the
parasyml'.1Ihetic nervous system
Parenteral nutrition the administrntion of high calorie nutri -
ents via a central vein, such as the subclavian vein
Parent eral route dispensation of medicatiollS via a needle into
the skin
Parietal cell cell in the stomach mucosa that secretes hydrochlo-
ric acid
Parkinsonism having tremor, muscle rigidity, stooped posture,
and a sbuffiinggait
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Partial (focal) seizure seizure that starts on one side of the
brain and travt'ls a short distance before stopping
Partial agonist medication that produces a or less effi-
cacious, respollSt' than an agonist
Passive immunity immune defense that lasts 2 to 3 weeki; ob-
tained by administering antibodies
Pathogen organism that is capable of causing disease
Pathogenicity ability of an organism to cause disease in
humans
Patient -controlled analgesia (PCA) use of an infusion pump to
deliver a prescribed amount of pain relief medication a des.-
ignated time
Pediculicide. medications that kill lice
Pegylation process that attaches polyethylene glycol (PEG) to
an interferon to extend its pharmacologic activity
Pellagra deficienq of niacin
Penicillin_bindingprotrin. (PBPs) en"YnleS used by bacteria to
build bacterial ceU walls that are targets for penicillins and re-
lated antibiotics
Peptic ulcer erosion of the mucosa in the alimentary canal,
most contmonly in the stomach and duodenum
Percutaneous transiuminal coronary angioplasty (PTCA)
procedure by which a balloon-shaped catheter is used to com-
press fatty plaque against an arterial wall for the purpose of
restoring normal blood flow
Perfusion blood flow through a tissue or organ
Peripheral edema sw\'lling in the limbs, particularly the feet and
ankles, due to an accuntulation of interstitial fluid
Peripheral nervous system division of the nervOU'l system
containing all nervous tissue outside the CNS, including the au-
tOllOmic nenuus system
Peripheral resistance antOWlt of friction encountered by blood
as it travels through the vessels
Peristalsis involuntary wavelike contraction of smooth muscle
lining the alimentary canal
Pernicious (megaloblastic) anemia type of anemia usually
caused by lack of secretion of intrinsic factor
pH measure of the acidity or alkalinity of a solution
Pharmacodynamics study of how the body responds to drugs
I'harmacogenetics area of pharmacology that fXlmines the
role of genetics in drug response
Pharntacokinetics study of how drugs are handled by the
body
Pharmacologic classification melhoo for organizing drugs on
the basis of their mechanism of action
Pharmacology the study of medicines; the discipline pertaining
to how drugs improw or maintain health
Pharmacopoeia medical reference indicat ing standards of drug
purity, strength, and directions for synthesis
Phobia fearful feeling attached to situations or obje<:ts such as
snakes, spiders, crowds, or heights
Phosphodiesterase enzyme in muscle cells that deaves phos-
phodiester bonds; its inhibition increases contrac-
tility
Phospholipid type of lipid that contains two fatty acids, a phos-
phate group, and a chemical backbone of glycerol
GIoss y 845
Photosensitivity condition in which theskin is highly sensitive
to sunlight
Physical dependence condition of experiencing unpleasant
withdrawal symptoms when a substance is discontinued
Planning phase linkage of strategies or interventions to estab-
lished goals and outcomes
Plaque fatty nl.1terial that builds up in the lining of blood ves.-
sels and may lead to hypertension, stroke, myocardial infarction,
or angina
Plasma cell cell derived from Blymphocytes that produces an-
tibodies
Plasma half-life (t Ul) the length of time required for the plasma
concentration of a drug to decrease by half after
administmtion
Plasmid small piea' of circular DNA found in some bacteria
that is able 10 transfer resistance from one bacterium to
allOther
Plasmin enzyme formed from plasminogen thai dlssotves btood
do"
Plasminogen protein that prewnts fibrin clot formation; pre-
cursor of plasnlin
Polarized condition in which tht' inside of a cell is more nega-
tively dJarged than the oUl.'lide of the
Polyene antifungal class containing anlphotericin B and
nystatin
Polypharmacy the taking of multiple drugs concurrently
Positive symptoms in schiwphrenia, symptoms that add to
IIOrmal behavior, including hallucinations, delusions, and a dis-
organized thought or speech pattern
postganglionic neuron autollOmic nervt' aftt'r the gans!ionk
synapse transmitting impulses to the target tissue
Postmarketing surveillance evaluation of a new drug after it
has been approval. and used in large numbers of patients
Postpartum depression occurring aftt'r childbirth
Post-traumatic stressdisorder type of amiety that develops in
response to reeq>eriencing a previous lift' e' .,ent that was psycho-
logically traumatic
Potassium ion channel pathway in a plasma membrane
through which potassium ions enter and leaw
Potency the strength of a drug at a specified concentmtion
or dose
Preclinical investigation procedure implemented after a drug
has been licensed for public use, designed to provide informa-
tion on use and on occurrence of sideetfects
pregllnglionic neuron autonomic nerve before the ganglionic
synapse carrying inlpulses from the spinal cord
preimplantation period period of life from I to 2 weeks post-
conception
Preload degree of stretch of the cardiac muscle fibers just before
they contract
Preschool child child from 3 to 5 years of age
primary-progressive MS one of the four recognized of
Multiple Sclerosis named for gradual advance of the disease
from onset and with no superimposed reillpses (new or r ... urfac-
ingsymptoms) and remissions (periods of recovery)
PRN order medication is administered as required by the pa-
tient's condition (L:ltin: pro re nata)
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Prodrug drug that becomes moreaclive aftt'f it is mernbolized
Progesterone hormone secreted by the corpus luteum and pla-
centa responsible for building up the uterine lining in the second
half of the menstrual cycle and during pregnancy
progressive- relapsing MS one of the four recognized forms of
Multiple Sclerosis named for gradual advance of the disease;
there is significant recovery relapse, but
there is a gradual worsening of symptoms
Prolactin hormone secreted by the anterior pituitary gland that
stimulates milk production in the mammaryglands
Protease viral enzyme that is responsible for the final assembly
of the HIV virions
Prothrombin blood protein that is converted to thrombin in
blood coagulation
Prothrombin activator enzyme in the coagulation cascade
t!wt cotM'rts prothrombin to thrombin; also called
protltrombilla5e
Proton pump inhibitor drug that inhibits the enzyme , .
ATPase
Prototype drug wellunderstood model drug with which other
drugs in a pharmacologic class may be compared
Protozoa single-celled animal
Provitamin inactive chemical that is converted to a vitamin in
thebody
Pruritus itching associated with dry,scalyskin
P50ralen drug used along with phototherapy for the treatment
of psoriasis and other severe skin disorders
Psoriasis chronic disorder characterized by red patches of skin
covered with flaky, silver colored scales
substance that alters peKeption and reality
Psychological dependence intense craving for a drug that
drives people to continue drug abuse
P!.yulU"""ial u.".;r;u..; a 1'''''Mln', U.,v.,[up",.,n( in
the context of one'ssocial environment
psychotic depression expression of intensely negative mood
shifts and WlUSUal behaviors involving hallucinations., delusions,
disorganized speech patterns., or loss of conrnct with reality
Purine building block of DNA and RNA, either adenine or
guanine
Purkinje fibers electrical conduction pathway leading from the
bundle branches to aU portions of the ventricles
Reabsorption movement of filtered substances from the kidney
tubule back into the blood
Rebound congestion adverse effect of intranasal decongestants;
prolonged use ClIlISes hypersecretion of mucus and mlrsening
nasal congestion once the drug effects wear ofT
Rebound insomnia increased sleeplessness that occurs when
long-tenn antianxiety or hypnotic medication is discontinued
Receptor the structural component of a cell to which a drug
binds in a dose-related mannt'f, to produce a response
Recommended Dietary Allowance (RDA) amount of vitamin
or mineral needed e:lCh to 3void 3 deficiency in he:llthy
adult
Red-man syndrome rash on the upper body caused by certain
anti-infe.;:tives
Reflextachycardia temporary increase in heart rate that occurs
when blood pressUJ'l' falls
Refractory period time during which the myocardial cells rest
and are not able to contract
relapse- remitting MS one of the four recognized forms of Mul -
tiple Sclerosis named whenever new symptoms appear or when
they resurface or worsen {relapse}; the patient then partially or
fully reco"t'rs from the acquired deficits (remitting)
hormone hormone secreted by the hypotlml'llllllS
that affects secretions in the pituitary gland
REM sleep srnge of sleep characterized by quick. scanning move
ments of the eyes
Renal failure a oondition characterized by a de.;:J'l'a5e in the kid-
neys' ability to m.intain ele.:trolyt .. and fluid balance and excrete
waste products
aldosterone system series of enzymatic
steps by which the body raises blood pressure
Rest -alld-digest response signs and symptoms produced when
the parasympathetic nervous system is activated
Reticular activating system (RAS) responsible for sJ.eeping
and wakefulness and performs an alerting function for the cere-
bral cortex; includes the J'l'ticubr formation, hypothalamus., and
P.1rt of the thalamus
Reticular fonnation portion of the brain affecting awareness
and wakefulness
Retinoid compound resembling vitamin A used in the treat -
ment of severe acne :md psoriasis
Reverse cholesterol transport the process by which cholesterol
is transported awayfrom body tissues to the liver
Reverse transcriptase viral enzyme that converts RNA to DNA
Rhabdomyolysis breakdown of muscle fibers llSuaHy due to
muscle trauma or ischemia
Rheumatoid arthritis systemic autoimmune disorder charac
terized by inflammation of multiple joints
Rhinophyma reddened, bullous, Irregular swt'Utng of the

Risk management system of reducing medication errors by
modifying policies and procedures within the institution
Rosacea chronic skin disorder charactt'fized by dusters of
papuleson the face
Routine order order not written as STAT, ASAP, NOW, or
PRN
Salicylates the chemical family to which aspirin belongs
Salicylism poisoning due to aspirin and aspirin-like drugs
Sarcoma cancer of connective tissue such as bone, muscle, or
cartilage
Scabicide drug that kWsscabies mites
Scheduled drug in the United States, a term describing a drug
placed into one of five categories based on its potential for mis-
useorabuse
Schizoaffective disorder psychosis with symptoms of both
schizophrenia and mood disorders
SchizophR'nia psychosis characterized by abnormal thoughts
and thought processes, withdrawal from other people and the
outside environment, and apparent preoccupation with ont"s
own mental state
School-age child child from 6to ]2 years of age
Scurvy deficiency of vitamin C
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SeaMl nal affecth-e disoro... r (SAD) a type of dl'l'ression experi.
eneed during the dark winter months
Seborrhea skin condition char.lcterl;red by OW'l'3(tlvity of oil
gUuu"
Second messenger caSColde ofbiochemltal events that init iates
a drug's lIctiOO by either st imulating or inhibit ing a Il()rmal 3(-
livityof thecell
Secondary hypertension hypertension having a specific identi-
fillb!... cause
MS one of the rour ft'COgJIl:t.ed forms of
Multiple Sclerosis named for gr.lduaJ advan of the dlsea.sr; su-
perimJXN'd relap5t'S (new or resurfacingS)'nlploms) and remis-
sions (periods of recovery) may occur, but they tend to tail off
o>'<' rtime
Se<:ret ion in the kidney, IT'IO\'etl'Ient of substances from tht'
blood into the tubule after filtntion hasocrurred
Sedati ve substance that depresses the CNS to cause drowsiness
"' ....
Sedati ve-h ypnotic drug with the ability to produce a calm-
ing effect at lower doses and to induce sleep at higher doses
Seizure symptom of epilepsy charaClerlzro by abnormal neu-
ronal discharges within the br.lln
Selective estrogen receptor modulator (SERM) drug that
produces an action Simi lar 10 estrogen In body tissues; used for
the treatmrnt of osteoporosis In postmenopausal women
Selective serotonin reuJlt ake inhibitor (SSRI) drug that se-
lectively inhibits the reuptake of serotonin Into nerYe terminals;
used mostly for depression
Septic shock type of shock u used by infeaion In the
bloodstream
Serotoni n syndrome 5d o( signs and symptoms as.soctiltOO
with o>t'rmedication with antidepressants thatlndudes altered
mental status, fe>t'r. sweating, and bck of II'lllSCIliM
coordination
Shock condition in which there is Inadequate blood flow to meet
the body's metabolic needs
Short height below the fifth percentile for aPt and gen-
der,or thall two deviations below the mean (av-
erage) for age and gender
Sho rt -tu m or insomnia lnJb\l!ty to sleep that is
often attributed to stress uused by a heal, Ufenyle or the in-
ability to re;o"'e day-ta-day conflicts withln t he homeor work-
pbu
Silmt angina ITl}'OC3rdiaJ ischemia that occurs In the absenceof
1"'"
Single order medication Is to be 81>'<'n only once, and at a
(jmo:, .u"h a. p'''''per.ll ..... uHkJ
Sinoatrial (SA) node pacemaker ofthe heart IOOi ted in thewall
of the right atrium that controls the basic heart rate
Sinus rhythm per minute normallygenerated
by the SA node
Situational by prople faced with a
stressful environment
Sleep d ebt lack of sleep
Social a nxiety of crowds
Sodium ion pathway In a plasma through
which sodium ions enter aoo !e<l\'e
Glomry 1&47
Somatic nervous nerve division that provides volun_
tary control o\'er skeletal muscle
Somatostatin synonym for growth Inhibiting facto r
from the hypothalamus
Somatotropin another name for growth hormone
Somogyi phenomeno n I1Ipid decrease In blood glucose level
dut stimulates the release of hormones (epinephrine, cortisol,
glucagon) resulting in an elev3ted mornlns blood glucose
Spast icity inability of oppo6ing m\lS(le groups to ITIO'o't' in a co-
ordiruued manner
Specialty supplement nonherNl dietary product used to en-
hance a wide variety of body functions
specific antidotes direct remedies to counter the effects of poi-
sons or totins in variouo; including heavy metals, radioac-
tive agents, and o\\'rd05ing of pharmacologic subsunces
Spirituality tM OIpacity to love, to convey compilSSion and em-
pathy, to give and forgive, to enjoy life, and to find peace of mlnd
and fulfillment in living
Stable angina type of angina that occurs In a predictable pat_
tern, usually relieved by rest
Standing order orderwrillen in advance of a si tuation that isto
be carried out under specific drcumstances
STAT order any mediCll tion that is needed lmmedJ,nely and Is
to be only once
Status asthmat icus condition characterized by repeated
or one proionPtd seizure attack th.lt continues for at least 30
minutes
Status epilepticus condition characterized by repeated sei)(U, es
or one prolonPtd seizure attack that continues (or at least 30
minult's
Steatorrhea the passing of bulky, foul-smelling fatty stools
St em ceU cell that resides in the bollt marrow and is capable of
maturing into any type of blood cell
Steroid type of lipid consistingo( lOur rings that Is a structural
component of certain hormones and drugs
St erol nudeus ring structure common to all steroids
Strategic National Stockpile (SNS) program designed to
the- immediate deployment of essential medical materbls to a
axnmunity in lheeventof a large-sale chemlcalorblologk
Stroke volume amount of blood. pumped out by a ventricle in
a single beat
Subcutaneous medication deli\\'red beneath IhesJdn
d ata information gathered reguding wh3t a patifonl
states or perceives
Sublingual rout e administration of medication by pladng it
under the tongue and allowing it to dissolYl! slowly
Substance abuse self-administrntton of a drl1& that does not
conform 10 the medical or social norms within the patient's
giwn culture or society
Substance P neurotransmitter within the spinal cord involved
in the neural tl1lllSmission of pain
Sub5tantia nigra location in th.e br.lin where dopamine is syn_
thesized that is responsible for regulation of unconscious muscle
movement
Superinfection new infection caused by an organism different
from the 0Ilt' causing the initi.1l intection; usually a side effect of
anti-infectM.- thel1lpy
LibraryPirate
848 Glomry
Su rgical a nesthesia stage 3 of anesthesia, In which m05t major
surgery occurs
r elease tablets or capsules designed to dissolve slowly
owr an atended tlme
Sympathet ic nervous syste m ponlon of the autonomic system
th.lt Is :lC!lve during periods of stress and results In the fight-or-
tlight response
symplilholytic a drug that blocks the actions of the sympathetic
nervous system
Sympa tho mimet ic drug that stlmuLltes or mimics the sympa-
thetic nervous system
Synapse junction between two neurons consisting of a presy-
naptic nerve, a synaptic deft, and a postsynaptic nerve
Synoptic t ransmission process by which a neurotransmitter
reaches receptors to regenemte the action potential
Syrup of Ipecac remedy primarily used to induce vomiting fol-
lowing ingestion of poisonous substances; ipecac irritates the
gastric mUCO!kl and promotes emesis by st imulating the
chemoreceptor trigger rone (CTZ) within the brainstem
Tardive dyski nesia unusual tongue and fuct' movements such
as lip smacking and wormlilw motions of the tongue Hut occur
during pharnucotherapy with cenain antipsychotics
Taxan es alkaloids i.solated from the oork o f the Pacific yew and
used for antineoplastic activity; rorrent drugs Include padllaxel
(Thxol) and dOCl.>Jaxel (Thxotere), but more Thun 19 oThers are
being Investig.lted
T cell type of lymphocyte that is essential for the ceU-
mediated immune response
Temion headach e common type of head pain caused by stress
and relieved by nonnarcotic analgesics
Teratogen drug or other agent that causes developmental birth
defects
Testost erone primary androgen responsible for maturation of
m:lle sex organs and secondary sex charocterlstlcs of men; se-
creted by h. 'Stes
Therap eutic cl assification method for organiling drugs on the
oosisoftheir clinical usefulness
Therapeutic index the ratio of a drug's LDIII to its
Therapeut ic range the dosage range or serum concentration
that achieves the desired drug effects
Therapeut ics the branch of medicine con cerned with the treat -
ment of disease and $uffering
Three che,ks of d r ug ad mini st rat.io n in conjundion
with the five rights, these ascertain patient safety and drug effec-
tiveness
Thrombin enzyme that causes dotting by catalyling the conver-
sion of fibrinogen to fibrin
Thrombocytopenia reduct ion in the nWllM of circulating
platelets
Thromboembolic disorder condit ion in which t he patient de-
velops blood dots
Thrombolytic drug used to dissolve existing blood clots
Thrombopoi etin hormone produced by the kidneys that con-
trols megakaryocyte activity
Thrombus blood dot obstructing a wssel
Thyroid storm a rare, life-threatening fo rm of t hyrotoxicosis;
also called thyroid crisis
Thyroxi ne- bindingglobulin (TBG) a plasma protein produced
in the liver
Tiss ue plasminogen activato r (tPA) rl.1tural enzyme and a
drug tMt dissolves blood clots
Titer measurement of the amount of a substance in the blood
Tocolytk drug used to Inhibit uterine contractions
Tocopherol generic name for vitamin E
To lerance process of adapting to a drug over a period of time
and subsequently r'-'(jUlrlng higher doses to achieve the 5:.lrtle
effect
Tonic spasm single, prolonged muscular contraction
To nic-donic seizure seizure characterized by intense jerking
motions and loss of consdousness
To ni ci ty the abllity of a solUTion to calise u chanse In Willer
movement a membrane due to osmotic forces
Topo isomerase enzyme that assists in the repair of DNA
d.'lmage
To to.] p arenteral nutritio n (TPN) nutrition prOVided through
a peripheral or central vein
To xicconcentration 11',"<'1 of drug that will result in serious ad-
verse effects
To xoid substance that has been chemically modified to remove
its harmful nature but Is stU) able to elicit all immune response
in the body
Trade n ame proprietary name of a drug assigned by the manu-
ldurer; also caUed the brand name or product name
Tranquilizer older term sometimes used to describe a drug that
produces a calm or tral1qull feeling
TTQlIsfcrrin protein complex lhatlransporu Iron to shes In the
lxxIy where it is needed
Transplant rejection re;:ognition by the immune sr,;tem of
a transplanted tissue as foreign and subsequent attack on the
tissue
Tri cyclic antidepressant (TCA) class of drugs used In the
pharmacotherapy of depression
Triglyceride type of lipid that contains three fatty acids and a
chemical backbone of glycerol
Tubercle cavity-like lesion in the IUl1gcbaracteriSlic of infection
by Myc:oll<lcterium tuberculosis
Tumo r abnormal or mass
"TYPe 1 di abetes metabolic disease by hyper-
glycemia caused by a Ia.:kof secretion of insulin by the pancreas
Type 2 diabetes chronic metabolic disease caused by insufficient
secretion of insulin by the pancreas, and a 13d of sensitivity of
insulin receptors
Tyramine form of the amino acid tyrosine that is found in foods
as cheese, beer, wine, and yeast products
Ulcerative colitis inflammatory bowel disease of the colon
Undernutrition lack of adequate nutrition to meet the meta-
bolic demands of the body
Unstable angina sewre angina that ocrurs frequently and that
is not relieved by rest
Urinalysis diagnostic test that examines urine for the presence
of blood celli., proteins, pH, specific gravity, Rtones, glucose, and
microorganisms
LibraryPirate
Urticaria hypersensitivity response that is .:haracterized by hives
and is often accompanied by pruritus, or itching
Vaccination/immlUlization inoculation with a vaccine or tox-
oid to pft'llent disease
Vaccine biologic material that confers protection against infec-
tion; p"," .. tion of m icmnrg,mi<m partide< thM i, injKTed inTn
a patient to stimulate the immune system, with the intention of
preventing disease
Vasomotor unter area of the medulla t hat controls baseline
blood pressure
Vasospastk (Prinzmetal's) angina type of angina in which the
decreased myocardial blood flow is caused by spillms of the coro-
nary arteries
Vendor Managed Inventory (VMI) supplies and pharmaceu-
ticals that are shipped after a chemical or biologic threat has been
identified
Ventilation process by which air is moved into and out of the
lungs
Very-low-density lipoprotein (VLDL) lipid-carrying particle
that is convened to LDL in the liver
Vesicant agent that can cause st'rious tissue injury if it escapes
from an anery or vein during an infusion or injection (enrava-
saUon); many antineoplastiG are j a n t s
Vinca alkaloid chemical obtained from the periwinkle plant
that has anttnooplasllc activity
Viralload a measurement of HIV RNA lewls in the blood which
provides an estimate of how rapidly the virus is replicating
GIos, y 1149
Virilization appearance of masculine secondary sex
characteristiG
Virion particle of a virus capable of causing an infection
Virulem:e the se'<'l:'rity of disease that a pathogen is able to cause
Virus nonliving panicle containing nucleic acid that is ablt' to
causedi&e3se
Vitamin organic compound required by tht' body in small
amounts
Von Willebrand's disease decrease in qnantity or quality of
'on Willebrand factor (vWF), which acts as a carrier of facror
VIII and has a role in platt'let aggregation
whole-bo .... 'l:'l irrigation the act of mechanically flushing the in-
gested poison from the gastrointestinal tract afterthe patient has
ingested potentially toxic doses of lead, zinc, or illicit drugs; this
technique may be used for overdosed sustained-relt'aSt' or en-
tericcoated drugs
Withdrawal physical signs of discomfort associated with the
discontinnation of an abused snbstance
Withdrawal syndrome symptoms that result wht'n a patient
discontinues taking a substance on which he or she was
dependent
Yeast type of fungus that is unicellular and divides by
budding
Young adulthood term applied to persons from 18 to 40 years
ufagt'
ZoUinger-Ellison syndrome disorder of excess acid secretion
in the stomach resulting in peptic ulcer disease
LibraryPirate
blJowed by figures
aod those by, indkatt tables,
boxes, or special fe,lIurts. The title' of
'pi<tl (e.s., Home 1nd
Community Con.iderations,
Treating the Diver.., Pau.nt ) are abo
capitalized.,
i'rotOl)'pf drua;sapptar in boldfaa, drug
cbsiir1.cation, :are In SMAl.L CAPS, tl1lde
names are -..pit<lliud and cross-n:f=ted
to mrir grnerk name. Disease, disorders,
and condition. a", in red type.
A
AAPMC
pscudO .... mbnl\OllS toliIU), 494
aN"",i 5301
aNtatept.742.
abbreviations:

dfU(!; administration, 20t
abcixlmab, 349, 379.
AbeI, John 3
Ahekn. Su Amphoterici n 0
Abilify. Su Aripipl1l101,
abortion. pharmacological. drugs for:
earboprost trO!llethamiJlt, 704
dlnoprostone, 703., 704
methotrexate with mi5Oproilol, 703., 704
mifrpriilOn, with mi5Oproiloi. 703., 704
Abreva. Su Docosanol
absl'Ilcc {pdit mal) "';zure, 169., 112
ab50rptlon:
d.finition.37
aff<'C1ing. 38. 39/
mechanisms. 381
In older adults, 7J
In
acamprosatt cakium. 108
aarbo5c:. 687., 683
Acroialt. Su Zafl rlu\<aj;!
Atcrdropin. Su Somatotropin
Atcuprll. SuQulnaprU
Atcurnic, 302.
Accut<lnt. Su bOIn:1inoin
ACE Su ANGIOTaiSIN
CONVEITINC I'.NZYME (ACE)

atebutolol:
actioll5 and uscs.I36.
for an8ina myocardial
343.
for dyYhyt/lmlas, 36(h
effecu durln8 bmutf<lin8, 67.
for bypc:rtension, 315.
/It;(01L Su PerindoprU
aCorIaminophrn. 4721
aclions and wes, 472.
'"
administl1ltion alm 4721
. ffects, 2281. 472r
alternation with ibuprofen In
chOdren.472r
in <;Q\dJalJ''8ycombination drugs. 5761
ethnk/ racial considerations, 473.
Interactions, 472.
mechanisms ofielion, 229
OYnd05t treatment, 472.
pbarmacokinrlk" 472.
route and adult d"..., 228.
AerllWllani. S- Acrlliz.olaDlid.
aat<lZDlamlde:
for giauconu. 773
for pancreatitis, 635
for renal bilure. 424, 425.
aertk addand hydrocortisone, 776.
acetylation. 81
amykhoJine (Io.ch):
bIotktr$. S- J.t.(l(Xllt:S
physiology, 130, 139
Stt Chollntr8k !'KeplOR
acctykholinestcrase (AchE), 131,264
1cctykholine:stcrase inhibitors. 5t'r
OiQUNUGlQ
( PAAASYMl'lI.11lOMIME1lCS). IN DlRf.CT
.en""
aCftylcysteine, 123 583.
amylsalkyJic acid. Su MI>i rin
acetyltl1losfen ... 81. 811
Achromydn. SuTdracyclil1c
acld-lxiK Imilal;rnt<', 440, 440/ Su a/UI
Acidosis; AIbJosis
1cidophUus.IOOI,623
acidusis:
cause .. 420., 4411
definition. 440, 440/
phunucothcl1Ipy. 440, 44 I.
AdpHa. Su RabepraZDle
.. dln:tin, 762.
Adavate. S- Aklomctasone
acne tarilill 755
acne vul(pris:
duratteristia. 755
Nursinl Proo;;en Poms
1!lse5Sment.7581
n-al.uation of outcome crittria, 759.
implementation
and
7SS-59t
patient and family nlucalion.
75S-59t
pati,nl goals and apectcd
outromrs. 753.
potentia! 758.
pbarm.acoth,rapy
adapaiC1le. 756. 7561
ud.J.k acid. 7561
peroxide, 756. 756.
doxycycline. Su Doz)1:ydine
erythromycin, 756
ethinyl n tndiol. Me Elhinyl estndiol
i5Olretinoin, 756.
. ,MlIc,tunidc.7561
tazarotl'lle. 7561
tctracyclinc. S .. Tet racycline
tretinoilL Su Trdinoi n
""(WI. Sn: Atptroban
1cqu1ted immune def.clency syndrome
(AIDS), 528. Su <'110 HIV- AIDS
acquired resiSlancc. 481-82,4821
acromqr,aly, 659,. 660
N ....... nue""' .... Su Black coboslt
ACTH. S- AdrenocortiCOlrol'k oormonr;
Corticotropin
AttlilB. S- HotcmophUus type B OOIljugate
Mlkin. Pcnnethrin
Attikd. S Pseudoephedrine
Attired Cold and AUelllY, 576,
AttllCd Cold a nd AUelllYtableu, 576,
1<.1ion potcmialf, 355
A(liq. S Fentanyl
AttNaK.S A1trpl ..,
IctlY.llcd charooal, 122
activ4trd dOlling time. 372r
1cti"u,d partiollthromboplaslin time
(aP'IT). l?i. 372.
immunity. 44'1, 45if
transport, 37
S- Etltinyl "tndiol/
norethindrone acetate
Atlond. Su Risedro .... te
ACTOplus me!. Sn Pioglitarone,
metformin
AttOL Su Piotliltazonr
Attron. Su Ketoprofen
anne lOUry arthritif, 744
arutepaln. 219
arut. radiation syndrome, 120
acyclovlr.539f
action. and U5eS. 539.
adminiSlntion aIm .. 539,
5391
inltractio!l5,539.
pharmacokinetlcs,519r
I'O\Ite I nd iiHluJt d05t, 5381
for viral $kin .. 752
AdaLa!. s...
adalimumab, 625
Adam!i!e, 121.
adapalene, 756. 7S6.
Adal'in. S- Doxqrin
ADD (ilttmion-ddictt dUonkr). 197
Adderall. S- D and L-aDlphetamin.
racemic mixture
LibraryPirate
addiction, 14, I().I , SAo 11110 SubslaD<C' abu ...
AddiJon's dlsnst, 659" 671
adtfovir, >II, 542,
tI..a (tI.-ddu) fibers. 220

admobypopllysis, 651
SAo i\dtnoiinc
360" 366
JillH. SAo oormonc
JillHD. Sn ddkll-hyperaclivily
dllOl\Jer

adjuvant 5SO
adol",",net, 71-72
adolroant" SAo Chlkl""n
JillP lCPTOl .lOCXDIS:
drll&' clmintd IS
Sn Clopidogrd
pnl$uarcl, 379,
tioclopkliM, 349, 379,. 3110
mrchanism,of acl lon, 380
otl"",al "",!>/>y. "'71. "'11
ad""nal si.;lnd:
disorder,
Addlsonsdisult. 659t. 671
ad",norortlQallnsuffklency,670-7]
So. Q .. rung,
""'-
runclion,667,670f
production, 65J1f, 6721
gluclXOetlcoids. 670, Sa..Jso
GlUcocomCOlI
gonarirxortiroids. 667
mln ..... loroftkolds.610
adrtnal mWulb. 130
Adrenalin. SAo Epin.orhrino
ad""n'''aic, 130
ADltl'.NIJl(;lCAGONlm (SYMPATHOMlMFJICS):
actions. nd uses. 131, 132-33, In,
AIJ'HA_. So. AU'!IA-AllIlENERG1C AGONISTS
BFrA_. S
mhanlsms of Ktlon, 132-33
Nursina Process Focus
_ .... _"t,IH,
tvaluatlon of OlI\OOmo aiteria, 135.
Impktntntation
rntiotWos,
1);1-35.
p.>til:nt and familywucation,
1);1-35.
planning: p;ltltnt pll and cxptctod
outtoma, 134,
po!<ntlal nursing diagnoKl, 134,
ADRI'.NIR(lIC ANTAGONISTS (SYMl'AlHOll'TICS):
actionl and uses. III
AIJ'HA_. SAo tl.U'!IA-AOlI'.NEItGIC
ANTloGONlm
BEll<_. Sa BnA-AllIlENEIlCIC
ANTloGONI5T5
diniocal applk .. tions, 136, ] 36t
Nunin, Procas Focus
a"''''mtnt, 131,
impicmentat ion
evaluation of outcome crimi>, 13'h
Inte/'Vt'ntionund rationales, 138-39.
p;ltimt and family education, 138-l9r
]>bnnlng: pilliont p;oaIs and apted
outco ...... s. 138.
poltntlal nursingdi;ognoses, 137.
AllIlENIllCIC NWlON I LO<:XIIS:
rcstrpint, 315" 318
adrmergk
Jcx:atlon rtspon .. s, 131,
types. 130, 130f, 1l]1
adrtl'lOCOI'llaollnsufncio:ncy, 670-7]
adrtnotortltotrovic hormone (ACTI-I), 670
Adriamydn, Sot Doxorubicin
Adrucij. SAo RoolOurodl
Advilr Dlskus. Sa FluliCluone; Silmomol
AdvilS Ibuprofm

AC1'OBid Sn
591
affinity. 'W
Afluria. Sot I nflumu,
Afrkan Amcri<:anl:
ACE Inhibitor e/ffCts. 31 It
angln;llnclden"'. 341 1
Incidence, S4&
dt:prtJ5ion trtatmont com.d ..... tions. 182,
G6PD deficiency, 517,
belrt failure Inddo""" 325,
tntn,'" IUroess 205.
pain maniliemmt, 220,
use and mortality rnles, 1 I 2t
Afrin. Sot OlymetllZOlino;
Afi.ote. SotToinaftate
325, J26f
.. t dJabd .... Sot Oi;obolt. md.l.itus.
,,,,.,
A&gn.\!at. Sn Tiroliban
agonlSl, SO
AIDS (ac.qulrtd deficiency
.,..ndl'OClW), 116t, See "''''
HJV-AIDS
abthld .. 206, 207.
Akin.oton, Sot Biporiden hydrochloridr
Ala"",.\!, S I'emlroLut
Albalon. Sot Napl'wollne

Alboma. Sn Albenduole
Albuminn. Sot Nonnal .. rum albumin
Sot Norm;ol .... um allUmin
albuteroJ:
actlonund uses. 1321
In anaphylaxis, 413
for uthma, 593, 5941
aklomelalOne, 160,
alC<)hol:
fm.ldfu:ts.6.!i,
mtUboIbm, 108
ph)'!'loIoak and psyci>ologic riJrcu,
'''-'
t<:Jricily _18J!s. 106,
Indn 151
akohoI.buw:
adverw heoltb 108
chronic panc""alitis and, 635, 6J5.
vitamin B, ddkioncy and, 641
wilhdtaWll symplOms, 106., ]08
42]
Ald<lClOnc. S Spironolacton.o
aidalnrkln. 4541, 563
See Methyldopa
aldosterone, 310, 423, 670
aldosterone antagonist. 329, 423. Sot ...
Silironolactolle
aldoSlerone reuptor bloi:kc:r. SN
a1emt'pt, 7621, 763
ilkmlurumab, 5631. 564
Ilmdroruole.717t
IIttions ;md IlKS, 737.
administration alens. 717.
a.MtK effects. 736t, 7371
intoractlons.137.
ovtrd_ trt.t .... nt. 737.
pharmacokinetics. 737.
rOlneand adult do .. , 736t
Ale .... Sot Naprw.:n sodium
Alfenta. Sa AJknlanilltydrochloride
a1ftntanll hydrochloride, 252,
N. s... Interferon alfa-nl
a1l'mosin, 125,
A]imta, SuPomet",Ied
phos['h;ota .. (ALP), 737
........
ClIu .... 44I'
dffinltlon.441
phumacoth ..... py, 44]-42
Alkenn. Sot Melphalan
elfects. 553, 5551
dru8' classified
busulfan. 5551
carboplatin.555,
dsplatln,555,
dacarbazino, 555,
mlUto.rd.
bMdomU<ti .... 555,
chlorambucil, 555.
cyclop/>osphamide, Sn
Cyclopho.phamide
ntrarnustillO,555.
Ifosf..mido,555.
mrcillordhamin.o, 555.
melphalan,5551
nlttOlOl.U:oas
cumusti ne, 553, 555,

Slrq)torocin, 555.
ox:aiipl.1in, 555,
procarbazine, 555,
tomozolomide, 555,

mhanllmS of action, 5so, 553, S54f

alkylation. 55), S54!
LibraryPirate
852 Index
All.sra. Sa I'rxof.nadin.
Allrr.st. SN Napharolin.
413. 574
all"gk "aclion. 18
all"8ic rhiniti 574
pathoph)"'iolosY. 574, 574/
pharmacotherapy
H, -recqltor antagoni.t .. SN
H,- RECEYroR t.NTMiQNJm
intranasal glucocortkoid .. SN
[mv.NASAL GWCOCOJmOOIDS
theraprotk approach. 574- 75
AWu,," ",a.UIn.
allopurinol. 744. 745.
almolriplan.233.
alor. drug int.ractions:
amioduon 3651
atropin 143.
chlorothiazid 423.
p",dnison 471.
alor vera. 763
aloped 552
alo .. tron.625
Aloxi. Sa PalonO.Ytron
ALP (alkalinephosphata>el. 737
alpha cdls. 679/
alpha interferon . Sa iN1"ElF1:RON,
alpha (a ) r=plor .. 131 133
All'1L\. -ADlU'.NI1tGIC!oGO N1m
(SYMPATHOMlM!ITIC'l ):
.dv ..... dfocts, 133. U5. 315.
drug. da..,ifil as
apradonidinc. 769. no.
brimonidin 769. 770.
donidin . SN Clonidin.
dexmldomidin. HCI. 132 160.
dopamine. SN D"""mine
.pin.phrin . Su Epi n<ph ,in.
md.raminol. In.
mdhyldopa. 132 315.
norrpin.phrin . Sa Norepin<phrin.
oxym.talOlin . SN Oxymdazalin.
phrnyl.phrin . Sa Ph.nyl'l'hrine
p .. udO'"f'hC"drin . Sere
P .. udO'"f'hrdrin.
intranasal u ... DlOONGESTANrS
mhani,m. of action. 30 If. 31,
for condition.
glaucoma. 769. 770.
hyprrlcmion. 315. 3151
n ... 1 Sa DECONG!SfANI"S
o ... rvirw. 1321. U3
All'1L\.-ADRENI1tCICANrAGONlSTI
(SYMPATHOLYTIC'l):
ad,.., .... dfrcts, 315. 315 72, 726
drug. cla..,ifil as
car_mol. 13&. 315.
doxa705in. Sere Donzo,in
lahrtalol. 315.
ph.ntolamin ]3&. 721
prazosin. Sere Praza, in
tamsulmin. 13&. 726
teraro.in. 1361. 315 725.
mrd,anisms of action, 1361, JOI!
in "'nign prostatic hyprrtrophy. 7M/
in hrarl faUu",. 327/
NUT5ing P=.., Focus, 137- 39.
...... mmt.137.
implrmcntation
rvaluation of outcomr eritrria. 139.
int ..... ntion nd rational ...
138-39r
patirnt and farnUy C"ducation.
138-39.
planning: patirnt goals and explI
outa>mr lJ6,
potmtial nursing diagno .... 137.
for specifIC condition.
benign pro.tatk hypertrophy.
7251.7M
hypertrn.ion. 315. 315.
mh.ni.m.of action. JOI/
Nursing I'ro< ... Focu .. 316-18.
0 .. erview.I36.136.
Alphagan. See Brimonidin.
AIJ'HA- GWCOIIfI\.!E INHIBITORS:
ad .. .,... dJts, 687.
characteristics.688
drugs d."ifiC"d a.
"",rho ... 687 688
miglitol. 6871
routr and adult do .... 687.
5-All'IL\.- I!.EIJ\.1Ct:A,E lNlllBITOl.I:
ad .. .,... dJrets, 725 727
drugs cla .. iflC"d a.
dutastrride.725.
finastrride. See Flna,t.ride
mhani,m. of aclion. 726f. 727
olprazolam.157.
alpro.tadU.721
Al"",. Sa Ramipril
Allazinc. Sa Trlrahydroroline
alt<pl.sc.3831
aclion. and u .... 383 386
administration alerts, 383.
ad",r .. effts, 3g3.
intoractions.3g31
",..,rdo .. trratmrnt. 383.
pharmawkinrtk .. 3831
routr and adult do ... 383.
AlI.rnaGEL Aluminum h)droxi d.
alternative hrallhca", ')'SIrm .. 96f
all.rnath.lhrrapies. See Complementary
and alternative therapies
all"'lamin 563.
hydroxid 6161
actions and ""'. 616.
administration alerts, 6161
ad .. rr .. rffls, 615 6]6.
intrraetion 616.
pharmacokinrtics. 6161
routr and aduh do ... 615.
Su Mdaprotr",nol
Alurale. See Aproharbital
al .. ooli. 590
Al .. csco. Sa Cidrsonid.
Alzheimer'. di ...... , 263
C3"'giving cone .. ns. 263,
charactrristics. 2561. 263--64
inddoncc.256.
li .. ing with. 257
natural thrrapy with ginkgo biloha. 258.
pharmacoth.rapy
ac.tylcholin trra .. inhibilors
1d .. rr .. dJti. 264. 264.
donrpail. Sa Oon<pezil
gaLantaminc.264.
mhani,m.ofaction.265/
ri .... "igminc.264. 264,
tacrin . 264. 264.
memantin 264-&;
th .. aprotk approach. 264-{i6
sleep disruptions in. 257 r
.tatins and. 28-8
Amani.a mu"",;", 131
amantadine. 257. 540. 540.
Am.ryl. SN Glimepirid.
ambenonium. 140.
Cough SyruP. 5831
Ambirn. Stv Zolpid.m
AmBisolJll.'. See Amphotericin B
ameinonide.760.
amrbia.i 517. 521.
a,",norrh .... 706
Amr'W. Naratriptan
Am .. icaine. See Beru.ocainr
Amrrican Pharmacrntical Association
(APhA).6/
Amrvi.-.. See M.racrpt
Amicar. Sa Aminocoproicadd
Amidate. SN Etomidato
amid.s, 242. 243f. SNalso I.ocAJ.
ANESlHEl1Ci
amikacin. 490 500.

amilorid 303 423,
Amin-Aid,651
aminoacids, as dirtary supplemrnt. 100.
aminOClprok add. 386,
action. and uses. 3861
administration al .. ts, 3861
ad ... r .. driS. 386.
inlrraclion 386.
pharm.cokin<1k 386.
route and adult do ... 386.
AMINOGL"!UISIDES:
ad ... r .. dfecu. 490 491
drug. cla"ifird a.
amikadn.490 SOOt
grnlamicin. Gentamidn
kanamydn.490 SOOt
nromrein. 490. 4901
paromomycin. 490. 490 521,
st",plomycin. 489. SOO.
lobramycin.490.
pharmacolherapy with. 490--91
aminophyllinr. 594 595
amino .. licylic acid. SOO.
amiodaronc, 3651
LibraryPirate
actions and u ... ., 365,
administration 365,
adyer ... dJm 360,. 364. 365,
for dl"rhythmia>, 358f, 360,. 364
hypothyroidi.m and. 663
interactions. 100,. 365,
o,,,,rdo ... 365,
365t
and adult do .... 360,
Amitiza. See

adyer ... 155t, 186,. 233t
po1ymorphi.m.affting
metabolism.81r
and adult do .... 155t
for <pit'ic conditions
anxkty symptom!. 155,
dep", .. ion. 186,
migraine. 233,. 2:J.4
amlodipine. 307,. :J.43,
ammonium chlorido:
for alkaline drug "''''rdo .... 122
for alkalosi>, 442
for o""rdOS<'. 41
amobarbital:
a. goneral anesthesia adjunct. 252,
for stdaHon and in",mnia. t59t
for ... izu",>, 171,
for ] 71
186t
amoxkmin:
adyer ... 484,
for ear infroion>, 776
for H. pylori. 616
of action. 484
rout. and adult do .... 484,
amoxkmin- davulanate. 484,. 485
AmoxU. Su AlIlOXicmin

abllS<'. I1Q.-II
ad,.r .... 198,. 199
drug. daSllif",d as
D- and racomil:
mixtur 198,
dextroamphetamine. Sa
Datroamphotamin.
11Q.-II. 198,
toxicity.ign 106,
for w.ight I",,>, 634
withdrawal S)1Ilptom . IOCt
Amphot. Sa Amphot. ricin B
am photericin B, 509,
action, and uses, >09,
administration al. m. 509,
adyer .. 508t. 509,
interactions. 509t
pharnlarokinotics.509,
pharnlacothorapy with. 509
and adult do ... 50s,
ampicillin. 484. 484,
amyl 343,
amyloid plaque 263. 265f
aml"trophic lat.ral .duo.i>, 256t
Amytal. See Amobarbital
anabolicst.roids,IOO',717
ana.rob'c. 479
Anafranil. See
anakinta. 458" 742,

ddinfion. no
nonopioid
au:aminophen. See Acotaminophen
comtaUy-acting
donidine. Sa ehnidin.
"an"dol, 228t
nonsteroidal anti-inflammatory
drugs, See NON;"fEROID.u
DltUGS
(NSAlDs)
opioid. Set OPIOlD (NUaJTIC)
}.l.AIJ3ESICS
anaphyloctil: shock. 406. 407,
"naphylwo:
ddinfion.18. 413
drugscaming,414
inflammatory mediators in, 466
pharma.cotherapy
rpilrphrine. Sff Epinephrine
tt...rap<>utk approach, 413--14
p",Yention.4t4.414,

5pI1ptom,,18. 4 13, 413f
Anapro:I. Set Naproxon sodium
Anaspaz. See Hl"scyamin.
anastro",l., 561. 561,
Ancobon. See
Andro LA. Set .nanthat.
Andro-Cyp. Set cypionate
Androd.rm, 718,. Sua/",
AndroGd., 718 . Set a(",
ANDIOGIN ANTAGONlm:
ad"" ... effects. 561,
561. 561,
lIutamid 561, 56lt
561. 561,
adult doses, 56lt
AND10GINS:
abu ... 717
ad,,,, ... effects. 561" 717, 717t
for ch.motherapy. 560. 561,
drugs classified a.
dar.awl,717,
fluoxymesteron . 560. 561t, 717,
717.
717,
oxandrolon.,717t
teslOlactone. 560. 561.
t .. Se.
cypional<, 71 7t
t .. lOst.ron nanthal<. 717,
formulation 718,
function 717
nOll"'Productiv. dr.ct .. 717
Nursbg Proc ... Porus
....... 720,
evaluation of criteria, 721,
Index 853

and rationales,
720---21,
patient and family tducation,
720---21,
planning: patient goal. and
outcom .... nOt
pot.ntial nursing diagno ... s, 720t
production. 667
route and adult do .... 717t
Android. Se< Methyltestosterone
Se. Succi nylc holine
anemia:
cau .... 397
cla .. iflcation, 398. 398,
397
iron-d.flckncy.400
pernicious. 399
pharmacotherapy
folic add. Set Folic add/folal<
iron. See lIloN s.un
vitamin Bu. Set Vitamin Bu
in renal
anesthetics:
See GINERAL ANISTIlrnCS
local. Se< lJxJJ. ANFSllIrncs
angina poetoris:
d.flnition.339
.. .. :J.4lt
con,iderations, 341,
.l4Ot
nonpharmarological manag.m<nt.
M0-41
pathophysiology, 339--40
pharmacotherapy
antasonist . Sn
BIITA-ADINEItGIC ANTAGONISTS
calcium clt.annd blockers. See C.UOUM
DMNNEL BWCUJ..\
:J.42f
organk nitrales. Me ORGANIC
NlTIUTf..I
o,"",,,-iew, 343,
ranolazin., J41
th.rapeutic approadt.. 341
.ymptom . :J.40
Angiomax. See Bivalirudin
angiot.nsin [[.310
ANGIQTIN,lN [[ lECll'IOR BLOCKERS
(ARB.):
adv ..... dfoct .. 311
drug. daSllifitd as
cande ... rtan. 311" 327, 328,
311t
irbosartan. 311,
losartan.31l,
olm .... nan mtdoxomil. 111,
teJmisartan.31l,
",l .. rtan, 311,. 327. )28,
mechani,m.of action. lOlf, 311
Nu"ing Proc .... Focu,
a, ... ssmenl,312t
n-a1uation of outrom.criteria, 3141
LibraryPirate
854 Index
ANGJOTI:NSIN II lI:CIYl'Oi BLOCKER,
(ARB.), (conI,)

and ralionales,
313- ]4.
patimt and family iucation,
313- 14.
pl.nning: patient goal. and exp<'<tOO
3131
pot.ntial nursing diagno .. 3] 2.
for condition.
failu"" 327, 3281
hyp<rten.ion, 3021, 3] I
(ACE), 310
ANGJOTI:NSIN- OONHRnNG ENrrME (ACE)
lNHmrrolS:
adVl'rsHikcts, JI<J.-II, 311t, 328t
druS' da .. ifii as
brnaupril, 3] ] I
captopril, 311r, 3281, .lSI
enalapril. s.., Enalapril
3111, 328,
lbinopril. Me Li ' inopril
moaipril,3]II
perindopril,3111
quinapril, 32&
328.

trandoiapril, 3] I,
considerations,)]],
mrchani.m. of action, 30 I/. 3lO,
326,327f
Nursing Proce .. Foeu.
" ..... ment, 3\2.
.... aloation of oulcome criteria, 3]41
implementation
.. ntion. and ralionale.,
313- 14,
patimt and family iucation,
313- 14.
planning: patimt goal. and exp<'<ted
oUlcomes, 3131
pot.ntial nursing diagno .. s, 3] 2,
for condition.
hearl failu"" 326-27, 3281
hyp<rtm,ion, 3021, 3lO- 11
m)'X3rdial infarclion, 351
anidulafungin, 5] 2
anions,436, 436,
anomia, 609
anorexiant., 631
s.., Sibulr .. mine
An<aid. Me Flurbiprofen
Antabu",. Sa Di.mlfiram
ANl"MJDS,6]S
dfects, 6] 5,
drug. da .. ifii as
aluminum hydroxide. Su Alumi num
hydroxide
calcium Sn Calcium
carbonate
caldum caroonate wi th magnesium
hydroxide,6lSI
magaldral<,6]5.
magnesium 615,
hydroxide and aluminum

magnesium hydroxide and aluminum
hydroxide with .im.thiconc, 6] 5.
sodium s.., Sodium
bicarbonate
inteJ";lction with H,-rretptor il nt.1gonist.,
on
mechanism. of action, 6]Of
pharmacotherapy with, 615
route and adult do ... , 615,
antagonism, 482
anta80niS!,5(I
anteriorchambtr, 767, 767f
ANT!:2101 PmJITAlY AG!Nn:
ady"", dJecl .. 6601
drugs dassified as
corticotropin, 660,
cosyntropin, 660., 670
somatotropin, 659, 6601
thyrotropin,660,
Nursing Proce .. Foeu.
.,,,,ssmcnt,6651
evalualion of outcome crit.ria, 6661

interventions and rational ,
""",
patienl and family education,
""",
planning: patient goals and
outcom",665.
potmtial nursing diagnoses, 665.
route and adult do ... , 6601
anthralin,761
anthrax:
baaeria cau,ing, 4,o,o,
dinical manife'tations, 119,
pathophy>iology, 118- 19
prophylaxi. and treatment, 119
vaccin. , lt9
ANl"IANEM!Ct.GENTI:
drugs classified a.
folic acid. See Folk
iron. Me [ION SAm
vitamin Bu. s.., Vitamin B"
Nursing Proa .. Foeu,
assessment, 401,
evalualion of outcome.riteria, 402.
impl. mentation
int.rvemionsand rationaks, 4021
patient and farnilyeducation, 4021
planning: patient goals and expected
outcom",402,
potential nursing diagnoses, 4011
ANI"!Il.\.CJU1MS:
acquired ""istance, 481412, 432(
.dYer", effects. specific drug. "nd drug
cr",",s
aUc'lO'to,483
drugs cla .. ified as
aminoglywsides. See AM1NO(;l=!DES
antitubtrculosis drug .. See
ANlTI1JBEilCULOSlS DRUGS
aztreonam,4951

49SI, 499
495., 499
4951, 499
CI'PHAW'POI1NS
chIoJ";lrnphcni,ol, 49SI,776
dindamydn, 494, 495,
c)'dic
daptomydn, 4951, 499
Uuoroquinolon ... Su
FWOIOQUINOWNE>
fosfomycin, 4951

teli!hromydn, 4951, 499
lincom),:in, 4951
m""rolid ... Sa MACROUDES
methenamine, 495,
metronidazole. Su Met mnid.wl e
nitrofurantoin, 495,
oxazolidinones
linfIDlid, 494,495" 499
]>fnkillin!. Sf .. i'tNIOlllNS
st"1'logramins
quinupriMin--dalfopri,{in, 494, 49S1
sulfonamid ... Su SULroNAMIDES
l<1ra'1"'line .. Me TJrrv.cyaml'5
vancomycin, 4951, 499
. thnic/radal consideralion.,483.
for H.pyle,;, 6lO/. 615-16
host faclors, 433
Nursing Proa .. Focus
a ...... m.nt,496'
evaluation of outcome crileria, 4981

inte,,mtion, and rationales, 496--98,
pati.nt and famil y education,
496-98,
plannins: palient goals and expeaed
oulcomes,4961
potential nursing diagnoses, 496,
prophylaaic,482
",lection,482413
antibiotic, 480
antibiotic-associated p..udomembranow
colitis (MPMC) , 494
ANI1B10TIa;. Su ANnMCTI'R1A15;
ANn!NPOCTIVl"S
ANI1BODlE.>, MONOClONAL. Su MONOCLONAL
ANI1BODl!'.l
an{ibody,447,449f
antiean",r drug . 5<1. ANI1NOOPLI.rna;
ANTIOiOUNERG1CS:
aaion. and u .... , 132
ad .... r'" effects, 144., 2601
drugs classified as
atropine. See Atropi nc
bcnztropin .. See
biptTiden hydrochloride, 260<
774,
dkydomine, 1431, 625
LibraryPirate
. Sn

gl)alpyrrolau, 143.
homatropine, 774,
ipratropium bromide.Sn
Iprdtropium bromide
oxybmynin, 143,
procydidine hydrochloride, 260.
143.
scopolamine. Su
tiotropium, 594. 594.
trihexyphenidyl
260.
tropicamide.774.
mechani,m.of action, 143, 259, 259f
Nursingl'roct .. Focu.
aN.I!mcnt, 145.
impltmentation
"""1,, ion "f OIl'CO..,.,. 14Ii'
intervention. and rationales, 146.
pationt and fantilyffiucation, 146.
planning: soal. and ""ptcted
outcom ... 145.
poI<ntial nursing diagn.,..,,;, 145.
for spKifk conditions
asthma
mechani.m. of action, 594
route and adult doses, 594.
overview, 143-44
Parkinoon. disea..,
mechani.m. of action. 259, 259f
route and adult do", .. 260.
ANTIOOAG\JlJJm:
adyer.., dJect" 374,374.
dennition,373
drug.cJassif .. d as
di",d thrombin inhibito .... Sn Dnu:cr
THROMBIN INHIBITORS
fondapariIllu, 374,
heparin. Su He porin
low-molecular-weight heparin . Sn
Low -MOLE.C1Jl.AJI- W<:IGIIT fill'ARIN!
warfarin. &e Warfarin
home cue conoid.ration .. l7j,
of action, 373, 373., 374f
Nursing Focu,
asses,ment, 376-77.
evaluation of outcome 379.
impltmentation
int ervention, and rational ...
377- 79.
pationl and famiiyffiucation,
377- 79.
planning: soal,and expected
outcom ... 377.
potential nursin8 diagno..", 376-77.
phamlacotherapy with, 373-75
for spifk condition,
m)'OCardial infarction, 349
thromoo..mbolic di .. a .. , 373-74, 374.

adyer .. dlect,. Sa .pocifj< drugs and drug
cia"""
black box warning, 183
drugs d.ssififfi a,
atypical ... nt . Sa !.TYPlCAL

monamine oxida .. inhibitors. S
MONOMlIN OXIDASE INIIIBlTORS
.. lecti' ... serotonin inhibitors.
SEIKl"IVE IEl uroNlN REUI'JAKE
INIIIBITORS
tricyclic .... nt .. Sn Tllcru.Jc
ANTIDEPll.ESSANTS
mechani,m. of action. 184, 185f
Nursin8 Process R>cu,
a ... 191.
evaluation of criteria, 193.
implementation
and ralionaki,
191- 93.
[>'It .nll f.mily MllC.lItion.
191- 93.
planning: patient goal, and apected
.. 191.
potential nu .. ingdiagno .... 191.
for 'pecifk oondition.
J\.IzlIeimtr'sdiseaSl'.266
anxiety syn-tptom" .. 'ne ... and
154-56, 155.
184, ISSf, 186.
suicid. risk and, 183-84
ANI1DIARIlHF.AI.I:
ad".r .. effects, 624,
drugs cla"ififfi a,
bi.muth ,ubsalicylat., 624" 625
loperamid., 624, 624,
oclrtotide, 624.
opioid
camphoralffi opium tineiU"',
"" difenoxin with alropine. 624.
with atropine. &
Diphell oxylale with alropi ne
Lxw/",dllOl5adiWphi/u., 100 623,
Nursing Process R>cu,
,.... .. men', 626<
evaluation of eril.ria, 627.
implementation
inter""ntions and rationale ..
626-27.
and fantily ffiucation,
626-271
planning: goal,and
outcom ... 6261
nursing diagno ... , 626,
nursing pro<:ess foeu .. 6271
with, 623-25
and adult do ... , 624,
antidiuretic hormone (J.DH):
in blood pres",,,, control. 299
in Huid balance, 432
with, 661. See also
Vaoopr .. ,in
production,658f
antidotes, 122, 123,
Index 855
ANI11JYS11ITIHMla:
Amiding Medication Errors, >65,
d as,ifkation, 359, 359.
drug. dassififfi a.
360 . 366
beta-adrenergic anla8Ollist . Sn also
BEfA-ADIINEIGIC ANTAGONISTS
actions and indications, 359,
ad .. er .. effect., 360t
C1hnic and racial ..
"',
mechanism, of action, 35Sf
and adult do .... , 360,
approaoh, 363
calcium clJannd bln<:urs
actions and indication" 359 . s..,
aoo CAlOUM CHANNEL !!.OC[ il,';
adyer .. eff""t .. 359.
m""h.ni,m, of 'Clion. ,<;lIf
and adult do ... , 359.
approach, 365
digoxin, 359 . 366. s.., alw
Digoxin
pota"ium channel blocurs. Sa aha
ParA"IUM CHANNEL Il!..OO:OO
actions and indications, 359,
adver ... ffects, 360.
mechani,m, of action, H8f
rout. and adult doses. 360,
approach, 36.J.-..64
sodium channel blochrs
actions and indication., 359.
adYer .. effect .. 3601
mechanism, of action. 35Sf
and adult do ... , 360,. s.., at",
SoDIUM atANNEL BLOCKIlIS
approach, 359
Nuning Process Focu,
a .... 'm.nt, 361,
evaluation of oulcomecriteria, 363,

int.""'ntionsand rationales, >62-63,
pati.nt and familyffiucation,
362-6),
planning: patient goal, and
outcome .. >62,
nursing diagno .... Mil.
629
.oh ..... .. 630,
druS' dassi/lffi as
antihistamines and anticholinergks. 629
630.
629, 6].0.
Sn
Diphe nhydramine
hydroxyzin.,6)o,
629, 630.
scopolamine,629,63O,
benwdiazepines
lorazepam. Lor.u.q>am
cannabinoids
dronabinol.629,63Ot
629, 6301
LibraryPirate
856 Index
ANI1EMITIcs,

See
Sa
MethylprinisoJon e
neurokinin r=ptor antaeonist
ap"'pilant, 629, 630.
phenothiazines
chara{tnislks,629
metoclopramid.,63Ot
. See
prochlorp<razin . See
Prochlorperazin..
prom<thazine. See Promtthazin.
... rolonin r=plOr antaeonists
characteristics,629
dolasmon, 629, 6301
grani>tuon,629.6JOt
ondan ... tron,629, 63(I.
palono .. tron, 629, 6JO.
Nursing Process Focus
a",ssllYnt.632.
n'alnation of outCOmt criteria, 633t
implem.ntation
intt rvtnlions and rdlionaks. 632- 331
patiem and family alucation, 632- 33t
planning: patient goal. and expe<ti
outcom ... 632.
pol.ntial nursing diagnost .. 632.
route and adult do .... 630.
antifibrinolyti". Sa HJ:MOITAllc.1
antill.tul.m,615
ANI1FUNGAI.I:
azol
adver ... 513., 514
drug. dassifoed as
butoconazolo,5[3.
dotrimazok. See Clotrimazol.
.conazole, 513.
floconazol . See Fluconazole
itraconazole, 20., 512, 513., 514
ketoconarole. Su Kttoconazol.
miconazol ., 5131. 752
oxiconazol., 513.
.. rtaconazok,513t
sukonazol., 5Ut
t.n:onazol.,513t
tioc:onazol., 513.

of action, 512
pharmacotb.rapy with, 512
rout. and adull do .... 513t
tchinocandins
anidulafungin, 512
caspofungin. 512
m""hani,m, of aclion, 508
Nursing Process Focu,
""SSllYnt, 510.
n'alnation of outcome criteria, 512t
implem.ntation
int.rwntion.and rationale .. 511}...12t
patient and family iucation,
510-12.
planning: pati.nt go.l, and txp<cli
outcom ... 510.
potential nursing diagno ..... SlOt
superficial
ad""r ... eff""t., 514.
drug, classified as
buunafme, S14.
ddopirox olamine, 514.
grbrofulvin, S14, SI 4r
n.rufin., 514t
nystatin. See Nystatin
514, 514.
tolnahal<, 514, 514.
add, 514, 514., 752
pharmacoth.rapy with, 512
route and adull dOS<"., 514.
systtmic
... effts, 508.
drugs classified a.
amphottricin B. Sa
Amphotericin B
flucytosine. 508, 508.
mkafungin,508t
ltinocandin,
anidulafuni;in. 50&. 512
ca'pofungin, 50&, 512
pharmacoth.rapy with, 508t, 509,
512,752
roul. and adult dosts, 508.
ami8On, 413. 447
ANTIGlAIJCOMA DRUGS:
adver ... ffts, 770t
drugs dassifl.-.:l as
alpha,-ad",ntrgk agoni'"
apradonidine, 769, 770.
769, 770t
btta-ad",nergic antagonist.
bttaxolol, 770.
cartrolol, 136t
770.
m<tipranolol,770.
timoloJ. Sn TImolol
carbonic anhydra .. inhibitors
acetazolamide. 770., 773
brinzolamid.,770t
dorrolamide, 77Ot, 773
m.thazolamidl', 770t
miotic. agonist.)
c .. ..ruchol.77fl.
hothiophal. iodide, 770t
770.
pilocarpin., 140., 770 . 771
osmotic diureti"
isosorbid.,773
mannitol,773
urea, 773
prostaglandin.
birnatoprost. 769, 770.
latanoprost. Su Lllanoprost
tra'>Uprost, 769, 770.
unoprostone, 769
5fII1pathomimetk.
dipiwfrin. 770 . 773
Nursing Process Focus
a ... ssm.nt. 772.
of criteria, 773.
implem.ntation
interwntions and rational .. ,
772- 73.
patient and
772- 73.
rlanning: patient go;Ib iUld txp<C1C"d
outcomes,772t
nur5ing diagnosts, 772.
routtand adult do .... 770.
ANI1GOUf DRUG!;:
allopurinol. 744, 745t
colchicine. Sa Cokhicine
Nursing Proce .. Focus
JSSI'ssmtnt, 7451
.. luation of criteria. 746.
implem.ntation
rationales, 746t
patient and
746t
planning: palient goals and ape<1ed
outcomes. 745t
pal<nlial nursinidiai;no .. s, 7451
probenecid, 744, 745.
sulfinpyrazon. , 745.
ANI1HElMlmHlc.l:
ad""r .. df""ts, 522.
drugs classifil'd a,
albtndazole, 522.
iverm""tin,522t
mckndazol . Su Meb.l1dawk
praziquant<l,522.
pyrantd, 522t
Nursing Proct", Focus
a ... ssm.nt,518.
of outcom. criteria. 520.
implem.nlation
im",,'entions and .. ,
518-20.
patient and
518-20.
planning: patient goals and ape<1ed
outcom .... 51llt
nur.ing diagnosts, 518.
roureand adult dose .. 522.
ANI1HlITAMlNJ:S. See H,-ROCEI'fOR
.NT ... """'''''': H .... ..., . vm.
ANTAGONlm;
ANI1HYFI:RTI:NSIVO. Set abc Hyperl<nsion
drug. classifil'd as
agonist . Su ALPHA
ADRENERGIC AGONlm
antaeonists. Su
AI.PW.- ADRENIJtGICANTAGONlSTI;
BETA- ADRENERGIC ANTAGONlm
calcium channd blochrs. SIX Gw::JUM
CHANNEL BLOCKlltS
diuretics. Sa DIUREI1c.1
vasodilalors. See VA>ODlL\.TORS
m""hanisms of action. 30 If
.. I""tion of, 301- 3
LibraryPirate
ANTI- INrncrlVl'.l:
acqui",d resista nce. 48 1-82. 482!
TO. 483
. See ANTI!lACIT.ItIAl.\
antifungal . See ANnFUNGAI.\
amihdminThics. See Ir.NTIHELMlmHlO
amimalarials. See Ir.NI1MALULUS
amiproTozoal . See Ir.NTIPROTOZOALS
drugs. Sa
ANnnJlll;RCIIWm DRIIGI
defmition.479
for H. pylori. 616-17
hOST fa<lor., 483
mrchanisms of action. 480. 481!
prophylacTic u"". 482
482-83
topical. 752
""Tili, ium. See Ph)"Ostigmine
Am1M.UARlAl.S:
advcr .. effects.516t
drug.dassif .. d a s
arTrnleTh.r/lumrlamrine. 516. 5 16.
atmaql1One a nd proguanil. 516t
chloroquine. See Chloroqu in.
hydroxychloroquine. See
Hydroxrcl!loroquin.
mefloquine.516.
primaquin 516t
pyrimethamine. 516.
quinine.516t
pharmacoTh.rapy with. SIS
and adult d05oO., 516.
Am1MEI"AIIOUfES:
adv .... dJects. 554. 555.
drug.dassif .. d as
folic add antagoniST'
meThoTrexate. See M<thoTrexaTe
p<nT<1rexed. 554. 555t
purine analogs
cladribine.555.
clofarabin., 555.
fludarabine.555.
m.r<:aplOpurin 550[, 555.
ntlarabine.555.
p<nTo",aTin.555.
thioguanine. 555 556!
pyrimidine analog.
capedtabine.555.
cyTarabine. 550[, 555t
floxuridin 555t
550[, 551. 555 556!
gemdTabine.555.
action. 457. 550[, 554
pham\aCOth.rapy with. 558
rouTe and adult do .. ., 555.
Am1MIatOB!A1.I. S'" ANTI-INI'EC11HS
Am1MIGRAINE DilIJ(;S:
adv .... effects. 233t
drug.dassifled a,
<IJIOI alkaloids. See ERGOT AllAL01DS
TripTan.
almotriptan.233.
1'TripTan.233.
rrovatriptan.233t
naraTripTan.233.
rizatriptan. 233,
SUmaTripTan. See Snmatript an
zolmitriptan.233.
Nursing Proce.s Focus
a ... 235.
impl.menTation
evaluaTion of ouTcom.
erilfria. H6t
inT .. ...,ntion. and rationale ..
235-361
pati.nT and family educaTion.
235-361
planning: pati.nt goal,and.xp<ekd
outcome .. 235t
pottntial nur.;ing 235.
route and adult doses. Z:J:Jt
AntiminTh. See PyranTd
AN11NEOPlASTICS:
administraTion .. 552- 53
ad,..,r"" .ffC"Cts. 552 553
cell km and. 551. 551[, 552
classification. 553
drug. da .. ifled as
alkylating agmT" 555t. See Qlsa
Ir.IXYL\.TING AGINI"S
altrffilmine.563.
anTimeTaboliTes. 555,. See alsa
Ir.NnM!."fAIlOLrITS
anTitu mor anTibiOTics. 557 . See alsa
Ir.NI1JUMOi AN11B1onO
ars.onic trioxide. 5631
a'Paragina.e, 550 563,
buarolfne.563t
biolQ&ic respan .. modifi ....
562-64.563.
campTOlhe<tn .. Sa
bormon. antagonists. 561 . Sa alw
HORMONE AlIT!oGON!STS
bormon 561 . Snalso HOlMONE5
hydroxyurea. 563.
interferon alfa-2b. See lnt. rf.ron
alf .. - 2b
ixab.pilone.563.
l. nalidomide.564
levami'lOk.563t
mitot .. ne. 563.
monoclonal antibodi ... 563t.
MONOCLONALAN11I!OD!F.I
p<ga <parga ... 563,
pl.rix.afor. 564
sorafenib, 563.
taxan .... 559,. See TA.lANES
topoisomera .. inhibiTors. 559 . S alsa
TOP01SOMDoASE INHlBrroRS
vinca alkaloid .. 559 . VINCA
AILAWIDS
""rinostat. 563,
,.,l.dronk add. 563t
8fO">"1h fra<lion and ,11<,"''' of. 551
II1tchani sms of 550[, 551
nadir.55Z
Nursing Procts, Focns
a, ... ,menl.565,
Index 857
evaluation of outcomecriT .. i., 568.
implementation
inle"",ntion. and raTionale., 566--68,
patimT and family education.
"'-'"
planning: paTi.nT goal, and
outcom .,565r
potential nursing diagno .... 565.
in older adulT .. 562t
pharmacotherapy proTocols and
... 552
ANI1PlATE!.f AGINI"S:
am" ... effect .. 379t
drug. dassified a.
alxiximab. 349. 379r
aspirin. See Aspirin
eilo,tazol. 379 380
dopidOS"'l See Clopidog"'l
dipyridamole. 379,
epTifibaTide. 379t
penToxifyllin 375. 380
prasugrd. 379 380
lidopidinr. 349. 379 300
Tiroflban.379.
mC"Chani,m.of action. 373 380
for myocardial infarction and "rou
prevmTion.349
Focu,
a, ... ,menl.381,
evaluation of outcomecriTtria. 382t
implemenlation
inT'''''nTion. and rationale ..
381-.82.
p'TimT and family education.
381-.82,
planning: paTienT goal, and exp<"<lfd
outcome .. 381.
potential nursing diagno .. ., 38lt
roul< and adulT doses. 379,
ANI1P1lOTOWAL>:
am ..... fffCt .. 521t
drug,dassifieda,
antimalarial See ANT!MALARlAL'i
iodoquinol. 521.
metronidazole. See McIronidazol.
nifurTimox.521.
paromom)'dn. 490. 490<. 521.
penTamidine. 52 It
sodium stibop,lnconalf. 521t
Tinidazol 517. 521.
Nursing Pnx .. , Focu,
a,..,smem.51St
evaluation of outcome criteria. 520.
implementation
inte""ntionsand raTionale .. 518-20.
paTknT and familyeduCiltion.
518-20.
planning: paTimTgoals and <XpC"I:lfd
outcome .. 51St
pot.ntial nursing diagno .. ., 518t
roUle and adulT do .... 521
LibraryPirate
858 Index
ANIlPSYUlOfIa:
ad"""", dfem, 206-7, 1fJ7 I, 472-73
drugs dassifii as
atypical.ntipsychOlks, Sa IirYPlCAl
ANIlPSYUlOTIQ
convemional (typical) amipsydx>lics
nonpbono!hiazlnes,
NONPHINOTI[L\.ZINL'i
Nursing Process Focus, 209-111
phenolltiazine . See PHINOTI[L\.ZINL'i
dopamine sysum stabiliz . .... 216
m""hanism.of action, 1fJ5/
ANIl!"fREI1(S, 471
drugs dassifii as
acetaminoph.n. Sa Autam ino phen
aspirin. Sa Aspirin
ibuprofen. See Ibu profen
Nursing Process Focus
a ... ssmem, 4731
.... aluation of oUico,"" criteria, 475,
implem.nlation
ime"",ntions and ration.les. 474-75,
patiem and family iucation,
474-75,
planning: patient goals and expeo:ted
oUicomes, 473,
pol.ntial nu ... ing diagno .. s, 473t
therapeutic approach, 472
ANIllf."I1tOVlv.u;:
ad"e"", df.cts, 557t
complianu, pSl"'ho.ocial issues, 533,
drugs dassifii as
fusion and .. inhibito ...
enfuYinide,5JOt, 531
maraviroc, 5JOt
raltegravir, 5JOt, 531
nonnucleoside ",,,,,r .. transcript ...
inhibito ...
delavirdine,5JO,
efavirtnz. Six Efovi",,1Z
etravirine,5JOt
n .... irapin., 5JO" 533
nucleoside and nucleotide "" . .,...
transcripta .. inhibilo ...
ahac.vir,530,
didanosine, 5301, 537
emlricitabin., 530" 538
lamivudine, 530" 538
st.vudin.,5JO,
t.nofovir, 5JOt, 531. 538
zid,wudine. Sa Zidovudine
prot.a .. inhibitors
adv.,... .ffects, 530,
.mprm.vir,530t
alazan.vir,5JOt
darun.vir, 5JO" 533
fosamprtnaYir, 5JO,
herb--drug int.ractions, lOOt
indinavir,5JOt
lopinavir/ritonavir. Sa l.opinavir/
ritonavir
mechanisms of action, 537
nelfinavir,5JO,
ritonavir, 537
saquinavir, 5JO,
tipran.vir, 5JO,
mechanisms of .ction, 528
Nursing Process Focus
a ... ssmem.534,
...... Iu.tion of outcome crit.ri 536t
impl.mmtation
intet"'ntions and rational .. , 534-361
patienl and family education,
534-36t
planning: palienl go.l nd npli
oUicomes,SM,
potemial nursing diagno .... 534,
for poSltlJ'OSUrt prophylaxis following
occupational exP<"'II.'" to HIV,
537- 38
for p"",emion of perinatal HN
transmission, 537
ANT!'ElZUU DIUGS:
adver .. dfects, 1711, Int
for .nxiety, 160,
drugs classified as
GAB" potemiators
harbiturates, 1711. Sa abo
""'-=
bonzodiazepin.s, l71t. Seulw
BrNWIJIAZEI'INL'i
gahapemin. Sa Gabapmtin
m""h.nisms of action, 170. 170/
primidon . 67t, 171.
liagabin.,17It
[opirnmate,17It, 193
hydantoins
,,,I> .. r .. df""ts, 173,
fospbonytoin, 1731
m""h.nism.of action, 172
pharmacotherapy with. 173-74
phenytoin. Sa Phenytoin
roUie and adult dose .. 1731
phtnytoin-lih .gents
carba=pin . Sa Carhamazepin.
fdbamate, 1731,
lamot,igine. lamonigine
I ...,tiracetam, 173, 1731
o",arhazerine, 173, 173,
valprok add. See Va lproi c acid
7Onisamide, 173-74. 1731, 174
.ruccinimides
ethosuximide. Sa Elho.uxi mide
m""h.nisms of action, 174
methsuximid . 174,
pharmacotherapy with, 175
phensuximid.,174t
herb--drug interaction., lOOt
mrchanism. of .ction. 168-69
Nursing Process Focus
a ... ssmmt, l77t
..... Iuation of outcome uit.ria, 179,
implement.tion
inter"'ntion.and rational .. , 177- 79,
pati.nt and family education,
177- 79,
planning: patimt goals and oulcome ..
177t
pot. ntial nur.ing diagno .. .., 1771
for specific conditions
bipolardioorder, 193,
suicide risk and,
ANl15PASMODlQ:
.d""r .. df""ts, 274,
characteristics, 273, 275
drugs classified as
botulinum toxin type 10., 273,
274',277t
bolulinum toxin type' B, 274, 274t
damrolen. sodium. Sa Dantrol ene
""'=
quinine, 274,
holm C<lreoonsidrrations, 177.
m""hanism. of action, 273, 274/
Nursing Proce.>s Focus, 276-771
a ... ssm.nt, 276,
" .. luation of outcom. criteria, 2761
implem. ntation
inte,,ention. and ralional .. ,
276-7711
patient and family education,
276-771
planning: palient goal. and apected
outcome., 276t
pot.ntial nur,ingdiagno .. s, 2761
route and adult do .... 2741
antithrombin,374
antithrombin 111, 373
Antithymocyte Globulin. &. Lymphocyte
immune globulin
ANTITHYROID AGINI"S:
ad""r .. d[""t., 663,
drugs classifi.d as
methimazole, 664
potassium iodide, 120- 21, 650,
663t, 667
potassium iodide and iodine, 66),
propylthiouracil. Propylthionracil
radio.eti..., iodin., 650, 663t, 664
Nursing Process Focus
a ... ssm.nt,668,
.valuation of outcom. criteria,6691
implem.nlation
intervention. and rational .. ,
"'-'"
palient and family education,
"'-'"
planning: patient goals and expected
outcomes, 668,
pot. ntial nursing diagno .. .., 668,
pharmacotherapy with, 663-64
route and adult doses, 663,
ANTITUBI1IC1Jl.O\IS DRUGS:
.d""r .. df""ts, 5(X),
drugs classified as
firsl -line ag.nt.
ethambutol,5(X),
isoniazid. Sa lsoni arid
pyrazinamide,5OOt
LibraryPirate
rifabutin, SOOt
rifampln, SOOr
rifaP<'ntiM,SOOr
Rif.tn,SOOr
second-liM
amibcln, SOOt
;unlOOAllcylk add, 500<
al'rwmydn,5OOt
c;prot1oadn. S(r Oproflo:udn
",doKrin(,500.
ethionamide, SOO,
kanamydn, SOO,
ot\oxacln, SOO,
Itrq>toot)'Cln, SOO,
Nuuin8 Proc..,s Focus
a .... $Sment. S02.
nalualion of Olltmmt crituia, 5031
impkrntntatlon
intf/fV(ntionf and ntlonalts, 502- 3.
p;ltitnt and family aiuration, 502- 3,
P .... nln8: p;ltknt piland apraed
outcomes. S02.
potential nI.trsin8 di"8"ootJ, S02,
pharmacotherapy with, 499-501
and adult doscs. SOO.
AmITUMOR ANTIBIOTICS:
adverK cffu, SS 7., 558
druglCiasslfoed u
bIcom)'Cln. 5SO/' 557.
dactinom)'Cln, 557,
dJunorubkln.557,
dounorubkln lJpoosonW, 557.
domrubicin. S I)<)mmbici n
domrubldn llpotOmal.557.
rpirubkln. 557 558
id.Jrubldn, 557" 5S8
mitomycin, 557,
mitOJ;antronc, 557.
mechanisml of action, 5SO/' 551
route and adult dost .. 557.
AN1TnMM'.S, 583
adverst dTu. 583.
wmbination dru8s for st......, cold
symptoms, 5-83.
drugldal,lfla!u
bmzonotale.583.
,<><kitW:. SuCodcine
dcxtromcthorph;ln. SN
Ocxtrometoorphan
hydrocodont . Su Hydroco<bne
pb.rm:oCOlherapy with. 582-84
route and adult dosn, 583,
Antiv<rt. S Mcdl1lne
AmMlAU:
for hcrpcsvirusct
Procns Fc-<:uJ, 543--45,
srSl.mlc aaenu
acyclovir. S Acr<lovi r
ad .... rKdJu.S38'
cidofovi 538.
famclclovlr. S381
foKarnct.538.
pnddovlr.538t
lOUt. and adult dosn,538,
''alacyclovir, 538,
thl:rapnrtk approach, 5J8.--39
IOJical'8
mu
dfws, 538.
doona.nol,S38.
lJoxuridipe, 53&. 539
ronclclovir, 538,
IOUI( and adull d_f, 5)81
triOurldin(, 538 539
for innu(nu. S lnflu.nu
for p.u-klnsonism
anu ntadln(, 25&, 25.3.
Antitole. S r'Omepiwlo
Anturant. Su
aiWdy:
Inin rtIiom rt5pOll!.ibk DT,
150-51.151/
au_'S,.
dolin.ion.1SO
incKkn.151.
intolT.nia .nd, 152
modd for Slr(S$ managcmtnl, 152f
nonph.armacologic
151-52. 1521
Nursb8l'rocull'oru.
'!S<lIm(nl.161,
lmplemmtatlon
I .. outwn .. cri .... ia, 1631
In ........ ntions and roulonal..,

90liml .nd family tducation.
162-'3t
plalnlng: p;ltlmt goal.and apccted
outromn, 162.
nul'$lngdillK .......... 1611
pcrfotman, ISO
pharmacotherapy
anlidtpr(SS<ll\I .. 155t. al."
ANT10tl'Af>SANTS
antistlzure drugs, 160 . Sualso
ANTlSElZUlE J)IIIGS
bcr.wdiaztpi ..... IS7 . Su .. /so

btu-adrm(rp; a.nlagonisu, 160'.5

nolbctuOdllupitW:. nonbubitunltc
CNS dtprmants, 160 16LScealw
NotlWlzoolAZll'lNE,
/(ONMUITUlATE CNS Dll'Rr5SAI'mi
lheraP<'ulic approach, 152. 154- 56
iilu;11.0nai, ISO
social. ISO
anxlolyt ic .. al$oAnxidy
Anumct. Dollostlron
Apldr . Insulin
A.P.L Stt Hunun chorionic gonadotropin
apomorphlllO:

for pakinJOOism. 257. 258.
apoprot<ln.283
apothtary system nfm",,,,rm>mt.
<t,21'
Index 859
appdhe,6JI
MlI'P,,"saRt .. Sa AIIoruiam.
apraclonidint. 769, 770.
apr"Pitanl. 629. 610.
421
SN Hydralazin.
>proNrbital, 159,
>protlnln, 386.
!.ptlvus. STlprallitvir
aP'TT (."ivat(d panial thromboplastin
llmcl,J71
AquaMEI'HYTON. K
Aquasol .... Vitamin A
Aqu:.osol E. Stt Vitamin E
Aquat(nson. MethyclothW:ide
aqueous humor, 767
Aralm. Stt Chloroquillf
Aramlne. SN Mrunminol
Aranesp. Su l)a.bcpo<1:in alfa
ARBs. AI'IQ(l'T[N:ltN II mH'lOR

Arduan. S Pipuronium
S
.rformolerol.594,
3n. 3nl
AricC'l't . Memamine
Arimldex. S Anastrozol.
ariplpr.uok, 194 213,. 216
ArlstoSp;ln. Su Triameinolom
Arlx, .... Sa Fondaparinux
Armour.Stt thyroid
Arom",ln. Sa ERm..w.c
AROMATM( lIiHttltTOlS:
anastl'OlOk. 561. 5611
ozmnllltW:. 561. 56"
lI:trozok. 561. 561.
mhanbml of action. 560-61
I1rhy1hm .... Stt Dysrttythmi ..
arsenic trioxide, 563.
ATtan( . Su Trlhayphrnidyl
aTtemetherllum.rantrine. 516, 516t

aTthritlf, \, 741,.
Osteoarthritis; Rt..umatold .rlbrilla
S Cbnlin.
anlaitW:. U2.
ASA. S
AAOOl. Su Mt$alamine
ASAP order, 20
ASCilrd. Sa Pyrantd
A5Olr;, 522
ascorbic Kid. SttVilamin C
Ascorbic.p. SttVilamin C
AKndln.
Asians:
depression treatment ronsid .... tion"
182.
pain managnnont,220.
prop ... noInl stnsitivity, 363,
AIlmMX. Su MortW:1;uotW:
aspua&iM.5t. 5501 563 S64
atptfJlllosis, 507.
fomiJir"'o, 507.
LibraryPirate
860 Index
.'pi rin, 2301
actions and uses, 230t, 380, 468
administration .. 230,
ad"""", .. 228t, 379., 467t, 468
b",ast-feeding and, 67.
.. 100" 2JOt
",..,rdOst treatmtnt, 41, 230.
.. BOt
rOUIC ilnd aduJl dQllt, 228r, 467.
for condition.
Qlrdiovas<ular risk ",duclion,
472t
f ... ..,r, 471
m)'>QIrdial infarnion, 349
pitas..:
ddlnilion,55
",laltd lodrug administralion, 55- 57, 56t
A<1.lin, See
20,
."luna, 592
593.
591,
in "bools, 593,
Nursingl'roa .. Fo<u.
3Ist=nl.5971
n-a1uation of outcon", criteria, 599t

intuv.ntions and rationales,
5'J7.J)9,
patient and family eduQltion.
5'J7.J)9,
planning: patirnt goals and expected
oulcomes, 597.
nursing diagoo .... 597,
pathophysiology,592.592/
pham,acoth.rapy. S.,.
BiONOlODlIATORS
anli-infl.mmatory agonts. INHALID
GWCOCOmCOIDS; LWWll1IENE
MODIFIERS; MAS[ c a l STAIlILIZI:&S
Astramorph PF. S Morph in. sulfate
.. 25
Atacand. See Omd.sanan
AtaraL See
atazanavir, 530t
alenolol, 3471
actions and use" IJ6. 136t, 347.
administration .. 34.7.
. It\O . 147.
inleraclion .. 347,
mechani,msof action. 136,
"""rdOst 347,
route and adult dost. 16Q,
for conditions
angina and m)'>QIrdial infarction, 343,
anxi<ty. lrot
hypertrn.ion.315,
233t
Atgam. See immune globulin
athermel""",i .. 283, 339, 339f
androgen abu .. by, 71 7
athlet< 's foot , 507 514
Ati",n. Sa Lor ..... l' .. m
AlOlone. Sa Triamdnolone
.tomoutine, 198t. 201
.tonk .. izUK. 168,
.Iopied.mtatiti .. 759. See ulw Lkrmatili.
alorvastalin, 2901
anions and u .. s. 290,
administration alert .. 29(},
adverst df.d .. 287., 290,
290r
290t
route and adull do", 287.
.to"'quone and proguanil, 516t
.tracurium.27&
.trial fibrillation, 355. 355.
.trial flutter, 355,
atrial tachycardia. 355.
atrioventrkular (AV) bundle.}>6
atrio .... ntrkular (AV) node, 356
A!ripla,531
Atromid-S. Sa Clofibrate
Atropa beUadonna, 143
Atropair. S Atropine
A!ro-ITn. S Atropine
atropine.l44r
actions and U>fl. 143r, 144. IHI
administration aI.", .. 144,
adyer .. eff..:t .. 144,
144,
Oy.rdo .. "eatment. 144,
pharmacokinetics. 144,
for .o;pedtk condilions
as 774,
a. nerYe 120
.tropine ",Ifate. ] 23.
IUropi",,!. Sa Atropine
At"""'nt. Sa I pratropiutll bromide
Atryn. See Antithrombin
ion defic il-hypera<:tivity disor<kr
(ADHD):
characteristia.197
Nu"ing Process Focus
assessment, 199t

... aluation of outcome criteria,
"",
interYention nd rational .. ,
199--200,
patient .nd familyC'ducation,
199--100.
planning: patient goal, and upted
outcom ... I99,
potential nursing diagnoses, 199.
pharmacotherapy
atomoutine. 198t, 201
D- and L-amph.tamin. racemic
mixtu,"" 198,
dextroamphetamine, 198,
198t
Su
Methyl phen idate
Ill , 197,
200- 201
anemion-defidt di'iOrd .. (ADD), 197
ATYPICAL ANTIDEPll.SM.NTS:
ad .... r .. dfects. 155 156. t86t
drug. classified as
bupropion.IS6 188
lS6t. 188
mirtazapine, lS6t. 188--89
ndawdone. 1861. 189
ISS., 189
venlafaxin., ISS" IU
Nursing Proc ... Rxus. Sa
.. Nursing Process
"""'
route.nd .dult dose .. ISS., 186t
fur .o;pe<ilk condition.
ADHD.200
anxiety .ymptom .. K.tle .. ... and
depression, 155r
184, IUt
A1YPlCAlANTII'!;'!UlOTIC5:
ad .... r .. dfects. 212, 2]3,
for bipolar di""rder, 193, 194,
characteristics, 212
drug. classified ..
aripiprazole, 216
dozapint.2UI
olanzapine,213 . 266
quetiapin. fumarat . 213,
Sn ai'perido"e
zipra,idon 213,
mechani.m. of action. 212
Nursing Process Rxus
. ..... 2U.
impl.ntent.tion
n-a1uation of outcome criteria, 2]5,
intervention. and .. 214- 15t
pati.nt and family
21 4-15,
planning: palient goals and <Xp<ctC'd
outCOIllC., 214,
nursingdiagno .... 213.
rout. and adult do .... 2]3,
},ugmrntin. S AmoxkiUin-daYnlanate
aura. 230
},uralgan. See Brnzocaine and antipyrine
autoantibodies. 74 1
automatkity.356
autonomk n .. ",,"s system:
divi,ion .. 128--29, ]28f
... _t;ne. d,,,ifica'ion. 111_ 12
function .. 128, 128f
nrurotran.mil1ersand ""'ptors. I JO.---31.
1:J(If, ])],
synap .. structure and function, 129. ]29f
AV (.trio .... ntrkular) 356
},V (atrim .. ntrkular) 356
Ayalide.302.
},vandamet. Se Ro.iglitazone/metformin
},Yandaryl. Sa
Avandia. See Rmiglitazone
AYapro. [rbesanan
},v.stin. S Be",cirumab
},ydax. Sa Maxitlox""in
}, .... ntyl. See Nortriptyline
LibraryPirate
Amdart. See
Amiding MNication Errors:
anticoagulants, 379,
antidysrhythmk .. 365,
calculation by 659,
drug a]]",gy. 489,
lipid-Iow"'ing 19Jt
184,
most common "'u .... 19,
patient idtntification. 740t
","ponsibUity for. 442t
of administration. 582,
Amna. Su Int",feron beta-la
"",,,rt. See Almotriptan
Axid. &. Nizatidinc
Azactam. &. Aztrconam
A.zaS3n. S
azathioprine.457. 458,. 625. 742,
az<lak add. 756. 756,
774
AIelex. Su ARlak acid
azithromydn. 489. 489t. 501
Azmacort. Set
512
azole antifungals. Su AN11FUNGAll. Jzoll'S
718
Awr.302,
AZT. &. Zidovudi nc
azt=nam.495,
Azulfidine. Sulfas;o lazine

Bc"[I.447
bacampkmin.484t
badlli. 479
Badl/u. anth,ads. 118. 480,. Snalso
Anthrax
Bacm .... (BCG)
454; 457
bacitracin 752
badofcn. 271. 272,
bact".mia. 480t
bacteria. 479. 479,. 480t. & a/so .pocifit:
bacteriD and dj..-a5e'
bacmioci""l. 480
480
baking soda. Sa Sodium bicarbonate
BAL in au. &.Dimerraprol
bal.ncN ane"b.sia. 246
Salndar. Sox Coal tar
Banflex. See
Baraclude. Su Entecavir
IV.J.BrrtJV.TI'S:
ad'<J>< <rr",,( 159,. t 7 tr
risl:. 158
drug. classified as
acting
amobarbital. &. Amobarbital
aprobarbital. 159,
butabarbital sodium. 1594 252,
long acting
In l7lt
pb.nobarbital. Sox Phenob. rbital
short acting
sodium. See
Pentobarbital sodium
sc<obarbital. &. Secobarbital
grndk polymorph isms affecting
melabolism. 81,
h",b-<irug tOO,
and adult doses. 159t
for specific conditions
as adjuncts to anesthesia
amobarbital. Set Amobarbital
butabarbital sodium. 252,
sodium. Sn
Pentobarbital sodium
sc<obarbital. See Secobarbital
as intravenous ane"b.tk.
etomidate.251,
methohexital sodium. 251t
propofol. 25 I,
sedation and insomnia. 158- 59. 159,
seizures
mechanisms of action. 170--71. 170{
route and adult do .. s. 171,
toxidty signs, l06t
uses. ISS-59
witlxlrawal symptoms, 106,
baror<ptors, 298
basal ganglia. 204. 205f
basal ratc. 661
ba .. lin. data. 55
bask 121
basUiximab, 457. 458t
BayRab. &e Rabies immune globulin
BayRho-D. See Rho(D) immune
globulin
BayTn &e Tetanus globulin
BCG (Badll .... CaJllYlte. Gutrin) vacdne.
454,.457
beclomdhasone.6oot
actions and u .... 600t
administration alerts. 600,
ad,..,rst effects. 596,. 600t
inhaled. 596,
intranasal.580t
pbarmacokinetics, 60(1,
rout e and adult do ... 596,
Becona ... Su Beclomnhasone
Becona .. AQ. See Bcc1omdh .. o ne
bchavionl (ohon. term) insomnia. 153
belladonna. 143
Benadryl. &. Diphenhydramine
caplet .. 576,
benaz.cpril. 311,
lxuda,uu>!iue.555.
bendrollumethiazide.422<
See Probenecid
Benicar. See mtdoxomil
BcnicarHC.J02t
benign. 549,
benign pro5latk hypcrtropby (BPH):
inddence.7lfu
natural with saw palm.tto,
726.
Indn 1161
pathophysiology. 724. 725f, 726f
pharmacotherapy
antagonists
adv" .. errect .. 725,. 726
alfuro,in.725,
doxawsin. Su Doxazo. in
mechanism. of action. 7l5-l6. 716f
pra"",in. See Prazo,in
tam,ulo,in. 725" 726
terawsin. 725t. 726
alpha-rMurt= inhibitors
ad.n .. errccts, 725t. 727
dutasteride.725,
Su Fina.leride
mechanism. of action. 726f, 727
therapeutic approach. 725- 26
symptom!. 724
benign tumor. 549t
Bcntyl See Dkydomine
benzocaine. 242. 242t. 763
benzocaine:
otic 776.
benzocaine and antipyrine. 776t

abuse. 107
ad .... "".ffw .. 157t.17I'
drugs dassifiN a.
alprazolam.157,
chlordiazepoxide. 157,
donaz.cpam. See Clonazcpam
157t. 171,
diazepam. See Di azepam
eslazolam.157t
halazepam.157.157,
loT"dzcpam. See Lorazepam
midazolam. lOt. 157.251'
oxazepam.157t
quaz.cpam.157t
trnlaz.cpam.157,
triazolam.157.
fall risk in older adults and. 158t
herb--drug interaction .. 100,
Lifespan Considerations. 158t
rouuand adult do .. s. 157,. 171,
for specific condition.
Alzheim",, di",. ... 266
anxiotyand insomnia
advcnedJ.cts,157,
mechanism. of action. 157
Nursing Process !'oeu .. 161-ii3,
.... 157t
a, intra""nous 251 ,
.. izurrs
ad,m.< .. t 7 t,
indication .. 172
route and adult do .... 171t
as skdetal musele reluant. 271. 272,
structure. 157
toxicity sign .. 106,
uses, 157
withdr ....... l symptom .. 106,
b.nzonatal<. 583. 583,
benzoyl 756. 756t
LibraryPirate
862 Index
rn.nztropine, 2631
actions and uses, 259f, 2631
administration alerts, 263,
ad"""" dfects, 2601, 2631
interactions, 263,
"""rdo,", treatment, 263,
pharmacokinetks, 2631
route .nd adult dOlle, 2601
u .... 143'
bepridil,343,
beractant, 601 1
beriberi, 643
bela ",lis, 679/
beta (II) r"""ptors, 13]" ]33
IlE.'JA- ADRND.GIC.-.GONISTS
(SYMPATIlOMIMIITIO) :
drects, 5941, 770t
drugs dassifii as
a1buterol. See Albuterol
arformottrol,594,
betaxolol,770t
<lil'iV<'frin, 77Ot, 771
dobutamine. Su Dobulamine
dopamine. See Dopamin.
epinephrinf. Set Epi tlq>h rin.
formoterol, 132" 594,
iooprolerenol. Su looprolfltnol
1"""lbuterol, 593, 594,
metaproterenol, 132t
metaraminol, ] 32,
norepinephrine. Su Nor<pin<ph rine
pirbuterol acelale, 593, 594t
pseudoephedrine. Su PotUdoephedrine
ritodrine, 132t, 709
salm<'lerol. See Salmeterol
terbutalin . Su Terbutaline
genetic polymorphism' affecring
metabolism, glt
for specific conditions
asthma. Su BJONCIlODlIATOI.I
glaucoma, 769, 770t
htarl failure, 335
o""rv;",w, 132t, ]33
'ocolyti<, 709
IlfA- ADREND.CICANI"AGONI!IT.I
(SYMPATHOLYfIO) :
ad""""dkcts, 314, 3]5t. 343" 360t
drug. dassifii as
acebutolol. Su Acebutolol
atenolol. SeeAttnOlol
betuolol. 3]5t. 770,
bisoprolol.3]5,
carl<"OIoI.136,
car"""'ilol. 136" 31St. nSt
.. molol, 136t. 360,
l"",bunolol. 770t
metipranolol.770t
metoprolol. Su Meloprolol
nadolol. ]361, 343t
pindolol. 315t
propranolol. See Propranolol
sotalol. ] 36,
timolot SlY Timolol
medunisms of acrion
in . ngina. 342/
in dysrhythmias. 358f, 363
in htarl failure. 327f, 33]
in hyperten,ion. 30]/
o .... rview. 136
Nunin8 Process Pocus
assessment, 137t
implementation
<Valuation of outcome criteria. ]39,
inter""ntion. and rational ... 138--39,
patient and family education.
138-39,
patient go.ls and exp:li
outcome 138,
potential nursing diagnoses, 137,
for specific ronditions
and mj<>cardial infarction.
:;43.343,
anxiety. 160,
dy.llhythmias
>c'ion., lSMi lS9,
hnk/racial considerations. 363,
indications. 359,
JOuteand adult dosts, 3601
theraprutk approach. 363
glaucoma. 769. 770,
hem failu .... 330-3]
hyptrlension
Nursing ProctSS Rxus, 3]6-18,
overview. 136
rout. and adult doses, 3 ]5,
tb.::raprutic approach. 314
mi&raine. 233" 234
rn .... view. 136.136" 3] 4
B<'Iacorl. See Bttamethasone
B<'Iagen. See Levobunolol
beta-Iactam ring, 484, 484/
beta-lactam.,.,. 484. 485/
m;"[A- LACTA.\.!ASI; INHlBrroRS, 485
Betalin 12. See Vitamin B"
betamethasone:
for ad",nocortical insufflcitncy, 671 t
adven. efftct., 470" 671,
for dermatitis, 7601
for psoriasis, 761
for ,.,.,.'" inflammation. 470t
Betapact. SaSotalol
Bet....,ron. Sa Interferon beta ]b
betaxolol. 3] 5t. 770,
bethanhol, 140t
aclior . and """. 139. l.tOt
administration altrts, 1.tOt
adyer .. effects, ]40,
dassifll:ation.14O,
as grr.eral.nesthesia adjuncr, 252. 252t
interactions. 140,
overd:! .. treatm<:nt. 140,
Iktimol. See limolol
B<'Ioptic. Sa BrtaIDlol
bevadzum.b.563,
bexarot",e.563,
Batra. Scf Vald""ib
Btnar. Sa Tositumomab
BGTD (Biologics and Gen<'lic n..rapies
Direclor.>I. ).9
Biaxin. SlY Clarithrom)"in
bicalutamiJe,56],
BkiUin. See Prnkillin G benzathine
BiCNU. See Carmustine


ad""r .. df ts. 687,
characteristics. 688
metformin. See Metformi n
roule and adult do"". 687,
bilberry. 961, 775t
B!I..E ACID
ad""r .. tffu. 289
drug! classifkd as
cholestyramine. See Cholestyramint
colt .... dam. 287,. 289
colestipol. 287,
mechanism. of action. 288. 289/
N"",inC 1'Toc.t'_"" I'oell.<, 292--94,
pharmacothtrapy with. 289
routt and adult do,.,s, 287,
biliary ucll'tion. 41
Biltrkide. See Prariqnantd
bimatoprost, 769. 770,
bioavailability. ]4
BIOLOGIC MODlFU'lIS. 452. Sa
CIOWJ1l FACTOl.I;
IMMUNOSJ!MIJLANP.i
for cancer m.motberapy. 562-04. 563,
biological-ba..d thmpies. 961.
Herbal therapies
biologks, 4. See a/so BIOI.O(;IC
MODlFUlI.S
Biologicsand Genelic Therapi .. Direcloratt
(BGTD).9
Biologics Control I>ct. 5. 6/
Bin-Statin. Su Nystatin
bioterrorism:
ch<mical and biologic agents
anthrax, ] ]8-19. 119,
bli".r/"".k.nt agenu. Ill,
blood agents. ]Ht
cattsorits. ] 17,
characttristics, ] ]6-17. 116t
choking/",miting agents. 121,
ionizing radiation. 120-2]
nerve agents, nl,
poliovirus, 119
smallpox, ] 19-20
loxic chemical., 120
definition. ]]6
Bin-Thyroid. See Dtsiccated thyroid
biotin. Sa Vitamin B complex
biotransformation. 40. Sec a/so Metabolism
biperiden hydrochloride. 260t
bipolar disorder:
characteristics. ]90
pharmacotherapy
antiseizult drugs, ]93. 194,. Sua/so
ILNTISEIZURE OIIUGS
LibraryPirate
atypical antipsydlOtk., 193, 194,. Sa
alsc "1Yl'ICALAmlPSYCIlcma
lithium. S lithium
the .... pcu'k approoo,h, 193
bi .. <ody!, 622,
bismmh ,ub..tkylau, 616, 624" 625
biooprolol,315'
Bl!PIlO:ll'HONAIT5:
ildvcnc 736t, 737
drug.dassifled as
S
etidronate disodium, 736t
ibandronate,736t
pamidronatc,7J&
risedronate,736t
tlludronate,736t
1.OlMroni<: add (wIMronate),
563; 736t
action, 736
Nursing Process Focus
a"""sm."t.738,
evaluation of outcomecritcria, 739,
impl."",ntation
interventions and rationale ..
738- 39t
patknt and familyroucation,
738- 39,
planning: patient soal. and nptcted
outcomes,738t
potential nursing diagnos<s. 738t
for Paget', dis<as<, 737
rome and adult dos< .. 736,
bivalirudin, 374, 374,
black cohosh, 961, 97t, 98/, 704t
Jermatitidis, 507t
blastomycosis, 507 t
bl.-eding time, 372,
bleomycin, 550f, 557t
blister/..."icant ag<nts, bioterrorism, 121,
Blocadren. &e Ii molo l
blood ag<nts, biotcrrorism, 121 ,
blood dots, 371
blood doping, 391 t
blood pressure. &e Hypet"tension
faaors affecting, 298, 29S/
physiological regulation, 298-99,
299f, 300/
BI.OOD PROD\.TCn:
to, ."",,".k. 40R
'n><>
f .. .>h frozen plasma,408,
pacud red blood ceU .. 408t
plamIa protein fraction . 408,
whole blood, 403t
blood thinn ... s, 373. Su alsc
1lNTt00AGUL\.lIT\
blood volume, 298, 299/
blood-brain barrier, 39-40
body Ouid .. 431, 431/
body rna .. index (BI>II),631
honedeposition,732
bone disorders:
osteomalacia. Sa
osteoporosis. Sa Osteoporosis
Paget'. diseas<. 737
hone resorption, 732
Bonine. Set; Meclizinc
Boni .... See lbandronate
homters, 448
Borrclia /;urgdo.fori, 480t
hone701nib,563,
bolaniC;lJ, 9S. See Rlw Hcrbalthcrapkl
Botox. Su Botulinum toxin type "
botulinun toxin typ< ", 273, 274f,
.74t,277t
tm:in typ< B, 273, 274f, 274,
Bowman'. 418
BPH. Su Benign prostatk
bradyki .... ia,256
br.ldykinin,4651
brand-norm drugs:
marhting and promotional
sptnding, 14t
vs. g<nerk" U- 14
Bra ... dle. Sec Urofollitropin
b",aluhrough bltroins, 699t, 706
b",ast -f<ling:
eli."t teaching about drull therapy
ciurinS,68
drug therapy considerations, 66--68, 67/
drugs with ad...,r", effects during, 67 t
oxytocin function in, 709/
B"'thine. Se
Brevibloc. Se Esmolol
Brevital. Se Methohoxital sodium
brimonidine, 769, 770,
brinzolamide,770,
broad-'ptrum antibiotia, 482. See
!&NTIMCIl'.R1A1S
broad-sptrum 484. 484,. Sf<
dso I'EN!CD..I.INS
bromoc,iptino:
ad...,r .. dfects during breast-feeding, 67,
for female infmility, 712, 712,
for p ... kinson'. di .... S<. 257, 258,
for Iy:>< 2 diabttes mellitus, 689
bromph,niramine,575,
bronchioles, 590
BlONCIlODl!A.TOJtS:
anticlolinugics
ad"""", effects, 595
ipn'mpi"m . . 'in
Iprat ropiullt
phumaroth ... apy with, 595
route and adult do",s, 594,
tiotropium, 594,. 595
btta gonists/.ympatoomimdia
ad""r .. effects, 593, 594,
S .. J..lbuterol
",formoterol,5941
formoterol, 132t, 593, 594,
le.,...]buterol, 593, 594,
me",aprote",nol, 132,
plurmacotherapywith,592-93
pirbut.rol acetate, 593, 594,
and adult doses, 594t
IndH 663
.. lmetero!' Se Salmcterol
terbutaline. Se Terbutaline
mechanism. of action, 590
mcthylx.onthino,
ad....".s< effed" 594r, 595
aminophyUine, 594,. 595
pharrnacotbtrapy with, 595
route and adult do .. s, 594,
theophylline, 1001, 5941, ,95
Nursing Proces. Focu.
a ..... ment, 597 t
.... aluation of outcome criteria, 599t

intervention. and rationale ..
597- 99t
pati."t and famllyroucation,
597- 95Ir
planning: patient goal. and expected
outcomes, 597t
JXltential nursing diagno .... 597t
pharmacotherapy with, 595, 599
broncoospasm,591
Btovan. Se Nformotcrol
buccal route, 23- 24, Ht, 24/
bucltthorn. dnli inuractions:
atropine, 144t
hydroconison.,673,
phenytoin,175t
p",dnisone,47I,
bude.<Ollide. 580" 596,. 625
buffers, 440
bumetanide:
o.J..e""effects, 303,
forhyp<n.",ion. J03t
for ",nal failu"" 421. 422,
Burna. See
Se. No nnal ",rum albumi n
bundle branche., 356, 356/
bundle of Hi 356, 356/
bupi,""caine,242t
Buprena. S ..
hydrochloride
buprenorphine hydrochloride. 221f,
222t,227
bupropion.I86" 188, 193,201
BuSpar. Se BU'Pirone
bmpirone, 159, 16Ot, 266
bmulfan.555,
h",.h.rhi .. l. 1 ';9 . 2.';)"
butenaflne.514,
Butiso!' S Butabarbital
butoconazole,5Ut
buto'1'hanol nIl, 222,
Byetta. See wnatide
c
C fIDers, 220
ea++. Se Calcium
CABG (coronary artery bypass graft)
surgery, 340
C!J) (coronary .nuydi",.",), 339, 341,
eafe'll"t. Se Ergotamine with caff";ne
caffeine,SI" III
LibraryPirate
864 Index
Calan. Sa "erapamU
Calcidrine Syrup, 584,
calcifediol. 732.732f
Cakikrol. Sa Ergocalciferol
Calcijtx. See Co.lcitriol
calcineurin. 457
CALaNFUJllN INHIBITORS:
cydosporine. Cydo"l'orine
pimecrolimus, 761
tacrolimm . .se. Tacrolimu.
calcipotrien<. 761. 762,
calcitonin:
functions. 732
forosteoporosi .. 7)6,. 737
for r.gd.di .... "". 739
736,
cakitriol. 7351. Snll/SO ViLimin D
actions .nd uses. 735,
administration alert .. 735,
ad"""",df<ets, 734,. 735t
formation. 732. 732f
interaction .. 735t
"""rdo .. t",atrnent. 735,
pharmacokinetics, 735t
mute and adult dOS!'. Boll
calcium (Ca++):
functions. 648. 732- 33
imbalances, 648. Sa
H)"p<J<alcemia; Hyp<><:alcemia
in myocardial con .. 358
in OSlwporosis, 735f
pharmacotherapy with. Sa CALCIUM
Mm
732- 33
calcium acetate. 420,. 647t
calcium carbon.te:
.s.nt.cid.615,
for cakium ddkient:y disorders.
647,.734,
for ,""nal failu,"". 420.
calcium carbonate wit h magnesium
hj<lroxide. 615,
CALaUM DlANNEL BWCKa5 (CCBs):
.d,.., .... dfects, 307,. 360,
drugs d.ssifii as
amlodipine. 307,
I>epridU.343,
devidipin 319
diltia7.f1ll. See Diltia,.,m
felodipine. 307,
i,radipine.307,
nicardipine. J07t 319. 343,
nifiipin . Sa Nifedipil1e
nirnodipine.233,
nisoldipine.307,
verapamU. See "<"'pamil
mechani,ms of action
in angina. 342[, 347
in dysrhythmia .. 358i 365
in hypenension. lOli 307
Nursing Proc.ss Foeus
as .. ssment. J09,
evaluation of outCOIl1< criteria. 311 t
implementation
interventions and rationales.
310-11,
patient and farnUyeducation.
310-11.
planning: patient goals and expti
outcomes. 310t
potential nursing diagnoses, J09,
for ipC"dfK ronditions
angina and myocardial infan:tion. 343.
343,.347
dysrhythmias
action. and indications, 359,
ad",r .. dfects, 36(].
mechanism. of action. 358f
rout. and adult do .... 36(1,
therapeutic approach. 365
hypertension
roule and adult do ..... 307,
theraprutic approach. 307
migraine. 233,
calcium dtloride.436,. 647t. 734,
calcium citrate. 647t. 734,
calcium EDTA. IB,
calcium gluconate. 6471. 7.J.4t
calcium ion channels, 358. 358f
calcium lactate. 647,
calcium phosphate tribasic. 647.
COIleium poly<arhophil. 622r
CAI.CIUM SAlIS, 734t
actions and u .. s. 734,
administration alerts, 7.J.4r
adVM"S< dfect .. 647,. 734,
drugs classified as
calcium acetate. 420,. 647t
cakium carbonale . .se" Calcium
carbonate
cakium carbonate with
hydroxide. 615t
calcium chloride. 436r. 647,. 7.l4,
cakium citrate. 647,. 734t
cakium gluconate . .sreG!lcium

calcium lactal<. 647<. 734,
cakium phosphate tribask.
647,.734,
interactions.734t
pharmacokinetics, 734,
route .nd adult doses.647t. 734,
",lfactant. 601 t
Cal -Lac. bct.1<
Calomist. Vitamin Bll
(cyanocohalamin)
Calphron. Sa Calcium
CAM (compl<mentary and .lternative
medicine). 95. Sa
Complement.ry and alternative
therapies
Campath. Sa Alemtuzumab
camphorated opium tincture. 624r
Campral. Sa Acamprosal< cakium
CAM!'fOTIlEC1NS:
characteristics. 559
drugsclassifi.d ..
irinotecan.559. 559,
topotan. Ssw. 559. 559,.
pharmacoth.rapywith.559--60
OImpwth,,",,,,,,mmata, 559
Canada:
drug and regulation process.
9.9,
regul,niom mlri'ting drugs of
15. 1St
Canadian Food and Drug.""t . 9. 15
canal ofs<hl.mm. 768. 768f
ca""er:
agmts associated with increa .. d risk
of. 549,
cau .. ,. 54&-49. 548,
(haracteriSlics.548
incidence. 548,
lifestyle changes for pre",mion. 549
metastasi .. 548. 548f
natural therapy with .. lenium for
prevc-ntion.549,
pharmacolherapy. Set AN"nNEOPlAIno
sur&o'ry.550
candesartan. 311t. 327
Candida albiraM" 507,
c.ndid ...... 507,
cannabinoid . Sa "I>" Marijuana
characteristics. 108-9
drugs dassified as
dronabinol. 629. 630,
nabilone. 629. 630t
o.M""hi. "'tiva, lOS. s.., Marijuana
Capamll Sa Capreomycin
capitabine.555t
Capoten. Sa Captoprll
C.pozide. 30lt
capreomycin. 5((),
cap .. icin.741
o.psi<llm "MMum. Sa Cayenne
capsid. 527

administration guideline .. 22. 23,

captopril. 311,. 328,. 351
Carac. s,., Fluorol1racll
Carafate . .se. Socralfal<
carbachol. 770,
carbamaupin.:
ad",r .. dfects. 173,. 194t
for bipolar disorder. 193. 194,
for .. izures. 169,. 173.173,
carhamide pero:rid 776
CARllAPENF.MS.499
ertapenem. 495,.499
imipenem-cilastatin. 495t. 499
mrropen.m. 495,. 499
carbenkUlin. 484r. 485
carbidopa-levodopa. 257. 258,
Carbocaine. Sa Mepivacaine
carbonic anhydra ... 424
CARIJONIC ANHYDlAS[ lNHlBrrolS:
adver .. dtects.425,
LibraryPirate
drug. dassifled a.
Sa
brinzolamidc.770,
dorwlamide. 770,. 773
425 770,
forglaueoma. 770 773
for faUur 424. 425,
carboplatin.555'
carboprost 704,
708.708.
cardnogm 548-49. 549,
carcinoma, 548. 549,
Cardene. s....
cardiac drcompensation. 326
CAJtDIAC GLlC()l;IDES:
adyer ... ffts. 328,
drugs dassiftcd as
digoxin. Sa Digoxin
H()
nursing consid.ration,
client t.aching. 336
action. 327f
cardiac output. 298.199 325
cardiac ",mod.ling. 326
41lS. 407.
cardiotonic druss. Sa INOTIOPIC AGENn;
cardi<w.rsiou.357
Cardium. Su DUti . um
Cardura. Sa Douro,in
Cardura XL Sn Dou..lo,in
Carimun. NF. Su Intravenous immune
globulin
carisoprodol. 272.
carmustin 553.555'
for hean failu",. 335,
carot.nes,641
caneolol.I36.
Cania XT. Sa Dilti az.m
Camol. Sa Carttolol
carve<laol. 315 328.
cascara "8rada bark:
druS int. raction,
atropin 144.
hydrocortioon 673.
phenytoin. 175,
standardization. 97,
05 ... './6.
Ca"",,651
Casoda. Sa Bicalutamid.
ca'pofungin.508.
ca"oroi!.622t
Cataflam. Sa Dielof.nac
Catapre . s.... donidin.
catecholamines. no
cathartic, 621
catheter ablation. 357
cation 436. 436.
ear..rjt. Sa Alpro.<tadil
273.
CBER (Center for Biologks Evaluation aud
R .... n:h ).5
a::B,. See CAlCIUM rnANNEL IlI.OCUti
a::NU. Su Lomustinc
CDt r=ptor. 528
CDER (Center for Drug Evaluation and
h ... n:h).5
Cebid. Su Vitamin C
cecum. 620f
CNU.Sa Lomu"in.
cdador. 487.
ccfadroxil. 487.
cefarolin, 487.
ccfdinir. 487.
cofdito,"n.487.
ccfcpimr. 487.
ceflXimr. 487t
ccfopc"razon 487.
cd"otaxime. 4861
486t.
aetiOT..! and u .. s, 466<
al.rt 486t
.d, ... , ... r.fi"t"C' .<. 4.'171
interactions, 486.
rout. and adult do ... 487.
ccfotetaA. 487.
ctfoxiti", 487.
cofpodo:rirne. 487.
cefprozil. 4871
ccftazidimr.487.
ctftibutm.487.
487t
ceftri;m,n 487t
cefuroxi:nc. 487.
Cdebrn Sa Cdecoxib
crl.coxib. 228t. 467.
Sn Iklamethason.
Cdna. SN Citalopram
cell cyel/. 550[, 551
C.llC.pt. Sa Mycophrnolat. mofrtil
ctll- mc<iiated immune respon ... 448[,
451}...51
cellular """ptors. 49-50. 49f
C.lontir .. Su Meth,uximide
Cenrstin. See
Centrr Biologks E.-aluation and
h ... n:h (CBER). 5
C""'<r Dru8 Evol" ion and Re<earch
(CDER).5
Crntu far Food Safety and Applied
Nutrition (CFSAN). 5
central r . emus (CNS):
drgrnerathe di .. a .... 256. 256 . Sa
Alzheimer', di .. a ... ; Parkinson,
di ... ..
drp", ... nts
alcohol. Sa Alcohol
barbiturates. Sa BAltBrruJ. .... I1'S
her.zodiaupines. Sco BI'NZODIAZEPINES
noahenzodiazcpines. Ste
NONllENWDIAZ.I1'INF.,
1I0Nll.\.R8ITUIATE CNS DIl'ItllSANI"S
opioids. Sn Opioid(.)
dhi.ion 127.127f
stimulant,
Sa
lll
cocaine. Sa Cocaine
Sa

crphalexin.487t
CIl'HAlOSPORlNf>:
.m .... se.ffeet., 487t. 488
allugy to, 488
drug, classified as
first -generation
cefildroxil. 487.
filmlin. 487.
cephalexin. 4871
cephradine. 487.
485
founh-grnrra.ion
487.
chara(teri!tics. 485
.. cond srnr ration

cefotrtan. 487.
cefm:itin.487.
cdprozil. 487.
cefuroxime.487.
characteristics. 487
third-generation
Index 865
cddinir. 487.
cdditorrn.487t
crfiximr.487t
cefopcrazone. 487.
St. Cd otaxim.
crfpodoxim 487.
487,
crRibutrn. 4871
crftizoJ:irnr.487t
487t
characteristic 487
pharmacotherapy with. 485. 487
route and adult do .... 487.

c=bralpalsy. 27It
G:rebyx. Su Fo'ph.nytoin
certolirumab 1'<"801.625. 742.
cerum.n.776
cerumen <often ..... 776
C.rvidil. Sa
Ctsam.t. Sa Nabilon.
Sa
cetirizine.575.
,"'rorcli>: acetat 7l2.
Sa
cetuximab, 563 564f
crvilllC"lin. HCI. 140t
CFSAN (Center for Food Safetyand
Applied Nutrition). 5
dt.ag.u' di ....... 521 ,
174 212.
Chrm ... Sa Suaimer
chrmical 13-1 4
chemoprophylaxi .. 482
chemoreceptor triggrrzonr (crz). 628
'hrmon:ceptors, 298
chrmotherapy.549. Sa
ANrrnwPlASTIcs
LibraryPirate
866 Index
chief cell" 608
childbirth, after, 182
Childhood Mt, 6f

of ibuprokn and
in, 472t
in, psychos<xiaI and cultural
impact, 682.
drug idrnini,tration d1a1knga, 191,
59,90.
drug administration guiddines
71- 72
pr."hool child, 70
ochool-aS" child, 70
school-agt child"n, 7If
toddl .... , 69-70
in, 286t
Gw,dja infection., 5BI
HN 5>8t
medication errors in, 91.
ophthalmic drug administration, 7751
pain exprossion and pelUption, 2231
para.itic infections, 523.
<1iologies, 1671
ClIMmydia ""dumlatil, 4801
chloral 159
chlorambucil.5551
chIoramphenicol, 4951, 776
chlordi=poxide, 1571
chloride (Cn:
functions, 648.
imbalances, 437.
recommended aU"",,,n, M&
Chloromag, Su Magnesium chloride
chloroprocaine, 2421
chloroquine. SlOt
actions and uses, 5201
administration alerts. 520.
ad""""dkcts, 5161. 5201
interactions, 5201
overdo"" t",atment, 520t
pharmacokin<1ics, 5201
r",i'tan, 516
route and adult dose, 5161
chlorothiazide, 4231
.ction. and uses, 4231
ad""""dfe<ls, 4221, 423.
interactions, 4231
"""nlo ... 4B,
pharmacokin<1ics, 4231
route and adult do"". 303 . 422.
for rondition.
",nal failu"" 423.
chlorphenesin.272.
chlorpheniramine, 57St
chlorpromazine, 2071
action, and U""', 2071
administration alert., 2071
ad"""",dfe<ls, 206-7, 206., 2071
interactions, 207.
overdo"" t",alment, 207.
pharmacokinetics, 2071
route and adult do"". 206.
chlorpropamide,6871
chlorprothixtne, 209.
chlorthalidone, 422, 422.
Chlor-Trimeton, Sn Chlorpheniraminr
Chlor-Trim<1011
tabl<1s.576.
chlorwxazone, 2721
chokinglvomiling3gents, bioterrori.m, 121.
chokcalciferol, 732, 732f, 7341
cholera.ll6t
cholestuol:
abnormal 1"",,1 .. !ire Lipid disorders
biosynthesis and =rrtion, 287, 2Uf
di<1ary restriction, 21'.6
functions, 283
laboraloryvalues, 285, 2861
in lipoprotein., 283, 21!Sf
t)'\J'ts, 283, 285f
chole.terol absorption inhibilors, Sa

chol ""tyr-dntine, 2911
anion, and U5tS, 291.
administration alerts, 291.
adv","" effects, 2871, 2911
inttrJction . 291t
pharmacokinetie&,29[1
route and adult do .. , 2871
cboline salicylate. 228.
cholinergic,13[
cholinrrgk cri,is, [45
receptors:
location, and responses, I 31.
\)'\J'ts, 130/. 131,131.
CHO!JNERGICS ( PAJtASYMPA11l0MlMrncs):
actions and u .. s, 132
D1iEcr-ACIlNG
drugs dassified a. bcthanechol.5tr
Belhanechol
HCl, [401
140., 7701. 771
mecbanhm' of action, [39
INDIREcr-t.cnNG
ad""r"" .ffects, 264, 264.
for Alzheimer'. di"","",
2M--M, 264,
drugs classified as
anlbenonium, 140.
dOllrp<Zil, Su Donepail
Mm[lhoninm, lMl.
galantamine hydrobromide,
264,
nrostigmine, ]39, loWl
139, [40., 770t
pyridostigmine, 139, t4O,
[40., 264, 264.
tacrine, ]401, 264, 264t
mechani.m, of action, 139
MIOTICS (ANTIGUUCOMA DR\JG\)
drugs classified a.
carbachol, 770.
ochothiophatc 7701
physostigmine, 770.
pilocarpine, 770 . 771
Nursing Focu.
a=ssment, 1411
ewluation of outrome crileria, 143.
implementation
and rational .. ,
[41--43.
patient and
[41--43.
planning; patient goals aJId ap1ed
outcomes, 1411
potential nursing diagno .. s, 141.
cholineura .. , See Acetylcholinesterase
.. inhibitors, See CHOL!N!'l!GICS,
INIJIIECT- ACIlNG
chondroitin, 100., 743t
chorionic gonadotropin HCG, 7[2,
712t,718t
chromium,649t
chronic bronchitis, 601
chronic obstructive pulmonary di"""",
(CDPD) :
char-"cteristie&,600
pharmacotherapy, 601- 2
chronk pain, 219
(hymt, 620
Cialis, See Tadalafil
cideoonide, 580., 5961
ddopirm: olaminc, 5[41
ddofoYir,538.
ciliary body, 767
(ilO'lawl, 380
6]2., 635
Cirnza, Sn CertoJizumab
cinacalC<1, 736t, 739
dnnamates, 763
Cinobac, SN- Cinoxadn
dnOLldn.4921
Cipro. Sa Ciproflordcil1
CiproDex, Sa CiproOoxacin;
Daameth.",ne
ciprofloncin, 493.
action. and u ... , 4931
adminbtration alerts, 493.
ad""r"" 493.
int eractions, 493,
pharmacokin<1ics, 493.
route and adult do"".4921
for "piflc conditions
[lmphybxi, .ntl '",alm""t,
1]9,49t
ear infections, 776, 776f
SOOt
drcadian rhythm,663.
cirmo,is, [08, 108.
ci.,lracurium, 278.
cisplatin, 555.
dtalopranl, [55., IS6t. 266
Cilanest, Se. Prilocaine
Citr""al, Sa Cakium
CitruL Sn MothylUulose
CK ("ratine kina",, ), 3491
a - , SN- Chloride
d.dribine, 555.
LibraryPirate
darithromycin, 489,4891, >01,616
aaritin. Sn
clavuJanate,48S

575" 576
aeodn. Su Clindamydn
aeocin-T. See aindamydn
307, 319
Qcyipra;. SIT Qevidipin(
dient teaching. See Patient and famUy
Nucation
aim.ra. Se. Estradiol
aindaMax. See Clindamycin
dindamydn,494, 495" 7561
dinical inve;tigation, in drug developm.nt,
6- 7,7f
phaSl' trials, in drug dt\tlopment, 6-7
ainorU. Sn Sulindac
aoar. Sre Clofarabine
dobetasol, 7601
docortolone,7f1J,
SS4, SSS,
dofibrate, 291
aomid. Sn Clomipb.n.
domiphene, 712, 7121, 71!
domipramine, ISS,
donaupam:
ad"crse effect., IS7t. 272,
a. muscle ",launt, 272,
for .. izuros, 171,
clonic "",.m, 271
donidin.:
action, and uses, 132,
interaction" 187" 198,
for 5Jlifk condition,
ADHD,200
hyperte05ion, 315,
pain management, HM. H':I
dopidogrel, 380,
actions and uses, 349, 3&0,
administration alerts, 380,
adyerse effects, 3791. 380,
interaction',3&01
o""rdo .. trratment, 3801
pharmacokinelic., 3&0,
and adult do ... 3791
doraupau, 157., 171/
dosed-angle gla\l<:Oma, 768, 768f
bolli/inurn, 273
C/m,ridium dijJirik, 4971
dotrimazole:
actiOll' and use .. 5 12, 51 5, 752
adversedJecls, SUI
and adult do .. , 5 DI
clotting disorders, 371- 73, 37lr. 372.
clotting factors, 370
d""" oil, 2421
doxacUlin, 484. 4841
aonpen. Sn Cloxa.cUlin
dozapine, 212, 213,
aozaril. Su a02.apine
CNS. Su Contra! nervous sysum
coagulation, 370
modification of, 373, 3731. Sre also
ANI"JC(W:;\JUNfI; AN1U'lATElEf
AGEIITI; HEMOSTATICS;
THROMllOlTIlCS
coagulation cascad., 370, 371f
coagulation disorde ... , 3721
coal tar, 761, 7621
Coartem. Su Art.metherflumdantrine
CoWil,6491
Cobex. See Vi tamin Bll
cocaine:
ad,..,r ... ff..:u during brmst -fuding, 67,
characteristics, III
df..:", III
fetal effect .. 681
a, local anestb.tk, 242
toxicity signs, l06r
witlxlrawal 'ymptom" 1061
cocci, 479
Cocddwide, immi,is, 5071
coccidioidomyco,is, s.o7,
Codamin. Syrup. 5841
codeine:
ad""rst .ff..:". 222" 5113,
as antil1lssilll', 583, 5831
generic polymorphism' aff..:ting
mrlaboli,m, 81, 81,
mechani,m, of action, nlf
for pain managtment, 222,
route and adult dose, 222" 5831
Codid.ar DH Syrup, 584,
Codimal DH, 584,
coenzj'IllC" QIO, 100,. 2901
Cogentin. Su B. nzlropin.
Cogna. Se. Tacrine
cosnit;...,-bthavioral therapy, 183
Colau. Sn Doc:usat.
colchlcin., 7441
action, and u .... 744,
admini,tration alert', 744,
ad""r .. elf..:", 7<141, 745,
interactions, 7441
overdose treatment, 7441
pharmacokinetics, 7441
route and adult do .. , 744,
cole .... dam. 2871, 289
Colestid
colestipol,237,
OOLl.OIDI, 408
characteristic .. 436
for specific condition,
fluid and
436,4361
,hock, 408, 4081
'n>"
5% albumin, 4361
dextran 40. Sre [)alran 40
dextran 70, 408, 4031, 436,
b.tastarch, 408.408" 436,
nomlal ... rum albumin. Norm.!
... rull1albulI1in
pla,ma protein fraction. 403,408"
436.436,
Index 867
Collyrium. s.-. TetrahydrozoUne
rolon. 620, 620f
OOI.ONY- .\"T!MUL\.TING FACIOIlS (CSF. ) :
am.rst effect .. 3911
drug,dassifiNa,
filgra,tim. Sre Fil gr .... 1illl
p<"8filgrastim, 391" 394
"rgrammtim, 391., 394
m..:hani,m, of Ktwn, 394
NUr>ing Proces, Focu,
., ..... mem, 395,
implen1entation
evaluation of outcom. criteria, 397,
inte,,mtion. and rationales,
396-97,
patient and family Nucation,
396-97,
planning: patimt goal, and exp<"Ctod
outcomes, 396,
nu ... ing diagno .... 395,
pharmacotherapy with, 394
ronto and adult dost" 391,
combination druS-, 13, 13,
CombiYent. Se< [pratropium
comedones, 756
common cold:
characteri,lics, 582
natural therapy with vitamin C. 644,
Nursing Proces, Focu,
a, .. ssment.585,
n<aluation of outcome criteria,
S8S--871
implementation
ime"..,ntionnnd rationaLes, 5-85--87,
patient and family Nncation.
585-117,
planning: patient goal, and expected
outcomes, 585,
nu ... ing diagnose .. 5851
pharmacotherapy
See H , - RECIl'l"OI
ANTAGONISTS
amitus'i .... '. AN1TTIJSSIVE.\
combination druS', 583,
decons""tant,. DEOONGESTAN15
expectorants. Se. EXPF.CroIt.'oNTS
Sa Proc:hlorp. r....m.
Compkat "'gular, 651
compl.ment, 465,
and alternatiye
(CAM),9S
and Altemati"" Tb.rapie .
See also Herbaltherapie>; ,pedJk
,lib.",,,,,,,,
for anxiety, 1531
bilb.rry for.,..., hralth, 775,
black oohmh. for mrnopausal 'ymptoms.
M,
,arnitine for hnrt n51
for nlUKular tension, 2731
d o"", tor dental pain, 242,
cotnzyme QIO for hrart di .. a .. , 2901
cranbtrrylor urinary ,)"t.m btalth, 42St
LibraryPirate
868 Index
and
(cont.)
for
.... nt, 453t
p.imrost oil for pain, 234,
flsh oils for inflammation, 470,
garlic for aordionscular h.,.]th, jl!,
for 616,
ginkso 258,
ginseng for m)'X'lrdial ischemia, .l49,
and chondroitin for
osteoarthritis, 743,
antibacterial p.oprnies, 501 ,
",I ""tracl for hyp<rtension, 303,
for respiratory disorders, 584,
for ""nollS inrufflciency,
413,
for insomnia, 153t
kava for anxiety and insomnia, 153t
ulogtnic diet for .. uur .. , 169,
melatonin for insomnia, 153,
milk thistle for alcohol liver damage, lOSt
saw palmetto, 726,
"'" 643,
selenium for cancer prevention, 549,
S!' )ohn"'M)rt .. ssion, 188t
val.rian for anxiety and insomnia, 153,
and alternative therapies:
attitudes toward, 96,
cultural and ethnic influences, 79
deflnition, 4
Su th .. rapks
types, 961
com pia partial.,im.e, 168t
compliance:

facio" affecting, 19---20
COmprehensi .... Drug Abu", P ... ''''ntion and
Control"ct,14
Com,,"x,452,
conduction pathway, 356, 3%/
conll"SliYe hun failu .. , 325, See ]-kart
failure
7051
actions and ""'s, 705t
administration .. 705,
ad"" .... effects, 705t, 707 t
interactions, 705t
pharmacokinetics, 705,
route and adult do .. , 707t
conj"8ated estrogen., '"'Iuine/
mlroxyprogesterone, 707,
conjugates, 40
conjogation, 481
constipation:


pathophysiology, 621
pha.macoth<rapy, Sec I.AVJ'lVl'.I
cont ... t dermalitis, 760
CONTIt.\.CEPTIVI.S:
ikpo-P""",ra, 697
Sa Emerg.ncy contracoption
implants
desogesml.698
[mplanon, 697
698
lemnorgemd, 698
Norplant, 697--98
NUYalting,6'iH
oraL Se. ORAL CONTlACEl"lWES
Ortho-Evra,698
contractiUty.325
Drug and Substances "cI
(Canada), 15
controUed .ub,tanc .. , 14
Controlled SubstancesAct of 1970, 14
convulsion., 166, Seea/", Scizu ....
Copaxone, See Glatiramer acetate
capo, Set Chronic obnructive pulntOllary
di",a ..
copolym .. - L Stx Glalirame. acetate
649<
Cordarone, Sa Amiodarone
Co.<'8, SeeCa .... edilol
Co.gard, Sa Nadolol
coronaryanerie ... 339
coronaryarterybypa>s graft (CABG)
surgery, .l4O
coronary anerydi .... '" (CAD), 339, 341,
corpora """'mosa, 719
corpus lutrum, 695
corpus Mriatum, 257, 259f
Corrrciol. See Bisacodyl:
Phenolphthalein
Co.tef, Sn Hydrocortisone
corticosteroids, Sa GlUCOCORTIOOIDS
corlil:otropin,66O,
corti""ne, 470" 671t
Cortisporin, Polymyxin B, neom),dn,
and hydrocortisone
Cortrosyn, Sre Cosyntropin
Co ...... t, SN Ibutilide
Corzide, 422,
cosyntropin,660,.670
Colazym, Stx Pancrdip""e
Coumadin, Warf. rin
count .. irritants, 741
CoY .. a- HS, Stx V .. apami[
COx. SaCyc100xygena",
COX- 2 inhibitors. Stx Cydooxygenase-2
(COX-2) inhibitors
Cozaa., SeE Losartan
crab lou"" 753
cranberry, 428,
""",tine kina .. (CK). >49t
Crestor, Sa Rosun,tatin
Crinone, SN Progesterone
CrWYan, Su Indin ... i.
Crohn', di"", .. , 625
"romolyn.580,59fu
c."'s-toleranee, 106
crotamilon.753
Cruox. Ste Mkonarol.
cryptO<OC<XHis, 507t
Ctyp,ococevs 507t
Cfypt"'poridio,l., 521,
Cryptospcridi.m 521,
CR'I'STAllOIDS, 408
charact .. istia;,432
mechanism, of action, 432- 33
for specific condition,
Huid placement, 4:JZ- JJ, 4JJ,
slxxk, 408, 40St
'IT"
5%dextrost in 0,2% saline, 433,
5%dextrose in lactated Ringer's, 433,
5%dextro", in normal sali ne, 433t
5%dextro", in Pla,malyte 56,433,
5%dextro", in water (D5W).
408t, 433t
hypertonic saline, 408., 433.
hypotonic 433,
laclatl Ring ..... 40&. 433,
normal salin., 408" 433t
Plasmalyte,408,
Plasmalyte 56, 433,
Plasmalyte 148.433t
CSP., See CoWNY-STIMUIMING IlICfOiS
crz (chemo""ceptor trigg .. zone), 628
OIbkin, See Daptomydn
cullural competence, 78
cnlm ... , 78, Stx Ethnic/racial
consid<ratiom
culm ... and ... nsitivily (C&S) t.,ting, 482
Cuprimine, Prnil:illamine
Cushina', syndrome:
glucocorticoid therapy and, 471
pathophy,ioiosy, 672, 676
pharmacotherapy, 66Ot, 676
symptoms, 676
cutilneouo anthrax, 119,
Cutar, See Coal tar
Cyanapin, SN Vitamin B"
cyanocobalamin, Sre Vita min B"
cyanogen chloride, III t
CYCUC U!'J'OP[!'I1Dl'.I, 494
daptom)'dn, 495" 499
cydiLine, 630t
cydobcnZilprine, 272.
aclionsand u ... , 272,
adrniniMration alerts. 272,
ad"" ... effects, 272,
int.ractions, 272,
OY .. dose treatment, 272.
pharmacokinetics, 272,
Cyclofiex, SN CydobcnZilprine
Cyclogyl, Sa Cyclopentolate
cydooxygena .. (COX):
forms, 228-29,467--68, 469,
functions, 228-29, 229/
in inflammation, 468
inhibition of, 468/
cydooxygena .. -2 (COX. 2) inhibitors:
action. and U"'", 228-29,467- 70
ad""r .. effects, 228,
celecoxib, 22&, 467t
route and adult do"" 228,
cydopentol.te, 143t, 774t
LibraryPirate
<y<lopho.phamide, 5561
action, and uses, 55&
administration 5561
adverst dJect., 5551, 5>6,
interaction',556,
550f
5561
and adult do .. , 5551
for :;pifi, ronditiom
canca, 5551, 556,
immunosupp",ssion, 458,
aUOPLfG1C5:
Sre Atropi""
charact.ristiC&, 774
774,
homatropinr, 774,
=polamine, 7741
tropkamide, 774,
SOOI
Cyclooti, Se
cy<:losporinc, 4591
action. and u"'s, 457.459,
admini,tration 459,
.dver", 4591
inU1'3ctiom, 201, 1001,4591
4591
for spifk rondition.
immunosupp",ssion, 459,
pooriasi" 762" 763
Cycrin, Su Mcdroxrprogcstero"e
>cetate
Cyklokapron, See Trane:camic acid
eylert, Set' P<moli".
Cpnbalta, Se DulORtine
cyproheptadine, 575,
550{. 554, 555,
CytoGam, Se Cytomrgaloviru, immune
globulin
cytokines, 451
cytomegaloviru, immune globulin, 450,
Cytomd, See liothyronin.
Cytosar, Se
Cyto,ine See
Cytot= Se Mioopro,lol
cytotoxic T cdl', 450
Sa Gancidovir
Cytoxan, Se Cyclopho.phamide
D
D- and L-amphdamine mixtu"',
200
D4T, See Slavudine
D5W, Su 5% dextro", in
dacarbazine, 555,
dadizumab, 457, 45&
dactinomycin,557,
Dalgan, Se Dewcine
Dalman", Se Flurazepam
dahoparin,374,
danazol, 7]2" 713, 7]7,
Danocrin., Sn Danazol
Damrium, Se.e Danl rolene ",dinm
dantrole nesodium, 2751
actior .. and u"'s, 2Uf, 275,
admimi,tration alerts, 275t
ad"" .... ffects, 275,
int.ractions, 275,
pharmawkinetiC&, 275,
Daptaen, Se.e manus, and
vaccine
d.ptomy<;in, 495" 499
Dilraprim, Set Pyrimethamine
d.ro.poetin alfa, 391, 391,
darunavir,5JOt
Darm<:<l- N 50, 223
Darmn, Set hydrochJoride
Darmn-N, Seo nap,yI.te
daunorLbicin,557,
daunorLbicin lipooomal, 557,
D.ypro, Se.e Oxaprozin
DDAVP,See Dc.mopr ... in
DDL Set Didano,ine
dcbrisoquin hydroxyla"" gl, 81,
Dcbrox,s.,., Carbamid. prroxide
Decadron, See
See Drmedocydine
decoctirn, 98,
DICONGISfANTI:
ad""nc effects, 581,
combinations with antihi,tamines, 576,
drug, classified a.
581,
iprotropium bromide, Seo
Ipratmpium
5111,
oX)-lllctawline, S.,. OxymdllZOli""
phenylephrine, Sn Phenyleph ri ne
pseudoephedrine, Se
P",udocphedrine
tfIJah)'drowline, 581,
58],
pharmacotherapy with, 580----81
rout. and adult do",., 581,
d<ql ,,,,b thrombosi. (DVT), 371" 372
defecation, 621
IB,
ddlbriU.tion, 357
dcgardiI, 561 1
Drl.test Se T .. to. terone
Drlate.>tryl, 7]8" Se a/so

ddavird,ne, 530,
Drlestrogrn, Se Estradiol
delirium tremens (DT), ]08
Drlsym, Sn Dcxtromethorphan
dclta.9-t.trahydrocannabinol (THe) , 109
Drlta- D, Se.e Otol.cakif.rol
Drltasone,
deltoid 'ite, 32
dclushns, 204
Demad= Sn
d<meclocyctine, 4891
dementi. , 258" 263, Se.e a/so Alzhrirner',
uiotaK
DemeroL See
[)mavir, Sn Pmcidovir
IndH 669
Drndrid, Sa Idoxuridine
116,
Sn Valproicacid
Drpakote, Se.e Valprokadd
Drpakole ER, Sec Va! proi< acid
Drprn, Sa PC1licillamine
Sn also Substanu abu ..
]4
opioid, 1061, 227
Drp-MedroL Se.e
Drpo-Cyt, Sn
58
d.po]arizing blockers, l7S, Sn ,,/so
NIUROMUSCUIAR BWCKfltS
Drpo-MedroL See Methylprednisolone
Drpo-Provera,697, See ,,1<0
MMtoxyprosesterone acetale
Drpote't, See Crriona!.
Drpo-Te.>tosterone, 718" See ,,1.0
cypionate
d'p",ssion:
a ... ]83
characteri,tiC&, ]82---113

tthnklradal considerations in trutmtnt,
1821
]82, 1831
natural with 51, lohn'. wort,
188,
nonpharmacological therapy, ]83
Nu"ing Proces, Focu,
a .... ,ment, ]91,
... aluation of outcome criteria, 1931

and rationales,
191---93,
patient and family education,
191---93,
planning: patient goal. and expected
outcomes, 191,
nursing diagno", .. ]9],
pharmacothCTdpy
atrrkal antid.pr .... nt .. Se ATIPtc.u

monamine oxida ... inhibitors, Sn
MON(w'UNE (llIDASE lNHlBITOlS
",rotonin uptake inhibitors.
Seo SIll:CI1VE SIltOfONIN llUYrAXE
lNH!IlITOlS
tricyclic antid.pr .... nt .. See TlIC'lUJc
ANI1DIl'RE>SANn;
d.rmatitis:
.. 759-61
pharmacotherapy
immunorupp",.sanu,760
pimecrolimm,760
tacrolimu .. 760
topical glncocorticoids, 760, 760,
dermatologk preparations, 24
d.rmatophytic infection., 508, Se olso
M),<o"",
750
DES, See DiethyistUbrstrol
LibraryPirate
870 Index
De .. na. Su add
.. nsitization. 414
Desfual. Su
246,
thyroid. 663. 663,
drugs, 104
ISS., 1861, 200
374, 374.
575,
desmop", ... in,6611
actions and use.,661<, 662
administration alens, 661,
ad"""", dfecls, 66Ot, 661,
interaaions, 661,
"""mo .. 661.
pharmacokinetics, 661,
route Jnd adult dOloI', 660t
698t
d.SOSC'strel,698t
760,
760,
Desoxyn. See
Methamphetamine
De.yrd. SeeTrazodon.
Detrol. SetTolterodine
de""lopment. 64
d.umelhason.:
ad,,,,,,,, effects, 470t, 671,
for spedlk conditions
adrmowrtica] insufficitncy, 671.
cancor 561t
dermatitis, 7601
nau .. a and ""m.iting, 629, 630.
.. ""re inllall1IJtation, 470,
d<J<bromphenirantin., 575,
DexchJor. See Dexchlorpheniramine
d<J<chJorphmiraminc, 575,
Dexirine. Datroamphetamine
Dex/"errum. See Iron dexlr.m
HC], 132., 160,
dextran 40, 4331
actions and uses, 4331
administration 433.
ad"""", 4331
436, 4361
interactions, 433t
pharmacokinetics, 433t
for .hock, 408,
... n 70 . .tOM. 4011 4'"",
dulran 75, 408

for atuntion defidt- hyperaclivity
disomor. 200
u .... 110
comrol,634
dextromethorphan, 584,
abu .. , 582,
actions and uses, 584,
administration 584,
ad,,,,,,,, effects, 5831, 584,
int.ractions, 5M,
pharmacokinetics, 584t
route and adult dose, 5831
5%dextro .. in 0.2% saline, 433,
5%datro .. in lactated Ringer's, 433,
5%d<J<t""'" in normal 433t
5%dext""'" in plasma-lyle 56, 433t
5%dextro .. in water (D5W), 408" 433,
dnocine.222.
D.H.E. 45. See Dihydroergotamine mesylale
OHM,I00,
Dill. See Dihydrotachyilerol
OiaBeta. See Glyburide
di.betnin.ipidm, 659., 661
diabet .. mdlitus:
in P'l"'hosocial and cultural
impact, 682t
complications, 680,
gestational,680,
inddenao, 680, 680,
lipid-lowering therapy in. 683.
pharmacotherapy. ORAL
HYP()(;LYU.MlU
fallu ... in, 41g,
symptoms, 680
type l. 680
type 2, 6g2
diabttic ketoaddosil (OUl. 680
Oiabine ... See Chlorpropamid.
Diamm:. See Acetazolamide
diarm.:a:
cultural mniies, 625,
definition. 622
nalural therapy with acidopbilus. 623
pathophysiology. 622- 23
pharmacoth.rapy. Su ANnDwtJtHl'.Al.\
diastolic p ... "" .... 297. 297 . See"/,,, Blood
p"'5SU ...
di oztp;lm.1741
actions and u .... 174.
administration alerts, 174,
ad, ..... 1571. 174,
41
gmeti< polymorphism.
metabolism, 81,
int.ractions, 174t
"""rdo .. tr .. 174,
174,
rout. and adult do .... 1571. 171.
for "",dlk conditions
anxidy.157,
"' ;n,,..",,",,,,,,,,, ]SI.
.. izu ..... 169,. 17]1. 172
a, sk.ktal ... laxant, 272.
319
dibucain 763
didofenac, 2281. 467.
didoxaclllin. 4S4,
dicl"'Jomine. 625, 635
didanosine, 530,
Didronet See Etidronate disodiurn
diet, cultural.nd in/lumces, 79
dittaryfiher,621
Dietary Intm (DRl),639
dietary
ddtnition, 98
herbal. See therapies
medication errors and. 57
for old .. adulls, 97.
,,%ulation. 98- 99
Dielary Supplemenl and
Drug Protection Act. 99
Dielary Supplement and Education
Acl. 5, 6 98
dkthyl>tilhestrol, 560, 5611
difenoxin with 6241
diffusion. 37
dillorasone,760t
Dillucan. Su Auco nazol.
dillunisal. 228,. 467t
digestion.607--8.620
Digibind. See Digoxin Fob
digitali, Ser CUDIAC cm:OSlDES
Digi.alis /a""til. 330
Disi,ali. purpurea, 330
digitalization, 334
Digitek. See Digoxin
digm:in.3311
aaion.and u...,;, 331.
administration alorts, 331.
tffem. 109/. 3281. 3311. 3601
100., 331t. 34&
Nursing Process Focus
a..., .. 332.
.... Iu.tion of outcome crileria. 333.

int.rvmtion. and 332- 33t
patient and
332- 33
planning: goals and exp<aed
outcomes,332t
nursingdiagno .. s, 332.
o"ordo .. 331,
pharmacokinetics.331.
for spedfic conditions
dysrhythmias, 360 J66
heart failure, 330
shock, 409t. 412
digoxin immune F.b. 331t
233 234
dihydrotachyst.rol,734.
Dllacor. Dilti ..... m
Ollacor XR. Dilti ..... ",
Dilantin. Su Phenytoin
.. <;." ;n;1
Dllaudid. See

diltiozem. :HilI
aaion.and u .... 348,
adntinistratiOll alerts, 348,
ad""r .. effects. 343,. 3481, 360.
interaction 348,
owmose treatmmt, 348,
pharmacokinetics. 348.
for specific condition,
angina and myocardial infarclion. 343,
dysrhythmias, 360., 365
hypertension. 3071
575,. 629, 630.
LibraryPirate
dimucaprol, ]23,
See Bromph. niramine
a,Udrm's Cold 576t
DIN (Drug ldmtification Numbtr), 9
dinoprostone, 703" 704, 708,
Diown. See Valsartan
Diown HCf. 302,
s.x
diphrnhydnmin(,576f
action. and uses, 5761
administration alert 576,
adYer,", 575t. 576. 576,
interactions, 576,
ph.mlacokin.rk . 576t
for spifk condition.
rhinitis. 575,
413
extrapyramidal 257
insomnia. 161
nau .... and vomiting. 630,
Parkinson's di .... '"', 260,
diphenoxylate with atropine, 6241
actions and u,",s, 624,
administration 624,
adwrse 6U.
interactions.6Ut
o,..,rdO'lt t .... tm.nt. 624,
624,
rout. and .dult dO'lt, 624,
diphtheria, tetanus, and ,,,,,,,ine, 4521
dipi, .. frin,770t.773
Diprivan. s.x Propofol
dipyridamole. 379,
DIItECf THROMBIN INHIBITORS. s.x
ANT!OOAGULl.lmi
drugs cl.ssifled as
argatroban. 374, 374,
bi-;alirudin, 374, 374t
desirudin, 374. 374,
lepirudin. 374, 374,
action, 374
dirithromydn, 489t
Disaldd. s.x
D1'EA.'iE- MODlFYlNG ANTIIHnJMATIC DRUGS
(DMARDs),742
adver .. 742t
drugs classified as
abat=pt.742,
adalimumab,742,
anakinra. 4Sg" 742,
742t
certolizumab pogol, 742,
742t
golirnumab.742,
hydroxychloroquin . See
Hydroxychlo""l uine
infliximab, 7421
742,
. s.x Methotrn.l te
ritw:imab, 742,
rulfasalazine. See Sul fa", Ja zi ne
phamtaeotbtrapy with. 742-43
and adult do,"" 742t
disorlium phosphate. 4361. See also
Phosphoruslphospbat.
disopyramide phosphate. 360t
distribution:
ddinition.39
facto .. affting. 39--40, 39/
medt.anisms, 38f, 39-40
in adults, 73
in pr( gllilflcy. 64-65
disulfrram. 108
Ditropan. See Oxyburynin
DlUJ.FnCS:
carbonic anhydr ..... inhibitors.
CAitooNlC ANHYDl,\Sl; INHlBrroltl
combination drugs, 421
home ca ... 42St
loop. See Loop DlVIUIT1CS
mechanisms of action, 298. J.Olf, 327f,
420-21.4211
osmotic. Sa O>MonCDlURlITlCS
potassium-sparing. See PorASSlUM-
SPAltlNG DlUJ.ITICS
for specific conditions
hean failu .... 328,. 329
hypertension. 303-4, 303.
Nuroing Process Focus. 305- 7t
rrnal 422t. 424" 425t
Nursing Process Focus, 425- 27t
thiazid . See TJiL\.ZJDE DIURETICS
DiurU. Chlorothiazi de
diwlpron sodium. See Va lpmk add
DKA (diabttk kotoacidmi.). 680
DMARD .. Sn DIS.\,E- MODIFYING
ANTIRHEUMATIC DlUG,

actions and u,",s, 132,
ad,.., .... effects. 409,
mechanisms or action, 4 t 2- 1 3
for specific conditions
hean failu ... , 335
.hock, 409,. oj 12
DOOurrex. See
docetaul. 559. 559,
docosanol.538,
docusate.622,
dofrtilide. 36O',.l64
dolasetron, 629. 630t
Dolobid. Sa Diflunisal
Dolophin . Sa
DaM. 110
donep<Zi J,2661
actions and u,",s, 140,. 145. 265f, 266,
administration 266,
ad,.., .... effects. 264,. 266,
classification. 140,
266,
mechanisms of action. 2651
overdo .. t ... atment, 266t
pharmacokinrtic., 266,
route and adult do ... 264,
dopamine, 4121
actions and u .. s, 132t. 413
adminimation alerts, 412t
am ...... ffocts, 4]2,
interactions, 412,
ovrnl"'" t .. atm.nt, 412,
pharmacokindks, 41 2t
for .pecific conditions
heart faUu .... 335
shock, 409" 413
Index 871
OOPAMINE SYSITM STABJUZE.It\. 215
2]3" 216
type 2 (D,) ... <epto .. ,
204.2051
OOPAMINERGIa.:
am ..... effects, 258,
drugs classified a,
258. 258,
apomorphine. 25&
bromocriptin . See Bromocriptine
carbidopa-kmdopa,258t
258,258t
In-odopa. Levodopa
258, 258,
pramipaole.2591
pramipomle dihydrochloride, 258, 258,
ropinirol. 258.
258t.259/
hydrochloride. 257, 258,
257. 258,
mechanisms of action, 2591
Nnr.ing Process Focus
as.s.essment.26It
n-aluation of outcomecritftia, 262t
implem.ntation
.. ntions and rationales,
261-{i2,
patimt and family education.
261-{i2,
planning: patient goals and
outcome., 26t,
potential nursing diagno .... 261.
route and adult do,", .. 258,
for .pecific condition.
Parkin""n'. di ....... 257- 58
Dopastat. Sa Dop;t mine
Dotal See QuaMpam
See
dorna,", alfa. 585
dorsogluteal site. 32
donolamide.77Ot
dose-respon,", 47-48, 471
Domna. Sa Cakipotriene
doxacurium,278,
donzosi n,3161
actions and u .. s, 3]6,
administration 316,
3]5 316,
intera.ctions, 316t
",..,nlo,", t .. atm.nt. 3161
3]6,
for 5pecific conditions
btnign prostatic hypertrophy, 726
hypenm,ion.315,
155" ]86,
734,
LibraryPirate
872 Index
dmorubkin,553t
actions and uses. 558t
administration 558,
ad"""", dfects, 558t
interactions, 558,
"""rdo .. 55&
pharmacokinetic .. 558,
route and adult d.,... 558t
doxorubicin liposomal. 557,
doxyo:ydine:
for acne. 756
ad"""", df""" 488--89.489,
mechani,m. of action. 48S--89
route and adult do .. , 489t
161,577
DPaT. See tetanu . and ""nm.i.
vacdne
DPI (dry powder inhalrr). 591. 591/
Dramamine. &.
Driodol. See Ergocalciferol
Drimral. See
P..,udoepbedrine
dronabinol, 629, 630t
J60" 364
drop at\llcu. See Atonk 5I"iml'l'
dro""ridol, 248, 252t. 629
698,
dru8(S):
administration. &. Drug administration
administration &e M..dication
errorhl
Canadian approval P='s, 9, 9,
ronsumer spending on,S
cost, for old .. adults, 8,
ddinition.4
cost., 8
FD" approval pro<e ..
nurses' panidpation in, 9
n:cent changes, 8--9
>-8, 7/
time 8t
timetin 7/
inl<'raction.
with grapefruit juice. 20t
"""r-tbe-counter. 4
pa ... through pla.ma membran ...
37- 3S. See also
pn:scriplion,4
reaction . See Drug reaction.
"'iulation, and standards, 4- 5. Sf
drug administration. Sualso
Pharmacotherapy
abbn:viation.,20,
compliance and. 19--20

buccal. 23- 24, 23" 24/
di .. 22
drug forms, 23t
ga"ro'tomy tube, 23t. 24
guiddines.23,
nasogastric tube. 23" 24
.ublingual, 23. 23" 24/
tablet. and cap.ule., 22. 23,
guidelines
Ii>.., rights, 19
overview. 22
thn:cchecks, 19
inhal..d. 591
lifespan consideration.
childn:n. See
infants, &e Infants
during lactation. &e B",ast-fn:ding
older adults, Su adults
in See Pn:gnancy
l"ung and middle-aged adult .. 72
nur .. '.responsibilities,18
nursing p=ss in
asse>sment pha .. , 55--57, 56t
.... luation pha .. , 59--60
implemenl3lion phase. 58- 5':1, 60.
nuningdiagno .... 57, 53t
planning pha .. , 57- 58
ordm;, 20-21

30-31,
2S. 29/
intramuscular, 29, 31- 32, 32f
intrnvenous, 32, 33/
subcutaneou 28-29. 31f
pediatric. See Inflint.
religious fasting and compliance
wilh.24'
time schedules, 20-21
topical
guideline .. 26-27,
nasal, 25, 2S/
ophthalmic. 25, 27/
olic. 25. 27/
rectal. 28
for systemic .... Iocal .. 24-25
25. 25/
24
vaginal. 27, 28f
transdermal, 25, 25/
Drug Enforcement "dmini"ration (DEAl.
14-15
Drug Number (DIN). 9
drug
absorption and. 38
with grapefruil juice, 20t
with hcrb.tltherapies, 100.
drug--protcin compl=s, 39, 391
",aclions:
anaphylaxis. See IuIaphylaxi.
Ste""ns-johnson 18t
toxic q>idermal necrolysis, IS,
dry powder inhaler (DPI), 591, 591f
DTIC- Dome. Dacarhaz.ine
Dukolax. S .. Bi .. codyl
186 188
ular, 609
duodenum, 620, 620f
Durag.n- l0. See Estradiol
Duragesk. Six Fentanyl citral.
Duralith. See lithium
Duramorph. S Morphine . ulfate
Durancst. See Etidocain.
725,
Duvoid. Six Bethan""hol
302 . 422
o,.:lone. See Dydonine
242t
Dynabac. Su Dirithromycin
DynaCir<:. Stx
Dyrenium. Triamterme
dysentery. 517
dy.functional uteriM bINding:
cau .... 706
ddlnition, 705
pharmacoth.rapy
707
nons(.roidal anti-inflammatory
drugs, 707
prog.stin . Su PRO(;ESTINS
types, 706
dy<lipidemia, 285. Sua/so lipid di,.,rde ..
Dysport. Six Botulinum toxin Iype"
dy .. hythmi. s:
cla",ification, 355. 355,
definition. 355
incidencF. 355, 355t
nonpharmacologicaltberapy.357
pharmacoth.rapy. &. /o.N"nm,IHYl1lM1CS
dy"h)1llN: disorder, 182
dystonia. 206. 2071, 271 273
E
car:
anatomy. 775. 775/
disord .... 775- 76
pharmacotherapy. See Otic
prrparation,
eadoop, 776
Eber's PdPyrUS, 3
ECG (cl.ctJo<ardiogram) , 356, 357/
cchinacea:
drug interaction., lOOt
amiodarono,365,
cyclophosphamide. 556,
nalomne hydro<hloride, 226,
sumatriptan.234,
testost.rone, 719,
for immune system enhancemenl. 453,
.tandardization.97t
u .... 96t
Echin"..,./Ipurpurro. Six &hinacea
fCIlINOCANDIN!:
anidulafungin.5O&,512
ca'pofungin. >0&, 512
echothiophate iodid 770,
. damp,ia,167
econazole, 513.
Ecsta.y, 110
ECf (ckctroconvul,ive (herapy). 183
. ctopk fod/pacemaurs, 356
eczema, 759. See also Dermatiti.
ED .. (median .ffective dose). 46, 46f
..drophonium. 140,
EEG. See Electroencephalogram
LibraryPirate
efovi",n., 5321
action, and uscs, 532,
administration 532,
adversc dJect., 530t. 532,. 533
interaction,. 100,. 532,
pharmacokin.lics.532t
rout. and adult do ... 530t
Effexor. Su
elJka,y. 48{, 49
Su Prasusrel
Efudex. Su Fluorouracil
Elavil. Su Amitriptylin.
Eldepryl. Su
dderlydient'. Su Oldu adulUl
(ECG). 356. 357/
therapy (ECT). IS3
tltClroeno:tphal08ram (EEG):
in diagno'i' of sleep and .. izure
153.166/
normal V5. abnormal. 166/
:
dermition.436
diuretic on. 304
function .. 436
imbalancts, 436, 437 t. S& also spedf/{
e1ec,,,,ly,,,.
important in human physiology. 436t
renal rrgulation. 437. 438/
Elestat. Su Epinastine
detriptan. 233,
Eleunu""ocl'lt.'Jst'n,k-Ojus. Su Ginst'ng
Elidel. S<-e Pimecrolimus
Eligard. Su leuprolide
limite. Su Permet hrin
El"""tin. Su Oxaliplatin
Elspar. See A>paragina ..
dtrombopag. 391 '. 397
.mbolus.372
embryonic period. 65
Emcyt. Se. Esiramustine
Emend. See Aprepitant
.merg.ncy oontraception:
.thinyl and
703.703,
700. 703. 703.
.merg.ncyprepandness. nur ... ' role.
117- 18
emesis, 625. See Nauoea aoJ
""mitinll
emetic.629
emetk (rnletogenic) 552. 628
emphY""ma. 601
Empirin with Codeine No.2. 223
emtridtabine. 530,. 538
Emtriva. Su Emtricitabine
EmulsoU. Castor oU
E-Mydn. Su Erythromycin
319
enaldpril .312t
actiOll' and usc .. 312,
admini'tration alert'. 312,
adver .. dJect,. 31lt. 3]2,. 328,
interactio",. 312,
owrdosc trratmmt. 3]2,
pharmacokinetics, 312,
for 'pecific condition,
heart failurr. 328t
hyp<rten,ion.311,
Enbrd. See Etan.n:ept
endocardilil, 480,
657/
endogc:nollS opi<Jids, 220. 220f, See alw
Opioid(s)
endometrial ,,".dnOll' . 706
Endometrin. Su Progesterone
endometri ... t .. 706. 7tZ
Enduron. See Methydothiazide
246t
enfuvirtid 530,. 531
Engeril- B. See HqJilliti s B vacci nt
Enjuvia. Su Conjugated estrosens
en"""parin. :J.49. 374t
E",ute- Plm. 651
entacapon . 257. 258. 25&
histolytic", 517.521'
enteca"ir. 542. 542t
enteral nutrition:
dtfinition.650
formulas. 651
NU!':'linS .. 1'ocu5
a ..... m.nt.651- 52t
<"Valuation of Olltoome criteria.
652- 53t
impl.mentation
intervention, and rationale .. 652- 53,
pat i.nt and family Nucation.
652- 53,
planning: pati.nt goals and uptCted
outcome .. 652t
potential nU!':'ling diasno .. ,. 651- 52t
routes. 650--51
enteral route. 22. Sua"" Drug
admini'tration.
emeric-coated .. 22
enterobia,; .. 522. 523
En",,,,bilu ''i'mlu-..lmis, 522
En",,,,,,,",,, 481
Enrerot:O<'CU' 481
enterohepatk rrcirculation. 41. 42/
Entocort-EC. Su Bud.sonide
enzyme induction. 40
ephedra:
druS interactions. 33lt
removal from marht.634
ephedrin 581,
epidermis, 750
Epidermopi1y","j1ac=u,n.507,
epidural anesthesia. 240f, 241,
epikpoy. 166. 168,. See also Seizurrs
epinastine.774
epinephrine,4141
action'''ndu ..... 132t.133. 4t4'
administration alerts. 414,
ad,..,,,,,, dfe<l,. 409,.

OYeTdose trratment. 414,
pharmarokinetic .. 414,
for .pecilk condition,
anaphylaxis. 413- ] 4
heart faUure. 335
'hoek.409,
Index 873
epinephryl borau. 770,. 771
417 t. See also
epirubidn. 557t
Epival. See
Epi"i . See lamivudine
311. 32S,. 423. 424,
epooetin alb. 3921
actions and uses. In,
administration alen .. 392,
.. 39],. 392.
intera.ction .. 392t
Consideration,. 391.
Nursing Process Foeu .. 392--94,
392,
pharmacokinetics, 392,
route and adult do ... 391,
EpDgfn. Su Epo"'in
eprosartan.311,
EPS. See Extrapyramidal side effects
Epsom salts. See Ma8llesium sulfute
Epstein- Barr "iru,. 539
eptifibatide.379,
Equal""tin. SeeCakium polycarbophU
Erbitux. See Cellu:imab
Ereaf. Sn with
=elile dysfunction:
cau .... 716t, 719
ddlniti<Jn,719
7]6,
Nursing Proces, Focus
a, .. ssment. 723,
.... aluation of outcome criteria.
723--24,

int."..,ntionsand 723--24,
patimt and family education.
723- 24,
planning: patient goal, and
outcomes, 723,
nU!':'lin8 dia&/lo .... 723,
pathophysiotosY. 719. 721
phamIacotherapy
alprostadil. 721
pap .... erine plu, phentolamine. 721
selection of agent. 724,
Set SildenafIl
tadalafil. 722. 722,
vardenafil. 722. 722,
E'W'misol. Sa
(vitamin D,), 641. 734,. Su
ar", Vitamin 0
ergonovine maleate, 708,
Ergo'taL See Ergotamine
508
I'lIGOT AI.K.l.WlI)!;:
dihydroergotamine 233t. 2>4
67t. 2B., 2M
u gotamine with caffeine. 233,
LibraryPirate
874 tndex
233" 234
"sotamine with caffeine, 233,
Ergotrate, Sa Ergonovine maltale
rrlolinib,563,
Ertaczo, Su
499
mlpti...., psoria,ilI, 761<
rrythema, 751
Erythr<xin, SIT Erythrororctn
erythrocyte sMim.mation rate (ESR),
349,
rrythrocytl' stage, malaria, 515
n, 4901
for acne, 756
actions and uses, 490,
administration ol.n .. 490,
.. 490t
interactions. 2Or, 490,
ointment, 752
pharmacokinetic .. 4'.1Or
rrythropoil'tin, 391. Sa Eroet in alfa;
Hematopoietio: growth factors
E",herid,;a 4S01
esci talopr-a m onlate, 1561
actions and 1561
administr,Uion al.n .. 156,
ad,..,,,,, dfects, 1551, 1561
int.raction .. 1561
"""roo .. treatm.nt, 156,
pharmacokinetics. 1561
route and adult do .. , 1551
for conditions
anxiety symptom .. reslles,ness, and
dep .. ssion, 1551
depression, 1861
EIkalith, Su IJIhium
.. molol, 1 361, 3601
esomeprarol., 611, 611,
esophageal .. Oux, 608, 609
ESR (l'rythrocyte .. dim.ntation rat.),
349,
.,.,..ntial hyptnen,ion, 299, !iuaisc
Hyptrt.noon
estazolam,1571
este", 242, 243/, See al.w l.ocAL
ANI'SfHFI1Q;
Estinyl Sn Ethinyl .. tradiol
Estrace, Su Estradiol
sO',
estradiol, 7071
estradiol cypionate, 707,
estradiol val.rat., 707,
estradiol/drospi .. non., 707,
estradiol/norgestimate, 707,
555,
E5T1OGENS:
dfect .. 704, 706,
con><q ... n",s of loss in menopau .. , 7051
drug. classifii as
oombination drug.
conjugated estrogl'n .. iuine/
medroxyprogestl'rone, 7071
7071
ethinyl.stradiol/no .. thindron.
acetat., 707,
conjugated estrogens. Se. Conjugated
.. t rtlllen
estradiol, 7071
estradiol cypionate, 707,
estradiol yal.rate, 707,
estropipate.7071
ethinylestradiol. Sa Ethinyl .. tradiol
functions, 695
Nursin8 Process Focu.
as .. ssment. 7011
implemmtation
evaluation of outoom. crit.ria, 703,
inte"",ntions and rationalt., 70 1- 31
pati.nt and famUyeducation. 701 - 31
planning: pati.nt goals and l'l(I(Ctl
outcomes,701t
potential nursing diagno .... 701,
for >pe<:ifI, oonditions
dysfunctional uterine bleeding, 707
hormone .. placement thrrapy. Sn
HORMON. ilJ'L.'JJ.MENT THElAP'(
oral contraception. Sn DiAL

mnvifW. 704
estropipate.7071
esropidone. 160" 161
etanen:<'Pt.458" 742" 7621, 763
ethacrynic add.422'
ethambutol,5h
ethchlorvynol. 1601
ethin)-i estradiol:
for acne. 7561
adyer .. .. 7fYlI
for can",r chemotherapy. 560, 5611
in oral oontracepti"" .. 695. 6981, 707,
in tran<d.rmal patm, 698
ethinylestradiol with lemnorgestrd, 70},
ethinyl estradiol with 700,
actions and list" 700,
administration alert .. 700,
ady ..... ff! .. 700.
interaction,. 7001
pharmacokinetics.7001
ethin)-i estradioVnorethindrone aC<tat .
707,
ethionamide, >DOl
ethnicity. 79
<!hnic/racial OOIIsid.rations:
ACE inhibitor action. 3111
angina, 341 ,
communication technique .. 591
depr .. sion treatment, 1821
dietary habits. 2861
enzyme ddkiend .. , 50,
. cc .... 791
in immunization. 451,
mental illn .... 2OS1
osteoporosi., 7401
pain and Jl<""ption. 220,
pharmacotherapy, 78---79
tobacoo U". 1121
1761
actions and u..,.. 1691, 176,
administration alert .. 176t
ad,..,r .. df""t 174" 176,
interaction., 1761
oyrrdo .. treatment. 1761
pharmacokinetics,176,
route and adult do ... 174,
Ethrane, Sre EntIurane
ethyl aloohol. Alcohol
etidronat. disodium, 7361
etodolac, 228,. 4671
etomidate,2511
etoposid 550 559. 559,
.traYirine, 530,
Eulexin. Se. Flutamide
EurJL Sre Crolamiton
",,"l .... tion pha .. :
definition, 59
in drug administration, 59----60
. "ming primrose. 961, 234,
Evista. Sa Ralm:ifel1e
awriation, 759
cxuetion. drug:
definition, 40
facto .. affecting, 41
m""hanism .. 38 40-41
in older.dult., 74
in pregnancy. 65
Exdderm. Sn Sukonazole
E:x.lon. Six Ri';.stigmine
nemestane. 561. 561,
nenatide. 6871, 688-89
nen:i .. -induced asthma. 592
exfoliati...., dermatiti .. 7611
E.dorge, 3021
Ex- Lax. Sn Phtnolphthalein
EXPCfOiANTI. 584
guairen .. in. 5831, 584--115
p<'nicmins, 4841, 485.
Sn PENlOIJ.!NS
external otitis. 775
extracellular Uuid (ECF) oompanment. 431,
431/
enract.98,
extrapyramidal side effect, (EPS):
with antipsydtotic drugs. 206, 2071
definition, 206
in I';"kin<e"'.' ... , 2S7

anatomy, 767, 767/
glaucoma. See Glaucoma
inftion .. 539
natural therapy with bilberry, 7751
pharmacotherapy. See Ophthalmic drug.
emimibe. 287" 289 291- 92
F
5- FU. Sn FluorouracU
Sa GerniU"""dn
falls:
benzodiazepines and. in old .. adults,
1581
LibraryPirate
famddovir, 538,
family See and family
..ducation

Famvir. Se Famd dovir
Fansidar. &.
faociculation . 275
fat -so1ubl. vitamins. See Vitamin(.), lipid-
soluble
FDA. Se Food and Drug

FDA Act, 6[, 8
FDA's Critical Path Initiati"", 6, 6/
"'''ure, 166, 168.
F..d.ra1 Bureau of Ch.mistry, 6/
F .. n-a_Mint. Se
fdhamato: , 1731
Fdhatol. Se F.lbamat.
.. w Pimri""m
fdodipin<, 307.
f<mal. inknility:
Qluses,712
ddinition,712
pharmacotb.rapy for
bromocriptint, 712t, 713
o:etrordix, 712.
chorionic gonadotropin, 7]2, 712t
712,712.
danal.Ol, 712., 713
foUitropin alfa, 712.
foUitropin beta, 712.
ganirdix, 712t
goserdin,7121
l<uprolide, 712., 713
m.notropins, 712,712.
nafardin, 712t, 713
tb.ral"'utic approach, 712- 13
urofoUitropin,712t
function:
hypothalamic and pituitary r<gUlation,
695,696/
infertility. Se F<1Ilal. inknility
owrian control, 695
Femo ... S.., 1.<1ro2.01.
FmtCa",. Se
F<mstat. Su
634
frnofibrate, 287.
frno/lbrk add, 287.
22St. 467 t
frn -ph.n, 634
frntanyl dtrate, 248, 251 t, 252., 351
ft-ntanylldrol"'ridol. 252.
F=l. Se krrou. sulfate
F=l-cap . &e Iron carbonyl
Feostat. Su F.rrous fumarnie
Sec F.rumoxytol
Fergon. Su knOllS sluconate
Fer- Iron. Su Fcrroussulfate
ferritin, 399
Ferronyl. Sec Iron carbonyl
398t, 400,647.
3981, 400, 647t
ferrous su Ifate, 401 t
actions and u .. s,401,
administration alerts, 40],
ad,,.r .. cffts, 398., 4Olt. 647.
interaction .. 40 I.
nursing P"""" focu .. 401- 2.
owrdo ... t",atm<nt, 401,
route and adult do .. , 398., 647t
f.mmoxytol, 398., 400
fetall"'riod. 65
fetal-placrntal barriu, 39--40
fe"""
dmg- induc..d,472- 73
dfts,472
pharmacotb.rapy. Su Antipy",tk.

drug interactions
aspirin,230t
"'"p .... fe.n.4I;9,
100.
warfarin, 376.
575,
See Caldum polycarbophil
HBilC ACID AGENn:
3d,'!'r5l' effens, 2871
drugs d""ifi..d as
dofibrate, 287t
knofLbrate, 287.
knofLbrk add, 287.
See G.mfibroril
Nursing Process Focus. 292- 94.
pharmacotherapy with, 291
route and adult dOS<"., 2a7 t
fLbriUation, 355
fLbrin,370
fLbrinogrn, 370
fibrinolysis, 371, 371/
fight -or- flightrespon .. , 128, 128/
fil ara,tim, 395t
actions and u .... 394. 395t
administration a1crts, 395,
ad"" ... offts, 3911, 395t
int.radion .. 395.
n" .. ins p=" roc"., J96.
pharmacokinetic .. 395.
route and adult do ... 391.
fLltrate, 418
FinacN. Set. Aulak acid
fin a,teride, 7271
actions and u .... 727t
admini'tration alerts, 727.
ad""" .. .. ff!S, 7251, 727t
interaction .. 727.
pharmacokinetics, 727.
route and adult do .. , 725.
fi,..t -pa .. 40/
fLshoils:
for inllammation, 470,
uses, lOOt
fLve rights of drug administration, 19
Flagyl. Su
flaXSetd oil , lOOt
lIainid<, 3591, 360,
Index 875
A.et Pbospho-Soda.!in Sodium
biphosphate
AeurU. See
Aexon. Su Orphenadrin<
Aomax. SuTamsulosin
Aon ..... Sn Flutic.so"e
Aorinef. Ser Fludroronisono
Aov<nt. See Autiar.so"c
Aoxin. Su OOoxadn
555t
Auarix. See Inlluenza ..... ((inc
lIuconaz.olc, SUt
actions and u .... 513,
administration alen .. 5131
am .... df.ct .. 513t
interaction .. 513,
.. 513r
route and adult dOS<". SIlt
'>fill..
555t
lIudrocortison., 671
FWID AND !'LOCIWUTE IEPVEMENT AGHns:
blood products. Ser BlOOD PIODUCTh
colloid . See CoUOIDS
crystalloids. Sn CRYSTALIDIDS
Nursing Process Focus
assessment, 434,
n-aluation of outcome criteria, 435.
implementation
inte"",ntionsand rational", .. 434-35.
patient and family ..ducation, 434-35t
planning: patient goals and
outcom .... 410.
nu,..ing diagno .... 4 IOt
for shock
Nursing Focus,410-11,
th .... peutk approach., 408
lIuid !>alan",:
body fluid companment .. 431,431/
cau ... of, 432
intau and output "'gulation, 432
mov<1ll.nt of lIuids. 431. 432/
lIuk ... 521
FluLavaJ. ",,"ine
Aumadine. See Rimantadine
lIum"",nil. 123 174,
lIunisolide, 580., 596.
lIuo<:inolone. 760,
lIuo<:inonid., 760,
lIuorin<,6491,65O
FWOIOQUINOIONi:S:
am..-... .. 492, 492.
drugs da .. ifi..d as
first -grneration
cinoxacin,4921
nalidixic add, 491, 492.
.. tion
gemifloxacin,4921
moxifloxacin,492, 4921
..
ciprofloxadn. See Oprofloxldn
norfloxacin, 4921
olloxadn, 492t, 500.
LibraryPirate
876 Index
fWOIlOQl!II'IOt.OtIES, (CO" . )
.hird,eneration
aaIiAoxadn,492,492.
IoMlfloucln,492.
m .... nISITII of lKtion, 491
p!l&nmlocolhn'apr with, 491-92
roule and odult do$ts,492.
551 554,555., 556{
flIWtmnf. S U.lothauf
fluOMline. ISS" 1861,266
lIuoxyme5leron(, 560, 561" 717.
lIuphenazine, 206.
lIunndrenoUde, 760.
lIunupam, 157,
lIurbiprofom, 228" 467.
lIutomide, S61,S6lt
lIulil<lwlJe,Snl
lKtionsand UK!, 577.
administntion alert!, 577.
odvnw effl!' 577., 580., S96,
interaction!, 577.
pnarmacokinella, 577,
for ipiS, conditio."
a1le'llic rhini([" 580.
asthma, 596.
dermatitis, 760.
lIu"".tolin,287,
Fluvirin. Set lnAuen;r.a, vO(Cine
lIumumine, 155" 186.
Fluzonc. Set Influenu, vaccine
Fobrin. s..: Folic Kldlk>bu
I'OIJC foCID AtlTACONIST$. Sa abo

melhottUot( . Sa Mcthotraote
555.
folk odd inhibitors. Set SIJ\.J'.otW,IIDES
folicadd/fohle, 399, 61
ad>Tr5e effccts. 39&
for anemia, 398-99, 398,
ddlciency, 399, 399',640.
functions. 492. 640.
p .... rm..:othenpywith.399
..:lIonl and uses, 644,
odministratlon akns,644,
odvns-e effu.. 644.
iDltHCIions, W.
p .... rmxokinctlcs, 644.
roule and adult dose. 398., 644.
in I'n-enanry, W'I,. """,
recommended dlctar, allowance, 6Wt
5OutCeJ,644
structure,5S6/
foUideslimulatlng hormone (FSH):
for f.male Infertility. 7[2.
in female function, 695.
697/
in male function. 7[6
sccretion,658/
foIliwLlr ctIIs, 662
FoIloom.Sa FoUltropin beta
roIlilropin a1fa, 11:!l
foUitropin bda, 712.
Foivile. Set folic add/folate
forn.pIz.lle, 1231
fooo.parinux, 374,
Food DlU,Adminmratlon ( FDA):
medlcotion ([!'Of rrponing, 87

new drug approval process
. tnl ehanges,&-9
staces,s-&' 7/
timdinc,7/
prcgruncy 65--66, 66t
roles,5
Food. Drug. and Cosme.ich:., 5.6/
food poIIonln&. 480.
ForndiL S I'oImOierol
Forane, Su hollurant
Forest. Su ...... rnpmsal. calcium
forrnOltnX. i321, S941
formulL-y, 4
Fortamn.Sa t.1.ttformin
Foneo. Su T([ip"nlide
Fortical. Set Cakllonin-4almon
FosamaL See
fosampreru.vir, 530.
foscamn.538.
Foscavir. Su Foscamtt
fosfomydn.4%.
fosinopTil, 311" 32&
fosphenrtoln.I73.
Saunthanum carbonate
-",
Fta8JI1ilL Sa DaI'cparin
Frank-Surlin, law, 325
frequency distribution curve, 46, (6/
huh froun pluma, >lOs.
Frov ... S I'rov;Itrlptan
fl'01lllnpian. B3.
FSH. Stt Foillclestimulating hormont
FUDIl S. Floxuridinc
fulve5Innl.S61'
Ful.lein. Set Grlsrofulvln
Su Myrooc"
fungi, 507. 5(17 Sa also Mrcos.es
Su Undyl<nk odd
Fungizone. Sa Amphotericin B
furwm.l d.,3.\Ol
ac:tior.und uws. 330.
admilistntion alert$, 330<
advme effccu, 303., 130., 422.
...... i<>n .. lV1.
overlhs-e trC'<l tmcnl , 330.
pharm;acoklne.ju, 330.
for 5plflc oondhion.
heart f.ilure. 328.
hrvcltnlion,30J.
rerul 42], 422.
Furosldc, Sa Furoonnide
Furoxont. Sa l'urawiidone
FlJSI)N AND tNHIBlTOlS. Su rilio

enfu-tinkk, 530., 531
rrR .... lroc, 5lO.
rali<'Jt1lvir, 530., 53]
Fuzcon.Su Enfuvinide
G
G6PD (g1ucott-6.pOOsp .... te
dehydrOi'"na ... ) ddkiency, SOt.
47)',517.
g;aboptntln:
171t
for 5tizu.cs, 169 ]7].
Gabltrll. SuThrgabine
GAD (gcncralitro anxiety disonkr), 1 SO
galantamlne hydrobromide. ]40., 2641
See Zinc acetate
ganrm"lIminobutyric add (GAllA).
170, L70/
G.mmaaard SID. Su [01 ....... """. immune
globulin
Gamma.P. Su [nlravtDOUS immllDe
"""""
ganddovir,S)8,
ganglionkblod,en, Ill, 278
ganglionic $filiP"', 129
ganlrellx 712.
Glnlnsln. Su SulfillOUZOlc
Garamycin. SetGtnll.mkin
Gard:alll. Su Htunan papillomavirm .... "Ine
Sorlk'
forcardiov.scularhcahh,3721
dlUg intenClions
IIp .... glucosidase inhibitors, 688
uplrln,23ll.
Ibuprolr:n, 469,
Insulin,683.
oycrvicw, 100.
3761-
-'"
,Ul ric IaVOl(lll' and aopiration., 122
listric uIttr. 609
pstroaophya! reOuxdiseasc (GERD), 609
gastroIntestinal anthrax, I ]9.
gastroin(e"inoitraC!. SN 1.0,,"01'
g;tstroin'eo'inal tract; Upper
pS(rointeSiinaitract
.a5lrostomy (G) lube. 23., 24
Gu-X. S<t Sirncthkone
ptiOoxacin, 492, 492.
,ri'lilnib,$63.
,nnclt3bine, 555.
gnn6brodl,2921
action, and U'l($, 292.
odmlnhu",ion al<n s,191.
effl$, 292.
inleraction 292.
p .... rmacokinctico., 292.
rou(cllod adult do .. , 287.
gemIOonc!n, 492t
gcm(ULumah omgamiein, 5631
Scndor, lnnucnc on pharmacoth.rapy,81
gomoral.nesthr$ia:
chiInCt([;stics, 240, 246

adjunctl
borbituratn
amobarbital Su Amobarbital
LibraryPirate
butabarbital. 1591. 252t
pc1Itobarbital. See Pentobarbital
oodium
... cobarbital. See S:obarbital
bnhan,""hol 252
droporidol.252t
opioids
alfemanil hydrochloride. 252t
lS2t
fentanyl/droporidol.252.
remifmtanil 252.
252.
pharmawthe rapywith.25] - 52
See
Su Sucdnylchol
tubocurarine. 252. 252.
follow-up caR. 248r
".
adv"",, dJed .. 2461
charact.ristic 247
nitrous oxide. Sox Nitrous oxide
intra",nous
a<h ... r .. dkct .. 25 1.
barbiturat
etomida!e. 251r
methohaital oodium. 25 1.
propofol. 251 t
bcnrodiaupine.
diazepam. Sa Oiaz"l'am
lorazq>am. See lon.upam
midazolam. 20 157. lSll
110. 248. 251.
opioids
alf.ntanil hydrochloride. 251t
f.ntanyl. 248
f.ntanyl dtrate. 25 1.
remifmtanil hydrochlorid 251.
suf.manil citra, 25tt
pharmawtherapywith.248
thiopental. Sn Thiopental
Nursing P""",S5 Focus
a""",,,sm.nt. 249.
evaluation of outeom. crit .. ia. 2S01
implementation
im.r.nlliOll. and rationale .. 2SOt
patiom and familyMucation. 2SOt
planning: goals and
outcomes. 249.
potential nursing diagnoses. 2491
phaml.awthtrapy "';th. 246-47
yolatll.liquid
adv ..... ff.n .. 246.
characteristic 247
drugs dassifiM as
dedlurane.2461
mfluran., 246.
halothan . See Halolhan.
isoflurane,246t. 249
methoxyflurane. 246.
... mflurane.2461
anxietydlsordrr (GAD) . ISO
167. 1681
gen .. ic drug .. vs. brand-narm drugs. !.J--14
gmeric name, 13
genetic poLymorphisms. SO. 81.
gmetics:
influmces on pharmacotherapy. SO. 8] I
.. izu", etioLogi .. and. 167.
See Somatotropin
491.
actions and u .... 4911
admini,tration al.m. 491r
ad", ... effects.49lt
cream and ointment. 752
interaction .. 491.
pharmarokinetk .. 491.
rout. and adult do .... 491t
40. Su IHxi.dn 40
75. See Oatran 75
Su Carbenicillin
Sa Ziprasidon.
GERD ",flux di .... ..,J. 609
gestationalag drug therapyand.65
lIestational mellitu .. 680.
GFR (glomerular mtration rate). 419
GH (growth hormones). 659-00
"'",h/i<l, 521t. 5D.
5 21 5231
ginger:
drug interaction.
aspirin. BOI
ibuprokn.4691
oye .... i.w. lOOt
warfarin. 3761
for ga.trointestinal disord.rs. 6161
standardization,97.
u ..... 96.
ginkjlO:
for d.mentia. 258t
drug interdctions
altepla .... 383,
aspirin. BOI
htparin.3751
ibuprokn.469.
imipramin IMI
oy ..... i.w. lOOt
n:t.pLa .... 35It
.umal riptan.234,
formulations. 97/. 98.
labeling, 97f
standardization.97,
""".96.
Ginkgo bik>ba. Sox GinkjlO
ginstng:
drug int .... ctions
alpha- glueosida .. inhibitors. 688
digoxin. 3311
diuretics, .1491
in.ulin. 6831
o ....... i.w. lOOt
ph.ndzin NOt
oumal riptan.234,
warfarin .l49t
for myoc;ardial is<hmtia. 349.
standardization.97.
use 961
glatiram .. acetate, 267, 267.
gLau.:oma:
diagnosis. 768
Index 877
incidence. 769.
pathophysioLOSy.768
pharmacoth .. apy. 769.
AmIGWJOJMA DIlUGS
ri!l:: factors. 768
type 763. 768/
GI...-vC"C. SN lmatinib
Gliadel. See Carmu5line
gLim.piride. 687.
gLioma. 549.
SLipizide. 687 t
glip;zide/metformin.68&
mtration (GFR). 419
glucagon. 123',679. 679[.682
GWCOCOItl100IDS:
adrenal ... <relion of. 670. 670[
am..-..... .. 470-71. 470,. 671 I.
672,673t
drugsclassified ..
760.
amcinonid 7601
beclomethasone. Ser Beclomethasone
. Sa Brlamethason.
bud.sonide. 580 596,
596t
dobrtasoL.760t
do<onolon . 7601
cortisone. 470 6711
desonide.76O.
desoximelasone.76O,
doxamelhasone. See Dexamethasone
diOorason 7601
5801. 596,
floodnolon.,76Ot
fluocinonidr.760.
7601
Sr. Flulkason.
haldnonide.76O,
hydrocortison . See H)drocorti .on.
Sa
Methylp",dnisolon.
mom''''son 580., 760t
prMnisolon 4701. 671 I
prinisone. See Pr. dnison.
triamcinolon . Sa Triamcinolon.
.fJ'""ts.670
inhaled. Sa INHALED GWCOCOItl100IDS
inlr.masal. See [mllAN.I.S.I.L
GWCOCOlTIOOIDS
mC"Chani,m. of action. 470. 671- 72, 672f
Nursing Proc.-ss Focus
assessment. 674.
n-aluation of outcom. crit .. ia. 675.
implem.ntation
int.rwntion.and rationa]" .. 674-75,
patimt and familyMuallion.
674- 75,
planning: patimt goal. and expn:t.d
outcome .. 6741
pot.ntial nursing diagno .... 674.
LibraryPirate
878 Index
GWCOCOJtTJCOIDS, (ront.)
for condition.
adrenocortical insufficiency. 671. 671,
a11.rgk rhiniti . Su lNTlANAMI.
GWcocomCOIDS
asthma. See INHAI.W G!U:OCOItl100IDS
560. 56J,
d.rmaliti., 760t. 761. 763
intlamm.lory txn.."l di ........ 625
intlammatory disord ..... 470-71. 470,
nau",a and ",miting. 629t. 630
o>tcoarthriti., 741
o""rvirw.671- 72
psoriasis, 761
topical
fordamatiti,. 760. 760,
forp.lOriasis.761
gluconeogrnesi,.679
Glucophagc. Ste. Motformin
Glucophagc XR. Set Mctformin
glucosamin lOll,. 743,
gluco .... 349t
gluco",-6-phosphatc dchydrogcna ...
(G6PD) dd',dcncy. 50,.
473t.517,
Glucotrol. Su Glipizidc
Ste. Glyburidc/mrtformin
Glumetza. Ste. M. tformin
glutothimid 159
glyburid 687,
alyburidrlmctformin. 6&k 692
glycoprotrin IIb/llla. 349. J80
GLYCOPMHlN IIBflIlA UcrvroR
ANTAGONISTS:
ad ......... dfcct., 3791
drugs dassifitd as
abdxim.b, 349. 379,
.ptiftbatid 379t
tirofiban.379,
mechani,m, of action. 380
route and adult do .... 379,
glycopyrrolate.143,
Glyna .... Su Glyburid.
Glyset. Su Miglitol
... '
d.flnition.57
in drugadministr.tion. 57- 58
OOLD SAII"S, 743
8OId.n",a1. SOl,
I/Onadocorticoids. 667
8Onadordin. 712. 712,
gonadotropin-n:l .. ,ing hormone (GnRH).
695.712. Sffalso Chorionk
gonadotropin- HCG
Gonal- F. Set Follitropin alfa
JIO'Iorrhra.480t
Gordochom. St"<" Und.cyl.nk add
8O ... rrlin. 56lt. 712,
80m-kola. 158,
I\0Il1:
eharactrri,li"".743
elas.ifkation.743
pathophysioIOflY.743
pharmacoth.rapy. 744, 745t. Seealso
Colchicine
prophylaxis. 744
grad.d dOSC-n:>pOn ... n:lationship.
47--48.47f
gram_nrsati"" bactrria. 479
gram-po'ili"" bactrria. 479
grand mal. See Tonk-donk (grand mal)
scirun:
grani"'tron.629.630,
granulocyt. colony_stimulating factor
(G-CSFl. 394. Setalsc CoWNY-
!iTIMUl.ATING FACfOlS
granulocyt./maerophas. colony_
stimulating faclor (GM-CSFJ. 394.
Sff also CoWNy- mMUlATING

grape ",rd. 303,
grapefruit juic . drug inl.raclions:
nif.dipin 3081
oy.eview.20,
statin., 290,
Gravn' di ... a ... , 659" 663. Su aJ",
Hyprrthyroidism
grl'en t!'a. 9151
griseofulvin. 514. 514,
growth. 64
growth fraclion. 551
growth hormones (GH). 659--(,(J
guaifenesin. 584-85
auanin . 556f
guttatr psoria.i., 761,
Gyn. -Lotrimin. Su Clolrimazol.
H
H .. K-IUP .... , 6IJ
H,_n:crptor.575
H, -REUPTOi ANTAGONISTS:
adya .... fJeet., 575,
combination. wilh dcconge.>tants, 576,
drugs d."ifled as
flrst _grnrration
aulastin 57S,
brompheniramin 575t
chlorph.niramin 575t. 576
cl.maotin 575,
cyproh.ptadin 575,
d.xbrompheniramin 575,
dexffiJorphrniramine.575,
dimrnhydrinatr.57S,
diphenhydramin . Ste.
Diph.nhydrnmin.
prom.thazin . S<Y Promrthazin.
triprolidin . 57S,
orcond-gen.ration
Ste. Crlirizin.
drsloratadin 575,
fexof.nadin 575.
1'''''''''irizin 575t
loratadin 575,
olopatadin 575,
Nursing Pr""ss Pocus
a' ..... ment.57S'
.valuation of out com. criteria. 580,
impl.m.ntation
intervrntion, and rational ...
578-80,
patient and family.du<,ation.
578-80,
planning: pa(i.nt goals and rIp<"cted
outcom .... 57St
potrnlial nur5ingdiagno ... ., 578,
for sprciflc conditions
.Urrsk rhinitis. 575-77. 575t
insomnia. 577
Parkinson'sdi",a",.577
urtkaria and skin rash ., 577
v.nigo and motion .klrn .... 577
H, - ItF.CEP"IOI Alffi\GONISTS:
dfects.6121
druS' classifi.d a,
dmetidin 187t. 612.
famotidin 612t
nizatidin 612,
ranitidin. HCl. Ste. Ranilidin. HQ
mechani,m. of action. 610/
Nursing Proce .. Focus, 613- 14,
pltarmacothrrapy with. 61 2
rout. and adult do ...... 612,
vitamin Bll absorption and. 614,
HAART (highlyacti", "'troviral th.rapy).
530. See alsc ANIllmtOVllAlS
HaemophiluJ, 480t
ha.mophilu, type B conjua;ol. vacein . 452.
HAt g (hepatitis A immunoslobulin). 541
halaz.pam.157.157t
haldnonid 760t
Haleion. SecTri'701am
Haldol. Sff Haloprridol
hallIKinations. 204
halludnog.ns:
LSD.I09-lO
mescalin., llO. llOf
physiologic and p"Y'hologic illrct., 106,
psilocybin. 109. 109f
loxicity.ign" l06t
type., llO
withdrawal symptom., 106,
208,
actionsand u ..... 208t. 266.629
administration alat., 20St
ad""r ... effects. 208,
polymorphi'm. afJeelinl:
mrtaholi,m.81,
int.raclions.208,
Oyerdosc tr.atmtnt. 208,
pharmacokinrtks.208,
route and adult do",. 208,
Halol.stin. Su Fluoxymrsl.ron.
halothane. 248,
action, and us .. 248t
ad .... r ... effects. 248,
int.raclions.248,
pharmacokinrtks.248,
Hashimoto', thyroiditis. 662
Hayri,,- Hepalitis A wcein.
LibraryPirate
hay r.,,,,,r. SeeAllugk rhinitis
HBlg (hrpatiti. B immunoglobulin).
541
HCG (human chorionic 8On.dotropin).
712.718
HCfZ. See Hyd
HDL. &e High-density
230. 230t. MiH ..
heallh beliefs, ,ultur41 and ethnic
influ."ces. 79
Canada. 9, 9,
history 55. 56t
Product. and Food Branch
(HPFB).9
statu community .. 80t
""ces.:
79
minority stam. and. 79t
Maring impairmem 74,
htan attock. See Myocaroiallnwaion
block. 355,
failu", (HF) :
definition. 325
diology.325
hypmen,ion and. 299
325,
natural therapy with camitinr. 335t
pathophysiology. 325- 26. 326f
phaml3cothrrapy
ACE inhibitors. 326-27. 328,. &e also
ANGKYIT.N5IN-OONVI:R11NG ENZ!ME
(ACE) INlI!BITOIIS
angiotensin- ",crplor blocke",. 327.
328t. Sua"" ANGlon:NSIN II
ROCEI'JOR Ewa::ElS
beta-adrrnrlllic agonist .. 335. See ulse>
BE."fA-ADJENERG[C AGONISU
beta-adrrnrlllic antagonists.
330-3l. Sa 11/'" BE."fA- ADJENEJG[C
ANrAGONlsn
<aroi"" glyco,ide .. 328t. 330. See"lso
Oigo.-.in
diuretics, 328t. 329. Sa "Iso D1UJ.ETICS
of aaion. 327f
ovrrvirw. 328t
phosphod;'"era ... inhibitors. 328,.
335. See "Iso 1'il000000Dl!"SID.AI!:
INHlBrroJS
p')'Chmorial issues in wmpliance. n5,
vasodilator .. 328. 334. Sa "btl
VASODlIMOJS
sympt"m .. 326
Sa DoRrcakifcrol
Hdicobucterpylod. 609. 61Of. 615--16
hrlminth .. 507,. 517. Sauoo
ANI1HEIMn;rn[CS
hdprr T cell,. 450
Hemabalr. &e Carhoprost
hemat"",,;'si .. 3'Xl. 390f
HEMATOPOIETIC GJ;owrn w.crOlS:
drugs classified a.
",lony-stimulating factors. Sa
CoLONY-snMUl.\.TING w.crOlS
darhrpor1in alfa. 391. 391,
alra. Sa Epodin alfa
platd", Sa 1'lATEI.ET

Nursing Proce.o;s Focus
a ... 323- 93t
<Valuation of criteria. 394t
implementation
imerl'l:ntioD! and rationalts.
393-94,
and family education.
393-94t
planning: patient goals and apted
.. 393t
potrntial nu",ing diagno .... 323-9),
pharmacotherapy With. )91
hffilO\lhilia. 371r. m
hemo,iderin.399
hemosta.is:
definition. 370
di,..,. .... of. 371- 73
mrdunism. of modification. 373. 373,
pnx:rs .. 370-71. 370f
HEM05TATIC<;:
am'trSof .. ffe.:t5. 31161
definition. 373
drugs daSliflrd as
aminocaproic ""id.
odd
apro!inin.386t
tranexami< add. 386,
IIlhanism. of action. 373. 373,
route and adult do ... , 3,0,6,
heparin, 375t
actions and u .... 375,
administration alerts. 375,
ad"" ... dfc<ts, 374,. )75,
interaction .. lOOt. 375,
overdose t",atment. 375t
pharmacokinetics, 375,
route and adult do ... , 374,
heparin anti-Xa. 372,
hepatic mkrosomalenzyme system.40
Hepatic-Aid II. 651
hrpatiti .. 540
hrpatiti' A, 540--41
hepatiti.A immunoglobulin (HAIg). 541
hepatiti." wccine. 541
hrpatiti. B. Il6t
charactrristks, 541
pharmacotherapy. 54l. 542,
hepatitis B immunoglobulin (HBlg).
450,.541
hepatitis B vacci ne, 4531
actions and u .... 453t
admini.tration alerts. 453,
ad"" ... df""". 4531
interaction .. 453,
pharmacokinr1ics, 453,
.gr. 452,. 541
hrpatitisC:
characteristic .. 541-42
pharmacotherapy.542t
Hrplock. Sn H'1"' rin
Hrp .. ra. Sa Adrfovir
hrrb.95
Index 879
hrrbal th.rapies. Sa "I..,
and Allfmati,'t Thrrapie.; ,pedfic
therapies
b,,51- .. Jling. primary u .. s, 96,
drug interaction .. 100,
formulations, %-97
hi,tory.95--96
labrling. 97f. 98f
liquid formulation .. 98t
in old .. adult .. 97,
pharmacological actions and .. frty. 99
..-gulation,98-99
standardization. 97. 97f. 97t
Herctptin. Sa Trasturumab
hrroin:
fetal 68,
hrrpcs .implex. 752
hrrprH.oster.752

d assification.538-39
infrctions. 539
incidtnct.5271
Nursing Proces, Focu.
as ... smrnt. 542,
n-aluation of out",mecriteria. 544,
implementation
interwntionsand rationaLe .. 54.3-44,
patirnt and family education. 543--44,
planning: patirnt goals and cxpc<trJ
outcomrs, 543,
potrntial nursing diagno ..... 542t
phamIawth.rapy. 539.

Herpla.
hrlastardt, 408. 408,
H"",,-Brtalin. Sa Vitamin B.
Haalen. Sa Altretamin.
HE Sa Hean f.ilu",
HibTITER. Sa Haemophilus type B
conjugat. weein.
(HOL):
chara<trriSlics. 283. 285f
labora!ory,"'[ue . 2&61
ratio to WI., 285
highly active retroviral therapy (HAART),
530. Sa aIM> ANrntErIOVIRAlS
hippocampus. 264
Hip"'x. Sa
HismanaL See A'irmizole
HispankAmcrican.:
t",alment considerations,
182,
hot and ",Id throryof illness, 483,
mental .. t",atmrnt. 205,
pain management. 2201
hiSiamine. 575
histamine rrptor antagonists. Sa
H,-RECEP"IOR ANrAGONlSn;
H, -RECEYIOR ANrAGONlSU
hiSiaminr r",tor .. 575.612
LibraryPirate
BBO Index
Seo T ..
Histoplllm", CII/"ukl",m. 507t
histoplasmosi .. 507,
histrclin. 560. 561,
HIV ( human
Seo HIV-AlDS; Human
virus
HIV-A1DS:
in S38r
ddlnition.528
527,
mortality rate. 527,
Nursing Proce .. Focus
a ..... m.nt.534'
tvaluation of outcome criteria. 5.l6t

inttnl'ntion' and rationales. 534-.l6t
patient and family Iucation.
534-.l6,
planning: pati.nt goals and expected
outcomts, 534,
potential nursing diagno .... 534,
in old .. adults, 538t
pathophysiology.528

antiretroviral . See ANnIFI1tOVU ... l.I
cla .. ification of drug .. 530-31
th.rapeutk approach aud goal 529
prophylaxis foUowing
occupational exposur 537- 38
... ntion of perinatal transmi .. ion. 537
stago 529
HMG-CoA 287. 2S8/
HMG-CoA .. inhibilors. S .. SrAJINS
HNKC (hyptrosmolar nonkelolk
coma).682
holistic, 77
homatropin 774,
Horm and Community
Alzhtimer's disc ...... 263,
anaphylaxi .. recurrent. 414,
anticoagulant th.rapy. 373t
a'pirin for caroioV"aocuJar ... .nt risk
rluction. 472,
asthma managoment
peak- flow meter for. 60It
in ",hooJs, 5931
autonomic agonl . safety
with.
dalromethorphan and drug abu ... 582,
OTC
mlications for howd
nausea. and ""miting. 635t
uc:ctile dysfunction drugs. 724,
hear! disea ... CPR and othc:rtducation
for. 341,
heart
i"ue 335,
sid ff.ru. 700,
hypcrnat",mia in athletes, 438,
mtdication errors
o ... drugs and. 91,
... nting, 87t
rdaxant 277,
neural tubt dekcts and folk add ... ls in
pr<gnancy.644,
nutritional for patirnts taking
diurttics, 428,
ophthalmic drug . 775,
drug.
for howd nausea., and
Jrniting, 6341
for gastroint",tin.l disord.rs.
interaclions.614,
medication errors and. 91,
ptdiculosis, psyffiosocial and community
impact, 755t
postan.sth.,ia 248t
and community
impact,7SSt
viral inkctions. 539,
ho",hound, for ""piratory disord ... , 584,
HOlMONE ANI"AGONISTS:
adyer .. .. 561,
for
anastrozol 561, 561,
5611
dftartlix. 561,
56lt
fuJ ... strant.56I,
8o .. ",lin, 5611
histrclin, 56],
ktrozol., 56lt. 562
kuprolid 56],
rmdtanisms of aClion, 550/
nilutamid.,56],
Seo Tamoxif.n
tor.mifrn 561, 561,
trip!ordin.56],
rout. and adult do..,;. 561,
.dliw .,.trogt"n-recc:ptor modifi .... Seo
SELOCTIVE EsnoGiN- RrCE!'JOI
MODI!11ltS
hormon. rc:plactrmnt (HRT). See
abc EsrIOGENS
ady ...... ffocts, 7Il4- 5
benefits, 704
NUr>ing Proct" Focus, 701- 3,
HOlMONES:
ady.,... 700,
andr"8'"n . See ANDROGENI
for
56lt
di<thyl'tilbtstrol. 560. 561,
.thinyl estradiol. 560. 561,
lIu0J<YIll"5teron 560. 561,
mechanisms of action, 550/
DYdroxyprogest.rone. Seo
acc:tatc:
mego.trol, 560, 56],
with, 559--60
pn:-dnison . Prcdni .on.
560. 561,
S<: T .. I",tc:ron.
for contractption. Sox CoNfUCE!'J!VE.\
.. nog.n,. Seo
functions, 657
pharmacotherapy with, 659
produaion, 657. 658f
horny goat ......,d, 96t
horso chc:stnut. for ",,"ous inrufficirncy, 413,
host 1I0ra. 483
hou",hoJd system of mururemrnt, 21. 21,
HPFB (Hc:alth Products and Food
Bnnch).9
HRT. See Hormon. therapy
HTN. See Hypcrlrn,ion
huffing. 106,
Humalog. Seo Insulin lispro
human chorionk gonadotropin (HCG).
712, 712t. 718. 718,
human immllDOlkficic:ncyvirus (HN). Seo
HlV-AlDS
posl."PO'ur. prophylaxi, foUowing
occupational rxPOSUK, 537- 38
pr ..... mion of perinatal tran5mi"ion, 537
rc:plication, 528. 528/
.tructu",. 527f
t .. ting for, 529,
transmission, 528
human in!t2ration pyramid cart mod.1.
77,77/
human papillomaYiru. Yacrin., 452t
human "'Sul ar in. ulin, 683t
aaions and uses, 683t
administration alerts, 683,
ad ... r .. dfects. 682" 683t
im. raction.,683,
o\"erdo5C 6113t
pharmacokin<1ics.683,
rout. and adult dOS<". 682,
Humatin. See P.romomydn
Humatrope. Seo Somatotropin
Hum<gon. Ste
Humira. Seo Adalimumab
humoral immun. r .. pon ... 447, 448/
Humulin N. Seo [sophan. insulin
.uspension
Humulin R. Seo Human rc:gul ar insulin
hungor,631
Hunling!on', chorea. 256,
Hyalgan. Seo Sodium hyaluronat.
Hyrodan.584,
Hywmin. Compound. 584,
Hywtus. Expectorant. 584,
JIYrnmoINS:
ad .... .. dfects, 173,
drug. cla .. as
fosph.nytoin.I73,
ph<nytoin. See Ph<nytoin
mechanism, of action. 172
roul.and adult do5Cs, 173,
for stirur .. , 173-74
hydral azine. 319,
aerion .. nd u ... , 319t
administration al.rts, 319,
ad".r .. dfects, 319,
gonetk polymorphism' affecting
81,
LibraryPirate
interaction" 319,
o""rdos. tmUntrnt, 319,
pharm"",kinr lk&, 3 ]9,
for spifk condition.
hean failuJ't , 328., 334
319t
Hydrwti.! """ad.",;., SeeGolden .... 1
Hydrea. Sec Hj<lroxyuJ'ta
,1041
a<lion. and usc .. 304.
admini.tration alrrt .. 304.
adYe"" Iffrcl., )04,
in combination drugs for hyprrtfnsion,
"''' inttTactiom, 3().t,
o""rdo .. trtatment, 304.
phamlacokinelks,3().j,
for spifk conditio",
hean failure , 328.
303t
",nal failu ... , 422.
hydrocodonr:
adYersc Iffrcl . 222t, 583.
asamitur.siYe, 583, 583,
for pain 222<
routl and adult do ... 222t, 583.
hydrocortisone, 673r
actio", and usc .. 673.
admini.tration alerts,673.
ady .... effrcl., 470t, 671 . 673t
inter-dctions,673,
pharrrtaCOkinrlics,673,
for spifk condition.
adl'tnocortical insuffidency, 671.
dermatitis,76Ot
"ar irrilation, 776t
inflammatory bowel di ..... , 625
psoriasis,76t
"""I't inflammation, 470.
Hydrocorton . Sec Hydrocortisone
H)droDlURIl. Sce H)'drochloro1hi azidc
hydrogtn cyanide. 121t
hydromorphone hydrochloridr, 222t
hj<lroxydl lo roquine, 7Hr
action. and uses, 743.
administration alert., 743.
ady .... effl., 516t, 742., 743t
interaction., 743,
o,.."do .. trtatmrnt, 743.
phamIacokinetic . 743t
route and adult do", 516., 742.
for spific conditions
malaria. 516,
rheumatoid arthriti .. 7421
hydroxyul'ta, 563.
hydroxyzinr, 161, 630.
Hygroton. Sn Chlorthalidone
Hyoocine. See Scopolamin"
hyoscyaminr,625
Set Rabies immunr globulin
hyprraldosteronism, 670
hypen;alcentia:
ddinition, 437.
suppon;ye treatm.m, 437.
spI1ptoms.648
.. mia, 437.
285. Sn aJ", Upid
dJ""rdu.
&f"dvidarum. 628
See Diabc:te. mellitus
dftet, 679
HYJ'frirnm pfrjimllum. See St. John's wort

causes, 438
d.finition, 437., 438
pharmacotherapy, 438
potassium.sparingdiul'ttic. and, 304
in I'tnal failure, 420.
rupport;ye treatment, 437,
hyptrlipidrmY.1SS. See also Lipid disordm
. 437t

in athlerl., 438.
cau .... 437
ddinition. 437,437.
pharmacothrrapy, 437, 437.
hyperglycemic statr
(HHS), 682
",,"utotic coma
(HNKC) . 682
420 . 437.
(HTN) . Blood
p ........
classification, 297, 797t
ddinitio n,297
o1iolO(lY, 299
incidence. 297.
managflll<nt I'tcommendations. 297t
n.tural tb.rapywith gra"" ""td
utract,303.
nonpltarmarological management,
""-"'"
Nut1ling Proc"" Focus
ACE inhibitor andARB blocker
therapy.313- 14.
adrenl'llic-anta80ni,t therapy,
316--18,
diul'ttic thlrapy, 305-7,
vasodilator therapy, 320--22.
pathogenesis, 299
pharma.colb.rapy
ACE inhibitors. SU /iNGIQTIN,IN-
CONVEItTING ENZ"tME (ACE)
INHlBITOIl>
adrenergic af,'Oni,u. S AlPHA_
ADRENERGIC IoGONI!IT'
adrenrrgic anra80ni,t&. See
AlPHA-ADif.NDtGIC ANTACONlm;
BETA- ADRENHGlC ANJIoGONI!IT1
calcium ,hannel bloeurs. Src Cl.I.CIUM
CHANNa Bl.OCKEItI
comb;nation drugs, 302, 302.
diuretics. Sn DIUIlITICS
mtehanisms of action, .3011
theraprutic approach, 301- 3
vasodilators. Sa VAIODIUTOR.I
primary, 299
secondary. 299
hyprrl<1lsi,.., emergency, 319t
Index 881
Tetanus immunr globulin
hyperthyroidi.m:
cau .... 662
inddrn"',662t
pharmacotherapy, 663-64. Sn
hNTITHYlOID
h)'P"nonic solutions:
cltaractrri.tics, 431, 4 321
uystalloid, 433, 433 . "/.,,
CRYSTAllOIDS
salinr.408.
191 . See a/so Lipid
dioord.t1l
hypt"TUrictmY, 743
hypnvitamin.,.is. 640
h)"Jl'<l"'ulemia, 420,
hypnotics, 154
hypocaI",mia:
cau .... 733
definition, 437.
nonpharmacological therapy, 733
pharnlacotherapy. See Cl.WUM.'iAln
in renal failul't. 420t
supporti.., treatment, 437.
symptoms,648,733
hypodtloremia, 437.
hypodermis_ 750
hypogl)"emia, 681
hypoglycemic efft, 679
hypogonadism:
cau .... 716--17
definition, 716
indden"',716o
pharmacotherapy. See ANDIOGINS
symptom .. 717
hypokalrmiil:
cau .... 304, 423, 438
438
pharmacotherapy, 438. 439.
supportiYe trtatment, 437.
.ymptoms,438
hypomagnesenua, 437., 648
hyponatl'tmia:
in athldes, 438t
,au .... 437
dlfinition, 4)7.
pharmacotherapy, 439.
supporti"" treatmlnt, 437.
symptoms,437
hypophosphatemia, 648
HYPO"IH.U.AM\C AGINI"S:
Nursing Pnx ... Foeus
asoessmom,665,
... aluation of oulcomr uiteria, 666t
inlplementalion
iml"",ntions and rationale .. 665-66.
patirm and family tdocation, 66S-f.6t
planning: patient goals and expn:ted
oulcome .. 665.
potlntial nursing diagno .... 665t
LibraryPirate
882 Index
HYPOlHAv.MIC ... carn, (amI.)
OClrtQIide, 6241, 660, 611

hypothalamus!
in anIitty, ISO. 151/
dioordM"S,6S9
borm<)R( production. 54&, 653/
in hunll..,.,631
hypo!hyroidlsm:
663
inci<;lenct, 662,
pharm.cOl hCTapr, 663. Su "Iso THnOID

in >hili worUrs,6631
symptoms, 662-43
hypotonk ""'Ullons:
duracteristla, 43], 43l{. 436
ooIloid. SCOUOIDS
crystalloid. S 0:Ysv.u.0uJs
sbock, .o6, 4011
Hysmn. S Dutnm 40
Hytakrml. Set Dlh)UrOla<:hr>tcrol
Hytrin. snruosln
Hyzaar,302<
11J]
ihandron.te, 7)6,
ibritumomab tlmetan, 5631
Ibul"""f ... , 4691
lClions.nd I.IK"S. 468-69, 469t
adminlltralion alerls. 4691

a.lt ....... tlon with aIilmlnoplxn in
,hiJdrm.4721
interaclions. 4691
pru.rll1.Kokinkt, -I69t
route.nd adull dose. 2281
ibutilide, 3-60',)64
ICD (jn'planlabk ,.rdio",rt..,.
dcfibrib.lor).351
ICI' {inlralIular Auid ) compartment,
431,431/
10 ( intl"alkrmal) drua administration, 28,
29f, XlI
idarubicin.5S7.,55S
idinpa1hic hypert ... sioo, m. S .wo
"""'rn"'"
idiooyncl"llt ic mponSft. 50
idor.uridine. S33,. 539
IfeI. Set If05f.1mkk
ifosf.mide. SS5.
arum, 620, 620!
iUnoion!, 2()4
1M (inlramuKular) dru8 administl"llti<>n,
29,3(11,31-32. n!
imalinib mcsyl.\(, 56h 564
Imdur.s IJOfIO.bide mooonitl"llte
imipc ....... dlalt.tln. 4951. 499
illlip .... ,,;nt. 1871
lClionsand usn, 181,
adminlltnlion alerts. 1811
adwtv dftl:ts. 155,. 233,
gmcl ic polrmorphlsms afkcting
Intl"illbolism, 811
interaclions. 1811
ovcrOOselatrnent,1811
pru.rruroklnetics. 187,
roUI,nd adult dose. 186.
for splfIt: conditions
ADHD,200
arulrlr symptoms, 1551
depKsslon, 186,
mi, .. ln., 2331
lmitra.Set
IMMUNE Gt.OlIUl.II<fo:
immune globulin. 450,
Immu ... globulin, 541
I><pollb a globulin,4501, 541
intl"lllll'llOlU Immune: 8Iobuiin,450.
r3b1n Immune &J.obulin. 450r
Rho(D) lmmuneaJobulin,45Ot
Ittanus Immune &Iobulin. 450r
immune mponsoe, 441. 443/
immunity. S<t.uso Vaccines
active, 449, ",51!
cdJ'{1lrolatro, 450-51
449, 451/
immuniUltlon, 448. 50: ul..,
immuno&looulin!, 441
IMMUNO'oIOUULATOIU. 447. S "Iso

lMMunOSUJlI'RDSANn
for mJltlpie sdnosis
ptlnmtr ;Ke\ale, 161, 261.
inlmm>n 261,261,
Inlmm>n bmIb..261,261.
tMloIlJI<IO>TlMIJI..M'TS:
adVCTM' dfls. 454,
drugl dassified as
aldesJeukin.454,
(Ba.:;)
',"eelnc, 454,
inl,rftrom. S IN"ID.FERONS
!r:vlll1OO1 5fi31
Nurllns Procnl FoeUI
aUUSmtnl,455,
e""' ..... 11oo or oulOO...., aileria, 4561
Iml'k....,ntalion
Inte,....,nllons and rational .. ,
4S5-5fi,
p.11;enland
455-56,
pla.,nlng: palienl goals and expr<:l ro
oltl,omes,",55,
pot.nllal nUriing diagnose!, 4551
pharmaoothcrapy with. 452- 53. 454,
rouleand adult doses, 454,

.dvclW cffKls. 457, 4531
eha. ... Urlslla,4S7
drUJlSdusifotd as
S MoHOW>NAl.

and q1010Dc agenl<
utaklnra, 4SSt. 142,
,ulhioprine, 457, 458., 625
cydophosphamide. S
C)ocIO(l/lospru.mide
762., 763
mrthotrnate. Set Melholrcn lt
mycophmotilt moktil, 458.
slroUmu!, 457.45&,
Itmsirolimus,458,
Ihalidomide, 458,
caldnenrin inhibitors
cydolporine. See C)ocl osl", rine
lacrolinm . S Tacrolimm
glucocorticoid . Su Gwcoconrcotus
mbanl.mlof ;Ktion, 457
lOr multiple
]fj7, 267,
NUl1h" I'rocal; Fows
155esUI1rnt,460.

"al""tion of OUIOOlll( c,it..,.ia, 46 if
Inte,....,mion. and rational..,
...... "
patient and filmily education,
460-61,
plannIng: patient goals lnd UJlKIM
. 460,
pountial nu .. ingdiagno,",,!, 4601
route and adult doses, 458,
10. Ir4nsplant rt;a;l ion prnoemion, 457
lmD(tium. Su Loptrrntidc
lmopm Rables-HT. S Rabies immun.c
globulin
imptl\aO. 152
Impli.oon,697
ImpLlnWllc cardioo-on..,.
(lCD).3S7
implm.nlation in drug
53--59
ImpoltnQ:, 719. s.. also Ertclae d}"functlon
lmuran. Sn Azathioprine
in.monon., 3281
lnapsln . !k<
Incldenl r.port. S3
Irocrt]C'I . Su McQKrmin
lrocettins. 688
In.o.bpamlde, 3031, 411, 422.
InderaJ. S Prop",,,o lol
IndraJ LA. S Prop",nolol
Indtride.3021
indinavlr,S301
Indodn. S
indomethacin. 2281. 4671, 744
[nran.lr. Sa Diphtheria, tetanu!, and
perlussis va<cinc
inranu:
drug adminiMralion <hallcngr ..
19,,59
drug admlniltralion guidelines,
68-69,69/
InrilSUri S. Calfactanl
Inrtlousa",nts., 1111
lnkcr!ouJdista ..... 1]61
Infuatn. s Inlerfm>n a/fawn. ]
LibraryPirate
infertility, 712
Stx F""",1e infertility
718--19
infiltration an<"Sth.osia, NO/, 241,
inflammation:
miiators, 4651
classification, 465
465
fISh oils for, 470r
function, 465
phaml.ilcotb.rapy, 466
glucocorticoid . Me GlucocomooIDS
non.tuoidal ami-inflammatory
drugs. Stx NONSlUOI[O'..L
ANTI-INFlAMMATORY DRUGS
pro<e ., 465, 466f
inflammatory 615
inflammatory disord .... , 465, 465,
infliximab:
45S,
as irnmunomppressant, 457, 458t
for inflammatory bowd di .. a ... 625
forp""ri i., 762" 763
for rheumatoid arthriti., 742,
influtrtza, 116t, 540
prophylaxis, 540
amantadin. , 257, 258" 540, 5401
rimantadin., 540, 540,
452" 540
tr.atment
osdtomivir. 540, 540,
zanamivir, 540, 540,
infusion, herbal, 98t
INH. Me honiazid
inhalation anthru, 119,
inhalation, for drug administration,
591,591f
inhalations, 24
lNHAllD GWCOCOmooIDS:
5%t
for asthma. 595. 5%" 599
. See
5%t
dde",nid. ,596t
5%,
Set Flutkasone
5%t
s.-.
Innohep. Me Tinzaparin
Innovar. Set l'entanyVdroperidol
Inowr. See
lNO"mOPlC AGlNI"S:
drugs classified a.
digoxin.. Me Digoxi n
Stx Dobutamine
do""mine. See Dorami""
of action, 412- 13
inotropic effect, 325
in,omn;':
anxiety and, 152
d.fmition,152
153t
insulin ""i.ton"" and, I 53t
Iong-1et"m,152
natunl 153,
pharmacotherapy
antihistamines, 577
antiseizur. drugs, 160 . Set aoo
AN"I1SflZUlE DIUG.
harbiturates, 159,. Stx ah.,
iWtBmJII.l.ITS
ber.zodiaz.epines, 157r. IIlw
BrnzoDl.l.ZEPlNES
antagonist., 160t. Set
aoo BIIT.I.-ADIINE1G1C .l.NfAGONISTI
noab<nzodiazepin.,
160,. Stx ,,00 NONBrnZODIAZEPlNI'.,
1I0NMRBITUlATE CNS DIl'ItF..>S.I.NI"S
153
ilionterm
Inspta. Eple .. non.
instaUation., 24
Institute for Saf. Miication Practice;
(ISMP),91
insulin:
function.,679,679f
panc...atic .. cretion, 679, 679f
pharmarothtrapy with. Set lNSUUNS
insulin analog., 681. Set also INSUlIN.
insulin ""part, 6821
insulin ddemir. 682,
insulin tlargine. 682,
insulin
insulin lspro, 682t
insulin pnmp,681, 682f
inwlin 153.,682
diab.:! ... Set Diabo"l",
"",Uitus, typ" I
INSUUNs:
adve ... . ffects,681
herb-.drug interaction., 100,
Nur. bg Process f'<x:us
a ... 684,
evaluation of crit. ria, 686,

int. rvention. and rational .,
"'-'"
pati.nt and family iucation,
",-",
goal. and upti
outenm ., 684,
potential nursing diagn"",., 684.
with
principles, 680-82
route. of administration, 681,
682f
preparations
human r<"8ular in.ulin. Sre Human

insulin aspart, 681,
insulin 681,
insulin 681 t
in.ulin glnli.in., 681.
insulin lispro, 681,
.uspension, 681 1
Intal. Set Cromolyn
Intd. n"". s". Etravirin.
intorforon lllfa-2b, 45-1,
actions and uses, 454t
. dministration alert., 454,
am'e"" 454,
for cancer, 562-fi3, 563,
for htpatitis, 542,
interaction., 454,
-1541
routo and adult do ... -154,
IndH 1183
int. rkron alfaenn-I, 454,. 542,
interkron alfa-nl, 542,
int.rferon alfa-nj. 454,
beta- la, 453t
for mnltipl. sd.ro.i., 267, U,7,
beta- Ib, 454,
for multiplf "lerosi., 267, 267,
lNTElH:RON. (IFNs):
454t
d.flnition,452
drugsclassifli as
interkron alfa-2b. Sre Int .. foron
aJfa-2b
int. rf. ron alfacon, 542,
interftron alfacon- l, 454.
interftron alfa- n I, 542t
interftron alfa- n3, 454,
int. rf. ron beta- la, 454,
interftron beta- I b, 454,
peginmferon alfa-2a.454 562-fi3
alfa-2b, 454" 542t
mechanism. of action, 452
Nursing Process Focus
assossm. nt, 455t
n-aluation of outcomo criteria, 4561

and rationales,
455- 56,
pati<nt and family iucation,
455- 56,
plannins : patient goal. and
outcomo., 455,
pot. ntial nursing diagnose., 455t
pltarrnacotherapywith, 452- 53
for .peciflc conditions
cancer, 562-fi3, 563.
htpatitis, 541-42, 542,
lNTEl LEUllN. (ILs):
563

mechanism. of action,453
oprdvekin, 391" 397, 457
daudication. 379" 380
intermittent infu.ion, 32, 33f
Int. mational Union of and Applii
Cb.mistry (iUPAC). 12
interper",nal IS3
space. 431, 431f
int. rventions:
in miication administration, 60,
int .. ""Uularfluid (ICF)
431,43lf
parasites, 527
LibraryPirate
884 Index
(ID) drug administration, 28,
291, 30t
imramus<ular (1M) drug administration,
29,301,31- 32,32f
inlranasal cromolyn, 580
INTlANAs..L GWcocomOJ1DS:
for allergic rhinili .. 577, 5771, 580
b.dom<1h.sone. S Bedometha.one
budciiOnidc, S80t
ddesonide,58Ot
nunisolide, 5801
nulic"sone. S F!uliCisone
furoate, 5801
See Triamcinolone
imraocul.rpr ..... '" (lOP), 768. See
Glauwma
imraV<l!iCular space, 431, 431f
imravmous (N) drug administration,
30-31',32, Hf
imra.enous immune globulin, 450,
imrin.ic faelOr, 398, 608
Imron-A. See Im .. fc-ron alfa- 2b
Imropin.S Dopamine
Inwnz. See Ertapenem
innsi>'entss.479
Inv .. ,ine. See Me<:amylamine
Im .. stigational Drug Application
(IND),7
Invira ... See Saquinavir
iodine, 649-50, 649,. 662
iodoquinol,521t
IOOotope. See Radio.eli"" iodine
ionizalion, 38, 39f
ionizing radiation, 120-21
lOP (intraocul.r pr.ssu",), 768.
Glauwma
ipecac, Ill. 629
Iplex. See M.ca .. rrnin
IPOL See Polioviru.vacdne
ipratropium bromid., 5961
action. and uses. 594, 596t
administration .. 596,
d"""" df"t .. 145. 594t, 5961
interaction .. 5961
pharmacokinetics, 596t
for specific conditions
asthma, 594, 594,
chronic obstrucli"" pulmonary
.-li ... t\O I
nasal wnseslion, 581,581 t
Iprivask. Se.
irbesartan, 311,
Ir ..... See Gmtinib
irinotecan, 559, 559,
iron. 399--400,649,649,. Seealw IIION .... 1J"S
iron caroonyl, 400
iron dextran, 400, 647,
iron poisoning, 70,
IION5AIn:
ad"."" dfeet .. 398t
drugs elassifii as
ferrous fumarale, 400,647,
f .. ron. sluwnat., 3981, 400, 647t
ferrous See FerroUll sulfale
ferurnoxytol, 398,. 400
iron dextran, 398" 400,6471
399--400
routo and adult do .. , 398,
irrigations. 14
irritable lxMd "I"'drome (IBS), 621,. 625
[salol. Set Timo!ol
[ .. m",ss. S
of Langerhan .. 679, 679f
[,mo. See lsosorbide rnononitrate
[,motk Set
isocari>oxazid, 186,
iso!luran., 247
isoni azid, 501 t
and lIStS, 50 I,
administration alms, 501t
ady" .. effocts, 499" 501,
gm<1ie polymorphi'ms affecting
metabolism, SI, SI,
intenetions. SOl t
o .... rdo .. treatm"nt, SOl,
pharmarokineliu,50I,
rout. and adult do", 5(X)r
insulin 681 t
isoprot.",nol:
aelim.and me., 1321, 133
for heart failor. , 335
[soptin.See
[soptin SR. V'''dpamil
[sopto Atropin . See
[sopto Carpine. Pilocarpine
[sopto Homatropine. Homatropine
[sopto See Scopolamin.
[sordil. Sa [sosoroid. dinitrate
isosorbede, 770" 773
iso""rbede dinitrat.:
ad ... , .. 328" 3431
for angina and myocardial infarction,
342,343,
for heart failure, 334
isosorb:de mononitrat . 343,
isotonk crr.;taUoid .. 433, 433t. See
CIYSTAUD1DS
isotretinoin, 756, 7561, 757
i.radipine. 3071
[suprel. Su
itraconuole, 512, 513,. 514
IlJPAC "f "".-I
Applied a.emislry), 12
[Vbol ... (push) administration, 31t, 32, 33f
[V (inna.mous) drusadministration,
3O-31<.32,33f
iV"""'<Iin.5llt
[V1G. S". Intra .... nous globulin
ixai>epilon., 563,
[xcrnpn. S [ui>epilOll'
J
JadeU., 69S. alw Lemnorgest",l
Januvia. See Sitagliptin
jejunum,620,620f
jock ilm, 5071, 514
Joint Commission onAccriitation of
Organization (JCAHO),
di ... planning requirements, I 17
joint disord .. s:
flOut. See Goul
o,teoarthriti .. See O<t.oanhritis
rheumatoid arthriti .. S Rheumatoid
atthriti.
jllcnil.-on:;ctdiabei ... S<e Diabete.
"",Uitu .. type I
K
P. Se, Potassium
See Calcium glllconate
Kaldra. S<e Lopina.ir/ritonavir
kanamycin, 490t, SOOI
Kamra. See Kanamyl:in
kappa receptor .. 221, 2211, 221,
ka\.,.:
for anxiety and insomnia, 1531
drug interactions
,hlorpromazine,207t
dia,.,pam, 173,
haloperidol, 208,
lorazepam. 15&
ntorphine sulfate. 223t
phenobarbital,I72,
risperidon.,212.
thiopental, 251,
parkinsonism and. 260t
standardization,97t
KaycxaLlIe. See Polystyrene sulfa"
KCI. Potassium chloride
K-Dur. See Pot a", ium
Komadrin. See Procydidine
hydrochlorid.
Konacort. See Triamdnolon.
Konalog. Triamcinolone
Krppra. See levetiracetam
keratolytic, 756
Korlonc. See Iktaxolol
Kttalar. See Kotamin
llO.24S.251,
Kttek. SeeTelithroml"in
ketoacid .. 680
ketoronazole,513,
ad .... r .. effects. 5131
for Cushing'. syndro""" 676
20',100.
route and adult do .. , 512. 513t
ketogenic diet, 169,
nTOllD!'.I, 499
tdithromydn, 495" 499
ketoprofen, 22SI, 4671
ketorol" 228,
KI (pota .. ium iodide), 120-21,650, 667
kidneys:
See Renal failure
drugs toxic to, 419,
function .. 418, 4191, 438f
transplants. 4\8,
See Anwnra
KlclJsiellll. 480,
LibraryPirate
Klonopin. SuClonaupam
Klor-Con. s.., ... ium ch
Konsyl s.., Calcium polycarbophil
K-PhosMF. Su Monobasic pota"ium and
sodium
K-Ph05 nfUtral. &. Monobasic pota"ium
and sodium phosphate.
K-Phos original. s.., Monobasic .. ium

Kutra ... &. Pancreatin
Ku-Zyme. Su
Kytril. s.., Grani .. tron
L
315t
.. 349,
lactalro Ringer's, 408r
lactation. See Breast-f.eding
I ar:ttlbarU/u.' 100 fin.
Lamiclal.
Lami.U. Sa
538, 542,542t
lamotriginr:
173t, 194,
forbipolardisordtr, 193, 1941
for .. izures, 1691, 173.173,. 175
Lampit. See Nifurtimox
lanoUn alcohol, 7741
Lanoxicap .. Sa Digoxi n
Lanoxin. Di goxin
lansoprazoJ., 6111
lanthanum calbonar., 4201
Lanlu .. &tlnsulin glargine
lapatinib, 5631
infusion, 32, 33f
Lariam. &e
Larodopa. See L",nd"""
Lasix. &e Furosemide
lalanoprosl, 771 t
action. and uses, 769, 771,
administration 7711
adver .. dJu, 770t. 771,
intaactions,77I,
pharmacokinetia, 771.
and adult dose, 770,
latent pha ... HN inftion, 529
laughing ga . Sa Nitrous
LUATIVES,621
drugs dassif .. d as
bulk forming
caldum polycarbophU, 622,
charactaistic., 621
m<1hylcellulose, 6221
psyUium mucilloid. Se< Psyllium
mudlloid
a&'"nts
characteristic., 622
senna. Sa
622, 622,
622, 6221
and osmotic
characteristics, 622
magnesium hydroxide, 622t
poly<1hylrne glyrol, 622,
sodium 6221
stimulant
bi .. codyl,622,
<astor oil, 6221
621- 22
stool
621
docu .. 6221
balance and, 4401
Nursbg Proces. Focus
a ..... 6261
muation of 627,
implermntation
inten'rntions and 626--271
and family education,
626--271
patient goalsand oxpted
outcome., 6261
por.ntial nursing diagno .. s, 626,
LD .. (modian dost ),46
L-Drprmyt. &. hj<lrochloride
WL Sn low-density
L-Dop.t.Se< Ltwdora
2&3
lenalidonide,564
lepirudin. 374, 374,
501
lescolSn FluYa'tatin
l"'rowl., 561, 561,
leucovorin. 123,
lcuk.",i . 549,
uuman. Sn ChJoramhu(U
leukine. Se< Sargramostim
leuropo:esi., 394
I.IUWfIIl:NE MODIFIERS:
ad""r .. effts, 596" 600
drugs cla"ifled as
montdukast. 596r, 599
zafirlukast. Zlfirlul<a!.1
zil .... ton, 596t. 599
pharmacotherapy with, 599--600
lrurotri,""" 599

for 560, 561,
forfemaldnfmility, 712" 713
1",-albut.rol,593,594,
1 ..... 457, 563,
Sa le\'Ofloucin
See
lev.",ir. See Insulin
l.wtiraatam, 173, 173,
levitra. s.., V.rdenam
levobunolol,770,
1"'"<>'tirizine.575,
l",'odor" 260.
actiouand u .. ., 2601
administration alats. 2601
ad"" ... effts, 258" 260,
interaction., 260,
n ... dunism, of action, 257, 259f
Nursbg Process Focus
a ... 261,
Index as5
.... aluation of 2621

and rational ...
261--{i2,
patient and family education,
261--{i21
planning: goals and
outcome., 261,
JXltential nursing diagno .. ., 261,
",..,rdose 260,
pharmacokinetic., 2601
route and adult do .. , 2581
l.mdopa-carbidopa, 257, 258,
u",,- Dromoran. Sa l.emrphanol
tartrate
1.""Ooucin, 4921
kvonorgemd:
for emorg<"ncy contraception, 700.
70\ 70"
implant., 697--98
in oral contrac"1'tiYes. 69g. 698,
Su Nor"1'in"1'hri"e
lemrphanol tartrate, 2221
le..,throid. s.., levothyrminc
Itl'Othyro.rine. 664.
actions and use., 664,
664,
..... 663" 664,
interaction., 664,
"""rdo .. 664,
pharmacokinetics, 664,
route and adult do .. , 6631
u-=yl. Set, kmthyrmi nc
mixture, 121,
Laapro. See
Lai ..... St.. Fosamprtnavir
uxxd,J02,
LH. s..
libido,717
Lihrium. Set: Ch!ordi=poxide
lice:
characteri'tics, 752- 53, 753f
pharmacotherapy. &" PEDICUl.lClDES
p<y<hooocial and community
impact, 755,
licorice, 423" 4711
lid",.i"e, 243.
actions and use., 243.
administration 243,
.. 242t. 2431, 3601
243f
intaaction., 2431
"""rdo .. 243,
pharmacokinetics, 243t
for .pedllc condition.
dysrhythmias, 360t
as local ane.th.rk, 2421
for sunburn, 763
Lifespan Considerations:
adve"" drug in older adult .. 41 1
.g<"-rtlated in drug administration,
."
.lcohol-rdated pancreatitis, 635,
LibraryPirate
886 Index
llfespan S, (ront. )
antirrtroviral drub 533,
botulinum toxin type 10., 277.
in oldu adults, 562.
didary and oldu adult,
'" alfa a. new "blood doping,"
3911
and rsy(hosodal 7061
H, and vitamin B" absorption
in oldu adults, 614.
HN in pMiatric and g<"riatric
populations, 538.
human ,horionic J\Onadotropin abu .. by
7]8t
iron poisoning, 70t
l.uatr.es and balana',
"",
living Parkinson',
di .. a .. , 257.
u .. in oldu adult., 20],
pain a)'"ssion and ptrception, 223.
parasitic inf"'lions in child",n, 523.
pMiatric drug administration, ]9.
pffiiatric 286t
p",scription dr'41 costs, on .. nior
citizens, 8.
psy<hosocial and cult ural impacts on
pffiiatrk patients with diaooes, 682.
.. distress 601 t
.. etiologies on gmetk .. and
factors, ]67.
shift workers, hypothyroidi.m, and drug

volatile inhalants abu ... in child"n and
adolescents, 106.
limbic ISO. lSI!
llnrocin. S .. llncomydn
lincomycin, 495t
lindane, 755
494. 495t, 499
Lio",...t. See
663, 663t
liotrix,663.
lipa ... inhibitors:
orli.tat,634
lipid(.), 39, 283, 284f. Sa also Cholesterol
lipid disordm:
in chilclhoocl. ?AAt
283t
laboratorywlu.s, 285, 2Mt
nonpharmacologkal 21\6-.87
pharmacotherapy. Su llpid-lOl'.'<ring
tb.rapy
lipid-IOl'.'<ring therapy:
bile add See BILE =0 ROINS
in 683.
n .. 287t. 289[. 291
flbrk add See F1Bl!CN:1D t.GENT.
niacin.SuVitamin B,
Nursing Proa .. FO<lI.
as ... ssll1tnt, 292.

of criteria, 294.
interwmion. and
293-94,
and family education,
293-94,
planning: patient goal. and
olltcom .. , 293.
""tmtial nursing diagnoses, 292.
statin . See STATIN'
vitamins. Su Viramin(s),
lipid-soluble
Lipitor. See AtoTVa5tatin
lipodystrophy, ,32
283. 285f. Su
liquid . admini.lration guid elines, 22, 23.
Liquifdm. Su Polyvinyl alcohol
329r
action. and u ... s, 329.
administration aluts, 329,
adver .. dJects, 311 328t 329t
interaction',329,
", .. rdo .. trratnlC"nt, 329.
329t
for "",dlk rondition.
heart failure. 318t

myocardial infarction, 351
hralthca", and, 7<)....8()
Uthium, 1941
action, and " .... , 194t
administration alerts, 19.tt
ad"", ... 67., 194,
for bipolar disordtr, 193, 1941
194t
Nur,ing Process Pocus
a,,,, .. ment, 195,

of criteria. 196.
interwntionsand rational es,
195-96t
and famUYMucalion,
195-96t
planning: patienl goal. and expecled
195t
potrntial nursing diagno",s, 195.
overdo .. trratll1tnt. 19.t.
19.tt
and aduh do,"", 19.t.
LMWH . Su UM- MOLfCUI.l.I- "'"ElGHT
HEPARINS
loading do ... , 43, 43f
local anesthesia, 240
lOCAl ANa11l1IT1CS:
administration techniques. 240.
2401. 241.
adv ..... 242<. 243
classifICation, 242--43
drugs da"iIlN as

artiCiline, 242.
bupiwcaine, 242.
cb.mical .truCiUr<, 243f
dibucaint, 242,
Su lldocai
242,
242.
dydonine, 242.
..
benzocaine. See
243f
242.
242, 242t, 243f
242,
2421
m""hani.m.ofaction, 240-41, 24 1f
Nursing !'roce .. R>c".
a .... 244.

n'aluation of outcome criteria, 245t
interventions and rationalc,
244--45.
patient and family
244--45.
planning: palient soolsand exp<ctN
outcomes.244t
nur'ingdiagno ...... 244.
Su Etodol ..
Loestrin 1.5/J.OFe.698t
l.omotil. Su with atmpi ne
555t
inOOJJUlia, 152
Loniten. Minoxidil
lOOP OIUlmc.l:
ad""r .. dT""ts, 304, 328t , 422.
drug, as
buntttanidt. Sa Bumetanidt
add. 422.
furo ... mide. Su
See Tor ...
m""hani.m, of action, 304,420, 421f
for "",cilk conditions
329
hyperumion, 303., 304
renal faUure, 4.21- 22, 422t
l<>p<ramide.624,6241
Lopid. Su
Lopidine. See
lo r ina vir lri Ion . vir:
actions and m .... 533t
adntinistration alerts, 533.
ad""r .. dT""ts, 530., 533t
533.
pharmacokinetics, 533.
route and adult do"" 5301
Lop",,,,,r, 302 . Su also Mfioprol ol
Loprox. See Cidopirox
Lopurin. Su Allopurinol
loratadine, ,75.
loraupam, 1581
action. and UstS, I).S,
administration alerts, 158.
ad""r,"" df""ts, 158t
. ]58.
overdo ... treaunmt, 158.
pharmacokinetics, 158.
for sprdfi, condition.
LibraryPirate
157,
as intra .... nousane>the!ic, 251,
nausm and vomiting, 629,6JO,
.. izurts. 169" l71,
asskddal mus<lt rolannt, 272,
losartan, 311,
Lott nsin. Sa Iknaupril
Lottn.in HCf, J02,
Loud, JOlf
Lotron= SaAlo .. tron
10'''OIatin, 20t, 2S7,
Lo .... no"" Sa Enox.oparin
(WL):
dtaracttristiu. 2S3, 2S5/
laboratory 286t
ratio to HOt, 285
mbdasses, 2115
lowrr gastrointestinal tmet:
anatomy, 6()7f, 620/
..
constipation, 621. Sa L\..UTlVH
622- 23.
ANI1DIMRHF..\.1S
621,
normal function, 620, 61fJi
low"" 590, 590/
WW-MOIRuv.Jt-WEJGfIT HEPARIN,
(LMWHs):
.. dJu, 374,
373- 74
drugsda"m.d as
dalttparin, 374,
.nox.oparin, 349, 374,
tinzaparin, 374,
action, 373--74
and adult do .. , 374,
for spifk condition.
myocardial infarction, 349
di .. a .. , 373--74.
374,
lox.opine 209,
Lro:itan . Sa Loxapin.
Lowl. Sa Indapamid.
Il'ROSTAGlANDlNl:
drugs da"m.d as
mi"",rostol,617
LSD, 109-10, 109/
L-tryptophan, 188,
622, 622,
WIIIICANT.>, OPHTHAlMIC:
lanolin alcohol, 774,
.. , 774,
polyvinyl akohol. 774,
Ludiomil. Sa Maprotiline
Lugol"s solution, 66-l
Lumigan. Sn Bimatoprost
Luminal. Sa Phenobarbital
Lundk Su
&, Eszopidone
Lupron. Sa Leuprolid.
Lupron Depot. &,
lutnnizing hormone (LH),658f, 695. 716
Lu",,""- Se. Flumxamin.
lyn .. di ...... , 480'
l)1llphatk 447
447
globulin, 458t
lymphoma, 549,
lyrica. See Prtsabalin
lysodreJI. Se. Mitotan.
M
rna huang, drug
digoXn, 331,
loraz<:parn, 158,
pb.ndzin., 190,
Maalo,," Sa Magn.,ium hydroxide and
aluminum hj<lrru:id.
Maalox Plus. Sa hydroxide and
aluminum with
simtthicone
MIr.C complex),
,01
macrocytic antmia, 398, 398,
Manod.x. Sa IHxtmn 70
MAUOUDf.S:
ad ........ tr.cts,489, 489,
drugs cla!>Sifled as
azithromydn, 489, 489t, 50 I
daJithromyrin, 489" SOl , 616
dirithromydn, 489t
rrythromydn. Sa Eryth romycin
for H.pylori, 616- 17
pharmawth.mpy with, 489
routtand adult doses, 489,
MACiOMINEJ.AlS:
caki\Ull. Se, Cakium
charaoteriOlks, 648
<hlonk Sa Chloride
funotions,648,
magn"ium. See Magnesium
pharmacothtmPrwith, 647t, 648
pho'rhorus. Sa
pota,,;um. Sr. Potassium
allowanas, 648,
sodiu:n. Sa Sodium
sulfur.648,

magnesium:
functions, 648, 648,
imhalmas, 437<, 648. Sa "/,,,
Hl'P"rmagn.sernia;
.. mia
with
chlorid., 647,
hj<lrru:id . 615" 622t, 647t
hj<lrru:ide and aluminum
615,
hj<lrru:ide and aluminum
with 615,
647,
Sn Mlgnesium
.uJfate
rODUI1tnded allowam,.. 648,
magnesium 647,
magnesium hydroxid., 615" 622" 647,
Index as7
hj<lroxid. and aluminum
615,
ma8ntsium hydrru:id. and aluminum
with simtthioont, 615,
masn.,ium 647,
magnesi um sulfate, 6491
actions and uses, 649, 649,
administration a1tns, 649,
647r, 6491, 708,
interactions, 649,
"""rdo .. 649,
649t
route and adult do,"", 647t, 70&
as tocolytk. 708t
Mag-Ox. Sa Magnosium
maintrnana do"", 43
major dtprtssi'il' disorder, 182. Sa "/,,,
lHpn:ssion
major mineral. Se, MACROMINElALI
malaria. 116t
S07t, 515
pathophysiology.515--16, 517f, 521,
pharmacotherapy. See Ir. NTIMAlMlIA15
pn: .... ntion, 516
Set. proguanil
malalhion.753
InfmiUty, 718- 19
mal. rcproducti .... function:
disord ....
and, 144,
dysfunction. Sa
dysfunction
hypogonadism. Sa HYJlO8OIIadhm
indd. net.716t
inkrtility,718--19
hypothalamic and pituitary n:8ulation,
716,716f
malignant hypathamia, 473
malignant tumor, 549,
Manddamin . Sa Meth. namin.
mandrake, 559
mangan ... , 649,
mania, 190. Sa "Iso BipoI ... disord.r
manic Bipolar doonkr
mannitol, 773
manual hraling, 95,
MAO (monoamineoxida .. ), 130
MIr.Ols. Sa MONOAMINE OXIDASE
INHIBITORS
Maolat . Sn
Maox. Sa Magn.sium oxide
maprotilin., 186t
MIr.R (m.:dication admini,tration
r<eord),88
mam'lirO<,530,
Maroain . Sa Bupivacaint
Marezin . Sa Cydizine
marijuana:
.ffu, 109
fetal . fkcts, 68,
toxicity signs. 106,
withdrawal symptoms, l06t, 109
Marinol. See Dronabinol
LibraryPirate
8B8 Index
Marplan. Sa lsocarboxazid
masculinization, 717
MAST CELL STAlIlllZERS:
ad..., .... df"ts, 596t, 600
drugs classifii as
cromolyn, 580, 5961, 600
nWocromil sodium, 596" 600
pharmacolhrrapy with, 600
mast cdls, 465
mastoiditis, 776
Medica, 3
See
755
maturity..,n .. 1 diaoo ... See
mdlitu .. typr 2
Mavik. Trandolapri/
Manir. See
Maxalt. Sa Rizatriptan
Mayapple, 559
MCT Oil, 651
MDA,IIO
MOl (metered do .. inhalu), 591, 591/
MDMA, llO
.. , 1161
measll'S, mumps, rubeUa vaccine. 4521
.. systems, 21- 22. lIt
Mebaral. See Mephobarbital
5231
actions and u ... s, 522, 523, 523,
administr.nion u ..... 523,
ad" ..... dfects, 522t. 523.
interactions, 5231
pharmacokinetics, 523t
rouU and adult dru<, 523t
278
meao ... rmin, 660, 660t
of action, 12
555.
meclizine, 629, 630,
median eff""t" .. do ... (ED,.),46, 46/
median 1.tha1 do .. (LD,.), 46
median t""idty do ... (TD,..), 4 7
medication. 4
medication administration rord
(MAR),SS
medication error(.):
a""iding. Se. also A""iding Miiaotion
,="
nu .... ', .. for, Ig, 19
cate""ri ... 89. 891
in child .. n, 9Ot, 91,
and, 57
faclors contributing 10, 85
in 85, 87t
impact, 85-86
OTe drugs and, 91,
r'"""rtins and
documenting in miiaol
r"""rd,87-8-8
.. poning to national databases, 88
writins an report, 88
strategies for reducing
education, 90-91, 90.
in facUities, 91
nursing p=ss in, 88--89
tracking,91
uror index, 85, 86/
reroncUiotion, 90
MEDMARX, 91
Mtdrol. Me Methylp .. dnisolone
706,
action. and u .. s, 706,
administration alerts, 7061
ad .. rr .. effls, 561., 707t
706t
pharmacokinetics,706t
for sp<dfic conditions
cancer, 561,
dysfunctional bl<ling,
707,707,
inj""tion for contraception, 697
MedWatch,87,91
mefenamic add, 228.
mdloquine,516.
Megace. See
mellalobla,lic (p<midou.) anemia, 399,
M'
megestrol, 560, 561 ,
MEGl.JfINIDE.\:
adyrr .. effls, 687,
688
drugs classified as
687t
rtpa&linide. 687,
and adult do>es,687t
mdanin,750
melanocytes,7so
melatonin, 153,
Mollari/. &. Thioridazine
mdoxicam, 467.
mdphalan,555.
264"";5, 265/
B ceUs, 447
meningitis, 480.

definition, 704
estrogen 10 ... in, 705t
hormone therapy in. See
Hormone .. placc:ment thaapy
nalural therapy wilh black coho'h, 704,
menorrh"l!ia, 706
712, 712t, 719
M.nta>:. Sa
222., 635
hydroxyl .... , 81 , 81t
mephobarbital, 159',171,171,
159
mercaptopurine, 5so/, 554, 558,
M.ridia.
499
515,517/
Me""m N. Meropenem
6281
110, IIOf
Mf.<tinon. Sa Pyridosligmine
metaholit: acidosis, 420" 44}.
mmbolk disea .. (MBD), 733
metabolism:
alcohol, 108
dru,
faclors aff'""ting, 40
m,""hani,m, lS/. 40
In older adults, 73--74
in pregnancy, 64"";5
Metaglip. Glipizidc/metformin
M.tamucil. Sre Psyllium mucilloid
Meland .. n. Sa Methyltestosterone
metaproterenol, 132t
metaraminol, 132,
metastasis, 548, 548/
metaxalone,272,
rn<trrido .. inhaler (MOl), 591, 591/

actions and u .... 689t
administration alrrts, 689.
ad...,r .. 688, 689,
interactions,689.
m""hanism.ofaction,688
oyrrdo ... treatment, 6891
pharmacokinetics,689.

foropioid 107. 227
for pain manascmen!, 222,
methadone 227
methampooamine, 110- 11, 198" 200, 581
methazolamide,770.
495,
Methergine. See m ..
rnrihimazok, 6631, 66.J
M.thitest. Sa
methocarbamol,2721
methohexital sodium, 251.
.. xate, 5571
actions and u ... ,557t
administration alerts, 557,
ad...,r .. effects, 555,. 557t, 742.
interactions, 100., 557t
mechanisms of action, 5so!
overdo .. 557t
pharmacokinetics, 557.
for sp<cilk condition,
aoncc:r 555,
458t
inflammatory bow.l disea ... , 625
poori",i . 762 . 763
rhrnrnatoid arthrilis. 742t
stmctu .. ,556/
methotrexate with mooprostol, 704
methoxyflurane. 246.
methsuximide.174,
M.thulo .... See Mcthykellulo ..
methyclothiazide, 303., 422t
methykeJlulOK, 622" 774.
methyldopa, 315.
methylfl"WJnovine 708t
1981
abust, III
action. and u ... , 198t
for ADHD, 200
LibraryPirate
administration 198,
adya .. 1981
im .... ction., 1981
mechani,ms of action, III
Nursing Pr"", .. Focu., 199--200,
in olda adult., 201,
o'-"'rdo .. 198,
1981
methylpminisolonc;
for ad",nocortkal insufficirncy, 67 1,
adva .. 4701
.. 629, 6301
for inflammatory bowel di .. a .. , 625
for .. ""'" inUammation, 4701
717,
MmIYIJlANTHINES:
aminophyUine, 5941, 595
characteristics, 595
pharmacotb.rapy with, 595
theophyUine, 594" 595
methysergide, 233,
metipranolol,770,
metodopramide, 617,630,
m.tocurin. , 278,
3031, 422, 4221
Soc Metyrapone
3341
action, and u .... 136" 334,
administration 334,
adva .. effts, 3281, 334" 3431
polymorphism. affecting
metaboli,m, 81,
jmfractions, 334,
o,,,,rdo .. tmtmem, 334,
3341
for specific condition.
angina and myocardial infarction, 3431
heart failure, 328,
3151
migraine,2B,
metric system of 21, 21,
MmoCmm, Se< Metronidazole
Urofollitropin
Su Metronidazole
mdronidazol e, 522,
actio", and u .... 522,
administration 522,
adyer .. eff15, 5221
as antibacterial, 494, 4951
imaactions,522,
for nonmalarial protozoan infections, 517
phamIaCOkindks, 522,
for specific condition.
H. pylori, 616
ro .. cea, 757
Mdubine, Soc Metocurine
metyrapone, 676
Mn-acor, Lowstatin
>601
MaitiL Sn
MJ. Soc M)"Xardial inf./'Ction
Miacakin, See CalcitoniJl-salmon
mibtfradil,20,
mkafungin, 508,
Mkardis, SecTdmi .. rtan
Micatin, Sn Miconazole
miconazolt, 513" 514, 752
MICRhoGAM, Se< Rho(D)

microcy:icanemia, 398, 398,
Mkro-K, Sn Pota.si um chloride
Microlirid, 651
MICltOMIf!'l!Al.\:
chrolllium, 649,
cobah,6491
copper, 649,
fluorbe, 649" 650
funcoon.,649,
iooino,649--5O, 662
iron, 399--400, 649,6191, Sa abo [roN

mangJneS<,6191
649,
allowa",,, .. 649,
stleni:.tm, 649,
zinc, 649" 650
zinc acotate, 6471
zio, &!uconn., 6471
zinc 6471
Micro""", See Glyburide
Micronor, Sn Norethindrone
Mie''''p"rum, 5071
Microsulfon, Sec Sulfadiazine
microvil i,607
Microzide, See Hydro<hlorothiazid.
Midamor, Sa AmUoride
midazohm, 20" 157, 251,
middle .dulthood, 72, 72/
Mi&pra. Se<
7031, 704
for CIt.<hing'. syndrome, 676
mi&!itol,6871
migraine:
230
incid,"co,2J.Ot
232, 234, Sn aoo
ANnM!GfJJNE DRUGS
propJ:ylaxis
blockers, 2331
calcium cbanne! blocurs, 233,
233,
riboUavin, 2331
topiramate, 2331
tricydic ... nt .. 2331
,;olprok acid, 233,
MigranaL Su DihydJ'Ort'gotamine
Milk of .\lagnesia, See Magnesium
hydroxide
milk 96" 97t. 108,
syndrome, 615
Milontin, Su Pb.nsuximide
Su Clomipb.ne
milrinOIl e, J36t
actior .. and u .... 336,
admimi,tration alal5, 3361
ad"" ... effects, 328" 3361
imeractions, 3361
"""rdo .. 336,
.. 3361
route and adult dOst, 328,
mind--body 951
min .... l oil, 622, 6221
mineralocorticoid .. 670, 671
minerals:
IndH 1189
macrominerals. Soc MACl{)MINIV.l.'i
micromin .... ls. Su )'lICROMlNlltM5
minimum effecti", concontration, 42, 43f
minipill .. 697
Minipress, Ste Prazosin
Minocin, Su Minocydin.
minocl"line, 489,
minoxidil, 3IS,
miosis, 770
Mio,tat, SIX Carbachol
M!OTICS:
,arbachol, 770,
770,770,
MiraLax, See glycol
Mirap<x. SIX

Mil'etl3, 698, Ste ah<)
mirtal.apine, 1551, 1861, 18S--89
misopro,tol, 703" 704, 7081
for p<ptic uker pre .. ention, 617
mitomycin,5571
milotane, 563" 564
5571
for mnltiple ""lerosis, 267, 267.
Mitrolan, Se. CaJcium poJycarbophU
Miwcron, Se< Mivacurium
mi,-.curium, 252, 278,
MMR II. Su Mea.!e .. mumps,and rubella

Moban, Sn
Mobie. Su Mdoxicam
modular formula .. 651
motXipru, 311,
molindone, 209,
649,
momerasone, 580" 596" 760,
Monistal. Sec Miconazolt
oxidase (MAO), 130
MONOAMINBoxtru.IE INHIBITOl.\ (MAOb):
.dve .... .. 155" 156, 1&6., 189
druss dassifil as
iso<arboxazid, 1861
phrndzine, SIX Ph.nelzine
tranylcypromine, 155., 186,
imaaction .. 156, ISS" 189
mechanisms of action, 18S!. 189
Nursing l'rocce .. Focu., Su
AntidC']l""sams, Pro.: ....
"""' for specific conditions
antitty symptoms, 155,
1861, 189
monoba,je potassium
monobasic potassium and sodium
pho.phat .. , 6471
LibraryPirate
890 Index
MONOCLONAL ANIl90DIE, (MASs):
ad"""", df .. ts, 458" 473
for 457
druss dassifil ...
5631, 564
ba,iliximab, 457,458,
b..vadzumab,563.
hortfWmib, 563.
563,
dadizumab, 457,453.
563.
gefitinib, 563.
gomlu:rumab 563.
ibritumomab tiuutan, 563,
imatinib rntsylate,563., 564
intliximab, Su In(iximab
lapatinib,563.
globulin, 458.
muromonab-CD3, 457, 458,
rituximab,563.
ocinitinib,563.
564
tositumomab, 563.
trastuzumab, 563--fi4, 563.
m<'Chani,msof
for conditior .
cancer 563--M, 563., 564/
immuno>uppression, 457, 453.
Monom. See lsosorbidr
Monopril See FminoprU
monosodium gluumat. (MSG), 230
monldukast, 599
Monurol See Foofomydn
mood disorder, 182. Set Bipolar
disord .... ; Dtprasioo
mood stabUizers, 193. 5eealso Uthium
mominH ... 628
. ulfat., ll31
action. and uses, lllt
administration alul5, 223.
ad"""", dr.cts, 2221, 223.
polymorphis:ns afi'eaing
mdaholism, 81t
223.
in mJ"'Xardial infarction, 35 I
"""rdo ..
pharmacokinetics,
rouuand adult do .. ; 222.
motion .kkneos. 577,621., 1\2'1
Set with atropine
Motrin. Su Ibuprofen
moxil\oxadn, 491, 492, 492,
MarobU. See
MSG (monosodium slulamatd, 2].0
mu n:cC'ptors, 221, 22 1t 221 .
Mudn.x. Set .. in
MUCOLYTICS:
583., ,85
characteristics, 585
dorna .. alfa, 585
pharmacothrrapy with, 585,601
Mucom)"l. Set
mucosalaycr,607
mucositis, 552
Multaq. Set Dron.ru.rone
multiple tdaosi. (MS):
266-07
classifICation, 267
di ..... -modifyin8 drug.
immunomodulators
glatiram.rac .... at., 267, 267,
beta- la, 267, 267.
interferon beta- Ib, .67, 267.
immunosuppressants
mitoxantron., 267, 1.67 t
2.\6.
mupirocin,752
Murin. T.ars Plu . See T""n.hydrozoline
muromonab-CD3, 457, 458<
mus<arinic antaGOnist . See.
AN11QlOl1NJIGlCS
mu"""rinic n:ceptors, 131, 131.
mus<l. relaxants. Su SUIEI.l.L MIJSCl.E

muscl. rigidity, 256
mUKk spaJlms:
causes. 271
definition, 271
home care consideralion>, 277.
27l.
natural therapy with cay<:nne, 273t
nonpharmacological tn: alm.nt, 271
Nursing Proc<ss Focus, 276--77.
pharmacoth.rapy, 271 , 272,. Seea/so
SKll.ETAL MUJ.Cl IIElJ.XANTS
Mustarg.n. St.
mutations, 481
Myambmol. See Elhambutol
my."h.nia gf1lYis:
characi<ristks,139
cholin.rgic agonts for,
nitrous ust in, 247
Myc<lex. St. Clotrimazol.
Mycoh<lc .. rium aV;lIm cIlmpia (MAC), 50 I
Mycobrutorium kprae, 480t, 50 I
Myrob.u .. riurn .uberru/",;<, 480., See
ali", Thberculo.i.
Myoobulin. Su Rifabutin
mycophrnolat. moktil, 45&
Afycoplru".a 430.
my<:<>..s:
mmmnnitY.""'1nirM, <;(17
definition, 508
507.
opportunistic, 507
pathog.ns, 507.
pharmacoth.rapy. See Alo.T!FUNGAI..S
ruperflC ial, 507 508
syst.mic, 507., 508
Mycostatin. Su N)"tatin
Mydfrin. See PhnylC'phrine
Mydriacyl See Tropicamid.
mydriasis, 770
MYDRIATIc.\, 774, 774.
phen}"iophrin . See
MyFortic. Ste Mywphenolat. mof .... il
Mylanta. St. Magnesium and
aluminum hydroxide with

MylantaAP. Sre
Mylanta Gas. Su Sim.thicon.
Mylanta . See Calcium <arbonate
with m.gn .. ium hydroxide
See Burulfan
Mylol.rg. See Gerntuzumab
Myobloc. Su Botulinum tm;in type B
m}'Xardial infarction (MI) :
d.finition, 347
diagnosis, 347--48, 349.
incidence, 340.
natural th.rapy with gin .. ng, 349.
pathophy.iology, 347, HOi

goals, 348
for symptoms and compliedt ions
ACE inhibitors, 350
anticoagulants, 349
antiplatdets, 349
beta-adren.rgic antaGOn.sts, 350--51
nitrates, 350
thromholylics.. Su TliROMOOLYf!CS
m}'Xardial i.m.mia, 339, 350/
m}'Xlonk ... i:rure, 168., 169., In
myoglobin, 349.
Myolin. s... Orphrnadrin.
MY.'lOlin . See Primidon.
mJ=<kma, 659., 662
N
N. ' . Su Sodium
nabilon., 629, 63(1.
nabum.lone, 228., 467.
472t
N.a. See Sodium
nadir, 552
315., 343.
nafan:lin,712.
N.fcU. See Nafcillin
nafdllin, 484.
nalliflD. , 514.
Nallin. Set Naflifin.
N.HCO,. St. Sodium
nalbuphin. hydrochlorid., 222.
Nalfon. Sr. F.noprofen
n.l ioi ixk Add, 4'11, 4'IIt
nalmefrn. hydrochlorid., 222.
n.loxon. hydmehlori de, 226t
actions and U=, 123., 221, 226" 227
administration alerts, 226.
ad, .. r .. effects, 226,
int.ractions, 226.
o""rdosc 226,
pharmacokinetics, 226.
route and adult do .. , 222.
nalnnone hydrochlorid., 2221, 227
NANDA (NorthAm.rican Nur.'in8
Diagnosi. Assoo:iation), 57
nandrolon.,717.
581.,774,774,
LibraryPirate
Naprdan. Su Naproxm
Naprosyn. Su Naproxm
naproxrn. 228,. 467t
naproxm sodium. 22&
naratriptan.2B,
Narcan. SN h}o:Iro<hloride
narcotk. 220. 221
narcotic SN OP[OID (NAJtCO"I1C)
t.NAI.G<.S!C5
Nardil. SN
Naropin.
antibiotk 482. SN also
ANI1MCfEllAlS
prnidllin .. SN
Pl:NICIllINS
Nasacon AQ. Sa
n.l!>JI drug administration. 25. 261. 28f
Sa
Na!>Jrd. SN
Naorobal. 5I:e Vitamin B"
(cyanocobalamin)
naoogamk (NG) tube, 23" 24
Naoona. Su
natalirumab. 625
nateglinide.687,
National Cbobl<rol Education Program
( NCEP),285
National Coordinating Coundl for
M..dkation Error Rrponing and
Pr< ... ntion (NCC MERP), 86f,
87.89f
NllIi"ntI/ furrnuillry (NFl. 5. 6f
Nati ...
tnatm.nt. 205,
Natncor. Sa N ... iritid.
Naturacil. Sa Ps}llium mudlloid
Natural Hoaltb Products
(NHPD).9
natural ponicillins. 484,
nau .. a. 625. SN ,,/so Nau .. a and
""miting
nausea and , umiting:
pathophysiology. 628-29
pharmacotb.rapy. 51' .. ANnEM!IT[c";
Sa
NO" .mew. 7
NE. Sa
N.lxin. SNTobramycin
nebulizer. 591. 591!
Nebur.nt. SN r.ntamidinc
nedocromU sodium, 5961
ndawdone. 186t. IS'}
negati"e formulary list. 14
negati"e inotropic agent .. 325
negati"e 'ymptom 204
NegGram. Sn Nalidixic acid
NeWeria go"o,"'o""". 480,
Nei5JniD mmingi,id;<, 4801
ndarabine.555t
ndfinavir.5JOt
Nembutal. Sa r.ntoharbital .ooium
Neoloid. Castor oU
neomydn. 490. 490,
neomycin cream/ointment, 752
neomycin with polymyxin B cream/
ointment. 752
neoplaSJll. 548
Neoral. SN
neostigmine, 123" 139. 140t
Neo-SJ"TIephrine. Oxymelazoli nc;

ntphron.418.419f
nephrotoxic drug .. 4ID,
Neptaune. 51:. Methazolamide
ne"", agents. lID. 121,
ne",e bind:: anesthesia, 240;; 241,
Nesacaine. See Chloroprocaine
nesiritide. 328t. 334
Neslfn:. Sa Vitamin B,
Neulasta. SN Pcgfilgrastim
Neumep. Sn OprthdJn
Neupogen. Sa Filgr...,tim
neural tube defect .. 644,
neurofibrillary tangl.s. 263. 265f
nrurogcnk .hock. 407t
neurohypophysi .. 657
NEUIO(1N1N iECEl'fOR ANTAGON!ST:
aprepitant.629.63Or
ncurol.."tanalge.ia.248
nrurol . ptic mal;,;nant ryndrome. 187,. ISSt,
473
neurol.."tics, 206. Sre ANnPSYUlOf!c";
NEUIOMUSCULU 1I!.OaE1.\:
d<p<>Jarizing
,uccinylcholine. Se.
as general anesth""i. adjunct. 252
nondepolarizing
miwcurium.252
tubocurarine. 252. 252t
Neuromin. Sre Gaoopontin
neuropathic pain. 219
Neutra-Pho .. Sa Potassium and sodium
pho.phor..
Neutra-Phos-K and sodium
pho.phates
Neuttogrna. Sre Salicylic add
n ... irapine.53Ot
administration alerts. 533,
New Druglo.pplication (NO",. 6;; 7
Noxa,.,.r. Sa Sorafcnib
Nexium. Sa Esomeprazole
NF furmtlillry), 5. 6f
NHPO (Natural Health Products
Dirtctoratc 1. 9
Niac. SN Vitamin B,
niadn. Sre Vitamin B,
nkardipine. 307. 307t. 319
Nicobid. SaVitamin B,
Nicolar. Sa Vitamin B,
nicotine:
characteristics, III
offecr.. III
toxidty sign .. 106,
witlxlrawal .ymptom 106,
nicotinic add. SNVitamin B,
nkotinic receptors. UI. Ult
308t
actions and u .... 307. 308,
administration alen .. 308,
Indn 891
am ..... .rf.ct .. 233t. 307,. 708t
interanion .. J08,
mechanisms of action. 307
ovrrdosc trtatmem, 308,
pharmacokinetics, 308t
for condition.
angina and myocardial infarction.
343,
hyponrn,ion. J07,
migrain 233,
a. tocolytk, 708,
nifurtimox,521,
NUandron. SN NUutamide
NUlla!. Sre Nystatin
nilutamide.5611
Nimbex. SN Ci .. tracurium
nimodipin 233,
Nimotop. See Nimodipine
nisoldipinc. J07,
Nitro- Bid. Se. Nit rogly<:erin
Nitro-Onr. Sa Nitrogl)'<"cTin
nitrofurantoin. 495t
nitrogen mu.tard. 121,
NIJlI()(;EN MUSTAltDS. Sa "UJ!A.l1NG

bc:ndamustin 555,
555,
51:.
Cyclophosphamide
estramustine.555,
ifosfamide. 555t
mechlortthamine.555,
mdphalan.555,
nitrogl yce rin, 344,
action. and u .... 344t
administration alm .. 344,
am ... ",dfcct .. 343t. 344,
interaction .. 344,
nursing proc ... foeu.
a ... ssm.nt. 344--45t
... aluation of outcome criteria. 346t
implementation
intervrntions and rationale ..
345-46,
patirnt and family..ducation.
345-46,
planning: patient goals and expecr.d
outcom . .. M5,
potontial nursing diagno .... 344--45,
m..,rdo .. trtatmem. 344,
pharmacokinetk .. 344,
route and adult do ... 343,
in "'-'J><CI<d myocardial inf."'tion, 350
Nitrop,""ss. Sre Nitroprusside
nitroprusside. 318t. 319
NitroQuick. See Nitroglycerin
NImOIOURfAS. Sa abo Mn!A.llNG AGElmi
carmustine.553.555t
lomustine.555,
strevtozocin.555t
LibraryPirate
892 Index
Nitrostat. Sn
nitrous 2471
actions and u,"" , 247,
administration 247.
ad""""d&cts, 2471
2471
"""nlo .. t .. 247.
pharmacokinetics. 2471
nils, 753
Nix. Sn
6121
Niwral. Sn
NOC (Notice ofComplian<C"),9
nockepti"" pain, 219
nociceplor, 220, 229f
Noct..: . Su Chloral hydrate
Sa
NONBJ:NWDIAZEPINE. NONllARBITUIATE CNS
DEPRESSANTh:
for anxiety and insomnia, 1601, 161
mechanisms of action, 161
Nursing Focus. 161-631
drugs dassifiro as
buspirone, 266
dexmooNomidine He!., 1601
esropiclone, 1601, 161
ethchlorvynol, 1601
zaleplon, 160.
Su Zolpidem
noncatecholamine drugs. 130
blockers. 275. &e a/$o
NruJIOMlJSCULl.R BLOCKIlIS
dients:
communication COIIsidorations. 591
pharmacotherapy considerations.
3O,30f
NONNUCLOOIIDE J.EVlJI.IE lRANSCRIPTAIE
INll!BITOlS. Sn ,,150 ANTIIIEI"IOI'IIAIS
ddavirdine,53O,
davi .. n7- Sn Efavi..,nz
..travirine, 53(1,
neYirapine, 5301, 5B
NONOPIOID ANAlGE..\!C.'i:
aCflaminophon. Sn At::rAMINOI'IiEN
centraUy-acting
donidine. Sn ClOllidine
tramadol,228,
22S,
nonsteroidal anti-inflammatory
dru&S. &. NONSTIlIOII"-L
AN11- INFV..\'\M.o\IOlY DiUGS
(NSAlDs)
NONPHJ:NOTIl!AZ.lNO:
ad,..,,,,, effects, 20S, 209,
drug. dassifiro as
chJorprothixene, 209,
haloperidol. Sec
loxapine succinate, 209.
molindonc, 209,
pimozidc, 2091
thiothiunc,209,
Nursing Proceso; Focu.
.s"ssllYnt,209,
implemmt.tion
rvaJuation of outcome criteria. 211,
and rationales,
211J.-ll,
patient and famUyeducation,
IllJ.-ll,
planning: patient goal. and cxpcctl
outcomes, 210,
potmtial nursins diagno""s, 209,
nOllspifk ceUularrcspon .. s. 50
nOll5piflc dden"" syst em, 447
NONSTEROIDALANTI- INI'l.AMMATOlY DRUGS
( NSAIDs):
drugs classified .s
ibuprofen and ibuprofen-like drugs
didofen.c, 228., 4671
difiunisal, 22Sr, 4671
otodola", 22SI, 4671
knoprofen, 4671
f1urbiprofm, 228 . 467.
ibupro&n. Sn Ibuprofen
indomethacin, 2281. 467., 744
kctoprofen, 228., 4671
kctorolac tromethamine, 228,
mefenantic acid, 228,
mdoxicam, 228" 467.
nabumetone, 4671
naprmm, 228., 4671
naproxen sodium, 22S,
oxaprozin. 4671
piroxicam. 2281. 467.
sulindac,228,
tolmetin, 228t, 4671
salicylates
aspirin. Sn A.pirin
cooline saJicylate, 228,
saJsaJate,2281
COX-2 inhibitors
cdecoxib, 22S" 467t
herb--drug 1001
mechanism. of action, 227
Nur,ing Process Focu,
assessment, BII
of 2321
implementation
intorvcmion.and rationales,
231- 32.
patient and famUyC"ducation,
231- 321
patient &oal, and expccll
outcomes,231.
""tmtial nursing diagnoses, 231.
for specifIC condilion,
inflammation, 467- 70, 741
oSlroarthriti.,74 1
pain man.gemmt, 227- 29,
228.,741
u .. .tatiSlic 465.
Non:uron. Sn Doxacurium
Norditropin. Sn Somatotropin
(NE), 411 r
action. and u ... , 132., 411.
administration alorts. 411,
ad""r ... 411,
imeraction',411,
overdo"" treatmon!. 4 11,
pharmacok.inetic,,411.
physiology, 130
.. ceptors. Sn Ad .. ncrgic .. ceptors
for speCific wudition.
hearl faUu .. , B5
shock, 409,
norethindrone, 707,
NorfleL Sn Orphenadrinc
norfloxacin, 492.
norgostimate,69S.
norgo.>l .. 1,698,
normal .. line, 4081
normal .... rum 409r
acrion! and Ula, 409r
admini.>lration alerts, 409.
ad""r ... cffcct.,409.
interaction,,409,
pharmacok.inetics,409,
normochromic anmIia. 398, 39S.
normocytic anemia, 39S. 398.
Normodyn . Labctalol
Noroxin. See Norfioxacin
See Disopyramide
Norplanl, 69S. also
Norpramin. See D .. ipramino
Nor-Q.D. See Norethindrone
North Americau Nursing Diagnosis
Association (NANDA). 57
nonriptyline, 1551, 186,
Norulate. See No .. thindrone
Norva5C. &. Amlodipine
nosocomial infcaions, 481
Notke of Compliance (NOC), 9
Novahistino DH, 584.
Novantrone. See Mitoxantrono
Nova .. l. StY Chorionic gonadotropin-HCG
Novastan. See Argatroban
Novocain. See Procaine
NomJin R. Sn Human ...,gobr insulin
N"""Log. See Insulin a']lOIrl
NPH. StY lsophane insulin .uspension
Nplate. See Romiplo.tim
NREM ,l'"<t', 153, 1541
NSAIDs. Se. NONSTIlIOlDAL
AN11- INFI.AMMATORY DiUGS
Nubain. S .. hydrochloride
NUCLEOSIDE AND NUUEm1DE REVD.,';I;
nAN>CR!!'fA.lE INHIBITOR>' S .. al50

abacavir.5>O.
didanosine, 5301
emtridtabine, 5>0., S38
lamivudine,53Ot
'iavudine, 530,
tenofoYir. 530 53]. 538
zidovudine. Sn Zidovudin.
s... Dibucaine
&. Dibucaine
nur ... (. ):
drug appro, .... l proces.s and, 9
LibraryPirate
nursing
ddinition, 51
in dnIJ 51, 5&.
nuning proass:
defUlition, 55
in d""
...wment 55-57, 56r
cvalU<ltion ph.lIt, 59-60
implemcnlal ion phut, 58-59, 601
nursing diagnoKS, 57, 58.
planning phase', 57-511
in mNicallon error n:duction .nd
&3-89
phases, 55/
NuninH Focus;
ACE inhibilornnd ARB bIockrn,
)]3-]4,
amc mf<iicalions,
ADHOand AOD thnopy, 199-2OOr
adrmc.rJk aJOnlm (J)'IIll'"thomimelks),
1J4-lS,
adrmc.rJk antaJOnlsu ( symp.tholytics),
316-18.
androgens. 720-2 1.


anlibacterials, 496-98<
antichoiin. rilcJ (choiin.l"gk-blacking
agoents),1 45-46.
316-7'9r
antideprWilnls, 191-93.
antidysrhythmks, 361-63.
antkmdiCl, 632-33.
antifullpb, 5 10-12.
ant;p.ucolN dNiSo n2_73.
antit\Out drug" 745-16.
antihistami nes, 57&-80.
anti-inn.mmillorln, 473-75.

antiplalelet thera py, 381-82.
antiprolOZCl;lls and antihdm.inthics,
518-20.
amipsychotlcs
atypical.2 1l-15.
con.-mliona!.21Q-11.
antipymkt. 41l-7S.
aotirctrovLtab. 534-36.
antise'izun: drugs, In_79.
anti,JWmodla, 276-n.
antithyroid agoenls, 668-69.
amitubcrculosis drup, 502-3.
bipolar di50rder therapy, 195-96.
bi.phosphonaln. 738-39.
bowel dl50rders, 626-27.
bronchodU.,on, 597-99.
aicium channel bIockrn. J09.--IO.
chonnerglcs (p;orasympathomimetiu),
141-&3,
f3e1Qrs, 395--97.
diJaxin,332-33.
diuretics
ror hyperlm,lon, )05-7.
for ",nal failun:, 425-27.
m te.-J and IOta! parenter.ll nutrition.
651-53.
epott,n alf,., 392-9.1.
... flCtilt d)'SfunCiion treatment,72.l--U.
eSl .. n and PTOBO$lin th"""py, 701- 3.
f ... t'OCI 401-21
fluid IDd tll rolyt. replacement the""py,
434-35,
fluid lfpJa>tment for !hock, 4 10-111
folie add. 401-2.
generll 249->0.
gluoocorlicoldl. 473_75., 674-75,
H,-n:cqltor anugoniw, 571!-11(1,
h ... peIVirul p ..... rm""oth.rapy,
!42-141
HIV-AiDS p ..... rma<OIMrapy. 534-36.
horroont 70] - 31
hypollW;lmk: In<! pituitary hormones,
" ..... ,
immunostlmu]ant .. 455-S6t
immunosuppn:JSOInls,
,n",lil Ihctapy. 634-86t
levodopil or levodopa-a.rbidopa,
:<61-62,
lipid-lowering IhfUPY, 292-941
loca] . ne5,h.lie.!. 244-45.
nilro"yurln, 344-4&
,lIlIj_innammatory drugs,
:il 1-32.
opiold In;tJanks, 224-26.
0011 hypoJI)'tOmk:s, 690-92.
O5I.lIOpOrosis and om... hoM di..,rders.
i3&-39.
oxyIo.:in.llQ-1 I.
pept ic uktr and autro .. ophlgn/ ", Oln
di5<'IK Ihcrapy,613-14t
skeleul muscle n:iaunlJ, 276-77,
cold ",Ii.r, 585-87.
thrombolyllcs, 384-115.
thyroid hormone ",plac.m.nt,
"'-'"
235-36<
vasodilators. 320-22,
vitamin and min.ral pbumacOlherapy,
" ..... ,
vitamin 1",401-21
nutritioaal Jupplcmmt'l'
.... t.ttI. S Entaal nutrition
indicl lions. 650
!otaI9an:nlcral nutrition. S Toul
rlrtnleral nutrition
Nutropb. S. Soma,otropin
Nuv. Rin8,698
N}'lrazid. hnnl.!zi d
n)'Jtatl n, 515'
acliou and IISOIo. SIS.
admi.lstratlon alert .. SIS.
ad.-erlt tlfta, 5 14., SIS.
p/1;IrmiKOkinelk:s, 51 5.
routnnd adult dolt, 514.
Nyslcx. S N)'Slalin
N)'Stop. S N)'Slatin
Nytol. S Diphenhydramine
Index Bill
o
obftity:
elloioaY,63 1
health risks. 629
Inddmc.,629

object!Yc dlola, 5S
obttsJiYe-compubj", doordcn 150
Ocu gam, Sa lntra-,,:nous globulin
660, 660.
OcuClear.
of\ou.dn, 492" SOOt
olanz.apln., 194., 213., 266
oId<'l' adulthood, 72
oId<'l' adulU:
ildvtrw df\l(l tlfrru in, 41.
btnzodi.altpintsand WI risk in, IS8I
chmlOtMrapy in, 562.
dlcury fIIppLcment use,9i.
d .... administration 511, 90t
druglldmlnisu'illion guiddi ......
72-74, 73/
H, reaplors and viumin B" .l>5orption
;n,6)4.
H,-w:epto. hlockers and vitamin Bu
In,6ll.
HIV Infection, 538,
methylphenidalc usc in, 20 I,
ophthalmi<: drug administration, n5.
pain .itprmion and pm:tp{ion, 223.
plwmacoi<inelks in

dISlribution,73
= relion,74
melabolism,73-74
polyph2..mxy in, 90
pn:scrlptlon drugcmu and, 8,
oIillOmcnorrhe., 706
oligomeric formulas. 651
718
olmesarhln mrdommU, 311.
n 4
ols..l.zin., 625
omtil-3 f,uy acids. S Fioh oib
omepfiuoIe,611t
llClionnnd 113<'S,61 635
administration al.n s,61 I
adv\>rw dINts, 61 I.
Inl<'l'''''llons,6 11,
pharmacoklnel\cs, 61 II
mule and adult dOS(', 61 I.
Omnar;" s acl.sonid.
Onca5p<lr,
ondlonse',ron. 629, 630.
opm-ansle .. , 7611, 7611/
nphlh.lm!r <I,ul\"
admlnistntion, 25, 26., 27/
.ntlglauco ..... S ANTJGl.\l!CCW" [)1UG5
C)tloplcak$
a'ropine, n4,
dIIf'ilCtmSlIa, n 4
cydopentolau, n,.
honull'OJ""', n4,
LibraryPirate
894 Index
ophthalmic drugs, (conI.)
774,
tropkamid 774,
hom. 775,
lubricants
lanolin alcohol. 774,
774,
polyvinyl alcohol. 774,
mydriati"
.. 774
Phenyl"1'hrine
natural u...rapy with bilberry. 775,
pemirolast. 774
vasoconstrictor.
naphazolin 774, 774,
Oxymdozoline
tflrahydrozolint. 774. 774,
opiale, 220
opioid(.). OF!OID (NAI1OOTIC)
ANALGESICS
combination drug. for
symptoms.5HI
ddlnilion.220
dependenul,bu,",
characteristics, 1061. 107
trealment.227
wilhdral';al symptom lOb,
endogenou 220. 220f
in gen<ral anestb..ia
alfmtanU hydrochlorid 2511. 252,
fmtanyl citr'l<. 248. 2511. 252,
.. mifenlanil hydrochloride. 252,
.ufentanU dtraie. 251 252.
rrceptor .. 221. 221f, 221,
opioid agonist 221. Oi>IOID
(N.uamc) ANALGE.lICS
OI'lOiD (NARCOTIC) ANALG.IICS:
in child .. n and older adul1S, 2231
combinal wilh nonnarcotic analge.ics.
221- 23
depend.m". Set, Opioid(.).
d."..ndm!abu,",
drugs classifial as
miHd opioid a(lOnist.
bup .. norphine hydro<hloride. nil,
2221,227
221f, 222,
charac1<ristics. 221 . 22lf
222,
nalbuphin. hydro<hloride. 222,
22 1.
22 1f, 222,
opioid a(lOnist.
characleristics. 221. 22lf
codeine. Su Codeine
See Hydrocodone
hydromorphone hydrochloride, 222,
lomrphanol tanral<. 2221
hydrochlorid .
Meperidin.
Su
morphine sulfate. See Morphine
sulfat.
oxywdone hydrochloride. 222,
222,
oxymorphone 2221
hydrochloride. 222,
propoxyphene napsy!al<. 222,
herb--drug int<raetion 1001
Nursing Proc",-, Pocus
........ m.nt. 2241
of 22ti1
impl.mentation
int.""'ntions and rational ...
224--26,
pati.nl and famUyalucation.
224--26,
planning: pati.nt goal. and expltd
outcomes. 2241
potrntial nursing diagnoses, 2241
for 'P"clfic rondilion.
ml"'ardial inb"'tion. 35 I
pain managemmt. 221- 23. 222,
toxicily sign .. 106,
OPIOID ANrAGONiSTS:
. 221. 22lf
drug. da .. ifial as
nalrnefene hydrochloride. 2221
nalonme hydrochlorid . Sn Naloxone
h}'dro<hloride
nalt",xone hydrochloride. 222,. 227
pharmacotherapy with. 226-27
opportunistk inftions, fungo!. 507
opponunist;': organism . 41U
op",lv"]<in, 391t. 397. 457
OptiPranolol. Mdipr.molol
Optivar. &e AzclaSiine
OIAL OON1lIAumvES, 699f
for acne, 756. 756.
administration. 697
adv .... dfl .. 698. 699,
benefit .. 695,
and PlOlilestin. a . 697--98. 6981
extended regim.n
Seasonal. 698
Seasonique.698
formulations. 697
bipha.k
charaClrri,,;.: 697
Mireelle,69S,
Onho-Novum 10/11.6981
monopha.ic:
eharaCirri.t;.: 697
Deso8en. 6981
r.o.,;trin 1.5/J.O 1'<. 698<
Onho-Cyden.6981
Yasmin.6981
Zovia l/SO/. 21 and 28. 698,
progestin only
eharaCieri.ti<:s.697
Mkronor.698,
Nor-Q.D..698,
OvretI 698<
triphasic
charaCirri.tics, 697
Unho
Ortho- Novum 7/7/7.6981
Triphasil.69St
interaction . 699
Nursing Proce .. !'oeu.
a"", .. mem.70I,
implem.ntation
evaluation of outcome ",it<lia. 70).
intrr.,..llIion.and rational ... 701- 31
and family education, 701- 31
planning: palient goals and exp<:aal
outcomes.7011
pol<ntial nur.ingdiagno,"" .. 701,
progestin-only. 697. 698<
ORAL HYPOGLlCEMICS:
ad.,..r .. rfl'ts. 687,
drugs classified a.
alpha-gluco,idasc inhibitors
acarbose.bIIl,. bill!
charae1<ri"ics.688
mig)itol.6871
biguanides, 688
m.lformin. Mdformin
combination drugs
<harae1<ri"ics.692
g)ipizidt/mttformin.689.
glyburid./metformin.688,
6881
rosig)itazon./g)imrpirid 688.
rosiglitazon./metformin.688,

characleristics.688

rtpaglinidt.687t
new ..
char""leristics.688-89
687,. 688-89
prarnlintid 687 689
sitagUptin. 687 689
sulfonylurea.
charaeleristics. 686. 688
6871
glimrp;ride. 6871
g)ipizide.687.
glyburid 6871
tolazamide. 687,
tolbutamid 6871
Ihiazolidintdione.
charaeleristics.688
pioglitazone, 687,
ro.iglilazon 687.
herh--<lrug inl.raction . 100,
Nursing I'roc= !'oem
a .... sment.6901
.""Iuation of outcom. critrria.692,
implementalion
inl<rvrnlion. and rationale .. 690--921
patient and family.ducalion.
690--921
plannins: goal. and rxp<aal
outcomes. 690,
pol<ntial nursing diagnoses, 690,
pharmacotherapy with. 683. 686
roule and adult doses, bl!/-8HI
LibraryPirate
Orap. Pimozid.
Orap ... d. Se.
Orazinc. Sa Zinc
Or.ncia. Sec Abataccpt
Orgalutran. Sa Gani ... lix
organ transplants:
frequency. 447t
"'j<"Ction.457
ORGAN!C NlnATI.S:
drug. dassiflCd a.
amyl nitriu. 343,
isosorbid. Sa lso.omid.
dinilral.
ioosorbid. mononitrat 343,
nitroglycerin. SN Nil roglyctrin
action. 341-.42. 342f
nUllling process focus, 344-16t
rout. and .dult do .... 343t
;n <",!"c'M ;nfardkm. l'i()
therap<lltk approach. 341-.42
Orinase. See
orli.tat.634
272t
Ortho Tri-Cyd.n.698t
Orthoclone OKT3. Sa Muromonab-CD3
698.,
Ortho-Evra.698
Ortho-Novum 7 f7 f7. 698t
Ortho-Novum IOJ ll. 698.
Orudi . See Kctoprof. n
O ... Cal 5((1. Sa Calcium carbonate
05fliamivir. 540. 540,
Osmilrol. Sa Mannilol
mmolality. 431. 432{
osmosi .. 431. 432f
mMOllC D1UIImCS:
adYOTsedfts. 425t. 770,
drug. dassif .. d as
ioosorbid 773
mannitol. 424. 425,. 773
773
of action. 4211, 425
for spiflc conditions
sJ.ucoma.773
,..,nal f.ilu ... ,424. 425,
OSl.it;' ddo..man . See Paget', di ......
OSl"",nhriti. (OA):
741. 7411, 741,
741,
natural therapy with glucosamine and
chondroitin. 743t
pharmacotherapy. 741
mi<oclast 731
osteomalacia:
caw; ... 733
charact.ristics, 733
diagnmi 733
pharmacotherapy.733- 34
ollroporosis:
calcium m.tabolism in. 735f
co",id.rations, 740,
736t
consid.rations. 740,
pharma.cothr:rapy
bi,phosphonates. Sa B!'PHOSPHOOAThS
hotmonal
caldtonin. 737. 739t
<in.cal"'t. 736,. 739
ralru:ikn . See Raloxif.n.
t:1"iparatide. 736,. 739
risk ["'tors. 735
otic preparations:
administration. 25. 26,. 27f
formulation.
.. ''''tic add and 776t
ber:zocain. and antipyrine. 776t
carbamide 776t
cip:oflox .. dn and d.xamethasone. 776,
cip",floxacin and hydrocortisone. 776t
polymy:Iin B. ntomycin. and
hydroconisone.776,
77(,
miti. ,",dia. 480,. 775
Otrivin. Sa
outoomts:
58
in .dministration. 58
o\"er -thHOUnler (OTC) drugs:
ad ..... age. and disad""ntages, 4
for oowd nausea., and
,"miting.634,
4
for gallroint. stinal
int .... actions, 614,
n .. di(ation and. 91,
Oyidrd. s... Chorionic gonadolropin-
HCG

ovulation.695
oxacillin, 484. 484,
oxaJipl"in.555,
Oxandrin. Sa
oxandrolon 717,
oxaproz:n. 22St. 467,
oxazrpan.157,
QlAZOllDlNONl'S, 494
linezolid. 495 499
173. 173,
ru:iconarole.513,
OxistaL Set
oxybutynin. 143.
oxycodon. 222,
222t
OxyComin. Sa hydrochlorid.
oxynl <1, rolin 5821
actior.sand uoes, 132,. 582.
admiai'tration alOTts. 58.2t
ad"""" eff<"Cts, 581,. 532,
int.ractions, 582,
pharmacokinetics, 582,
for specific conditions
nam decongestion. 581,
ophthalmic irrit.tion. 774,
oxynlorphon. 222t
QlYTOC!a:
707
Index 895
drug. dassifird a.
carboprost 70},.
704.708,
dinoproston 7031. 704. 708,
maleat 708,
maI.at 708.
mi5Oprostol. 617. 703t. 704. 708,
oxytocin. &. Oxytoci n
oxytoci n,709t
P
action, and uscs, 708--9. 709,
administration 709,
ad .... ""'dkcts, 7081
function 708-9.709f
iDlOT""tions, 709,
Nursing Proces, Focu,
..... ssm.nt. 71O'
evaluation of omwmc"iIOTia. 71 It
impl"", . ntation
.nel .... 7t t.
pati.nt and familyrducation. 711,
planning: pati.nt goals and
710.
nUllling diagnoscs, 710t
"""rdo .. t .. 709,
709t
rout. and adult do ... 70S.
secmion. 658f
p53 gm 549
paceJ1"laker.356
Pa'OTon . Sa Ami odaron.
559
packed red blood ceUs.408,
paditaxd.55O(. 559.559,
P.lget'.disca ... 737
poin:
219
cla .. ification. 219
ddlnition.219
exp .... ion and pcrCtption
age and. 223,
con.id.rations. 220t
;ndd.nc..219.
mechani,ms
220. 2'lJ.Jf
nociCtptor Irwl. 229f
nonpharmacologic 219
pharmacotherapy
Sa Actlam
Sa Clonidin.
nonsteroidal anti- inflammatory
drugs. Sa NON'n:R01DAL
AN11-1NFV.MMATOn DIUGI
opioid. s... OPJOID (NAi.OOTIC)
ANMGEI1CS
..
aspirin. See Aspirin
salicyJau. 228.
salsaJate.228,
tramadol.228.,
palliation. 550
palonooetron.629.630,
LibraryPirate
896 Index
Pamdor. Sa Nortriptyline
pamidronau, 736.
p-aminob.nzok add (pABA), 763
Panaxgi""ns. Gin ... nE
I'Ilnaxqu;nquefoliu . SeeGinsmg
679, 679f
... See ..... e
enzymes:
ilctions wd US<"i,633- 34
drugs classified as
pancreatin, 635
Sa Pancrelira.e
635
pancr.",tit;':
acute, 635
chronic,635
pharmacoth.rapy, 635
p.ychosodal and communily impact.
635,
panertli r a .. , 6361
actions and u ... s, 636,
administration a1erl .. 636,
ad,..,,,,,, effects, 636,
interactions, 636,
O\.."doS<" malmenl. 6].6,
.. 636,
pancuronium, 278,
panic disorder:
deflnition, ]50
pharmacotherapy. 154- 55
pantoprazole, 611,6] I.
pantothenic acid (vitamin 8,),640,
papa""rine,721
Paracmldohyde. Sa Paraldehyde
P .. rafl<x. See Chlor7OXllZOne
parafollicular cell., 66]
Parafon Pone. Su Chlorzoxa70ne
paraldehyde. ] 59
paranoia,204
Paraplatin. See C;'platin
parasitk infections:
childhood playamls and, 5231
lice. S .. Lice
scabies. Sa Scabies
parasympathetic nermu, .ystem,
128-29, ]28f
PAlt.\..YMPA11IOM!MEI1a. See CHOliNERGICS
parathyroid gland, 73],73]f
I".arhymid h"nn"ne (PTH). HI
Paregoric. Su Camphorated opium
parenteral nntrition, 6>0. Secal", Total
nutrilion
parenteral route. 28. Sa a/", Drug
administration,
parkaldtol, 734,
paririalcoJls, 608
parkinsonism, 206, 207., 256
Parkinson's dista ... :
characteristics, 256-57, 2561
incidence, 256, 256t
living with, 257.
pharmacotherapy
anticholinergics. S .. AN11DlOLINE.lGICS
diphenhydramine,577
dopaminergics. See DoPAMINERGICS
mc:chanism, of action, 259, 25\1f
Nursing PlOCe5S Kx:us, 261-fi2.
P.rlodd. Sn Bromocriptine
Pamate. Su Tran}"icypromine
paromomycin, 490, 521.
pamutine, 155" 1S6t
Pdr""I, 763
partial a80nist, SO
pania! (focal) seizure, 167, 169t
P.ser. See Aminosalicylic add
passi"" immunity, 449, 451f
passi.., transport, 37
P.tana .... See Olopatadine
Patanol. See Olopatadine

pathogenicity. 479
patient and family education:
acne, 758-59,
ADHD and ADD pharmacotht-rapy,
199- 200t
agonist. (sympathomimelics),
1>4- 35,
adrtntri;ic antaitOnim (sympatholytics ).
138- 39t
androgen., 720-21.
agent .. 4021
antianxiety therapy, 162-fi3,
antibacttTials, 496-98t
antkholinergks, 146,
anlidepressants, 191- 93t
antidysrhythmics, 362-fi3,
antiemetics, 632- 33.
anliglaucoma drugs, 772- 73t
antigoul drugs, 745-46,
antihistamine .. 578410,
antinwpiastics, 566-fi8,
antiplatdet agent., 381-$2t
antiprotozoal. and anlihdminthks,
518- 20t
antipyretic5, 474-75t
anti .. izure drugs, 177- 79,
anli'pasmodics, 276-77t
antithyroid drug . 66iH'i9.
antitub.rculosi. drugs, 502- 3.
alypical antip.y<chotics, 21 4-15.
bipolardi""rder ih<rapy, 195--96.
h;<ph",pMn 71l!- Wt
bowel disorders, 626-27,
brondX><lilators, 597- 99.
cholinergics (parasympathomimetico),
141-43,
colony-.tinmlaling factors, 396--97,
com<ntional antip'ychotics, 210-11,
digoxin, 332- 33.
diuretics, 305-fi1
enteral and IOlai partnl.ral nutrition,
652- 53.
rpo<tin alfil, 393-94,
ertctile dy.fun<lion treatment, 723-24.
fluid and electrolyte replacemenl therapy,
4>4- 35,
fluid rq>lacement therapy for .hock,
410-1I,
genrral anesthesia, 25(1,
glucocortiroids, 474- 75" 674- 75.
herpesvirus pharmacolherapy, 54:J-.44,
H[V-AIDS pharmacotherapy, 534-->61
hypothalamic and piluitary hormones,
",-",
immunoNpprtisam., 460-611
insulin therapy,684--86t
lemdopa or levodopa with anbidopa,
261-fi2.
lipid-l""..,ring therapy, 293-94,
local anesthelics, 244-45,
nitrog]y<cerin, 345--461
nonsteroidal anti-inflammatory drugs,
231- 321
opioids, 224--26.
oral hypogly<:emico,690-92,
05troporo,;' and other bone disorders,
738-39.
oxytocin, 71 I,
peptic ulcer and ga.tro.-oophagealreflux
di ...... therapy, 613-14,
sulml muoclt ,tJaxants, 276-771
.ymptomaticcold rdief. 585-87.
thrombolytic., 384--85.
thyroid replacement th.rapy, 668--69.
vaoodilators, 320-22,
vilamin and minerdl phamlacotherapy,
"'-',,
pati<nt-controUed analgesia (PCA), 222
PaxiJ. Sa Parontine
PCP. 110
pediatric clients. Su Children; [nfilnt,
PI"lJICUUODE.I:
definition, 753
drugs classified a.
755
mal.thion, 753
permethrin,753
pyrethrin,753
Nursing Proce .. !'oeus
a ..... ment, 754,
evaluation of outcome criteria. 755.
implementation
intrr\"ention.and rationales, 754- 55t
patient and family education,

planning: palient goals and apected
outrom"',754,
potenlial nur,ingdiagno.s.es, 754,
pharmarotherapywith, 753. 755
pediculosis:
characteristics, 752- 53, 753f
pharmacotherapy. Su PmlCUlIODE.I
psycho"",ia! and community 755,
R:dil"Ulu. capitis, 753, 753f
R:dil"Ulu, rorpus, 753
PedvaxHlB. See Haemophilu. typoe B
conjugate vaccine
prga' parga"', 5SO/' 563.
Pegasys. Sa Peginterferon alfa- 2a
LibraryPirate
391 394
alfa-2a, 454., 542.
a1fa -2b.454., 542.
Su alfil- 2b
PEG-L-a'paragin ..... SN Prga'parga'"
661
542

554, 555.
774
PIm Tscw, 3

trisodium, 123.
trisodium, 123.
123.
G 484.
G procaint, 4S4t
penicilli n G sodium/potassium, 4861
action, and u ... s, 4861
administration 486.
... dJcet" 484" 486,
ima.ction',486t
486t
and adult 00.... 484,
penkilUn V, 4Mr
484. 485f
484, 484 .
Su a/s" P!N1C1LUN.
prot. in, 484
PE.NlOLLlNS:
ad= ... 484" 485
to, 485
dru8' cI.ssif..d a.
broad-.ptctrum (amin"P"nkmin.)
amoxkillin. Su Arnoxidllin
484" 484
ampkmin, 484, 484,
bacampiciUin,454.
charactaistk" 484

(amipseudomonal)
caro..nidllin, 484., 485
charactaistk" 485
sodium, 484; 485
lazobactam, 484,
IkarcUlin, 484t
natural ""nkUlin.
pmicillin G 484,
pmicillin G 484.
G sodium/potassium.
Set sodium/
potassium
penicillin V, 484,
pmicmina ... -ro.istant
charact.ristics, 485
cloxadUin, 484, 484,
did""""min,484,
nafcillin, 484.
oxadUin, 484,484.
of aClion, 485
pharmacothtrapy with, 485
and adult do .. " 484,
Su Cklopirox
Pentam. SN
pentamidin.,521.
Pentasa. Su M<"SaIaminc
221,
all. 222.
Su
pmtobaroital sodium:
as sc""ral anesthesia adjunct, 252t
for ... 4iuion wd insomnia, 159.
forscirur." 171.
Pentolair. Su Cycl"P"ntolal.
Pentostam. See Sodium .tibogluconal.
555.
Pentot .... l. Su Thi op<ntal
J><ntoxilyllin., 375, 379., 380
Pen- K. Su V
Pepcid. SN F:irnolidin.
I'rplamm Liquid. 651
J'qIUC ULel" di ... ..-:
609
herbal 616,
nonpharmacolosical th"",py, 609
Nurshg Proces. Focus
..... ssm.m, 613.
e<.'3!uation of outcome criteria, 614r

inter.-.,ntion. and
613-14.
a nd fantily education,
613-14.
pati.m goalsand .xptcted
613,
pokntial nursing diagno ... , 613.
pathophy.iology, 608' 609
pharma.cothc:rapy
anudd . SN ANTAOns
H,r=ptoranta80nim. SN H,-
iKEI'IOR ANTAGONISTS
mo:hani.ms of action. 610f
mi"'pro,tol, 617
pr.-on pump inhibitors. &e PwroN
lUMP INHIBITORS
sucralfutc, 616
thcraprntic approach, 609--10
risk frctors, 609
symptom,,6JY)
Pepto- B:Smol. See Bi,muth ",b .. licylat.

Parocet 5. SN
Percodan, 223
tran.luminal coronary
.ngiopla,ty (PTCA), 340
pct"iormiUlce anx;'ty, ] 50
Perforomi'l. See Forrnotcrol
59(jf
persolid., 257, 258.
Prr80na!. See M.nolropins
pct"indoprU.311'
(PNS), ]27f
r i,tanu, 298, 298f
. 607
558-59
p. rmetbrin, 7531
actions and uses, 753, 753,
administration 753.
753.
intaa.ction" 753.
753t
See Fluphenazine
Index 897
(m.-galobla.tic) an<rnia. 399,644

gen.tk polymQrphism! affecting
8] t
for nausea and ""miting, 6J.Ot
for psycho ... , 206; 207
SN D ...
mal. See Absence mal ) ... illl'"
pH:
d.finition,440
on absorption. 38, 39f
pl ma.440
pharmacodynamics:
cdlular r<plor" 49--50, 49f
cuslontization of drug therapy, 50- 5]
d.finition,46
int"",ction., 50
dkacr, 481. 49
gradl'd dose-response relationship,
47-48.47f
imerp,ati . nt yariabmty, 46, 46f
pot.ncy, 48-49, 48f
second m .... 49
theraprntk index.46-47. 47f
5], 80. Su
Genetic>
pharmacokinetics:
absorption. 37- 38, 38' 39f
d.finilion,37
distribution, 38f. 39-40, 39f
drug pla.ma conc<ntration. 41-42, 43f
38j. 40-41
loading dOS<", 43-44, 4Jf
do .... 43
m("[aholi.m, 3S/' 40
in old adult" 73-74
pla.ma half- lif., 42
in pregnancy, 64-{i5
therapeutic rang<", 42, 43f
pharmacologic classification:
]2
exampl., ]2t
pharmacology:
d.finition,3
history, 3
y . 4
pharmacopotia,4
pharmacoth.rapy. See Drug
admini'lration
community and
influenu .. 79--80
cultural and ("[hnk influences, 78-79
d.finition, 4
8]
influences, 80--81, 8],
holi.tic. 77
psychosocial 78-79
LibraryPirate
898 Index
Pharmacotb.rapy
and passi..., immunity. 451f
Almrimd. dis<:a"" drugs, 265f
angina drugs, >42f
.. nt therapy. IS5f
drugs, JOlf
antiparkinsonism drugs. lS"If
antispasmodics, 274f
antiulur drugs. 610{
htnign pro'tati< hyperplasia, 726/
cholestmll-lown'ing agrots, 289{
corticosteroids (glucocorticoids) and
ad"'nal atrophy, 672/
diu",tics, 421{
GABA channd
mole<uI. ,170{
heart failure drugs, 327{
limbk system and reticular ""tn'.ting

local anestooks, 241{
monoclonal antibodies and canur un
'M,
Pharml'acl>:
ahmati..., attitude. toward.
".
ane'th"ia and 242.
angina, 340,
anxiety 1511
arthriti .. 741,
a.thma, 591,
attention
,,,.
infection .. 479.
canur, 5481
dotting disorder .. 3711
community health 5tatistics in the
U.S., SO,
distases of the central
n.rmu, syst.m. 256.
d.p", .. ion. IS3,
mellitus. 680,
dysrhythmia .. 3551
.pil.psy, 168,
femal. r.productive conditions, 6951
of drug uoe during
prognancy.68,
fungal infection 507.
disorders, 621 ,
glaucoma. 769,
juke and drUJ, interactions.
".
headachu and 2301
h. althca ... ""uss among minoriti.s, 79,
hoan failur., 325.
helminth infection 507.
h.matopoietk disord.rs, 390,
blood ,holest.rol. 2831
2971
inflammatory disorders, 4651
insomnia and insulin resistanu. 153.
insomnia indd.nu, 153,
male reproducti..., 716.
spasm., 271.
m)'Xardial infarction,.l4Q,
orpn transplants. 447.
ost.oporosis, 736,
pain, 219,
poisoning,711
prescription drugs
consumer "",nding, 5.
marming costs, 14,
time length fur FDA appro",l, S,
protozoal infrctions. 5071
psycho""s. 204t
r.nal disorders. 418.
.<hock, 406.
skin disord.rs. 751,
St ...,no--Johnson .yndrome. IS.
substanu abu ... tatistics. 14., 1041
terrorist mach, polential chemical and
biologic agents for. 116.
thyroid disorders. 6621
tox", tpidermal nrerolysis, 18.
upper gastroint"tinal trad disorders,
"".
vacdnes, 447,
viral inf. clions, 527,
minerals, and nutritional
supplement,,639t
pharyngitis, 480,
Siie
phenelzine, 190.
actions and ...... 190.
administration alerts, 190,
... ff.d .. ISS., 190t
interaction lOOt
overdo"" trratment, 1901
pharmacokinetic .. 190.
route and adult do ... 1551
for specific conditions
anxiety symptoms, 155,
dep"'ssion, 186.
Phenergan. s"., Promethazine
Phenergan with Codeine. 584.
phenindione.67.
phenoharbital,I 721
actions and U""S, 172.
administration alerts, 172,
... effts,67/, 159t, 17lr,I72.
interaction I72t
.. trratment, 1721
pharmacokinetics.lnt
route and adult do .. , 159.
for spedfic condilions
sedalion and insomnia. 159.
.. iru", .. 1691, 171. 171.
PHENOTIlIAZlNIS:
adver .. effrets, 206--7. 206., 2071
cbaraderistks,206.--7
drugs classified as
See Chlorpromazi nc
Oupb.nazine. 206.
Sa
promazine, 2061
206. 206t
trifluoperazine. 206. 206,
mrcbanism, of o<tion, 206- 7
Nursing 1'rO<:< .. ""'us
a ... ssment, 209.
e""luationof criteria, 211,
implementation
inte,,'entions and rationales.
1l0--11.
patient and famil y education.
210--]].
planning: patient goa), and <XpCcted
outcomes.210t
potential nur,ingdiagnose .. 2091

pb.ntermin 634
pb.nlolamine. 136., 721
13JI
actiOn! and UIO. 132" lBI
administration alert .. 133.
ad...,r .. dfects, 409t
in cold/allergy combination drugs, 5761
interactions, ]33.
oyerdosetreaunrnt.IBt
pharmacokinrtk., l331
fur specific conditions
e)'l' irritation, 774. 774t
nasal congestion/allergic rhinitis,576,
576t, 581t
shod::. 409.
pb.nylpropanolamine. 634
Pb.nytek. s".,
1751
action. and u .... 175.
administration alert .. 175t
ad...,r .. dfrcts, 175., 360.
interactions, 175/, 187t
o .. 175t
pharmacokinetk., 1751
for specific conditions
dysrhythmias,360.
seizures. 169t, 173,1731
PH' NYJOIN- IlKE !.GENTI:
drugs cla .. ified a,
See Carbamazepine
174
lamotrigin . See lamotrigin.
valprok acid Stx
zonh,amide. 173-74,1731, 175
phobia .. ISO
oxime, 12],
I'hosLo. Siie Caldum
335
lNillBITORI:
adver .. dfects, 328
drugs classified as
328t, 335
Stx
mrcbanism,of action, 327f, 335
route and adult doses. 3281
therapeutic approach. 335

adver .. dfects, 722. 722.
drugs classified as
,ildenafiJ. Stx Sildenafil
LibraryPirate
tadalafil, 722, 722t
722.
NUr>ing p= .. Focus
assessment, 723.
n"aluation of outcome
723- 24.

and rationales,
723- 241
patitm and family education,
723- 24,
planning: soaJsand
outcom"',711t
potential nursing diagnoses, 723t
Phospholine Iodide, &e Echothiophate
iodide
phosphoUpids, 283, 2Mf
phosphorus/phosphate:
functions, 648, 648,
imbalances, 4371, See. at.o

Hypophosphatemia
for nutritional and
monobasic potassium and sodium
pho,phate,6471
monobasic potassium phosphate, 647,
potassium and sodium phosphates,
... "
potassium 647t
",commended dietary aUowance, 648t
photo""nsitivity, with 489
phototherapy, 763
Phm;rw 753
physical activity:
substance abu .. and, lOSt
physical Ml"'ndrnce, ] 4, 105, Sre alsc
Soollance abwe
PItyso51;gma """""0SItm, ] 39
physo.tigmine, 123t, 139, ].tOt, 770t
phytonadione, See.Vitamin K
]4Ot, 770, 770t
Pilopine, & Pilocarpine
760
pimoride,209.
pindolol, 315,
Pin""rm Caplet .. See. Pyrantd
Pin-X. See. Pyrantd
pioglitazone, 687 t
pioglitazone/metformin, 688.
pipecuronium, 278,
Piper m.:thysricum, See. Ka""
piperacillin sodium, 484., 485
piperaciUin tazoooctam, 484.
pirbuterol, 593, 5W.
piroxicam, 467t
Pitodn, &eOxytodn
pituit ary gland:
anterior, Sn ANI1:J.IOl
disorders, 59t
production,65Sf, 659
See. PruTIltlOR PfI1JlTAAY AGENTS
Placidyl, See. Ethchk'''')'I101
Plan B, 700, 703, 703t
plannintphase, in drug administration,
,5--56
plaq....:
corornry
in p",riasis, 760, 761f
& Hydroxychloroquine
Plasburr.in, &. Normal seru m a lbumi n
pla.ma ",Us, 447
plasma .anu:ntr.i1ion,41-42
plasm. half-life (t,,,), 42
plasma .,embranes, 37
pla.ma fraction, 408, 408,
plasma expanders. Sa COUO[D:\
408t
Plasmarnte, &. Plasma protein fraction
Pl.sma-?lex. Sa Plasm. protein fraction
plasmat';n, See Plasma protein fraction
pl.,mids, 48 t
pla,min. 37]
pl minogon,371
Plasmodium, 515, 5]71, 52],
""unt, 372t
1'1..\.= ENHANCEIS:
drugHla .. ifled as
t1trombopag, )911, 397
391t, 397
romiplostim, 391" 397
with, 394, 397
Platinol.Sn Ci.platin
Plavix. SocClopidogrd
Plendil. See.
pkrixafor,564
Pletal. Ste Cilostazol
pneunto.:OC<al infections, 47<;1,
pnewnooxcal vac.;in .. , 4 52t
480t
f'!1eum,,:v,,;, carin;; (PMumocysrk prowd),
,07,
pneumonia, 4SOt
Pneumovax 23. Sn Pnrumococ<al vac.;ines
pNS (peripheral nervous .ystem), ]27, 127/
peI""um, 559
poisonir_B:
inddrnce,7],
iron, 70.
prev01ltion,69
top 2S substance. invotv.d in, ]22,
t ... fundamental., 12t - 22
Poladex. Su DexffiJorphrniramine
Polararnine. &e
polariztd,358
poUo',ins, 1]9
poliovirus ""ccine, 452t
Polyco .. , 65]
glycol, 622t
polymeric fommla, 65 I
polymyxin B, neomy<in, and
hydroconisone,776t
polypharmacy, 73, 90
sulfate, 420t
polyviJl}1 alcohol, 774.
Ponstel. & add
Pontoca.n . Su
P",;';or. Su
positi..., inotropic 325
positi..., symptoms, 204
posteriorchamber, 767, 767/
POSTIlIIOR PfI1JlTARY AGENTS:
IndH 899
.. in. Sn D""-lno pr .. sin
Nur.ing Pro< .. s Focus
as ... smont, 665t
cv;a/uation of outoomc criteria, 666t

intervrntion. and rationales,
665--M,
patirnt and familylucaHon,
665--Mt
planning: patient goals and
outcomes, 665,
potential nursing diagnoses, 665t
vasop", .. in,66O,
pollganglionk neuron, ] 29
postmarketing surwillance, 7
postpanum depression, 182
poll-traumat;'; 5Iressdisokr (PTSD) , 150
po""",l inllability, 256
Posture. Su Calcium phosphate tribasic
potassium (K'):
functions, 648t
imbalances. Sn HYl"'rkalemia;
Hypokakmia
in mYOC-drdial cells, 358
pharmacotherapy with. See Potassi um
chloride
recommended dietary aU"" .. nee, 648,
renal regulation, 423, 438, 438/
POTAS'illM CHANNEL Bl.OCKEl.I:
drugs classified as
Su Amiodarone
doktilide, J60t,.l64
360" 364
ibutilide, 360t, 364
sotalol, 3601,.l64
mechanisms of action, 358f
pharmacotherdpy with, J.63--6t
potassium chloride (KO), 4391
action, and uses, 439,
administration 439,
ad.,.."" .. 439., 647 t
interactions, 439,
ion,, 4J.6t
"""rdo .. 439,
route and adult dose, 647t
potassium iodide {KIl, 120--21, ] 23.,
650,667
potassium ion dtannds, 358, 35Sf
potassium and sodium phosphat .. , 647t
POlA.I'IIJM- SPARlNG DlIJIIETICS:
.. 303., 304,328.
drugs classified as
303t, 424,
eple",none, 303t, 311, 423, 424,
spironolactone. &. Spironolactone
303., 424,
mechanisms of ""tion, 42If, 423
for specific conditions
LibraryPirate
900 Index
I'OTA.SSIDM- SPARING DllJRFllCS, (amL)
faUu",. 32&. 329
hyptrl<nsion. 302,. 3031. 304
",nal faUu",. 423. 424,
potency. 48--49. 48/
PPF. St. Pla,ma fraction
pralidoxime.IDI
257. 2581. 259/
pramlinlidc.689
pramoxin 242,
Frandin. S Ropaglinid.
prasug"'l. 3791. 380
FranchoJ. St. Pran'lalin
pranstatin.287,
praziquantd.522,
pnlzosi n.137,
Jctions Jnd uses. 1361. 1.l71
administration .. 137,
ad,..,,,,,,./hcts, 1371. 315,
classification. 13fu
int.ractions, 137,
",..,rdo .. 137,
pharmacokinetics, 1371
for condition.
prosutic hypertrophy. 725,
hyptrtension. 315,
fucia. S Dtxmod.tomidin. HCl
preclinical inVC":'ltigation. in drug
7/
fuco ... SN. Aalrbo ..
pmlnisolon 470.. aI,
predni sone.UI,
action, and uses. 471,
administration 471,
ad"""", dft" 4701. 471,. 561,. 671,
int.ractions, 471,
pharmacokinetics, 471,
for conditions
"d .. noconical insufficioncy. 671,
cancer. 560. 561,
intlammalory bowd di .... se. 625
intlamrnalory disorders, 470,
fukst. St.
pregabalin.169,. l7I,
preganglionic nruron.129
pregnancy:
drug, during. 167
oornplications, 167

drug 66
FDIo. drug cat.-gori. s, 65-66. 6fu
folic add in. 3991. 644,
gestational age and therapy. 6,
patient teaching about drug th.rapy
during. 68
pharmacokinetic, during
absorption. 64
distribution and mdabolism.64--65
=""ion.65
pharmacological agents for <"arly
termination
carboprost 7031. 704
dinopro,'on 7031. 704
mt1hotraale with misopro'lOl,
703,.704
mif<priston< with misoprostol.
703',704
P"'gnyJ. Sn Chorionic sonadotropin-HCG
p",implantation period. 6,
p",load. 325. 326/
St.
P",marin. Str Conjugated (lltrogell5
p",mature atrial contraction,. 3551
p",mature yontricular contractions
(PVCS},355,
p",menstrual syndrome. 706
P",mpha ... Sn Conjugati estrogens.

P",mpro. Su Conjugati <mog<ns,

P"'pidU. Su Dinopro,ton<
p",,,,hool child. 70. SN. abo Child .. n
P",scription Drug UKr Iff Act. 61. 8
p",scription drugs:
abll5C. lOS
brand-name .... generic
13--14
consumer spendillion. 51
4
ffect of costs on adults, 8,
marketing and promotional sp<nding.
",
fun-D. St. Ephedrin.
P""",id. Ste lansoprazol<
P",..,n. 703. 7031
P",vnar. Su Pneumococcal vacdnes
P",ziSi.a. Ste Darunayir
Prialt. S Ziconotide
priapi'm,320
242t
Prilo .. c. S Ornept""dzole
Primacor. Su MUrinon.
primaquin 5161
primary 299. Ste,.]",
Hypertension
primary-V"'ll ..... i .. " multiplo. .. lerosi 267
Su
Primaxin. St.
primidone.671, 1691. 17lt
ILmpicillin
Prinivil. Su J.isinopril
(""""-'p"<fkj 140 .. v,
abo Angina
Privin . St.
PRL (prolactin). 6581. 708
PRN order. 20
Probalan. St. Probenecid
proben.dd. 744. 7451
procainan,id 3611
actions and n .. s. 36 1,
administration alerts, 36] I
.dyer .. J.6O'. 361,
for dysrhythmia,.3'Sf. 359,. 360,
genetic polymorphi.m, .fk<ling
m<1abolism. gl I
361 I
o,..,rdo .. treatment, 3611
pharmacokinetics. 361,
242, 242,. 243/
Procan. St. Procainamid.
Procanbid. Su Procaina mid.
procarbazin., 55"
Procardia. Sn Nifedipin.
Prochi""". See
prochlorp(razi.IJe.6311
action. and u .... 631,
adntinistration alerts, 631,
ad""r .. df<cts. 631,
interactions, 631,
Oyerdo .. tr.atment. 631 I
pharmacokinetics. 631,
rout nd adult do ... 630,
Procrit. Su Epoetillilfa
procydidine 2601
prodrugs.40
695. 706. 7071. Suolso
PROGFSfINS
PIlOGESTINS:
action, and u .... 706
drug, classified as
combination druiS
conjugati

7071
<stradiol/dro'pirenon 707,
estradiol/n0'1l"51imate.707,

7071
acetate. Six
M. d roxyprogcsteron. """t.'e
no",thindron 7071
progest.ron 707,
functions, 695. 706
Nursing Proce .. Focus
a ... "ment.701,

evaluation of outoomecriteria. 703,
inurYCntion.and rationales, 701- 3,
pati.nt and 701- 31
planning: pati.nt goals and exp<Cled
outcom .... 701'
nur.ing diagnosts, 701 ,
Prograf. SteTacrolimu,
prog .... i..........,lapsing multiple scl<ro,i 267
J1"'t1I.nil. 'ill>'
prolactin (PRLj.658f. 708
Proleukin. Su Akkll"ul::in
Prolixin. SN.
Promacla. Su Eltrombopag
promethazine:
a, adjunct to 252. 2521
for rhiniti,. 575,
for nau\oeO and mmiting. 6301
Prometrium. St.
Pronestyl. Su Procainamid.
propaknon 36O,
propanthdin<, 143,
Propin<. S Dipiydrin
Propionw,,<1erium acrr"" 755
LibraryPirate
propofol,251t
propoxypt.tM hydrochloride, 222l
napsylilte, 222,
propranolol, )6.tf
lClionnnd "SfS. 136, 1361, 364.
;adminisl",tlon :alttts,3641
;ad...,nt dfKU, 1601. 2)31, 31St. 343;
l6Ol, )6.1,1
tthnk/n'ial oomlderalions, Xi)r
generic polymorphism! affKtin8
n'l(raboUsm, 811, 3631
inunclions.3641
o"".dose trtatment, 3641
pharnuooklnetlcs, 3641
route and ;adult dose, 1601
for spmrtc conditions
:lIIgil\Ol and m)'OCudial inftraion, 3431
:lIIIiety, 1601
dy$rhythmlu, 358/. 3591, l60t
hypntmsion, 3151
migraine, 2331
propric!.1ry ( m,de ) IIiOnlC, 13.
Brand-name dmgs
propylthi ouracil,6671
actioDi . IId uses. 664, 667,
administration aleru, 6671
advent dfKIi, 6631, 6671
interactions, 6671
o""rdost lIutment,6671
pharnt;w;:ol;lnetk:s, 6671
mute and ;adult dose, 6631
Proquad,4521
Prosar.Su Fi" . ste ride
Prosom. S EstazoAm
PlKJSTAC.l.ANDlNS:
' ..... cleri lties. 708
druRHlassiflCd IS
bimatoprolt, 769. 7701
carboprost tromethamine. 7031, 704.
70s, 708.
dinoproltonc, 1031, 704, 703. 70St
l.tanoprosl, S Lot . nop'l'OoI
mil?priltGne, 7031, 71J.4
mUoopIOlIGI, 7031, 71J.4, 703, 70IIt
travopl'OSl, 769, 770,
unopt'OStone, 769
functions.217-28
mKhartisms of action.. 4651, .c67
fGr conditions
as emergency contraception, 703.
.Jauroma, 769, 770/
abortion, 7031
as tocolytlcs. 708, 7M.
p""tate. S Iknl. n prostotic hrpertroplty
Prostigmln. S NeoSliQmine
Prostln E,.
prot.mlne :sulfate, 123" 375
protealt,528
I'ItOTTASE tNlUlitlOltS. S.
Nml.lnOVllALio
;ad...,,,,e dfKIS. SlOt
drup wstiflt<.l IS
ataunavir, S30f
daroruovir, 5301
I'osampunovir, 5301
indinavlr,S301
IopiMVi.!litonavi . s
lopi,uvir/ rilooavir
ne13D<1vlr, S30f
rilolUvlr, 537
saquinovif,530t
530t
herb-dru8 int ... /Ction., 100.
nlCdt'niSDlS of oct ion. 537
ph'lrmacotheral'Ywith.533,537
route and adult dose, 5301
Pf<)tenate, S Plasm. prlllcin fraction
i"rott'u, .. ;",bilis. 48(1/
prothmtnbin.. J71
prothroobln actlY.lIOr, 170
pmthmtnbln lime ( PT), 371, 3n.
I'IIOTCItII'UMP INiGIlfOU:
dru8'wssitloed OS
aomeprnole, 611, 611.
I;!ruopr.IZOIe, 611
omepruole, See OmeprolZOle
p.>r.lOprazoJe, 611,611.
robtprnzole.6111
n>edunlsms of .clion, 610/
NUl1bgl'rocess Focus, 6]3--141
... py With. 6] I
Pmtonb:, Sa
ProIOPUI, S
ProIOpk. See Tltcrolimus
pMOIy!" drua. 12
pnMo-.Sl5
pfO(OW,&J lnfKtiOf1s:
incidence,5IJ7/
malolti;t. S
nonmaiarlal,S21.
prot.ipMlnc, l&a., H31
Pro""ntil, S Albuterol
Pro""ra. Mcdroxyproge. tcronc
provita.mlnl, 639
ProU(. Fh,lORtiM
prurll .... 7SO
Pnusian blUl', 1231
p$UdocphedriM:
actior., and U5<.'J, 1321, 133
itt ODr:tbination ooIdIallergy drugs, 576.
metlt.unpheiamiM abu"" and, 58]
for nar.Il dKO/18estion, 581.
pseooomembr.nolis colitis ntibiotic_
anGelatN, 494
Psn<dc>"'-Or'<lS """,gl,.,u., 480., 4S1
ps;iJOC)'bin. IW/
p50nolens, 763
p$Ot'iash:
cha ... "erlstkl, 760, 76]/
dt\l8flrlggerin&.761
rtloloiy, 761
nonpUntlilCOlogicallherapy, 763
pharmKOlhelllPY
.,..mk
KiIMin,7621,163
adalimllmab, 7621, 763
Indn 901
7621, 763
cyclosporine. Su Cyclospori.lC
etanerpt, 7621, 763
Infiiximab, 7621. 763
merltotraatr. Su Metholraale
ustck!nllmab, 7621, 763
lopical,761
anthr.litt,761
calclpotriene, 761, 762.
coal la 761. 7621
SOIlkylk acid. 7621
t.crolimw.,761
t.l<lrolme, 761, 762,
1yp",76]/
ptOriasis vulprls, 7611
ptOrialk artlvil il, 7611
(Wriatlc 761 1
pl)'Che'ClellcJ, IW.:- abo H.JlJ""inogcns
psychodyn<lmic Ilterapy,for o:kplnSion,
'"
t>SYt'hoIo&kdeprn<knu, 14, 105. Saaho
Substance abu""
ptytbo5et. S also S<hizophrenia
,"'r,cleristics, 204. 204.
loddtn.204t
p"'rmaeother.opy. Sa Am1PS"/OIOTICI
psydtosoclol dimension, phann.cotherapy, 77
psychotic depression, 183
psyllium rnudUoid, 6211
acl lonnod ....... 623; 625
;administration alen.. 623.
Mtvme effrcls. 623,
Inttuctlons, 6231
phatnucokinrtks., 6231
PT (prothrombin time), 371
PTCA (perrulanc-ous Iransluminal COrolUry
anglopL .. ty},340
PTlt (parathyrotd hormone), 731. HI!
PTSD (post-lllIumalk otressdi"'nler), 150
PTU, Propylthiouracil
publc 11, 152-53
Public Heallh Service AC!. 6/
Pulmlcort. Stt! Budeoonide
PuImocI.u,651
Puu Food and OrugAa,5, 6/

purine,
PVlINE .o.NALOGS. S. ANTlMEl'AIIOUTlS
cbdtiblne, SsSt
SS51
fi\ld.:lr.bine,5S51
mCTC'optopurine, 550/. 555,
5551
j)('ntostatin.5551
thiogu<lnine, 556f
Purklnje ftben, 356, 356[
push ( IV bolus ) odminiit",tion, 32, H/
push pltaage, 113
pwlU];Ir ptOritiis, 76lr
522" S13
pyrulnamide, SOOt
pyrtthrin.. 753
pyridost.i.m'M,IJY,I4U.
LibraryPirate
902 tndex
pyridoxine. SuVitamin S.
516t
554
PYII.!MIDINE ANAlOGS, Su "I",
ANr!MEl'AOOLITES
ca""dtabine, 555,
c)'larabine, 5>0[. 5'4,555.
Ooxuridine, 555,
nuorouracU, 5SO{, 551, 554, 555,
555.
pZt\, See Pyrazinamide
Q
quazepam, 157.
Qudicin, See SUc<in ykholi ne
Questran, Su Cholest yram ine
qudiapine fumarale, 213r
Quin.mm, S .. Quinine
quinapril,328,
quinidine glumnate, 360r
quinidine sulfal<, J60r
quinine,516t
quinupristin--<lalfopristin, 494, 495t
Q""r, See Bedomdha'lOn.
R
rabeprazole, 6]],
immune globulin, 450r
radal wnsideration., Sf< Ethnic/radal

r.odiation .kkn .... 120
radiation therapy, 550
radioadive iodine, 650, 6631, 664
Radiogardase, See Prus.ian blue
raloxifene, 740r
actions and uses, 561, 740.
administration 740.
adv."", dkcts, 5611, 740.
inl<'ractions, 740t
pharmacokinetics, 740t
route and adult dose, 7)6,
raltegravir, 530., 531
ramiprU, 31lt, 3281
Su Ranolazine
ranitidine bismuth citral<, 617
ranitidine HO, 6]2r
action. and uses, 6121
administration alons, 6121
ad,."", dkcts, 6121
interaelions, 6]2,
pharmacokinetics, 6]2,
route and adult dose, 6] 2t
ranolazine,341
Rapamune, Su Sirolimus
rapid movement (REM) sleep, 153, 154.
Rapt;,,'a, See Efalirumab
ItAS (reticular act;"'aling syst<1l1), ISO
Razadyne, &. Galantamine hydrobromide
reabsorption, tubular, 4 18
&. Ribavirin
lkbif. See beta la
rri>ound congation, 5S1
",bound insomnia, 153
"'ceplor(.), 49---50,49f
"'ceptor theory, 49
Rccomb;..'iX HR Sre H'1'atitis Bwcci n.
ROII1mendw Dietary Allowan,.s (RDA.):
definition, 639
macrominerals,648.
microminerals,649t
vitamins, 640,
",ctal drug administration, 27., 28
",ctum,620f
red-man oyndrome, 499
",na tachyardia, 309, 319
See Lepirudin
",frac:tory""riod,358
"'gional ane"he,ia, 240
Sf., Phentolamine
Reglan, See Metodopramide
"'gular insulin, See Human regular ins ulin
Relafrn, See NabullY1ono
",lapse--remittins multiple selerosi., 267
",lrasing hormones, 657
Rdrnza, &e Zanamivir
Relpax, See Flotriptan
REM (rapid eye mowmen!) s[ft'p, 153, 154.
",melt<on, 160., 161
Remeron, Sre Mirtazapine
InHiximab
hydrochloride, 252.
&. Galantamine hydrobromide
&.Sr,eJamer
",nal failu",:
causes, 4181
classifICation, 419
definition,418
diasnosis,418--20
drugs causing, 419t
incidence, 41St
pathophysiology, 4 18, 418,

aorbonic anhy.Jrase inhibitors, Su
CUIlONICANHYDltAI' 1NH!BIT01S
loop diuretics, See Loop DlUJ:ETICS
Nursing Prace .. Focu', 425--271
osmotic diuretics. See OsMOl1C
DIURETICS
therapeutic approach, 418.--20, 4201
diuretics, S THIAZIDE
DIURETICS
system:
in Huid balance, 432
",nin--an nsin-aldosteron e syst<1l1:
characteristics, 3 H'- II, 3 tof
drugs affrctin8, &e ANGIQTIN,IN II
ll=R BLOCKElt\; ANGIQTIN,IN-
OONVEn1NG ENZYME (ACE)
INHlBl101S
in hyp<rtemion, 299, 3OO{, 310- 11, 310f
R<oPro, Sre Abdximab
"'paglinide,687t
",,,,,titi"" transeranial magnetic stimulation
(r'fMS), 183
Sa Mrnotropins
lkquip, Sa Ropinirole
Rescriptor, Sre Delavirdine
Rescula, &.
Resear<h Shows:
dose. of ibuprofen and
acetaminophen for child"n, 4 Ht
folic add prior 10
399,
HIV testing, influences on, 529.
lipid-lowrring therapy in diabetics, 683,
mediaotion errors in child",n, mosl
common types, 9 II
mwiaotions for <hikl .. n with chronic
cough,584,
substance abuse and ..dentary
to5r
_ight loss .. , 635t
"serpine, 315,
r.sistance, 48 1-82,4S2f
respiration, 590
=piratory acidosi" 44 I r, See "Iso Adooli.
",.piratory distress .yndrome (RDS), 601,
rest-and-dig<'Sl "'sponse, 128, 12gf
Restora, SfeTemazepam
Reta,,,se, See lkt'1'l.se
""'1'I ... ,351r
actions and uoes, 351,
administration alerts, 35 I,
ad""rse dfe<ts, 351., 383,
interaelions,351,
pharmacokinetics,351.
route and adult dose, 383,
reticular activating sysl<m (ItAS), ISO
reticularformation, 110, ISO, 151f
lktin-A, See Tretinoin
llETINOIOS:
characteristics, 756
drugs classified as
756, 7561
isotretinoin, 756, 756,
t"'tinoin, See Tretinoin
lktrovir, See Zidovudine
r .... "'" ,holesterol Iran sport, 283
rn'e ... lranseriptaS<', 52S
TItANSCIt!l'fA,E lNH!I!ITOIS, S

Rnex. See hydrochloride
lkYia, See Naltremne hydrochloride
Rf..iimid, &. Lenalidomide
Reyataz, Sre AIazanavir
lk:zulin, Sa
rhalxlomyoly,is, 288
Rhromacrodex. Sre Dcxtr-dn 40
rheumaloid arthritis [RA}:
characteristics, 741-42, 742f
741,
pharmacotherapy, &. DI,EASE-MODlFYlNG
AN111HEUMATIC DJlJGS
Rheumatr"", See Mciliot rexate
Rhinown, &. Budesonide
rhinophyma, 757
LibraryPirate
RhoGAM. &e Rho(O) immunr globulin
Rho(O) immunr globulin, 4501
ribavirin, 542,
ribavirin/intrrfrron alpha-2b, 542,
riboflavin. &e Vitamin B,
RidelUi<! ,He",;;. 480,
RID. See Pyrethrin
rifabutin,500,
Rifadin. Srr Rifampin
rifampin, SOOI
rifalKntin., SOO,
rufater, SOO,
Rimaetan . See Rifampin
rimantadine. 540, 540,
ringworm, 507,
Riomet. See Melformin
Riopan. &e Magaldrate
ri..dronate,73&
r;'},: nunagement, SlI
Rispadal. See Risperidone
risperidon. ,266
risperidone:
actions and uses, 212,
administration alerts, 212,
adwrseefJem, 212, 2121, 2131
contraindica tions, 212,
interactions, 2l2,
o, .. "dose treatntent, 212,
rout. and adult dose, 212" 213,
for specific conditions
bipolar disorder, 1<).11
psychotic symptoms in Alzheimer',
disease, 266
Ritalin. See Methylphenidate
ritndrin . 132" 709
ritonavir.5301
Rituxan. See Rituximab
rituximab, 563" 7421
rivasrigmine, 140" 264, 2641
rizatriptan, 233,
ROOmn. See Methocarbamol
Rob<:tron. & . rubavirin/intrrreron alpba- 2b
ROOidone. See Hydrocodone
Robinu!. See Glyt:opyrrol,,,c
Robitu"in. See Dcxt romethorphan;
Guaifrnesin
RobitussinA-C,584,
Rocky Mountoin .poll..d fnn, 4SOt
meuronium, 27S,
roferoxib,470
Roreron-A. See Inte rferon alfa-2b
Rolaids. See Calcium carbonatr with
masnesium hydroxide
Romazicon. See Flumazenil
romiplostim, 3911, 397
ropiniroJe, 257, 25-8" 259f
ropivacaine, 242,
r!>IaC.., 757. 757/
rosiglitazonr , 687 688
rosiglilazonr/glimrpiridr, 6881
rosislitazone/metformin, 688,
rosuvastatin,2S71
Rotarix. See Rotavirus vaccine
RotaT"'I. See Rotavi"", nccine
rotoviru, wccin . 4521
round""rm., 521
routine order" 20
Roxic"t. &e Oxycodonr terephthalate
Ro".rrm. Stx Ramr henn
rTMS (""",titi.., transcranial magnetic
ltimulation),183
rubella. 752
rubeola, 752
RUbeL Doxorubicin
RythmoL Stx Propafenon.
5
SA [sinoatrial) nnde, 356, 356/
SAD affectM disoroerl, 182
SaiLen. Somalotropin
SalOL S", Salicylic add
SAL!CYLIIT.S, 468, 741, 763
&e Aspi rin
choline .. licyla". 2281
salsa],te, 228,
salicylk acid, 7621
468
salmeterot, 5951
actior.sand u .... 1321, 593, 595,
admimistration alem, 5951
ad,.r .. rffects, 594" 595,
interaction .. 595,
overdose t .. atmrnt, 5951
pbarmacokinrtks, 595,
routrand adult dose, 595,
Salmo"lIla ,,,teritidi,, 480,
oaloalate.228,
Sancuso. Stx Granisetron
SandimlllUne. &e eye/o.pori""
Sandostllin. Octreotide
San,.rI.See Methl""'rWde
saquinaYir, 530,
.. rcoma. 549,
752
sargranlJstim, 391" 394
Sarin,
saw palmrtto, 96" 97" 7261, 727,
SCABlQIU:
characteristics, 753
drugs da .. ifi..d as
(rotamiton, 753
lindane. 755
See
Nursbg Proce .. 1'ocu.s
754,
evaluation of crilrria, 755,
implrmentation
int ..... entions and rationalr ..
754-55,
patient and family ..ducation,
754-55,
patient goal. and upect..d
outcomes. 754,
por.ntial nursins diagnoses, 754,
IndH 903
pharm.cotherapywith,753
scabies:
752, 752/
pharmacotherapy. See ScABICIDES
psy<hosocial and community impact,
755,
sch..dulrd druSS:
Canada, 15,
definition, 14
U.S., 14, IS,
ochizoaffective disorder, 205
ochizoph .. nia:
definition, 204
pathophysiology, 204--5. 205/
pharmacotherapy, &e al5c
ANrIPS'lCHUJ1CS
atypiLal antipsychotics. See AITJl[CAl
AN11PSYCHOTICS
dopamine ')'Icem "abiliuro , 2 t6
mechani.m.ofaction, 205/
Stx
NONPHENOTIILl.ZJNn
Nur.;ing Proc.ss Focus
atypkal antip.,..,hotics, 213-15,
conventional antipsychotics,
2()9....II,
phmothiazin ... See PHENanJLl.ZJNB;
,ign.and symptom" 204-5
child, 70-71. See al50 DlUdrm
scinitinib, 5631

actions and uses, 14 5
asantiemrtk,629,6301
774,
ocurvy, 644
sea ... , 643,
seasonalaffti,,,, disorder (SAD), IS2
Seasonale. 698
Seasonique,698
seborrhea, 755
760
secobarbital:
as genua! adjunct, 252,
for ..,J...ion and inllODln;", 159,
Seconal Secobarbital
second me;senger ""ml" 49
secondary 299
secondary-progr .. ,;'" multiple scl.rosis,
'" sec .. tion, tubular, 41S
Sectral. See ,,"cdmtolol
sedati,-.{.), 107, 154
..dati' ..... hypnotics, 107.154
seizures:
age-.. latl factors, 167,
cau .... 166--67,167,
definition. 166
EEG recordings. 166/
genetic factor., 1671
inddence, 1681
natural th<rapy with ketogenic
dirt, 1691
LibraryPirate
904 Index
"';zu", .. (am,.)
pharmacotherapy. Su at.e "NTI,ErZ\JRE
DRUGS
Nursing P""" .. Foew. 177- 79t
by .. iru"'typ<.169t
theraprutk approach, 167-69
types. 166J. 167. 168t
S=VE E5llOGEN- J ECI'J'lOR MODlFlEl.I
(SERMS):
characteristics. 562, 737
drugs d ..,ifir<i as
ralru:ifene. Se< Raloxifene
tam""ifm. SNTam""ifen
to",mifene, 561, 561,
for 05leoporosis. 737
S=VE SEROlOOIN n:tWfAXE INHIBITOR'>
(SSRIs):
adw"",dfrcts,155,. 156, 1861,137,472
drugs d ..,ifii as
dtalopram, 155t, 186t, 266
dtalopram oxaIatr. SN EsdtaJopl""dm
""alale
tluantine, 1551, 186t, 266
tlm"Oxamine, ISS" 186t
paroRtin. ,155t.l&&
... rlTaline. See S.rt l""aline
.ibutramin . Su Sibutramine
herb-<lrug inleractions, 1001
m<"<hanism.ofaction, 184, ISSJ.
186J. 137
Nursing Proc<: .. Focu . Su
"nlidq>ressants, Nursing Pro<e ..
Focm
for condition.
anxirty, "'.il .... n .., and d.p", .. ion,
155t
depre..,ion, 186" 187
obesity, 634
.. Iegiline hydro<hloride, 257, 258,
.. Ienium, 100" 549,. 649,
Sdzmtry. Sn Maraviroc
.. niorcitiuns. Se< Older adults
.. nna:
.... dfecu. 622.
drug interoctions, 175" 471 673,
m<"<hanism. of action, 622
route and adult do ... 622t
s<:nolroL Se< S<:nna
Sen,ipar. Su Cinacalcrt
.. ntind event., 118
",ptk shoo:k, 406. 407,
"'pti",mia, 480t
Seplodont. See "rtkaine
Septra. S .. Trimet hoprim-
ul fameth o:<aZO Ie
Serax. Oxazepam
5rt" ... ent. Se< Salmeterol
SElU.t S. Set S!llECl1V[ ES1l!O(;EN- RECE!'fOI
MODlFlEb
S<:rom)'l"in. SN Cydo .. rine
Serophen . Set Clomiphen.
Seroqud. Su Qurti.pine fumarate
S<:rostim. Set Somatotropin
SEROTONIN IECIl'IOR ANTAGONISTS. See tilio
SEl.E.Cl1V[ ,HcrroNIN REUPTAKE
r<HIBl1O&.I
dola .. tron, 629, 630t
grani .. lJOn, 629, 6.lOt
for nausea and vomiling,629. 6.lOt
ondan .. tron,629,6)O,
palonDsetron, 629, 6301
.. rotonin syndrome (SES), 187-i18, 472
SEROTONIN-NOJEPlNl'I'HRINE n:tWfAn
r<HIBl1O&.I (SNRIs), 186t. 18S.
, I.e 1irYl'lCAl. ANT!DEPlI.""ANTS
S<:rpasil. Su lkserpin.
.. rtaconazole, 5]3,
... rttaline, l88t
U"', 1118" 266
ildmiDistration alerts, 1881
ady ..... 155" 186,. ISSt
interactions. ISSt
""e,,:b .. lreatrn<nt, 188,
phannacokinetics, 1118,
.dOlIt dn ... I",
for specifIC ronditions
ami.ty symptom .. ",.tle..,n ... s, and
dtpression,15Sr
dq>re .. ion, 186,
.. ""lam .. , 420t
.. 246,
Sherley Am.ndment, 5, 6f
539
mock:
406
morldity rat . ... 4061
Nursins Proc<:.., Focus
a,sessm<nt, 41 Ot
implemmtation
evaluation of outcome crit<ria, 411,
interventions and rationales,
4]() .... llt
patient and famUyiucation,
41(1....11,
patient goals and exp<eti
ootcom", 4IOt
potenti. 1 DUrlins diasnou<, 4[0.
pathophysiolo8Y,
pharmacotherapy
eff<ets, 4071
fluid replacement agents. SN flUID
MID ELECIWLYrn JEPL\.CEMENT
-,
inotropic agents. S .. lNOTIO;OPlC ACENTs
"""""onstricto ....
VA.lOCONS1l!!croRS/VA>OPRIToSOJ.I
signs ODd .ymptoms. 406, 406f
treatmem prioritie.,406, 408
typ<., 406, 4071
short .tatu",659, 659,
,oort-1<rm (behavioral) insomnia, 152
sibul ram inc, 634t
actior.s and u .. s, 634t
administration alerts, 634,
ady ..... effects. 634,
interaction., 634,
owrdo .. tr. atm.nt, 634,
pharmacokin.tics,634,
. ildenafil ,7221
actions and uses, 721, 722t
administration alerts, 7221
ad""r ... effects. 7211
imeraclions, 722,
pharmacokinrtics, 7221
roule and adult do .. , 722,
silem anHina. 340. Sa also ""gi",,
pecto,is
,iImthicone,615,615,
simpl. partial "uu"', 168t
Simukct. SN Ba,Uiximab
,inwa"alin, 2S7,
Sin"",et. See Carbidopa. levodopa
Sinrquan. Sa Doxrpin
single order, 20
Singulair. SN Montduk.o51
sinoatrial (SA) nooe. 356, 356f
sinw 3551
<inn . 'hythm. l';t;
sinusitis, 480,
.irolimw, 457, 458,
sitagliptin, 687 r, 689
sitU.1tional anxirty, ISO
Skdaxin. Sa Metaulone
SKEL!."l"AL MUSCLE f.ElAlANTS:
drug. das,ifi.d as
badof.n, 271, 2721
carisoprodol. 272,
chlorphen .. in,272,
chlorzoxamne,272t
donoupam. See Clonazepam
cydobenz.aprin . Set c,.clobenz.aprine
diazepam. Sa Di azq>am
lorazepam. Su Lof"Ll"l'am
mrtaxalon . 2721
mrthocarbamol,272t
orphenadrine, 272,
tizanidin., 272t, 273
hom. care consid.rations, 277t
m..,hanism. of action. 271
Nu .. inS Proce .. F-o.::w;
... ..,m.m, 276t
.""IU.1tion of outcom. crit ... ia, 276,
implemenlalion
int ...... ntions and rationales, 276-nn
patient and family . ducation,
276-77,
planning: patient goals and UJ"'cted
oulcom ... , 276t
potential nursinsdiagno .... 276,
Skelid. Set Tiludronate
skin:
disorders
"cn . Set Acn. vulgari.
cau .... 75(J....51
classification, 750" 751
dermatitis. Su Dermatiti.
indd.nce.751,
inf..,tions, 750t, 752
inflammatory, 7501
LibraryPirate
750,
para,ite., s.., Lia; &abie.
pooria.i., Sa Pooriasi>
rosac"", 757, 757/
interrdatiomhip, with other body
.ystem., 751/
layers.750
s.leep:
functions, 152
.tages, 153, 154,
s.leep debt, 153
sIping .idrness, 521 t
Slo-Mag, s.., Magne,ium chloride
SJlla!lpox, 119--20
,moking, s.., Nicotine; Tobacco US<'
SNRls (SrROI'ONlN- NOlPlNEPHRINE
186r, 188, Set
alsc A TYl'ICAL AmID!:PI!!'5SI.NTI
t til
social anxiety, I 50
sodium (Na'):
functions, 64g,
imbalanct., s.., HYP"matremia;
Hyponatremia
in myocardial cflls, 358
pharmacotherapy with, See Sod inm
bicarbonate
recommended dietary aUow.nct, 648,
rena! regulation,423, 437, 438/
sodium bicarbonate (NaHOO,), 44lt
actions and uses, 441,
administration alens, 44 I,
adyerse dfeds, 441 t, 647,
for aspirin ",,,,rdose, 41, 122
interactions, 441,
ions, 436,
overdose tmllment, 441,
pharmacokinetics, 441 t
route and adult dose, 647t
for spociflc condition.
acidosi 440, HI,
a. antacid, 615t
nutritional and electrolyte disorder.,
647,
sodium biphospltate, 622t
SODIUM CIIANN.L BI.OCKDS:
drug, classified a,
disopyramide phosphate, J6(Jt
fl=inide, 360,
lidocaine, See Lidocaine
maUetine,36O,
phenytoin, s.., Phenytoin
pro<:ainamide, s.., Procainamide
propafenone,360,
quinidine gluconate, 360,
quinidine mlfate, 360,
fordysrhythmias, 3581, 359. 359" 360,
.. local anesthetics, s.., l.ocAI. ANlSlHEllO
sodium chloride (N.O), 439t
action. and u ..... 439,
administration alert., 439,
adycrse dIed" 439t
intera<tion',439t
ions,H6t
pbarmacokinetics, 439,
sodium Iryaluronate, 741
sodium hydroxide, 242
sodium iodide- 131, s.., Radioaaive iodine
sodium ion channds. 358, 358/
sodium ,tibogluconate, 521,
Solarau. s.., Didofenac
Solarcaine, See Benzocaine
Solu-M.droL s.., Methylprednisolone
Soma, St, Carisoprodol
Soman, 121,
somatic nervom systrm, 127- 28
somatic pain, 219
somatostatin, 660
somatotropin,659,659,
Somavel!. Set Prgvisomant
Somin"", See Diphenhydr-dffiine
Somoeri
Sonata, Stx Zaleplon
""rafenib, 563t, 564
Sorbitratr, s.., lso.omide dinitr-dtc
Soriatanr, See "dtretin
""talol, 136" 360" 364
soy, 961
spasticc%n,625
spasticity:
273
273
homrcarecomiderations, 277,
non pharmacological treatm.nt, 273
pbarma<:om.rapy, Sa aJ..,
ANTI' PA.lMODICS
mo;:hani,m.of action, 274/
Nursing Process 276-77,
m.raprntic approach, 273
spukins impaimlents. 74,
spocialtl5upplement,99, lOOt
spocific .ntidotes, 122, IHt
Spectaz<lle, See Eronazole
Speclraccf. Sn Cdditoren
Spectrobid, s.., BacampiciUin
spinal anestho.ia, 2401, 241,
'Pirilla,H9
spiritual therapies. 95t
spiritualitl. 77
Spiriva, Sa Tiotropium
. pironolactone, 424/
actioL'land u ... s, 329, 424,
admiai'tration a!erts, 424,
adverse .ffects. 303" 328t, 424,
interactions, 424,
treatment, 424,
pharmacokinetics, 424,
for 'p",ifie conditions
heart failure. 328" 329
hrrerten.ion, J.02" J.03,
renal failure, 423, 424,
Sparano:<. s.., ItraconalOle
Sporo,h,;x 507t
sporOlrim.o.is, 5071
SSRls, St. SEUCl'lVE SEJ:OTONlN REUl'I'AKE
l'<IlIBITOLI
St, john', >rort:
for dfpr.ssion, ISS,
drug interaction.
chlorpromazine, 2071
efavirenz, 532,
esdtalopram, 156,
Index 905
<Ihinyl.stradiol with norethindrone,
""" imipramine, IS7t
medroxyprogc'trrone 706,
morphine sulfdte, 223,
phenelzine, 190,
senraline,188,
.umatriptan, 234,
zid<wudin. , ,31,
standardization,97t
uses, 961
stable angina. 340, S .. alsc Angina
!""""';.
Stadol. s.., Butorphanol tanra!e
standing ordus, 20
S",p/tyk>axru5
di ....... , caused by, 480t
methkUlin- r .. istant, 481, 498
tesiSlanU' to 4791, 481
skin infection,. 752
StarliL Sa Nateglinide
STAT order, 20
STAnN. (HMG-CoA REDuC1l'.,';l;
INll!l!ITOlS):
administration, 288
adY.""dfects, 287t, 288
coenzyme Q I 0 and, 290,
drug. dassifii a,
atorva'tatin, s.., Aton....t.tin
Huvastatin,2871
lon'tatin, 287,
pra'''statin, 287t
roSllva'tatin, 287,
.inwa".!in, 20" 287t
mechanism. of a<:tion, 287-83, 2S9/
NUr>ing Proce .. 292--94,
pharmacotherapy with, 287-83
.... , ... a .. hma,ku., 592
'talU5 rpUrptirus, 16St, 169" 171
,tavudine, 530,
steatorrhea. 635
Stdazine, s.,., Trifluoperazine
stem aU, 390, 390/
St emrtU, Sa Proch lorpernzi ne
steroid .. 283, 284/
sterol nudeus, 283
Strvens---john""n syndrome, 1St
StUbostroL s.., Diethylstilbostrol
Stirnate, &e
stimulants, central ncrmu ystem:
a mph.tamin .. , s.,., Amphetamine,
caffein., 81" III
cocaine, See Cocaine
methylphonidate, See Methylphenidate
stoma<:h, 608, 608/, See a/so Upper
gastroint.stinal tract
Strat<gic National StockpU. (SNS), 118
LibraryPirate
906 Index
&.
stratum 75-0
stratum cornrnm. 750
stralum granulmum. 750
stralum luddum. 750
stratum spinosum. 750
Srreprococcu" 480,. 752
StreptococCI" p<"lellmOM;"'. 479,. 499
S"l1U'P"lQ(; RAMlNS. 494
quinupri.tin/dalfopristin. 494. 4951
stJqltokina",.383,
stJqltomydn. 489. 490,. SOO,
stJqltozocin.555,
Striant. 7181. Su,,"o T ..
strou mlum<.198. 298/. 299/
Su [vermectin
subcutaneous drug administration. 28-29.
30dl!
sub.k<;livedata.55
Sublimau. Su Fentanyl
sublingual route. 23. B,. 24!
Suboxone.227
sub,tanu abuse:
androgen .. 717
dtfinition.104
d=rometborphan.582,
and extent, 14,
neurobiological and psychosocial
104- 5
nur .. .rol 1I2
opioids
.. 106,. 107
treatment. 227
withdra ..... al symptom,. 1061
104
physical . ctivityand. lOS,
physical depend.nu. 105
psychological 105
stati'tics. 104,
terminolosy.14--15
106
volatUe inhalants. 106,
withdrawal syndrom ... 105. 106,
sub,lanu 105--6
.ubstance p. 220. nO!
substantia nigra. 257
123,
S\JCCINIMIDO:
"'
Su Etho. uximide

ph.nsuximid 174,
mechani,ms of action. ] 74
pharmacolherapywilh, 175
2531
actions and u", 253,
administration alert .. 253,
ad,..,,,,, dfccts, 2521. 278
interaction .. 253,
overdo", tn:atment. 253,
pharmacokinetics. 253,
sucralfale. 616
Sudafl. Su P .. udoophedrine
Sudafed PE Nighttim< cold. 5761
SudafedPE Sinus and Allergy tablets. 5761
Sufenla. Su Sufentanil dlratc
sufootar.U dtrate. 2511. 252,
.ukide risk:
antid<pr=nts.nd. ]83-84
antisrizun:drugsand.167
sulbactam. 485
sukoniUOk.513r
756,
493. 493,
sulfadolinc--pyrimethamine. 493. 493,
.ulfamethoxarole. Su
Tri mcthopri
,ulfasalazine:
adv.,... effects, 742,
for rheumatoid anhritis. 7421
. u]f",. lazine. 6281
aClior., and u.-s. 492- 93. 6281
admimistration alen .. 6281
adva .. 67,. 62St
for bowel disea ... 625
interactions. 6281
overdo'''' Irratm<nt. 628,
phallllacokinttic .. 6281
,ulfinpy;awne.745,
sulfisoxazolr.493. 4931

ad.-a .. effecl .. 493,
drug, cla"ified as
SIllfacetamid 7S61
sulfadiazine. 493. 493,
sul:'adoIinC'-pyrimethamin . 493.
' 931
sulfasalazine. & Su]f",alarill e
493. 493,
trirlelhoprim-oulfamethoIalOle.
Tri methopri m-sulfal11ct hoXlzole
mec .... ni'm' of action. 492- 93
With. 492--493. 497
aduh do .... 493,
IULFONY"..uRl'AS:
adv""",, effects, 687,
characleristics.686
drugs classified as
chlorpropamide. 6871
glimcvirid 687,
glipizid . 687,
elyhmid,.
6871
tolbutamide. 687,
route and adull do .... 6871
sulfur. 648,
.ulfur mustard. l21t
,ulinda .. 2281
. umalriptan,2341
aclior_.and u"' .. 234,
admimistration 2.J.4,
adV<T>O effects, 233,. 234,
interactions. 2341
owrd-, .. Irratm<:nt. 234,
phallllacokinetics, 2341
route and adult do ... 233,
Sum)'dn. Soc Tct racyt"line
sunburn. 763
run.,,,,,,,n 763
wperfidal myco.is. 5071. 508
wpcrint'caion .. 483
supplements. Su and
Allanatm Therapies
dietary. See Dietary .uppl<ment{.)
htrbal. 5
specialty. 1001
Suprane. Su D ..
ruprawntricular.355
surfaa anesthesia. 240
rurgk .. l anesthesia. 246
Surmontil. Se. Trimipramine
Surv.nla. Su Beractant
Sustlcal 651
5UStainl-n:leasc tablet .. 22
Sustin. Su FIavin:nz
Sutrnt. See Scinilinib
Symlin. Su Pramlintide
Symmetn:l. See Amantadine
synlpalhetk "ystem. 128. 128!
SYMPArnoITI1CS. See IillRINE1GlC
ANTAGONI!i1ll
SYM001l0M!MErICS. Sa ADRENElGIC AGONISTI
synap",.129
synaptic transmi.sion. 129
Synan:l. Nafarclin
Su Quinupristin--<lalfopristin
Synthroid. Su l.r\nthyroxine
Syrup of[pccac. ] 22
systemic mycosis, 507,. 508
systolic pressure. 297. 297,. Su ""0 Blood
pressun:
T
T uU .. 45O
tablets:
administration guidelines, 22. 23,
cru.hing. 22
IYP"" 22
Tabun. 121,
tacrine. 140. 1401. 264. 264,
tacrolimus:
ad.,..,r .. cl'fects. 458,
forderm.liti .. 761
as immunosuppr .... nt. 457. 458,
mT p_""ri._,i . 7';1
tadalafd. 722. 722,
Tagamet. Cimetidine
Talwin. Su Pentazocine hjdrochloride
Thmbocor. Sec Flrcainide
Thmillu. Sa O",ltamivir
tamOIifen.5621
actions and u ..... 5621
administration alals. 562,
ad.,..,r .. effects. 561,. 5621
interactions. 562,
pharmacok.in.tic 562,
for spo<ifk condition,
brrast can=. 560--61. 561,
mal. inferlmty. 718
LibraryPirate
tamsulo,in, 136" 725" 726
P<'rfhmium. See F ..... erffW
tapnoourm., 521
Taractan. See Chlorprothix<ne
Tarct"Va. s... Erlolinib
t.rdj,..., 206, Nl,
largnti,sue,41
Targretin. s... Baarotene
Tarb, )02,
Tasmar. s... Tokapone
Tavist. See Clem. stine
Tavist AU .. rgy tablets, 576,
TA.UNI:'i:
chanmeristiC&. 559
drug. classified as
docetaxd, ,59, 559,
padituel, 5501, 559. 559,
phamJaootherapy with, 559
Taxw bac,,"o, 559
tazarotene, 756" 762,
tazobacram,485
Tawrac. Sre Tazarotene
Tazlia XT. See Dihiazem
HC. See Lamivudine
TR!acuc
TD .. (median toxicity do .. ). 47
t .. a,981
tepserod,625
Tegison. See Etretinate
T<"gretol. s... Carbamaupine
Tekuma HCT, 302.
tdbiYlldine, 5421
tdithromydn, 495" 499
tdmisartan, 31],
temazcpam, 157.
T.modar. See Ternowlomide
temorolomid.,555,
t.msirolimu .. 45&
tendonitis. fluoroquinolones and, 492
tenect.pl .... , 3831, 386
t.niposide, 559, 559,
tenofo ... ir, 5301, 53], 53S, 541
Tenoretk,302,
Tenorrnin. See Atenolol
ten,ion headachr: , 230
teratogen, 65
Trrarol. See T.n:onawle
terazosin, 3]5" 7251, 726
t .. rbinafine, 514, 514.
terbutaline:
action. and uses, 1321
ad ... er .. effeclS, 594,. 708,
for asthma. 59-l,
as torolytk. 7081
terronazole, 5] 3.
Terfluzine. Sa
t .. riparatide, 739
Teslac. Sec T..,tolactone
Tessalon. Su Benzonatate
Testim, 7]8 . 5"lso Testo,terone
T .. tod.rrn. Su Testosterone
T . stoderrn TIS. Sec Testosterone
testolactone, 560, 561., 7]9
Testopd. 7IS . Sa al", Te,tosterone
testosterone, 7191
actior ... and u .... 719,
administration alerts, 7 ]9,
ad"" ... effects, 561., 7] 7,. 7181, 7] 91
formulations. 717. 7]&
functions, 7] 6
int.ractions, 719.
phumaookinctk .. 7191
"""mion,716
for s,,",ifk conditions
cancer chemotherapy, 561,
hypogonadism, 716--17
testosteron.cypionate, 71S,
t .. tosteron. enanthate, 7171, 7181
T.stred. Sa Mnhyltestosterone
wanus, I 161
tetanus immune globulin, 4501
tetra",ir . . 2421, 763
tn rdqdine, 4881
actio .... and u .... 488,
administration alerts, 4881
ad".r .. effects,488.
interactions, 4881
pharmacokinetks, 4881
route and adult doses, 4881
for sp.dfic conditions
""De,7S6t
H.;>yl<>ri,617
rosacea, 757
skin infections (topical), 752
lFI1!AC'/CllNI'.\:
ad"" .... ffeclS, 48.'.-89, 489.
drugs classified a.
de",eclocycline, 489.
doxycycline. Ser Doxycyclin.
miAocycline, 4891
teuacrdine. Ser Tnra<y<:line
tigteycline, 488" 489
facton affecting absorption, 38
pharmacotherapy with, 488--89
tetrahydrozoline, 774, 7741
T ...,ten.Sre Eprosartan
Te""ten HCT, 302.
thalidomide,4581
THC (ddta-9-tetrahydrocannabinoll, 109
Then- Dor. See ThenphyUine
theophy'Jin. , 5941, 595
TheraQ . See Bacillus Calmeno-Guain
(BCG) ncdn.
d ... ification, 12, 12.
index, 46--47, 47[
Therapnnk Products Directorate
(TPD),9
range. 42,43[
4
thiamin . Su Vitamin B,
lllIAZlD[ IJIUJ.ETICS:
ad..., ... effects, 3031, 304, 328t
drugs classified as
ber.droHumethiazide, 4221
chlorothiazide. Sa Ch lorothi azide
chlorthalidone, 303,. 422.
Index 907
hydrochlorothiazide. See
Hrdroc: h
indapamide, 303t, 422.
methydothiazide, 4221
metolarone, 303" 422,
mechanisms of action. 420, 421[
for 'prdfic condition.
heart faUure, 328" 329
h)'l.'tnemion, J.O.l--4, JOJ,
rtnal failurt, 422- 23, 422,
TIlIAZOLINEDlONE5:
adve""dfe,ts, 687t
,haracteristic&' 688
drugs classified as
pioglitawne,6871
rosiglitazone,6871
and adult doses, 6871
thioguanin . 555" 556[
251 1
actions and uses, 251.
administration alens, 251.
.dve""effect .. 2511
intera.r:tion .. 251,
OYerd05e treatment, 251,
pharmacokinetics, 251 I
ThiopkL Sa Thiot."a
thioridazin., 206, 206t
thiotepa, 555,
thiothixen. , 209.
Thorazine. See Chlorpromazine
thrtt ch<-cksof drug administration. ]9
thrombin. 370
thrombin time, 372.
372
thrombocytopoie.is,394
thromboernbo.lk disordtrs., 37]
TIlIOMBOLTIlCS:
definition, 373
drugs classified as
alt."la .... See
rtt."la ... Su ikt."lase
strtptokina .. ,383t
tenccr."la .. , 386
mechanisms of action, 373, 3731, 383
Nursing i'ro< .... Focu.
....... m.nt,384'
... ;oluation of outcomecrit<Tia, 385t
implementation
interv.ntions and rationale ..
384--f15,
patient and famUy education,
384--&5.
planning: patient goals and expected
outcome .. 384,
potenlial nursing diagno .... 384,
pharrnacotherapywith,348-49,
383,386
thrombopoietin, 397
thrombu., 37]
Thyro- Bkxk. Sa Potassium iodide
Thyrogen. See Thyrotropin
TIIYJ.OID AGINI"S:
am. "" dlr,'" 663.
LibraryPirate
908 Index
(",MI.)
drugs classified as
deskcatrd thyroid. 663. 6641
lrvothyroxine. Su Ln"Olhyroxinr
liothyroninr. 663. 6631
liotri", 6631
NU,"ing Process Focus
as .. ssment.6681
.valuation of outcome critrria. 6691
implfmr ntation
interwntion. and rationales. 668--691
pat""t and family rdocation. 668--691
planning: patimt goals and expected
outcome .. 668,
polential nursing diagnooe .. 6681
pharmacotherapy with. 662-{i3
thyroid gland:
in cakium metabolism. nlf
6621.
Hyperlhyroidism; Hypothyroidism
functions. 662. 662f
thyroid storm. 664
Thyroid USP. Sa thyroid
thyroid-stimulating hormone (TSH).
6581, 660.
Thyrolar. See Liotrix
ThyroSafe. See Polassium iodide
thyrotropin. 6581, 6601
thyroxine. 662
thyroxine -binding globulin (TIlG). 662
. 1691. l71,
Tiamate. Diltiaum
Tiazae. Sa Diltiazem
Ticor. See TIeardUin
tkaremin.4841
Tic . See Haemus (BCG)
vaccine
Tidid. See Tidopidine
tidopidin 349. 379,. 380
tigtcydine. 488,. 4g9
Tikosyn. See Dofetilid.
Tilad . See Nedocrornil .'lOdium
tiludronate. 7391
Timentin. 4g5
Timolide. 302t
limo!ol. n it
actions and U""'. 1361. 771,
administration alrrt .. 7711
adv ..... dfrct .. 315 771,
inleraclions, 7711
pharmacokinetics, 771,
for condition.
angina and m)UC3rdial infarction. 3431
glaucoma. 769. 7701
hyprrtfn,ion. 3151
migrain 2331
Tirnoptk. See Timo!ol
Tinactin. See Tolnafiate
tinetur 98,
Tindamax. Sa Tinidazole
tin.a capitis. 507,. 752
tinea crun . 5071. 514. 752
tinra redi .. 507,. 514. 752
tinra unguium. 752
tinidazole. 517. 5211
tinzaparin.374,
tioconazole. 5]3,
tiotropium. 594. 594,
tipranavir.530,
tirofiban.379'
tissue pla,minogm activator (TPIr.). 371
tilanium dioxide. 763
tit ... 449
Titralac. See Cakium carbonale
tizanidine. 273
tobacco u .... a/w Nicotine
ethnic considerations. 112.
frlal dfr<ts. 68,
tobramydn.4901
tOOlinid 3601
TOCOtJ"TlC<;:
characteristics. 707. 708--9
drugs classified as
magnesium ,ulfate. See Magne5ium
sulfal.
nifrdipine. See Nifedipin.
riloorine. I 32,. 709
terbutaline sulfale. See T!"l"butaline
pharmacotherapy with. 708--9
tocopherols. 4 1. Sa a/w Vitamin E
toodlerhood. 69--70. See a/so Children
Tofranil. Sa Imipramin.
tolazarnide. 687,
tolbulamide.6871
tokapon 257. 258. 258,
Toleclin. SuTolmetin
tolerance. 106
Tolina .... See Tolazamide
tolmetin. 228,. 467,
tolnahate. 514,. 515
toherodin . 1431
tonk spasm. 271
tonk-donk (grand mal) "uu"'. 168,. 1691
tonidty. 431. 432f
Topamax. Topiramal<
topkal anrsthrsia. 2401, 2411. S aIJc
Benzocaine
topkal antibiotics. 752
topkal drug administration. See Drug
administralion. topicol
topkal glucocorticoids:
for drrmatiti .. 760. 7601
for psoriasis. 761
topiromate. 169,. 233t
topoi"'mera .. I.559
TOPOOOMER.l.SE INHIBITORS:
drugs classified as
etoposide. 5501, 559. 559,
irinote""n. 559. 559,
tenipo.ide. 559. 5591
tOpoir<an. 5501, 559. 559,
pharmaootherapywith. 561
topotccan.61. 550 559,
Toprol. Se. Metopmlol
Toprol-XL S Metopro!ol
Toradol. S Kotorolae trornethamin.
torrmifm 561, 561,
Thri ... l. S .. Tem,irolirnus
torsad de pointe .. 364
torsemide:
ad""r .. effects. 303 3281
for heart failure. 3281
for hypert.nsion. J.OJI
for renal failure. 421. 422,
tositumomab, 5631
total parenteral nutrilion (TPN):
definition. 651
indication,. 651
Nursing Process Rxus
a...,ssmrnt,651- S21
e""luation of outcome crileria.
652- 531
implrmentation
intervmtions and 652- 531
patient and family.ducation.
652- 531
planning: pali.nt goals and expected
outcomes. 6521
potential nur,ing diagnooes, 651- 52.
nursing proce .. focus. 651- 531
toxic concrntrution. 42. 43f
toxic epid.rmal nrerol)w, 181
toxic shock .yndrome. 480,
toxin .. 118
toxoid .. 449
T=pla.slfUl gond;;. 521,
toxopla,mosis, 521,
TPA. See AII.pla.e
TPA (Iis",e pla5lllinogm aclivalor}.371
TPD Products Directorate). 9
TPN. s... Total parmteral nutrition
trahular me.sh>rork, 767
trace minerals. Su MIClOM!N!'lIAl.\
Tracrium. S Ir.tracurium
trade (proprielary) name. 13. See aIM>
drugs
tramadol. 22&. 229. 741
Trandat . S Labrtalol
trandolapril. 311,
tranexamic add. 386,
tranquilizers. 154. Saa/w Sedati",,(.)
transd.rmal drug administration. 25.
2526.
Transdrrm.Scop. SlY Scopolamine
transfrrrin. 399
transplant rr;lion. 457
TrallX<ne. Set Clorazepate
tranykypromine. 155,. 1861
trastuzumab, 55Of, 563-{i4. 563,. 564f
Trasylol. S Ir.protinin
Travatan. Su Tramprost
t .. "rI .... diarrh ..... 4801
travoprost. 769. 770,
trawdone. 1551. 189
Trranda. Su Brndarnustin.
Treating the Diverse Patient:
Ir.CE inhibitors and ethnidty. 311,
acr"laminophen metabolism. ethnk
diff ... nces in. 4731
LibraryPirate
angina, inn""n", of l\'"nder and ethnidty,
341t
amibactorials, Hispank cultural b<lirls,
483t
amimalarials and G6PD defkiency, 517 t
Asian patiem.' .emitivityto propranolol,
",;,
cultural dietary habits, 286,
cullum influen= on irnmuniI.ations,
451t
cultural influences on pain up", .. ion
and prrcoption, 2201
cultural remli ror diarrhea, 625,
cultural virwsand memal illnr..,
t"",tmem,2051
depre..,ion, 182,
enzyme in a'rtain ethnic
populations, SOt
.thnk groups and .moking, 112t
G6PD defidency
amimalarialsand, 51 7t
medication adh.nnce, 78t
non- Engli'h-speaking patients,
im .. pm ... for, 591
oSltoporosis, 740,
religiou, fa'ting and compliance with
mlkation administration, 24,
'praking, visual, or hraring impairmcms,
",
vitamin D and diab<tes risk,6421
Trator-SC. Su Ethionamid.
Trd,tar. Su Tripto",lin
t",mors,256
Trental. Stx P.moxifylline
Trentin- X. Tminoin
tretinoin,7571
action, and uses, 756, 757,
admini,tration al .. ts. 7571
adv ..... fflS, 756t, 757,
intrractions,757,
0""' 00... treatmrm, 757,
route and adult do .. , 756t
Troxall. Stx M. thot re""t.
Traan. Me Naltre""n. hydrochlorid.
Triadn-C Cough Syrup, 584,
triamcinolone:
adv ..... ffeo.:t" 470t, 596/.671t
for specific conditions
ad",nocortical insufficiency, 671,
aUrrgk rhiniti" 5801
asthma,596t
.. ""'" inilammation, 470,
topical,760t
Triamink Cold/AUergy, 576t
triamt ... n., 30),. 4241
triazolam. ]57,
TricJwmoM,,", ."Sinall!, 521,
trichomoniasis, 521t
Trirhaphyron,507,
Tricor. Me
11lICYCUCANfIDEPI!ESSANTS (TCA,):
adv .... 155t. 156, ]861
contraindications, 156
drugs classiflla,
amitriptylin . Su Amitriptyline
am=pine,I86,
do,"ipraminc, 155/
desipramine. 186,. 200
dOl"'pin, 155,. ]86t
im\>ramine. Me Imipr-dmine
ma;>rotiline. 186,
nottriptylinc, 155" 186,
protriptyline, 186t
triJ:lipramine.I861
h .. b-drug intrractions, 100,
"",chinisms of action, 184, 1&5[
Nursbg Proce .. Focus. See
Antidrp",,,ants, Nursing Proct>S
"""'
for conditions
ADHD.200
ami'ty symptom" 155t
depression, 184, 186t
enuresis, ]84
migrain.,233t
ob ..... h. -compul,i'.., disordrr. 184
triethanolamine polypeptide olrate 10%
(Ondensat.,7761
tritluoptrarine, 206, 2061
triHurid:n., 538t, 539
triglycrrides:
charactrristks, 283, 284/
laboratory values, 286t
trihexyphenidyl hydrochloride,
260,
triiodotbyronin., 662
TrUaron. Stx Perphrnazin.
TrUoptaL &. Oxcarba"'pine
trimethoprim--1l ulfamethOJQlZole,
492,494t
actiou and u .. s, 494,
admimistration a1rrts, 494,
ad""n ffects, 494,
interaction .. 494,
ovrrd"", treatment, 494,
pharmacokinetics, 494,
rout r and adult do .. , 494,
trimipramine. 155" 186/
Trimox. See Amoxkmin
Triostat. Set Liothyronine
Tripedia. Set Diphtheria, tetanu" and
r .. tussis '"3ccine
Triphasil,698,
Triplix. s.,. Fenoflbric add
triprolidine, 575,
TI!!I'fANS:
drugs classifled a,
a1rr.otriptan,23).
detriptan.233,
fro;"3triptan,23),
naratriptan,2331
rizariptan,233.
sumatriptan. S .. Sum. triptan
zolmitriptan,23),
NUr.lbg Process Focus
.... "mem, 2351
IndH 909
impl<mentaoon
evaluation of outcome,riteria, 236t
interventions and rational.s,
235- 36,
pati.nt and famUy Iucation,
235- 361
planning: patient goals and expected
outcomes, 235,
potmtial nursing diagno>es, 235t
triplorelin, 561,
Tri .. nox. Stx Arornic trioxidr
Trit= Stx Ranitidine bismuth citrate
troglitazone, 7, 638
Tronothane. Stx Pramoxine
Tropicacyl Stx Tropicamide
tropicamide,774,
lroponin 1,3491
troponin T. 349t
Truphylline. Su
Trusopt. Set Dorrolamide
Trypa""",ma b ... u"i, 521,
TrypalWsoma auzi, 521,
trl'P"nosomiasis, 521t
TSH (thyroid-,timulatinghormone),
658 660t
TSPA. Stx Thiotrpa
tub< f..-ding. See Enteral nutrition
tubc:rdes,499
tuberculo,is, 116.
inddence, 499
pharmacothrraPr, 499, 501. Set al,.,
AN"rmJII.ICULOS1S DRUG>
tubocurarine, 252" 278, 278,
tumor, 548. 549,
tumor ,upp",ssor genes, 549
Turns. Set Calcium caroonate
Twinri:., 452., 541
Tyga,U. Se.Tigecydine
Tyuro. See Lapatinih
Tylenol. Set Acetaminophen
TylenolAllergy Sinuscapl<'l" 576t
Tylenol PM srlcap . 576,
typt" I diab<t"" mdUtw, 680. Stx 01",
Diab<tc. mellit'"
typt" 2 diab<tc, mdUtu" 682. Stx "I",
Diabetes mdllt",
typical antipsychotic .. Me
NONP!INUTIlIA.Z.INn;
PHENOTHIAZINE.\
tyramine:
deflnition,189
food, containing, 189,
MAOls and, 156. 189
Tysabri. Set Natalizumab
Tyuka. Stx Telbivudine
Tyzine. Stx Tetrahydrozoline
U
ulcer, 60
ulcerath.., colitis, 621 " 625
Ultan . Stx
Uhiva. Set R<mifenlanU hydrochloride
Ultram. Se.Tramadol
LibraryPirate
910 Index
ulu .. ;oki lighllMrapy, 763
Unasyn.485
und.cylenic 515, 752
undernulrition, 65O
Unirdic, 302t
Unisom. See Doxylamine
Univaoc. See Moaipril
unopr"'ton.,769
W1sLibk 'lngiIw, 340. See alH> hngilla
ptoris
up!'"r gastroinustinal tract:
acid produclion.608
analOmy.607f
process, 607-11
disord.r>
gast",",sophagm ,eHIlI di,..,. ... See
disease
607<
peptic uk .. disea,.,. Sn Peptic uk ..
disease
up!'"r respiralorytraCl, 573-74, 573f
Urabtth. See B.thane<hol
uracil, 556f
urea, 424, 425" 773
Ur.aphil. Sn Um
Urholine. See Bethanechol
Urn. See Meu..naminc
URIC AOD INH!IlITDRS. s..c AN11GOIJr DRUGS
urinaly.is, 418
urinaryt""'t inkction ( UTI ):
ba<uria causing, 480,
incidence, 479,
natural tkrapywith cranbury. 42S,
urine,418
Urodde. See Hydrochlorothi azide
urofoUitropin.712t
Uro- KP neutral. See Pot assium and sodium
phosphates
Uroxatral. Sn Alfu,min
urticaria,577
U.S. Depanmrnt of H....Jth and Human
S.rvices,6f
U.S.drupctt.dules, 14, lSI
U.S. PhamtfICcpocW (USP):
histcry. 4-5.6f
medkation error ll'porting sl"tf1ll. 91
U.S. PMrmfIC<>poeia-N"tioM/liJrmulllry
(USP-NF). 5, 6f
I JSP I,h<-I. 'if
uterus:
v
dysfunclional bleeding.
Dysfunctional uterine blding
rdaxant . See TOCOLYTICS
stimulants. See 0xrr0cJcs
vaccination, 448. See a!so Vaccine.
vaccines:
administration, 448--45O
ad, .... dfects, 450
anthrax, 119
cultural influ<uce. on administralion,
451t
definition, 448
diphtheria. tetanus, and ponu"i . 452t
haemophilus type Bconjugate, 452t
hrpatiti.A.452t
hrpatitis B. Sn Hrpatili s B vaccine
human papillomavirus,452,
influenza, 452t. 540
mea>!e., mumps, and rubodla, 452,
pnrumoco<ul. 452t
poliovirus, 452t
public tt.alth dfe<ts. 447 t
rotavirus, 452t
schiules and ages, 452t
smallpox, 120
type 449
varicdla zoster/chickn pox, 452,
vaginal drug 26t. 27, 28f
Vagi stat. Sn Tioconarole
valacydoYir.538,
"'ldecoxib, 470
Valergen. See Estradiol ",lerate
",lerian:
drug interactions
Joraupam, ] 58,
morphine sulfuu. 223t
ovrrvifW. 1001
ptt.nobarbilal. 172,
risp"ridone, 2] 2t
thiopental, 251,
u .. s,96t.153,
Vakri<>na officiMu.. Se Valerian
Valium. See Diazopam
vaJprok!lcid (dh-alproa sodium), 176,
action. and u .... 176t
administration alerts, 176t
adverse effts, 160t, 173,. 176,. 194,
interactions,176t
owrdo .. treatllXnt. ]76,
pharmacokinetics, 176t
route and adult do ... 160/, 194,
for sp"dtlC conditions
anxiety. 16(1,
bipolar disorder. 193. 194,
migraine. 233,
"UUll", 169" 173, 173,
",l""rtan, 31 It. 327
Valtrcx, S<Y Valacyclovir
Vanrodn. See Vancomycin
v.nmmydn. 499
",ncomycin-re.istant enterococd
(VRE),481
Vam .... Se< Histrelin
V .... QTA. See HepatitisA vae<:ine
722. 722,
",rkella.752
",rkella vaccine. 452,
",rkdlazoster virus, 539
VarivaL Sn Varicdla ... a:ine
Va"",r. Sn Ikpridil
V .... K1k,302'
W.soaJNSTItlCfOlS!W.>oPItF..I>01tS, 408
ad. .. '" effects, 409,
drugs da"med a.
epinephrine. See Epi n<ph rine
napharoline HCI, 774, 774t
norepinephrine. See Norepi nephrine
oxymelazoline. See Oxymetazoline
phenylephrine. See Phenyl "l' hri ne
tetrahydrozoline. 774, 774,
for sp"dlic conditions
ophthalmic irritation. 774. 7741
slxxk,409, 4091, 412
VA>ODlL\.TOlS:
advrrse dfe<ts. 328t
drugs classifi.d as
dia:zm:ide,319
hydralazine. Sn Hydralazi"e
isosorbide dinitrate, 328,. 3>4
minoxidil.318,
nesiritide, 334
nitroprus.ide. 318t. 319
me<hanismsof action, 34, 327f
Nursing Process Focus
a ... "mem,320,
impl.mentation
evaluation of outcomecriteri., 322,
intervention. and rationales,
320-22t
palient and family education.
320-22,
planning: patient goakand expeCied
outcomes, 320,
potential nursing diagno ..... 320,
for sp"dlic conditions
heart failure, 3>4
hypcrl<:n<ion. 318- ]9, 3\8t
298
Ya""p"""in, 66Ot. 66]. See a/", Antidiu .. lic
hormone
"'''''p",,,,,,rs. Sn

,",sos"">tk (Prinzmclal. ) angina, 340. Su
a/", hngin. pectoris
V.sotce. S .. Enalapril
",stu. laterali. site, 32, 69. 70
vrcocuronium,278t
Vtt-CiUin-K. See Penicillin V
Vttlids. Six PenkiUin V
V.leade. S<Y Bonezomib
vrndOl-managi im=tory (VMI)
pa<"kage. ]]8

vrnlilation,590-91
Ventolin. See Albuterol
""ntricular fibrillation, 355,
vtnuicula r fluner,3551
""ntricular tochycardia. 355,
vrntrogluteal .ite, 31
Veramyst. Se< Flulicasone
'''''''dpamil,3661
aCiions and u ... , 366t
administration al .. ts, 3661
advrrse dfe<t., 307t. J.O/
J60t. 366t
int eraction . 366,
mechanism. of action. 307
LibraryPirate
o""rdo .. 366.
phamlarokinetks, 366t
for 5ptCifk condition.
angina and nI)'>GIrdial infar<tion, 343.
dysrhythmia., 358 360,. >65
J07t
migraine. 233,
Ver.lan. Me Verapamil
Yrrmox. Sre Mcbt nddwk
V .... d. Me Midazolam
v<rtigo.577
verylow.<f.nsity lipoprotein (VLDL).
283.285/
ve.icanls.553
vrend. Me VorkoDa7.0I.
Viadur. Me Uuprolid.
Viagra. Su
Vibramydn. Su Doxycydine
Vkodin.222
Vida. Me Didanooine
viUi.607
vinblastine. 5sw, 559. 559,
VINCA AUAWID>:
adver .. df.cts, 559t
dtltracteriiltics, 559
drugs classifl.d as
vinblastin 550 559. 559,
vinorelbin 559. 559,
pham13cotherapy with. 559
and adult do .. s. 559t
Vinca "'_ 559
vincristine, 560.
actions and uses, 550{, 551. 559. 56(1,
administration aler". 560.
adver .. 560,
interactions. 560,
o""rdose treatm.nI. 560.
pharmacokin.tics.56Ot
route and adult dose. 560t
vinOldbin 559. 559t
Vion. See Roferoxib
Viracept. Me Nelfinavir
viral inftions. 527. 527 . Me als<>

viral load. 529
Viramune. Su Nevirapine
See T.nofovir
virilization. 717
Virilon. See Methyltestost.rone
virion. 527
Viroptic. Su Trilluridine
virulence. 479
viru .. ., 527. 527,. Su also ANI1VIRAIS;
,pedftt:v;r1I5I"'
vi"",ral pain. 219
Viorulo ... Su M.thykellulo ..
Vi,in . S<"C
Vi,ine LR. Su Oxym<lazoli".
S. Pindolol
Vistari!. Se. Hydroxyzine
S. Cidofovir
visual impairments, 74t
Vita-C. Vitamin C
vitamin(.):
characteristics. 639
classification, 639
ddki.ndes.641J-.41, 640t
<XU>$, 640
functions.640t

characteristics, 639
vitamin A. SIT VitlJUin A
vitamin D. Su Vitamin D
vitamin E. S<"C Vitamin E
vitamin K. Su Vitamin K
Nursing Process Focus
a .... "m.nt.645.
evaluation of outcom. criteria. 646,
impl.mentation
intrr""ntions and
645--46,
pati.nt and family education,
645--46.
planning: patient goals and expted
645t
nursing diagno .... 645.
dietary aU"" .. ncc-s, 640r
.\1Ipplements, 639,
water- soluble
characteristic 639
vitamin B,. s.. Vitamin B,
vitamin 8,. s.. Vitamin 8,
vitamin B,. Sec Vitamin B,
,;tamin B,. s.. Vitamin B,
vitamin Bo. Se. Folk addlfolate
vitamin B". Su Vitamin B"
vitamin C. Sa Vitamin C
vitamin A. 642,
characteristics, 641
ddki.ncy. 640.
functions. MO.
pharmacoth.rapy with
actions and uses.64I. 642t
administration alert., 6.012t
ad""r .. 642t
interactions.642.
route and adult do ... 64I'
dietary aUowan",. 64(),
sources. 641
vitamin B complex. 64().
vitamin B,:
defid.ncy. 640., 643
functions. 640,
pharmaroth.rapy With. 643. 643t
rDmm.nded didary aU"" .. n",. 64()t
sources. 643
vitamin 8,:
defid.ncy. 640., 643
function 640.
for migraine prophylaxis. 233,
pharmaroth.rapy With. 643. 643t
rDmm.nded dietary aUowan",. 64()t
sources. 643
vitamin B, (niadn):
defid.ncy. 640., 643
hrnctions.640.
Indn 911
for h)1l'<rlipid.mia
adver .. effects. 287t, 290
action, 289/
pham13cotherapy with. 290--91
and adult dose. 287t
pharmacotherapy with, 643. 643.
recommended dietary aUow,IOec:. 640,
source',643
vitamin B, (pantothc:nk acid).640r
vitamin B. :
d.ficiency. 640t. 644
function 64(),. 644
pharmacoth<Tapy With. 643., 644
lecommendcd dietary aUowanec:. 640.
vitamin B,.. See Foli<
vitamin B" (.-yanorobalaminl.400r
dtficifncy. 3901. 398. 640., 641
fun<tion . 64()t. 644
H, -re"'ptor blockers and. 614t
metabolism. 398--99. 399/
pharmacotherapy with
a<lion. and u .... 400.
administration al.rts. 400.
adver ... ffts. 400., 643,
interactiom. 400,
route and adult do ... 398t. 643.
recommended dietary aUowanec:. 640,
source 644
vitominC:
d.ficiency. 644
a,dietary supplem.nt. 100.
function 64(),. 644
phamIacotherapy with. 643., 6M
recommended di.tary allowan",. 640,
vita min D:
daily "'qui",ments, 733
640.
risk and. 6421
functions. 64()t
pharmacotherapy with. 641 . 641.
caldtriol. SNeakitriol
cholakif.rol.73.(,
dihydrotachysterol. 734.
doxercakiferol. 734,
ergocakiferol, 734,
paricaldtol.734,
rommended dietary aU"", .. nec:. 64(),
sourcc:,.641
synthesi . 732. 732/
vitamin E:
deficiency. 641
functions. 64(),
pharmacotherapy with. 641. 641.
romm.nded dietary aUowanec:. 640.
sources.641
vitamin K:
. 642
functions. 640,
pharmacotherapy with. 641., 642
recommended dietary aUowanco. 640.
sourcc:s.642
a. warfarin antidote. ID.
Vita- Plus E. S. Vitamin E
LibraryPirate
912 Index
Vivactil. Sn
Vivdl . Se. E.tradiol
VimnaT.E.N.,651
VLDL (""ry low-den.itylipoproteinl,
283,28S!
""latile inhalant .. abus<, 10&
Voltarm. See Uidofenac
",miting, 625. Sn Antiemotks
""miting cmter,628
""n Willdmond', 371., 372- 73
""rioonazol. ,5l3.
""rinostat, 563.
VoSoI. See Acetic acid and hydroconisone
VoSpire. See Albuterol
VX,I2I.
Vytorin,292
W
warfarin, 3761
action, and 3761
administration alert .. 376,
ad .... ""'dfect .. 374" 3761
distribution, 39
genetic polymorphi'm' affecring
melabolism, SIr
imfracrion,
dietary supplemrnu, 57
drug, 39
herbal tb.rapie., 376,
oral comra"'pti ...... 699
overdos< trealm.nt. 376.
pharmacokinetics, 3761
for specific conditions
after myocardial infarction, 349
thromboembolic diseas<, 374., 375
WBC (white blood co.]] counll,3491
Wekhol. s .. Coles<"dam
WeUbutrin. Sn Bupropion
W.U,m..,rin. See Lmoo""rin
whit. blood ",Ucount (WBC), 349.
whole blood,408,
whole-bo...,l irrigation, 122
whoopinSOJugh, ]]6,
WinRho SDF. See Rho(Dl
withdrawal, 14, lOS
withdnwal.yndrom..{J l, 10>-6, 1061
Wl"'illin. Sa Penidllin G procain.
X
Xalatan. Sn !.alanof'm,1
Xanax. Alprazolam
Xenkal.
Xopen.L Sa Uvalbuterol
Xy!ocaine. See Lidocain.
Xy!ocard. Sn Lid"". i".
xylom.talOline, 581.
Xyzal. See u,..otirizine
y
Yasmin, 698,
yeast., >07
Yodoxin. lodoquinol
yohiml>e,223.
young adulthood, 72
Yutopar. Sn Ritodrine
Z

action. and us<" 599, 6011
administration alerts, 601,
ad"er .. effeet .. 596 . 601,
interactions, 601.
pharmaookinetics,60I,
route and adult d<lS<, 5961
zaleplon, 160., 161
Zanaflex. See Tizanidine
""nami .. ir, 540, 540r
Zanmar. See Strept<lzocin
Zanlac. Sn Ranilidin< Hd
Zarontin. See Ethosuximid.
Zaromlyn. See Metolawn.
Zrl>eta. See Bisoprolol
Zrlnorm. Se. T.ga ... rod
Ztmplar. Su Parl,.kilol
Zrmuron. See Rocuronium
Zrnapax. Se. Dadizu mab
Zrrit. See Stavudine
Zestomk, 302" 421
Zrstril. See Lisinopril
Zrtia. See Emimibe
Zevalin. See Ibritumomab tiuxetan
Ziac, 302,
Ziag.n. See "bacavir
Ziana, 756,
zioonotid. , 228., 229
zidovudine,5311
actKm.and US<', 531,
administration alert .. 531,
.dv .... effeets. 530., 531,
;nteracti<ln .. 531.
pharmaookinetics. 531 t
532
for spedlk condition,
HN prophylaxi' aft .. "",,pational
apo,uf<,538
HN-Ir.lDS, 530" 532
p""..,ntion of perinatal HIV
tran,mi"ion, 537
zikuton,
zinc, 649., 650
zinc acetate, 647 1
zinc gluo:onat., 647,
zinc oxide, 763
zinc sulfat. , 647.
Zincate. Zinc sulfate
Z;ngiber S .. Ginger
zipra,ioon., 194; 2l3.
Zithrontax. S .. lr.zithromydn
Zocor. SEe 5imv.!Ii11in
Zofran. SOndan .. tron
Zoladu. See Go .. rdin
zolroronic add (roledronatel,
563',736,
Zolinza. S .. Vorino'tat
Zollinger- Ellison syndrome, 612.
zolmitriptan, 233,
Zoloft. See Si' rtl'lt line
zolpid. m, 1601
acrion, and uses, 159, 161
administration alert .. lro.
ad .... rS< <ffeelS, 161
contraindication .. 161
interaction,. 160,
oyerdos< treatm""t, 160,
pharmacokinrtic., 1601
rout. and adult do .. , 160.
Zomela. See Zollronic acid
Zomig. Su Zolmitriptan
Zon. gran. See Zoni",mid.
zonisamide, 169., 173--74, 173" 175
ZOrnli ..... See Somatotropin
zoster (,hinSI .. ), 539
Zosyn. See Piperadllin I.zobactam
Zoyia 21 and 28, 698t
Zovirax.
Z-Pak. See Ir.zithromycin
Zyban. See Bupropion
Zyflo. Su Zileuton
Zyloprim. See Allopurinol
Zymar. See Gatifloxacin
Zyprexa. Sre Ol.nzapine
Zyrtee. See C.tirizin.
Zymx. s.. Linezoli<l
LibraryPirate
A VOIDING M EDICATION ERRORS
Chapter3,p.19
Chapter 16, p. 184
Chapter 22, p. 291
Chapter 26, p. 365
Chapter 27, p. 380
Chapter3 1,p.442
Chapter 32, p. 457
Chapter 34, p. 489
Chapter 38, p. 582
Chapter 43, p. 659
Chapter 47, p. 740
HOME & COMMUNITY CONSIDERATIONS
- - -
Aspirin for CardIovascular Event RIsk Reduction, p. 472
Asthma Management In the Schoo1s. p. 593
Cardiopulmonary Resuscitation (CPR) and Other Education
for Heart Disea.st, p. 341
Caring for I..oved Ones with AWleimer's Disease, p. 263
Den["()methorphan and Drug Abme, p. S112
Educating Patients About OTC Medications for Bowel
Dlsorders., Nausea, and VomIting, p. 635
Helping Patients Manage Asthma, p. 601
Hypernatremb and Hyponatrem.la In Athletes, p. 438
Muscle Relaxant Ther3Pl' in the Home SettIng, p. 275
Nutritional Therapy for Pat ients Needing Diuretic ThefllPY,
p.428
Ophthalmic Drugs in the Home Setting, p. 775
OTC Drug.'! and MedicatIon Errors., p. 91
o.er-the-Counter Medications for GI Disorders., p. 614
Patients Taking Anticoagulant Thempy, p. 37J
Posunesthesla FOllow-Up Care, p. 248
Preventing MedicatIon Errors In the Home, p. 87
Promoting Safety with Medications That Affect the AN5,
p.145
Psychosocial and Community Impact of Scabies and
Pediculosis, p. 755
Psychosodal l5SUes and Adherence in Patients with Heart
Failure, p. JJ5
Recurrent Anaphylaxis, p. 414
Sample Packs of Mediations for Erectile Dysfunction, p. 724
Serious Adverse Effects of Hormone Ther3py, p. 700
Vitamin B, and Neural1\Jbe Defe-ru, p. 644
" ~
Special Features .
COMPLEMENTARY AND A LTERNATIVE THERAPIES
Actdophilus for Diarrhea, p. 623
Aloe Vera, p. 759
AntIbacterial Properties of Goldenseal, p. SOl
Bilberry for Eye Heal th, p. n5
Black Coh06h for Menopause, p. 704
Carnit lne for Heart Disease, p. 335
Cayenne for Muscular Pain and "!ension, p. 273
Coves for Dental Pain, p. 242
Coenzyme QIO fo r Heart Disease, p. 290
Cranberry for Urinary System Health, p. 428
Echinacea (01" Boosting the Immune System, p. 453
Evening Primrose Oil for Pain, p. 234
Fish OIls for Inflammation, p. 470
Garllc for CardIovascular Health, p. 372
Ginger's Tonic Effects on the GI Tract, p. 616
Ginkgo Biloba for Denwltia, p. 258
Ginseng and Cardiovascular Disease, p. 349
Gluoosamine and Chondroitin for Osteoarthritis., p. 743
Grape Seed Extrad fOr Hypertension, p. 303
Horehound for Respiratory DIsorders, p. 584
Horse Chestnut for VenOll5 lnsuffitiency, p. 4iJ
Kava,p.153
Milk Thistle for Alcohol Liver D ~ m a g e p. 108
Saw P.llmetto, p. 726
Sea Vegetables, p. 643
Selenium's Role in Cancer Prevention, p. 549
St. John's Wort (or Depression, p. 188
The Ketogenic Diet for Epilepsy, p. 169
Valerian for AnxIety and InsomnIa, p. 152
TREATING THE DIVERSE PATIENT
Asian Patients' SensitivIty to Propranolol, p. 363
O!ltunl Dietary H.1bits, p. 286
CUltural Influences and the Treatment of Depression, p. 182
Cultural Influences on Immunizations, p. 451
Cultural Influences on Pain Expression and Perception, p. 220
Olitural Remedies for Diar rhea, p. 625
O!ltural VIews and Treatments of M.ental Uiness., p. 205
Enzyme Dcfidency In Certain Ethnic PopulatIons, p. SO
Ethnic Differences in Acetaminophen Metabolism, p. 473
Ethnic Groups and Smoking, p. 112
G6PD DefiCiency and Antimalarials, p. 517
Hispanic Cultural Beliefs and Antihaderials. p. 483
LibraryPirate
Manllgement ofHypertemion In African Americans. p. 311
Mediation Adherence, p. 78
Non-English-Speaking and a.dtumUy Oivme Pioltients, p. 59
Pioltienu with Speaking, Visual, or Impillrments. p. 74
Religkrus Fasting and Compliance with Medkatlon
AdministnUlon, p. 24
The Impact of Ethnicity and lifestyle on Ostroporosls, p. 740
The Innumc.t of Gender and Ethn1clty on Angina. p.l" I
Vitamin D and Diabetes Risk, p. 642
LIFESPAN CONSIDERATIONS
ofVobtJlc Inhalanu by Children and Adolescents.
p.I06
Adverse Drug E/fel;ts and Older Adulu. p. 4 L
Age-ReL1ted Issues in Drug Administration, p. 90
Chemotherapy In fJderly Patients. po 562
Childhood Play Areas and Parasitic Infections. p. 523
Dkiary Supplemmu and the Older Adult. p.97
Epoe!In A1fa as the Doping." P. 391
Estrogtn Use and Psychosocial Issues. p. 706
RIs .... in Older Adults and p. 158
H: Rectplors and Vitamin BI1 in Older Adults. p. 614
HIY in the and Geriatric Populations, p. 533
Human Chorionic Gonadotropin (hCGj Abuse by Athletes,
P. 718
Iron Poisoning. p. 70
Laxatives and Fluld-EleI;trolytt Balance, p. 440
Living with Alzheimer's and Parldnson'$ Obeases, p. 257
Methylphenidate Use in Older Adults, po 201
Parasitic Infections in Children, p. 523
Pediatric DysIipidemiils, po 286
Prescription Drug Costs and the Doughnut Holt- for Senior
Otizens, p. 8
Psydtosocial and Community [mpxts of Alcohol-Related
Pancrutitis, p. 635
Psychosocial and on Pediatric with
Diabetes, p. 682
Psychosocial Issues with Antift.'1rovinl Drug Compliance,
p.513
Respiratory Distre$S Syndrome, po 601
Selrure Etiologies Based on Genetics and Age-Related Factors,
po [67
Shill Workers, Hypothyroidism, and Drug Compliance, p. 661
TheQuillmgcs of Pediatrk Drug Administration, p. 19
The Influtn" of Ail' on Pain Expresskln and I\-rctptlon,
.223
The New Fountain of Youth!, p. 275
Alzheimer'. Drugs Work by intensifying the Effect of
Acetylcholine at the Receptor, p. 265
Antidepressant Therapy [$ Directed Toward the Amelioration
of Depresslve Symptoms, p. 185
Antipilrkinson Drugs Focus on Restoring Dopamine
Functlon and 8locklng Cholinergic Activity in the
Nig.rostriataJ po 259
Cortlcosterlods (Glucorortoldi) and Adrenal Atrophy, p. 672
Mechanism of Action of Antihypertensive Drugs. p. 30 I
Mechanism of Ation of Direct-Acting AntispasmOOlc.s,
p.274
Mechanism of Action of lipid.Lawering Drugs. p. 289
Med!anlsm of Action of Local Anesthetics, p. 241
Mechanisms of Adion of Antiprostatic Drugs. p. 726
Mechanlsms of Action of Antiulcer Drugs, p. 6 10
Mechanisms of Action of Diuretics, po 421
Mechanisms of Action of Drugs Used for Heart Failure, po 327
Mechanisms of Action of Drug:; Used to Treat Angina, p. 3"2
Mechanisnu of Active and PaSo$ive immunity, po "51
Model oftht GADA Receptor-Chloridt Channel Molecules In
Relationship to Antlseizure Vharm:llcotht'npy. p. 170
Monoclonal Antibodies and Cancer Cells, p. SM
The Rl.>licubr Acllnllng System:llld Relltrd RegionS In Ihe
Brain Are Important Area.s of Focus for Drugs Uied to
Treat Amlely and Anxiety-Related Symptoms, p. 151
PHARMFACTS
AlternativeThtrapies in America, p. 96
Anesthesia and Anesthetics, p. 242
Angina Pectoris. p. 340
ArWl'ty Dlsoroers, po 15 1
Arthrllis,p.741
Asthma, p. 591
Attention Dendt-Hyperactivity Disorder. po 196
Bacteria! Infections, p. "79
Cancer, p. 548
Chapter 45, p. 695
aolling Disorders, p. 371
Community Sbtistic.s In the United States., p. 80
Consumer Spending on Prescription Drugs, p. 5
iJegenemtive Diseases of the Central Nervous System, p. 256
Diabetes Mellitus, p. 680
Dysrhythmtas. p. 355
EpiIrpsy. p. 168
F.:s:tentofDrogAbuse,p.I"
Ht.al Effecu Caused by Specific Drug Use During Pregnancy,
p.68
Fungal, Proloroan, and Helminthic DIsea5es, p. 507
Gastrolntl'Sllnal Disorders, p. 621
LibraryPirate